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Li EW, Jones E, Bryant C, King T, Talaulikar D, Ng JY, Bryant A, Ridha Z, Doo NW, Menzies A, Ling S, Ho SJ, Abadir E, Vanguru V, Joshua D, Ho PJ. A single-day polychemotherapy regimen with proteasome inhibitor combinations for relapsed/refractory myeloma in the era of novel therapies. Eur J Haematol 2024; 113:521-529. [PMID: 38956924 DOI: 10.1111/ejh.14266] [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: 04/22/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
PCAB (prednisone, cyclophosphamide, doxorubicin, carmustine) is a single-day regimen previously used for induction and now in relapsed/refractory multiple myeloma (RRMM). We retrospectively analysed the outcomes of 85 patients from five Australian centres. These included 30 patients (35.3%) who received PCAB with one additional agent (bortezomib most frequently). Median age of the patients was 65 years (37-80), with a median of four (1-8) prior lines of therapy. ORR was 37% (CR 4.9%). Median progression free survival and overall survival were 4.4 months (95% CI 3.5-6.7) and 7.4 months (95% CI 6.4-10.2), respectively. Extramedullary disease (EMD) was associated with shorter survival. Grade 3 or 4 cytopenia and febrile neutropenia occurred in 76.2% and 39.1%, respectively, with six (7.1%) treatment-related mortalities. Median inpatient stay was 3.3 days/28-day cycle (IQR 0.6-13), and for patients who died, a median of 20.2% of days alive were spent inpatient (IQR 6.4-39.1%). Three patients were successfully bridged to CAR T-cell therapy using PCAB, despite being penta-exposed and having EMD. PCAB may be considered as a useful salvage therapy amongst other polychemotherapy regimens in late relapse. Further studies is warranted to investigate and define its role as a bridging therapy to novel therapeutics.
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Affiliation(s)
- Eric Wenlong Li
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Esther Jones
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christian Bryant
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Tracy King
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Dipti Talaulikar
- Department of Haematology, ACT Pathology, Canberra Health Services, Canberra, Australia
- College of Health and Medicine, Australian National University, Canberra, Australia
| | - Jun Yen Ng
- Department of Haematology, ACT Pathology, Canberra Health Services, Canberra, Australia
| | - Adam Bryant
- Department of Haematology, Liverpool Hospital, Sydney, Australia
| | - Zainab Ridha
- Department of Haematology, Liverpool Hospital, Sydney, Australia
| | - Nicole Wong Doo
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Australia
| | - Anna Menzies
- Department of Haematology, St George Hospital, Sydney, Australia
| | - Silvia Ling
- Department of Haematology, Liverpool Hospital, Sydney, Australia
- School of Clinical Medicine, The University of New South Wales, Kensington, Australia
| | - Shir Jing Ho
- Department of Haematology, St George Hospital, Sydney, Australia
| | - Edward Abadir
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Vinay Vanguru
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Douglas Joshua
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - P Joy Ho
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
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2
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Riva E, Garrido D, Villano F, Bove V. Epidemiology and risk factors for the development of infectious complications in newly diagnosed multiple myeloma: a multicenter prospective cohort study in Uruguay. Hematol Transfus Cell Ther 2024; 46:434-442. [PMID: 38307822 PMCID: PMC11452561 DOI: 10.1016/j.htct.2023.09.2362] [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: 03/27/2023] [Revised: 06/20/2023] [Accepted: 09/05/2023] [Indexed: 02/04/2024] Open
Abstract
INTRODUCTION Infections represent a significant cause of morbidity and mortality in patients with multiple myeloma (MM). In Latin America, data on infectious complications in newly diagnosed MM (NDMM) patients are limited. METHODS We conducted a multicenter, prospective cohort study of patients with NDMM in Uruguay between June 2019 and December 2020. Patients with active disease, on active therapy and who provided written informed consent were included. Elegible patients were followed for 6 months from the time of diagnosis and before proceeding to autologous stem cell transplantation or until death, whichever occurred first. Our primary endpoint was the number of infectious events that required hospitalization for ≥ 24 h. MAIN RESULTS Of 124 patients with NDMM, 54 (43.5 %) had infectious complications (74 infectious events), the majority (74.3 %) within the first 3 months from diagnosis. The most common sites of infection were urinary (39.2 %) and respiratory tracts (33.8 %). The microbial agent was identified in 60.8 % of patients with Gram-negative bacteria (71.4 %) as the most common pathogen. Viral and fungal infections were infrequent. In the multivariable analysis, the Eastern Cooperative Oncology Group (ECOG) performance status was ≥ 2 (odds ratio [OR], 2.16; 95 % confidence interval [95 %CI], 1.23 - 3.79; p = 0.008) and creatinine ≥ 2 mg/dl (OR, 2.33; 95 %CI, 1.33 - 4.07; p = 0.003) were independent factors associated with bacterial infections. At 6 months, 14 patients (11.3 %) had died, 50 % related to infectious complications. CONCLUSION Bacterial infections are a substantial cause of hospital admissions and early death in patients with NDMM. Antibiotic prophylaxis should be considered to reduce infectious complications in patients with MM.
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Affiliation(s)
- Eloísa Riva
- Hospital de Clínicas, Montevideo, Uruguay; Hospital Británico, Montevideo, Uruguay
| | | | | | - Virginia Bove
- Hospital Central de las FF.AA., Montevideo, Uruguay.
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Akhmedov M, Zeynalova P, Fedenko A. Multiple myeloma and infections in the era of novel treatment modalities. Leuk Res 2024; 143:107544. [PMID: 38963989 DOI: 10.1016/j.leukres.2024.107544] [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: 02/07/2024] [Revised: 05/14/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024]
Abstract
Infections are major cause of morbidity and mortality in patients with multiple myeloma. Current treatment landscape of newly-diagnosed multiple myeloma includes different classes of drugs, such as proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies, all of which are characterized by specific risk and pattern of infectious complications. Additionally, autologous and allogeneic hematopoietic cell transplantation, widely used in the treatment of multiple myeloma, are complex procedures, carrying a significant risk of complications, and mainly infections. Finally, novel treatment modalities such as bispecific T-cell engagers and chimeric antigen receptor T-lymphocytes have been changing the paradigm of myeloma treatment in relapsed-refractory setting. These agents due to unique mechanism of action carry distinct pattern of infectious complications. In this review, an attempt has been made to summarize the incidence, risk factors, and patterns of infections during different stages of myeloma treatment including novel treatment modalities, and to provide evidence underlying the current concept of infectious disease prophylaxis in this category of patients.
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Affiliation(s)
- Mobil Akhmedov
- Department of High-dose Chemotherapy and Bone Marrow Transplantation, P.A. Herzen Moscow Oncology Research Institute, branch of the National Medical Radiology Research Center, Russian Federation; Department of Oncology and Oncosurgery, Russian University of Medicine, Russian Federation.
| | - Pervin Zeynalova
- Department of Oncology, Sechenov University, Russian Federation; Department of Oncology, Lapino Clinical Hospital, Russian Federation
| | - Alexander Fedenko
- Department of High-dose Chemotherapy and Bone Marrow Transplantation, P.A. Herzen Moscow Oncology Research Institute, branch of the National Medical Radiology Research Center, Russian Federation
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An J, Zhao J, Zou P, Zhang Y, Wei J, Tian W, Wei J. Infections associated with CAR-T cell therapy in patients with relapsed refractory multiple myeloma: Risks and prevention strategies. Cancer Med 2024; 13:e7372. [PMID: 38923216 PMCID: PMC11196838 DOI: 10.1002/cam4.7372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/13/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor T (CAR-T) cell therapy has emerged as a potent treatment for relapsed or refractory multiple myeloma, demonstrating significant clinical efficacy. Despite these advances, treatment-related toxicities, particularly infections, pose a significant challenge to patient safety. METHODS This review synthesizes current knowledge on the mechanisms underlying post-CAR-T therapy infections, focusing on the interplay between immune dysfunction, host factors, and treatment-induced toxicity. It provides a comprehensive analysis of the temporal and individual variability in infection characteristics and the confounding clinical presentation of cytokine release syndrome. RESULTS The review identifies that patients receiving CAR-T cells are at increased risk of concurrent infections due to the heterogeneity in infection characteristics across different time periods, individuals, and patient groups. It highlights the diagnostic and therapeutic complexities introduced by the overlapping symptoms of infection and cytokine release syndrome. CONCLUSION To enhance the infection control post-CAR-T therapy, this review proposes preventive strategies tailored to the early and long-term management of patients. It underscores the need for a nuanced understanding of infection mechanisms and the importance of personalized prevention plans to improve clinical outcomes in multiple myeloma treatment.
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Affiliation(s)
- Jing An
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- School of Public HealthShanxi Medical UniversityTaiyuanShanxiChina
| | - Jie Zhao
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- Sino‐German Joint Oncological Research LaboratoryShanxi Bethune Hospital, Shanxi Academy of Medical SciencesTaiyuanShanxiChina
| | - Ping Zou
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
- Immunotherapy Research Center for Hematologic Diseases of Hubei ProvinceWuhanHubeiChina
| | - Junni Wei
- School of Public HealthShanxi Medical UniversityTaiyuanShanxiChina
| | - Weiwei Tian
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- School of Public HealthShanxi Medical UniversityTaiyuanShanxiChina
- Sino‐German Joint Oncological Research LaboratoryShanxi Bethune Hospital, Shanxi Academy of Medical SciencesTaiyuanShanxiChina
| | - Jia Wei
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- Sino‐German Joint Oncological Research LaboratoryShanxi Bethune Hospital, Shanxi Academy of Medical SciencesTaiyuanShanxiChina
- Department of Hematology, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
- Immunotherapy Research Center for Hematologic Diseases of Hubei ProvinceWuhanHubeiChina
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Yun X, Zhou Y, Wu D, Liu Y, Wu Q. A real‑world pharmacovigilance study of FDA adverse event reporting system events for daratumumab. Expert Opin Drug Saf 2024; 23:581-591. [PMID: 38600747 DOI: 10.1080/14740338.2024.2328321] [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: 08/18/2023] [Accepted: 01/03/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Daratumumab, a first-in-class humanized IgG1κ monoclonal antibody that targets the CD38 epitope, has been approved for treatment of multiple myeloma by FDA. The current study was to evaluate daratumumab-related adverse events (AEs) through data mining of the US Food and Drug Administration Adverse Event Reporting System (FAERS). RESEARCH DESIGN AND METHODS Disproportionality analyses, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN) and the multi-item gamma Poisson shrinker (MGPS) algorithms were employed to quantify the signals of daratumumab-associated AEs. RESULTS Out of 10,378,816 reports collected from the FAERS database, 8727 reports of daratumumab-associated AEs were identified. A total of 183 significant disproportionality preferred terms (PTs) were retained. Unexpected significant AEs such as meningitis aseptic, leukoencephalopathy, tumor lysis syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, sudden hearing loss, ileus and diverticular perforation were also detected. The median onset time of daratumumab-related AEs was 11 days (interquartile range [IQR] 0-76 days), and most of the cases occurred within 30 days. CONCLUSION Our study found potential new and unexpected AEs signals for daratumumab, suggesting prospective clinical studies are needed to confirm these results and illustrate their relationship.
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Affiliation(s)
- Xiaolin Yun
- Department of Pharmacy, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Yingying Zhou
- Department of Pharmacy, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Danna Wu
- Department of Pharmacy, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Yuanbo Liu
- Department of Pharmacy, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Qiongshi Wu
- Department of Pharmacy, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
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Valentine JC, Gillespie E, Verspoor KM, Hall L, Worth LJ. Performance of ICD-10-AM codes for quality improvement monitoring of hospital-acquired pneumonia in a haematology-oncology casemix in Victoria, Australia. HEALTH INF MANAG J 2024; 53:112-120. [PMID: 36374542 DOI: 10.1177/18333583221131753] [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] [Indexed: 02/17/2024]
Abstract
BACKGROUND The Australian hospital-acquired complication (HAC) policy was introduced to facilitate negative funding adjustments in Australian hospitals using ICD-10-AM codes. OBJECTIVE The aim of this study was to determine the positive predictive value (PPV) of the ICD-10-AM codes in the HAC framework to detect hospital-acquired pneumonia in patients with cancer and to describe any change in PPV before and after implementation of an electronic medical record (EMR) at our centre. METHOD A retrospective case review of all coded pneumonia episodes at the Peter MacCallum Cancer Centre in Melbourne, Australia spanning two time periods (01 July 2015 to 30 June 2017 [pre-EMR period] and 01 September 2020 to 28 February 2021 [EMR period]) was performed to determine the proportion of events satisfying standardised surveillance definitions. RESULTS HAC-coded pneumonia occurred in 3.66% (n = 151) of 41,260 separations during the study period. Of the 151 coded pneumonia separations, 27 satisfied consensus surveillance criteria, corresponding to an overall PPV of 0.18 (95% CI: 0.12, 0.25). The PPV was approximately three times higher following EMR implementation (0.34 [95% CI: 0.19, 0.53] versus 0.13 [95% CI: 0.08, 0.21]; p = .013). CONCLUSION The current HAC definition is a poor-to-moderate classifier for hospital-acquired pneumonia in patients with cancer and, therefore, may not accurately reflect hospital-level quality improvement. Implementation of an EMR did enhance case detection, and future refinements to administratively coded data in support of robust monitoring frameworks should focus on EMR systems. IMPLICATIONS Although ICD-10-AM data are readily available in Australian healthcare settings, these data are not sufficient for monitoring and reporting of hospital-acquired pneumonia in haematology-oncology patients.
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Affiliation(s)
- Jake C Valentine
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Elizabeth Gillespie
- Infection Prevention Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Karin M Verspoor
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- School of Computing and Information Systems, University of Melbourne, Parkville, VIC, Australia
| | - Lisa Hall
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- School of Public Health, University of Queensland, Brisbane, QLD, Australia
| | - Leon J Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Infection Prevention Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Hughes D, Yong K, Ramasamy K, Stern S, Boyle E, Ashcroft J, Basheer F, Rabin N, Pratt G. Diagnosis and management of smouldering myeloma: A British Society for Haematology Good Practice Paper. Br J Haematol 2024; 204:1193-1206. [PMID: 38393718 DOI: 10.1111/bjh.19333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Multiple myeloma is a bone marrow-based plasma cell tumour that develops from asymptomatic pre-cursor conditions smouldering myeloma and monoclonal gammopathy of uncertain significance and all are characterised by the presence of a monoclonal protein in the blood. Diagnosis and distinction between these conditions is based on blood tests, the bone marrow biopsy and cross sectional imaging. There are various risk stratification models that group patients with smouldering myeloma into risk groups based on risk of progression to symptomatic disease. Management is mainly observational for patients with smouldering myeloma although clinical trials for high-risk disease may be available. Restaging is required if evidence for progression.
