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Phillips E, Wilson W, Benjamin R, Popat R, Braganza N, Clifton-Hadley L, Bygrave C, Cavenagh J, Chapman M, Owen R, Ramasamy K, Sive J, Streetly M, Nador G, Arnott S, Hassan S, Kishore B, Moore S, Virchis A, Willis F, Yong K. PF599 EFFICACY OF BORTEZOMIB, THALIDOMIDE AND DEXAMETHASONE FOR TREATMENT OF PATIENTS WITH CARFILZOMIB-REFRACTORY MYELOMA IN THE UK NCRI CARDAMON TRIAL. Hemasphere 2019. [DOI: 10.1097/01.hs9.0000560684.31002.b1] [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: 11/25/2022] Open
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Cavenagh J, Oakervee H, Baetiong-Caguioa P, Davies F, Gharibo M, Rabin N, Kurman M, Novak B, Shiraishi N, Nakashima D, Akinaga S, Yong K. A phase I/II study of KW-2478, an Hsp90 inhibitor, in combination with bortezomib in patients with relapsed/refractory multiple myeloma. Br J Cancer 2017; 117:1295-1302. [PMID: 28873084 PMCID: PMC5672925 DOI: 10.1038/bjc.2017.302] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/07/2017] [Accepted: 08/08/2017] [Indexed: 01/17/2023] Open
Abstract
Background: KW-2478 is a novel non-ansamycin Hsp90 inhibitor with modest single-agent activity in relapsed/refractory myeloma but which shows synergistic antimyeloma activity with bortezomib (BTZ) in preclinical studies. This study determined the safety, preliminary clinical activity, and pharmacokinetics of KW-2478, an Hsp90 inhibitor, in combination with BTZ in patients with relapsed/refractory multiple myeloma (MM). Methods: Phase I dose escalation determined the recommended phase II dose (RP2D) of KW-2478 plus BTZ, which was then used during phase II. Results: The maximum tolerated dose was not reached during phase I and the RP2D was KW-2478 175 mg m−2 plus BTZ 1.3 mg m−2 on days 1, 4, 8, and 11 every 3 weeks. In the efficacy evaluable phase I/II population treated at the RP2D (n=79), the objective response rate was 39.2% (95% confidence interval: 28.4–50.9%), clinical benefit rate 51.9% (40.4–63.3%), median progression-free survival 6.7 (5.9-not reached (NR)) months, and median duration of response 5.5 (4.9-NR) months. In the phase I/II safety population (n=95), the most frequently observed treatment-related grade 3/4 adverse events were diarrhoea, fatigue, and neutropenia (each in 7.4% of patients), and nausea and thrombocytopenia (each in 5.3%). Conclusions: KW-2478 plus BTZ was well tolerated with no apparent overlapping toxicity in patients with relapsed/refractory MM. The antimyeloma activity of KW-2478 in combination with BTZ as scheduled in this trial appeared relatively modest; however, the good tolerability of the combination would support further exploration of alternate dosing schedules and combinations.
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Affiliation(s)
- J Cavenagh
- Department of Haematology, St Bartholomew's Hospital, West Smithfield, London SE24 9LG, UK
| | - H Oakervee
- Department of Haematology, St Bartholomew's Hospital, West Smithfield, London SE24 9LG, UK
| | - P Baetiong-Caguioa
- Benavides Cancer Institute, University of Santo Tomas Hospital, Manila and St Luke's Medical Center, Quezon City, The Philippines
| | - F Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - M Gharibo
- Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers, State University of New Jersey, New Brunswick, NJ 08901, USA
| | - N Rabin
- UCL Cancer Institute, University College London, Gower Street, London WC1E 6BT, UK
| | - M Kurman
- Kyowa Kirin Pharmaceutical Development, Inc., Princeton, NJ 08540, USA
| | - B Novak
- Kyowa Kirin Pharmaceutical Development, Inc., Princeton, NJ 08540, USA
| | - N Shiraishi
- R&D Division, Kyowa Hakko Kirin Co. Ltd., Tokyo 100-0004, Japan
| | - D Nakashima
- R&D Division, Kyowa Hakko Kirin Co. Ltd., Tokyo 100-0004, Japan
| | - S Akinaga
- R&D Division, Kyowa Hakko Kirin Co. Ltd., Tokyo 100-0004, Japan
| | - K Yong
- UCL Cancer Institute, University College London, Gower Street, London WC1E 6BT, UK
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Hunt BJ, Tueger S, Pattison J, Cavenagh J, D'Cruz DP. Microangiopathic haemolytic anaemia secondary to lupus nephritis: an important differential diagnosis of thrombotic thrombocytopenic purpura. Lupus 2016; 16:358-62. [PMID: 17576739 DOI: 10.1177/0961203307077151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 11/15/2022]
Abstract
Systemic lupus erythematosus (SLE) has been described as a cause of microangiopathic haemolytic anaemia (MAHA), however there is little literature to support this assertion. We report on three patients presenting with SLE and MAHA with a clinical picture indistinguishable from thrombotic thrombocytopenic purpura (TTP), who had underlying lupus nephritis. They all had significant proteinuria and normal Von Willebrand Factor cleaving protease (vWF-CP) levels. Their MAHA fitted better for haemolytic syndrome (HUS) and their cerebral signs were explained either by malignant hypertension or cerebral lupus. Their MAHA only improved when the appropriate treatment for lupus nephritis was given.We propose that the previously described association between SLE and MAHA, in actuality relates to the underlying presence of lupus nephritis causing haemolytic uraemic syndrome, not TTP. Significant proteinuria was present in all cases of MAHA due to lupus nephritis, so may be a useful discriminatory sign. Furthermore the demonstration of a normal vWF-CP assay aided in the distinction between TTP and MAHA due to lupus nephritis. All our patients responded to mycophenolate mofetil suggesting this may be useful in other cases of lupus nephritis causing HUS. Lupus (2007) 16, 358—362.
