1
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Chase TN, Al-Sabbagh A, Koga M, Clarence-Smith K. Reduced Plasma Levodopa Fluctuations with More Frequent Administration of a Novel Carbidopa/Levodopa Functionally Scored Tablet. Clin Pharmacol Drug Dev 2024; 13:380-388. [PMID: 38176907 DOI: 10.1002/cpdd.1360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024]
Abstract
Levodopa/carbidopa remains the gold standard for treating Parkinson disease (PD), but chronic pulsatile administration contributes to motor complications. This Phase 1 study used a new immediate-release (IR) formulation of carbidopa/levodopa 25/100 mg that is functionally scored for easy and precise splitting to evaluate the effects on levodopa plasma variability when smaller doses are taken more frequently. These functionally scored tablets were shown to be bioequivalent to carbidopa/levodopa 25-/100-mg IR generic reference tablets. Twenty-two healthy volunteers received a whole tablet every 4 hours versus half of the tablet every 2 hours. Plasma levodopa fluctuations were significantly reduced with half-tablets dosed every 2 hours, with a 44% reduction in peaks (P < .0001). While drug exposure did not differ, parameters that underlie motor response variations, including mean peak-to-trough difference and variance, were 51% and 56% less, respectively, with more frequent dosing (both P ≤ .0024). Safety and tolerability of both regimens were similar. In conclusion, more frequent administration of half-tablets of the new functionally scored IR formulation safely provided more constant levodopa levels than whole tablets dosed less often. This tablet technology could facilitate the benefits of more physiologic dopamine replenishment in patients with PD, particularly those with reduced manual dexterity.
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Affiliation(s)
| | | | - Minako Koga
- Riverside Pharmaceuticals, Washington, DC, USA
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2
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Escobar M, Castaman G, Boix SB, Callaghan M, de Moerloose P, Ducore J, Hermans C, Journeycake J, Leissinger C, Luck J, Mahlangu J, Miesbach W, Mitha IH, Négrier C, Quon D, Recht M, Schved JF, Shapiro AD, Sidonio R, Srivastava A, Stasyshyn O, Vilchevska KV, Wang M, Young G, Alexander WA, Al-Sabbagh A, Bonzo D, Macie C, Wilkinson TA, Kessler C. The safety of activated eptacog beta in the management of bleeding episodes and perioperative haemostasis in adult and paediatric haemophilia patients with inhibitors. Haemophilia 2021; 27:921-931. [PMID: 34636112 PMCID: PMC9292935 DOI: 10.1111/hae.14419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia patients with inhibitors often require a bypassing agent (BPA) for bleeding episode management. Eptacog beta (EB) is a new FDA‐approved recombinant activated human factor VII BPA for the treatment and control of bleeding in haemophilia A or B patients with inhibitors (≥12 years of age). We describe here the EB safety profile from the three prospective Phase 3 clinical trials performed to date. Aim To assess EB safety, immunogenicity and thrombotic potential in children and adults who received EB for treatment of bleeding and perioperative care. Methods Using a randomized crossover design, 27 subjects in PERSEPT 1 (12‐54 years) and 25 subjects in PERSEPT 2 (1‐11 years) treated bleeding episodes with 75 or 225 μg/kg EB initially followed by 75 μg/kg dosing at predefined intervals as determined by clinical response. Twelve PERSEPT 3 subjects (2‐56 years) received an initial preoperative infusion of 75 μg/kg (minor procedures) or 200 μg/kg EB (major surgeries) with subsequent 75 μg/kg doses administered intraoperatively and post‐operatively as indicated. Descriptive statistics were used for data analyses. Results Sixty subjects who received 3388 EB doses in three trials were evaluated. EB was well tolerated, with no allergic, hypersensitivity, anaphylactic or thrombotic events reported and no neutralizing anti‐EB antibodies detected. A death occurred during PERSEPT 3 and was determined to be unlikely related to EB treatment by the data monitoring committee. Conclusion Results from all three Phase 3 trials establish an excellent safety profile of EB in haemophilia A or B patients with inhibitors for treatment of bleeding and perioperative use.
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Affiliation(s)
- Miguel Escobar
- Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | | | | | | | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Janna Journeycake
- Oklahoma Bleeding and Clotting Disorders Center at OU Health, Oklahoma City, Oklahoma, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - James Luck
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA.,Oregon Health & Science University, Portland, Oregon, USA
| | - Jean François Schved
- Haemophilia Treatment Centre, University Hospital Montpellier, Montpellier, France
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | | | | | | | - Craig Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
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3
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Escobar M, Luck J, Averianov Y, Ducore J, Fernández MFL, Giermasz A, Hart DP, Journeycake J, Kessler C, Leissinger C, Mahlangu J, Martinez LV, Miesbach W, Mitha IH, Quon D, Reding MT, Schved JF, Stasyshyn O, Vilchevska KV, Wang M, Windyga J, Alexander WA, Al-Sabbagh A, Bonzo D, Mitchell IS, Wilkinson TA, Hermans C. PERSEPT 3: A phase 3 clinical trial to evaluate the haemostatic efficacy of eptacog beta (recombinant human FVIIa) in perioperative care in subjects with haemophilia A or B with inhibitors. Haemophilia 2021; 27:911-920. [PMID: 34614267 PMCID: PMC9292306 DOI: 10.1111/hae.14418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/17/2021] [Accepted: 09/06/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Surgical procedures in persons with haemophilia A or B with inhibitors (PwHABI) require the use of bypassing agents (BPA) and carry a high risk of complications. Historically, only two BPAs have been available; these are reported to have variable responses. AIM To prospectively evaluate the efficacy and safety of a new bypassing agent, human recombinant factor VIIa (eptacog beta) in elective surgical procedures in PwHABI in a phase 3 clinical trial, PERSEPT 3. METHODS Subjects were administered 200 µg/kg (major procedures) or 75 µg/kg eptacog beta (minor procedures) immediately prior to the initial surgical incision; subsequent 75 µg/kg doses were administered to achieve postoperative haemostasis and wound healing. Efficacy was assessed on a 4-point haemostatic scale during the intra- and postoperative periods. Anti-drug antibodies, thrombotic events and changes in clinical/laboratory parameters were monitored throughout the perioperative period. RESULTS Twelve subjects underwent six major and six minor procedures. The primary efficacy endpoint success proportion was 100% (95% CI: 47.8%-100%) for minor procedures and 66.7% (95% CI: 22.3%-95.7%) for major procedures; 81.8% (95% CI: 48.2%-97.7%) of the procedures were considered successful using eptacog beta. There was one death due to bleeding from a nonsurgical site; this was assessed as unlikely related to eptacog beta. No thrombotic events or anti-eptacog beta antibodies were reported. CONCLUSION Two eptacog beta dosing regimens in PwHABI undergoing major and minor surgical procedures were well-tolerated, and the majority of procedures were successful based on surgeon/investigator assessments. Eptacog beta offers clinicians a new potential therapeutic option for procedures in PwHABI.
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Affiliation(s)
- Miguel Escobar
- Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - James Luck
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Yevhenii Averianov
- City Research and Development Center for Diagnostics and Treatment of Patients with Abnormal Hemostasis, Kyiv, Ukraine
| | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | | | - Adam Giermasz
- Division of Hematology/Oncology, University of California at Davis, Sacramento, California, USA
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Janna Journeycake
- Oklahoma Center for Bleeding and Clotting Disorders, Oklahoma City, Oklahoma, USA
| | - Craig Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Jean-François Schved
- Haemophilia Treatment Centre, University Hospital Montpellier, Montpellier, France
| | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | | | | | | | | | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Kohla S, El Kourashy S, Nawaz Z, Youssef R, Al-Sabbagh A, Ibrahim FA. P190 BCR-ABL1 in a Patient with Philadelphia Chromosome Positive T-Cell Acute Lymphoblastic Leukemia: A Rare Case Report and Review of Literature. Case Rep Oncol 2021; 14:1040-1050. [PMID: 34326740 PMCID: PMC8299423 DOI: 10.1159/000516270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 11/20/2022] Open
Abstract
T-acute lymphoblastic leukemia/lymphoblastic lymphoma (T-ALL/LBL) is rare and aggressive leukemia. Philadelphia chromosome positive (Ph+) is the most common cytogenetic abnormality in chronic myeloid leukemia (CML) and B-acute lymphoblastic leukemia (B-ALL). Ph+ T-ALL is exceeding rare and has a therapeutic and prognostic significance. The incidence and outcome of Ph+ T-ALL are unknown. Differentiation between Ph+ T-ALL/LBL and T-cell lymphoblastic crises of CML may be difficult. We report a rare case of adult de novo T-ALL with significant monocytosis, having Ph+ with (P190 BCR-ABL1) as a cytogenetic abnormality. He was treated with ALL induction chemotherapy and imatinib and achieved complete remission, then relapsed twice and expired shortly after the last CNS relapse.
