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Cisneros GS, Dvorak CC, Long-Boyle J, Kharbanda S, Shimano KA, Melton A, Chu J, Winestone LE, Dara J, Huang JN, Hermiston ML, Zinter M, Higham CS. Diagnosing and Grading of Sinusoidal Obstructive Syndrome after Hematopoietic Stem Cell Transplant of Children, Adolescent and Young Adults treated in a Pediatric Institution with Pediatric Protocols. Transplant Cell Ther 2024:S2666-6367(24)00345-2. [PMID: 38631464 DOI: 10.1016/j.jtct.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/31/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Sinusoidal obstructive syndrome (SOS), or veno-occlusive disease (VOD), of the liver has been recognized as a complex, life-threatening complication in the post-hematopoietic stem cell transplant (HSCT) setting. The diagnostic criteria for SOS have evolved over the last several decades with a greater understanding of the underlying pathophysiology, with two recent diagnostic criteria introduced in 2018 (EBMT criteria) and 2020 (Cairo criteria). OBJECTIVE We sought out to evaluate the performance characteristics in diagnosing and grading SOS in pediatric patients of the four different diagnostic criteria (Baltimore, Modified Seattle, EBMT, and Cairo) and severity grading systems (defined by the EBMT and Cairo criteria). STUDY Design: Retrospective chart review of children, adolescent and young adults (CAYA) who underwent conditioned autologous and allogeneic HSCT between 2017 and 2021 at a single pediatric institution. RESULTS A total of 250 consecutive patients underwent at least one HSCT at UCSF Benioff Children's Hospital San Francisco for a total of 307 HSCT. The day 100 cumulative incidence of SOS was 12.1%, 21.1%, 28.4%, and 28.4% per the Baltimore, Modified Seattle, EBMT, and Cairo criteria, respectively (p<0.001). We found that patients diagnosed with grade ≥4 SOS per the Cairo criteria were more likely to be admitted to the PICU (92% vs. 58%, p=0.035) and intubated (85% vs. 32%, p=0.002) than those diagnosed with grade ≥4 per EBMT criteria. Age <3 years-old (HR 1.76, 95% [1.04-2.98], p=0.036), an abnormal BMI (HR 1.69, 95% [1.06-2.68], p=0.027), and high-risk patients per our institutional guidelines (HR 1.68, 95% [1.02-2.76], p=0.041) were significantly associated with SOS per the Cairo criteria. CONCLUSIONS We demonstrate that age <3 years, abnormal BMI, and other high-risk criteria associate strongly with subsequent SOS development. Patients with moderate to severe SOS based on Cairo severity grading criteria may correlate better with clinical course based on ICU admissions and intubations when compared to the EBMT severity grading system.
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Affiliation(s)
| | | | | | | | | | - Alexis Melton
- University of California, San Francisco, California, USA
| | - Julia Chu
- University of California, San Francisco, California, USA
| | | | - Jasmeen Dara
- University of California, San Francisco, California, USA
| | - James N Huang
- University of California, San Francisco, California, USA
| | | | - Matt Zinter
- University of California, San Francisco, California, USA
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Hayashi RJ, Hermiston ML, Wood BL, Teachey DT, Devidas M, Chen Z, Annett RD, Asselin BL, August K, Cho S, Dunsmore KP, Freedman JL, Galardy PJ, Harker-Murray P, Horton TM, Jaju A, Lam A, Messinger YH, Miles RR, Okada M, Patel S, Schafer ES, Schechter T, Shimano KA, Singh N, Steele A, Sulis ML, Vargas S, Winter SS, Wood C, Zweider-McKay PA, Loh ML, Hunger SP, Raetz EA, Bollard CM, Allen CE. MRD at the End of Induction and EFS in T-cell Lymphoblastic Lymphoma: Children's Oncology Group Trial AALL1231. Blood 2024:blood.2023021184. [PMID: 38457359 DOI: 10.1182/blood.2023021184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/10/2024] Open
Abstract
Defining prognostic variables in T-lymphoblastic lymphoma (T-LL) remains a challenge. AALL1231 was a COG phase 3 clinical trial for newly diagnosed with T Acute Lymphoblastic leukemia or T-LL patients randomizing children and young adults to a modified augmented BFM backbone to receive standard therapy (Arm A) or with addition of bortezomib (Arm B). Optional bone marrow (BM) samples to assess minimal residual disease (MRD) at the end of induction (EOI) were collected in T-LL analyzed to assess the correlation of MRD at the EOI to event-free survival (EFS). Eighty-six (41%) of the 209 T-LL patients accrued to this trial submitted samples for MRD assessment. Patients with MRD <0.1% (n= 75) at EOI had a superior 4-year EFS versus those with MRD >0.1% (n= 11), (89.0±4.4% versus 63.6±17.2%, p= 0.025). Overall survival did not significantly differ between the two groups. Cox regression for EFS using Arm A as a reference demonstrated that MRD EOI ≥0.1% was associated with a greater risk of inferior outcome (Hazard Ratio, HR= 3.73 (1.12-12.40, p= 0.032), which was independent of treatment arm assignment. Consideration to incorporate MRD at EOI into future trials will help establish its value in defining risk groups. CT# NCT02112916.