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Affiliation(s)
- B J Hunt
- Department of Haematology, Guy's & St Thomas Trust, London, UK. Beverley.hunt@ gstt.nhs.uk
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Yong K, Cavet J, Johnson P, Morgan G, Williams C, Nakashima D, Akinaga S, Oakervee H, Cavenagh J. Phase I study of KW-2478, a novel Hsp90 inhibitor, in patients with B-cell malignancies. Br J Cancer 2015; 114:7-13. [PMID: 26695442 PMCID: PMC4716540 DOI: 10.1038/bjc.2015.422] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [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: 07/06/2015] [Revised: 10/12/2015] [Accepted: 10/26/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND KW-2478 is a novel, non-ansamycin, non-purine heat-shock protein 90 (Hsp90) inhibitor. METHODS In this phase I, multicentre study, KW-2478 was administered intravenously over 1 h at doses ranging from 14 to 176 mg m(-2) once daily on days 1-5 of a 14-day cycle in a standard 3+3 design in 27 patients (22 with multiple myeloma and 5 with non-Hodgkin lymphoma). Patients enrolled had relapsed/refractory disease previously treated with ⩾2 regimens. RESULTS There were no dose-limiting toxicities, thus the maximum-tolerated dose was not reached. KW-2478 was well tolerated and did not manifest significant retinal or ocular toxicity. The most common treatment-related adverse events were diarrhoea (33.3%), fatigue (29.6%), headache (25.9%), hypertension (22.2%), nausea (14.8%), vomiting (7.4%), and dizziness (7.4%). Plasma concentrations peaked at the end of infusion and decayed in a biphasic manner with a terminal half-life of ∼6 h. Target inhibition was inferred from the increase in Hsp70 levels in peripheral blood mononuclear cells at doses ⩾71 mg m(-2). Twenty-four of 25 (96%) evaluable patients showed stable disease, with five being free of disease progression for ⩾6 months. CONCLUSIONS Preliminary clinical response data were encouraging and warrant further investigation of KW-2478 in combination regimens for relapsed/refractory B-cell malignancies.
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Affiliation(s)
- K Yong
- UCL Cancer Institute, University College London, Huntley Street, London WC1E 6DD, UK
| | - J Cavet
- Department of Haematology, Christie Hospital/University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
| | - P Johnson
- Cancer Research UK Clinical Centre, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - G Morgan
- Myeloma Institute for Research and Therapy, West Markham Street, Little Rock, AR 72205, USA
| | - C Williams
- Centre for Clinical Haematology, Nottingham University Hospital, Hucknall Road, Nottingham NG5 1PB, UK
| | - D Nakashima
- Kyowa Hakko Kirin Pharma Inc., Princeton, NJ, USA
| | - S Akinaga
- Kyowa Hakko Kirin Co. Ltd, Tokyo Research Triangle Park, Tokyo 194-8533, Japan
| | - H Oakervee
- Department of Haematology, St. Bartholomew's Hospital, West Smithfield, London SE24 9LG, UK
| | - J Cavenagh
- Department of Haematology, St. Bartholomew's Hospital, West Smithfield, London SE24 9LG, UK
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Zdenkowski N, Cavenagh J, Ku YC, Bisquera A, Bonaventura A. Administration of chemotherapy with palliative intent in the last 30 days of life: the balance between palliation and chemotherapy. Intern Med J 2013; 43:1191-8. [DOI: 10.1111/imj.12245] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/05/2013] [Indexed: 11/27/2022]
Affiliation(s)
- N. Zdenkowski
- Department of Medical Oncology; Mercy Hospice; Calvary Mater Newcastle; Newcastle New South Wales Australia
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
| | - J. Cavenagh
- Department of Palliative Care; Mercy Hospice; Calvary Mater Newcastle; Newcastle New South Wales Australia
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
| | - Y. C. Ku
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
- Clinical Systems Team; Information Technology and Telecommunication Department; Hunter New England Local Health District; Newcastle New South Wales Australia
| | - A. Bisquera
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
- Clinical Research Design, IT and Statistical Support; Hunter Medical Research Institute; Newcastle New South Wales Australia
| | - A. Bonaventura
- Department of Medical Oncology; Mercy Hospice; Calvary Mater Newcastle; Newcastle New South Wales Australia
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
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Pratt G, Bowcock S, Lai M, Bell S, Bird J, D'Sa S, Cavenagh J, Cook G, Morgan G, Owen R, Snowden JA, Yong K, Davies F. United Kingdom Myeloma Forum (UKMF) position statement on the use of bendamustine in myeloma. Int J Lab Hematol 2013; 36:20-8. [PMID: 23615178 DOI: 10.1111/ijlh.12097] [Citation(s) in RCA: 9] [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: 11/29/2012] [Accepted: 02/25/2013] [Indexed: 11/29/2022]
Abstract
Bendamustine is a unique bifunctional alkylating agent with promising activity in myeloma. Despite the increasing number of studies demonstrating its efficacy in both the upfront and relapse settings, including patients with renal insufficiency, the optimal use of bendamustine, in terms of dosage, schedule and combination with other agents, has yet to be defined. It is currently licensed for use as frontline treatment with prednisolone for patients with myeloma who are unsuitable for transplantation and who are contraindicated for thalidomide and bortezomib. Studies in relapsed/refractory patients are currently ongoing with other combinations. Given the increasing data to date, the UK Myeloma Forum believes that bendamustine with steroids alone or in combination with a novel agent could be considered for patients with multiply relapsed myeloma. This document provides guidance for the use of bendamustine for patients with myeloma until the results of definitive studies are available.