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Affiliation(s)
- Samah Kohla
- Department of Lab Medicine and Pathology, Hematology Division, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Pathology, Hematology Division, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.,Weill Cornell Medicine, Doha, Qatar
| | - Sarah El Kourashy
- Department of Hematology-Oncology, Hamad Medical Corporation, Doha, Qatar
| | - Zafar Nawaz
- Department of Lab Medicine and Pathology, Cytogenetic Division, Hamad Medical Corporation, Doha, Qatar
| | - Reda Youssef
- Weill Cornell Medicine, Doha, Qatar.,Department of clinical Imaging, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Lab Medicine and Pathology, Hematology Division, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
| | - Feryal A Ibrahim
- Department of Lab Medicine and Pathology, Hematology Division, Hamad Medical Corporation, Doha, Qatar
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5
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Kohla S, Ibrahim F, Bilal I, Al Kuwari E, Al-Sabbagh A. A Challenging Case of Gamma Delta T-Cell Lymphoma with Precursor T-Cells and Marked Eosinophilia: A Case Report. Case Rep Oncol 2020; 13:1520-1529. [PMID: 33564293 PMCID: PMC7841746 DOI: 10.1159/000512188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 11/23/2022] Open
Abstract
Gamma-delta (γδ) T-cell lymphomas are very rare and aggressive neoplasms. We describe here a challenging case of γδ T-cell neoplasm composed of γδ mature T-cells and γδ precursor T-cells with marked eosinophilia that is inapplicable to the current 2016 World Health Organization (WHO) classification. A 3-year-old female child who was presented with fever and marked leukocytosis. Peripheral blood smear showed marked lymphocytosis, marked eosinophilia, neutrophilia, monocytosis, and 5% circulating blasts. CT scan showed anterior mediastinal mass, lymphadenopathy, and hepatosplenomegaly. The patient underwent a bone marrow examination and a biopsy taken from the mediastinal mass. Peripheral blood and bone marrow findings were consistent with a γδ T-cell neoplasm with increased blasts and eosinophilia. The patient was sequentially treated with imatinib (tyrosine kinase inhibitor), acute lymphoblastic leukemia protocol (BFM 2009) then shifted to lymphoma protocol (LMP 96). In conclusion, we report a unique rare case of γδ T-cell neoplasm with a combination of mature and immature γδ T-cells and eosinophilia that is inapplicable to the current 2016 WHO classifications. This case raises a challenging concept of a mature T-cell lymphoma arising in an immature T-cell neoplasm. It also highlights the need to target all neoplastic components to eradicate the disease.
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Affiliation(s)
- Samah Kohla
- Department of Laboratory Medicine and Pathology, Hematology Section, NCCCR, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Pathology, Hematology Division, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.,Weill Cornell Medicine, Doha, Qatar
| | - Feryal Ibrahim
- Department of Laboratory Medicine and Pathology, Hematology Section, NCCCR, Hamad Medical Corporation, Doha, Qatar
| | - Ilham Bilal
- Department of Pediatric Hematology/Oncology, Hamad Medical Corporation, Doha, Qatar
| | - Einas Al Kuwari
- Department of Laboratory Medicine and Pathology, Anatomic Pathology Section, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, Hematology Section, NCCCR, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
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6
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Soliman DS, Al-Kuwari E, Siveen KS, Al-Abdulla R, Chandra P, Yassin M, Nashwan A, Hilmi FA, Taha RY, Nawaz Z, El-Omri H, Mateo JM, Al-Sabbagh A. Downregulation of Lymphoid enhancer-binding factor 1 (LEF-1) expression (by immunohistochemistry and/ flow cytometry) in chronic Lymphocytic Leukemia with atypical immunophenotypic and cytologic features. Int J Lab Hematol 2020; 43:515-525. [PMID: 33314668 DOI: 10.1111/ijlh.13420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/17/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Lymphoid enhancer-binding factor 1 (LEF-1) overexpression has been recently remarkably reported in chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and has shown utility in distinguishing CLL/SLL from other B-cell lymphomas. CLL has a well-defined immunophenotype, yet, some cases of CLL demonstrate atypical morphology/ phenotype reflected by low Matutes score (atypical CLL). Till date, LEF1 expression has not been systematically studied in cases of CLL with atypical features. METHODS In this study, LEF-1 expression was assessed by two different techniques, (immunohistochemistry and flow cytometry), to investigate the expression profile of LEF-1 in cases of CLL/SLL, in comparison with other low-grade B-lymphomas and CLL with atypical features, including atypical immunophenotype and CLL with increased prolymphocytes or morphologically atypical cells. RESULTS We found that LEF-1 expression is downregulated in CLL with atypical immunophenotype/features compared to classic CLL; Chi-Square P < .0001. The ratio for LEF-1 expression in malignant B-cells/NK (by flow cytometry) in CLL/SLL with classic immunophenotype was higher than atypical CLL and is significantly higher in other small B-cell lymphomas (P < .01). Absence of LEF-1 expression in CLL/SLL is correlated (P < .05) with downregulation of CD5, CD23, CD200, expression of FMC7, brighter expression of CD79b, brighter expression of surface light chain, increased prolymphocytes and lower Matutes score. CONCLUSION As downregulation of LEF-1 expression is well correlated with atypical CLL, we suggest adding LEF-1 to Matutes score as a beneficial marker to differentiate classic from atypical CLL LEF-1 could also serve as a potential prognostic indicator for CLL clinical course.
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Affiliation(s)
- Dina S Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine - Qatar, Doha, Qatar.,Department of Clinical Pathology, National Cancer Institute, Cairo, Egypt
| | - Einas Al-Kuwari
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
| | - Kodappully S Siveen
- Flow Cytometry Core Facility, interim Translational Research Institute, Hamad Medical Corporation, Doha, Qatar
| | - Rajaa Al-Abdulla
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
| | - Prem Chandra
- Medical Research Center, Academic Health Systems, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Yassin
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Abdulqader Nashwan
- Nursing Department, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Feryal A Hilmi
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ruba Y Taha
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Zafar Nawaz
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
| | - Halima El-Omri
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Jericha M Mateo
- Flow Cytometry Core Facility, interim Translational Research Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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7
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Al-Sabbagh A, Ibrahim F, Szabados L, Soliman DS, Taha RY, Fernyhough LJ. The Role of Integrated Positron Emission Tomography/Computed Tomography (PET/CT) and Bone Marrow Examination in Staging Large B-Cell Lymphoma. Clin Med Insights Oncol 2020; 14:1179554920953091. [PMID: 35185352 PMCID: PMC8855442 DOI: 10.1177/1179554920953091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/31/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction: In the era of routine use of positron emission tomography/computed tomography (PET/CT) for staging, it is not yet clear whether PET/CT can replace bone marrow biopsy for the assessment of bone marrow involvement in large B-cell lymphoma. Objectives: To compare the clinical utility of bone marrow biopsy and PET/CT scanning in the staging of large B-cell lymphoma. Methods: This was a retrospective analysis of all patients who presented to single center over a 4-year period with large B-cell lymphoma who had concurrent PET/CT and bone marrow biopsy performed in the assessment and staging of the lymphoma. Results: Out of 89 patients, 24 had bone marrow involvement either by PET/CT, by bone marrow biopsy, or by both. Bone marrow biopsy identified 12 patients (sensitivity 50%, specificity 100%, negative predictive value 84%), whereas PET/CT identified 23 patients (sensitivity 96%, specificity 100%, negative predictive value 98%). No patients were upstaged by the bone marrow biopsy result, and no patients had their treatment plan changed based on the bone marrow biopsy result. Conclusion: The results show that PET-CT is more sensitive and has better negative predictive value than bone marrow biopsy. This suggests that PET-CT could replace bone marrow biopsy in detecting bone marrow involvement for staging of large B-cell lymphoma.