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Affiliation(s)
- Robert J Hayashi
- Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Michelle L Hermiston
- University of California, San Francisco, San Francisco, California, United States
| | - Brent L Wood
- Childrens Hospital Los Angeles, Los Angeles, California, United States
| | | | - Meenakshi Devidas
- St Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Zhiguo Chen
- University of Florida, Gainesville, Florida, United States
| | - Robert D Annett
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States
| | - Barbara L Asselin
- University of Rochester Medical Center, Rochester, New York, United States
| | - Keith August
- Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Steve Cho
- Wisconsin Institute for Medical Research, United States
| | | | | | | | | | - Terzah M Horton
- Baylor College of Medicine/Dan L. Duncan Cancer Center and Texas Children's Cancer Center, Houston, Texas, United States
| | - Alok Jaju
- Phoenix Children's Hospital, Phoenix, Arizona, United States
| | | | - Yoav H Messinger
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, United States
| | - Rodney R Miles
- University of Utah -- Huntsman Cancer Institute, Salt Lake City, Utah, United States
| | - Maki Okada
- University of Alberta- Stollery Children's Hospital, Edmonton, AB, Canada, United States
| | | | | | | | - Kristin A Shimano
- University of California San Francisco, San Francisco, California, United States
| | - Neelam Singh
- Michigan State University Clinical Center, East Lansing, Michigan, United States
| | - Amii Steele
- Carolinas Medical Center/Levine Cancer Institute, Charlotte, North Carolina, United States
| | - Maria Luisa Sulis
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Sarah Vargas
- childrens oncology group, Monrovia, California, United States
| | | | - Charlotte Wood
- University of Florida, gainesville, Florida, United States
| | | | - Mignon L Loh
- Seattle Children's Hospital, the Ben Town Center for Childhood Cancer Research, University of Washington, Seattle, WA., Seattle, Washington, United States
| | - Stephen P Hunger
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | | | | | - Carl E Allen
- Baylor College of Medicine, Houston, Texas, United States
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Apsel Winger B, Devine WP, Hsiao EC, Zapala M, Van Ziffle J, Gupta N, Frieden IJ, Shimano KA. EML4::ALK fusions in complex lymphatic malformations. Pediatr Blood Cancer 2023:e30516. [PMID: 37377128 DOI: 10.1002/pbc.30516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
Gorham-Stout disease (GSD) and generalized lymphatic anomaly (GLA) are subtypes of complex lymphatic malformations (CLMs) with osseous involvement that cause significant complications, including pain and pathologic fractures. As with other vascular anomalies, somatic mosaic mutations in oncogenes are often present, and the mTOR inhibitor sirolimus alleviates symptoms in some, but not all, patients. We describe two patients, one with GSD and one with GLA, found to have EML4::ALK fusions. This report of a targetable, oncogenic fusion in vascular malformations expands our understanding of the genetic basis for CLMs and suggests additional targeted therapies could be effective.
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Affiliation(s)
- Beth Apsel Winger
- Department of Pediatrics, Division of Hematology, University of California San Francisco, San Francisco, California, USA
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Walter Patrick Devine
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Edward C Hsiao
- Department of Medicine, and the Institute for Human Genetics, University of California San Francisco, San Francisco, California, USA
| | - Matthew Zapala
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Jessica Van Ziffle
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ilona J Frieden
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Kristin A Shimano
- Department of Pediatrics, Division of Hematology, University of California San Francisco, San Francisco, California, USA
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Cisneros GS, Dvorak CC, Kharbanda S, Shimano KA, Melton A, Chu J, Winestone LE, Dara J, Huang JN, Hermiston M, Higham CS. Diagnosing and Grading of SOS: Which Criteria Are Best? Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00241-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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5
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Cho S, Dvorak CC, Higham CS, Cisneros GS, Chu J, Melton A, Winestone LE, Shimano KA, Dara J, Hermiston M, Huang JN, Long-Boyle JR, Kharbanda S. Prophylactic Tocilizumab Decreases Incidence of Acute Graft-Versus-Host Disease Following Alpha/Beta T-Cell Depleted Haploidentical Hematopoietic Stem Cell Transplantation in Children and Young Adults. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00414-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Shimano KA, Vanderpoel V, Stone H, Resar L, Kucine N. Clinical features associated with thrombotic events in children with myeloproliferative neoplasms. Am J Hematol 2022; 97:E353-E355. [PMID: 35751861 PMCID: PMC9378702 DOI: 10.1002/ajh.26646] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/05/2022]
Abstract
In children with MPNs, clots are most common in those with JAK2 mutations and those with polycythemia vera.
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Affiliation(s)
- Kristin A Shimano
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Victoria Vanderpoel
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Hannah Stone
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Linda Resar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicole Kucine
- Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
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Shimano KA, Eng W, Adams DM. How we approach the use of sirolimus and new agents: Medical therapy to treat vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29603. [PMID: 35253343 DOI: 10.1002/pbc.29603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 12/11/2022]
Abstract
Vascular anomalies (VAs) are a heterogeneous group of primarily congenital tumors and malformations. The International Society for the Study of Vascular Anomalies (ISSVA) has developed a standard classification of these disorders, creating a uniform approach to their diagnosis. Recent discoveries evaluating the genetic causes of VAs have revealed that they are due to mutations in cancer pathways, including the PI3K/AKT/mTOR and RAS/MAPK/MEK pathways. These discoveries have led to improved phenotype-genotype correlation and have expanded medical therapy for this group of unique disorders.