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Affiliation(s)
- Daniel Hughes
- UCL Cancer Institute, University College London, London, UK
| | - Kwee Yong
- UCL Cancer Institute, University College London, London, UK
| | - Karthik Ramasamy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Translational Myeloma Centre, NDORMS, University of Oxford, Oxford, UK
| | - Simon Stern
- Epsom and St Helier University Hospitals NHS Trust, Sutton, UK
| | - Eileen Boyle
- UCL Cancer Institute, University College London, London, UK
| | - John Ashcroft
- The Mid Yorkshire Teaching Hospitals NHS Trust, Wakefield, UK
| | - Faisal Basheer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Rabin
- University College London Hospitals, London, UK
| | - Guy Pratt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Garnica M, Crusoe EDQ, Ribeiro G, Bittencourt R, Magalhães RJP, Zanella KR, Hallack Neto AE, Lima JS, Solo CB, Souza EG, Fernandes AM, Maiolino A, Hungria V. COVID-19 in multiple myeloma patients: frequencies and risk factors for hospitalization, ventilatory support, intensive care admission and mortality -cooperative registry from the Grupo Brasileiro de Mieloma Multiplo (GBRAM). Hematol Transfus Cell Ther 2024; 46:153-160. [PMID: 37718131 DOI: 10.1016/j.htct.2023.08.002] [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: 03/18/2023] [Accepted: 08/04/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION This study evaluated outcomes and risk factors for COVID-19 in 91 Brazilian multiple myeloma (MM) patients between April 2020 and January 2022. RESULTS Of the 91 MM patients diagnosed with COVID-19, 64% had comorbidities and 66% required hospitalization due to COVID-19, with 44% needing ventilatory support and 37% intensive care. Age (OR 2.02; 95%CI 1.02 - 7.7) and hypertension OR 4.5; 95%CI 1.3 - 15.5) were independently associated with hospitalization and certain MM therapies (corticosteroids and monoclonal drugs) were associated with ventilatory support (OR 4.3; 95%CI 1.3 - 14 and OR 5.7; 95%CI 1.8 - 18, respectively), while corticosteroids and immunomodulatory drugs were linked to ICU admission (OR 5.1; 95% CI 1.4 - 18 and OR 3.4; 95%CI 1.1 - 10, respectively). The overall mortality rate was 30%, with the highest rate observed in the ICU (73%). Additionally, the ECOG performance status was linked to increased mortality (OR 11.5; 95%CI 1.9 - 69). The MM treatment was delayed in 63% of patients who recovered from COVID-19. CONCLUSIONS The findings highlight the need for preventing COVID-19 and prioritizing vaccination among MM patients, as they have high rates of severe outcomes in the event of COVID-19. It is also essential to monitor the potential clinical impacts of COVID-19 on MM patients in the long-term. Given the limited resources available in treating MM patients in Brazil during the COVID-19 pandemic, outcomes might be worse in this population.
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Affiliation(s)
- Marcia Garnica
- Universidade Federal do Rio de Janeiro (UFRJ), Brazil; Tranplant Unit, Complexo Hospitalar de Niterói (DASA - CHN), Brazil.
| | - Edvan De Queiroz Crusoe
- Hospital Universitário Professor Edgar Santos (HUPES), Universidade Federal da Bahia, Brazil
| | | | | | | | | | | | | | | | | | | | - Angelo Maiolino
- Universidade Federal do Rio de Janeiro (UFRJ), Brazil; Américas Centro de Oncologia Integrado, Brazil
| | - Vania Hungria
- Hematology, Santa Casa Medical School, Brazil; São Germano Clinic, Brazil
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Nooka AK, Rodriguez C, Mateos MV, Manier S, Chastain K, Banerjee A, Kobos R, Qi K, Verona R, Doyle M, Martin TG, van de Donk NWCJ. Incidence, timing, and management of infections in patients receiving teclistamab for the treatment of relapsed/refractory multiple myeloma in the MajesTEC-1 study. Cancer 2024; 130:886-900. [PMID: 37960969 DOI: 10.1002/cncr.35107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with relapsed/refractory multiple myeloma are at increased risk of infection. Infections during treatment with teclistamab, the first B-cell maturation antigen-directed bispecific antibody approved for triple-class-exposed relapsed/refractory multiple myeloma, was examined in the phase 1/2 MajesTEC-1 study. METHODS Patients (N = 165) received subcutaneous teclistamab 1.5 mg/kg weekly after a step-up dosing schedule (0.06 mg/kg and 0.3 mg/kg, each separated by 2-4 days). Patients were monitored frequently for infections; prophylaxis and management were per institutional guidelines. RESULTS At a median follow-up of 22.8 months (range, 0.3-33.6), infections were reported in 132 patients (80.0%). Grade 3/4 infections occurred in 91 patients (55.2%), including COVID-19 (21.2%), respiratory infections (19.4%), Pneumocystis jirovecii pneumonia (4.2%), viral infections (4.2%), and gastrointestinal infections (1.2%). Twenty-one patients died from infections (18 from COVID-19). Median time to first onset of any-grade and grade 3 to 5 infections was 1.7 and 4.2 months, respectively. Overall, 70.9% of patients had ≥1 postbaseline immunoglobulin G (IgG) level <400 mg/dL; median time to IgG <400 mg/dL was 1.2 months (range, 0.2-19.8) and 46.1% received ≥1 dose of IgG replacement. Grade 3/4 neutropenia occurred in 65.5% of patients (median time to grade ≥3 neutropenia/febrile neutropenia was 2.3 months [range, 0-18.1]). CONCLUSION Based on the infection profile of B-cell maturation antigen-targeted bispecific antibodies such as teclistamab, it is recommended that clinicians and patients remain vigilant for a range of infection types throughout treatment to facilitate prompt intervention. Appropriate screening, prophylaxis, and management of infections, hypogammaglobulinemia, and neutropenia are important. CLINICAL TRIAL REGISTRATION NCT03145181/NCT04557098 (ClinicalTrials.gov) PLAIN LANGUAGE SUMMARY: Before starting teclistamab, patients should be up to date with vaccinations (including COVID-19) and screened for hepatitis B and C and HIV. Teclistamab should not be given to patients with any active infections. Prophylactic antimicrobials should be administered per institutional guidelines. Prophylaxis for Pneumocystis jirovecii pneumonia and herpes simplex/varicella zoster virus is recommended during teclistamab treatment. Close monitoring of infections and immunoglobulin G (IgG) levels should continue throughout teclistamab treatment. IgG replacement (administered every 3-6 weeks) should be used to maintain IgG ≥400 mg/dL. Growth factors should be considered for grade ≥3 neutropenia with infection/fever and grade 4 neutropenia.
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Affiliation(s)
- Ajay K Nooka
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Cesar Rodriguez
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | - Arnob Banerjee
- Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Rachel Kobos
- Janssen Research & Development LLC, Raritan, New Jersey, USA
| | - Keqin Qi
- Janssen Research & Development LLC, Titusville, New Jersey, USA
| | - Raluca Verona
- Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | | | - Thomas G Martin
- University of California, San Francisco, San Francisco, California, USA
| | - Niels W C J van de Donk
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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10
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Giralt S, Jolles S, Kerre T, Lazarus HM, Mustafa SS, Papanicolaou GA, Ria R, Vinh DC, Wingard JR. Recommendations for Management of Secondary Antibody Deficiency in Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:719-732. [PMID: 37353432 DOI: 10.1016/j.clml.2023.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/05/2023] [Accepted: 05/18/2023] [Indexed: 06/25/2023]
Abstract
Secondary antibody deficiency (SAD) is a subtype of secondary immunodeficiency characterized by low serum antibody concentrations (hypogammaglobulinemia) or poor antibody function. SAD is common in patients with multiple myeloma (MM) due to underlying disease pathophysiology and treatment-related immune system effects. Patients with SAD are more susceptible to infections and infection-related morbidity and mortality. With therapeutic advancements improving MM disease control and survival, it is increasingly important to recognize and treat the often-overlooked concurrent immunodeficiency present in patients with MM. The aims of this review are to define SAD and its consequences in MM, increase SAD awareness, and provide recommendations for SAD management. Based on expert panel discussions at a standalone meeting and supportive literature, several recommendations were made. Firstly, all patients with MM should be suspected to have SAD regardless of serum antibody concentrations. Patients should be evaluated for immunodeficiency at MM diagnosis and stratified into management categories based on their individualized risk of SAD and infection. Infection-prevention strategy education, early infection reporting, and anti-infective prophylaxis are key. We recommend prophylactic antibiotics or immunoglobulin replacement therapy (IgRT) should be considered in patients with severe hypogammaglobulinemia associated with a recurrent or persistent infection. To ensure an individualized and efficient treatment approach is utilized, patient's immunoglobin G concentration and infection burden should be closely monitored throughout treatment. Patient choice regarding route and IgRT treatment is also key in reducing treatment burden. Together, these recommendations and proposed management algorithms can be used to aid physician decision-making to improve patient outcomes.
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Affiliation(s)
- Sergio Giralt
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
| | - Tessa Kerre
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - S Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States; University of Rochester School of Medicine & Dentistry, Rochester, NY, United States
| | - Genovefa A Papanicolaou
- Department of Medicine, Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Roberto Ria
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Donald C Vinh
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - John R Wingard
- Department of Medicine, Division of Hematology Oncology, University of Florida, Gainesville, FL, United States
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11
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Sheu M, Molina Garcia S, Patel M, Granat L, Williams L, Khouri J, Mossad S, Anwer F, Majeed A. Intravenous immunoglobulin prophylaxis is associated with decreased rate of infection-related hospitalizations in multiple myeloma patients. Hematol Oncol 2023; 41:718-724. [PMID: 37231908 DOI: 10.1002/hon.3185] [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: 03/03/2023] [Revised: 04/23/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
This study explored the efficacy of intravenous immunoglobulin (IVIG) prophylaxis in reducing infection-related hospitalizations (IRHs) in MM patients. This was a retrospective study of MM patients who received IVIG at Taussig Cancer Center between July 2009 and July 2021. The primary endpoint was rate of IRHs per patient-year on-IVIG versus off-IVIG. 108 patients were included. There was a significant difference in the primary endpoint of rate of IRHs per patient-year on-IVIG versus off-IVIG in the overall study population (0.81 vs. 1.08; Mean Difference [MD], -0.27; 95% Confidence Interval [CI], -0.57 to 0.03; p value [P] = 0.04). The subgroup of patients with a 1-year period of continuous IVIG (49, 45.3%), the subgroup with standard-risk cytogenetics (54, 50.0%) and the subgroup with 2 or more IRHs (67, 62.0%) all showed a significant reduction in IRHs while on-IVIG versus off-IVIG (0.48 vs. 0.78; MD, -0.30; 95% CI, -0.59 to 0.002; p = 0.03) and (0.65 vs. 1.01; MD, -0.36; 95% CI, -0.71 to -0.01; p = 0.02) and (1.04 vs. 1.43; MD, -0.39; 95% CI, -0.82 to 0.05; p = 0.04) respectively. IVIG showed significant benefit in reducing IRHs in the overall population and in multiple subgroups.
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Affiliation(s)
- Michael Sheu
- Cleveland Clinic, Internal Medicine, Cleveland, Ohio, USA
| | | | - Meera Patel
- Cleveland Clinic, Internal Medicine, Cleveland, Ohio, USA
| | - Lauren Granat
- Cleveland Clinic, Internal Medicine, Cleveland, Ohio, USA
| | - Louis Williams
- Cleveland Clinic, Hematology and Medical Oncology, Cleveland, Ohio, USA
| | - Jack Khouri
- Cleveland Clinic, Hematology and Medical Oncology, Cleveland, Ohio, USA
| | - Sherif Mossad
- Cleveland Clinic, Infectious Disease, Cleveland, Ohio, USA
| | - Faiz Anwer
- Cleveland Clinic, Hematology and Medical Oncology, Cleveland, Ohio, USA
| | - Aneela Majeed
- Cleveland Clinic, Infectious Disease, Cleveland, Ohio, USA
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12
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Jandial A, Lad D, Jain A, Khadwal A, Singh C, Prakash G, Suri V, Sreedharanunni S, Sachdeva MUS, Ray P, Varma N, Varma S, Malhotra P. Characteristics and outcome of infectious complications after autologous hematopoietic cell transplantation in multiple myeloma patients. Transpl Infect Dis 2023; 25:e14123. [PMID: 37573150 DOI: 10.1111/tid.14123] [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: 07/28/2022] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Infections are a significant cause of morbidity and mortality after autologous hematopoietic cell transplantation (AHCT) in multiple myeloma (MM) patients. There has been a rapid advancement and evolution in MM treatment landscape in the last decade. There is limited information on post-AHCT infectious complications among MM patients with or without levofloxacin prophylaxis from developing countries. MATERIALS AND METHODS We performed a retrospective study to explore the incidence, pattern, and clinical outcome of infections following AHCT in MM patients from 2010 to 2019 at our center. Patient-specific, disease-specific, and transplant-specific details were retrieved from the case files. The characteristics of infectious complications (site, intensity, organism, treatment, and outcomes) were analyzed. All patients who underwent transplantation from 2010 to 2016 received levofloxacin antibiotic prophylaxis. Common terminology criteria for adverse events (CTCAE) criteria (v5.0) were used for the grading of infections and regimen-related toxicity. International Myeloma Working Group updated criteria were used for the assessment of disease response before transplant and at day +100. RESULTS Ninety-five consecutive patients with newly diagnosed multiple myeloma (NDMM) (n = 85), RRMM (n = 7), plasma cell leukemia (n = 2), and Polyneuropathy, Orgaomegaly, Endocrinopathy, Monoclonal gammopathy, skin abnormalities (POEMS) syndrome (n = 1) underwent AHCT during the study period. Their median age was 55 years (range 33-68); 55.8% were males. Immunoglobulin IgG kappa was the most common monoclonal protein (32.6%), International Staging System stage III disease was present in 45.3%, and 84.2% of patients achieved more than very good partial response before AHCT. The median time from diagnosis to AHCT was 10 months (range 4-144). Eighty-nine patients (93.7%) developed fever after AHCT. Fever of unknown focus, microbiologically confirmed infections, and clinically suspected infections were found in 50.5%, 37.9%, and 5.3% of patients, respectively. Clostridiodes difficile-associated diarrhea was observed in eight patients (8.4%). Neutrophil and platelet engraftment occurred after a median of 11 days (range 9-14) and 12 days (range 9-23), respectively. The median duration of hospital stay was 16 days (range 9-29). Only two patients (2.1%) required readmission for infections within 100 days of AHCT. Transplant-related mortality (TRM) in the study population was 4.2% (n = 4). The levofloxacin prophylaxis group (n = 32, 33.7%) had earlier neutrophil engraftment (day +10 vs. day +11) and platelet engraftment (day +11 vs. day +12), but time to fever onset, duration of fever, hospital stay, TRM, and day +100 readmission rates were not significantly different from those of patients without levofloxacin prophylaxis. There was no significant difference in the spectrum of infections between patients with and without levofloxacin prophylaxis. The overall survival and progression-free survival of the study population at 5 years were 72.7% and 64.8%, respectively. CONCLUSION This study shows that the incidence of infections and TRM are higher in MM patients from lower-middle income countries after AHCT than in those from developed countries. The majority of such patients lack clinical localization and microbiological proof of infection. There was no significant difference in the spectrum of infections and their outcomes in patients with and without levofloxacin prophylaxis.
