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Grant B, Ratnayake G, Williams CL, Long A, Halsall DJ, Semple RK, Cavenagh JD, Drake WM, Church DS. Resolution of dysglycaemia after treatment of monoclonal gammopathy of endocrine significance. Eur J Endocrinol 2023; 189:K25-K29. [PMID: 37818852 PMCID: PMC10711369 DOI: 10.1093/ejendo/lvad138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/14/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
In very rare cases of monoclonal gammopathy, insulin-binding paraprotein can cause disabling hypoglycaemia. We report a 67-year-old man re-evaluated for hyperinsulinaemic hypoglycaemia that persisted despite distal pancreatectomy. He had no medical history of diabetes mellitus or autoimmune disease but was being monitored for an IgG kappa monoclonal gammopathy of undetermined significance. On glucose tolerance testing, hyperglycaemia occurred at 60 min (glucose 216 mg/dL) and hypoglycaemia at 300 min (52 mg/dL) concurrent with an apparent plasma insulin concentration of 52 850 pmol/L on immunoassay. Laboratory investigation revealed an IgG2 kappa with very high binding capacity but low affinity (Kd 1.43 × 10-6 mol/L) for insulin. The monoclonal gammopathy was restaged as smouldering myeloma not warranting plasma cell-directed therapy from a haematological standpoint. Plasma exchange reduced paraprotein levels and improved fasting capillary glucose concentrations. Lenalidomide was used to treat disabling hypoglycaemia, successfully depleting paraprotein and leading to resolution of symptoms.
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Affiliation(s)
- Bonnie Grant
- Department of Endocrinology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - Gowri Ratnayake
- Department of Endocrinology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - Claire L Williams
- Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research, Southmead Hospital, Bristol BS10 5NB, United Kingdom
| | - Anna Long
- Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research, Southmead Hospital, Bristol BS10 5NB, United Kingdom
| | - David J Halsall
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Robert K Semple
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
- MRC Human Genetics Unit, Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh EH4 2XU, United Kingdom
| | - James D Cavenagh
- Department of Haematolo-Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - William M Drake
- Department of Endocrinology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - David S Church
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
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Heydt Q, Xintaropoulou C, Clear A, Austin M, Pislariu I, Miraki-Moud F, Cutillas P, Korfi K, Calaminici M, Cawthorn W, Suchacki K, Nagano A, Gribben JG, Smith M, Cavenagh JD, Oakervee H, Castleton A, Taussig D, Peck B, Wilczynska A, McNaughton L, Bonnet D, Mardakheh F, Patel B. Adipocytes disrupt the translational programme of acute lymphoblastic leukaemia to favour tumour survival and persistence. Nat Commun 2021; 12:5507. [PMID: 34535653 PMCID: PMC8448863 DOI: 10.1038/s41467-021-25540-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 08/17/2021] [Indexed: 11/09/2022] Open
Abstract
The specific niche adaptations that facilitate primary disease and Acute Lymphoblastic Leukaemia (ALL) survival after induction chemotherapy remain unclear. Here, we show that Bone Marrow (BM) adipocytes dynamically evolve during ALL pathogenesis and therapy, transitioning from cellular depletion in the primary leukaemia niche to a fully reconstituted state upon remission induction. Functionally, adipocyte niches elicit a fate switch in ALL cells towards slow-proliferation and cellular quiescence, highlighting the critical contribution of the adipocyte dynamic to disease establishment and chemotherapy resistance. Mechanistically, adipocyte niche interaction targets posttranscriptional networks and suppresses protein biosynthesis in ALL cells. Treatment with general control nonderepressible 2 inhibitor (GCN2ib) alleviates adipocyte-mediated translational repression and rescues ALL cell quiescence thereby significantly reducing the cytoprotective effect of adipocytes against chemotherapy and other extrinsic stressors. These data establish how adipocyte driven restrictions of the ALL proteome benefit ALL tumours, preventing their elimination, and suggest ways to manipulate adipocyte-mediated ALL resistance.
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Affiliation(s)
- Q Heydt
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - C Xintaropoulou
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - A Clear
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - M Austin
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - I Pislariu
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - F Miraki-Moud
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - P Cutillas
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - K Korfi
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - M Calaminici
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - W Cawthorn
- BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, Edinburgh BioQuarter, University of Edinburgh, Edinburgh, Scotland, UK
| | - K Suchacki
- BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, Edinburgh BioQuarter, University of Edinburgh, Edinburgh, Scotland, UK
| | - A Nagano
- Centre for Molecular Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - J G Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - M Smith
- Department of Haemato-Oncology, St Bartholomew's Hospital, West Smithfield, London, UK
| | - J D Cavenagh
- Department of Haemato-Oncology, St Bartholomew's Hospital, West Smithfield, London, UK
| | - H Oakervee
- Department of Haemato-Oncology, St Bartholomew's Hospital, West Smithfield, London, UK
| | - A Castleton
- Christie NHS Foundation Trust, Manchester, UK
| | - D Taussig
- Haemato-oncology Unit, The Royal Marsden Hospital, Sutton, UK
| | - B Peck
- Centre for Tumour Biology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - A Wilczynska
- CRUK Beatson Institute, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - L McNaughton
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
| | - D Bonnet
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
| | - F Mardakheh
- Centre for Molecular Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK
| | - B Patel
- Centre for Haemato-Oncology, Barts Cancer Institute, John Vane Science Centre, Charterhouse Square, Queen Mary University of London, London, UK.
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Yong K, Camilleri M, Wilson W, Ramasamy K, Streetly MJ, Sive J, Bygrave C, Chapman MA, De Tute R, Chavda SJ, Phillips E, Cuadrado M, Pang G, Jenner R, Dadaga T, Kamora S, Cavenagh JD, Clifton-Hadley L, Owen RG, Popat R. Upfront autologous stem cell transplantation (ASCT) versus carfilzomib-cyclophosphamide-dexamethasone (KCd) consolidation with K maintenance in transplant-eligible, newly diagnosed (NDTE) multiple myeloma (MM). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.8000] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8000 Background: Upfront ASCT for NDTE MM remains under evaluation with high MRD rates following novel induction and consolidation (cons) strategies. Current phase 3 trials support ASCT, however these employ lenalidomide maintenance which predominantly benefits standard risk (SR) patients (pts). The CARDAMON trial investigated the role of ASCT using K based induction and maintenance. Methods: NDTE pts received 4 x KCd induction (K 20/56 mg/m2 biweekly, C 500 mg D 1,8,15, d 40mg weekly) before 1:1 randomisation to ASCT or 4 x KCd cons. All received 18 months K maintenance (56mg/m2 D1,8,15). Flow cytometric MRD (10-5) was assessed post induction, pre-maintenance and at 6 months maintenance. Primary endpoints were ≥VGPR post induction and 2-year PFS from randomisation. 210 randomised pts were needed to exclude a 10% non-inferiority margin with 15% 1-sided alpha, 80% power. Results: 281 pts were registered, median age 59y (33–74), 24% high risk [t(4;14), t(14;16), t(14;20) or del(17p)]. Post induction, ≥VGPR rate was 58.5%, ORR was 87% with similar responses for high risk vs SR. 52 pts did not proceed to PBSCH (6 MR, 16 PD, 19 toxicity, 4 deaths: 3 infection, 1 cardiac event, 7 other). 109 were randomised to ASCT, 109 to KCd cons. ≥VGPR rate was 78.5% after cons and 80.0% after ASCT (p = 0.8). Median KCd cons dose was 55.5 mg/m2, 99 (90.8%) pts completed 4 cycles, 104 (95.4%) pts received ASCT. After 2.6 years follow-up, median PFS was not reached for ASCT vs 3.8 years for cons (HR: 0.82 (70% CI 0.65, 1.05, p = 0.4). Observed 2-year PFS for ASCT was 75.5% vs 70.7% for cons; calculated difference in 2-year PFS rate (cons vs ASCT) was -4.5% (70% CI -9.2%, +1.1%, non-inferior). High risk pts had inferior outcomes to SR overall regardless of randomisation (2-year PFS ASCT: 52% vs 82% (HR 4.09); cons 48% vs 77% (HR 2.83)). 2 year PFS did not differ according to randomisation: SR 82% (ASCT) vs 77% (cons) HR: 1.29 (0.71-2.35); high risk: 52% (ASCT) vs 48% (cons) HR: 1.06 (0.50-2.23). MRD negativity post induction was 24.3% and similar by genetic risk. MRD negative rates were higher post ASCT (53.1%) than cons (35.8%) (p = 0.02) independent of genetics: SR 49% (ASCT) vs 36% (cons); high risk: 57% (ASCT) vs 32% (cons). G3+ adverse events to induction were infections (18.7%), hypertension (11.2%), anaemia (10.4%), cardiac disorders (3.6%), vomiting (2.2%), fatigue (2.2%), diarrhoea (1.8%). Conclusions: In NDMM receiving KCd induction and K maintenance, KCd cons was non-inferior to ASCT. High risk pts had inferior outcomes, that were not influenced by ASCT or cons randomisation. Clinical trial information: NCT02315716. [Table: see text]
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Affiliation(s)
- Kwee Yong
- University College Hospital, London, United Kingdom
| | - Marquita Camilleri
- Haematology Department, University College Hospitals, London, United Kingdom
| | - William Wilson
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, United Kingdom
| | - Karthink Ramasamy
- Haematology Department, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | | | - Jonathan Sive
- Haematology Department, University College Hospitals, London, United Kingdom
| | - Ceri Bygrave
- Haematology Department, University Hospital of Wales, Cardiff, United Kingdom
| | - Michael A Chapman
- Haematology Department, Cambridge Institute for Medical Research, Cambridge, United Kingdom
| | - Ruth De Tute
- HMDS Laboratory, St James’ Institute of Oncology, Leeds, United Kingdom
| | - Selina J Chavda
- Cancer Institute, University College London, London, United Kingdom
| | - Elizabeth Phillips
- Division of Cancer Sciences, Manchester Cancer Research Centre, University of Manchester, Manchester, United Kingdom
| | - Maria Cuadrado