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Affiliation(s)
- Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Feryal Ibrahim
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Lajos Szabados
- PET/CT Center, Clinical Imaging, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Dina S Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Ruba Y Taha
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Liam J Fernyhough
- Department of Medicine, Weill Cornell Medicine - Qatar, Doha, Qatar.,Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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8
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Kohla S, Ibrahim FA, Mudawi D, Akiki S, Soliman D, Al-Sabbagh A, Youssef RRH, Yassin MA. High-Grade Epstein-Barr Virus-Negative Biphenotypic Lymphoma with Expression of B- and T-Cell Markers and Leukemia Presentation: Case Report and Literature Review. Case Rep Oncol 2020; 13:1215-1226. [PMID: 33173488 PMCID: PMC7590753 DOI: 10.1159/000510403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 01/28/2023] Open
Abstract
Lymphomas are presently categorized according to their origin from B or T lymphocytes. The co-expression of CD3 in B-cell lymphomas or CD20 in T-cell lymphomas has been rarely reported. Immature and less often mature lymphomas may incorporate the rearrangements of both B- and T-cell antigen receptor genes (dual genotype or bigenotype). Lymphoma cells with a sole genotype hardly concurrently express both B- and T-cell markers (biphenotypic lymphomas). We describe a 63-year-old female who was presented with obstructive jaundice and epigastric pain of 10 days. Initial CBC revealed 43×10<sup>3</sup>/μL white blood cells, 11.2 g/dL hemoglobin, and 88x10<sup>3</sup>/μL platelets. CT abdomen revealed hepatomegaly and suspected pancreatic mass with large retroperitoneal lymph nodal mass. Peripheral smear showed 56% lymphoid cells with blast morphology. The bone marrow (BM) aspirate smear was infiltrated by 83% immature-looking cells. BM biopsy showed interstitial to diffuse extensive infiltration by primitive-looking cells, positive for pan-B-cell antigens CD20, CD79, and PAX5 as well as the T-cell antigen CD4, CD5, CD3, while negative for all immaturity markers (CD34, TdT, and CD1a). In situ hybridization for Epstein-Barr virus (EBV)-encoded small RNA (EBER) was negative. Flow cytometry on BM aspirate showed an abnormal population (50%) expressing the B-cell antigens (CD19, CD20, CD79, CD22) and CD10, and showed lambda light chain restriction as well as the T-cell antigens cCD3 and CD4 with partial CD5. The analysis showed, also, another abnormal population of lambda restricted monotypic B cells (8%) with dimmer CD45 (blast gate) and showed the same immunophenotype (expressing the B-cell antigens), but negative for CD10, cCD3, CD5, and CD4. Conventional cytogenetic revealed complex karyotype. Molecular studies revealed rearrangements of the immunoglobulin heavy chain region consistent with a clonal B-cell population. TCR gene rearrangement analysis was equivocal concerning clonality but was not conclusive for clonal T-cell disease. Our final diagnosis was peripheral blood and BM involvement by EBV-negative high-grade lymphoid neoplasm (in leukemic phase with blast morphology) and an ambiguous immunophenotype with a differential diagnosis that may include the rare entity of bigenotypic lymphoma or an unusual case of high-grade B-cell lymphoma with aberrant expression of T-cell markers (biphenotypic lymphomas).
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Affiliation(s)
- Samah Kohla
- Department of Lab Medicine and Pathology, Hematology Division, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Pathology, Hematology Division, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Feryal A Ibrahim
- Department of Lab Medicine and Pathology, Hematology Division, Hamad Medical Corporation, Doha, Qatar
| | - Deena Mudawi
- Department of Hematology-Oncology, Hamad Medical Corporation, Doha, Qatar
| | - Susanna Akiki
- Department of Lab Medicine and Pathology, Molecular and Cytogenetic Division, Hamad Medical Corporation, Doha, Qatar
| | - Dina Soliman
- Department of Lab Medicine and Pathology, Hematology Division, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Lab Medicine and Pathology, Hematology Division, Hamad Medical Corporation, Doha, Qatar
| | - Reda R H Youssef
- Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed A Yassin
- Department of Hematology-Oncology, Hamad Medical Corporation, Doha, Qatar
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9
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Sameh Soliman D, Ali M, Akikki S, Ibrahim F, El-Omari H, Al-Sabbagh A, Okar L. Transient Pleural Fluid Infiltration by Clonal Plasma Cells Associated with Pulmonary Tuberculosis. Case Rep Oncol 2020; 13:883-891. [PMID: 32884535 PMCID: PMC7443684 DOI: 10.1159/000507984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/17/2020] [Indexed: 11/19/2022] Open
Abstract
Pleural effusion is a rare presentation of plasma cell myeloma, occurring in around 6% of patients during the course of their disease, most commonly as a consequence of a concurrent disease process like heart failure secondary to amyloid deposition. Direct infiltration of the pleural fluid by malignant cells leading to myelomatous pleural effusion is a rare mechanism occurring in less than 1% of patients with plasma cell myeloma, and it is associated with a worse prognosis. There are few case reports of myelomatous pleural effusion as an initial presentation of multiple myeloma. Pleural fluid infiltration by monoclonal plasma cells in the absence of an underlying plasma cell myeloma was not reported before in the literature. Tuberculosis is a known cause of polyclonal gammaglobulinemia, however few case reports described the coexistence of monoclonal gammopathy of undetermined significance and tuberculosis. Here we present an interesting case of pleural fluid infiltration by an abnormal looking clonal plasma cells associated with active pulmonary tuberculosis and parapneumonic effusion in a patient with a background of acute myeloid leukemia. Interestingly, the clonal plasma cell proliferation was confined to the pleural fluid without any evidence of an underlying plasma cell neoplasms (including monoclonal gammopathy of undetermined significance and plasmacytomas). Since our patient had an underlying meyloid neoplasm, we though about the possibility of secondary malignancy. However, in almost all patients with coexisting myeloid and plasma cell neoplasms, myeloid neoplasms developed following chemotherapeutic treatment of plasma cell neoplasms not the other way around. Given that, one must conclude localized extramedullary (pleural) plasma cell proliferation probably represents a transient reactive process to pulmonary tuberculosis which is an extremely rare phenomenon and not described before.
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Affiliation(s)
- Dina Sameh Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Laboratory Medicine and Pathology-Weill Cornell Medicine, Doha, Qatar
| | - Mohammad Ali
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Susanna Akikki
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Department of Laboratory Medicine and Pathology-Weill Cornell Medicine, Doha, Qatar
| | - Feryal Ibrahim
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Halima El-Omari
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Department of Laboratory Medicine and Pathology-Weill Cornell Medicine, Doha, Qatar
| | - Lina Okar
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
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Elsabah H, Soliman DS, Ibrahim F, Al-Sabbagh A, Yassin M, Moustafa A, Nashwan AM, Nawaz Z, ElOmri HM. Plasma Cell Myeloma with an Aggressive Clinical Course and Anaplastic Morphology in a 22-Year-Old Patient: A Case Report and Review of Literature. Am J Case Rep 2020; 21:e920489. [PMID: 32152261 PMCID: PMC7081950 DOI: 10.12659/ajcr.920489] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 01/28/2020] [Accepted: 11/26/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Plasma cell myeloma is a neoplastic plasma cell disorder that usually presents after the fifth decade of life; it is rarely described in younger population especially under 30 years of age. However, there are conflicting reports in the literature about the clinical behavior and overall survival in younger age groups. In approximately 2% of plasma cell myeloma, the morphology of the neoplastic cells is highly pleomorphic, quite anaplastic, and may resemble metastatic tumor cells. While this poses a challenge for morphological interpretation during diagnosis, it has been demonstrated that bone marrow morphologic features (including diffuse sheet growth pattern, immature cell morphology and high mitotic index) significantly correlates with high risk disease. Moreover, there is limited description available about the morphology of the neoplastic cells when correlating the age at presentation with the clinical outcome/biological behavior; hence, the need to report and collect such cases. CASE REPORT We report a case of plasma cell myeloma in a 22-year-old male who presented with non-specific clinical features and posed a diagnostic challenge during clinical, radiological, and laboratory examination. The pathology specimens showed anaplastic morphology. Unfortunately, after diagnosis, despite treatment with brotezomib, his disease had an aggressive clinical course and he passed away 4 months after diagnosis. CONCLUSIONS Although plasma cell myeloma is rare in patients younger than 30 years, it must be considered in the differential diagnosis and investigated properly especially in patients with clinical suspicion of a metastatic non-hematological tumor. The anaplastic variant in a young patient is a diagnostic challenge and is associated with bizarre morphology, aggressive presentation, adverse cytogenetics, resistance to chemotherapy, and poor, short-term, survival.
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Affiliation(s)
- Hesham Elsabah
- Department of Medical Oncology, National Center for Cancer Care and Research(NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Dina S. Soliman
- Department of Laboratory Medicine and Pathology, National Centre for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
- Department of Laboratory Medicine and Pathology, Weill Cornell Medical College, Doha, Qatar
- Department of Clinical Pathology, National Cancer Institute, Cairo, Egypt
| | - Feryal Ibrahim
- Department of Laboratory Medicine and Pathology, National Centre for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Centre for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Yassin
- Department of Medical Oncology, National Center for Cancer Care and Research(NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Abbas Moustafa
- Department of Radiology (Clinical Imaging), National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Abdulqadir M. Nashwan
- Cancer Clinical Trials Unit, Department of Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Zafar Nawaz
- Department of Laboratory Medicine and Pathology, National Centre for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Halima M. ElOmri
- Department of Medical Oncology, National Center for Cancer Care and Research(NCCCR), Hamad Medical Corporation, Doha, Qatar
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Abdullah MA, Amer A, Nawaz Z, Abdullah AS, Al-Sabbagh A, Kohla S, Nashwan AJ, Yassin MA. An uncommon case of chronic myeloid leukemia with variant cytogenetic. Acta Biomed 2018; 89:28-32. [PMID: 29633730 PMCID: PMC6179100 DOI: 10.23750/abm.v89i3-s.7217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 12/03/2022]
Abstract
Chronic Myeloid Leukemia (CML) is myeloproliferative neoplasm characterized by Philadelphia chromosome which is a balanced translocation between chromosome 9 and 22 in 90% of cases. However, variant cytogenetic still happens in 5-10% of cases, the importance of which is controversial as well as its response to therapy, prognosis and progression to acute leukemias. Here we report a male patient with CML and variant cytogenetic who responded to low dose of Dasatinib (50 mg daily). (www.actabiomedica.it)
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Affiliation(s)
- Mohamed A Abdullah
- Department of Medical Oncology, Hematology Section, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.
| | - Aliaa Amer
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar.
| | - Zafar Nawaz
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar.
| | - Ali S Abdullah
- Department of Medical Education, Internal Medicine Section, Hamad Medical Corporation, Doha, Qatar.