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Affiliation(s)
- Aditya Jandial
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Charanpreet Singh
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreejesh Sreedharanunni
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Man Updesh Singh Sachdeva
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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13
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Teh BW, Reynolds G, Slavin MA, Cooley L, Roberts M, Liu E, Thursky K, Talaulikar D, Mollee P, Szabo F, Ward C, Chan H, Prince HM, Harrison SJ. Executive summary of consensus clinical practice guidelines for the prevention of infection in patients with multiple myeloma. Intern Med J 2023; 53:1469-1477. [PMID: 37093163 DOI: 10.1111/imj.16100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
Infection remains a significant contributor to morbidity and mortality in patients with myeloma. This guideline was developed by a multidisciplinary group of clinicians who specialise in the management of patients with myeloma and infection from the medical and scientific advisory group from Myeloma Australia and the National Centre for Infections in Cancer. In addition to summarising the current epidemiology and risk factors for infection in patients with myeloma, this guideline provides recommendations that address three key areas in the prevention of infection: screening for latent infection, use of antimicrobial prophylaxis and immunoglobulin replacement and vaccination against leading respiratory infections (severe acute respiratory syndrome coronavirus 2, influenza and Streptococcus pneumoniae) and other preventable infections. This guideline provides a practical approach to the prevention of infection in patients with myeloma and harmonises the clinical approach to screening for infection, use of prophylaxis and vaccination to prevent infectious complications.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Louise Cooley
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Matthew Roberts
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eunice Liu
- Department of Infectious Diseases, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Dipti Talaulikar
- Department of Haematology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Peter Mollee
- Queensland Haematology Department, Princess Alexandra Hospital, Sydney, Queensland, Australia
- School of Medicine, University of Queensland, Sydney, Queensland, Australia
| | - Ferenc Szabo
- Haematology Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Flinders University, Adelaide, South Australia, Australia
| | - Chris Ward
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Henry Chan
- Department of Haematology, Waitemata District Health Board, Auckland, New Zealand
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - H Miles Prince
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Epworth Healthcare, Melbourne, Victoria, Australia
| | - Simon J Harrison
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
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14
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Ashruf OS, Orozco Z, Kaelber DC. Risk and Severity of COVID-19 Infection in Monoclonal Gammopathy of Undetermined Significance: A 3-Year Propensity Matched Cohort Study. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:626-632. [PMID: 37208255 PMCID: PMC10140469 DOI: 10.1016/j.clml.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant disorder causing monoclonal plasma cell proliferation in bone marrow. This population is at risk of developing multiple myeloma (MM) and severe viral infections; risk factors of severe COVID-19 infection. Using TriNetX, a global platform providing data of 120 million patients, we aimed to quantify the risk and severity of COVID-19 in MGUS patients. PATIENTS AND METHODS A retrospective cohort analysis was performed using the TriNetX Global Collaborative Network. From January 20, 2020, to January 20, 2023, we identified a cohort of 58,859 MGUS patients and compared to non-MGUS patients, determined by relevant diagnosis/LOINC test codes. After 1:1 propensity score-matching, we identified COVID-19 cases to quantify risk and identify patients who had been hospitalized, ventilated/intubated, and deceased to quantify severity. Measures of association and Kaplan-Meier analysis were conducted. RESULTS After propensity-score matching, there were 58,668 patients in both cohorts. MGUS patients were found to be at a reduced risk of contracting COVID-19 (RR 0.88, 95% CI 0.85-0.91). MGUS patients with COVID-19 showed higher mortality risk and decreased survival time compared to the general population (HR 1.14, 95% CI 1.01-1.27). MGUS patients with COVID-19 who were hospitalized exhibited significantly decreased survival time (log-rank test, P = 0.04). CONCLUSION As COVID-19 remains a looming health concern, especially amongst vulnerable populations, our analysis emphasizes the need for adequate vaccination and treatment regimens as well as an understanding of the severity of infection in MGUS patients and justification for precautionary measures.
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Affiliation(s)
- Omer S Ashruf
- Northeast Ohio Medical University, College of Medicine, Rootstown, OH, United States.
| | - Zara Orozco
- Northeast Ohio Medical University, College of Medicine, Rootstown, OH, United States
| | - David C Kaelber
- Center for Education and Training in Health Informatics, The Metro Health System and the Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
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15
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Rubinstein SM, Derman BA. Infection rates are high across the multiple myeloma continuum, not just with bispecific antibodies. Eur J Cancer 2023; 189:112926. [PMID: 37307686 DOI: 10.1016/j.ejca.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Samuel M Rubinstein
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Benjamin A Derman
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA.
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16
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Thompson MA, Boccadoro M, Leleu X, Vela-Ojeda J, van Rhee F, Weisel KC, Rifkin RM, Usmani SZ, Hájek R, Cook G, Abonour R, Armour M, Morgan KE, Yeh SP, Costello CL, Berdeja JG, Davies FE, Zonder JA, Lee HC, Omel J, Spencer A, Terpos E, Hungria VTM, Puig N, Fu C, Ferrari RH, Ren K, Stull DM, Chari A. Rates of Influenza and Pneumococcal Vaccination and Correlation With Survival in Multiple Myeloma Patients. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e171-e181. [PMID: 36641358 DOI: 10.1016/j.clml.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infections are a common reason for hospitalization and death in multiple myeloma (MM). Although pneumococcal vaccination (PV) and influenza vaccination (FV) are recommended for MM patients, data on vaccination status and outcomes are limited in MM. MATERIALS AND METHODS We utilized data from the global, prospective, observational INSIGHT MM study to analyze FV and PV rates and associated outcomes of patients with MM enrolled 2016-2019. RESULTS Of the 4307 patients enrolled, 2543 and 2500 had study-entry data on FV and PV status. Overall vaccination rates were low (FV 39.6%, PV 30.2%) and varied by region. On separate multivariable analyses of overall survival (OS) by Cox model, FV in the prior 2 years and PV in the prior 5 years impacted OS (vs. no vaccination; FV: HR, 0.73; 95% CI, 0.60-0.90; P = .003; PV: HR, 0.51; 95% CI, 0.42-0.63; P < .0001) when adjusted for age, region, performance status, disease stage, cytogenetics at diagnosis, MM symptoms, disease status, time since diagnosis, and prior transplant. Proportions of deaths due to infections were lower among vaccinated versus non-vaccinated patients (FV: 9.8% vs. 15.3%, P = .142; PV: 9.9% vs. 18.0%, P = .032). Patients with FV had generally lower health resource utilization (HRU) versus patients without FV; patients with PV had higher or similar HRU versus patients without PV. CONCLUSION Vaccination is important in MM and should be encouraged. Vaccination status should be recorded in prospective clinical trials as it may affect survival. This trial was registered at www. CLINICALTRIALS gov as #NCT02761187.
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Affiliation(s)
- Michael A Thompson
- Aurora Cancer Care, Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI,.
| | | | - Xavier Leleu
- Pôle Régional de Cancérologie, Department of Hematology, CHU La Milétrie-Poitiers, Poitiers, France
| | - Jorge Vela-Ojeda
- Department of Hematology, UMAE Hospital de Especialidades Centro Medico La Raza IMSS, Mexico City, Mexico
| | - Frits van Rhee
- University of Arkansas for Medical Sciences, Little Rock, AR
| | - Katja C Weisel
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robert M Rifkin
- Rocky Mountain Cancer Centers/US Oncology Research, Denver, CO
| | | | - Roman Hájek
- Department of Hemato-oncology, University Hospital Ostrava, and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Gordon Cook
- Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Rafat Abonour
- Indiana University School of Medicine, Indianapolis, IN
| | - Mira Armour
- Mijelom CRO, Croatian Myeloma Support Association, Zagreb, Croatia
| | | | - Su-Peng Yeh
- China Medical University Hospital, Taichung City, P.R.China
| | | | - Jesus G Berdeja
- Department of Hematology, Tennessee Oncology and Sarah Cannon Research Institute, Nashville, TN
| | | | - Jeffrey A Zonder
- Department of Malignant Hematology, Barbara Ann Karmanos Cancer Institute/Wayne State University School of Medicine, Detroit, MI
| | - Hans C Lee
- Department of Lymphoma and Myeloma, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Jim Omel
- The Central Nebraska Myeloma Support Group, Grand Island, NE
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health Monash University, Melbourne, Australia
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vania T M Hungria
- Department of Hematology, Clinica São Germano and Santa Casa Medical School, São Paulo, Brazil
| | - Noemi Puig
- Hematology Department, Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Chengcheng Fu
- First Affiliated Hospital, Soochow University, Suzhou Jiangsu, P.R.China
| | | | - Kaili Ren
- Takeda Development Center Americas, Inc. (TDCA), Lexington, MA
| | | | - Ajai Chari
- Department of Hematology-Oncology, Mount Sinai School of Medicine, New York, NY
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17
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Ludwig H, Kumar S. Prevention of infections including vaccination strategies in multiple myeloma. Am J Hematol 2023; 98 Suppl 2:S46-S62. [PMID: 36251367 DOI: 10.1002/ajh.26766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/12/2022]
Abstract
Infections are a major cause of morbidity and mortality in multiple myeloma. The increased risk for bacterial and viral infections results mainly from the disease-inherent and treatment-induced immunosuppression. Additional risk factors are older age with immune senescence, T cell depletion, polymorbidity, and male gender. Hence, every effort should be taken to reduce the risk for infections by identifying patients at higher risk for these complications and by implementing prophylactic measures, including chemoprophylaxis and immunization against various relevant pathogens. Here, we review the available evidence and provide recommendations for medical prophylaxis and vaccination in clinical practice.
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine I, Center for Medical Oncology and Hematology with Outpatient Department and Palliative Care, Wilhelminen Cancer Research Institute, Vienna, Austria
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Yang J, Zhou W, Li D, Niu T, Wang W. BCMA-targeting chimeric antigen receptor T-cell therapy for multiple myeloma. Cancer Lett 2023; 553:215949. [PMID: 36216149 DOI: 10.1016/j.canlet.2022.215949] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/29/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022]
Abstract
Multiple myeloma (MM) remains an incurable hematologic malignancy, despite the development of numerous innovative therapies during the past two decades. Immunotherapies are changing the treatment paradigm of MM and have improved the overall response and survival of patients with relapsed/refractory (RR) MM. B cell maturation antigen (BCMA), selectively expressed in normal and malignant plasma cells, has been targeted by several immunotherapeutic modalities. Chimeric antigen receptor (CAR) T cells, the breakthrough in cancer immunotherapy, have revolutionized the treatment of B cell malignancies and remarkably improved the prognosis of RRMM. BCMA-targeting CAR T cell therapy is the most developed CAR T cell therapy for MM, and the US Food and Drug Administration has already approved idecabtagene vicleucel (Ide-cel) and ciltacabtagene autoleucel (Cilta-cel) for MM. However, the development of novel BCMA-targeting CAR T cell therapies remains in progress. This review focuses on BCMA-targeting CAR T cell therapy, covering all stages of investigational progress, including the innovative preclinical studies, the initial phase I clinical trials, and the more developed phase II clinical trials. It also discusses possible measures to improve the efficacy and safety of this therapy.
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Affiliation(s)
- Jinrong Yang
- Department of Hematology, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and National Collaborative Innovation Center, Chengdu, 610041, China
| | - Weilin Zhou
- Department of Hematology, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and National Collaborative Innovation Center, Chengdu, 610041, China
| | - Dan Li
- Department of Hematology, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and National Collaborative Innovation Center, Chengdu, 610041, China
| | - Ting Niu
- Department of Hematology, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and National Collaborative Innovation Center, Chengdu, 610041, China.
| | - Wei Wang
- Department of Hematology, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and National Collaborative Innovation Center, Chengdu, 610041, China.
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19
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Lu X, Liu W, Zhang L, Chen X, Yang L, Yao Q, Zhao J, He S, Wei J, Tian W. Eastern Cooperative Oncology Group, β2-microglobulin, hemoglobin, and lactate dehydrogenase can predict early grade ≥ 3 infection in patients with newly diagnosed multiple myeloma: A real-world multicenter study. Front Microbiol 2023; 14:1114972. [PMID: 36778870 PMCID: PMC9911534 DOI: 10.3389/fmicb.2023.1114972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023] Open
Abstract
Introduction This research explored the clinical application of grade ≥ 3 infection predictive models for the newly diagnosed multiple myeloma (NDMM) population. Methods It evaluated 306 patients with NDMM based on three different predictive models. The relationship between the grade ≥ 3 infection rates in NDMM and the scores was analyzed retrospectively. The cumulative incidence of early grade ≥ 3 infection was estimated using the Kaplan-Meier method and log-rank test to assess the statistical significance of the difference. To compare the predictive performance in the prediction of infection, the Receiver Operating Characteristic Curve (ROC) curve was used to show the area under the curve (AUC), and DeLong's test was used to analyze the difference in AUC. Results The incidence of grade ≥ 3 infection within the first 4 months of NDMM was 40.20%. Concerning the FIRST score (predictors: ECOG, β2-microglobulin, hemoglobin, and lactate dehydrogenase), GEM-PETHEMA score (predictors: albumin, male sex, ECOG, and non-IgA type MM), and Infection Risk model of Multiple Myeloma (IRMM) score (predictors: ECOG, serum β2-microglobulin, globulin, and hemoglobin), the probability of early grade ≥ 3 infection in the different groups showed statistically significant differences (low-risk vs. high-risk: 25.81% vs. 50.00%, p < 0.001; low-risk vs. moderate-risk vs. high-risk: 35.93% vs. 41.28% vs. 60.00%, p= 0.045; low-risk vs. moderate-risk vs. high-risk: 20.00% vs. 43.75% vs. 52.04%, p < 0.001). Statistical differences existed in the probability of early grade ≥ 3 infection among the different groups by the FIRST and IRMM scores but no statistical differences in the GEM-PETHEMA score (p < 0.001, p< 0.001, and p = 0.090, respectively). The FIRST score showed good discrimination and simple calculation with highest AUC. Further subgroup analysis showed that the FIRST score could still apply for patients treated with bortezomib-based regimen and frail patients. Discussion Our findings indicate that the FIRST score (consisting of ECOG, β2-microglobulin, hemoglobin, and lactate dehydrogenase) is a simple and robust infection stratification tool for patients with NDMM and could be used in routine clinical work.
