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Merjaneh N, Young J, Mangoli A, Olsen M, Setty B, Lane A, Nagarajan R, Pressey JG, Turpin B. Chemotherapy-induced thrombocytopenia in Ewing sarcoma: Implications and potential for romiplostim supportive care. Pediatr Blood Cancer 2022; 69:e29548. [PMID: 34962714 DOI: 10.1002/pbc.29548] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/24/2021] [Accepted: 12/08/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Maintaining dose-dense, interval-compressed chemotherapy improves survival in patients with Ewing sarcoma but is limited by myelosuppression. Romiplostim is a thrombopoietin receptor agonist that may be useful in the treatment of chemotherapy-induced thrombocytopenia (CIT). METHODS Patients aged between 3 and 33 years with Ewing sarcoma from 2010 to 2020 were reviewed. CIT was defined as a failure to achieve 75,000 platelets per microliter by day 21 after the start of any chemotherapy cycle. Fisher's exact test was used for univariate analysis and Pearson's correlation coefficient was used for the association between continuous variables. RESULTS Twenty-seven out of 42 patients (64%) developed isolated CIT, delaying one to four chemotherapy cycles per patient. CIT occurred during consolidation therapy in 24/27(88.9%) and with ifosfamide/etoposide cycles in 24/27 (88.9%). Univariate analysis failed to identify risk factors for CIT. The use of radiation approached significance (p-value = .056). Ten patients received romiplostim. The median starting dose was 3 μg/kg (range 1-5). Doses were escalated weekly by 1-2 to 4-10 μg/kg and continued throughout chemotherapy. A higher romiplostim dose was associated with a higher change in average platelet counts from baseline, r = .73 (p = .04). No romiplostim-related adverse events were identified aside from mild headache. CONCLUSIONS CIT is the primary reason for the inability to maintain treatment intensity in Ewing sarcoma. The concurrent use of romiplostim with chemotherapy was safe and feasible, and efficacy was associated with higher romiplostim doses.
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Affiliation(s)
- Nawal Merjaneh
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Jennifer Young
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Avani Mangoli
- Division of Pediatric Hematology-Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Mallery Olsen
- Division of Pediatric Hematology, Oncology and BMT, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Bhuvana Setty
- Division of Pediatric Hematology, Oncology and BMT, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Adam Lane
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Rajaram Nagarajan
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Joseph G Pressey
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Brian Turpin
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Emerging targets for radioprotection and radiosensitization in radiotherapy. Tumour Biol 2016; 37:11589-11609. [DOI: 10.1007/s13277-016-5117-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/09/2016] [Indexed: 01/12/2023] Open
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Tamamyan G, Danielyan S, Lambert MP. Chemotherapy induced thrombocytopenia in pediatric oncology. Crit Rev Oncol Hematol 2016; 99:299-307. [DOI: 10.1016/j.critrevonc.2016.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 10/06/2015] [Accepted: 01/12/2016] [Indexed: 01/19/2023] Open
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Radhakrishnan K, Lee A, Harrison LA, Morris E, Shen V, Gates L, Wells RJ, Wolff JE, Garvin JH, Cairo MS. A novel trial of topotecan, ifosfamide, and carboplatin (TIC) in children with recurrent solid tumors. Pediatr Blood Cancer 2015; 62:274-278. [PMID: 25382188 DOI: 10.1002/pbc.25309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/17/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ifosfamide, carboplatin, and etoposide (ICE) in children with refractory or recurrent solid tumors and lymphomas has resulted in good overall response rates (ORR). Etoposide, a topoisomerase-II inhibitor, however, has been associated with a significant increase in secondary leukemia. The rationale for substituting topotecan, a topoisomerase-I inhibitor, for etoposide in this regimen, a topoisomerase-II inhibitor, includes its limited toxicity profile and decreased leukemogenicity. Furthermore, topotecan in combination with both alkylators and platinating agents are additive and/or synergistic against a variety of solid tumors. PROCEDURE Patients with relapsed/refractory solid tumors received ifosfamide (9 g/m2 ) and carboplatin (area under the curve: 3 mg/ml/min). Topotecan was also administered at 0.5 mg/m2 /day × 3 days (N = 12) and in a small cohort (N = 3) at 0.75 mg/m2 /day. RESULTS Fifteen patients were entered onto study. Two patients developed seizures/encephalitis secondary to ifosfamide. One patient had dose-limiting thrombocytopenia secondary to TIC that resolved with supportive care. Patients received a median of three cycles (1-3) of TIC. Of the 14 evaluable patients for response, 4/14 had a complete response (CR), 2/14 had a partial response (PR), and 1/14 patients had stable disease (SD). The ORR (CR + PR) was 43%. CONCLUSION TIC chemotherapy is feasible and tolerable in children and adolescents with refractory/recurrent solid tumors and lymphomas and results in a 43% excellent ORR in this poor-risk group of patients. A larger cohort of patients, especially in Wilms tumor and central nervous system (CNS) tumors, should be studied in the future to attempt to confirm these preliminary findings. Pediatr Blood Cancer 2015;62:274-278. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Alice Lee