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar;.
| | - Samah Kohla
- Clinical Pathology Department, Faculty of Medicine, AlAzhar University, Cairo, Egypt.
| | - Abdulqadir J Nashwan
- Department of Medical Oncology, Hematology Section, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.
| | - Mohamed A Yassin
- Department of Medical Oncology, Hematology Section, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.
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12
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Soliman DS, Amer AM, Mudawi D, Al-Sabbagh Z, Alkuwari E, Al-Sabbagh A, Ibrahim F, Yassin MA. Chronic Myeloid Leukemia with cryptic Philadelphia translocation and extramedullary B-lymphoid blast phase as an initial presentation. Acta Biomed 2018; 89:38-44. [PMID: 29633732 PMCID: PMC6179102 DOI: 10.23750/abm.v89i3-s.7219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 11/25/2022]
Abstract
Chronic Myeloid Leukemia (CML) is a clonal myeloproliferative neoplasm (MPN) characterized by the presence of a reciprocal translocation between the long arms of chromosomes 9 and 22, t(9;22)(q34:q11), resulting in fusion of the break point cluster region (BCR) with the ABL gene, which forms an oncogene, the transcript of which is an oncoprotein with a tyrosine kinase function. In the great majority of CML; BCR/ABL1 is cytogenetically visualized as t(9;22); giving rise to the Ph chromosome, harboring the chimeric gene. Cryptic or masked translocations occur in 2-10% patients with no evidence for the BCR/ABL rearrangement by conventional cytogenetics but are positive by Fluorescence in Situ Hybridization (FISH) and/or reverse transcriptase polymerase chain reaction (RT-PCR). These patients are described as Philadelphia negative (Ph negative) BCR/ABL1-positive CML with the chimeric gene present on the derivative chromosome 22, as in most CML cases, or alternatively on the derivative 9 in rare occasions. In the majority of cases, CML is diagnosed in the chronic phase; it is less frequently diagnosed in accelerated crises, and occasionally, its initial presentation is as acute leukemia. The prevalence of extramedullary blast phase (BP) has been reported to be 7-17% in patients with BP. Surprisingly, no extramedullary blast crises of B-lymphoid lineage have been reported before among cases of CML as the initial presentation. We report an adult male diagnosed as CML-chronic phase when he was shortly presented with treatment-naive extramedullary B-lymphoid blast crises involving multiple lymph nodes, with no features of acceleration or blast crises in the peripheral blood (PB) and bone marrow (BM). In addition the patient had variant/cryptic Philadelphia translocation. This is the first report of CML, on the best of our knowledge, with extramedullary B-lymphoid blast phase, as initial presentation, that showed a cryptic Ph translocation. (www.actabiomedica.it)
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Affiliation(s)
- Dina S Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha,Qatar.
| | - Aliaa M Amer
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha,Qatar.
| | - Deena Mudawi
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.
| | - Zafar Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha,Qatar.
| | - Einas Alkuwari
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha,Qatar.
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha,Qatar.
| | - Feryal Ibrahim
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha,Qatar.
| | - Mohamed A Yassin
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.
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13
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Soliman DS, Al-Sabbagh A, Ibrahim F, Fareed S, Talaat M, Yassin MA. De Novo Precursor B-Lymphoblastic Leukemia/Lymphoma With Double-Hit Gene Rearrangements ( MYC/BCL-2) Presented With Spinal Cord Compression and Acquired Factor XIII Deficiency. J Hematol 2017; 6:62-67. [PMID: 32300395 PMCID: PMC7155824 DOI: 10.14740/jh329w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/29/2017] [Indexed: 11/29/2022] Open
Abstract
Double-hit lymphomas (DHLs) are aggressive mature B-cell neoplasms associated with rearrangements involving MYC and B-cell lymphoma-2 (BCL-2). Such DH events are extremely rare in B-cell precursor acute lymphoblastic leukemia (B-ALL), especially in young adults. A 29-year-old male patient initially presented to emergency department with right mandibular mass of 2 months duration associated with intermittent fever. Laboratory workup revealed very high lactate dehydrogenase at 2,026.0 U/L. Peripheral blood revealed pancytopenia with many circulating blasts (about 77%). Bone marrow (BM) aspirate revealed infiltration with many small sized blasts of very high nucleocytoplasmic ratio, finely dispersed nuclear chromatin and prominent nucleoli. The BM biopsy reflected marked hypercellularity with diffuse replacement by sheets of blasts, positive for TdT, PAX-5, CD10, cMYC, BCL-2 and CD20 with Ki-67 > 90%. Flow cytometry on BM revealed a precursor B-immunophenotype (CD45 (dim), CD19, CD10, Tdt and CD20). The blasts are negative for cytoplasmic and surface IgM. Cytogenetics revealed complex karyotype: 46,XY,del(6)(q21q23),t(8;22)(q24.1;q11.2),t(14;18)(q32;q21)(20). A diagnosis of B-lymphoblastic leukemia/lymphoma with t(8;22)(q24.1;q11.2) and t(14;18)(q32;q21) was made. Fluorescent in situ hybridization (FISH) analysis revealed an abnormal hybridization signal pattern for CDKN2A probe, indicating biallelic (homozygous) deletion of the short arm of chromosome 9 (9p) in 94% of the cells analyzed. The patient had severe life-threatening bleeding despite of normal prothrombin time (PT) and activated partial thromboplastin time (APTT) due to acquired factor XIII deficiency, an overlooked rare coagulopathy disorder. In addition, the patient developed acute sudden onset paraplegia, and magnetic resonance imaging (MRI) of spine showed acute cord compression which necessitated emergency radiotherapy after which chemotherapy was started on hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, adriamycin, and dexamethasone) protocol. MRI showed dramatic resolution of the mass. Very few cases of B-ALL with DH rearrangement with true precursor B-cell phenotype (positivity for TdT with negativity for surface light chain) have been reported. Many of these had frequent central nervous system (CNS) involvement, with complex karyotypes, highly aggressive course, with short survival of less than 1 year. This case however showed very good response to treatment. In contrary to DHL, de novo B-ALL with double-hit rearrangements is more prevalent in pediatrics and young adults. Although most of reported cases represent transformation of follicular lymphoma, our patient’s young age, acute onset and absent lymphadenopathies all support de novo ALL.
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Affiliation(s)
- Dina Sameh Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Feryal Ibrahim
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Shehab Fareed
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Talaat
- Department of Radiology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed A Yassin
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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14
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Hilmi FAI, Al-Sabbagh A, Soliman DS, Sabah HA, Ismail OM, Yassin M, El-Omri H. Acute Myeloid Leukemia With Inv(16)(p13q22) Associated With Hidden Systemic Mastocytosis: Case Report and Review of Literature. Clin Med Insights Blood Disord 2017; 10:1179545X17700858. [PMID: 28579854 PMCID: PMC5428180 DOI: 10.1177/1179545x17700858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/12/2017] [Indexed: 01/08/2023]
Abstract
Systemic mastocytosis (SM) is a condition associated with clonal neoplastic proliferation of mast cells. In up to 40% of systemic mastocytosis cases, an associated clonal hematological disease of non-mast cell lineage, such as acute myeloid leukemia (AML), is diagnosed before, simultaneously with, or after the diagnosis of SM. Herein, we report a case of a 30-year-old man diagnosed with AML with inv(16) (p13;q22) CBFB:MYH11. Associated mastocytosis was not noted at diagnosis and was only detected in the bone marrow at time of remission after successful chemotherapy. The diagnosis of mastocytosis was based on the demonstration of a multifocal dense mast cell infiltrate in the marrow biopsy with aberrant immunophenotype, with coexpression of tryptase, CD117, and CD25. The mast cells showed atypical morphology mostly with irregular nuclear contour, bilobed or multilobed nuclei with cytoplasmic hypogranulation or irregular metachromatic granule distribution, and some cells with eccentric nucleus or spindle shape. Reexamination of the pretherapeutic bone marrow with immunostain for tryptase and CD25 revealed that mastocytosis was present from the start but masked by extensive blast proliferation. This case indicates that mast cell infiltrates are sometimes underappreciated at the original diagnosis of AML with inv(16) and that the concurrent diagnosis of SM with AML requires a high index of suspicion supported with comprehensive morphologic and immunohistochemical evaluation for a neoplastic mast cell proliferation.