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Affiliation(s)
- G Pratt
- Haematology, Heart of England NHS Trust, Institute for Cancer Studies, University of Birmingham, Birmingham, UK
| | - S Bowcock
- Haematology, South London Healthcare NHS Trust, Haematology Kent, Kent, UK
| | - M Lai
- Myeloma UK, Edinburgh, UK
| | - S Bell
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - J Bird
- Avon Haematology Unit, Bristol Haematology and Oncology Centre, Bristol, UK
| | - S D'Sa
- Department of Haematology, University College Hospital, London, UK
| | - J Cavenagh
- Department of Haematology, St. Bartholomew's Hospital, London, UK
| | - G Cook
- Department of Haematology, St. James's Institute of Oncology, Leeds, UK
| | - G Morgan
- Haemato-Oncology Unit, Royal Marsden Hospital, Sutton, UK
| | - R Owen
- Haematological Malignancy Diagnostic Service Laboratory, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J A Snowden
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - K Yong
- Department of Haematology, University College Hospital, London, UK
| | - F Davies
- Haemato-Oncology Unit, Royal Marsden Hospital, Sutton, UK
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Craddock C, Quek L, Goardon N, Freeman S, Siddique S, Raghavan M, Aztberger A, Schuh A, Grimwade D, Ivey A, Virgo P, Hills R, McSkeane T, Arrazi J, Knapper S, Brookes C, Davies B, Price A, Wall K, Griffiths M, Cavenagh J, Majeti R, Weissman I, Burnett A, Vyas P. Azacitidine fails to eradicate leukemic stem/progenitor cell populations in patients with acute myeloid leukemia and myelodysplasia. Leukemia 2012; 27:1028-36. [PMID: 23223186 DOI: 10.1038/leu.2012.312] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Epigenetic therapies demonstrate significant clinical activity in acute myeloid leukemia (AML) and myelodysplasia (MDS) and constitute an important new class of therapeutic agents. However hematological responses are not durable and disease relapse appears inevitable. Experimentally, leukemic stem/progenitor cells (LSC) propagate disease in animal models of AML and it has been postulated that their relative chemo-resistance contributes to disease relapse. We serially measured LSC numbers in patients with high-risk AML and MDS treated with 5'-azacitidine and sodium valproate (VAL-AZA). Fifteen out of seventy-nine patients achieved a complete remission (CR) or complete remission with incomplete blood count recovery (CRi) with VAL-AZA therapy. There was no significant reduction in the size of the LSC-containing population in non-responders. While the LSC-containing population was substantially reduced in all patients achieving a CR/CRi it was never eradicated and expansion of this population antedated morphological relapse. Similar studies were performed in seven patients with newly diagnosed AML treated with induction chemotherapy. Eradication of the LSC-containing population was observed in three patients all of whom achieved a durable CR in contrast to patients with resistant disease where LSC persistence was observed. LSC quantitation provides a novel biomarker of disease response and relapse in patients with AML treated with epigenetic therapies. New drugs that target this cellular population in vivo are required.
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Affiliation(s)
- C Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK.
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Ishii T, Seike T, Nakashima T, Juliger S, Maharaj L, Soga S, Akinaga S, Cavenagh J, Joel S, Shiotsu Y. Anti-tumor activity against multiple myeloma by combination of KW-2478, an Hsp90 inhibitor, with bortezomib. Blood Cancer J 2012; 2:e68. [PMID: 22829970 PMCID: PMC3346683 DOI: 10.1038/bcj.2012.13] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 03/16/2012] [Accepted: 03/23/2012] [Indexed: 11/09/2022] Open
Abstract
Heat shock protein 90 (Hsp90) is a promising target for anti-tumor therapy. We previously reported the anti-tumor activity of a novel Hsp90 inhibitor, KW-2478, in multiple myeloma (MM) as a single agent. In this study, we examined the combinational effect of KW-2478 and bortezomib, a proteasome inhibitor, in vitro and in vivo. In vitro, KW-2478 enhanced bortezomib-induced cell growth inhibition, both in MM cell lines and primary patient MM cells. The combination of KW-2478 and bortezomib also induced caspase activation in MM cell lines. Interestingly, the combination synergistically enhanced the expression of Hsp70B, a homolog of Hsp70, in human MM cells and peripheral blood mononuclear cells, indicating Hsp70B could be a surrogate biomarker for the combination of Hsp90 and proteasome inhibitors. In vivo, the combination of KW-2478 with bortezomib showed synergistic anti-tumor activity without significant body weight loss in a subcutaneously inoculated human myeloma model. Furthermore, the combination also showed synergistic reduction of tumor burden in bone marrow in an orthotopic myeloma model. Our results strongly suggest that combination of KW-2478 with bortezomib could exhibit enhanced anti-tumor activity against human myeloma.