- Haematology Department, King's College Hospital, London, United Kingdom
| | - Gavin Pang
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, United Kingdom
| | - Richard Jenner
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, United Kingdom
| | - Tushhar Dadaga
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, United Kingdom
| | - Sumaiya Kamora
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, United Kingdom
| | - James D. Cavenagh
- Haematology Department, St Bartholomew's Hospital, Bart’s Health NHS Trust, London, United Kingdom
| | - Laura Clifton-Hadley
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, United Kingdom
| | - Roger G. Owen
- HMDS Laboratory, St James’ Institute of Oncology, Leeds, United Kingdom
| | - Rakesh Popat
- NIHR UCLH Clinical Research Facility, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Freeman SD, Hills RK, Virgo P, Khan N, Couzens S, Dillon R, Gilkes A, Upton L, Nielsen OJ, Cavenagh JD, Jones G, Khwaja A, Cahalin P, Thomas I, Grimwade D, Burnett AK, Russell NH. Measurable Residual Disease at Induction Redefines Partial Response in Acute Myeloid Leukemia and Stratifies Outcomes in Patients at Standard Risk Without NPM1 Mutations. J Clin Oncol 2018; 36:1486-1497. [PMID: 29601212 PMCID: PMC5959196 DOI: 10.1200/jco.2017.76.3425] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [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: 12/13/2022] Open
Abstract
Purpose We investigated the effect on outcome of measurable or minimal residual disease (MRD) status after each induction course to evaluate the extent of its predictive value for acute myeloid leukemia (AML) risk groups, including NPM1 wild-type (wt) standard risk, when incorporated with other induction response criteria. Methods As part of the NCRI AML17 trial, 2,450 younger adult patients with AML or high-risk myelodysplastic syndrome had prospective multiparameter flow cytometric MRD (MFC-MRD) assessment. After course 1 (C1), responses were categorized as resistant disease (RD), partial remission (PR), and complete remission (CR) or complete remission with absolute neutrophil count < 1,000/µL or thrombocytopenia < 100,000/μL (CRi) by clinicians, with CR/CRi subdivided by MFC-MRD assay into MRD+ and MRD-. Patients without high-risk factors, including Flt3 internal tandem duplication wt/- NPM1-wt subgroup, received a second daunorubicin/cytosine arabinoside induction; course 2 (C2) was intensified for patients with high-risk factors. Results Survival outcomes from PR and MRD+ responses after C1 were similar, particularly for good- to standard-risk subgroups (5-year overall survival [OS], 27% RD v 46% PR v 51% MRD+ v 70% MRD-; P < .001). Adjusted analyses confirmed significant OS differences between C1 RD versus PR/MRD+ but not PR versus MRD+. CRi after C1 reduced OS in MRD+ (19% CRi v 45% CR; P = .001) patients, with a smaller effect after C2. The prognostic effect of C2 MFC-MRD status (relapse: hazard ratio [HR], 1.88 [95% CI, 1.50 to 2.36], P < .001; survival: HR, 1.77 [95% CI, 1.41 to 2.22], P < .001) remained significant when adjusting for C1 response. MRD positivity appeared less discriminatory in poor-risk patients by stratified analyses. For the NPM1-wt standard-risk subgroup, C2 MRD+ was significantly associated with poorer outcomes (OS, 33% v 63% MRD-, P = .003; relapse incidence, 89% when MRD+ ≥ 0.1%); transplant benefit was more apparent in patients with MRD+ (HR, 0.72; 95% CI, 0.31 to 1.69) than those with MRD- (HR, 1.68 [95% CI, 0.75 to 3.85]; P = .16 for interaction). Conclusion MFC-MRD can improve outcome stratification by extending the definition of partial response after first induction and may help predict NPM1-wt standard-risk patients with poor outcome who benefit from transplant in the first CR.
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Affiliation(s)
- Sylvie D. Freeman
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Robert K. Hills
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Paul Virgo
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Naeem Khan
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Steve Couzens
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Richard Dillon
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Amanda Gilkes
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Laura Upton
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Ove Juul Nielsen
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - James D. Cavenagh
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Gail Jones
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Asim Khwaja
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Paul Cahalin
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Ian Thomas
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - David Grimwade
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Alan K. Burnett
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Nigel H. Russell
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
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Garcia-Manero G, Sekeres MA, Egyed M, Breccia M, Graux C, Cavenagh JD, Salman H, Illes A, Fenaux P, DeAngelo DJ, Stauder R, Yee K, Zhu N, Lee JH, Valcarcel D, MacWhannell A, Borbenyi Z, Gazi L, Acharyya S, Ide S, Marker M, Ottmann OG. A phase 1b/2b multicenter study of oral panobinostat plus azacitidine in adults with MDS, CMML or AML with ⩽30% blasts. Leukemia 2017; 31:2799-2806. [PMID: 28546581 PMCID: PMC5729337 DOI: 10.1038/leu.2017.159] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [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: 10/07/2016] [Revised: 02/13/2017] [Accepted: 02/23/2017] [Indexed: 12/15/2022]
Abstract
Treatment with azacitidine (AZA), a demethylating agent, prolonged overall survival (OS) vs conventional care in patients with higher-risk myelodysplastic syndromes (MDS). As median survival with monotherapy is <2 years, novel agents are needed to improve outcomes. This phase 1b/2b trial (n=113) was designed to determine the maximum tolerated dose (MTD) or recommended phase 2 dose (RP2D) of panobinostat (PAN)+AZA (phase 1b) and evaluate the early efficacy and safety of PAN+AZA vs AZA monotherapy (phase 2b) in patients with higher-risk MDS, chronic myelomonocytic leukemia or oligoblastic acute myeloid leukemia with <30% blasts. The MTD was not reached; the RP2D was PAN 30 mg plus AZA 75 mg/m2. More patients receiving PAN+AZA achieved a composite complete response ([CR)+morphologic CR with incomplete blood count+bone marrow CR (27.5% (95% CI, 14.6–43.9%)) vs AZA (14.3% (5.4–28.5%)). However, no significant difference was observed in the 1-year OS rate (PAN+AZA, 60% (50–80%); AZA, 70% (50–80%)) or time to progression (PAN+AZA, 70% (40–90%); AZA, 70% (40–80%)). More grade 3/4 adverse events (97.4 vs 81.0%) and on-treatment deaths (13.2 vs 4.8%) occurred with PAN+AZA. Further dose or schedule optimization may improve the risk/benefit profile of this regimen.
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Affiliation(s)
- G Garcia-Manero
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M A Sekeres
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - M Egyed
- Kaposi Mor County Teaching Hospital, Kasposvár, Hungary
| | | | - C Graux
- Mont-Godinne University Hospital, Yvoir, Belgium
| | | | - H Salman
- Augusta University, Augusta, GA, USA
| | - A Illes
- University of Debrecen, Debrecen, Hungary
| | - P Fenaux
- Hôpital Saint-Louis, Université Paris Diderot, Paris, France
| | | | - R Stauder
- Innsbruck Medical University, Innsbruck, Austria
| | - K Yee
- Princess Margaret Cancer Centre, Toronto, Canada
| | - N Zhu
- University of Alberta Hospital, Edmonton, Canada
| | - J-H Lee
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - A MacWhannell
- The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - L Gazi
- Novartis Pharma AG, Basel, Switzerland
| | - S Acharyya
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - S Ide
- Novartis Pharmaceuticals Corporation, Cambridge, MA, USA
| | - M Marker
- Novartis Pharma S.A.S., Rueil-Malmaison, France
| | - O G Ottmann
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
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6
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Knapper S, Russell N, Gilkes A, Hills RK, Gale RE, Cavenagh JD, Jones G, Kjeldsen L, Grunwald MR, Thomas I, Konig H, Levis MJ, Burnett AK. A randomized assessment of adding the kinase inhibitor lestaurtinib to first-line chemotherapy for FLT3-mutated AML. Blood 2017; 129:1143-1154. [PMID: 27872058 PMCID: PMC5364440 DOI: 10.1182/blood-2016-07-730648] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [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] [Received: 07/26/2016] [Accepted: 11/06/2016] [Indexed: 01/28/2023] Open
Abstract
The clinical benefit of adding FMS-like tyrosine kinase-3 (FLT3)-directed small molecule therapy to standard first-line treatment of acute myeloid leukemia (AML) has not yet been established. As part of the UK AML15 and AML17 trials, patients with previously untreated AML and confirmed FLT3-activating mutations, mostly younger than 60 years, were randomly assigned either to receive oral lestaurtinib (CEP701) or not after each of 4 cycles of induction and consolidation chemotherapy. Lestaurtinib was commenced 2 days after completing chemotherapy and administered in cycles of up to 28 days. The trials ran consecutively. Primary endpoints were overall survival in AML15 and relapse-free survival in AML17; outcome data were meta-analyzed. Five hundred patients were randomly assigned between lestaurtinib and control: 74% had FLT3-internal tandem duplication mutations, 23% FLT3-tyrosine kinase domain point mutations, and 2% both types. No significant differences were seen in either 5-year overall survival (lestaurtinib 46% vs control 45%; hazard ratio, 0.90; 95% CI 0.70-1.15; P = .3) or 5-year relapse-free survival (40% vs 36%; hazard ratio, 0.88; 95% CI 0.69-1.12; P = .3). Exploratory subgroup analysis suggested survival benefit with lestaurtinib in patients receiving concomitant azole antifungal prophylaxis and gemtuzumab ozogamicin with the first course of chemotherapy. Correlative studies included analysis of in vivo FLT3 inhibition by plasma inhibitory activity assay and indicated improved overall survival and significantly reduced rates of relapse in lestaurtinib-treated patients who achieved sustained greater than 85% FLT3 inhibition. In conclusion, combining lestaurtinib with intensive chemotherapy proved feasible in younger patients with newly diagnosed FLT3-mutated AML, but yielded no overall clinical benefit. The improved clinical outcomes seen in patients achieving sustained FLT3 inhibition encourage continued evaluation of FLT3-directed therapy alongside front-line AML treatment. The UK AML15 and AML17 trials are registered at www.isrctn.com/ISRCTN17161961 and www.isrctn.com/ISRCTN55675535 respectively.