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Affiliation(s)
- Xinyi Lu
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Wenhua Liu
- Department of Hematology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
| | - Lan Zhang
- Department of Hematology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xinyue Chen
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Liping Yang
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Qiong Yao
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Jie Zhao
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Shaolong He
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Jia Wei
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China,Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, Shanxi, China,Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China,*Correspondence: Jia Wei, ✉
| | - Weiwei Tian
- Department of Hematology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences Tongji Shanxi Hospital, Taiyuan, Shanxi, China,Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, Shanxi, China,Weiwei Tian, ✉
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20
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Lutz C, Feiten S, Chakupurakal G, Heymanns J, Thomalla J, van Roye C, Weide R. Patients with indolent lymphomas are at high risk of infections: experience from a German outpatient clinic. BMC Immunol 2023; 24:2. [PMID: 36631764 PMCID: PMC9833869 DOI: 10.1186/s12865-022-00536-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Patients with indolent B-cell non-Hodgkin lymphomas (B-NHLs) have an increased risk of infections which is caused by pathomechanisms of the diseases itself but also as a result of anti-tumor therapy. Especially the effects of anti-CD20 antibodies are well understood as these lead to decreased antibody production. Most studies regarding immunodeficiency in B-NHLs were conducted with multiple myeloma and chronic lymphocytic leukemia patients. As these studies not always represent the general population we collected and analyzed real world data from patients with indolent lymphomas and a control group (CG). RESULTS Patients with B-NHLs undergoing therapy or who were regularly monitored in a watch and wait approach had, over the time of one year, an increased rate of infections compared to the CG of 145 healthy volunteers (mean: 11.66 vs. 7.13 infections per 1000 days). Consistent with this finding B-NHL patients received more antibiotic treatment (mean: 11.17 vs. 6.27 days) and were more often hospitalized than persons from the CG (mean: 5.19 vs. 0.99 days per 1000 days). Lymphoma patients without immunodeficiency had a lower infection rate than patients with non-symptomatic and symptomatic immunodeficiency (mean: 10.91 vs. 12.07 and 12.36 per 1000 days). The number of infections differed statistically significant for the subgroups and CG (7.13 per 1000 days). Patients with symptomatic immunodeficiency were mostly treated with regular immunoglobulin substitutions and infection rates were comparable to those of patients with asymptomatic immunodeficiency. CONCLUSIONS Our data suggest the use of an approach with regular immune monitoring including the measurement of immunoglobulin levels and regular appointments for clinical assessment of all indolent lymphoma patients in order to identify patients with increased risk of infections. It also raises the question if patients with immunodeficiency should be treated more often with regular immunoglobulin substitution, but so far more studies are necessary to answer this question.
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Affiliation(s)
- Christoph Lutz
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany.
| | - Stefan Feiten
- Institut für Versorgungsforschung in der Onkologie, Koblenz, Germany
| | - Geothy Chakupurakal
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany
| | - Jochen Heymanns
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany
| | - Jörg Thomalla
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany
| | - Christoph van Roye
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany
| | - Rudolf Weide
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany
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21
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John L, Miah K, Benner A, Mai EK, Kriegsmann K, Hundemer M, Kaudewitz D, Müller-Tidow C, Jordan K, Goldschmidt H, Raab MS, Giesen N. Impact of novel agent therapies on immune cell subsets and infectious complications in patients with relapsed/refractory multiple myeloma. Front Oncol 2023; 13:1078725. [PMID: 37152008 PMCID: PMC10160457 DOI: 10.3389/fonc.2023.1078725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/30/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction Infections are a leading cause of morbidity and mortality in patients with multiple myeloma (MM). Methods To examine the effects of modern second-generation novel agent therapy on immune cell subsets, in particular CD4+-T-cells, and infectious complications in patients with relapsed/refractory MM (RRMM), we conducted a prospective cohort study in 112 RRMM patients. Results Substantially decreased CD4+-T-cells <200/µl before initiation of relapse therapy were detected in 27.7% of patients and were associated with a higher number of previous lines of therapy. Relapse therapy with carfilzomib or pomalidomide showed a significant further decrease of CD4+-T-cells. All novel agents led to a significant decrease of B-cell counts. Overall, infections were frequent with 21.3% of patients requiring antibacterial therapy within the first 3 months of relapse therapy, 5.6% requiring hospitalization. However, in the setting of standard antimicrobial prophylaxis in RRMM patients with very low CD4+-T-cells, no significant association of CD4+T-cell count and an increased risk of infection could be detected. Discussion Our findings imply that reduced CD4+-T-cell numbers and infections are common in patients with RRMM. We also demonstrate an association with the number of previous therapies and certain substances suggesting an increased need for personalized prophylaxis strategies for opportunistic infections in this patient cohort.
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Affiliation(s)
- Lukas John
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Molecular Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- *Correspondence: Lukas John,
| | - Kaya Miah
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Elias K. Mai
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Kriegsmann
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Hundemer
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dorothee Kaudewitz
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Karin Jordan
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Hematology, Oncology and Palliative Medicine, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Hartmut Goldschmidt
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Marc S. Raab
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Molecular Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nicola Giesen
- Department of Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
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Charalampous C, Goel U, Gertz M, Lacy M, Dispenzieri A, Hayman S, Dingli D, Buadi F, Kapoor P, Kourelis T, Warsame R, Hogan WJ, Kumar S. Impact of the time interval between end of induction and autologous hematopoietic transplantation in newly diagnosed patients with multiple myeloma. Bone Marrow Transplant 2023; 58:46-53. [PMID: 36203088 PMCID: PMC9812760 DOI: 10.1038/s41409-022-01835-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 01/10/2023]
Abstract
Multiple Myeloma patients eligible for autologous hematopoietic transplantation (AHT) typically receive 3-6 cycles of induction therapy before transplant. The last induction cycle is completed 2-4 weeks prior to mobilization. We evaluated the impact of the time interval between end of induction and AHT on progression-free survival (PFS) and overall survival (OS). A total of 1055 patients who underwent AHT were identified. The median time to transplant (TTT) was 33 days (27-42 quartile range). Patients with less than 33 days of TTT had significantly prolonged PFS (35.6 vs. 32.1 months, p < 0.03) but non-significant OS differences compared to those with more than 33 days. Quartile comparisons showed that patients in the 1st quartile (less than 27 days) had significantly prolonged PFS (36.7 vs. 30.9 months, p < 0.01) compared to the 4th quartile group (more than 42 days). In a subgroup analysis of patients with partial or worse biochemical response prior to transplant, patients in the 1st quartile had significantly prolonged PFS (37.7 vs. 28.7 months, p < 0.04) compared to the 4th quartile group. In conclusion, we showed that a prolonged TTT is associated with inferior outcomes compared to tighter chemotherapy schedules. This finding was especially prevalent in patients with partial response at induction.
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Affiliation(s)
- Charalampos Charalampous
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Utkarsh Goel
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Morie Gertz
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Martha Lacy
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Angela Dispenzieri
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Suzanne Hayman
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - David Dingli
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Francis Buadi
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Prashant Kapoor
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Taxiarchis Kourelis
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Rahma Warsame
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - William J. Hogan
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Wang Z, Chen C, Wang L, Jia Y, Qin Y. Chimeric antigen receptor T-cell therapy for multiple myeloma. Front Immunol 2022; 13:1050522. [PMID: 36618390 PMCID: PMC9814974 DOI: 10.3389/fimmu.2022.1050522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Multiple myeloma (MM) is a malignant plasma cell disorder that remains incurable for most patients, as persistent clonal evolution drives new mutations which confer MM high-risk signatures and resistance to standard care. The past two decades have significantly refashioned the therapeutic options for MM, especially adoptive T cell therapy contributing to impressive response rate and clinical efficacy. Despite great promises achieved from chimeric antigen receptor T-cell (CAR-T) therapy, the poor durability and severe toxicity (cytokine release syndrome and neurotoxicity) are still huge challenges. Therefore, relapsed/refractory multiple myeloma (RRMM), characterized by the nature of clinicopathologic and molecular heterogeneity, is frequently associated with poor prognosis. B Cell Maturation Antigen (BCMA) is the most successful target for CAR-T therapy, and other potential targets either for single-target or dual-target CAR-T are actively being studied in numerous clinical trials. Moreover, mechanisms driving resistance or relapse after CAR-T therapy remain uncharacterized, which might refer to T-cell clearance, antigen escape, and immunosuppressive tumor microenvironment. Engineering CAR T-cell to improve both efficacy and safety continues to be a promising area for investigation. In this review, we aim to describe novel tumor-associated neoantigens for MM, summarize the data from current MM CAR-T clinical trials, introduce the mechanism of disease resistance/relapse after CAR-T infusion, highlight innovations capable of enhanced efficacy and reduced toxicity, and provide potential directions to optimize manufacturing processes.
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Affiliation(s)
| | | | | | - Yongxu Jia
- *Correspondence: Yongxu Jia, ; Yanru Qin,
| | - Yanru Qin
- *Correspondence: Yongxu Jia, ; Yanru Qin,
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24
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Vassilopoulos S, Vassilopoulos A, Kalligeros M, Shehadeh F, Mylonakis E. Cumulative Incidence and Relative Risk of Infection in Patients With Multiple Myeloma Treated With Anti-CD38 Monoclonal Antibody-Based Regimens: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac574. [PMID: 36438616 PMCID: PMC9685179 DOI: 10.1093/ofid/ofac574] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/27/2022] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Patients with multiple myeloma are at higher risk for infections due to disease pathogenesis and administered therapies. The purpose of this study was to estimate the risk for any grade and severe infections associated with the use of anti-CD38 monoclonal antibodies in patients with multiple myeloma. METHODS We searched PubMed and EMBASE for randomized controlled trials (RCTs) that included patients with multiple myeloma who received CD38-targeting monoclonal antibody regimens and reported outcomes of infection and performed a random-effects meta-analysis to estimate the relative risk for infections. RESULTS After screening 673 citations, we retrieved 17 studies providing data on 11 RCTs. Overall, the included reports evaluated 5316 patients (2797 in the intervention arm and 2519 in the control arm). The relative risk (RR) for both any grade or severe infections was 1.27 (95% CI, 1.17-1.37 and 1.14-1.41, respectively). The cumulative incidence of any grade infections for patients who received anti-CD38 agents was 77% (95% CI, 68%-86%), while for severe infections it was 28% (95% CI, 23%-34%). Patients treated with anti-CD38 agents had a 39% higher risk for any grade pneumonia (RR, 1.39; 95% CI, 1.12-1.72) and a 38% higher risk for severe pneumonia (RR, 1.38; 95% CI, 1.09-1.75). For upper respiratory tract infections, the relative risk was 1.51 and 1.71 for any grade and severe infections, respectively. Regarding varicella-zoster virus (VZV) reactivation, we found no evidence of increased risk (RR, 3.86; 95% CI, 0.66-22.50). CONCLUSIONS Patients with multiple myeloma treated with regimens that included an anti-CD38 monoclonal antibody were at higher risk for any grade or severe infections without an associated higher mortality rate during the follow-up period of the retrieved studies. No evidence of increased risk for VZV reactivation was noted, but there was a significant association between CD38-targeting treatment and pneumonia risk. Increased surveillance for infections, development of effective prophylactic strategies, and studies with long follow-up are needed for patients with multiple myeloma treated with anti-CD38-based regimens.
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Affiliation(s)
- Stephanos Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Athanasios Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Markos Kalligeros
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Fadi Shehadeh
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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25
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Lin W, Tsai C, Yeh C, Chian T, Liu Y, Wang H, Ko P, Lin T, Hsiao L, Chen P, Gau J, Liu C. Herpes zoster prophylaxis: Essential for treating newly diagnosed multiple myeloma patients. Cancer Med 2022; 12:3013-3026. [PMID: 36127838 PMCID: PMC9939124 DOI: 10.1002/cam4.5215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Multiple myeloma (MM) is known for its immune disturbance and patients suffering from MM are thus vulnerable to opportunistic infections, including herpes zoster (HZ). As HZ infection remarkably affects patients' quality of life and poses huge economic burdens on the health system, we aim to identify the risk factors of HZ infection and evaluate the effects of different dosages, types, and durations of anti-HZ prophylaxis drugs to prevent HZ infection. METHODS 551 MM patients at Taipei Veterans General Hospital in Taiwan between January 1, 2009 and August 31, 2021 were restrospectively analyzed. The patients' baseline characteristics were recorded. The primary endpoint of the study was the incidence of HZ infection among the studied patient population. Due to the lack of cost coverage from Taiwanese public health insurance on HZ prophylaxis drugs, the use of anti-HZ drugs mainly depends on physicians' preferences and patients' choices. RESULTS In our study, prophylaxis was given to 283 of the patients. In the multivariate analysis, we included non-prophylaxis, age ≥ 60, corrected serum calcium ≥12 mg/dl, serum creatinine ≥2 mg/dl, serum β2-microglobulin ≥5500 mg/L, autologous stem cell transplant (SCT), and allogeneic SCT for analysis. Our results demonstrated that the non-prophylaxis group (HR: 2.37, 95% CI 1.57-3.57) and patients receiving autologous SCT (HR: 2.22, 95% CI 1.28-3.86) and allogeneic SCT (HR: 5.12, 95% CI 1.13-23.22) had higher risk of HZ infection. The difference in dosage and types of anti-HZ drugs showed similar protective effects. In patients who stopped anti-HZ prophylaxis before active cancer-related treatment, a higher risk of getting HZ infection compared to the corresponding group was also observed (adjusted HR 3.09, 95% CI 1.35-7.07, p = 0.008). CONCLUSIONS We concluded that MM patients should receive HZ prophylaxis drugs while receiving active cancer-related treatment. Patients receiving SCT are also at high risk of getting HZ infection, even under prophylaxis.