- Department of Pediatrics, Columbia University, New York, New York
| | - Lauren A Harrison
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Erin Morris
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Violet Shen
- Department of Pediatrics, Children's Hospital of Orange County, Orange, California
| | - Laura Gates
- Department of Pediatrics, Children's Hospital of Orange County, Orange, California
| | - Robert J Wells
- Department of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Johannes E Wolff
- Department of Pediatrics, Tufts Medical Center, Boston, Massachusetts
| | - James H Garvin
- Department of Pediatrics, Columbia University, New York, New York
| | - Mitchell S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, New York
- Department of Medicine, New York Medical College, Valhalla, New York
- Department of Pathology, New York Medical College, Valhalla, New York
- Department of Microbiology and Immunology, New York Medical College, Valhalla, New York
- Department of Cell Biology and Anatomy, New York Medical College, Valhalla, New York
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Trobaugh-Lotrario AD, Feusner JH. Relapsed hepatoblastoma. Pediatr Blood Cancer 2012; 59:813-7. [PMID: 22648963 DOI: 10.1002/pbc.24218] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 05/08/2012] [Indexed: 12/11/2022]
Abstract
Successful treatment of recurrent hepatoblastoma (HB) relies largely on surgical resection. When tumors are responsive, chemotherapy can be used to render patients resectable. Various chemotherapeutic regimens studied in small numbers of patients on phase I/II trials have shown few responses. The best available data indicate that doxorubicin, if not given during intial treatment, and irinotecan are the most active agents in recurrent HB. Stem cell transplantation and radiation therapy have been reported in several patients with unclear successes. Advances in therapy for relapsed patients require concentrating enrollment in one or two phase I/II trials utilizing agents with promising preclinical data.
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Affiliation(s)
- Angela D Trobaugh-Lotrario
- Department of Pediatric Hematology/Oncology, Sacred Heart Children's Hospital, Spokane, Washington 99204, USA.
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Abstract
Thrombocytopenia is a common problem in hematology/oncology patients. In the past two decades a number of thrombopoietic growth factors and related cytokines have become available for clinical investigations. Unfortunately, most of the pleiotropic cytokines have been limited by their modest activity and toxicity profile. The discovery of thrombopoietin (TPO), a key regulator of platelet production, led to the clinical development of two recombinant versions of the molecule: full-length, recombinant human thrombopoietin (rhTPO), and truncated and pegylated, megakaryocyte growth and development factor (Peg-rHuMGDF). Both agents showed significant biologic activity in various clinical settings, including nonmyeloablative chemotherapy, mobilization of progenitors, platelet apheresis, and treatment of thrombocytopenia related to other conditions. Despite promising thrombopoietic activity, the clinical development of the first generation of recombinant TPOs was discontinued due to the neutralizing antibodies observed with PEG-rHuMGDF. This has led to the development of TPO agonists with no sequence homology to TPO, which can bind to the TPO receptors and activate signaling, leading to an increase in platelet production. The clinical experience with the first generation of thrombopoietic agents has provided insight into the biology and future directions for a second generation of thrombopoietic agents in various disorders of thrombocytopenia.
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Affiliation(s)
- Saroj Vadhan-Raj
- Section of Cytokines and Supportive Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Application of human CFU-Mk assay to predict potential thrombocytotoxicity of drugs. Toxicol In Vitro 2009; 23:194-200. [DOI: 10.1016/j.tiv.2008.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 10/21/2008] [Accepted: 11/13/2008] [Indexed: 11/22/2022]
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Kobos R, Bussel JB. Overview of Thrombopoietic Agents in the Treatment of Thrombocytopenia. ACTA ACUST UNITED AC 2008; 8:33-43. [DOI: 10.3816/clm.2008.n.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
AbstractThrombocytopenia is a primary manifestation of immune thrombocytopenic purpura (ITP) and may occur as a result of hepatitis C, malignancy, and treatment with chemotherapy. There is a need for additional means to treat thrombocytopenia in these settings. Recombinant thrombopoietin-like agents became available after the cloning of thrombopoietin in 1994. In clinical trials, these agents showed some efficacy in chemotherapy-induced thrombocytopenia, but their use was ultimately discontinued due to the development of neutralizing antibodies that cross-reacted with endogenous thrombopoietin and caused thrombocytopenia in healthy blood donors and other recipients. Subsequently, “second-generation” thrombopoietic agents without homology to thrombopoietin were developed. In the past 5 years, these second-generation thrombopoeitic growth factors have undergone substantial clinical development and have demonstrated safety, tolerability and efficacy in subjects with ITP and hepatitis C–related thrombocytopenia. These completed studies, many of which are available only in abstract form, and other ongoing studies suggest that thrombopoietic agents will enhance the hematologist’s ability to manage these and other causes of thrombocytopenia.