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Affiliation(s)
- Steven Knapper
- Department of Haematology, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospital, Nottingham, United Kingdom
| | - Amanda Gilkes
- Experimental Cancer Medicine Centre, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Robert K Hills
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Rosemary E Gale
- Department of Haematology, University College London Cancer Institute, London, United Kingdom; Department of Haematology, Bart's Health NHS Trust, London, United Kingdom
| | - James D Cavenagh
- Department of Haematology, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Gail Jones
- Department of Haematology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Lars Kjeldsen
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
| | - Ian Thomas
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Heiko Konig
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN; and
| | - Mark J Levis
- Division of Hematological Malignancies, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, MD
| | - Alan K Burnett
- Department of Haematology, Cardiff University School of Medicine, Cardiff, United Kingdom
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7
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Usmani SZ, Cavenagh JD, Belch AR, Hulin C, Basu S, White D, Nooka A, Ervin-Haynes A, Yiu W, Nagarwala Y, Berger A, Pelligra CG, Guo S, Binder G, Gibson CJ, Facon T. Cost-effectiveness of lenalidomide plus dexamethasone vs. bortezomib plus melphalan and prednisone in transplant-ineligible U.S. patients with newly-diagnosed multiple myeloma. J Med Econ 2016; 19:243-58. [PMID: 26517601 DOI: 10.3111/13696998.2015.1115407] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To conduct a cost-effectiveness assessment of lenalidomide plus dexamethasone (Rd) vs bortezomib plus melphalan and prednisone (VMP) as initial treatment for transplant-ineligible patients with newly-diagnosed multiple myeloma (MM), from a U.S. payer perspective. METHODS A partitioned survival model was developed to estimate expected life-years (LYs), quality-adjusted LYs (QALYs), direct costs and incremental costs per QALY and LY gained associated with use of Rd vs VMP over a patient's lifetime. Information on the efficacy and safety of Rd and VMP was based on data from multinational phase III clinical trials and a network meta-analysis. Pre-progression direct costs included the costs of Rd and VMP, treatment of adverse events (including prophylaxis) and routine care and monitoring associated with MM. Post-progression direct costs included costs of subsequent treatment(s) and routine care and monitoring for progressive disease, all obtained from published literature and estimated from a U.S. payer perspective. Utilities were obtained from the aforementioned trials. Costs and outcomes were discounted at 3% annually. RESULTS Relative to VMP, use of Rd was expected to result in an additional 2.22 LYs and 1.47 QALYs (discounted). Patients initiated with Rd were expected to incur an additional $78,977 in mean lifetime direct costs (discounted) vs those initiated with VMP. The incremental costs per QALY and per LY gained with Rd vs VMP were $53,826 and $35,552, respectively. In sensitivity analyses, results were found to be most sensitive to differences in survival associated with Rd vs VMP, the cost of lenalidomide and the discount rate applied to effectiveness outcomes. CONCLUSIONS Rd was expected to result in greater LYs and QALYs compared with VMP, with similar overall costs per LY for each regimen. Results of this analysis indicated that Rd may be a cost-effective alternative to VMP as initial treatment for transplant-ineligible patients with MM, with an incremental cost-effectiveness ratio well within the levels for recent advancements in oncology.
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Affiliation(s)
- S Z Usmani
- a a Levine Cancer Institute/Carolinas Healthcare System , Charlotte, NC , USA
| | - J D Cavenagh
- b b St. Bartholomew's Hospital , West Smithfield, London , UK
| | - A R Belch
- c c Cross Cancer Institute , University of Alberta , Edmonton, AB , Canada
| | - C Hulin
- d d Bordeaux Hospital University Center (CHU) , Bordeaux , France
| | - S Basu
- e e Royal Wolverhampton Hospitals NHS Trust , Wolverhampton , UK
| | - D White
- f f Dalhousie University and QEII Health Sciences Center , Halifax, NS , Canada
| | - A Nooka
- g g Winship Cancer Institute , Emory University , Atlanta , GA , USA
| | | | - W Yiu
- h h Celgene Corporation , Summit, NJ , USA
| | | | - A Berger
- i i Evidera , Lexington, MA , USA
| | | | - S Guo
- i i Evidera , Lexington, MA , USA
| | - G Binder
- h h Celgene Corporation , Summit, NJ , USA
| | - C J Gibson
- h h Celgene Corporation , Summit, NJ , USA
| | - T Facon
- j j Service des Maladies du Sang , Hôpital Huriez , CHRU Lille, Lille , France
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8
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Orlowski RZ, Gercheva L, Williams C, Sutherland H, Robak T, Masszi T, Goranova-Marinova V, Dimopoulos MA, Cavenagh JD, Špička I, Maiolino A, Suvorov A, Bladé J, Samoylova O, Puchalski TA, Reddy M, Bandekar R, van de Velde H, Xie H, Rossi JF. A phase 2, randomized, double-blind, placebo-controlled study of siltuximab (anti-IL-6 mAb) and bortezomib versus bortezomib alone in patients with relapsed or refractory multiple myeloma. Am J Hematol 2015; 90:42-9. [PMID: 25294016 DOI: 10.1002/ajh.23868] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/03/2014] [Indexed: 11/12/2022]
Abstract
We compared the safety and efficacy of siltuximab (S), an anti-interleukin-6 chimeric monoclonal antibody, plus bortezomib (B) with placebo (plc) + B in patients with relapsed/refractory multiple myeloma in a randomized phase 2 study. Siltuximab was given by 6 mg/kg IV every 2 weeks. On progression, B was discontinued and high-dose dexamethasone could be added to S/plc. Response and progression-free survival (PFS) were analyzed pre-dexamethasone by European Group for Blood and Marrow Transplantation (EBMT) criteria. For the 281 randomized patients, median PFS for S + B and plc + B was 8.0 and 7.6 months (HR 0.869, P = 0.345), overall response rate was 55 versus 47% (P = 0.213), complete response rate was 11 versus 7%, and median overall survival (OS) was 30.8 versus 36.8 months (HR 1.353, P = 0.103). Sustained suppression of C-reactive protein, a marker reflective of inhibition of interleukin-6 activity, was seen with S + B. Siltuximab did not affect B pharmacokinetics. Siltuximab/placebo discontinuation (75 versus 66%), grade ≥3 neutropenia (49 versus 29%), thrombocytopenia (48 versus 34%), and all-grade infections (62 versus 49%) occurred more frequently with S + B. The addition of siltuximab to bortezomib did not appear to improve PFS or OS despite a numerical increase in response rate in patients with relapsed or refractory multiple myeloma.
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Affiliation(s)
- Robert Z. Orlowski
- Department of Lymphoma/Myeloma; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Liana Gercheva
- University Hospital for Active Treatment “St. Marina,”; Varna Bulgaria
| | - Cathy Williams
- Nottingham University Hospitals NHS Trust; Nottingham United Kingdom
| | | | - Tadeusz Robak
- Medical University of Łódź and Copernicus Memorial Hospital; Łódź Poland
| | - Tamás Masszi
- St. Istvan and St. Laszlo Hospital of Budapest and Semmelweis University; Budapest Hungary
| | | | | | | | - Ivan Špička
- Charles University in Prague; Prague Czech Republic
| | - Angelo Maiolino
- Universidade Federal do Rio de Janeiro; Rio de Janeiro Brazil
| | | | - Joan Bladé
- Hospital Clinic i Provincial and Institut d'Investigacions Biomediques August Pi I Sunyer; Barcelona Spain
| | - Olga Samoylova
- Nizhniy Novgorod Region Clinical Hospital; Nizniy Novgorod Russia
| | | | - Manjula Reddy
- Janssen Research & Development; Spring House Pennsylvania
| | | | | | - Hong Xie
- Janssen Research & Development; Spring House Pennsylvania
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9
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Orlowski RZ, Gercheva L, Williams C, Sutherland HJ, Robak T, Masszi T, Goranova-Marinova V, Dimopoulos MA, Cavenagh JD, Spicka I, Maiolino A, Suvorov A, Blade J, Samoilova OS, Van De Velde H, Bandekar R, Kranenburg B, Xie H, Rossi JF. Phase II, randomized, double blind, placebo-controlled study comparing siltuximab plus bortezomib versus bortezomib alone in pts with relapsed/refractory multiple myeloma. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.8018] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8018^ Background: Preclinical studies of siltuximab (S), a chimeric anti-IL-6 mAb, in combination with bortezomib (B) indicate an additive to synergistic effect in multiple myeloma (MM) cell lines. This randomized study evaluated the safety and efficacy of S+B compared with placebo (plc)+B in pts with relapsed/refractory MM after 1−3 prior tx lines, measurable disease but no prior B exposure. Methods: 286 pts were randomized 1:1 to S+B: B+plc. S 6 mg/kg or plc was given IV q2w. B 1.3 mg/m2 was given IV on d 1, 4, 8, 11, 22, 25, 29, 32 for a max of 4 of 42-d cycles and then reduced to q1w for 35-d cycles. B was stopped for pts with PD/intolerability, and high dose oral dexamethasone (dex) 40 mg could then be started qd on d 1−4, 9−12, 17−20 for a max of 4 of 28-d cycles and on d 1−4 of subsequent cycles until PD, while S/plc continued. Primary endpoint was PFS by EBMT criteria censored at the start of dex/subsequent tx. Secondary endpoints included overall response rate (ORR), OS, and safety before dex. Results: 142 and 144 pts received S+B and B+plc, respectively. Baseline demographics and disease characteristics were well balanced across S+B and B+plc, except for age (median 64 vs. 61 yrs) and myeloma type (IgG 65 vs. 71%, IgA 27 vs. 20%). Median tx duration was 5.1 mo in both grps. Median PFS was 8.1 mo in S+B and 7.6 mo in B+plc (HR 0.869, p = 0.345). ORR (CR+PR) was 55% in pts on S+B and 47% on B+plc (p = 0.213); CR rates were 11 and 7% (p = 0.342), respectively. With 24.5 mo median follow up, median OS was 30.8 mo for S+B and 36.9 mo for B+plc (HR 1.353 for S+B, p = 0.103). Fewer pts on S+B than B+plc moved to dex (23 vs. 31%) and had subsequent SCT (5 vs. 11%). Gr ≥3 AEs occurred in 91% on S+B and 74% on B+plc. Common gr ≥3 AEs in S+B were neutropenia (49%), thrombocytopenia (48%), leukopenia (14%). SAEs occurred in 29% on S+B and 24% on B+plc. Death occurred within 30 d of last study agent administration pre-dex in 8% on S+B and 5% on B+plc. Conclusions: The combination of S+B had higher response rates but did not prolong survival compared with B+plc. A negative survival trend heavily influenced by differences in dex and SCT rescue was noted. S+B appears to be generally well tolerated but had a higher incidence of hematologic AEs.