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Affiliation(s)
- Feryal Abbas Ibrahim Hilmi
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Dina Sameh Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Hesham Al Sabah
- Department of Hematology/Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Omar Mohammad Ismail
- Department of Hematology/Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Yassin
- Department of Hematology/Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Halima El-Omri
- Department of Hematology/Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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15
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Soliman DS, Fareed S, Alkuwari E, El-Omri H, Al-Sabbagh A, Gameel A, Yassin M. Concomitant Classic Hodgkin Lymphoma of Lymph Node and cMYC-Positive Burkitt Leukemia/Lymphoma of the Bone Marrow Presented Concurrently at the Time of Presentation: A Rare Combination of Discordant Lymphomas. Clin Med Insights Blood Disord 2016; 9:23-8. [PMID: 27512341 PMCID: PMC4973772 DOI: 10.4137/cmbd.s39908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/16/2016] [Accepted: 05/24/2016] [Indexed: 12/05/2022]
Abstract
Discordant lymphoma is rare condition in which different types of malignant lymphomas occurring in different anatomic sites. The two diseases may present clinically as concurrent or sequential disease (10). Herein we are reporting a Pakistani female in her 60s, a carrier of hepatitis B virus with multiple comorbidities presented with cervical lymphadenopathy, diagnosed as Hodgkin’s lymphoma, mixed cellularity. During the staging workup, the patient was discovered to have extensive bone marrow (BM) involvement by Burkitt leukaemia/lymphoma (BL). Cytogenetic analysis revealed positivity for t(8;14)(q24;q32) confirmed by Fluorescence In Situ Hybridization (FISH) for IGH/MYC. Epstein-Barr virus (EBV) was demonstrated heavily in our case, with (EBV) DNA of 24,295,560 copies/ml by PCR at time of presentation, in addition, the neoplastic cells in both diagnostic tissues (cervical lymph node and BM) demonstrated positivity for EBV. A diagnosis of concomitant EBV related discordant lymphoma (classical Hodgkin lymphoma (cHL) and Burkitt lymphoma (BL) in leukemic phase was made. Among all reported cases, this case is highly exceptional because it is the first case of discordant/composite lymphoma, with this combination and concomitant presentation. Since we are dealing with a case with an exceptionally rare combination, we found it significant to elaborate more on its clinical features, contributing factors including EBV role, response to treatment, complications, and prognosis.
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Affiliation(s)
- Dina S Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.; Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Shehab Fareed
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Einas Alkuwari
- Department of Laboratory Medicine and Pathology, Hamad General Hospital, Doha, Qatar
| | - Halima El-Omri
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Amna Gameel
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Yassin
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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16
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Ibrahim FA, Shanmugam V, Amer A, El-Omri H, Al-Sabbagh A, Taha RY, Soliman DS. An Unusual Case of Hepatosplenic αβ T-Cell Lymphoma Presenting with Coombs'-Negative Hemolytic Anemia. Clin Med Insights Oncol 2015; 9:123-8. [PMID: 26688667 PMCID: PMC4668954 DOI: 10.4137/cmo.s35120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 11/12/2022]
Abstract
Hepatosplenic T-cell lymphoma (HSTCL) is a rare and aggressive extranodal T-cell lymphoma that comprises <5% of peripheral T-cell lymphomas. The majority of cases harbor the γδ T-cell receptor (TCR), but recently, a few cases have been shown to express the αβ TCR. Comparison of these two subtypes (αβ and γδ) shows similar clinicopathologic and cytogenetic features; however, due to the paucity of reported cases, it is not clear whether they are prognostically distinct entities. We report a case of αβ HSTCL with a rather unusual presentation of Coombs’-negative hemolytic anemia. Diagnosis proved challenging due to an unusual blastoid morphology with the absence of typical intrasinusoidal distribution of tumor cells in the bone marrow. This unique case adds to the growing list of this rare subtype of T-cell lymphomas, which warrant urgent attention due to the lack of effective treatment options and dismal prognosis.
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Affiliation(s)
- Feryal A Ibrahim
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Vignesh Shanmugam
- Department of Laboratory Medicine and Pathology, Weill Cornell Medical College in Qatar, Education City, Doha, Qatar
| | - Aliaa Amer
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Halima El-Omri
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al-Sabbagh
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ruba Y Taha
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Dina S Soliman
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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Friedman A, Al-Sabbagh A, Santos LMB, Fishman-Lobell J, Polanski M, Das MP, Khoury SJ, Weiner HL. Oral Tolerance: A Biologically Relevant Pathway to Generate Peripheral Tolerance against External and Self Antigens. Mechanisms of Immune Regulation 2015. [DOI: 10.1159/000422696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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18
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Garcia-Borreguero D, Allen R, Bonzo D, Lassauzet ML, Al-Sabbagh A. Baseline IRLS Rating Scale Scores, Pain Associated with RLS Symptoms and 24-Hour RLS Symptoms in a US Clinical Trial Population (P04.038). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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19
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Thyagarajan S, Chavan A, Al-Sabbagh A, Latifi S, Kelsall AW. The provision of cardiology services in a non-cardiac paediatric intensive care unit setting. Arch Dis Child 2010; 95:1068. [PMID: 20605866 DOI: 10.1136/adc.2009.170720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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20
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Funch D, Norman H, Wong J, Bennett R, Hillier J, Al-Sabbagh A, Seeger JD. Adherence to recommended dosing and monitoring for mitoxantrone in patients with multiple sclerosis: a healthcare claims database study supplemented with medical records--the RETRO study. Pharmacoepidemiol Drug Saf 2010; 19:448-56. [PMID: 20333778 DOI: 10.1002/pds.1918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE Mitoxantrone was approved for treatment of multiple sclerosis (MS) in October 2000. Monitoring and dosing guidelines in the product labeling accompanying this indication include blood counts, liver function, and pregnancy tests at each administration. Due to potential cardiotoxicity, left ventricular ejection fraction (LVEF) testing prior to initial infusion and all infusions at a cumulative dose >or=100 mg/m(2) was recommended until April 2005 when LVEF testing before all infusions was recommended in the approved labeling. We sought to estimate provider adherence to dosing and monitoring guidelines and the effect of changes in LVEF monitoring guidelines. METHODS MS patients who received mitoxantrone between October 2000 and June 2006 were selected from the claims of a large US health insurer. Claims for infusions and for specified tests prior to an infusion determined adherence to guidelines, with medical records providing additional information for a subset. RESULTS There were 1827 mitoxantrone infusions to 548 eligible patients; medical records were obtained for 261 patients (1096 infusions). Most mitoxantrone recipients were 30-59 years of age and 73% were female. Adherence to recommended dosing was higher than for recommended monitoring. Blood counts were conducted for most infusions (78-83%), while liver function tests (LFT) were performed less often (47-54% of infusions). Pregnancy tests were performed for 10% or fewer of the infusions administered to reproductive age women. Adherence with LVEF testing guidelines improved following labeling changes. CONCLUSIONS Adherence to recommended monitoring was incomplete, but amenable to change. Automated assessment through insurance claims supplemented with medical record data provides a balanced means for studying adherence to recommendations.
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Affiliation(s)
- Donnie Funch
- Epidemiology, i3 Drug Safety, Waltham, MA 02451, USA.