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Affiliation(s)
- Kristin A Shimano
- Division of Allergy, Immunology, and Bone Marrow Transplant, UCSF Benioff Children's Hospital, University of California, San Francisco, California, USA
| | - Whitney Eng
- Division of Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Denise M Adams
- Division of Oncology, Comprehensive Vascular Anomalies Program/Frontier Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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8
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Lloyd-McLennan AM, Shimano KA, Dorsey M, Cordoro KM. Eczema and Petechiae in an Infant. Pediatr Rev 2022; 43:e19-e23. [PMID: 35773537 DOI: 10.1542/pir.2020-004900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | | | - Kelly M Cordoro
- Department of Dermatology, University of California at San Francisco School of Medicine, San Francisco, CA
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Higham CS, Shimano KA, Melton A, Kharbanda S, Chu J, Dara J, Winestone LE, Hermiston ML, Huang JN, Dvorak CC. A pilot trial of prophylactic defibrotide to prevent serious thrombotic microangiopathy in high-risk pediatric patients. Pediatr Blood Cancer 2022; 69:e29641. [PMID: 35253361 DOI: 10.1002/pbc.29641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/05/2022] [Accepted: 02/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial injury complication of hematopoietic stem cell transplant (HSCT) leading to end-organ damage and high morbidity and mortality. Defibrotide is an anti-inflammatory and antithrombotic agent that may protect the endothelium during conditioning. PROCEDURE We hypothesized that prophylactic use of defibrotide during HSCT conditioning and acute recovery could prevent TA-TMA. A pilot single-arm phase II trial (NCT#03384693) evaluated the safety and feasibility of administering prophylactic defibrotide to high-risk pediatric patients during HSCT and assessed if prophylactic defibrotide prevented TA-TMA compared to historic controls. Patients received defibrotide 6.25 mg/kg IV q6h the day prior to the start of conditioning through day +21. Patients were prospectively monitored for TA-TMA from admission through week 24 post transplant. Potential biomarkers of endothelial injury (suppression of tumorigenicity 2 [ST2], angiopoietin-2 [ANG-2], plasminogen activator inhibitor-1 [PAI-1], and free hemoglobin) were analyzed. RESULTS Twenty-five patients were enrolled, 14 undergoing tandem autologous HSCT for neuroblastoma and 11 undergoing allogeneic HSCT. Defibrotide was discontinued early due to possibly related clinically significant bleeding in 12% (3/25) of patients; no other severe adverse events occurred due to the study intervention. The other 22 patients missed a median of 0.7% of doses (0%-5.2%). One patient developed nonsevere TA-TMA 12 days post HSCT. This observed TA-TMA incidence of 4% was below the historic rate of 18%-40% in a similar population of allogeneic and autologous patients. CONCLUSIONS Our study provides evidence that defibrotide prophylaxis is feasible in pediatric patients undergoing HSCT at high risk for TA-TMA and preliminary data indicating that defibrotide may reduce the risk of TA-TMA.
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Affiliation(s)
- Christine S Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Julia Chu
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Jasmeen Dara
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Lena E Winestone
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Michelle L Hermiston
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - James N Huang
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
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10
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Forlanini F, Zinter MS, Dvorak CC, Bailey-Olson M, Winestone LE, Shimano KA, Higham CS, Melton A, Chu J, Kharbanda S. Hematopoietic Cell Transplantation-Comorbidity Index Score Is Correlated with Treatment-Related Mortality and Overall Survival following Second Allogeneic Hematopoietic Cell Transplantation in Children. Transplant Cell Ther 2021; 28:155.e1-155.e8. [PMID: 34848362 DOI: 10.1016/j.jtct.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) can lead to considerable complications and treatment-related mortality (TRM); therefore, a detailed assessment of risks is essential. The Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) can predict both TRM and overall survival (OS). Although the HCT-CI has been validated as a useful tool for first HCT, its potential utility for second HCT has not yet been investigated. Here we aimed to evaluate the utility of the HCT-CI score in assessing the risk of TRM and OS in the setting of a second allogeneic HCT. This was a retrospective analysis of all pediatric patients (age <21 years) who underwent a second allogeneic HCT at UCSF Benioff Children's Hospital San Francisco between 2008 and 2019. According to their HCT-CI, patients were classified as "low risk" with an HCT-CI of 0 or "intermediate-high risk" with an HCT-CI ≥1. A total of 59 patients were included in the study. Our primary endpoint was TRM, observed at 100 days, 180 days, 1 year, and last follow-up following HCT, and our secondary endpoint was OS at 1 year and at 5 years or last follow-up. We also evaluated outcomes of patients admitted to the pediatric intensive care unit based on the HCT-CI score. Seventy-six percent of patients had an HCT-CI of 0. The most frequent comorbidities were pulmonary, seen in 7 patients (12%; 95% CI, 5% to 23%), including 5 (71%) with moderate and 2 (29%) with severe comorbidities. The OS and the cumulative incidence of TRM at 1 year for the entire cohort were 81% (95% CI, 69% to 90%) and 12% (95% CI, 5% to 22%), respectively. The cumulative incidence of TRM and OS at 1 year showed a significant correlation with HCT-CI score; TRM was 4% (95% CI, 1% to 13%) for an HCT-CI of 0 versus 36% (95% CI, 13% to 60%) for an HCT-CI ≥1 (P < .001), and OS was 89% (95% CI, 75% to 99%) for an HCT-CI of 0 versus 57% (95% CI, 28% to 78%) for an HCT-CI ≥1 (P = .003). After adjusting for covariates, HCT-CI continued to be associated with both TRM (P = .004) and OS (P = .003). In addition, comparing patients with malignancies and nonmalignant disorders, disease-free-survival at last follow-up was higher in the nonmalignant disorder group and also was influenced by the HCT-CI score in each group (P = .0035). There also was a significant difference in outcomes of patients admitted to the pediatric intensive care unit; 15 patients (68%) with an HCT-CI of 0 were alive at last follow-up, compared with only two (22%) with an HCT-CI ≥1 (P = .016). HCT-CI has an impact on TRM and OS and may serve as a predictor of outcomes of second allogeneic transplantation. Although this study was conducted in a relatively small sample, it is the first to investigate the utility of the HCT-CI score in predicting outcomes after a second allogeneic HCT in pediatric recipients. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Federica Forlanini
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California; Department of Pediatrics, V. Buzzi Hospital, Università degli Studi di Milano, Milan, Italy
| | - Matt S Zinter
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Mara Bailey-Olson
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Lena E Winestone
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Christine S Higham
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Julia Chu
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California.