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Affiliation(s)
| | - Liana Gercheva
- University Multiprofile Hospital for Active Treatment, Varna, Bulgaria
| | - Cathy Williams
- Nottingham University Hospitals, Nottingham, United Kingdom
| | | | - Tadeusz Robak
- Medical University of Lodz and Copernicus Memorial Hospital, Lodz, Poland
| | - Tamás Masszi
- St. István and St. László Hospital, Budapest, Hungary
| | | | | | | | - Ivan Spicka
- Charles University in Prague, Prague, Czech Republic
| | - Angelo Maiolino
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Joan Blade
- Hospital Clinic de Barcelona, Barcelona, Spain
| | - Olga S Samoilova
- Nizhnii Novgorod Regional Clinical Hospital, Nizhnii Novgorod, Russia
| | | | | | | | - Hong Xie
- Janssen Research & Development, Spring House, PA
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10
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Shaw BE, Mufti GJ, Mackinnon S, Cavenagh JD, Pearce RM, Towlson KE, Apperley JF, Chakraverty R, Craddock CF, Kazmi MA, Littlewood TJ, Milligan DW, Pagliuca A, Thomson KJ, Marks DI, Russell NH. Outcome of second allogeneic transplants using reduced-intensity conditioning following relapse of haematological malignancy after an initial allogeneic transplant. Bone Marrow Transplant 2008; 42:783-9. [PMID: 18724393 DOI: 10.1038/bmt.2008.255] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Disease relapse following an allogeneic transplant remains a major cause of treatment failure, often with a poor outcome. Second allogeneic transplant procedures have been associated with high TRM, especially with myeloablative conditioning. We hypothesized that the use of reduced-intensity conditioning (RIC) would decrease the TRM. We performed a retrospective national multicentre analysis of 71 patients receiving a second allogeneic transplant using RIC after disease relapse following an initial allogeneic transplant. The majority of patients had leukaemia/myelodysplasia (MDS) (N=57), nine had lymphoproliferative disorders, two had myeloma and three had myeloproliferative diseases. A total of 25% of patients had unrelated donors. The median follow-up was 906 days from the second allograft. The predicted overall survival (OS) and TRM at 2 years were 28 and 27%, respectively. TRM was significantly lower in those who relapsed late (>11 months) following the first transplant (2 years: 17 vs 38% in early relapses; P=0.03). Two factors were significantly associated with a better survival: late relapse (P=0.014) and chronic GVHD following the second transplant (P=0.014). These data support our hypothesis that the second RIC allograft results in a lower TRM than using MA. A proportion of patients achieved a sustained remission even when relapsing after a previous MA transplant.
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Affiliation(s)
- B E Shaw
- Department of Haematology, Royal Marsden Hospital, Institute of Cancer Research, London, UK.
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11
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Abstract
We present here a patient with end stage renal failure who received two weeks antimalarial prophylaxis at full dose leading to life threatening toxicity with severe acute megaloblastic anaemia, symptomatic pancytopenia and exfoliative dermatitis. Prompt recognition and treatment can rapidly reverse these fatal effects but more importantly, education of patients before travel is imperative in preventing such events.
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Affiliation(s)
- N Thorogood
- Princess Alexandra Hospital, Harlow, Essex, UK
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12
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Abstract
Bortezomib (Velcade) is a boron containing molecule which reversibly inhibits the proteasome, an intracellular organelle which is central to the breakdown of ubiquinated proteins and consequently crucial for normal cellular homeostasis. Phase II clinical trials demonstrate it is effective for the treatment of relapsed refractory myeloma, and a phase III trial comparing bortezomib to dexamethasone in second/third line treatment showed superiority in progression free and overall survival. It is administered intravenously in the outpatient setting on days 1, 4, 8 and 11 of a 21-day cycle and regular monitoring for side effects is essential. It is currently approved for the treatment of multiple myeloma patients who have received at least one prior therapy and who have already undergone or are unsuitable for transplantation. Given the strength of this data the UK Myeloma Forum and British Committee for Standards in Haematology believe that bortezomib should be available for prescription by UK haematologists according to its licensed indication in patients with relapsed myeloma.
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Affiliation(s)
- G J Morgan
- Haemato-Oncology Unit, Royal Marsden Hospital, London, UK
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13
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Quint J, Mills W, Lewis D, Cavenagh JD, Agrawal SG. A complication of steroid therapy in acute leukaemia--a case report. Hematology 2006; 11:97-9. [PMID: 16753848 DOI: 10.1080/10245330500469916] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Common complications associated with steroid therapy are well documented. We report a rare and fatal complication, in which oesophageal erosion secondary to the use of steroids was associated with pneumopericardium.
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Affiliation(s)
- J Quint
- St Bartholomew's Hospital, (Queen Mary University of London), Department of Haematological Oncology, West Smithfield, London, EC1A 7BE, UK
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14
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Killick SB, Cavenagh JD, Davies JK, Marsh JCW. Low dose antithymocyte globulin for the treatment of older patients with aplastic anaemia. Leuk Res 2006; 30:1517-20. [PMID: 16530266 DOI: 10.1016/j.leukres.2006.02.003] [Citation(s) in RCA: 10] [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] [Received: 02/01/2006] [Revised: 02/01/2006] [Accepted: 02/02/2006] [Indexed: 11/25/2022]
Abstract
We report 14 older patients with aplastic anaemia (AA) who were treated with 'low dose' antithymocyte globulin (ATG). The aims of the study were to assess the efficacy and safety of reduced dose ATG in patients over the age of 60 years. Median age was 71 years (range 62-74 years). At the study endpoint (response to treatment at 6 months) 12 patients were evaluable. All patients received lymphoglobuline (horse ATG; Genzyme) at a dose of 0.5vials/10kg/day for 5 days (5mg/kg/day, equivalent to one-third of the standard dose). There were no deaths attributed to ATG. Two patients died during follow-up, from sepsis and anaphylaxis following platelet transfusion, respectively. Only one of the 12 evaluable patients responded to treatment and remains transfusion independent at 14 months after ATG. These results suggest that this lower dose of ATG, though well tolerated, had low efficacy in the treatment of AA.
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Affiliation(s)
- S B Killick
- Department of Haematology, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK.
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15
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Davies JK, Cavenagh JD. The importance of consistent use of denominators across patient groups in assessing responses in clinical trials. Br J Haematol 2006; 132:794-5; author reply 795. [PMID: 16487183 DOI: 10.1111/j.1365-2141.2006.05962.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Kaya B, Davies CE, Oakervee HE, Silver NC, Gawler J, Cavenagh JD. Guillain Barré syndrome precipitated by the use of antilymphocyte globulin in the treatment of severe aplastic anaemia. J Clin Pathol 2005; 58:994-5. [PMID: 16126887 PMCID: PMC1770826 DOI: 10.1136/jcp.2004.020354] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This report describes the case of a 54 year old woman with very severe aplastic anaemia who was treated with antilymphocyte globulin (ALG) and developed Guillain Barré syndrome (GBS). No antecedent infective aetiology was identified. Although there are numerous reports of autoimmune disease after treatment with ALG in aplastic anaemia, and GBS after immunosuppressive treatment, there are none reporting GBS after the use of ALG for severe aplastic anaemia. The occurrence of autoimmune disease after immunosuppressive treatment, in particular ALG, is discussed, together with the possible mechanisms that result from T cell depression.
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Affiliation(s)
- B Kaya
- Department of Haematology, Barts and the London NHS Trust, London EC1A 7BE, UK
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17
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Gordon AC, Oakervee HE, Kaya B, Thomas JM, Barnett MJ, Rohatiner AZS, Lister TA, Cavenagh JD, Hinds CJ. Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: a prospective observational study of ward and intensive care unit based care. Anaesthesia 2005; 60:340-7. [PMID: 15766336 DOI: 10.1111/j.1365-2044.2005.04139.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [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: 01/01/2023]
Abstract
To determine the incidence and outcome of critical illness amongst the total population of hospital patients with haematological malignancy (including patients treated on the ward as well as those admitted to the intensive care unit), consecutive patients with haematological malignancy were prospectively studied. One hundred and one of the 1437 haemato-oncology admissions (7%) in 2001 were complicated by critical illness (26% of all new referrals). Fifty-four (53%) of these critically ill patients survived to leave hospital and 33 (34%) were still alive after 6 months. The majority (77/101) were not admitted to the intensive care unit but were managed on the ward, often with the assistance of the intensive care team. Independent risk factors for dying in hospital included hepatic failure (odds ratio 5.3, 95% confidence intervals 1.3-21.2) and central nervous system failure (odds ratio 14.5, 95% confidence intervals 1.7-120.5). No patient with four or more organ failures or a Simplified Acute Physiology Score II >/= 65 survived to leave hospital. There was close agreement between actual and predicted mortality with increasing Simplified Acute Physiology Score II for all patients, including those not admitted to intensive care.
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Affiliation(s)
- A C Gordon
- Department of Anaesthesia and Intensive Care, Barts and The London Queen Mary's School of Medicine and Dentistry, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
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18
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Leaver S, Amlot P, Thuraisingham R, Norton A, Aitken C, Cavenagh JD. Subacute immune response to primary EBV infection leading to post-transplant lymphoproliferative disease in a renal transplant patient. ACTA ACUST UNITED AC 2004; 26:351-3. [PMID: 15485466 DOI: 10.1111/j.1365-2257.2004.00626.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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 23-year-old man sero-negative for Epstein-Barr virus (EBV) developed recurrent sore throats 3 and 6 months after a renal transplant from an EBV sero-positive donor. Tonsillar biopsy at 9 months post-transplant showed post-transplant lymphoproliferative disease (PTLD) caused by EBV. Following reduction of immunosuppressive treatment, he developed further signs and symptoms, and serological evidence of infectious mononucleosis followed by resolution of lymphadenopathy. This case emphasizes the difficulty in interpreting EBV serology in immunosuppressed patients and the importance of pre-transplant EBV serology.