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Vargaftig J, Taussig DC, Griessinger E, Anjos-Afonso F, Lister TA, Cavenagh J, Oakervee H, Gribben J, Bonnet D. Frequency of leukemic initiating cells does not depend on the xenotransplantation model used. Leukemia 2011; 26:858-60. [PMID: 21926966 PMCID: PMC3272414 DOI: 10.1038/leu.2011.250] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Cavenagh J. Myeloma therapy: pursuing the plasma cell. Br J Cancer 2010. [PMCID: PMC2905283 DOI: 10.1038/sj.bjc.6605710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Davies F, Morris C, Bird J, Cook G, Williams C, Tighe J, Cavenagh J, Behrens J, Schey S, Morgan G. United Kingdom myeloma forum position statement on the use of lenalidomide in multiple myeloma. Int J Lab Hematol 2008; 31:119-31. [PMID: 19016917 DOI: 10.1111/j.1751-553x.2008.01106.x] [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: 11/28/2022]
Abstract
Lenalidomide is an immunomodulatory drug, which has anti-myeloma activity in vitro. Phase II clinical trials have demonstrated lenalidomide in combination with dexamethasone is effective for the treatment of both relapsed refractory myeloma and newly diagnosed patients. Two large phase III studies comparing lenalidomide and dexamethasone to dexamethasone alone in relapsed patients showed superiority in response, progression free and overall survival. It is administered orally for 21 days in a 28 day cycle. Side effects are manageable and include neutropenia and venous thrombotic events. It is currently approved, in combination with dexamethasone, for the treatment of multiple myeloma patients who have received at least one prior therapy. Studies in front line patients and with other drug combinations are ongoing. Given the strength of this data the UK Myeloma Forum believe that lenalidomide in combination with dexamethasone should be available for prescription by UK haematologists according to its licensed indication in patients with relapsed myeloma.
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Affiliation(s)
- F Davies
- Royal Marsden Hospital, London, UK.
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Abstract
BACKGROUND Many palliative care patients have reduced oral intake during their illness. The management of this can include the provision of medically assisted hydration with the aim of prolonging the length of life of a patient, improving their quality of life, or both. OBJECTIVES To determine the effect of medically assisted hydration in palliative care patients on their quality and length of life. SEARCH STRATEGY Studies were identified from searching CENTRAL, MEDLINE (1966 to 2008), EMBASE (1980 to 2008), CINAHL, CANCERLIT, Caresearch, Dissertation abstracts, SCIENCE CITATION INDEX and the reference lists of all eligible studies, key textbooks, and previous systematic reviews. The date of the latest search was February 2008. SELECTION CRITERIA All relevant randomised controlled trials (RCTs) or prospective controlled studies of medically assisted hydration in palliative care patients. DATA COLLECTION AND ANALYSIS Five relevant studies were identified. These included two RCTs (93 participants), and three prospective controlled trials (360 participants). These were assessed independently by two review authors for quality and validity. The small number of studies and the heterogeneity of the data meant that a quantitative analysis was not possible, so a description of the main findings was included only. MAIN RESULTS One study found that sedation and myoclonus (involuntary contractions of muscles) were improved more in the intervention group (28 - hydration, 23 - placebo). Another study found that dehydration was significantly higher in the non-hydration group, but that some fluid retention symptoms (pleural effusion, peripheral oedema and ascites) were significantly higher in the hydration group (59 - hydration group, 167 - non -hydration group). The other three studies did not show significant differences in outcomes between the two groups. AUTHORS' CONCLUSIONS There are insufficient good quality studies to make any recommendations for practice with regard to the use of medically assisted hydration in palliative care patients.
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Affiliation(s)
- P Good
- Calvary Mater Hospital and University of Newcastle, Palliative Care, Locked Bag 7, Hunter Regional Mail Centre, Warabrook, Newcastle, NSW, Australia, 2310.
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Carter GL, Clover KA, Parkinson L, Rainbird K, Kerridge I, Ravenscroft P, Cavenagh J, McPhee J. Mental health and other clinical correlates of euthanasia attitudes in an Australian outpatient cancer population. Psychooncology 2007; 16:295-303. [PMID: 16921477 DOI: 10.1002/pon.1058] [Citation(s) in RCA: 11] [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: 11/12/2022]
Abstract
A majority of patients with cancer have been reported to endorse euthanasia and physician assisted suicide (PAS) in general and a substantial proportion endorse these for themselves. However, the potential influence of mental health and other clinical variables on these decisions is not well understood. This study of 228 outpatients attending an oncology clinic in Newcastle, Australia used a cross-sectional design and logistic regression modelling to examine the relationship of demographic, disease status, mental health and quality of life variables to attitudes toward euthanasia and PAS. The majority reported support for euthanasia (79%, n=179), for PAS (69%, n=158) and personal support for euthanasia/PAS (68%, n=156). However, few reported having asked their doctor for euthanasia (2%, n=5) or PAS (2%, n=5). Three outcomes were modelled: support for euthanasia was associated with active religious belief (adjusted odds ratio (AOR) 0.21, 95% CI: 0.10-0.46); support for PAS was associated with active religious belief (AOR 0.35, 95% CI: 18-0.70) and recent pain (AOR 0.87, 95% CI: 0.0.76-0.99); and personal support for euthanasia/PAS was associated with active religious belief (AOR 0.26, 95% CI: 0.14-0.48). Depression, anxiety, recent suicidal ideation, and lifetime suicide attempt were not independently associated with any of the three outcomes modelled.