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Shimano KA, Narla A, Rose MJ, Gloude NJ, Allen SW, Bergstrom K, Broglie L, Carella BA, Castillo P, Jong JLO, Dror Y, Geddis AE, Huang JN, Lau BW, McGuinn C, Nakano TA, Overholt K, Rothman JA, Sharathkumar A, Shereck E, Vlachos A, Olson TS, Bertuch AA, Wlodarski MW, Shimamura A, Boklan J. Diagnostic work-up for severe aplastic anemia in children: Consensus of the North American Pediatric Aplastic Anemia Consortium. Am J Hematol 2021; 96:1491-1504. [PMID: 34342889 DOI: 10.1002/ajh.26310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
The North American Pediatric Aplastic Anemia Consortium (NAPAAC) is a group of pediatric hematologist-oncologists, hematopathologists, and bone marrow transplant physicians from 46 institutions in North America with interest and expertise in aplastic anemia, inherited bone marrow failure syndromes, and myelodysplastic syndromes. The NAPAAC Bone Marrow Failure Diagnosis and Care Guidelines Working Group was established with the charge of harmonizing the approach to the diagnostic workup of aplastic anemia in an effort to standardize best practices in the field. This document outlines the rationale for initial evaluations in pediatric patients presenting with signs and symptoms concerning for severe aplastic anemia.
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Affiliation(s)
- Kristin A. Shimano
- Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco California USA
| | - Anupama Narla
- Department of Pediatrics Stanford University School of Medicine Stanford California USA
| | - Melissa J. Rose
- Division of Hematology, Oncology, and Bone Marrow Transplant Nationwide Children's Hospital, The Ohio State University College of Medicine Columbus Ohio USA
| | - Nicholas J. Gloude
- Department of Pediatrics University of California San Diego, Rady Children's Hospital San Diego California USA
| | - Steven W. Allen
- Pediatric Hematology/Oncology University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Katie Bergstrom
- Cancer and Blood Disorders Center Seattle Children's Hospital Seattle Washington USA
| | - Larisa Broglie
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Beth A. Carella
- Department of Pediatrics Kaiser Permanente Washington District of Columbia USA
| | - Paul Castillo
- Division of Pediatric Hematology Oncology UF Health Shands Children's Hospital Gainesville Florida USA
| | - Jill L. O. Jong
- Section of Hematology‐Oncology, Department of Pediatrics University of Chicago Chicago Illinois USA
| | - Yigal Dror
- Marrow Failure and Myelodysplasia Program, Division of Hematology and Oncology, Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Amy E. Geddis
- Cancer and Blood Disorders Center Seattle Children's Hospital Seattle Washington USA
| | - James N. Huang
- Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco California USA
| | - Bonnie W. Lau
- Pediatric Hematology‐Oncology Dartmouth‐Hitchcock Lebanon New Hampshire USA
| | - Catherine McGuinn
- Department of Pediatrics Weill Cornell Medicine New York New York USA
| | - Taizo A. Nakano
- Center for Cancer and Blood Disorders Children's Hospital Colorado Aurora Colorado USA
| | - Kathleen Overholt
- Pediatric Hematology and Oncology Riley Hospital for Children at Indiana University Indianapolis Indiana USA
| | - Jennifer A. Rothman
- Division of Pediatric Hematology and Oncology Duke University Medical Center Durham North Carolina USA
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics University of Iowa Carver College of Medicine Iowa City Iowa USA
| | - Evan Shereck
- Department of Pediatrics Oregon Health and Science University Portland Oregon USA
| | - Adrianna Vlachos
- Hematology, Oncology and Cellular Therapy Cohen Children's Medical Center New Hyde Park New York USA
| | - Timothy S. Olson
- Cell Therapy and Transplant Section, Division of Oncology and Bone Marrow Failure, Division of Hematology, Department of Pediatrics Children's Hospital of Philadelphia and University of Pennsylvania Philadelphia Pennsylvania USA
| | | | | | - Akiko Shimamura
- Cancer and Blood Disorders Center Boston Children's Hospital and Dana Farber Cancer Institute Boston Massachusetts USA
| | - Jessica Boklan
- Center for Cancer and Blood Disorders Phoenix Children's Hospital Phoenix Arizona USA
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12