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Affiliation(s)
- S Leaver
- Department of Haematology, St Bartholomew's Hospital, London, UK.
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19
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Pellagatti A, Esoof N, Watkins F, Langford CF, Vetrie D, Campbell LJ, Fidler C, Cavenagh JD, Eagleton H, Gordon P, Woodcock B, Pushkaran B, Kwan M, Wainscoat JS, Boultwood J. Gene expression profiling in the myelodysplastic syndromes using cDNA microarray technology. Br J Haematol 2004; 125:576-83. [PMID: 15147372 DOI: 10.1111/j.1365-2141.2004.04958.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [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: 11/28/2022]
Abstract
The myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal disorders of the haematopoietic stem cell and primarily involve cells of the myeloid lineage. Using cDNA microarrays comprising 6000 human genes, we studied the gene expression profiles in the neutrophils of 21 MDS patients, seven of which had the 5q- syndrome, and two acute myeloid leukaemia (AML) patients when compared with the neutrophils from pooled healthy controls. Data analysis showed a high level of heterogeneity of gene expression between MDS patients, most probably reflecting the underlying karyotypic and genetic heterogeneity. Nevertheless, several genes were commonly up or down-regulated in MDS. The most up-regulated genes included RAB20, ARG1, ZNF183 and ACPL. The RAB20 gene is a member of the Ras gene superfamily and ARG1 promotes cellular proliferation. The most down-regulated genes include COX2, CD18, FOS and IL7R. COX2 is anti-apoptotic and promotes cell survival. Many genes were identified that are differentially expressed in the different MDS subtypes and AML. A subset of genes was able to discriminate patients with the 5q- syndrome from patients with refractory anaemia and a normal karyotype. The microarray expression results for several genes were confirmed by real-time quantitative polymerase chain reaction. The MDS-specific expression changes identified are likely to be biologically important in the pathophysiology of this disorder.
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Affiliation(s)
- Andrea Pellagatti
- Leukaemia Research Fund Molecular Haematology Unit, Nuffield Department of Clinical Laboratory Sciences, John Radcliffe Hospital, Oxford, UK
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20
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Taussig DC, Davies AJ, Cavenagh JD, Oakervee H, Syndercombe-Court D, Kelsey S, Amess JAL, Rohatiner AZS, Lister TA, Barnett MJ. Durable remissions of myelodysplastic syndrome and acute myeloid leukemia after reduced-intensity allografting. J Clin Oncol 2003; 21:3060-5. [PMID: 12915594 DOI: 10.1200/jco.2003.02.057] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [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: 11/20/2022] Open
Abstract
PURPOSE To evaluate the use of reduced-intensity (RI) conditioning with allogeneic hematopoietic stem cell transplantation (HSCT) from HLA-identical family donors in patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). PATIENTS AND METHODS Sixteen patients (median age, 54 years; range, 37 to 66 years) underwent RI-HSCT using a conditioning regimen of fludarabine 25 mg/m2 daily for 5 days and either cyclophosphamide 1 g/m2 daily for 2 days (14 patients) or melphalan 140 mg/m2 for 1 day (two patients). The median number of CD34+ cells and CD3+ cells infused per kilogram of recipient weight was 4.5 x 106 (range, 1.8 to 7.3 x 106 cells) and 2.9 x 108 (range, 0.1 to 9.6 x 108 cells), respectively. RESULTS There was no transplant-related mortality (TRM) within 100 days of HSCT. Grade 1 to 2 acute graft-versus-host disease (GVHD) occurred in three patients, but neither grade 3 nor grade 4 disease was observed. Chronic GVHD occurred in 10 patients. One patient had cytomegalovirus (CMV) reactivation but did not develop CMV disease. With a median follow-up of 26 months (range, 15 to 45 months), 11 patients are alive (nine in continuous complete remission and one in complete remission after a second transplantation), and five have died (four from disease progression and one from bone-marrow aplasia induced by cyclosporine withdrawal). The 2-year actuarial overall and event-free survival rates were 69% (95% confidence interval [CI], 40% to 86%) and 56% (95% CI, 30% to 68%), respectively. CONCLUSION This strategy of RI-HSCT resulted in reliable engraftment with low incidence of acute GVHD and TRM. Durable remissions were observed in patients with MDS and AML consistent with a graft-versus-leukemia effect.
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Affiliation(s)
- D C Taussig
- Department of Medical Oncology, 45 Little Britain, St Bartholomew's Hospital, London EC1A 7BE, United Kingdom
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Abstract
We describe two cases of recurrent autoimmune cytopenias, which were subsequently diagnosed with a 22q11.2 deletion/DiGeorge syndrome. The cases are of particular interest as both possessed limited clinical features of this syndrome, and the investigation of haematological abnormalities led to the establishment of a definitive genetic diagnosis.
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Affiliation(s)
- J K Davies
- Department of Haematology, Barts and the London Trust, London, UK.
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22
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Micallef IN, Apostolidis J, Rohatiner AZ, Wiggins C, Crawley CR, Foran JM, Leonhardt M, Bradburn M, Okukenu E, Salam A, Matthews J, Cavenagh JD, Gupta RK, Lister TA. Factors which predict unsuccessful mobilisation of peripheral blood progenitor cells following G-CSF alone in patients with non-Hodgkin's lymphoma. Hematol J 2002; 1:367-73. [PMID: 11920216 DOI: 10.1038/sj.thj.6200061] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2000] [Accepted: 06/15/2000] [Indexed: 11/09/2022]
Abstract
INTRODUCTION High-dose therapy with haematopoietic progenitor cell support has increasingly been utilised for patients with haematological malignancies. Peripheral blood is the stem cell source of choice, however, various mobilisation strategies are used by different centres. PATIENTS AND METHODS Over a 2-year period, 52 patients with non-Hodgkin's lymphoma (median age 47 years, range 16-64 years) underwent peripheral blood progenitor cell mobilisation using G-CSF alone (16 microg/kg/day). The harvest was considered successful if > or =1 x 10(6) CD34(+) cells/kg were collected by leukapheresis. The histological subtypes of non-Hodgkin's lymphoma comprised: follicular (24 patients), diffuse large B-cell (14 patients), lymphoplasmacytoid (four patients), mantle cell (three patients), lymphoblastic lymphoma (one patient) and small lymphocytic lymphoma/chronic lymphocytic leukaemia (six patients). The median interval from diagnosis of non-Hodgkin's lymphoma to mobilisation was 27 months (range 2 months to 17 years). The median number of prior treatment episodes was 2 (range 1-5); 26 patients had received fludarabine alone or in combination. At the time of peripheral blood progenitor cell mobilisation, 20 patients were in 1st remission and 32 were in > or =2nd remission; 30 patients were in partial remission and 22 were in complete remission; the bone marrow was involved in nine patients. RESULTS Peripheral blood progenitor cell mobilisation/harvest was unsuccessful in 19 out of 52 (37%) patients (mobilisation: 18, harvest: 1). The factors associated with unsuccessful mobilisation or harvest were: prior fludarabine therapy (P=0.002), bone marrow involvement at diagnosis (P=0.002), bone marrow involvement anytime prior to mobilisation (P=0.02), histological diagnosis of follicular, mantle cell, or lymphoplasmacytoid lymphoma, or small lymphocytic lymphoma/chronic lymphocytic leukaemia (P=0.03) and female gender (P=0.04). CONCLUSION Although peripheral blood progenitor cells can be successfully mobilised and harvested from the majority of patients with non-Hodgkin's lymphoma after treatment with G-CSF alone, the latter is unsuccessful in approximately one-third of patients. These factors should be taken into account when patients are being considered for high-dose treatment.
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Affiliation(s)
- I N Micallef
- Imperial Cancer Research Fund Medical Oncology Unit, Department of Medical Oncology, St. Bartholomew's Hospital, 45 Little Britain, West Smithfield, London EC1A 7BE, UK
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23
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McBride NC, Cavenagh JD, Ward MC, Grant I, Schey S, Gray A, Hughes A, Mills MJ, Cervi P, Newland AC, Kelsey SM. Liposomal daunorubicin (DaunoXome) in combination with cyclophosphamide, vincristine and prednisolone (COP-X) as salvage therapy in poor-prognosis non-Hodgkins lymphoma. Leuk Lymphoma 2001; 42:89-98. [PMID: 11699226 DOI: 10.3109/10428190109097680] [Citation(s) in RCA: 13] [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: 11/13/2022]
Abstract
We treated 33 patients with a variant of the standard 3 weekly CHOP regime, replacing doxorubicin with liposomal daunorubicin (DaunoXome, NeXstar Pharmaceuticals) 120 mg/m2 (COP-X). Eighteen subjects had relapsed/refractory aggressive NHL and 15 had indolent NHL/CLL. Median number of courses received was 4 (1-8). Thirty-two patients were evaluable for efficacy and 26 (81%) responded. 88% of patients with aggressive NHL responded; three (18%) patients achieved complete remission (CR), 12 (70%) achieved partial remission (PR), 1 (6%) patient had stable disease (SD) and 1 (6%) patient progressed through treatment. Median duration of response for patients with aggressive NHL was 3 months. The response rate in indolent NHL/CLL was 73%. Four (27%) patients achieved CR, 7 (46%) PR and 4 (27%) SD. At two years post treatment, 55% of the patients with indolent NHL/CLL remain progression-free, although 4 patients have proceeded to consolidation therapy. Twenty-seven out of 28 (96%) patients developed neutropenia of short duration following one or more of their treatments. Twenty-three patients developed an infection at some stage during therapy (all associated with neutropenia) and required hospitalisation. There were two toxic deaths (infection) both of which occurred in patients who were neutropenic before starting COP-X. Platelet toxicity was mild in patients with normal platelet counts at the commencement of therapy. Alopecia and mucositis were mild. No clinical evidence of myocardial failure was observed. We conclude that the substitution of DaunoXome for doxorubicin in the CHOP regimen to form COP-X provides excellent efficacy against non-Hodgkin's lymphoma. Response durations were short but comparable to those reported with other regimens. COP-X was well tolerated with some suggestion of reduced non-haematological toxicity. The regimen should be considered as an alternative to CHOP with potentially less non-haematological toxicity, particularly cardiac; further studies are required to evaluate the regimen in this context.