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Affiliation(s)
- G L Carter
- HEAD, Suicide Prevention Research Unit, Centre for Mental Health Studies, Hunter Mail Centre, NSW 2310, Australia.
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Lim ZY, Killick S, Germing U, Cavenagh J, Culligan D, Bacigalupo A, Marsh J, Mufti GJ. Low IPSS score and bone marrow hypocellularity in MDS patients predict hematological responses to antithymocyte globulin. Leukemia 2007; 21:1436-41. [PMID: 17507999 DOI: 10.1038/sj.leu.2404747] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.9] [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: 11/09/2022]
Abstract
Immunosuppressive therapy has been shown to induce sustained hematological responses in a subset of patients with myelodysplastic syndromes (MDS). In particular, antithymocyte globulin (ATG), a polyclonal immunoglobulin induces hematological responses in up to 60% of MDS patients. We report herein on the results of a retrospective multicenter study on the use of ATG in the treatment of 96 patients with MDS. Patients were evaluated for duration of response to ATG, as well as survival after administration of ATG. The median age of the cohort was 54.7 years (range: 19-75 years), with a median follow-up of 33.8 months (range: 0.8-133 months). A total of 40 patients (42%) achieved a hematological response, of which 30 patients (75%) had a durable hematological response lasting a median duration of 31.5 months (range: 6-92 months). On multivariate analysis, both low International Prognostic Scoring System (IPSS) and bone marrow (BM) hypocellularity were independent predictive factors for improved response to ATG (IPSS Int-2/high: odds ratio (OR) 0.08, P=0.018 and BM normo/hypercellularity: OR 0.49, P=0.012). In addition, IPSS was the sole predictor of overall survival, with Int-2/high risk patients having a significantly poorer survival outcome (OR 0.08, P<0.01). In conclusion, this study identifies BM hypocellularity and a low IPSS as important factors predicting response to ATG.
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Affiliation(s)
- Z Y Lim
- Kings College London, Department of Haematological Medicine, Kings College Hospital, London, UK
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Lim Z, Killick S, Germing U, Cavenagh J, Culligan D, Bacigalupo A, Marsh J, Mufti G. C025 Low IPSS score and bone marrow hypocellularity in MDS patients predict haematological responses to anti-thymocyte globulin. Leuk Res 2007. [DOI: 10.1016/s0145-2126(07)70063-2] [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: 10/23/2022]
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Summers K, Stevens J, Kakkas I, Smith M, Smith LL, Macdougall F, Cavenagh J, Bonnet D, Young BD, Lister TA, Fitzgibbon J. Wilms' tumour 1 mutations are associated with FLT3-ITD and failure of standard induction chemotherapy in patients with normal karyotype AML. Leukemia 2007; 21:550-1; author reply 552. [PMID: 17205055 DOI: 10.1038/sj.leu.2404514] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
Patients suffering from neuropathic pain continue to pose challenges in clinical practice. This descriptive review discusses the continuing debate on the definition and concerns about increasing incidence of neuropathic pain. The clinical features of neuropathic pain are outlined, and the current understanding of the possible mechanisms of neuropathic pain is highlighted. Current management strategies are reviewed, and future advances in our understanding of the mechanisms, accurate clinical diagnosis and more effective treatment strategies are eagerly awaited.
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Affiliation(s)
- J Cavenagh
- Department of Palliative Care, Mater Misericordiae Hospital, Newcastle, New South Wales, Australia.
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Bhattacharyya M, Oakervee H, Dalley C, Glynn M, Cavenagh J. Hepatitis-associated aplastic anaemia treated successfully with antilymphocyte globulin. ACTA ACUST UNITED AC 2005; 27:331-3. [PMID: 16178916 DOI: 10.1111/j.1365-2257.2005.00708.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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: 11/28/2022]
Abstract
Aplastic anaemia may occur following an acute attack of hepatitis. This is a rare condition, which if not recognized and promptly treated, may be fatal. Antilymphocyte globulin and allogeneic bone marrow transplantation have been used in the treatment of this condition. We report the case of a young man who developed severe aplastic anaemia following nonviral hepatitis.
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Affiliation(s)
- M Bhattacharyya
- Department of Haematology, Barts and The London NHS Trust, West Smithfield, London, UK.
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19
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Abstract
AIMS To assess whether opioid and sedative medication use affects survival (from hospice admission to death) of patients in an Australian inpatient palliative care unit. BACKGROUND Retrospective audit. Newcastle Mercy Hospice--a tertiary referral palliative care unit. All patients who died in the hospice between 1 February and 31 December 2000. METHODS Length of survival from hospice admission to death, and the median and mean doses of opioids and sedatives used in the last 24 h of life. Comparison of these with published studies outside of Australia. RESULTS In this study, the use of opioids, benzodiazepines and haloperidol did not have an association with shortened survival and the only statistical significant finding was an increased survival in patients who were on 300 mg/day or more of oral morphine equivalent (OME). The proportion of patients requiring greater than or equal to 300 mg OME/day (at 28%) was higher than published studies, but the mean dose of 371 mg OME/day was within the range of other studies. The proportion of patients receiving sedatives (94%) was higher than other studies, but the median dose of parenteral midazolam equivalent of 12.5 mg per 24 h was lower than other studies from outside Australia. CONCLUSIONS There was no association between the doses of opioids and sedatives on the last day of life and survival (from hospice admission to death) in this population of palliative care patients.