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Weiss NM, Kuzniewicz MW, Shimano KA, Walsh EM, Newman TB. Use of Complete Blood Cell Count Components to Screen for Hereditary Spherocytosis in Neonates. Pediatrics 2021; 148:peds.2020-021642. [PMID: 34376530 DOI: 10.1542/peds.2020-021642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The neonatal hereditary spherocytosis (HS) index, defined as the mean corpuscular hemoglobin concentration divided by the mean corpuscular volume, has been proposed as a screening tool for HS in neonates. In a population of mostly white infants, an HS Index >0.36 was 97% sensitive and >99% specific. We evaluated the utility of the HS Index among a more racially and ethnically diverse population and determined if its discrimination varies with total serum bilirubin (TSB) levels. METHODS Infants born at ≥35 weeks' gestation at 15 Kaiser Permanente Northern California hospitals from 1995 to 2015 were eligible (N = 670 272). Erythrocyte indices from the first complete blood count drawn at ≤7 days and TSB levels drawn at ≤30 days were obtained. Diagnoses of HS were confirmed via chart review. RESULTS HS was confirmed in 79 infants, 1.2 per 10 000. HS was more common among infants of white and "other" race or ethnicity and among those with higher peak TSB levels. The area under the receiver operating characteristic curve for the HS Index was 0.84 (95% confidence interval 0.78-0.90). Likelihood ratios ranged from 10.1 for an HS Index ≥0.380 to 0.1 for an HS Index <0.310. Dichotomized at 0.36, the HS Index was 56% sensitive and 93% specific. Discrimination of the HS Index appeared best among infants with TSB levels <10 mg/dL. CONCLUSIONS The HS Index, when obtained from a CBC drawn within the first week after birth, had only modest ability to alter the probability of HS.
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Affiliation(s)
- Nicole M Weiss
- Departments of Pediatrics .,Department of Pediatrics, Kaiser Permanente Santa Clara, Santa Clara, California
| | - Michael W Kuzniewicz
- Departments of Pediatrics.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Eileen M Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Thomas B Newman
- Departments of Pediatrics.,Division of Research, Kaiser Permanente Northern California, Oakland, California.,Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
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13
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Shimano KA, Grace RF, Despotovic JM, Neufeld EJ, Klaassen RJ, Bennett CM, Ma C, London WB, Neunert C. Phase 3 randomised trial of eltrombopag versus standard first-line pharmacological management for newly diagnosed immune thrombocytopaenia (ITP) in children: study protocol. BMJ Open 2021; 11:e044885. [PMID: 34452956 PMCID: PMC8404450 DOI: 10.1136/bmjopen-2020-044885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Immune thrombocytopaenia (ITP) is an acquired disorder of low platelets and risk of bleeding. Although many children can be observed until spontaneous remission, others require treatment due to bleeding or impact on health-related quality of life. Standard first-line therapies for those who need intervention include corticosteroids, intravenous immunoglobulin and anti-D globulin, though response to these agents may be only transient. Eltrombopag is an oral thrombopoietin receptor agonist approved for children with chronic ITP who have had an insufficient response to corticosteroids, intravenous immunoglobulin or splenectomy. This protocol paper describes an ongoing open-label, randomised trial comparing eltrombopag to standard first-line management in children with newly diagnosed ITP. METHODS AND ANALYSIS Randomised treatment assignment is 2:1 for eltrombopag versus standard first-line management and is stratified by age and by prior treatment. The primary endpoint of the study is platelet response, defined as ≥3 of 4 weeks with platelets >50×109/L during weeks 6-12 of therapy. Secondary outcomes include number of rescue therapies needed during the first 12 weeks, proportion of patients who do not need ongoing treatment at 12 weeks and 6 months, proportion of patients with a treatment response at 1 year, and number of second-line therapies used in weeks 13-52, as well as changes in regulatory T cells, iron studies, bleeding, health-related quality of life and fatigue. A planned sample size of up to 162 randomised paediatric patients will be enrolled over 2 years at 20 sites. ETHICS AND DISSEMINATION The study has been approved by the centralised Baylor University Institutional Review Board. The results are expected to be published in 2023. TRIAL REGISTRATION NUMBER NCT03939637.