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Affiliation(s)
- N C McBride
- Department of Haematology, St Bartholomew's and the Royal London School of Medicine and Dentistry, UK
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24
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Newland AC, Burton I, Cavenagh JD, Copplestone A, Dolan G, Houghton J, Reilly T. Vigam-S, a solvent/detergent-treated intravenous immunoglobulin, in idiopathic thrombocytopenic purpura. Transfus Med 2001; 11:37-44. [PMID: 11328570 DOI: 10.1046/j.1365-3148.2001.00281.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [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: 11/20/2022]
Abstract
The efficacy of Vigam-S, a highly purified intravenous immunoglobulin, was investigated by an open, noncomparative study in 20 adults with chronic idiopathic thrombocytopenic purpura (ITP). Fifteen patients responded to the initial 3-day infusion of 0.4 g kg(-1) day(-1) by exhibiting an incremental increase in platelet count of >or= 30 x 10(9) L(-1), in eight of whom platelet count normalized (> 150 x 10(9) L(-1)). The peak platelet count for responders on day 4 was 163 x 10(9) L(-1) (baseline = 18 x 10(9) L(-1)). No benefit was derived from an extra 2 days infusion in nonresponders. Further treatment (either a single 0.8 g kg(-1) dose or another 3-day infusion) given to responders when platelet counts fell below 30 x 10(9) L(-1) was effective on eight of 14 occasions. Increases in total serum IgG concentration (to a mean peak of 25.3 g L(-1)) were not correlated with platelet response. There was no evidence of seroconversion to virus markers, or of alteration in renal function, following Vigam-S infusion. Most adverse events were mild and transient; however, three patients had severe headache and vomiting (possible aseptic meningitis syndrome) and one had marked superficial thrombophlebitis. Therefore Vigam-S provides effective and well tolerated therapy in the management of adults with ITP although individual patient response remains difficult to predict.
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Affiliation(s)
- A C Newland
- Department of Haematology, Royal London Hospital, Whitechapel, UK.
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25
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26
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McBride NC, Cavenagh JD, Newland AC, Lillington DM, Murrell C, Kelsey SM. Autologous transplantation with Philadelphia-negative progenitor cells for patients with chronic myeloid leukaemia (CML) failing to attain a cytogenetic response to alpha interferon. Bone Marrow Transplant 2000; 26:1165-72. [PMID: 11149726 DOI: 10.1038/sj.bmt.1702671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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
Between October 1993 and March 1999, 29 patients with CML who were ineligible for allogeneic BMT underwent PBSC harvest using idarubicin, cytarabine and G-CSF. In 9/29 (31%) patients all collected stem cells were Ph-negative, and 15/29 patients' (52%) collections were substantially (>95%) Ph-negative. The proportion of patients from whom Ph-negative stem cells were obtained was similar between patients who had, or had not, received prior alphaIFN. Fifteen patients in chronic phase (median age 45) proceeded to PBSCT following busulphan 16 mg/m2 and cyclophosphamide 120 mg/m2. Nine of the 13 patients who had failed to respond to prior alphaIFN proceeded to stem cell transplantation as soon as was feasible and six of the newly diagnosed patients were transplanted after failing to achieve a cytogenetic response after a minimum of 12 months on alphaIFN following progenitor cell harvest. The median number of days to neutrophils >0.5 and platelet >50 was 18 (range 13-69) and 28 (range 13-234), respectively. There was no procedure-related mortality. At median follow-up of 2.3 years post autograft 10 of 15 patients remain alive and in chronic phase. Overall survival for all 27 patients at 5 years after initial diagnosis is 70% and median survival from diagnosis 7.3 years. Survival for alphaIFN non-responders who were transplanted is 74% at 5 years from diagnosis and 75% at 3 years from transplant. Cytogenetic analysis performed 3 months post transplant demonstrated one patient with a complete cytogenetic response, seven with a partial response and three with no response. Six patients remain partially Ph-negative, with one major CR. Survival for all patients in the protocol is favourable compared with conventional therapy and is particularly encouraging following PBSCT for alphaIFN non-responsive patients. Patients not responding to alphaIFN can be induced into Ph-negativity with PBSCT but this may not always be sustainable. There seems to be no obvious disadvantage in harvesting stem cells after prior exposure to alphaIFN, providing an adequate alphaIFN-free rest period is used.
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Affiliation(s)
- N C McBride
- Department of Haematology, St Bartholomew's and Royal London Hospital School of Medicine and Dentistry, UK
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27
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Jenner MJ, Micallef IN, Rohatiner AZ, Kelsey SM, Newland AC, Cavenagh JD. Successful therapy of transplant-associated veno-occlusive disease with a combination of tissue plasminogen activator and defibrotide. Med Oncol 2000; 17:333-6. [PMID: 11114714 DOI: 10.1007/bf02782200] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [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: 11/30/1999] [Accepted: 02/08/2000] [Indexed: 11/24/2022]
Abstract
A 36-year-old man underwent matched unrelated donor bone marrow transplantation for chronic myeloid leukaemia. He developed severe hepatic veno-occlusive disease as an early post-transplant complication. Tissue plasminogen activator was initially felt to be contraindicated since the patient had concomitant pericarditis. Defibrotide was therefore commenced as treatment for veno-occlusive disease. The pericarditis improved but the veno-occlusive disease continued to worsen (peak bilirubin 353 micromol/l). Tissue plasminogen activator followed by a heparin infusion was therefore administered. However, he proceeded to develop haemorrhagic cardiac tamponade that required drainage. Thrombolysis was therefore discontinued and treatment with defibrotide resumed after an interval of 48 h. The veno-occlusive disease gradually resolved and defibrotide was discontinued once the bilirubin had plateaued. He was discharged home on day +52 post-transplant.
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Affiliation(s)
- M J Jenner
- Imperial Cancer Research Fund Department of Medical Oncology, St Bartholomew's Hospital, London, UK.
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28
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Smith PR, Cavenagh JD, Milne T, Howe D, Wilkes SJ, Sinnott P, Forster GE, Helbert M. Benign monoclonal expansion of CD8+ lymphocytes in HIV infection. J Clin Pathol 2000; 53:177-81. [PMID: 10823134 PMCID: PMC1731162 DOI: 10.1136/jcp.53.3.177] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [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: 11/03/2022]
Abstract
BACKGROUND A transient expansion of the CD8+ T cell pool normally occurs in the early phase of HIV infection. Persistent expansion of this pool is observed in two related settings: diffuse infiltrative lymphocytosis syndrome (DILS) and HIV associated CD8+ lymphocytosis syndrome. AIM To investigate a group of HIV infected patients with CD8+ lymphocytosis syndrome with particular emphasis on whether monoclonality was present. METHODS A group of 18 patients with HIV-1 infection and persistent circulating CD8+ lymphocytosis was compared with 21 HIV positive controls. Serum samples were tested for antinuclear antibodies, antibodies to extractable nuclear antigens, immunoglobulin levels, paraproteins, human T lymphotropic virus type 1 (HTLV-1), Epstein-Barr virus, and cytomegalovirus serology. Lymphocyte phenotyping and HLA-DR typing was performed, and T cell receptor (TCR) gene rearrangement studies used to identify monoclonal populations of T cells. CD4+ and CD8+ subsets of peripheral blood lymphocytes were purified to determine whether CD8+ populations inhibited HIV replication in autologous CD4+ cells. RESULTS A subgroup of patients with HIV-1 infection was found to have expanded populations of CD8+ T cell large granular lymphocytes persisting for 6 to 30 months. The consensus immunophenotype was CD4- CD8+ DRhigh CD11a+ CD11c+ CD16- CD28+/- CD56- CD57+, consistent with typical T cell large granular lymphocytes expressing cellular activation markers. Despite the finding of monoclonal TCR gene usage in five of 18 patients, there is evidence that the CD8+ expansions are reactive populations capable of mediating non-cytotoxic inhibition of HIV replication. CONCLUSIONS A subgroup of HIV positive patients has CD8+ lymphocytosis, but despite the frequent occurrence of monoclonal TCR gene usage there is evidence that this represents an immune response to viral infection rather than a malignant disorder.
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Affiliation(s)
- P R Smith
- Department of Genitourinary Medicine, Royal Hospitals NHS Trust, Whitechapel, London, UK
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29
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McBride NC, Ward MC, Mills MJ, Eden AG, Hughes A, Cavenagh JD, Lamont A, Newland AC, Kelsey SM. Epic as an effective, low toxicity salvage therapy for patients with poor risk lymphoma prior to beam high dose chemotherapy and peripheral blood progenitor cell transplantation. Leuk Lymphoma 1999; 35:339-45. [PMID: 10706458 DOI: 10.3109/10428199909145738] [Citation(s) in RCA: 5] [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: 11/13/2022]
Abstract
We treated 33 patients with relapsed or refractory non-Hodgkin's lymphoma (NHL) or Hodgkin's disease (HD) with a combination of etoposide, prednisolone, ifosfamide and carboplatin (EPIC). After a median of two courses (range 1-5) complete response was achieved in 7 (22%) patients and partial response in 12 (37%) patients, an overall response rate of 59%. The regimen was well tolerated with myelosuppression being the most common toxicity. There were no toxic deaths. 25 (78%) patients were able to proceed to high dose therapy (BEAM) with peripheral blood progenitor cell transplantation either immediately post EPIC or following further salvage therapy. Most patients mobilised peripheral blood progenitor cells well and 24 out of 25 patients subsequently undergoing autologous transplantation had rapid regeneration of counts. EPIC is an effective salvage therapy in the majority of patients with relapsed or refractory lymphoma and does not appear to be toxic to stem cells. Although severe, myelosuppression is of short duration and the generally low toxicity enables patients to proceed to successful peripheral blood stem cell harvest and transplantation.