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Affiliation(s)
- Wen‐Ying Lin
- Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Chun‐Kuang Tsai
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Chiu‐Mei Yeh
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,Institute of Public HealthNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Tin Chian
- Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Yao‐Chung Liu
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Hao‐Yuan Wang
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Po‐Shen Ko
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Ting‐An Lin
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Liang‐Tsai Hsiao
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Po‐Min Chen
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Jyh‐Pyng Gau
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Chia‐Jen Liu
- Division of Hematology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan,Institute of Emergency and Critical Care MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
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26
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Bove V, Riva E, Vásquez J, Peña C, Seehaus C, Samanez C, Bustos J, Hernández M, Fernández J, Ríos O, Rodríguez Y, Figueredo I, Fantl D, Malpica L. Epidemiology and Risk Factors for the Development of Infectious Complications in Newly Diagnosed Multiple Myeloma: A Multicenter Prospective Cohort Study in Latin America. JCO Glob Oncol 2022; 8:e2200068. [PMID: 35867949 PMCID: PMC9812460 DOI: 10.1200/go.22.00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Infections are a significant cause of morbidity and mortality in patients with multiple myeloma (MM). In Latin America, data on infectious complications in this patient population are lacking. METHODS We conducted a prospective cohort study of patients with newly diagnosed MM (NDMM) in seven Latin American countries between June 2019 and May 2020. Patients with active disease, on active therapy, and with a follow-up of 6 months from the time of diagnosis were included. Our primary end point was the number of infectious events that required hospitalization for ≥ 24 hours. RESULTS Of 248 patients with NDMM, 89 (35.9%) had infectious complications (113 infectious events), the majority (67.3%) within the first 3 months from diagnosis. The most common sites of infection were respiratory (38%) and urinary tract (31%). The microbial agent was identified in 57.5% of patients with gram-negative bacteria (73.5%) as the most common pathogen. Viral infections were infrequent, and no patients with fungal infection were reported. In the multivariable analysis, diabetes mellitus (odds ratio [OR], 2.71; 95% CI, 1.23 to 6.00; P = .014), creatinine ≥ 2 mg/dL (OR, 4.87; 95% CI, 2.29 to 10.35; P < .001), no use of trimethoprim-sulfamethoxazole prophylaxis (OR, 6.66; 95% CI, 3.43 to 12.92; P < .001), and treatment with immunomodulatory drugs (OR, 3.02; 95% CI, 1.24 to 6.29; P = .003) were independent factors associated with bacterial infections. At 6 months, 21 patients (8.5%) had died, 47.6% related to infectious complications. CONCLUSION Bacterial infections are a substantial cause of hospital admissions and early death in patients with NDMM. Antibiotic prophylaxis should be considered to reduce infectious complications in patients with MM.
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Affiliation(s)
- Virginia Bove
- Department of Hematology, Hospital Central de las FF.AA., Montevideo, Uruguay,Virginia Bove, MD, Department of Hematology, Hospital Central de las FF.AA., Av. 8 de Octubre 3060, Montevideo 11600, Uruguay; Twitter: @VirginiaBove10; e-mail:
| | - Eloísa Riva
- Department of Hematology, Hospital de Clínicas, Montevideo, Uruguay
| | - Jule Vásquez
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Camila Peña
- Department of Hematology, Hospital del Salvador, Santiago, Chile
| | - Cristian Seehaus
- Department of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - César Samanez
- Department of Medical Oncology, Oncosalud—AUNA, Lima, Peru
| | - Justina Bustos
- Department of Hematology and Bone Marrow Transplantation, Instituto Oncológico Nacional, Panamá, Panamá
| | - Marcos Hernández
- Department of Hematology, Universidad de Carabobo, Hospital Metropolitano del Norte, Carabobo, Venezuela
| | - Julio Fernández
- Department of Hematology, Hospital General Universitario Dr Gustavo Aldereguía Lima, Cienfuegos, Cuba
| | - Oliday Ríos
- Department of Hematology, Hospital Hermanos Ameijeiras, La Habana, Cuba
| | - Yusaima Rodríguez
- Department of Hematology, Hospital Hermanos Ameijeiras, La Habana, Cuba
| | - Irving Figueredo
- Department of Hematology, Centro de Investigaciones Médico Quirúrgicas, La Habana, Cuba
| | - Dorotea Fantl
- Department of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Luis Malpica
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
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Sheybani F, Brouwer MC, van de Beek D. BACTERIAL MENINGITIS IN PATIENTS WITH MULTIPLE MYELOMA: A PROSPECTIVE NATIONWIDE COHORT STUDY AND REVIEW OF THE LITERATURE. Int J Infect Dis 2022; 122:492-496. [PMID: 35760383 DOI: 10.1016/j.ijid.2022.06.038] [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: 01/17/2022] [Revised: 05/13/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE To study the clinical features of bacterial meningitis in myeloma patients. METHODS We analyzed myeloma patients included in a nationwide cohort of patients >16 years old with community-acquired bacterial meningitis in the Netherlands between 2006 and 2018. Subsequently, we reviewed the literature for articles reporting myeloma patients with bacterial meningitis. RESULTS A total of 27 of 2306 (1.6%) episodes of bacterial meningitis occurred in myeloma patients. Six of 27 (22%) patients received stem cell transplantation. CSF showed a median leukocyte count of 172/µL and 12 (46%) of 26 patients had a CSF leukocyte count <100/µL. Streptococcus pneumoniae was the causative pathogen in 25 (93%) patients. Fourteen (52%) patients had unfavorable outcome of whom 10 (37%) died. Ninety-one myeloma patients with bacterial meningitis were described in the literature. The most common pathogen in these patients was S. pneumoniae (35 of 48; 73%) and four (20%) of 20 cases died. CONCLUSION Bacterial meningitis in patients with multiple myeloma is a severe disease with high rates of unfavorable outcome. Patients often present with a low CSF leukocyte count compared to bacterial meningitis in patients without multiple myeloma. Physicians should have a low threshold to perform a lumbar puncture in myeloma patients and start antibiotic treatment pending CSF chemistry and culture results.
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Affiliation(s)
- Fereshte Sheybani
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Infectious diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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28
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Waszczuk-Gajda A, Penack O, Sbianchi G, Koster L, Blaise D, Reményi P, Russell N, Ljungman P, Trneny M, Mayer J, Iacobelli S, Kobbe G, Scheid C, Apperley J, Touzeau C, Lenhoff S, Jantunen E, Anagnostopoulos A, Paris L, Browne P, Thieblemont C, Schaap N, Sierra J, Yakoub-Agha I, Garderet L, Styczynski J, Schoemans H, Moiseev I, Duarte RF, Peric Z, Montoto S, van Biezen A, Mikulska M, Aljurf M, Ruutu T, Kröger N, Morris C, Koenecke C, Schoenland S, Basak GW. Complications of Autologous Stem Cell Transplantation in Multiple Myeloma: Results from the CALM Study. J Clin Med 2022; 11:jcm11123541. [PMID: 35743620 PMCID: PMC9225651 DOI: 10.3390/jcm11123541] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 01/27/2023] Open
Abstract
Background: The main goal of this post hoc analysis of the Collaboration to Collect Autologous Transplant Outcomes in Lymphoma and Myeloma (CALM) study was to evaluate the rate of short- and long-term infectious and non-infectious complications occurring after ASCT in patients with multiple myeloma (MM). Methods: The analysis included all patients with MM from the CALM study who underwent ≥1 ASCT. The primary endpoint of the analysis was to determine the rate of infectious and non-infectious complications after ASCT and to compare them in three time periods: 0−100 days, 101 days−1 year, and >1 year after the first transplant. Results: The analysis included a total of 3552 patients followed up for a median of 56.7 months (range 0.4−108.1). Complication rates decreased with the time from ASCT with 24.85 cases per 100 patient-years from day 0 to 100 days after the transplant, and <2.31 cases per 100 patient-years from the 101st day. At 100 days after ASC T, 45.7% of patients had complications, with infectious events being twice as frequent as non-infectious complications. Bacterial infections (6.5 cases per 100 patient-years, 95% CI: 6.1−7.0) and gastrointestinal complications (4.7 cases per 100 patient-years, 95% CI: 4.3−5.1) were the most common early events. The pattern of complications changed with time from ASCT. The presence of complications after ASCT was not associated with overall survival. Conclusions: Our data provide a solid basis for comparing ASCT-related complications to those caused by emerging treatments in multiple myeloma, such as CAR T-cell therapy and other immunotherapies.
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Affiliation(s)
- Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, University Clinical Centre—The Medical University of Warsaw, 02-097 Warsaw, Poland;
- Correspondence:
| | - Olaf Penack
- Charité Universitätsmedizin Berlin, 10771 Berlin, Germany;
| | | | - Linda Koster
- EBMT Data Office Leiden, 2333 AA Leiden, The Netherlands; (L.K.); (A.v.B.)
| | | | | | | | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska Comprehensive Cancer Center, Karolinska University Hospital Huddinge, 17177 Stockholm, Sweden;
- Division of Hematology, Department of Medicine Huddinge, Karolinska Institute, 171 77 Stockholm, Sweden
| | - Marek Trneny
- University Hospital, 12808 Prague, Czech Republic;
| | - Jiri Mayer
- University Hospital Brno, 62500 Brno, Czech Republic;
| | | | - Guido Kobbe
- Heinrich Heine Universitaet, 40225 Duesseldorf, Germany;
| | | | | | | | | | - Esa Jantunen
- Department of Medicine, University of Eastern Finland and Hospital District of North Carelia, Kuopio University Hospital, 70211 Kuopio, Finland;
| | | | - Laura Paris
- Division of Hematology, SST Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | | | | | - Nicolaas Schaap
- Radboud University Medical Centre, Department of Hematology, 6525 GA Nijmegen, The Netherlands;
| | - Jorge Sierra
- Hospital Santa Creu i Sant Pau, 08001 Barcelona, Spain;
| | | | - Laurent Garderet
- Centre de Recherche Saint-Antoine, Sorbonne Université-INSERM, UMR_S 938, 75013 Paris, France;
- Département d’Hématologie et de Thérapie Cellulaire, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpetrière, 75012 Paris, France
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum UMK, 85-067 Bydgoszcz, Poland;
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Public Health and Primary Care, ACCENT VV, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Ivan Moiseev
- R.M. Gorbacheva Memorial Institute of Hematology, Oncology and Transplantation, Pavlov University, 197022 Saint-Petersburg, Russia;
| | - Rafael F. Duarte
- Hospital Universitario Puerta de Hierro Majadahonda—Universidad Autónoma de Madrid, 28222 Madrid, Spain;
| | - Zinaida Peric
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
| | - Silvia Montoto
- Department of Haemato-Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, UK;
| | - Anja van Biezen
- EBMT Data Office Leiden, 2333 AA Leiden, The Netherlands; (L.K.); (A.v.B.)
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genoa, 16121 Genoa, Italy;
- Division of Infectious Diseases, IRC CS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Mahmoud Aljurf
- Section of Adult Haematolgy/BMT, King Faisal Specialist Hospital & Research Centre Oncology, Riyadh 11564, Saudi Arabia;
| | - Tapani Ruutu
- Comprehensive Cancer Center, Department of Hematology, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland;
- Clinical Research Institute, Helsinki University Hospital and University of Helsinki, 00280 Helsinki, Finland
| | | | | | - Christian Koenecke
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, 30625 Hannover, Germany;
| | - Stefan Schoenland
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Grzegorz W. Basak
- Department of Hematology, Transplantation and Internal Medicine, University Clinical Centre—The Medical University of Warsaw, 02-097 Warsaw, Poland;
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29
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Shah MR, Gabel A, Beers S, Salaru G, Lin Y, Cooper DL. COVID-19 Vaccine Responses in Patients With Plasma Cell Dyscrasias After Complete Vaccination. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e321-e326. [PMID: 34872881 PMCID: PMC8580561 DOI: 10.1016/j.clml.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Due to functional hypogammaglobulinemia, patients with multiple myeloma are at increased risk for infection and generally have poorer responses to vaccines. In this study, we examined antibody responses after complete COVID-19 vaccination in patients with plasma cell dyscrasias, most of whom were receiving treatment. PATIENTS AND METHODS Real world study of consecutive patients with multiple myeloma and other plasma cell dyscrasias (PCD) were evaluated after complete vaccination with either the 2-shot mRNA vaccines from BioNTech and Moderna or the 1-shot adenoviral vector vaccine from Johnson & Johnson (J&J). Patients received vaccines 1-4 months before antibody testing without controlling for the type of vaccine or the timing of drug therapy. Patients with a clinical history or antibody evidence of prior infection were excluded. Antinucleocapsid and quantitative anti-spike antibody levels were measured with the Roche Elecys assay. RESULTS Ninety-five percent of patients had detectable antibody responses. Multivariate analysis showed that higher age, ongoing anti-CD38 monoclonal antibody therapy and the J&J vaccine negatively affected quantitative response. A small number of ineffectively vaccinated patients receiving IVIG subsequently had detectable nucleocapsid and spike antibodies confirming the presence of the latter in currently administered IVIG. CONCLUSIONS Nearly all PCD had detectable anti-spike antibodies after vaccination but age, anti-CD38 monoclonal antibody therapy, and the single-shot J&J vaccine negatively affected responses. In patients who received the J&J vaccine, second doses or heterologous mRNA vaccines should be tested. Quantitative antibody testing might make future management more rational, particularly in patients with poor responses.
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Affiliation(s)
- Mansi R Shah
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Alissa Gabel
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Stephanie Beers
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gratian Salaru
- Division of Clinical Pathology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Yong Lin
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, New Brunswick, NJ
| | - Dennis L Cooper
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ.
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30
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Alkis N, Baysal M. Subacute thyroiditis after SARS-CoV-2 BNT162b2 vaccine in a multiple myeloma patient. SAGE Open Med Case Rep 2022; 10:2050313X221091392. [PMID: 35495295 PMCID: PMC9047813 DOI: 10.1177/2050313x221091392] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Viral infections emerge in the pathogenesis of subacute thyroiditis. Aside from this, subacute thyroiditis following vaccines utilizing inactivated viruses has been shown on rare occasions. Due to the COVID-19 pandemic, several vaccines have been developed all over the world; mass and unprecedented vaccination has thus been initiated. However, it is known that cases such as subacute thyroiditis have been reported, albeit rarely, after administration of COVID-19 vaccines. In this case report, we present a 59-year-old patient with multiple myeloma developing subacute thyroiditis following BNT162b2 vaccine. Patient had swelling in the neck, and his symptoms were controlled with non-steroidal anti-inflammatory drugs. Subacute thyroiditis following administration of the COVID-19 vaccine is rare; however, it is likely an under-reported condition that is difficult to detect. Clinicians should stay informed and have increased awareness of post-COVID-19 vaccine subacute thyroiditis.