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Abstract
Megakaryocytopoiesis involves the commitment of haematopoietic stem cells, and the proliferation, maturation and terminal differentiation of the megakaryocytic progenitors. Circulating levels of thrombopoietin (TPO), the primary growth-factor for the megakaryocyte (MK) lineage, induce concentration-dependent proliferation and maturation of MK progenitors by binding to the c-Mpl receptor and signalling induction. Decreased platelet turnover rates results in increased concentration of free TPO, enabling the compensatory response of marrow MKs to increased platelet production. C-Mpl activity is orchestrated by a complex cascade of signalling molecules that induces the action of specific transcription factors to drive MK proliferation and maturation. Mature MKs form proplatelet projections that are fragmented into circulating particles. Newly developed thrombopoietic agents operating via c-Mpl receptor may prove useful in supporting platelet production in thrombocytopenic state. Herein, we review the regulation of megakaryocytopoiesis and platelet production in normal and disease state, and the new approaches to thrombopoietic therapy.
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Affiliation(s)
- Varda R Deutsch
- The Haematology Institute, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel.
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Abstract
The liver plays a central role in the maintenance of normal hemostatic function. Because liver disease alters pathways of coagulation and anticoagulation, patients who have advanced disease can experience severe bleeding or thrombotic complications. Complications of advanced liver disease may also contribute to bleeding or thrombosis. This article reviews and discusses the management of the most common coagulation problems encountered in patients who have end-stage liver disease, which are thrombocytopenia and impaired humoral coagulation as measured by prolongation of the prothrombin time and international normalized ratio.
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Affiliation(s)
- James F Trotter
- Division of Gastroenterology/Hepatology, University of Colorado Health Sciences Center, 4200 East 9th Avenue, B-154 Denver, CO 80262, USA.
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Li K, Sung RYT, Huang WZ, Yang M, Pong NH, Lee SM, Chan WY, Zhao H, To MY, Fok TF, Li CK, Wong YO, Ng PC. Thrombopoietin protects against in vitro and in vivo cardiotoxicity induced by doxorubicin. Circulation 2006; 113:2211-20. [PMID: 16651473 DOI: 10.1161/circulationaha.105.560250] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Doxorubicin (DOX) is an important antineoplastic agent. However, the associated cardiotoxicity, possibly mediated by the production of reactive oxygen species, has remained a significant and dose-limiting clinical problem. Our hypothesis is that the hematopoietic/megakaryocytopoietic growth factor thrombopoietin (TPO) protects against DOX-induced cardiotoxicity and might involve antiapoptotic mechanism exerted on cardiomyocytes. METHODS AND RESULTS In vitro investigations on H9C2 cell line and spontaneously beating cells of primary, neonatal rat ventricle, as well as an in vivo study in a mouse model of DOX-induced acute cardiomyopathy, were performed. Our results showed that pretreatment with TPO significantly increased viability of DOX-injured H9C2 cells and beating rates of neonatal myocytes, with effects similar to those of dexrazoxane, a clinically approved cardiac protective agent. TPO ameliorated DOX-induced apoptosis of H9C2 cells as demonstrated by assays of annexin V, active caspase-3, and mitochondrial membrane potential. In the mouse model, administration of TPO (12.5 microg/kg IP for 3 alternate days) significantly reduced DOX-induced (20 mg/kg) cardiotoxicity, including low blood cell count, cardiomyocyte lesions (apoptosis, vacuolization, and myofibrillar loss), and animal mortality. Using Doppler echocardiography, we observed increased heart rate, fractional shortening, and cardiac output in animals pretreated with TPO compared with those receiving DOX alone. CONCLUSIONS These data have provided the first evidence that TPO is a protective agent against DOX-induced cardiac injury. We propose to further explore an integrated program, incorporating TPO with other protocols, for treatment of DOX-induced cardiotoxicity and other forms of cardiomyopathy.
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Affiliation(s)
- Karen Li
- Department of Pediatrics, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
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