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Affiliation(s)
- N C McBride
- Department of Haematology, St Bartholomew's Hospital School of Medicine and Dentistry, London, UK
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30
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Macey MG, McCarthy DA, Milne T, Cavenagh JD, Newland AC. Comparative study of five commercial reagents for preparing normal and leukaemic lymphocytes for immunophenotypic analysis by flow cytometry. Cytometry 1999; 38:153-60. [PMID: 10440853 DOI: 10.1002/(sici)1097-0320(19990815)38:4<153::aid-cyto2>3.0.co;2-e] [Citation(s) in RCA: 30] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The flow cytometric analysis of leucocytes in whole blood is usually performed on samples in which the erythrocytes have been lysed and the leucocytes fixed. Because lysis and fixation reagents have the potential to introduce artefacts, several commercially available reagents were used to prepare normal and leukaemic lymphocytes for immunophenotypic analysis by flow cytometry, and the results were compared with those obtained from live whole blood. The reagents tested were the ImmunoPrep system and OptiLyse C (Coulter), LF-1000-Lyse and Flow (Harlan), Uti-Lyse (Dako) and FACS Lysing Solution (Becton Dickinson). The effect of each reagent on the apparent expression of CD3, CD5, CD11b, CD45, FMC7, kappa and lambda antigens was determined on lymphocytes from six normal controls and from six patients with chronic lymphocytic leukaemia (CLL). The following observations were made: (i) the time in minutes for each procedure varied markedly and was 1.5, 15, 20, 30 and 30 for the ImmunoPrep system, OptiLyse C, Uti-Lyse, FACS Lysing Solution, and LF-1000, respectively, but only 0.5 min for live whole blood. (ii) The forward and side scatter characteristics were affected by all of the lysis and fixation procedures, and this was most marked for LF-1000-Lyse and Flow. (iii) OptiLyse C gave preparations with poor forward and side scatter resolution due to the presence of residual red cell fragments. (iv) Lysis and fixation procedures did not affect the apparent expression of the CD3, CD45, or FMC7 antigens on normal or CLL samples, but gave highly variable results for the expression of the CD5, CD11b, kappa, and lambda antigens on the CLL samples. We conclude that lysis and fixation procedures can introduce different artefacts in the analysis of normal and leukaemic samples that are best avoided by analysing live whole blood.
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Affiliation(s)
- M G Macey
- Department of Haematology, The Royal London Hospital, Whitechapel, London, United Kingdom.
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31
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Abstract
Cellular adhesion molecules (CAMs) are critical components in the processes of embryogenesis, tissue repair and organization, lymphocyte function, lymphocyte homing and tumor metastasis, as well as being central to the interactions between hemopoietic progenitors and bone marrow microenvironment, and between leukocytes and platelets with vascular endothelium. Expression of CAMs regulates normal hemopoiesis and migration and function of mature hemopoietic cells. CAMs are an important part of the inflammatory response and may regulate cytokine synthesis. In addition, CAM expression may be critical for tumorigenesis. Monoclonal antibodies to CAMs have been developed for clinical use; initial results suggest that these agents have great potential in the prevention and treatment of inflammation, thrombosis, reperfusion injury, and graft rejection.
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32
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Affiliation(s)
- V Vijay
- Department of Anaesthetics, Royal Hospitals NHS Trust, London
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33
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Macey MG, Hou L, Milne T, Parameswaren V, Howe D, Cavenagh JD, Howells GL, Newland AC. A CD4+ proliferation of large granular lymphocytes expresses the protease activated receptor-1. Br J Haematol 1998; 101:78-81. [PMID: 9576186 DOI: 10.1046/j.1365-2141.1998.00673.x] [Citation(s) in RCA: 4] [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: 02/07/2023]
Abstract
The platelet-type thrombin receptor was the first member to be identified in a family of protease activated receptors (PARs) and has been designated PAR-1. We recently reported that the large granular lymphocytes (LGLs) in patients with proliferations of CD8+ cells co-expressed PAR-1 and the expression of PAR-1 correlated with the expression of CD57. Here we show, by three-colour immunofluorescence, that the LGLs from a patient with a rare CD4+ CD57+ monoclonal expansion also expressed PAR-1. Northern blot analysis confirmed the presence of high levels of mRNA for PAR-1 in these LGLs.
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Affiliation(s)
- M G Macey
- Department of Haematology, The Royal London Hospital, Whitechapel
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Cahill MR, Macey MG, Cavenagh JD, Newland AC. Protein A immunoadsorption in chronic refractory ITP reverses increased platelet activation but fails to achieve sustained clinical benefit. Br J Haematol 1998; 100:358-64. [PMID: 9488627 DOI: 10.1046/j.1365-2141.1998.00568.x] [Citation(s) in RCA: 28] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adults with chronic relapsing ITP present a difficult therapeutic challenge. The ongoing antibody-mediated platelet destruction in this group might be expected to be associated with increased expression of platelet surface membrane activation antigens. We have studied a group of 10 patients with refractory ITP and 35 healthy controls. Using an immediate, sensitive, unfixed, whole blood, flow cytometric method to detect platelet surface P-selectin and GP53, we have detected markedly increased platelet activation in the ITP group compared with the controls (P-selectin; patient median 24.5% v control median 2.0%. GP53 median 6.5% v 2.1%, P < 0.01 for both). Five patients underwent protein A immunoadsorption therapy. The effect of protein A immunoadsorption on platelet activation before, during and after 18 treatments in these patients was studied and patients were followed-up to assess clinical outcome. Platelet-associated immunoglobulin measurements were made before and at the end of six treatments. Platelet activation decreased after immunoadsorption. P-selectin expression fell significantly; pre- and post-treatment median values differed by 15.5%, P < 0.01, for GP53 the difference was 2.5%, P = NS. A reduction in both platelet-associated IgG (median reduction of 11.8 ng/10(6) platelets, P = 0.08) and IgM (7.6 ng/10(6) platelets, P = 0.06) was recorded.
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Affiliation(s)
- M R Cahill
- Department of Haematology, Royal London Hospital, Whitechapel
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Richardson DS, Kelsey SM, Johnson SA, Tighe M, Cavenagh JD, Newland AC. Early evaluation of liposomal daunorubicin (DaunoXome, Nexstar) in the treatment of relapsed and refractory lymphoma. Invest New Drugs 1997; 15:247-53. [PMID: 9387047 DOI: 10.1023/a:1005879219554] [Citation(s) in RCA: 31] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We have treated 19 patients with relapsed or refractory lymphoma with liposomally encapsulated daunorubicin (DaunoXome) at two dose schedules; 40 mg/m2 repeated every 14 days and 120 mg/m2 repeated every 21 days. Non-haematological toxicity was mild, in particular, no patient treated with the higher dose schedule showed clinical deterioration in cardiac function. At the lower dose (10 patients) no objective responses were seen but at the higher dose (9 patients) one complete response and two partial responses were achieved. Liposomal daunorubicin at 120 mg/m2 appears to have some activity against refractory lymphoma and we suggest that further studies with this agent are required.
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Cavenagh JD, Milne TM, Macey MG, Newland AC. Thymic function in adults: evidence derived from immune recovery patterns following myeloablative chemotherapy and stem cell infusion. Br J Haematol 1997; 97:673-6. [PMID: 9207421 DOI: 10.1046/j.1365-2141.1997.982913.x] [Citation(s) in RCA: 13] [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: 02/04/2023]
Abstract
We studied 45 patients aged 14-66 years who had undergone stem cell transplantation for a variety of malignant conditions at least 12 months previously. Compared to normal controls, they had significantly reduced absolute numbers of CD4+, CD4+ CD45RA+ and CD4+ CD45RO+ T cells and a reduced CD4+ CD45RA+:CD4+ CD45RO+ ratio. In all subsets T-cell numbers were significantly greater 24 months, compared to 12-24 months, after transplantation and there was a nonsignificant trend towards lower T-cell numbers with increasing age. We conclude that the thymus, or putative thymic-equivalent tissue, remains functional in older adults.
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Affiliation(s)
- J D Cavenagh
- Department of Haematology, The Royal London Hospital, Whitechapel, London
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Abstract
AIMS To prove the safety and effectiveness of "Professor Belmonte", a knowledge-based system for bone marrow reporting, a formal evaluation of the reports generated by the system was performed. METHODS Three haematologists (a consultant, a senior registrar, and a junior registrar), none of whom were involved in the development of the software, compared the unedited reports generated by Professor Belmonte with the original bone marrow reports in 785 unselected cases. Each haematologist independently graded the quality of Belmonte's reports using one of four categories: (a) better than the original report (more informative, containing useful information missing in the original report); (b) equivalent to the original report; (c) satisfactory, but missing information that should have been included; and (d) unsatisfactory. RESULTS The consultant graded 64 reports as more informative than the original, 687 as equivalent to the original, 32 as satisfactory, and two as unsatisfactory. The senior registrar considered 29 reports to be better than the original, 739 to be equivalent to the original, 15 to be satisfactory, and two to be unsatisfactory. The junior registrar found that 88 reports were better than the original, 681 were equivalent to the original, 14 were satisfactory, and two were unsatisfactory. Each judge found two different reports to be unsatisfactory according to their criteria. All 785 reports generated by the computer system received at least two scores of satisfactory or better. CONCLUSIONS In this representative study, Professor Belmonte generated bone marrow reports that proved to be as accurate as the original reports in a large university hospital. The haematology knowledge contained within the system, the reasoning process, and the function of the software are safe and effective for assisting haematologists in generating high quality bone marrow reports.
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Affiliation(s)
- D T Nguyen
- Department of Haematology, St Bartholomew's Hospital, London, United Kingdom
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Abstract
We describe a 28-year-old male patient who presented with apparently de novo acute myeloid leukaemia (AML) who was subsequently found to have Fanconi's anaemia (FA). The gene for complementation group A (FAA) has recently been localized to chromosome 16q24.3 and utilizing genetic markers closely linked to this locus we were able to conclude that this patient was likely to belong to complementation group A. FA presenting as AML is an exceptionally rare event and all previously described cases have occurred in patients less than 21 years of age. We conclude that the diagnosis of FA should always be considered in younger patients presenting with AML. It is important that the correct diagnosis is made in these individuals because the administration of conventional chemotherapy may well have devastating consequences for them. Correlations between the specific mutations causing FA and clinical phenotypes are likely to become apparent as more genetic analyses are performed in this group of patients.