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Affiliation(s)
- Nihan Alkis
- Department of Hematology, Bursa City Hospital, Bursa, Turkey
| | - Mehmet Baysal
- Department of Hematology, Bursa City Hospital, Bursa, Turkey
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31
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Encinas C, Hernandez-Rivas JÁ, Oriol A, Rosiñol L, Blanchard MJ, Bellón JM, García-Sanz R, de la Rubia J, de la Guía AL, Jímenez-Ubieto A, Jarque I, Iñigo B, Dourdil V, de Arriba F, Pérez-Ávila CC, Gonzalez Y, Hernández MT, Bargay J, Granell M, Rodríguez-Otero P, Silvent M, Cabrera C, Rios R, Alegre A, Gironella M, Gonzalez MS, Sureda A, Sampol A, Ocio EM, Krsnik I, García A, García-Mateo A, Soler JA, Martín J, Arguiñano JM, Mateos MV, Bladé J, San-Miguel JF, Lahuerta JJ, Martínez-López J. A simple score to predict early severe infections in patients with newly diagnosed multiple myeloma. Blood Cancer J 2022; 12:68. [PMID: 35440057 PMCID: PMC9018751 DOI: 10.1038/s41408-022-00652-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/21/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022] Open
Abstract
Infections remain a common complication in patients with multiple myeloma (MM) and are associated with morbidity and mortality. A risk score to predict the probability of early severe infection could help to identify the patients that would benefit from preventive measures. We undertook a post hoc analysis of infections in four clinical trials from the Spanish Myeloma Group, involving a total of 1347 patients (847 transplant candidates). Regarding the GEM2010 > 65 trial, antibiotic prophylaxis was mandatory, so we excluded it from the final analysis. The incidence of severe infection episodes within the first 6 months was 13.8%, and majority of the patients experiencing the first episode before 4 months (11.1%). 1.2% of patients died because of infections within the first 6 months (1% before 4 months). Variables associated with increased risk of severe infection in the first 4 months included serum albumin ≤30 g/L, ECOG > 1, male sex, and non-IgA type MM. A simple risk score with these variables facilitated the identification of three risk groups with different probabilities of severe infection within the first 4 months: low-risk (score 0-2) 8.2%; intermediate-risk (score 3) 19.2%; and high-risk (score 4) 28.3%. Patients with intermediate/high risk could be candidates for prophylactic antibiotic therapies.
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Affiliation(s)
- Cristina Encinas
- Hospital General Universitario Gregorio Marañón (HGUGM), IiSGM, Madrid, Spain
| | | | - Albert Oriol
- Hospital Universitario Germans Trias i Pujol, Badalona (Barcelona), Barcelona, Spain
| | | | | | - José-María Bellón
- Hospital General Universitario Gregorio Marañón (HGUGM), IiSGM, Madrid, Spain
| | - Ramón García-Sanz
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | | | | | | | - Isidro Jarque
- Hospital Universitario la Fe, CIBERONC, Valencia, Spain
| | | | - Victoria Dourdil
- Hospital Clínico Universitario "Lozano Blesa", Zaragoza, IIS Aragón, Spain
| | | | | | | | | | - Joan Bargay
- Hospital Son Llatzer, Palma de Mallorca, Spain
| | | | | | | | | | - Rafael Rios
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Adrián Alegre
- Hospital Universitario de la Princesa y Hospital Universitario Quirónsalud, Madrid, Spain
| | | | | | - Anna Sureda
- ICO-L'Hospitalet, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Antonia Sampol
- Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Enrique M Ocio
- Hospital Universitario Marqués de Valdecilla, (IDIVAL). Universidad de Cantabria, Santander, Spain
| | - Isabel Krsnik
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | | | | | - Jesús Martín
- Complejo Hospitalario Regional Virgen del Rocío, CIBERONC, Sevilla, Spain
| | | | - María-Victoria Mateos
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Joan Bladé
- Hospital Clinic, CIBERONC, Barcelona, Spain
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32
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Shang Y, Wang W, Liang Y, Kaweme NM, Wang Q, Liu M, Chen X, Xia Z, Zhou F. Development of a Risk Assessment Model for Early Grade ≥ 3 Infection During the First 3 Months in Patients Newly Diagnosed With Multiple Myeloma Based on a Multicenter, Real-World Analysis in China. Front Oncol 2022; 12:772015. [PMID: 35372017 PMCID: PMC8967980 DOI: 10.3389/fonc.2022.772015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose The study aimed to assess factors associated with early infection and identify patients at high risk of developing infection in multiple myeloma. Methods The study retrospectively analyzed patients with MM seen at two medical centers between January 2013 and June 2019. One medical center reported 745 cases, of which 540 of the cases were available for analysis and were further subdivided into training cohort and internal validation cohort. 169 cases from the other medical center served as an external validation cohort. The least absolute shrinkage and selection operator (Lasso) regression model was used for data dimension reduction, feature selection, and model building. Results Bacteria and the respiratory tract were the most common pathogen and localization of infection, respectively. In the training cohort, PS≥2, HGB<35g/L of the lower limit of normal range, β2MG≥6.0mg/L, and GLB≥2.1 times the upper limit of normal range were identified as factors associated with early grade ≥ 3 infections by Lasso regression. An infection risk model of MM (IRMM) was established to define high-, moderate- and low-risk groups, which showed significantly different rates of infection in the training cohort (46.5% vs. 22.1% vs. 8.8%, p<0.0001), internal validation cohort (37.9% vs. 24.1% vs. 13.0%, p=0.009) and external validation cohort (40.0% vs. 29.2% vs. 8.5%, p=0.0003). IRMM displayed good calibration (p<0.05) and discrimination with AUC values of 0.76, 0.67 and 0.71 in the three cohorts, respectively. Furthermore, IRMM still showed good classification ability in immunomodulatory (IMiD) based regimens, proteasome-inhibitors (PI) based regimens and combined IMiD and PI regimens. Conclusion In this study, we determined risk factors for early grade ≥ 3 infection and established a predictive model to help clinicians identify MM patients with high-risk infection.
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Affiliation(s)
- Yufeng Shang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Weida Wang
- Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,Department of Hematologic Oncology, State Key Laboratory of Oncology in South China/Cancer Center, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yuxing Liang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | | | - Qian Wang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Minghui Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaoqin Chen
- Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhongjun Xia
- Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,Department of Hematologic Oncology, State Key Laboratory of Oncology in South China/Cancer Center, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University, Guangzhou, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
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Caro J, Braunstein M, Williams L, Bruno B, Kaminetzky D, Siegel A, Razzo B, Alfandari S, Morgan GJ, Davies FE, Boyle EM. Inflammation and infection in plasma cell disorders: how pathogens shape the fate of patients. Leukemia 2022; 36:613-624. [PMID: 35110727 PMCID: PMC8809233 DOI: 10.1038/s41375-021-01506-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 12/26/2022]
Abstract
The role of infection and chronic inflammation in plasma cell disorders (PCD) has been well-described. Despite not being a diagnostic criterion, infection is a common complication of most PCD and represents a significant cause of morbidity and mortality in this population. As immune-based therapeutic agents are being increasingly used in multiple myeloma, it is important to recognize their impact on the epidemiology of infections and to identify preventive measures to improve outcomes. This review outlines the multiple factors attributed to the high infectious risk in PCD (e.g. the underlying disease status, patient age and comorbidities, and myeloma-directed treatment), with the aim of highlighting future prophylactic and preventive strategies that could be implemented in the clinic. Beyond this, infection and pathogens as an entity are believed to also influence disease biology from initiation to response to treatment and progression through a complex interplay involving pathogen exposure, chronic inflammation, and immune response. This review will outline both the direct and indirect role played by oncogenic pathogens in PCD, highlight the requirement for large-scale studies to decipher the precise implication of the microbiome and direct pathogens in the natural history of myeloma and its precursor disease states, and understand how, in turn, pathogens shape plasma cell biology.
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Affiliation(s)
- Jessica Caro
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Marc Braunstein
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Louis Williams
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Benedetto Bruno
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - David Kaminetzky
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Ariel Siegel
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Beatrice Razzo
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Serge Alfandari
- Service de Réanimation et Maladies Infectieuses, CH Gustave Dron, Tourcoing, France
| | - Gareth J Morgan
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Faith E Davies
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Eileen M Boyle
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA.
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34
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Consensus guidelines and recommendations for infection prevention in multiple myeloma: a report from the International Myeloma Working Group. Lancet Haematol 2022; 9:e143-e161. [DOI: 10.1016/s2352-3026(21)00283-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022]
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35
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Chastain DB, Golpayegany S, Henao-Martínez AF, Jackson BT, Stoudenmire LL, Bell K, Stover KR, Franco-Paredes C. Cryptococcosis in a patient with multiple myeloma receiving pomalidomide: a case report and literature review. Ther Adv Infect Dis 2022; 9:20499361221112639. [PMID: 35898694 PMCID: PMC9310278 DOI: 10.1177/20499361221112639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/23/2022] [Indexed: 11/16/2022] Open
Abstract
While overall survival with multiple myeloma (MM) has improved, patients suffer from overwhelming tumor burden, MM-associated comorbidities, and frequent relapses requiring administration of salvage therapies. As a result, this vicious cycle is often characterized by cumulative immunodeficiency stemming from a combination of disease- and treatment-related factors leading to neutropenia, T-cell deficiency, and hypogammaglobulinemia. Infectious etiologies differ based on the duration of MM and treatment-related factors, such as number of previous treatments and cumulative dose of corticosteroids. Herein, we present the case of a patient who was receiving pomalidomide without concomitant corticosteroids for MM and was later found to have cryptococcosis, as well as findings from a literature review. Most cases of cryptococcosis are reported in patients with late-stage MM, as well as those receiving novel anti-myeloma agents, such as pomalidomide, in combination with corticosteroids or following transplantation. However, it is likely cryptococcosis may be underdiagnosed in this population. Due to the cumulative immunodeficiency present in patients with MM, clinicians must be suspicious of cryptococcosis at any stage of MM.
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Affiliation(s)
- Daniel B Chastain
- Clinical Associate Professor, Department of Clinical & Administrative Pharmacy, College of Pharmacy, University of Georgia, 1000 Jefferson Street, Albany, GA 31701, USA
| | - Sahand Golpayegany
- Department of Clinical & Administrative Pharmacy, College of Pharmacy, University of Georgia, Albany, GA, USA
| | | | | | | | - Kaye Bell
- Department of Microbiology, Phoebe Putney Memorial Hospital, Albany, GA, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS, USA
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36
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Martinez-Lopez J, Hernandez-Ibarburu G, Alonso R, Sanchez-Pina JM, Zamanillo I, Lopez-Muñoz N, Iñiguez R, Cuellar C, Calbacho M, Paciello ML, Ayala R, García-Barrio N, Perez-Rey D, Meloni L, Cruz J, Pedrera-Jiménez M, Serrano-Balazote P, de la Cruz J. Impact of COVID-19 in patients with multiple myeloma based on a global data network. Blood Cancer J 2021; 11:198. [PMID: 34893583 PMCID: PMC8661359 DOI: 10.1038/s41408-021-00588-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/18/2021] [Accepted: 11/23/2021] [Indexed: 12/13/2022] Open
Abstract
The COVID-19 pandemic has represented a major cause of morbidity/mortality worldwide, overstressing health systems. Multiple myeloma (MM) patients show an increased risk for infections and they are expected to be particularly vulnerable to SARS-CoV-2 infection. Here we have obtained a comprehensive picture of the impact of COVID-19 in MM patients on a local and a global scale using a federated data research network (TriNetX) that provided access to Electronic Medical Records (EMR) from Health Care Organizations (HCO) all over the world. Through propensity score matched analyses we found that the number of new diagnoses of MM was reduced in 2020 compared to 2019 (RR 0.86, 95%CI 0.76-0.96) and the survival of newly diagnosed MM cases decreased similarly (HR 0.61, 0.38-0.81). MM patients showed higher risk of SARS-CoV-2 infection (RR 2.09, 1.58-2.76) and a higher excess mortality in 2020 (difference in excess mortality 9%, 4.4-13.2) than non-MM patients. By interrogating large EMR datasets from HCO in Europe and globally, we confirmed that MM patients have been more severely impacted by COVID-19 pandemic than non-MM patients. This study highlights the necessity of extending preventive measures worlwide to protect vulnerable patients from SARS-CoV-2 infection by promoting social distancing and an intensive vaccination strategies.
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Affiliation(s)
- J Martinez-Lopez
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain.
| | | | - R Alonso
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - J M Sanchez-Pina
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - I Zamanillo
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - N Lopez-Muñoz
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - Rodrigo Iñiguez
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - C Cuellar
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - M Calbacho
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - M L Paciello
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | - R Ayala
- Hematology Department, Hospital 12 de Octubre, Complutense University, CNIO, Madrid, Spain
| | | | - D Perez-Rey
- Biomedical Informatics Group, Universidad Politécnica de Madrid, Madrid, Spain
| | - L Meloni
- TriNetX, LLC, Cambridge, MA, USA
| | - J Cruz
- Data Science Group, Hospital 12 de Octubre, Madrid, Spain
| | | | | | - J de la Cruz
- Research Institute imas12, Hospital 12 de Octubre, Madrid, Spain
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Heck C, Steiner S, Kaebisch EM, Frentsch M, Wittenbecher F, Scheibenbogen C, Hanitsch LG, Nogai A, le Coutre P, Bullinger L, Blau IW, Na IK. CD4+ T Cell Dependent B Cell Recovery and Function After Autologous Hematopoietic Stem Cell Transplantation. Front Immunol 2021; 12:736137. [PMID: 34659226 PMCID: PMC8519398 DOI: 10.3389/fimmu.2021.736137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/10/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction High-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (auto-HSCT) represents a standard treatment regime for multiple myeloma (MM) patients. Common and potentially fatal side effects after auto-HSCT are infections due to a severely compromised immune system with hampered humoral and cellular immunity. This study delineates in depth the quantitative and functional B cell defects and investigates underlying extrinsic or intrinsic drivers. Methods Peripheral blood of MM patients undergoing high-dose chemotherapy and auto-HSCT (before high-dose chemotherapy and in early reconstitution after HSCT) was studied. Absolute numbers and distribution of B cell subsets were analyzed ex vivo using flow cytometry. Additionally, B cell function was assessed with T cell dependent (TD) and T cell independent (TI) stimulation assays, analyzing proliferation and differentiation of B cells by flow cytometry and numbers of immunoglobulin secreting cells in ELISpots. Results Quantitative B cell defects including a shift in the B cell subset distribution occurred after auto-HSCT. Functionally, these patients showed an impaired TD as well as TI B cell immune response. Individual functional responses correlated with quantitative alterations of CD19+, CD4+, memory B cells and marginal zone-like B cells. The TD B cell function could be partially restored upon stimulation with CD40L/IL-21, successfully inducing B cell proliferation and differentiation into plasmablasts and immunoglobulin secreting cells. Conclusion Quantitative and functional B cell defects contribute to the compromised immune defense in MM patients undergoing auto-HSCT. Functional recovery upon TD stimulation and correlation with CD4+ T cell numbers, indicate these as extrinsic drivers of the functional B cell defect. Observed correlations of CD4+, CD19+, memory B and MZ-like B cell numbers with the B cell function suggest that these markers should be tested as potential biomarkers in prospective studies.
