Therapeutic strategies for chemotherapy-induced neutropenia in patients with solid tumors

Research progress on the premature ovarian failure caused by cisplatin therapy

Cisplatin is a common anticancer drug able to kill tumor cells, but it causes adverse reactions in the kidney, digestive tract, and other systems. The antitumor effects of cisplatin are mainly due to its ability to bind to the DNA in tumor cells to prevent replication, thereby reducing RNA and protein syntheses, leading to cell damage and death. Cisplatin has a wide range of applications; it can be used to treat cervical, thyroid, ovarian, and other cancers. Cisplatin has a beneficial therapeutic effect, but its therapeutic selectivity is poor. In addition to eliminating diseased target cells, cisplatin can damage normal cells; in women of reproductive age being treated for cancer, cisplatin can lead to ovarian function impairment, premature ovarian failure (POF), and/or infertility. Therefore, reducing the adverse effects of cisplatin on ovarian function is an important topic in clinical research. In this paper, we explore the research progress on the POF caused by cisplatin treatment.

Therapeutic Drug Monitoring of Amikacin in Neutropenic Oncology Patients

Amikacin is the antibiotic of choice for the treatment of Gram-negative infections, namely, those in neutropenic oncology patients. No populational pharmacokinetic studies are currently available reporting amikacin pharmacokinetics in neutropenic oncology patients despite their specific pathophysiological features and treatments. A large-scale retrospective study was herein conducted to specifically investigate the effects that tumor diseases have on the pharmacokinetic parameters of amikacin and identify whether chemotherapy, the lag time between administration of chemotherapy and amikacin, age and renal function contribute to amikacin pharmacokinetics in neutropenic cancer patients. A total of 1180 pharmacokinetic analysis from 629 neutropenic patients were enrolled. The daily dose administered to oncology patients was higher than that administered to non-oncology patients (p < 0.0001). No statistical differences were found in amikacin concentrations, probably because drug clearance was increased in cancer patients (p < 0.0001). Chemotherapy influenced amikacin pharmacokinetics and drug clearance decreased as the lag time enhanced. The elderly group revealed no statistical differences between the doses administered to both the oncology groups, suggesting that the impact of ageing is stronger than chemotherapy. Our research suggests that cancer patients require higher initial doses of amikacin, as well as when chemotherapy is received less than 30 days before amikacin treatment has started.

The Potential Contribution of Dental Foci and Oral Mucositis to Febrile Neutropenia in Patients Treated With Myelosuppressive Chemotherapy for Solid Tumors and Lymphoma

Introduction

Febrile neutropenia (FN) is a potential life-threatening complication of myelosuppressive chemotherapy, particularly when induced by infection. There is evidence that FN can originate from the oral cavity, but its contribution to FN is largely understudied in patients treated for solid tumors. The aim of this study was to assess the prevalence of FN in these patients and to evaluate its relation with dental foci and oral mucositis.

Material and Methods

A prospective longitudinal observational study was conducted. Patients diagnosed with solid tumors and lymphoma scheduled to be treated with myelosuppressive chemotherapy with an intermediate risk of developing FN were included. A pre-chemotherapy dental examination was performed and patients were followed during and after chemotherapy regimen. During subsequent hospital visits for chemotherapy administration, the oral cavity was inspected and oral mucositis (OM) was scored using the CTC-AE version 3.0. When patients presented with fever, a comprehensive full body examination including laboratory/microbiological/imaging investigation was performed.

Results

Eighty-eight patients were included. Pre-chemotherapy, 39 patients (44.3%) were diagnosed with a dental focus. During chemotherapy, 46 patients developed OM (53.4%), of which 15 patients had a maximum score of grade II (ulcerative mucositis). Ten patients developed FN during the follow-up period. Patients with FN more often suffered from ulcerative OM compared to patients without FN; both FN and mucositis risk was associated with the myelotoxicity of chemotherapy. However, no relation could be established between the presence of dental foci prior to chemotherapy and the development of FN (p > 0.05).

Conclusion

A significant relation was identified between ulcerative OM and FN, but no robust conclusions could be drawn with respect to a relationship between the presence of dental foci and FN.

Early subcutaneous drainage of skin and soft tissue infections in patients with febrile neutropenia: A new treatment option

OBJECTIVES

Patients with febrile neutropenia presenting a cutaneous portal of entry for an infectious agent are at high risk of death (19-32%). If medical management is well codified, surgical management represents a therapeutic dilemma because the only available option is an aggressive debridement of the infected area which is associated with a high morbidity rate. Our objective was to implement a low-risk technique that is quick to perform and does not delay major surgical debridement if the latter turns out to be necessary.

PATIENTS AND METHODS

We performed an early subcutaneous drainage of the infected areas by percutaneous approach in order to avoid the evolution towards skin and subcutaneous necrosis. Five consecutive patients were treated with this technique associated with the recommended medical treatment between March and September 2017. This technique is based on the mechanical concept of the evacuation of the edema from the inflammatory area which would allow a better efficiency of the antibiotic treatment thanks to a better blood perfusion and a higher tissue concentration of antibiotics.