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Affiliation(s)
- P D Good
- Division of Palliative Care, Newcastle Mater Misericordiae Hospital, Waratah, New South Wales, Australia.
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20
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Cummins M, Cwynarski K, Marktel S, Dazzi F, Cavenagh J, Clark RE, Holyoake TL, Milligan D, Parker A, Russell NH, Marks DI. Management of chronic myeloid leukaemia in relapse following donor lymphocyte infusion induced remission: a retrospective study of the clinical trials committee of the British Society of Blood & Marrow Transplantation (BSBMT). Bone Marrow Transplant 2005; 36:1065-9. [PMID: 16247434 DOI: 10.1038/sj.bmt.1705180] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [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: 11/09/2022]
Abstract
Donor lymphocyte infusion (DLI) can restore remission in a high percentage of patients with chronic myeloid leukaemia (CML) who relapse after allogeneic stem cell transplant (SCT). Subsequent relapses after a DLI-induced remission do occur and the optimal management of these patients is not defined. A retrospective study of the practice of UK transplant centres was conducted. In all, 13 patients from seven centres were identified: all were treated for relapse post allogeneic SCT with DLI and achieved either a complete cytogenetic (n=5) or molecular (n=8) remission. All patients subsequently had a second relapse, at molecular (n=7), cytogenetic (n=4) and haematological (n=2) levels. Further DLI was used in the treatment of 11 patients, imatinib mesylate in three and chemotherapy in two. The two patients with haematological relapse died of blastic disease. The remaining 11 patients achieved either a complete cytogenetic (n=2) or molecular (n=9) remission. Nine patients remain in molecular remission at a median follow-up of 29 months, seven of whom had received DLI alone as treatment for second relapse, one DLI plus imatinib and one imatinib alone. Toxicity following DLI for second relapse was low. Longer follow-up will be required to see if these second DLI-induced remissions will be durable.
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Affiliation(s)
- M Cummins
- Adult BMT Unit, Bristol Royal Children's Hospital, Bristol, UK
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21
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Bennett AN, Sangle SR, Jan W, Jenner M, Cavenagh J, Hughes G, D'Cruz DP. Hepatomegaly as a rare presentation of Churg–Strauss syndrome. Rheumatology (Oxford) 2005; 44:1458-9. [PMID: 16105912 DOI: 10.1093/rheumatology/kei021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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22
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Hunter HM, Peggs K, Powles R, Rahemtulla A, Mahendra P, Cavenagh J, Littlewood T, Potter M, Hunter A, Pagliuca A, Williams CD, Cook G, Towlson K, Marks David I, Russell NH. Analysis of outcome following allogeneic haemopoietic stem cell transplantation for myeloma using myeloablative conditioning - evidence for a superior outcome using melphalan combined with total body irradiation. Br J Haematol 2005; 128:496-502. [PMID: 15686458 DOI: 10.1111/j.1365-2141.2004.05330.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [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: 11/30/2022]
Abstract
We have undertaken a retrospective multicentre analysis of 139 patients (median age 44.4 years) undergoing allogeneic haematopoietic stem cell transplantation (HSCT) for multiple myeloma using myeloablative conditioning. The majority of patients received total body irradiation (TBI) combined with either melphalan (56.9%) or cyclophosphamide (28.5%). Overall, transplant-related mortality (TRM) was 37.9% at 1 year and was not significantly different for patients receiving melphalan/TBI compared with cyclophosphamide/TBI. The overall complete remission (CR) rate, including patients in CR at the time of transplant, was greater for patients receiving melphalan/TBI (64.7%) compared with cyclophosphamide/TBI (47.2%)(P = 0.085). A significantly higher proportion of patients with continuing disease at the time of transplant achieved CR post-transplant following melphalan/TBI conditioning compared with cyclophosphamide/TBI (52.9% and 33.4% respectively, P = 0.009). Relapse/progression rates at 5 years were significantly lower for melphalan/TBI (36.7%) compared with cyclophosphamide/TBI (80.8%, P < 0.0001) and remained significant in multivariate analysis. This resulted in an overall survival at 5 years of 44.1% and 28.1% for melphalan/TBI and cyclophosphamide/TBI, respectively (P = 0.059). These results demonstrate that the type of conditioning for sibling allogeneic HSCT for myeloma has a major effect on transplant outcome.
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Affiliation(s)
- H M Hunter
- Nottingham City Hospital, Nottingham NG5 1PB, UK
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23
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Schey SA, Cavenagh J, Johnson R, Child JA, Oakervee H, Jones RW. An UK myeloma forum phase II study of thalidomide; long term follow-up and recommendations for treatment. Leuk Res 2003; 27:909-14. [PMID: 12860011 DOI: 10.1016/s0145-2126(03)00027-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Myeloma remains incurable with conventional treatment in the vast majority of patients. The introduction of thalidomide in 1999 for the treatment of relapsed disease offers the opportunity to treat patients who have developed myelotoxicity or who are refractory to conventional chemotherapy. The optimal schedule remains unresolved and only two studies have reported long term follow-up data. We report a phase II low dose escalation study of thalidomide with long term follow-up showing overall survival (OS) of 19 months and progression free survival (PFS) of 14 months. In addition we report on the side effects and toxicity and give recommendations for the use of thalidomide in the relapsed setting based upon these findings.