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Affiliation(s)
- Clarissa Heck
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sophie Steiner
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eva M Kaebisch
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Marco Frentsch
- Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Friedrich Wittenbecher
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Leif G Hanitsch
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Axel Nogai
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Philipp le Coutre
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Lars Bullinger
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Cancer Consortium (DKTK), Berlin, Germany.,Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Igor-Wolfgang Blau
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Il-Kang Na
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Cancer Consortium (DKTK), Berlin, Germany.,Experimental and Clinical Research Center, Berlin, Germany
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Ge J, Zhao TT, Wan CY, Xia JY, Guo SY, Yu MX, Chen J, Wang Y, Xu KL, Li ZY. [Comparison of single infusion of anti-BCMA versus combined infusion of anti-CD19 chimeric antigen receptor T cells for immune reconstruction in relapsed/refractory multiple myeloma]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:733-738. [PMID: 34753227 PMCID: PMC8607032 DOI: 10.3760/cma.j.issn.0253-2727.2021.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/05/2022]
Abstract
Objective: We observed and compared the differences in immune reconstruction between single-infusion anti-B-cell maturation antigen (BCMA) , chimeric antigen receptor T cells (CAR-T) , and combined infusion of anti-CD19 CAR-T cells in the treatment of recurrent/refractory multiple myeloma (RRMM) . Methods: Sixty-one patients with RRMM who underwent CAR-T cell therapy in our hospital from June 2017 to December 2020 were selected. Among them, 26 patients received anti-BCMA target, and 35 patients received anti-BCMA combined with anti-CD19 target. Using flow cytometry, we determined T cell subsets (CD3(+), CD4(+), CD8(+), CD4(+)/CD8(+)) , B cells (CD19(+)) , and NK cells (CD16(+) CD56(+)) at different time points before and after CAR-T treatment, and detected immunoglobulin IgG, IgA and IgM levels by immunoturbidimetry. We compared the reconstruction rules of lymphocyte subsets and immunoglobulins in the two groups. Results: CD8(+) T lymphocytes recovered most rapidly after the infusion of CAR-T cells, returning to pre-infusion levels at 3 months and 1 month after infusion, respectively[BCMA: 695 (357, 1264) /μl vs 424 (280, 646) /μl; BCMA+CD19: 546 (279, 1672) /μl vs 314 (214, 466) /μl]. NK cells returned to normal levels at 3 months after infusion in both groups[BCMA: 171 (120, 244) /μl, BCMA+CD19: 153 (101, 218) /μl (Normal reference range 150-1100/μl) ]; however, the NK cells were not maintained at stable levels in the BCMA CAR-T cells group. The recovery of CD4(+) T lymphocytes in both groups was slow and remained persistently low within 12 months after infusion, and no recovery was observed in most patients. The reversal of the ratio of CD4(+)/CD8(+) lasted for more than a year. The levels of CD19(+) B cells in both groups returned to baseline 3 months after infusion[BCMA: 62 (10, 72) /μl vs 57 (24, 78) /μl; BCMA+CD19: 40 (4, 94) /μl vs 29 (14, 46) /μl]. IgG returned to the pre-infusion level 12 months after infusion in the group with anti-BCMA cells alone, but not in the group with combined infusion of CD19 CAR T cells[7.82 (6.03, 9.64) g/L vs 6.92 (4.62, 12.76) g/L]. IgA returned to pre-infusion levels at 9 and 12 months after infusion, respectively[BCMA: 0.46 (0.07, 0.51) g/L vs 0.22 (0.12, 4.01) g/L; BCMA+CD19: 0.46 (0.22, 0.98) g/L vs 0.27 (0.10, 0.53) g/L]. IgM in both groups returned to pre-infusion levels 6 months after infusion[BCMA: 0.43 (0.06, 0.60) g/L vs 0.20 (0.13, 0.37) g/L; BCMA+CD19: 0.53 (0.10, 0.80) g/L vs 0.16 (0.11, 0.28) g/L]. There was no significant difference in the indexes of lymphocyte subpopulation reconstruction and immunoglobulin recovery between the two groups at each time point. Conclusion: This study showed that in patients with RRMM treated with CAR-T cells, the appropriate target antigen can be selected without considering the difference of immune reconstruction between anti-BCMA CAR-T and combined anti-CD19 CAR-T therapy.
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Affiliation(s)
- J Ge
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - T T Zhao
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - C Y Wan
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - J Y Xia
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - S Y Guo
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - M X Yu
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - J Chen
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - Y Wang
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - K L Xu
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
| | - Z Y Li
- Department of Hematology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China
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Cerchione C, Nappi D, Martinelli G. Pegfilgrastim for primary prophylaxis of febrile neutropenia in multiple myeloma. Support Care Cancer 2021; 29:6973-6980. [PMID: 33990881 PMCID: PMC8464555 DOI: 10.1007/s00520-021-06266-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/30/2021] [Indexed: 11/01/2022]
Abstract
Multiple myeloma (MM) survival rates have been substantially increased thanks to novel agents that have improved survival outcomes and shown better tolerability than treatments of earlier years. These new agents include immunomodulating imide drugs (IMiD) thalidomide and lenalidomide, the proteasome inhibitor bortezomib (PI), recently followed by new generation IMID pomalidomide, monoclonal antibodies daratumumab and elotuzumab, and next generation PI carfilzomib and ixazomib. However, even in this more promising scenario, febrile neutropenia remains a severe side effect of antineoplastic therapies and can lead to a delay and/or dose reduction in subsequent cycles. Supportive care has thus become key in helping patients to obtain the maximum benefit from novel agents. Filgrastim is a human recombinant subcutaneous preparation of G-CSF, largely adopted in hematological supportive care as "on demand" (or secondary) prophylaxis to recovery from neutropenia and its infectious consequences during anti-myeloma treatment. On the contrary, pegfilgrastim is a pegylated long-acting recombinant form of granulocyte colony-stimulating factor (G-CSF) that, given its extended half-life, can be particularly useful when adopted as "primary prophylaxis," therefore before the onset of neutropenia, along chemotherapy treatment in multiple myeloma patients. There is no direct comparison between the two G-CSF delivery modalities. In this review, we compare data on the two administrations' modality, highlighting the efficacy of the secondary prophylaxis over multiple myeloma treatment. Advantage of pegfilgrastim could be as follows: the fixed administration rather than multiple injections, reduction in neutropenia and febrile neutropenia rates, and, finally, a cost-effectiveness advantage.
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Affiliation(s)
- Claudio Cerchione
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori "Dino Amadori" (IRST), IRCCS, Via Piero Maroncelli 40, Meldola, (FC), 47014, Italy.
| | - Davide Nappi
- Department of Hematology and Cell Bone Marrow Transplantation (CBMT), Ospedale di Bolzano, Bolzano, Italy
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori "Dino Amadori" (IRST), IRCCS, Via Piero Maroncelli 40, Meldola, (FC), 47014, Italy
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40
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Valentine JC, Hall L, Verspoor KM, Gillespie E, Worth LJ. Use of a Victorian statewide surveillance program to evaluate the burden of healthcare-associated Staphylococcus aureus bacteraemia and Clostridioides difficile infection in patients with cancer. Intern Med J 2021; 52:1215-1224. [PMID: 33755285 DOI: 10.1111/imj.15301] [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: 12/07/2020] [Revised: 02/18/2021] [Accepted: 03/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with cancer are at high risk for infection, but the epidemiology of healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) and Clostridioides difficile infection (HA-CDI) in Australian cancer patients has not previously been reported. AIMS To compare the cumulative aggregate incidence and time trends of HA-SAB and HA-CDI in a predefined cancer cohort with a mixed statewide patient population in Victoria, Australia. METHODS All SAB and CDI events in patients admitted to Victorian healthcare facilities between 1st July 2010 and 31st December 2018 were submitted to the Victorian Healthcare Associated Infection Surveillance System Coordinating Centre. Descriptive analyses and multilevel mixed-effects Poisson regression modelling were applied to a standardised data extract. RESULTS In total, 10,608 and 13,118 SAB and CDI events were reported across 139 Victorian healthcare facilities, respectively. Of these, 89 (85%) and 279 (88%) were healthcare-associated in the cancer cohort compared to 34% (3,561/10,503) and 66% (8,403/12,802) in the statewide cohort. The aggregate incidence was more than two-fold higher in the cancer compared to the statewide cohort for HA-SAB (2.25 [95% CI: 1.74-2.77] vs. 1.11 [95% CI: 1.07-1.15] HA-SABs/10,000 OBDs) and three-fold higher for HA-CDI (6.26 [95% CI: 5.12-7.41] vs. 2.31 [95% CI: 2.21-2.42] HA-CDIs/10,000 OBDs). Higher quarterly diminishing rates were observed in the cancer cohort than the statewide data for both infections. CONCLUSIONS Our findings demonstrate a higher burden of HA-SAB and HA-CDI in a cancer cohort when compared with state data and highlight the need for cancer-specific targets and benchmarks to meaningfully support quality improvement. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jake C Valentine
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Lisa Hall
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Karin M Verspoor
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth Gillespie
- Infection Prevention Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Leon J Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Infection Prevention Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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41
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Longhitano AP, Slavin MA, Harrison SJ, Teh BW. Bispecific antibody therapy, its use and risks for infection: Bridging the knowledge gap. Blood Rev 2021; 49:100810. [PMID: 33676765 DOI: 10.1016/j.blre.2021.100810] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/28/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
Relapsed haematological malignancies have a poor disease prognosis with current therapies. Bispecific antibodies (BsAbs) are becoming increasingly recognised for their efficacy in the treatment of these malignancies and are approved for the treatment of B-cell acute lymphoblastic leukaemia (B-ALL). BsAbs are manufactured to consist two variable chain fragments combined by a peptide linker amongst other structures to increase the half-life of the molecules. BsAbs function by bringing targeted tumour cells in close proximity of T-cells to allow killing via perforin and granzyme release. The increasing numbers of trials of BsAbs has highlighted their toxicity profile, including cytokine release syndrome (CRS), cytopaenia and hypogammaglobulinemia - which all increase risks for infection. The patterns and risks for infections with these novel agents remain unclear. This review article provides an overview of the risks of infection with various BsAbs platforms. A review of clinical trials reveals rates of infections amongst patients on BsAbs between 15 and 45% with a high proportion grade 3 severity or higher. A predominance of bacterial respiratory and line-related infections were identified amongst all haematological malignancies. In particular, high rates of febrile neutropaenia were identified in use of BsAbs in myeloid malignancy. Infection patterns identified in this review are utilised to inform infection prevention practice, including focused infection screening, line management, prophylaxis and vaccination strategies. Prophylaxis strategies against Pneumocystis pneumonia, herpes simplex and herpes zoster, candida and mould infections are considered, along with vaccination strategies against respiratory viral and bacterial infections. The long-term impacts of BsAbs on the immune system continue to be established.
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Affiliation(s)
- Anthony P Longhitano
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Simon J Harrison
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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Epidemiology and Risks of Infections in Patients With Multiple Myeloma Managed With New Generation Therapies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:444-450.e3. [PMID: 33722538 DOI: 10.1016/j.clml.2021.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/28/2021] [Accepted: 02/10/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Treatment for multiple myeloma (MM) has continued to evolve with second generation immunomodulatory drugs (IMiDs), proteasome inhibitors (PIs), and monoclonal antibodies (mAbs). This study aims to evaluate the epidemiology and risks of infection in patients with MM managed with these therapies. PATIENTS AND METHODS Clinical and microbiological records were reviewed to capture patient demographics, disease characteristics, treatment received, episodes of infection, and outcomes. Infections were classified as microbiologically defined (MDI), clinically defined (CDI), and fever of unknown focus (FUF). Univariate and multivariate analyses were performed to determine risk factors for infection, with a P value < .05 considered statistically significant. RESULTS A total of 148 patients with MM with 345 infection episodes were identified. Of these, 29.0% (100/345), 58.0% (200/345), and 13.0% (45/345) were defined as MDI, CDI, and FUF, respectively. Of 100 MDIs, 50.0% were owing to viruses, whereas 45.0% were owing to bacterial infection. The most common infection site was the respiratory tract (56.8%). Hospital admission occurred in 41.7% of infection episodes, and the 30-day all-cause mortality rate was 5.4%. On multivariate regression, receipt of a PI (odds ratio [OR], 16.80; 95% confidence interval [CI], 2.47-114.52), combination of IMiD and PI (OR, 13.44; 95% CI, 2.39-75.76), mAb-combination (OR, 10.44; 95% CI, 1.99-54.51), and lines of therapy (> 4) (OR, 7.72; 95% CI, 1.25-47.81) were associated with increased risk of infection (all P < .05). CONCLUSION Viral infections now constitute the majority of infections in patients with MM treated with newer agents. Receipt of a PI and lines of therapy (> 4) were associated with higher risk for infection.
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Abstract
Multiple myeloma is the second most common haematological malignancy in high-income countries, and typically starts as asymptomatic precursor conditions-either monoclonal gammopathy of undetermined significance or smouldering multiple myeloma-in which initiating genetic abnormalities, such as hyperdiploidy and translocations involving the immunoglobulin heavy chain, are already present. The introduction of immunomodulatory drugs, proteasome inhibitors, and CD38-targeting antibodies has extended survival, but ultimately the majority of patients will die from their disease, and some from treatment-related complications. Disease progression and subsequent relapses are characterised by subclonal evolution and increasingly resistant disease. Patients with multiple myeloma usually have hypercalcaemia, renal failure, anaemia, or osteolytic bone lesions-and a detailed diagnostic investigation is needed to differentiate between symptomatic multiple myeloma that requires treatment, and precursor states. Risk stratification using both patient-specific (eg, performance status) and disease-specific (eg, presence of high-risk cytogenetic abnormalities) is important for prognosis and to define the best treatment strategy. Current research strategies include the use of minimal residual disease assays to guide therapy, refining immunotherapeutic approaches, and intercepting disease early in smouldering multiple myeloma.
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Affiliation(s)
- Niels W C J van de Donk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Charlotte Pawlyn
- The Institute of Cancer Research, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Kwee L Yong
- University College London Cancer Institute, London, UK.