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Affiliation(s)
- Kristin A Shimano
- UCSF Benioff Children's Hospital, San Francisco, California, USA
- Pediatrics, UCSF, San Francisco, California, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Ellis J Neufeld
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Carolyn M Bennett
- Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Wendy B London
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Biostatistics, Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy Neunert
- Pediatrics, Columbia University Medical School, New York, New York, USA
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14
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Shimano KA, Neunert C, Bussel JB, Klaassen RJ, Bhat R, Pastore YD, Lambert MP, Bennett CM, Despotovic JM, Forbes P, Grace RF. Quality of life is an important indication for second-line treatment in children with immune thrombocytopenia. Pediatr Blood Cancer 2021; 68:e29023. [PMID: 33764667 DOI: 10.1002/pbc.29023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND The decision to initiate second-line treatment in children with immune thrombocytopenia (ITP) is complex and involves many different factors. METHODS In this prospective, observational, longitudinal cohort study of 120 children from 21 centers, the factors contributing to the decision to start second-line treatments for ITP were captured. At study entry, clinicians were given a curated list of 12 potential reasons the patient required a second-line treatment. Clinicians selected all that applied and ranked the top three reasons. RESULTS Quality of life (QOL) was the most frequently cited reason for starting a second-line therapy. Clinicians chose it as a reason to treat in 88/120 (73%) patients, as among the top three reasons in 68/120 (57%), and as the top reason in 32/120 (27%). Additional factors ranked as the top reason to start second-line treatment included severity of bleeding (22/120, 18%), frequency of bleeding (19/120, 16%), and severity of thrombocytopenia (18/120, 15%). Patients for whom QOL (p = .006) or sports participation (p = .02) were ranked reasons were more likely to have chronic ITP, whereas those for whom severity (p = .003) or frequency (p = .005) of bleeding were ranked reasons were more likely to have newly diagnosed or persistent ITP. Parental anxiety, though rarely the primary impetus for treatment, was frequently cited (70/120, 58%) as a contributing factor. CONCLUSION Perceived QOL is the most frequently selected reason pediatric patients start second-line therapies for ITP. It is critical that studies of treatments for childhood ITP include assessments of their effects on QOL.
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Affiliation(s)
| | - Cindy Neunert
- Columbia University Medical Center, New York, New York, USA
| | | | | | - Rukhmi Bhat
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carolyn M Bennett
- Emory University School of Medicine, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Atlanta, Georgia, USA
| | - Jenny M Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts, USA
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15
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Edwards EA, Phelps AS, Cooke D, Frieden IJ, Zapala MA, Fullerton HJ, Shimano KA. Monitoring Arteriovenous Malformation Response to Genotype-Targeted Therapy. Pediatrics 2020; 146:peds.2019-3206. [PMID: 32859736 DOI: 10.1542/peds.2019-3206] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 11/24/2022] Open
Abstract
Arteriovenous malformations (AVMs) have recently been reported to have a high incidence of somatic KRAS mutations suggesting potential for treatment with mitogen-activated protein kinase inhibitors. In this case report, we describe genotype-targeted treatment of a KRAS mutant metameric AVM in a patient with Cobb syndrome using the mitogen-activated protein kinase inhibitor trametinib. Therapeutic response was monitored with phase-contrast magnetic resonance angiography to quantify AVM arterial inflow as an imaging biomarker. Treatment with trametinib resulted in a substantial decrease in blood flow to the AVM, with a >75% reduction in arterial inflow after 6 months of trametinib therapy.
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Affiliation(s)
- Emily A Edwards
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon; and .,Departments of Radiology
| | | | | | | | | | | | - Kristin A Shimano
- Pediatrics, University of California San Francisco, San Francisco, California
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16
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Contreras CF, Long-Boyle JR, Shimano KA, Melton A, Kharbanda S, Dara J, Higham C, Huang JN, Cowan MJ, Dvorak CC. Reduced Toxicity Conditioning for Nonmalignant Hematopoietic Cell Transplants. Biol Blood Marrow Transplant 2020; 26:1646-1654. [PMID: 32534101 DOI: 10.1016/j.bbmt.2020.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) for children with nonmalignant disorders is challenged by potential drug-related toxicities and poor engraftment. This retrospective analysis expands on our single pediatric medical center experience with targeted busulfan, fludarabine, and intravenous (IV) alemtuzumab as a low-toxicity regimen to achieve sustained donor engraftment. Sixty-two patients received this regimen for their first HCT for a nonmalignant disorder between 2004 and 2018. Donors were matched sibling in 27%, 8/8 HLA allele-matched unrelated in 50%, and 7/8 HLA allele-mismatched in 23% (some of whom received additional immunoablation with thiotepa or clofarabine). Five patients experienced graft failure for a cumulative incidence of 8.4% (95% CI, 1 to 16%). In engrafted patients, the median donor chimerism in whole blood and CD3, CD14/15, and CD19 subsets at 1-year were 96%, 90%, 99%, and 99%, respectively. Only one patient received donor lymphocyte infusions (DLIs) for poor chimerism. Two patients died following disease progression despite 100% donor chimerism. The 3-year cumulative incidence of treatment-related mortality was 10% (95% CI, 2 to 17%). Overall survival and event-free-survival at 3-years were 87% (95% CI, 78 to 95%) and 80% (95% CI, 70 to 90%), respectively. The 6-month cumulative incidence of grade II to IV acute graft-versus-host disease (GVHD) was 7% (95% CI, 3 to 13%), while the 3-year cumulative incidence of chronic GVHD was 5% (95% CI, 0 to 11%). These results suggest that use of targeted busulfan, fludarabine and IV alemtuzumab offers a well-tolerated option for children with nonmalignant disorders to achieve sustained engraftment with a low incidence of GVHD.
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Affiliation(s)
| | - Janel R Long-Boyle
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California; Department of Clinical Pharmacy, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California; Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Jasmeen Dara
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Christine Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - James N Huang
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California; Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Morton J Cowan
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, California.