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Affiliation(s)
- S A Schey
- Department of Haematology, Guy's Hospital, King's College London Medical School, University of London, London SE1 9RT, UK.
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24
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Longhurst HJ, O'Grady C, Evans G, De Lord C, Hughes A, Cavenagh J, Helbert MR. Anti-D immunoglobulin treatment for thrombocytopenia associated with primary antibody deficiency. J Clin Pathol 2002; 55:64-6. [PMID: 11825928 PMCID: PMC1769561 DOI: 10.1136/jcp.55.1.64] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [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] [Indexed: 11/03/2022]
Abstract
AIMS To review our experience of anti-D immunoglobulin for immune thrombocytopenia (ITP) in patients with primary antibody deficiency. METHODS/PATIENTS A retrospective case notes review of four Rhesus positive patients with ITP and primary antibody deficiency, treated with anti-D. Patients were refractory to steroids and high dose intravenous immunoglobulin (IVIG). Two patients were previously splenectomised. RESULTS All patients responded to anti-D immunoglobulin. Improved platelet counts were sustained for at least three months. Side effects included a fall in haemoglobin in all cases; one patient required red blood cell transfusion. Two patients had transient neutropenia (< 1 x 10(9)/litre). CONCLUSION Anti-D immunoglobulin may be an effective treatment for antibody deficiency associated thrombocytopenia, even after splenectomy. Anti-D immunoglobulin may have considerable clinical advantages in this group of patients, where treatments resulting in further immunosuppression are relatively contraindicated.
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Affiliation(s)
- H J Longhurst
- Department of Immunopathology, Barts and The London NHS Trust, London EC1A 7BE, UK.
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25
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Abstract
AIM To compare anticardiolipin (ACL) and anti-beta2 glycoprotein 1 (beta2gp1) enzyme linked immunosorbent assays (ELISAs) in the diagnosis of antiphospholipid syndrome (APS) and to incorporate these results into a meta-analysis of published data. METHOD Three representative commercial ACL ELISAs and an in house beta2gp1 assay were optimised and then assessed on 124 sera from normal donors, patients with infection, or patients with APS. A Medline search was screened for papers meeting defined criteria to conduct a meta-analysis. The performance of the assays used in this study was included. RESULTS A non-quantitative ACL assay performed at least as well as the anti-beta2gp1 assay in the diagnosis of APS. Meta-analysis confirmed that neither assay is perfect, although the anti-beta2gp1 assay had a higher specificity and lower sensitivity than the ACL assay. CONCLUSIONS The pooled data suggest that the ACL assay is used to investigate thrombosis without overt underlying pathology and that the improved specificity of the anti-beta2gp1 assay is exploited where infection, connective tissue disease, or atheroma are present.
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Affiliation(s)
- M Helbert
- Department of Immunopathology, St Bartholomews and the London NHS Trust, London EC1A 7BE, UK.
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26
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Matutes E, Taylor GP, Cavenagh J, Pagliuca A, Bareford D, Domingo A, Hamblin M, Kelsey S, Mir N, Reilly JT. Interferon alpha and zidovudine therapy in adult T-cell leukaemia lymphoma: response and outcome in 15 patients. Br J Haematol 2001; 113:779-84. [PMID: 11380470 DOI: 10.1046/j.1365-2141.2001.02794.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [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: 11/20/2022]
Abstract
Adult T-cell leukaemia lymphoma (ATLL) is an aggressive disease caused by the human T-lymphotropic virus 1 (HTLV-I) with a short survival. Responses to interferon alpha (IFN-alpha) and zidovudine (AZT) have been documented but not with long-term follow-up. We treated 15 ATLL patients with IFN and AZT. Eleven patients had acute ATLL, two had lymphoma and two smouldering ATLL, with progression. The main features were: organomegaly (14), skin lesions (10), high white blood cell (WBC) count (11) and hypercalcaemia (9). Eleven patients had previously received chemotherapy and one had received an autograft. At the time of the study, seven patients had progressive disease and eight were in partial or complete clinical remission. Responses (PR) lasting 2+ to 44+ months were seen in 67%; 26% did not respond (NR) and one patient was not evaluable. Hypercalcaemia predicted a poor outcome but differences were not significant. Eight of the 15 patients have died 3-41 months from diagnosis. Median survival for the 15 patients was 18 months. Survival of the NR ranged from 4 to 20 months; six PR patients are alive 8-82 months from diagnosis. The differences in survival between NR (median: 6 months) and PR (55% of patients alive at 4 years) were statistically significant (P = 0.002). In conclusion, IFN and AZT improves the outcome of ATLL patients and helps maintain responses.