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Doerflinger M, Garnham AL, Freytag S, Harrison SJ, Prince HM, Quach H, Slavin MA, Pellegrini M, Teh BW. Successful identification of predictive profiles for infection utilising systems-level immune analysis: a pilot study in patients with relapsed and refractory multiple myeloma. Clin Transl Immunology 2021; 10:e1235. [PMID: 33437482 PMCID: PMC7790592 DOI: 10.1002/cti2.1235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/18/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives Patients with multiple myeloma (MM) are at increased risk for infection. Clinical assessment of infection risk is increasingly challenging in the era of immune‐based therapy. A pilot systems‐level immune analysis study to identify predictive markers for infection was conducted. Methods Patients with relapsed and/or refractory MM (RRMM) who participated in a treatment trial of lenalidomide and dexamethasone were evaluated. Data on patient demographics, disease and episodes of infection were extracted from clinical records. Peripheral blood mononuclear cells (PBMCs) collected at defined intervals were analysed, with or without mitogen re‐stimulation, using RNA sequencing and mass cytometry (CyTOF). CyTOF‐derived cell subsets and RNAseq gene expression profiles were compared between patients that did and did not develop infection to identify immune signatures that predict infection over a 3‐month period. Results Twenty‐three patients participated in the original treatment trial, and we were able to access samples from 17 RRMM patients for further evaluation in our study. Nearly half the patients developed an infection (8/17) within 3 months of sample collection. Infections were mostly clinically diagnosed (62.5%), and the majority involved the respiratory tract (87.5%). We did not detect phenotypic or numerical differences in immune cell populations between patients that did and did not develop infections. Transcriptional profiling of stimulated PBMCs revealed distinct Th2 immune pathway signatures in patients that developed infection. Conclusion Immune cell counts were not useful predictors of infection risk. Functional assessment of stimulated PBMCs has identified potential immune profiles that may predict future infection risk in patients with RRMM.
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Affiliation(s)
- Marcel Doerflinger
- Infectious Disease and Immune Defence Division Walter and Eliza Hall Institute Parkville VIC Australia.,Department of Medical Biology University of Melbourne Melbourne VIC Australia
| | - Alexandra L Garnham
- Department of Medical Biology University of Melbourne Melbourne VIC Australia.,Department of Bioinformatics Walter and Eliza Hall Institute Parkville VIC Australia
| | - Saskia Freytag
- Department of Bioinformatics Walter and Eliza Hall Institute Parkville VIC Australia.,Molecular Medicine Division Harry Perkins Institute of Medical Research Perth WA Australia
| | - Simon J Harrison
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne VIC Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne VIC Australia.,Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne VIC Australia
| | - H Miles Prince
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne VIC Australia.,Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne VIC Australia
| | - Hang Quach
- Department of Haematology St Vincent's Hospital Melbourne Fitzroy VIC Australia.,Department of Medicine University of Melbourne Melbourne VIC Australia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne VIC Australia.,Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne VIC Australia.,Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne VIC Australia
| | - Marc Pellegrini
- Infectious Disease and Immune Defence Division Walter and Eliza Hall Institute Parkville VIC Australia.,Department of Medical Biology University of Melbourne Melbourne VIC Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne VIC Australia
| | - Benjamin W Teh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne VIC Australia.,Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne VIC Australia.,Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne VIC Australia
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Bupha-Intr O, Haeusler G, Chee L, Thursky K, Slavin M, Teh B. CAR-T cell therapy and infection: a review. Expert Rev Anti Infect Ther 2020; 19:749-758. [PMID: 33249873 DOI: 10.1080/14787210.2021.1855143] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Chimeric antigen receptor T-cell therapy (CAR-T cell therapy) is a novel immunotherapy with promising results in the treatment of relapsed or refractory B cell malignancies. Patients undergoing CAR-T cell therapy are at increased risk of infection due to prior immunosuppression, lymphodepleting chemotherapy, treatment of unique toxicities with tocilizumab and/or steroids, on-target effects of hypogammaglobulinaemia, and prolonged cytopenias.Areas covered: A narrative review of infections (PubMed, August 2020) occurring in patients undergoing CAR-T cell therapy is described, and the evidence for infection prevention strategies is presented.Expert commentary: The rapid adoption of CAR-T cell therapy into clinical practice presents many challenges for the diagnosis, management, and prevention of infection. Ongoing surveillance of the spectrum of infectious complications and effectiveness of prophylaxis is required to support safe and effective patient care.
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Affiliation(s)
- Olivia Bupha-Intr
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Gabrielle Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Australia
| | - Lynette Chee
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and the Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
| | - Benjamin Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,National Centre for Infection in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
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Busca A, Cattaneo C, De Carolis E, Nadali G, Offidani M, Picardi M, Candoni A, Ceresoli E, Criscuolo M, Delia M, Della Pepa R, Del Principe I, Fanci RR, Farina F, Fracchiolla N, Giordano C, Malagola M, Marchesi F, Piedimonte M, Prezioso L, Quinto AM, Spolzino A, Tisi MC, Trastulli F, Trecarichi EM, Zappasodi P, Tumbarello M, Pagano L. Considerations on antimicrobial prophylaxis in patients with lymphoproliferative diseases: A SEIFEM group position paper. Crit Rev Oncol Hematol 2020; 158:103203. [PMID: 33388453 DOI: 10.1016/j.critrevonc.2020.103203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/15/2020] [Accepted: 12/20/2020] [Indexed: 11/16/2022] Open
Abstract
The therapeutic armamentarium for the treatment of patients with lymphoproliferative diseases has grown considerably over the most recent years, including a large use of new immunotherapeutic agents. As a consequence, the epidemiology of infectious complications in this group of patients is poorly documented, and even more importantly, the potential benefit of antimicrobial prophylaxis remains a matter of debate when considering the harmful effect from the emergence of multidrug resistant pathogens. The present position paper is addressed to all hematologists treating patients affected by lymphoproliferative malignancies with the aim to provide clinicians with a useful tool for the prevention of bacterial, fungal and viral infections.
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Affiliation(s)
- Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy.
| | - Chiara Cattaneo
- Divisione di Ematologia, ASST-Spedali Civili di Brescia, Brescia, Chiara, Italy.
| | - Elena De Carolis
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
| | - Gianpaolo Nadali
- U.O.C. Ematologia, AOU Integrata di Verona, Ospedale Borgo Roma, Verona, Italy.
| | - Massimo Offidani
- Clinica di Ematologia, AOU Ospedali Riuniti di Ancona, Ancona, Italy.
| | - Marco Picardi
- Department of Advanced Biomedical Science, Federico II University, Italy.
| | - Anna Candoni
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata di Udine, Italy.
| | - Eleonora Ceresoli
- Ematologia Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy.
| | - Marianna Criscuolo
- Dipartimento di scienze radiologiche, radioterapiche ed ematologiche Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Italy.
| | - Mario Delia
- U.O.: Ematologia con Trapianto Azienda Ospedaliero-Universitaria Dipartimento dell'Emergenza e Dei Trapianti di Organo Policlinico di Bari, Italy.
| | - Roberta Della Pepa
- Department of Clinical Medicine and Surgery", University of Federico II Naples, Italy.
| | - Ilaria Del Principe
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università degli studi di Roma "Tor Vergata", Italy.
| | - Roma Rosa Fanci
- Hematology Department, Careggi Hospital and University of Florence, Italy.
| | - Francesca Farina
- U.O. Ematologia e Trapianto di Midollo - IRCCS Ospedale San Raffaele, Milano, Italy.
| | - Nicola Fracchiolla
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Italy.
| | - Claudia Giordano
- Department of Clinical Medicine and Surgery", University of Federico II Naples, Italy.
| | - Michele Malagola
- Department of Clinical and Experimental Sciences, University of Brescia, Bone Marrow Transplant Unit, ASST Spedali Civili of Brescia, Italy.
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - Monica Piedimonte
- Department of Clinical and Molecular Medicine, Hematology Sant'Andrea University Hospital, Sapienza University of Rome, Italy.
| | - Lucia Prezioso
- Hematology and BMT Unit, Azienda Ospedaliero-Universitaria di Parma and Department of Medicine and Surgery, University of Parma, Italy.
| | - Angela Maria Quinto
- UO Ematologia e Terapia Cellulare, IRCCS - Istituto Tumori "Giovanni Paolo II" Bari, Italy.
| | - Angelica Spolzino
- Department of Clinical and Molecular Medicine, Hematology Sant'Andrea University Hospital, Sapienza University of Rome, Italy.
| | | | - Fabio Trastulli
- Department of Clinical Medicine and Surgery", University of Federico II Naples, Italy.
| | - Enrico Maria Trecarichi
- Dipartimento di Scienze Mediche e Chirurgiche, UO Malattie Infettive e Tropicali, Università degli Studi "Magna Graecia", Catanzaro, Italy.
| | - Patrizia Zappasodi
- Division of Hematology, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Mario Tumbarello
- Fondazione Policlinico Universitario A. Gemelli - IRCCS - Istituto di Malattie Infettive -Università Cattolica del Sacro Cuore, Livio, Italy.
| | - Livio Pagano
- Fondazione Policlinico Universitario A. Gemelli - IRCCS - Istituto di Malattie Infettive -Università Cattolica del Sacro Cuore, Livio, Italy.
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Szabo AG, Iversen KF, Rosenvinge FS, Möller S, Plesner T. The Incidence and Timing of Blood Cultures in Multiple Myeloma - Results from a Retrospective, Single Center, Real-World Study. Clin Hematol Int 2020; 2:168-172. [PMID: 34595458 PMCID: PMC8432406 DOI: 10.2991/chi.k.200719.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Agoston Gyula Szabo
- Department of Hematology, Vejle Hospital, Beriderbakken 4, Vejle 7100, Denmark
- University of Southern Denmark, J.B. Winsløws Vej 9 A, Odense C 5000, Denmark
| | - Katrine Fladeland Iversen
- Department of Hematology, Vejle Hospital, Beriderbakken 4, Vejle 7100, Denmark
- University of Southern Denmark, J.B. Winsløws Vej 9 A, Odense C 5000, Denmark
| | | | - Sören Möller
- University of Southern Denmark, J.B. Winsløws Vej 9 A, Odense C 5000, Denmark
- OPEN – Open Patient data Explorative Network, Odense University Hospital and Department of Clinical Research, Odense C 5000, Denmark
| | - Torben Plesner
- Department of Hematology, Vejle Hospital, Beriderbakken 4, Vejle 7100, Denmark
- University of Southern Denmark, J.B. Winsløws Vej 9 A, Odense C 5000, Denmark
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48
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Mikkilineni L, Kochenderfer JN. CAR T cell therapies for patients with multiple myeloma. Nat Rev Clin Oncol 2020; 18:71-84. [PMID: 32978608 DOI: 10.1038/s41571-020-0427-6] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2020] [Indexed: 12/21/2022]
Abstract
Despite several therapeutic advances over the past decade, multiple myeloma (MM) remains largely incurable, indicating a need for new treatment approaches. Chimeric antigen receptor (CAR) T cell therapy works by mechanisms distinct from those of other MM therapies and involves the modification of patient or donor T cells to target specific cell-surface antigens. B cell maturation antigen (BCMA) is expressed only on plasma cells, a small subset of B cells and MM cells, which makes it a suitable target antigen for such therapies. At the time of writing, data from >20 clinical trials involving anti-BCMA CAR T cells have demonstrated that patients with relapsed and/or refractory MM can achieve objective responses. These early investigations have been instrumental in demonstrating short-term safety and efficacy; however, most patients do not have disease remission lasting >18 months. Attempts to reduce or delay the onset of relapsed disease are underway and include identifying additional CAR T cell target antigens and methods of enhancing BCMA expression on MM cells. Engineering CAR T cells to enhance both the activity and safety of treatment continues to be a promising avenue for improvement. In this Review we summarize data from clinical trials that have been carried out to date, describe novel antigens that could be targeted in the future, and highlight potential future innovations that could enhance the efficacy and/or reduce the toxicities associated with CAR T cell therapies.
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Affiliation(s)
- Lekha Mikkilineni
- Surgery Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA.
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49
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Lin C, Shen H, Zhou S, Liu M, Xu A, Huang S, Shen C, Zhou F. Assessment of infection in newly diagnosed multiple myeloma patients: risk factors and main characteristics. BMC Infect Dis 2020; 20:699. [PMID: 32972385 PMCID: PMC7517606 DOI: 10.1186/s12879-020-05412-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/10/2020] [Indexed: 12/15/2022] Open
Abstract
Background Infection is a leading cause of morbidity and death in patients with multiple myeloma (MM). The increased susceptibility to infection is complicated and multifactorial. However, no studies have explored the spectrum and risk factors of infections in newly diagnosed MM patients at the first admission. This cross-sectional study aimed to provide ideas for the assessment, prevention and treatment of infection in newly diagnosed MM patients when admitted for the first time. Methods Retrospectively, the data from electronic medical records for 161 patients newly diagnosed with MM from May 2013 to December 2018 were analysed. All the information was collected at the time of admission, and the patients had received no antineoplastic therapy previously. Independent risk factors of infection in multiple myeloma were determined by univariate and multivariate analysis. Results Newly diagnosed patients with MM were highly susceptible to viruses (43.9%), especially Epstein-Barr virus (EBV) (24.4%) and hepatitis B virus (HBV) (17.1%). Advanced stage (ISS stage III, P = 0.040), more severe anaemia (Hb < 90 g/L, P = 0.044) and elevated CRP (> 10 mg/L, P = 0.006) were independent risk factors for infection. Moreover, infections represented a major survival threat to patients with newly diagnosed MM (P = 0.033), and the existence of risk factors for infection was significantly correlated with poor prognosis (P = 0.011), especially ISS stage III (P = 0.008) and lower haemoglobin level (P = 0.039). Conclusions Newly diagnosed MM patients are highly susceptible to viruses. Advanced ISS stage, more severe anaemia and the elevation of CRP are independent risk factors of infection, which also have a strong impact on prognosis. Our results suggest that viral infection should be taken into account if antibacterial drugs are not effective, and the prevention of infection and improvement of prognosis should be paid more attention in newly diagnosed patents with advanced stage and more severe anaemia.
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Affiliation(s)
- Chenyao Lin
- Department of Clinical Laboratory, Ningbo Medical Treatment Center Lihuili Hospital, Ningbo, P.R. China.,Genetic Diagnosis Centre, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P.R. China
| | - Hui Shen
- Department of Hematology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, P.R. China
| | - Shuimei Zhou
- Blood Transfusion Department, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, P.R. China
| | - Minghui Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, P.R. China
| | - Anjie Xu
- Department of Hematology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, P.R. China
| | - Shuang Huang
- Genetic Diagnosis Centre, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P.R. China
| | - Changxin Shen
- Blood Transfusion Department, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, P.R. China.
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430071, P.R. China.
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50
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Djebbari F, Panitsas F, Eyre TA, Prodger C, Davies F, Burton K, Khera A, Vallance G, Moore S, Kothari J, Peniket A, Ramasamy K. Infection-related morbidity in a large study of transplant non-eligible newly diagnosed myeloma patients treated with UK standard of care. Haematologica 2020; 105:e474-479. [PMID: 33054067 PMCID: PMC7556501 DOI: 10.3324/haematol.2019.240762] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Faouzi Djebbari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Fotios Panitsas
- Department of Haematology, Larissa University Hospital, Larissa, Greece
| | - Toby A Eyre
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Catherine Prodger
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fearn Davies
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Burton
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Akhil Khera
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Grant Vallance
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Moore
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jaimal Kothari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andy Peniket
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karthik Ramasamy
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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