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Talevi R, Barbato V, Mollo V, De Stefano C, Finelli F, Ferraro R, Gualtieri R, Zhou P, Liu AH, Cao YX, Roman H, Pura I, Tarta O, Bourdel N, Marpeau L, Sabourin JC, Portmann M, Nagy ZP, Behr B, Alvaro Mercadal B, Demeestere I, Imbert R, Englert Y, Delbaere A, Lueke S, Buendgen N, Koester F, Diedrich K, Griesinger G, Kim A, Han JE, Eunmi C, Kim YS, Cho JH, Yoon TK, Piomboni P, Stendardi A, Palumberi D, Morgante G, De Leo V, Serafini F, Focarelli R, Tatone C, Di Emidio G, Carbone MC, Vento M, Ciriminna R, Artini PG, Kyono K, Ishikawa T, Usui K, Hatori M, Yasmin L, Sato E, Iwasaka M, Fujii K, Owada N, Sankai T, McLaughlin M, Fineron P, Anderson RA, Wallace WHB, Telfer EE, Labied S, Beliard A, Munaut C, Foidart JM, Turkcuoglu I, Oktay K, Rodriguez-Wallberg K, Kuwayama M, Takayama Y, Mori C, Kagawa N, Akakubo N, Takehara Y, Kato K, Leibo SP, Kato O, Yoon H, Shin Y, cha J, Kim H, Lee W, Yoon S, Lim J, Larman MG, Gardner DK, Zander-Fox D, Lane M, Hamilton H, Oktay K, Lee S, Ozkavukcu S, Heytens E, Alappat RM, Sole M, Boada M, Biadiu M, Santalo J, Coroleu B, Barri PN, Veiga A, Rossi L, Bartoletti R, Mengarelli M, Boccia Artieri G, Gemini L, Mazzoli L, Giannini L, Scaravelli G, Kagawa N, Silber SJ, Kuwayama M, Yamanguchi S, Nagumo Y, Takai Y, Ishihara S, Takehara Y, Kato O, Lee S, Heytens E, Ozkavukcu S, Alappat RM, Oktay K, Soleimani R, Heytens E, Rottiers I, Gojayev A, Oktay K, Cuvelier AC, De Sutter P, Salama M, Winkler K, Murach KF, Hofer S, Wildt L, Friess SC, Okumura N, Kuji N, Kishimi A, Nishio H, Mochimaru Y, Minegishi K, Miyakoshi K, Fujii T, Tanaka M, Aoki D, Yoshimura Y, Hasegawa K, Juanzi S, Zhao W, Zhang S, Xue X, Silber S, Zhang J, Kuwayama M, Kagawa N, Meirow D, Gosden R, Westphal JR, Gerritse R, Beerendonk CCM, Braat DDM, Peek R, Coticchio G, Dal Canto M, Brambillasca F, Mignini Renzini M, Merola M, Lain M, Fadini R, Nottola SA, Albani E, Coticchio G, Lorenzo C, Carlini T, Maione M, Scaravelli G, Borini A, Macchiarelli G, Levi-Setti PE, Rienzi L, Romano S, Capalbo A, Iussig B, Albricci L, Colamaria S, Baroni E, Sapienza F, Giuliani M, Anniballo R, Ubaldi FM, Beyer DA, Schultze-Mosgau A, Amari F, Griesinger G, Diedrich K, Al-Hasani S, Resta S, Magli MC, Ruberti A, Lappi M, Ferraretti AP, Gianaroli L, Prisant N, Belloc S, Cohen-Bacrie M, Hazout A, Olivennes F, Aubriot FX, Alvarez S, De Mouzon J, Thieulin C, Cohen-Bacrie P, Wozniak S, Szkodziak P, Wozniakowska E, Paszkowski M, Paszkowski T, Diaz D, Nagy ZP, Dragnic S, Hayward B, Bennett R, Al-Sabbagh A, Novella-Maestre E, Teruel J, Carmona L, Rosello E, Pellicer A, Sanchez-Serrano M, Lee JR, Lee JY, Kim CH, Lee Y, Lee S, Jee BC, Suh CS, Kim SH, Moon SY, Sanchez-Serrano M, Novella-Maestre E, Teruel J, Mirabet V, Crespo J, Pellicer A, Schiewe M, Nugent N, Zozula S, Anderson R, Zulategui JF, Meseguer M, Pellicer A, Remohi J, Castello D, Romero JLL, De los Santos MJ, Cobo AC, von Wolff M, Jauckus J, Kupka M, Strowitzki T, Lawrenz B, Meirow D, Raanani H, Kaufman B, Maman E, Mendel MM, Dor J, Buendgen NK, Lueke S, Diedrich K, Griesinger G, Combelles C, Wang HY, Racowsky C, Kuleshova L, Tucker M, Graham J, Richter K, Carter J, Lim J, Levy M. Posters * Fertility Preservation. Hum Reprod 2010. [DOI: 10.1093/humrep/de.25.s1.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Goldberg LDD, Edwards NC, Fincher C, Doan QV, Al-Sabbagh A, Meletiche DM. Comparing the cost-effectiveness of disease-modifying drugs for the first-line treatment of relapsing-remitting multiple sclerosis. J Manag Care Pharm 2009; 15:543-55. [PMID: 19739877 PMCID: PMC10437839 DOI: 10.18553/jmcp.2009.15.7.543] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory autoimmune disorder of the central nervous system that primarily afflicts young adults. Approximately 400,000 people in the United States are affected by MS. Although several forms of MS exist, the most common course is known as relapsing-remitting MS (RRMS), which affects about 85% of MS patients. This form of MS is characterized by relapses of neurologic symptoms followed by periods of recovery. Progression of disease can lead to increasingly severe disability. Since the introduction of immunomodulatory biologic agents, such as interferon betas and glatiramer acetate, treatment has helped to change the course of the disease. Under budgetary constraints, health services payers are challenged to differentiate the economic value of these agents for formulary selection and/or placement. OBJECTIVE The primary objective of this analysis was to evaluate the 2-year cost-effectiveness of 4 disease modifying drugs (DMDs) used as first-line treatment of RRMS: glatiramer acetate, interferon (IFN) Beta-1a IM injection, IFN Beta-1a SC injection, and IFN Beta-1b SC injection. METHODS An Excel-based model was developed to compare the relative effectiveness and cost components of relapses, disability progression, and DMDs in the treatment of RRMS over a 2-year time horizon. The relative risk reduction (RRR) method was used to compare reduction in relapse rates and disease progression data from pivotal randomized double-blind placebo-controlled clinical trials of the DMDs. RRRs for relapses and disability progression, respectively, were calculated as the relative difference (treatment vs. placebo) in relapse rates and disease progression rates from placebo-controlled clinical trials. These RRRs were applied to the weighted average rates of relapse and number of disability progression steps seen in the placebo arms of the pivotal studies. The evaluation was conducted from the perspective of a U.S. health care payer (only direct medical costs considered). Medical savings were calculated as costs saved due to relapses avoided and prevention in disability progression steps. In the base case analysis, we assumed 89.4% persistence, a cost per relapse of $4,682, and a cost per disability progression step of $1,788. Monthly cost of therapy was defined as wholesale acquisition cost ($0 contractual discounts and $25 patient copayment assumed in the base case analysis) plus routine monitoring costs as assessed by an expert panel. The primary economic endpoint was cost per relapse avoided. Costs and outcomes occurring in the second year were discounted 3% to bring to 2008 present values. Oneway and multiway probabilistic (Monte Carlo) sensitivity analyses were conducted on key input variables to assess their impact on cost per relapse avoided. RESULTS Without DMD treatment, patients were predicted to experience 2.55 relapses and 0.44 disability progression steps over a 2-year period (discounted values). The 2-year reductions in clinical relapses for treatment with glatiramer acetate, IFN Beta-1a IM injection, IFN Beta-1a SC injection, and IFN Beta-1b were 0.66, 0.42, 0.74, and 0.70, respectively. The 2-year reductions in disability progression steps for treatment with glatiramer acetate, IFN Beta-1a IM injection, IFN Beta-1a SC injection, and IFN Beta-1b were 0.05, 0.15, 0.12, and 0.11, respectively. In the base case analysis, IFN Beta-1a SC injection, IFN Beta-1b SC injection, and glatiramer acetate had the most favorable costs per relapse avoided ($80,589; $87,061; and $88,310; respectively) and IFN Beta-1a IM injection had the least favorable cost-effectiveness ratio ($141,721 per relapse avoided). Sensitivity analyses showed that these results were robust to changes in key input parameters, such as the number of relapses and disease progression steps in untreated patients, the RRR in clinical relapse and progression rates, the rate of persistence, the average cost of relapse, and the average cost of a disease progression step. CONCLUSION This evaluation suggests that IFN Beta-1a SC injection, IFN Beta-1b SC injection, and glatiramer acetate represent the most cost-effective DMDs for the treatment of RRMS, where cost-effectiveness is defined as cost per relapse avoided, assuming that (a) the RRR in relapses and disease progression steps calculated from multiple DMD placebo-controlled clinical trials reflect real differences among DMDs over 2 years; and (b) resource unit costs derived from published sources reflect economic consequences of relapses and disease progression.
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Guo S, Bozkaya D, Ward A, O'Brien JA, Ishak K, Bennett R, Al-Sabbagh A, Meletiche DM. Treating relapsing multiple sclerosis with subcutaneous versus intramuscular interferon-beta-1a: modelling the clinical and economic implications. Pharmacoeconomics 2009; 27:39-53. [PMID: 19178123 DOI: 10.2165/00019053-200927010-00005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The EVIDENCE trial concluded that administering high-dose/high-frequency subcutaneous (SC) interferon-beta-1a (IFNb1a) was more effective in preventing relapses among patients with relapsing multiple sclerosis (MS) than low-dose weekly intramuscular (IM) IFNb1a after 64 weeks. This analysis utilized discrete-event simulation (DES) to model the potential longer-term clinical and economic implications of this trial. A DES predicting the course of relapsing MS and incorporating the effect of IFNb1a therapy was developed. The model began by randomly reading in actual patient data from the trial to create 1000 patients. Each simulated patient was replicated - one was assigned to receive SC IFNb1a three times a week and the other to receive IM IFNb1a once a week. During the simulation, patients may (i) experience relapses, with associated short- and long-term impacts on costs and disability; (ii) develop new T2 lesions detected by a magnetic resonance imaging scan; (iii) discontinue treatment because of adverse events or lack of response; (iv) advance to secondary progressive MS; or (v) die. Model inputs were mainly obtained from the EVIDENCE trial, but were taken from published literature if they could not be obtained from the trial. Direct medical costs ($US, year 2006 values) to the US payers were primarily obtained by updating a published cost analysis. Costs and benefits were discounted at 3% per annum. Extensive sensitivity analyses were conducted to test the robustness of the model results. Based on 100 replications of 1000 patient pairs over 4 years, SC IFNb1a was predicted to enable more patients to avoid relapse (216 vs 147). Total mean costs per patient (discounted) were $US79 890 with SC IFNb1a versus $US74 485 with IM administration, a net increase of $US5405 per patient. However, SC IFNb1a was estimated to prevent 0.50 relapses and save 23 relapse-free days per patient, yielding incremental cost-effectiveness ratios of $US10 755 per relapse prevented and $US232 per relapse-free day gained. Sensitivity analyses revealed that the result was most sensitive to the treatment efficacy, model time horizon and cost of IFNb1a treatment. Based on the results observed in the EVIDENCE trial, the model predicted that SC IFNb1a would yield greater health benefits over 4 years than IM IFNb1a, at a cost that would seem to be a reasonable trade-off.