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Affiliation(s)
- J D Cavenagh
- Department of Haematology, Royal London Hospital, Whitechapel
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Cavenagh JD, Colvin BT. Guidelines for the management of thrombophilia. Department of Haematology, The Royal London Hospital, Whitechapel, London, UK. Postgrad Med J 1996; 72:87-94. [PMID: 8871458 PMCID: PMC2398376 DOI: 10.1136/pgmj.72.844.87] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [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: 02/02/2023]
Abstract
Although there are numerous risk factors for venous thromboembolic disease, the term 'thrombophilia' refers only to those familial or acquired disorders of the haemostatic system that result in an increased risk of thrombosis. The inherited thrombophilias include antithrombin III deficiency, resistance to activated protein C (factor V Leiden), protein C and protein S deficiencies as well as some rare forms of dysfibrinogenaemia. It is possible that other inherited conditions might also predispose to thrombosis. In contrast, when using the above definition, the antiphospholipid syndrome is the only genuine acquired thrombophilic state. Patients who have thromboembolic disease at a young age with no provoking event or who have a positive family history or whose thrombosis involves an unusual site should be investigated for thrombophilia. The management of a patient identified as having a laboratory abnormality associated with thrombophilia will depend on a variety of factors such as the patient's individual and family thrombotic history, the site of the thrombosis and the presence of other prothrombotic risk factors. The use of prophylactic anticoagulation during pregnancy and the puerperium requires particularly careful consideration in thrombophilic women. As more becomes known about the thrombophilias it will become possible to formulate more exact guidelines as to the management of these conditions.
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Affiliation(s)
- J D Cavenagh
- Department of Haematology, The Royal London Hospital, UK
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Abstract
Aplastic anaemia (AA) is a disease of bone marrow failure. Evidence has been produced for both a stem cell and a stromal cell defect in this disease. The contribution of deficient or defective cell adhesion molecules (CAMs) has not been determined. CAMs have been shown to be important in stem cell-stromal cell interactions and maintenance of haemopoiesis. In this study the expression of CAMs (LFA-1, LFA-3, ICAM-1. VLA-4, CD44, sLex and L-selectin) on CD34+ progenitor cells from 10 normal donors and eight patients with AA was investigated using double immunofluorescence. There was no significant difference in the percentage of CD34+ cells that were CAM+ between normal and AA bone marrow, suggesting that abnormal CAM expression on AA progenitor cells is not responsible for nor contributes to the pathogenesis of the disease. However, these findings do not exclude abnormal CAM function on progenitor cells, or abnormal expression or function of CAM ligands or counter-receptors on AA stromal cells.
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Affiliation(s)
- M Karakantza
- Haematology Department, Dimokritios Medical School, Alexandrouplois, Greece
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Rea AJ, Cavenagh JD, Goh BT. Haemoglobin SC disease presenting as a case of priapism to a GUM clinic. Int J STD AIDS 1995; 6:361-2. [PMID: 8547420 DOI: 10.1177/095646249500600512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- A J Rea
- Department of Genitourinary Medicine, Royal London Hospital, Royal Hosptials' NHS Trust, Whitechapel, UK
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Abstract
AML blast cell adhesion to endothelium is in all likelihood a prerequisite for blast cell migration across the vascular wall in the periphery and the subsequent establishment of leukemic extravascular disease. A general feature of malignant cells is their acquisition of altered or aberrant adhesive capabilities which appear to be associated with their ability to metastasize. Aberrant expression of integrin adhesion molecules and of membrane oligosaccharide structures is found in AML and various solid tumors. With respect to AML, these alterations in adhesive phenotype may confer a proliferative advantage on the malignant cells in the marrow, may facilitate egress from the bone marrow into the peripheral vasculature and may enable AML blast cells to traverse the vessel wall and so establish extravascular disease. Oncogenes may be directly involved in the acquisition of such aberrant adhesive phenotypes. Neutrophil extravasation is described as a model for leukocyte migration across the vessel wall and brief summaries of experimental work involving aspects of AML blast cell and normal CD34+ bone marrow cell adhesion to endothelium in vitro are described.
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Affiliation(s)
- J D Cavenagh
- St. George's Hospital, Medical School, London, U.K
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Gattera JA, Charles BG, Williams GM, Cavenagh JD, Smithurst BA, Luchjenbroers J. A retrospective study of risk factors of akathisia in terminally ill patients. J Pain Symptom Manage 1994; 9:454-61. [PMID: 7822885 DOI: 10.1016/0885-3924(94)90202-x] [Citation(s) in RCA: 15] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Akathisia is a distressing disorder that manifests as a state of restlessness and motor agitation. We aim to highlight the problem of akathisia to the palliative care physician by identifying and quantifying risk factors in the terminally ill. A retrospective case-control study was utilized to investigate risk factors for akathisia. Medical records of cases (N = 100) and controls (N = 365) archived in a computerized database were downloaded and risk factors determined using conditional logistic regression analyses. Exposure to pharmacologically similar drugs, such as haloperidol [odds ratio (OR), 18.4; 95% confidence interval (CI), 8.2-41.4], prochlorperazine (OR, 8.1; 95% CI, 3.0-21.8), and promethazine (OR, 3.3; 95% CI, 1.3-8.0), conferred an increased risk. Other significant variables were exposure to morphine (OR, 5.3; 95% CI, 1.9-14.2), sodium valproate (OR, 2.5; 95% CI, 1.0-6.4), and sodium bicarbonate/tartrate (Ural) (OR, 4.2; 95% CI, 1.2-15.3). Highlighting factors that predispose patients to akathisia emphasizes that this syndrome should not be forgotten when treating the terminally ill. It is recommended that those drugs identified should be judicially used and carefully monitored.
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Affiliation(s)
- J A Gattera
- Department of Pharmacy, University of Queensland, Australia
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Karakantza M, Gibson FM, Cavenagh JD, Ball SE, Gordon MY, Gordon-Smith EC. SLe(x) expression of normal CD34 positive bone marrow haemopoietic progenitor cells. Br J Haematol 1994; 86:883-6. [PMID: 7522525 DOI: 10.1111/j.1365-2141.1994.tb04850.x] [Citation(s) in RCA: 9] [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: 01/25/2023]
Abstract
We investigated sialylated Lewis x (sLe(x)) antigen expression on CD34 positive (CD34+) haemopoietic progenitors in the bone marrow of eight healthy volunteers using monoclonal antibodies. We found that in all the samples examined, CD34+ bone marrow progenitors strongly expressed the sLe(x) antigen. This contradicts previous publications which reported sLe(x) expression on malignant blast cells but not on normal CD34+ progenitor cells.
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Affiliation(s)
- M Karakantza
- Department of Cellular and Molecular Sciences, St George's Hospital Medical School, London
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Abstract
We describe two patients with sickle cell disease (SCD) who developed infections situated in the spleen. One patient had a splenic abscess and there was strong clinical evidence for an infected splenic infarct in the second patient. SCD predisposes to splenic infection because of functional hyposplenism, defective phagocyte function and splenic infarction. Splenic infections can occur in patients who might be considered to have an absent spleen and the diagnosis of splenic abscess should be considered in individuals with SCD who present with fever and abdominal pain.
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Affiliation(s)
- J D Cavenagh
- Division of Haematology, St George's Hospital Medical School, London
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Cavenagh JD, Gordon-Smith EC, Gibson FM, Gordon MY. Acute myeloid leukaemia blast cells bind to human endothelium in vitro utilizing E-selectin and vascular cell adhesion molecule-1 (VCAM-1). Br J Haematol 1993; 85:285-91. [PMID: 7506565 DOI: 10.1111/j.1365-2141.1993.tb03168.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [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: 01/25/2023]
Abstract
The adhesion of acute myeloid leukaemia (AML) blast cells to human umbilical vein endothelial cells (HUVECs) was investigated in vitro. Adhesion of blast cells from 10 cases of AML to unstimulated and interleukin-1 beta (IL-1) stimulated HUVECs was similar to or greater than that of control neutrophils. The extent to which endothelial E-selectin and vascular cell adhesion molecule-1 (VCAM-1) were involved in this adhesive process was investigated using blocking monoclonal antibodies to these proteins. In the majority of cases studied (7/8), anti-E-selectin significantly inhibited adhesion to IL-1 stimulated endothelium (26-65% inhibition) and in 5/8 cases so did anti-VCAM-1 (maximum of 31% inhibition). All cases were found to express the sialylated Lewis x antigen and very late activation antigen-4, ligands for E-selectin and VCAM-1 respectively. Our results indicate that leukaemic blast cells adhere to human endothelium and that there are E-selectin and, to a lesser extent, VCAM-1-dependent components to this process. Such adhesive interactions are likely to confer on AML blast cells the ability to migrate across the vascular wall and so to establish extravascular disease.
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Affiliation(s)
- J D Cavenagh
- Division of Haematology, St George's Hospital Medical School, London
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Schneider JJ, Ravenscroft PJ, Cavenagh JD, Brown AM, Bradley JP. Plasma morphine-3-glucuronide, morphine-6-glucuronide and morphine concentrations in patients receiving long-term epidural morphine. Br J Clin Pharmacol 1992; 34:431-3. [PMID: 1467139 PMCID: PMC1381473 DOI: 10.1111/j.1365-2125.1992.tb05651.x] [Citation(s) in RCA: 6] [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: 12/27/2022] Open
Abstract
Plasma morphine concentrations were measured in five cancer patients receiving long-term epidural morphine administration. Peak concentrations were observed within 1 h of dosage and concentrations then declined biexponentially. Plasma morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) concentrations were measured in two patients and plasma M3G concentrations were observed to be much higher than plasma M6G and morphine concentrations. Peak plasma M6G concentrations occurred within 1.0 h of dosing and plasma M6G concentrations then remained higher than plasma morphine concentrations.
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Affiliation(s)
- J J Schneider
- Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Qld., Australia
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