Extended survival and reduced risk of AML progression in erythroid-responsive lenalidomide-treated patients with lower-risk del(5q) MDS

Lenalidomide is the approved treatment for patients with red blood cell (RBC) transfusion-dependent lower-risk myelodysplastic syndromes (MDS) and chromosome 5q deletion (del(5q)). We report the long-term outcomes (median follow-up 3.2 years) in patients treated with lenalidomide in the MDS-003 trial. RBC transfusion independence (TI) ≥ 8 weeks was achieved in 97 of 148 treated patients (65.5%), with a median response duration of 2.2 years. Partial or complete cytogenetic response was achieved by 63 of 88 evaluable patients (71.6%). Median overall survival (OS) was longer in patients achieving RBC-TI ≥ 8 weeks (4.3 vs 2.0 years in non-responders; P<0.0001) or cytogenetic response (4.9 vs 3.1 years in non-responders; P=0.010). Time to acute myeloid leukemia (AML) progression was longer in patients achieving RBC-TI ≥ 8 weeks or any cytogenetic response versus non-responders (P=0.001 and P=0.0002, respectively). In a landmark multivariate analysis, RBC-TI ≥ 8 weeks was associated with prolonged OS (P<0.001) and a trend toward reduced relative risk of AML progression (P=0.080). Among these lower-risk MDS patients with del(5q), lenalidomide was associated with prolonged RBC-TI and cytogenetic responses, which were linked to improved OS and reduced risk of AML progression.

Multicenter analysis of 81 solid organ transplant (SOT) recipients with posttransplantation lymphoproliferative disease (PTLD): Examination of survival and prognostic factors

8510

Background: PTLD has a reported 3-year (yr) overall survival (OS) of 35–40% (Leblond, JCO 2001). The impact of rituximab (RTX) on the prognosis or outcome of PTLD is not known. Methods: We examined the clinical features, treatment, and outcomes among a large population-based cohort of SOT-related PTLD patients (pts) at 4 Chicago institutions (1/98–2/08). Prognostic factors were evaluated in univariate and Cox proportional hazards regression for survival. Results: 81 PTLD pts were identified (SOT: 47 kidney ± pancreas, 4 pancreas, 17 liver, 8 heart, 5 lung) with median age at diagnosis (dx) of 48 yrs (range 20–72). Median time from SOT to PTLD was 42 months (mo) (range 1–216 mo). PTLD dx (per WHO) were 55 monomorphic, 22 polymorphic and 4 plasmacytic, while 42 were EBV+ and 30 EBV-negative (9 unknown). 74% of pts (60/81) were treated with rituximab ± chemotherapy (and reduction of immune suppression). With 38-mo median followup for all pts, 3-yr progression-free (PFS) was 58% and 3-yr OS 62%, despite 16% of pts dying ≤ 6 weeks from dx. Most relapses (30/32) occurred ≤ 12 months from dx. Pts receiving RTX as part of therapy had 3-yr PFS of 69% and OS 71% (vs 21% (p=0.0002) and 33% (p=0.001), respectively, without RTX). Univariate analysis identified prognostic factors for PFS/OS (all <0.01): 1) PS, 2) serum albumin, 3) >1 EN site, 4) marrow involvement, 5) CNS disease and 6) RTX as part of initial therapy. Neither histology nor EBV status predicted outcome. On multivariate analysis, 4 factors remained significant ( Table 1a ). Further, a survival model based on 3 factors was constructed ( Table 1b ). Conclusions: This study represents the largest PTLD report in RTX-treated pts. We are the first to identify the prognostic significance of low albumin and a low PTLD relapse rate beyond 1 yr (6.3%). Further, it appears that the introduction of RTX has improved the survival of PTLD. In addition, clinical factors at dx identified pts with markedly divergent outcomes.

[Table: see text]

[Table: see text]

No significant financial relationships to disclose.

A case report of sarcoma regression in a patient with MDS treated with lenalidomide

20535

Background: Lenalidomide is an immunomodulatory drug recently approved for the treatment of MDS patients with del 5q cytogenetic abnormality. Here we describe a case of sarcoma regression in a patient with MDS who had been treated with lenalidomide. Method: An 84 year old man was diagnosed with low risk MDS in November 2002, he was transfusion dependent requiring 2–4 units of blood a month. He was enrolled on the MDS 002 trial in February 2004. He became transfusion independent by cycle 4. Results: In March 2005 he developed abdominal pain and a CT of the abdomen revealed a 2 x 2 cm mass involving the lesser curvature of the stomach. An MRI of the abdomen followed, confirming the presence of an enhancing gastric lesion, a biopsy of the mass revealed low grade malignant sarcoma. The patient was a poor surgical candidate and the decision was made to follow the progression of the mass with repeat imaging. In October 2005 a repeat MRI failed to visualize the previously noted mass, a recent CT performed in December 2006 was also negative for the presence of the mass. A potential therapeutic role for lenalidomide in this case which may have led to the regression of the sarcoma is possible although spontaneous regression can not be ruled out. It is not known if the mass was present at the time of enrollment on the clinic trial, it is also not clear as to why the patient presented with abdominal pain several months into the clinical trial. There had been several case reports in the literature describing similar results with thalidomide in patients with soft tissue sarcoma however, to our knowledge this clinical observation has never been reported with lenalidomide previously. Conclusion: This observation merits consideration for prospectively evaluating the efficacy of lenalidomide in patients with sarcoma for whom limited therapeutic options currently exist.

No significant financial relationships to disclose.

First two cases of immune hemolytic anemia associated with ceftizoxime

BACKGROUND

Second- and third-generation cephalosporins have been associated with immune-mediated hemolytic reactions. This report discusses two patients who developed clinically significant extravascular hemolysis while receiving the third-generation cephalosporin ceftizoxime (Ceftizox). This is believed to be the first time hemolysis has been described in patients receiving this drug.

STUDY DESIGN AND METHODS

Immunologic workup of drug-dependent antibodies was performed on blood samples using drug-coated and immune complex methodologies. Antibody classes and titers were analyzed.

RESULTS

Both the patients' sera contained anti-ceftizoxime that reacted with red cells only when ceftizoxime was added to the sera ("immune complex" method). The patients recovered without complications following discontinuation of the drug. Each patient had IgM and IgG drug-dependent antibodies. The drug-induced antibodies from each patient cross-reacted with cefotaxime, which is structurally similar to ceftizoxime, but cross-reacted either weakly or not at all with ceftriaxone, which has a more complex side chain.

CONCLUSION

This report describes the first cases of immune hemolytic anemia associated with ceftizoxime. In drug-induced hemolytic reactions, prompt recognition and discontinuation of the drug may be important factors in reducing the chance of serious sequelae.