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Affiliation(s)
- Shien Guo
- United BioSource Corporation, Lexington, Massachusetts 02420, USA.
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Freedman MS, Hughes B, Mikol DD, Bennett R, Cuffel B, Divan V, LaVallee N, Al-Sabbagh A. Efficacy of disease-modifying therapies in relapsing remitting multiple sclerosis: a systematic comparison. Eur Neurol 2008; 60:1-11. [PMID: 18437041 DOI: 10.1159/000127972] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 11/13/2007] [Indexed: 11/19/2022]
Abstract
The treatment of relapsing-remitting multiple sclerosis (RRMS) has become more effective over the last decade with the advent of the currently available disease-modifying therapies (DMTs). Pivotal clinical studies differ in many characteristics, such that cross-comparisons of relative risk reductions are of limited value and can be misleading. Our objective was to compare the clinical efficacy of currently approved first-line DMTs in patients with RRMS, applying an evidence-based medicine approach. We reviewed all phase III pivotal trials of DMTs. Six clinical trials of Avonex, Betaseron, Copaxone, Rebif and Tysabri in patients with RRMS were identified for analysis. Only randomized, placebo-controlled, double-blind studies were included. The clinical efficacy endpoints compared were: proportion of relapse-free patients at 1 and 2 years; annualized relapse rate at 2 years; proportion of progression-free patients at 2 years, and proportion of patients free of gadolinium-enhancing lesions at 1 year or 9 months. Based on these analyses, Betaseron, Rebif, and Tysabri show comparable effects, whereas for several endpoints Avonex or Copaxone did not significantly differ from placebo. In the absence of head-to-head studies for all products used to treat RRMS, it still may be possible to compare treatment effects by applying evidence-based medicine principles.
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Affiliation(s)
- Mark S Freedman
- Department of Medicine (Neurology), University of Ottawa, Ottawa, Ontario, Canada.
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Traboulsee A, Al-Sabbagh A, Bennett R, Chang P, Li DKB. Reduction in magnetic resonance imaging T2 burden of disease in patients with relapsing-remitting multiple sclerosis: analysis of 48-week data from the EVIDENCE (EVidence of Interferon Dose-response: European North American Comparative Efficacy) study. BMC Neurol 2008; 8:11. [PMID: 18426595 PMCID: PMC2374794 DOI: 10.1186/1471-2377-8-11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 04/21/2008] [Indexed: 11/18/2022] Open
Abstract
Background The EVIDENCE (EVidence of Interferon Dose-response: European North American Comparative Efficacy) study was an international, randomized, open-label, assessor-blinded, parallel-group study assessing the efficacy and tolerability of interferon (IFN) beta-1a, 44 mcg subcutaneously (sc) three times weekly (tiw), and IFN beta-1a, 30 mcg intramuscularly (im) once weekly (qw), in patients with relapsing-remitting multiple sclerosis (RRMS). The aim of this analysis was to assess whether reductions in T2 burden of disease (BOD) were greater for patients receiving IFN beta-1a, 44 mcg sc tiw, than for those treated with IFN beta-1a, 30 mcg im qw, and to assess the impact of neutralizing antibodies (NAbs). Methods A post-hoc analysis was performed on magnetic resonance imaging (MRI) data collected prospectively from the EVIDENCE study. The analysis included all patients with evaluable T2 MRI scans at the start of dosing and at week 48, and those who received at least one drug dose (n = 553). Lesions were identified by a radiologist blinded to treatment codes and the total volume of T2 lesions (BOD) was reported in mm3. Results Both median percentage decreases and absolute reduction in BOD were greater in the IFN beta-1a, 44 mcg sc tiw, treatment group. The adjusted mean treatment difference in percentage change in BOD from baseline to week 48 showed a significant treatment benefit for patients treated with IFN beta-1a, 44 mcg sc tiw, over those treated with IFN beta-1a, 30 mcg im qw (-4.6%; standard error: 2.6%; p = 0.002). The presence of NAbs reduced the effect of IFN beta-1a 44, mcg sc tiw, on BOD, but BOD changes were still similar to those seen with IFN beta-1a, 30 mcg im qw. Conclusion Patients with RRMS treated with IFN beta-1a, 44 mcg sc tiw, had greater reduction in T2 BOD after 48 weeks than those treated with IFN beta-1a, 30 mcg im qw, which is consistent with other clinical and MRI outcome measures in the EVIDENCE study. In patients testing positive for NAbs (NAb+) to IFN beta-1a 44 mcg sc tiw, changes in BOD were smaller than in NAb negative (NAb-) patients, but similar to those receiving IFN beta-1a, 30 mcg im qw.
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Affiliation(s)
- A Traboulsee
- Division of Neurology, Medicine, University of British Columbia, Vancouver, BC, Canada.
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Sergott RC, Frohman E, Glanzman R, Al-Sabbagh A. The role of optical coherence tomography in multiple sclerosis: Expert panel consensus. J Neurol Sci 2007; 263:3-14. [PMID: 17673257 DOI: 10.1016/j.jns.2007.05.024] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 05/21/2007] [Accepted: 05/23/2007] [Indexed: 10/23/2022]
Abstract
Optic neuritis (ON), a common manifestation of multiple sclerosis (MS), often occurs as the initial manifestation of central nervous system demyelination or develops during the course of this disease. Since the retinal nerve fiber layer (RNFL) is composed only of unmyelinated axons, measuring RNFL thickness represents a viable method of monitoring axonal loss in these patients. Optical coherence tomography (OCT) is a noninvasive, noncontact, accurate, and reproducible technique that quantitates the thickness of the peripapillary RNFL, fovea, and macula. Because of its potential role in defining axonal loss in ON and in assessing longitudinal changes in the RNFL before and after MS treatment, a multidisciplinary expert panel was charged with the following tasks: assess the current capabilities of OCT; review the current data about OCT, ON, and MS; and determine whether OCT could be a primary or secondary outcome measure in future MS clinical trials. The panel concluded that: [1] OCT is valid and reproducible; [2] OCT has yielded some important limited data concerning cross-sectional studies with ON and MS; [3] more studies are required to correlate OCT results with other measures of MS disease activity; [4] after correlation with these other measures and upon agreement of standardized technical and statistical methods, OCT may evolve into a important primary or secondary outcome metric for MS clinical trials and patient care.
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Affiliation(s)
- Robert C Sergott
- Thomas Jefferson University, Wills Eye Hospital, Neuro-Ophthalmology Service, 840 Walnut Street, Suite 930, Philadelphia, PA 19107, USA.
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Affiliation(s)
- Japa Volchok
- Department of Surgery, University of Massachusetts at Berkshire Medical Center, 725 North St, Pittsfield, MA 01201, USA.
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Abstract
OBJECTIVES To develop a measure of treatment satisfaction assessing attributes specific to injected interferon-beta-1a (IFN-beta-1a) for multiple sclerosis (MS), and to test pain and instrument sensitivity to change among patients changing injection devices. MATERIALS AND METHODS The MS Treatment Concerns Questionnaire (MSTCQ) was developed and tested with pain assessments before and 3 months after patients changed devices from Rebiject to Rebiject II. RESULTS The MSTCQ was organized with two domains: Injection System Satisfaction and Side Effects (three subscales: Injection Site Reactions, Global Satisfaction, and Flu-Like Symptoms). Significant improvements (P = 0.002 to P < 0.001) occurred with the new injection device in all MSTCQ subscales (except Flu-Like Symptoms), and all pain measures (P < 0.0001). Clinically meaningful improvement was demonstrated in all scales, except Flu-Like Symptoms, by effect sizes (0.23-0.59). CONCLUSIONS These statistically significant and clinically meaningful improvements in MSTCQ and pain measures show the value of technologically advanced devices in domains of concern to patients.
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Affiliation(s)
- J A Cramer
- Department of Psychiatry, Yale University, New Haven, CT 06516-2770, USA.
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Abstract
BACKGROUND African Americans (AAs) with multiple sclerosis (MS) seem to have a more severe disease course than white Americans (WAs). To our knowledge, it is not known to what extent treatment with interferon beta-1a will effect the MS disease course within the AA population. OBJECTIVE To compare the response to treatment with interferon beta-1a between AA and WA MS patients. DESIGN This is an exploratory post hoc analysis of the Evidence of Interferon Dose-Response: European North American Comparative Efficacy (EVIDENCE) study. SETTING The EVIDENCE study is a randomized controlled trial that compared the efficacy of once weekly, intramuscular, 30-microg interferon beta-1a treatment with thrice weekly, subcutaneous, 44-microg interferon beta-1a therapy in treatment-naïve MS subjects. PARTICIPANTS Thirty-six AA subjects were compared with 616 WA subjects. MAIN OUTCOME MEASURES The number of MS exacerbations, the proportion of exacerbation-free subjects, and the number of new MS lesions present on brain magnetic resonance imaging were compared between AA and WA subjects at 24 and 48 weeks after initiating treatment with interferon beta-1a. RESULTS The AA subjects experienced more exacerbations and were less likely to remain exacerbation free (statistical trends). The AA subjects developed more new MS lesions on T2-weighted brain magnetic resonance imaging at 48 weeks (P = .04). CONCLUSIONS Despite the small sample size, AA subjects appeared less responsive to treatment than WA subjects on outcome measures, reaching significance only for T2-weighted lesion count at 48 weeks. However, it is difficult to base these differences solely on response to treatment given the potential differing in MS disease course in AA patients.