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17
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Grace RF, Klaassen RJ, Shimano KA, Lambert MP, Grimes A, Bussel JB, Breakey VR, Pastore YD, Black V, Overholt K, Bhat R, Forbes PW, Neunert C. Fatigue in children and adolescents with immune thrombocytopenia. Br J Haematol 2020; 191:98-106. [PMID: 32501532 DOI: 10.1111/bjh.16751] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP), an acquired autoimmune disorder of low platelets and risk of bleeding, has a substantial impact on health-related quality of life (HRQoL). Patients with ITP often report significant fatigue, although the pathophysiology of this is poorly understood. In this observational cohort of 120 children receiving second-line therapies for ITP, we assessed reports of fatigue using the Hockenberry Fatigue Scale. Children and adolescents with ITP reported a similarly high level of fatigue with 54% (29/54) of children and 62% (26/42) of adolescents reporting moderate-to-severe fatigue. There was no correlation between fatigue and age or gender. Adolescents with newly diagnosed and persistent ITP had higher mean fatigue scores than those with chronic ITP (P = 0·03). Fatigue significantly improved in children and adolescents by 1 month after starting second-line treatments, and this improvement continued to be present at 12 months after starting treatment. Fatigue scores at all time-points correlated with general HRQoL using the Kids ITP Tool, but did not correlate with bleeding symptoms, platelet count, or platelet response to treatment. Fatigue is common in children and adolescents with ITP and may benefit from ITP-directed treatment even in the absence of bleeding symptoms.
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Affiliation(s)
- Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Robert J Klaassen
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Kristin A Shimano
- Division of Allergy/Immunology/Bone Marrow Transplant, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amanda Grimes
- Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | | | | | | | - Vandy Black
- Division of Pediatric Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kathleen Overholt
- Riley Hospital at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rukhmi Bhat
- Ann and Robert H. Lurie Childrens Hospital of Chicago, Chicago, IL, USA
| | - Peter W Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Cindy Neunert
- Columbia University Medical School, New York, NY, USA
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18
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Friend BD, Bailey-Olson M, Melton A, Shimano KA, Kharbanda S, Higham C, Winestone LE, Huang J, Stieglitz E, Dvorak CC. The impact of total body irradiation-based regimens on outcomes in children and young adults with acute lymphoblastic leukemia undergoing allogeneic hematopoietic stem cell transplantation. Pediatr Blood Cancer 2020; 67:e28079. [PMID: 31724815 DOI: 10.1002/pbc.28079] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Total body irradiation (TBI)-based conditioning is the standard of care in the treatment of acute lymphoblastic leukemia (ALL) that requires allogeneic hematopoietic stem cell transplantation (HSCT). However, TBI is known to be associated with an increased risk of late effects, and therefore, non-TBI regimens have also been utilized successfully. A recent study showed that patients that were next-generation sequencing-minimal residual disease (NGS-MRD) negative prior to allogeneic HSCT had a very low risk of relapse, and perhaps could avoid exposure to TBI without compromising disease control. We examined outcomes at our institution in patients that received a TBI or non-TBI regimen, as well as explored the impact of NGS-MRD status in predicting risk of relapse post transplant. PROCEDURES This retrospective analysis included 57 children and young adults with ALL that received their first myeloablative allogeneic HSCT from 2012 to 2017 at the University of California San Francisco. Our primary endpoint was the cumulative incidence of relapse at 3 years post transplant. RESULTS We demonstrated similar cumulative incidence of relapse for patients treated with either a TBI or non-TBI conditioning regimen, while NGS-MRD positivity prior to transplant was highly predictive of relapse. The presence of acute graft-versus-host disease was associated with decreased relapse rates, particularly among patients that received a TBI conditioning regimen and patients that were NGS-MRD positive prior to HSCT. CONCLUSIONS Our data suggest that the decision to use either a TBI or non-TBI regimens in ALL should depend on NGS-MRD status, with conditioning regimens based on TBI reserved for patients that cannot achieve NGS-MRD negativity prior to allogeneic HSCT.