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Affiliation(s)
- E Matutes
- Haematology Department of the Royal Marsden NHS Trust, London, UK. estella.icr.ac.uk
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27
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Silberstein L, Davies A, Kelsey S, Foran J, Murrell C, D'Cruz D, Vinnicombe S, Norton A, Cavenagh J. Myositis, polyserositis with a large pericardial effusion and constrictive pericarditis as manifestations of chronic graft-versus-host disease after non-myeloablative peripheral stem cell transplantation and subsequent donor lymphocyte infusion. Bone Marrow Transplant 2001; 27:231-3. [PMID: 11281399 DOI: 10.1038/sj.bmt.1702775] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The clinical features of chronic graft-versus-host disease (cGVHD) following a non-myeloablative peripheral blood stem cell (PBSC) transplant may differ from those that occur after a conventional allograft. We describe a man with Hodgkin's disease refractory to chemotherapy and radiotherapy who was transplanted from an HLA-identical brother, who developed cGVHD characterised, in particular, by polymyositis, polyserositis with a large pericardial effusion and constrictive pericarditis, 1 month after donor lymphocyte infusion for relapsed disease. Constrictive pericarditis has not been previously reported after a conventional allograft, and none of these features have been reported after a non-myeloablative transplant. The course of cGVHD necessitated potent immunosuppression leading to the presumed loss of graft-versus-lymphoma (GVL) effect.
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Affiliation(s)
- L Silberstein
- Department of Haematological Oncology, St Bartholomew's Hospital, London, UK
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28
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Smith P, Helbert M, Raftery M, Forster G, Cavenagh J. Paraproteins and monoclonal expansion of CD3+CD8+ CD56-CD57+ T lymphocytes in a patient with HIV infection. Br J Haematol 1999; 105:85-7. [PMID: 10233367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
An expansion of CD8+ lymphocytes associated with a monoclonal rearrangement of the T-cell receptor gamma locus was found in a woman with HIV-1 infection. A subpopulation of HIV-positive patients display an unusual response to HIV infection characterized by a persistent marked CD8+ lymphocytosis, the presence of which appears to be associated with an improved long-term prognosis. This condition is thought to represent a florid immune response to an ongoing viral infection which may be HIV itself, and suggests that monoclonal proliferation of CD8+ lymphocytes does not imply the presence of an underlying malignant process.
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Affiliation(s)
- P Smith
- Department of Genitourinary Medicine, Royal Hositals NHS Trust, Whitechapel, London
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29
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Wijker M, Morgan NV, Herterich S, van Berkel CG, Tipping AJ, Gross HJ, Gille JJ, Pals G, Savino M, Altay C, Mohan S, Dokal I, Cavenagh J, Marsh J, van Weel M, Ortega JJ, Schuler D, Samochatova E, Karwacki M, Bekassy AN, Abecasis M, Ebell W, Kwee ML, de Ravel T. Heterogeneous spectrum of mutations in the Fanconi anaemia group A gene. Eur J Hum Genet 1999; 7:52-9. [PMID: 10094191 DOI: 10.1038/sj.ejhg.5200248] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Fanconi anaemia (FA) is a genetically heterogeneous autosomal recessive disorder associated with chromosomal fragility, bone-marrow failure, congenital abnormalities and cancer. The gene for complementation group A (FAA), which accounts for 60-65% of all cases, has been cloned, and is composed of an open reading frame of 4.3 kb, which is distributed among 43 exons. We have investigated the molecular pathology of FA by screening the FAA gene for mutations in a panel of 90 patients identified by the European FA research group, EUFAR. A highly heterogeneous spectrum of mutations was identified, with 31 different mutations being detected in 34 patients. The mutations were scattered throughout the gene, and most are likely to result in the absence of the FAA protein. A surprisingly high frequency of intragenic deletions was detected, which removed between 1 and 30 exons from the gene. Most microdeletions and insertions occurred at homopolymeric tracts or direct repeats within the coding sequence. These features have not been observed in the other FA gene which has been cloned to date (FAC) and may be indicative of a higher mutation rate in FAA. This would explain why FA group A is much more common than the other complementation groups. The heterogeneity of the mutation spectrum and the frequency of intragenic deletions present a considerable challenge for the molecular diagnosis of FA. A scan of the entire coding sequence of the FAA gene may be required to detect the causative mutations, and scanning protocols will have to include methods which will detect the deletions in compound heterozygotes.
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Affiliation(s)
- M Wijker
- Department of Human Genetics, Free University of Amsterdam, The Netherlands
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30
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Tsetis D, Bhattacharya J, Cavenagh J, Thakkar CH. Case report: CT and MRI demonstration of hypothalamic and infundibular relapse in childhood acute lymphoblastic leukaemia. Br J Radiol 1996; 69:269-71. [PMID: 8800873 DOI: 10.1259/0007-1285-69-819-269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [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: 02/02/2023] Open
Abstract
The central nervous system is affected in up to 10% of patients with acute lymphoblastic leukaemia, usually in the form of leptomeningeal infiltration. Parenchymal spread is rare. We report a case in which CT and MRI demonstrated hypothalamic and infundibular relapse.
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Affiliation(s)
- D Tsetis
- Department of Radiology, Royal London Hospital, UK
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31
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Zuiable A, Treleaven JG, Powles RL, Aboud H, Tiley C, Kenny MW, Cavenagh J. Acute Myeloid Leukaemia Following Matched Allogeneic Bone Marrow Transplantation for T-Cell Lymphoblastic Lymphoma. Leuk Lymphoma 1991; 5:431-3. [DOI: 10.3109/10428199109067639] [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: 11/13/2022]
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32
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Cavenagh J. Flight 30 ... over the end! JEMS 1982; 7:34-6. [PMID: 10256336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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