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Affiliation(s)
- Bruce A C Cree
- Multiple Sclerosis Center, University of California, San Francisco, 94117, USA.
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Yasuda CL, Al-Sabbagh A, Oliveira EC, Diaz-Bardales BM, Garcia AA, Santos LM. Interferon beta modulates experimental autoimmune encephalomyelitis by altering the pattern of cytokine secretion. Immunol Invest 1999; 28:115-26. [PMID: 10484677 DOI: 10.3109/08820139909061141] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The mechanism of action underlying the beneficial effect of IFNbeta in Multiple Sclerosis is poorly understood. Experimental Autoimmune Encephalomyelitis (EAE) is the experimental model for Multiple Sclerosis; therefore, we investigated the effects of recombinant mouse IFNbeta on the severity of EAE induced in SJL mice and on cytokine production by Th1 and Th2 lymphocytes. The results indicated that rmIFN beta reduced the disease activity with an I.P. dosage of 10,000 U/day every other day, and successfully treated EAE mice revealed reduced amounts of IFN gamma; no changes in the levels of IL4 were observed, although thera was a significant increase in IL10 and TGFbeta production. Beneficial effects on EAE are associated with inhibition of inflammatory cytokines and stimulation of anti-inflammatory cytokines.
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Affiliation(s)
- C L Yasuda
- Department of Microbiology and Immunology, University of Campinas--UNICAMP, SP, Brazil
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Al-Sabbagh A, Garcia CA, Diaz-Bardales BM, Zaccarias C, Sakurada JK, Santos LM. Evidence for cross-reactivity between antigen derived from Trypanosoma cruzi and myelin basic protein in experimental Chagas disease. Exp Parasitol 1998; 89:304-11. [PMID: 9676708 DOI: 10.1006/expr.1998.4279] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Some autoimmune diseases are thought to arise after an infection. Infectious agents can initiate a chronic inflammatory response associated with autoimmune reactions. Chagas disease, caused by the intracellular parasite Trypanosoma cruzi, is an excellent model for autoimmune disease induced by an infection. The chronic disease is characterized by rich inflammatory infiltrate in myocardial and nervous tissues, with virtually no demonstrable parasites. We were able to demonstrate the presence of antibody to myelin basic protein (MBP) in the serum from T. cruzi chronically infected mice. Lymphocytes from mice immunized with T. cruzi-derived soluble extract antigen (TCSE) proliferate in response to MBP in vitro. Lymphocytes from animals immunized with MBP also were activated by TCSE in vitro. By studying the overlapping peptides from the MBP molecule, we were able to identify two regions responsible for the cross-reactivity.
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Nelson PA, Akselband Y, Dearborn SM, Al-Sabbagh A, Tian ZJ, Gonnella PA, Zamvil SS, Chen Y, Weiner HL. Effect of oral beta interferon on subsequent immune responsiveness. Ann N Y Acad Sci 1996; 778:145-55. [PMID: 8610968 DOI: 10.1111/j.1749-6632.1996.tb21123.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Oral administration of myelin antigens reduces the incidence and severity of EAE in rat and mouse models and decreases the frequency of MBP-reactive cells and the frequency of attacks in some patients with multiple sclerosis. Low-dose oral tolerance has been shown to be mediated by Th2-type regulatory cells that secrete TGFbeta and IL-4/IL-10. Adjuvants and cytokines may modulate oral tolerance. The addition of betaIFN to the experimental therapy regimen, either orally or by intraperitoneal injection, has been shown to enhance the suppressive effects of oral myelin antigens when either are fed the suboptimal dosing regimen to suppress EAE. The current studies were conducted to elucidate the mechanism of the observed in vivo synergy of betaIFN and antigen feeding. Analysis of the in vitro proliferative response and cytokine production by lymphocytes from fed animals in response to specific antigen in culture shows that the synergistic effect may be related to both independent suppression of the immune response by oral betaIFN and enhanced production of TGFbeta and IL-4/IL-10. There was an unexpected increase in the production of gammaIFN by lymphocytes in vitro after three doses of oral betaIFN in vivo. These observations have important implications for the use of cytokines to modulate oral tolerance.
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MESH Headings
- Administration, Oral
- Animals
- Antigens/administration & dosage
- Antigens/immunology
- Cattle
- Cells, Cultured
- Crosses, Genetic
- Cytokines/biosynthesis
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Encephalomyelitis, Autoimmune, Experimental/prevention & control
- Female
- Guinea Pigs
- Immune Tolerance
- Injections, Intraperitoneal
- Interferon Type I/administration & dosage
- Interferon Type I/pharmacology
- Interferon-beta/administration & dosage
- Interferon-beta/pharmacology
- Lymphocyte Activation
- Mice
- Mice, Inbred Strains
- Mycobacterium tuberculosis/immunology
- Myelin Basic Protein/administration & dosage
- Myelin Basic Protein/immunology
- Ovalbumin/immunology
- Rats
- Rats, Inbred Lew
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Affiliation(s)
- P A Nelson
- AutoImmune Inc., Lexington, Massachusetts 02173, USA
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Offermann H, Von Brachel G, Al-Sabbagh A, Farelo F. Crystallization Kinetics of NaCl in Multicomponent Solutions. Cryst Res Technol 1995. [DOI: 10.1002/crat.2170300511] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Markovic-Plese S, Hikoaki Fukoara, Al-Sabbagh A, Sette A, Kuchroo VK, Hafler DA. T cell recognition of immunodominant and cryptic proteolipid protein epitopes in humans. J Neuroimmunol 1994. [DOI: 10.1016/0165-5728(94)90423-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Offermann H, Al-Sabbagh A. 181. Einfluß unterschiedlicher Entschäumer auf die Kristallisation und Filtrierbarkeit von Gipskristallen. CHEM-ING-TECH 1994. [DOI: 10.1002/cite.3306609182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Rautenbach R, Widua J, Al-Sabbagh A. 182. Einsatz der Seeding-Technik zur Aufarbeitung härtehaltiger, wäßriger Lösungen im Horizontalrohr-Fallfilmverdampfer. CHEM-ING-TECH 1994. [DOI: 10.1002/cite.3306609183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Miller A, Al-Sabbagh A, Lider O, Sporn MB, Roberts AB, Weiner HL. Antigen driven bystander suppression of acute and relapsing EAE following oral tolerization to MBP: Immunoregulatory pathway dependent on TGF-β. J Neuroimmunol 1991. [DOI: 10.1016/0165-5728(91)90939-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Syrogiannopoulos GA, Al-Sabbagh A, Olsen KD, McCracken GH. Pharmacokinetics and bacteriological efficacy of ticarcillin-clavulanic acid (timentin) in experimental Escherichia coli K-1 and Haemophilus influenzae type b meningitis. Antimicrob Agents Chemother 1987; 31:1296-300. [PMID: 3314696 PMCID: PMC174930 DOI: 10.1128/aac.31.9.1296] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The pharmacokinetics and bacteriological efficacy of ticarcillin and clavulanic acid administered individually or in combination were assessed in rabbits with experimental Escherichia coli K-1 and Haemophilus influenzae type b meningitis. The mean penetrations into the cerebrospinal fluid (CSF) of infected animals after a single dose of ticarcillin-clavulanic acid were approximately 11 and 28% for ticarcillin and clavulanic acid, respectively. In continuous-infusion experiments, the mean penetrations into CSF were 14.6 and 35% for ticarcillin and clavulanic acid, respectively, in rabbits with E. coli meningitis and 6.1 and 24%, respectively, in rabbits with H. influenzae meningitis. In animals that received a continuous infusion of the two drugs alone or in combination, the median CSF bactericidal titers for E. coli were less than 1:2, less than 1:2, and 1:2 for ticarcillin, clavulanic acid, and ticarcillin-clavulanic acid, respectively, and for H. influenzae the titers were less than 1:2, less than 1:2, and 1:4, respectively. The addition of clavulanic acid potentiated significantly the bacteriological efficacy of ticarcillin in reducing the number of bacteria in CSF of infected rabbits. Additional studies in animals and humans are required before recommendations can be made regarding the use of ticarcillin-clavulanic acid for treatment of meningitis.
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Affiliation(s)
- G A Syrogiannopoulos
- Department of Pediatrics, University of Texas Health Science Center at Dallas, Southwestern Medical School, Dallas 75235
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