RESULTS

Of the 5 patients managed in the department, no skin necrosis occurred, no surgical debridement was necessary, and no patient died during the episode of febrile neutropenia.

CONCLUSION

Early subcutaneous drainage by percutaneous approach of an area of skin infection in a patient with febrile neutropenia may be considered as an interesting option. This technique allows without loss of chance for the patient to increase survival and decrease the number of aggressive surgical debridement and their high morbidity.

The impact of the oral cavity in febrile neutropenia and infectious complications in patients treated with myelosuppressive chemotherapy

Febrile neutropenia (FN) is an inflammatory response causing fever that may develop during cancer therapy-induced neutropenia. FN may herald life-threatening infectious complications and should therefore be considered a medical emergency. Patients presenting with FN are routinely subjected to careful history taking and physical examination including X-rays and microbiological evaluations. Nevertheless, an infection is documented clinically in only 20-30% of cases, whereas a causative microbial pathogen is not identified in over 70% of FN cases. The oral cavity is generally only visually inspected. Although it is recognized that ulcerative oral mucositis may be involved in the development of FN, the contribution of infections of the periodontium, the dentition, and salivary glands may be underestimated. These infections can be easily overlooked, as symptoms and signs of inflammation may be limited or absent during neutropenia. This narrative review is aimed to inform the clinician on the potential role of the oral cavity as a potential source in the development of FN. Areas for future research directed to advancing optimal management strategies are discussed.

Prescribing patterns from medical chart abstraction of patients administered lipegfilgrastim: a pilot study in Europe

Purpose: The objective of this pilot study was to explore the feasibility of conducting a drug utilization study of lipegfilgrastim in Europe using medical records and to examine the pattern of lipegfilgrastim on-label and off-label use.

Methods: Data on lipegfilgrastim use between September 2014 and April 2017 were abstracted from medical records by two independent medical abstractors. Lipegfilgrastim indication was categorized either as on-label or as one of four types of off-label (I–IV) according to pre-defined criteria. An inter-rater reliability analysis was conducted to measure the degree of abstractor agreement for on-label and off-label use.

Results: Information from 46 medical records was abstracted. Lipegfilgrastim use during the first chemotherapy treatment cycle was mostly indicated for prevention of neutropenia (82.6% of patients). On-label use was documented in 42 patients (91.3%), while off-label use was documented in two patients (4.3%); all events of off-label use were attributed to use with non-cytotoxic drugs. The remaining two patients (4.3%) had missing data. Overall agreement between the abstractors was high (91.6%). For three types (Types I–III) of off-label use, the kappa values suggested a perfect agreement (κ = 1). For Type IV off-label use (use in patients treated with non-cytotoxic drugs), κ = 0, suggesting a poor agreement.

Conclusions: While recruitment was challenging, the results of this pilot study confirm the feasibility and availability of medical records and the use of pharmacists as abstractors to assess on- and off-label use of lipegfilgrastim. Lipegfilgrastim was mainly prescribed according to the approved indications.

Key points

Findings from this pilot study confirm the feasibility and availability of medical records and the use of pharmacists as abstractors to assess on-label and off-label use of lipegfilgrastim in routine clinical practice.

Lipegfilgrastim was mainly prescribed according to the approved indications, and the proportion of off-label use was low.

The high inter-rater agreement between the two abstractors suggests that one abstractor is sufficient for conducting chart abstraction of on- and off-label use.

Additional data abstraction sources other than pharmacists will need to be identified to improve response rate and center recruitment.

Findings from this pilot study are important for the successful planning and execution of subsequent drug utilization studies.

Non-chemotherapy drug-induced neutropenia - an update

INTRODUCTION

To date, non-chemotherapy drug-induced severe neutropenia (neutrophil count of ≤0.5 x 10⁹/L) also called idiosyncratic drug-induced agranulocytosis is little discussed in the literature. In the present paper, we report and discuss the clinical data and management of this rare disorder. Areas covered: To do this, we carried out a review of the literature using PubMed database of the US National Library of Medicine. We also used data from the American Society of Hematology educational books, textbooks of Hematology and Internal medicine, and information gleaned from international meetings. Expert opinion: Idiosyncratic agranulocytosis remains a potentially serious adverse event due to the frequency of severe sepsis with severe deep tissue infections (e.g., pneumonia), septicemia, and septic shock in approximately two-thirds of all hospitalized patients. In this context, several prognostic factors have been identified that may be helpful when identifying 'susceptible' patients. Old age (>65 years), septicemia or shock, renal failure, and a neutrophil count ≤0.1 × 10⁹/L have been consensually accepted as poor prognostic factors. In our experience, modern management with pre-established procedures, intravenous broad-spectrum antibiotics and hematopoietic growth factors (particularly G-CSF) is likely to improve the prognosis. Thus with appropriate management, the mortality rate is currently between 5 to 10%.