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Affiliation(s)
- Brian D Friend
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California.,Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Mara Bailey-Olson
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California.,Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital, San Francisco, California
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California
| | - Christine Higham
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California
| | - Lena E Winestone
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California
| | - James Huang
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California.,Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital, San Francisco, California
| | - Elliot Stieglitz
- Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital, San Francisco, California
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Blood & Marrow Transplantation, UCSF Benioff Children's Hospital, San Francisco, California
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19
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Grace RF, Shimano KA, Bhat R, Neunert C, Bussel JB, Klaassen RJ, Lambert MP, Rothman JA, Breakey VR, Hege K, Bennett CM, Rose MJ, Haley KM, Buchanan GR, Geddis A, Lorenzana A, Jeng M, Pastore YD, Crary SE, Neier M, Neufeld EJ, Neu N, Forbes PW, Despotovic JM. Second-line treatments in children with immune thrombocytopenia: Effect on platelet count and patient-centered outcomes. Am J Hematol 2019; 94:741-750. [PMID: 30945320 DOI: 10.1002/ajh.25479] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 04/01/2019] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder with isolated thrombocytopenia and hemorrhagic risk. While many children with ITP can be safely observed, treatments are often needed for various reasons, including to decrease bleeding, or to improve health related quality of life (HRQoL). There are a number of available second-line treatments, including rituximab, thrombopoietin-receptor agonists, oral immunosuppressive agents, and splenectomy, but data comparing treatment outcomes are lacking. ICON1 is a prospective, multi-center, observational study of 120 children starting second-line treatments for ITP designed to compare treatment outcomes including platelet count, bleeding, and HRQoL utilizing the Kids ITP Tool (KIT). While all treatments resulted in increased platelet counts, romiplostim had the most pronounced effect at 6 months (P = .04). Only patients on romiplostim and rituximab had a significant reduction in both skin-related (84% to 48%, P = .01 and 81% to 43%, P = .004) and non-skin-related bleeding symptoms (58% to 14%, P = .0001 and 54% to 17%, P = .0006) after 1 month of treatment. HRQoL significantly improved on all treatments. However, only patients treated with eltrombopag had a median improvement in KIT scores at 1 month that met the minimal important difference (MID). Bleeding, platelet count, and HRQoL improved in each treatment group, but the extent and timing of the effect varied among treatments. These results are hypothesis generating and help to improve our understanding of the effect of each treatment on specific patient outcomes. Combined with future randomized trials, these findings will help clinicians select the optimal second-line treatment for an individual child with ITP.
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Affiliation(s)
- Rachael F. Grace
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Kristin A. Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow TransplantationUCSF Benioff Children's Hospital San Francisco California
| | - Rukhmi Bhat
- Center for Cancer & Blood Disorders, Ann and Robert H. Lurie Childrens Hospital of ChicagoFeinberg School of Medicine, Northwestern University Chicago Illinois
| | - Cindy Neunert
- Division of Hematology, Oncology, and Stem Cell TransplantColumbia University Medical School New York New York
| | - James B. Bussel
- Department of PediatricsWeill Cornell Medicine New York New York
| | - Robert J. Klaassen
- Division of Hematology/OncologyChildren's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Michele P. Lambert
- Division of HematologyThe Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Jennifer A. Rothman
- Division of Pediatric Hematology/OncologyDuke University Medical Center Durham North Carolina
| | - Vicky R. Breakey
- Division of Pediatric Hematology/OncologyMcMaster University Hamilton Ontario Canada
| | - Kerry Hege
- Division of Pediatric Hematology/Oncology, Riley Hospital at IU HealthIndiana University School of Medicine Indianapolis Indiana
| | - Carolyn M. Bennett
- Division of Hematology/Oncology, Aflac Cancer and Blood Disorders CenterEmory University School of Medicine, Children's Healthcare of Atlanta Atlanta Georgia
| | - Melissa J. Rose
- Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's HospitalThe Ohio State University College of Medicine Columbus Ohio
| | - Kristina M. Haley
- Division of Pediatric HematologyOregon Health & Science University Portland Oregon
| | - George R. Buchanan
- Division of Hematology‐OncologyUniversity of Texas Southwestern Medical Center Dallas Texas
| | - Amy Geddis
- Division of Pediatric Hematology/OncologyUniversity of Washington, Seattle Children's Hospital Seattle Washington
| | - Adonis Lorenzana
- Division of Pediatric Hematology/OncologySt. John Ascension Hospital Detroit Michigan
| | - Michael Jeng
- Department of PediatricsStanford School of Medicine Palo Alto California
| | - Yves D. Pastore
- Division of Hematology/OncologyCHU Sainte‐Justine Montreal Québec Canada
| | - Shelley E. Crary
- Department of PediatricsUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Michelle Neier
- Division of Pediatric Hematology/OncologyGoryeb Children's Hospital Morristown New Jersey
| | - Ellis J. Neufeld
- Division of HematologySt. Jude Children's Research Hospital Memphis Tennessee
| | - Nolan Neu
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Peter W. Forbes
- Clinical Research CenterBoston Children's Hospital Boston Massachusetts
| | - Jenny M. Despotovic
- Department of PediatricsHematology/Oncology Section, Baylor College of Medicine Houston Texas
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20
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Dvorak CC, Long-Boyle J, Dara J, Melton A, Shimano KA, Huang JN, Puck JM, Dorsey MJ, Facchino J, Chang CK, Cowan MJ. Low Exposure Busulfan Conditioning to Achieve Sufficient Multilineage Chimerism in Patients with Severe Combined Immunodeficiency. Biol Blood Marrow Transplant 2019; 25:1355-1362. [PMID: 30876930 DOI: 10.1016/j.bbmt.2019.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/08/2019] [Indexed: 11/17/2022]
Abstract
After allogeneic hematopoietic cell transplantation (HCT), the minimal myeloid chimerism required for full T and B cell reconstitution in patients with severe combined immunodeficiency (SCID) is unknown. We retrospectively reviewed our experience with low-exposure busulfan (cumulative area under the curve, 30 mg·hr/L) in 10 SCID patients undergoing either first or repeat HCT from unrelated or haploidentical donors. The median busulfan dose required to achieve this exposure was 5.9 mg/kg (range, 4.8 to 9.1). With a median follow-up of 4.5 years all patients survived, with 1 requiring an additional HCT. Donor myeloid chimerism was generally >90% at 1 month post-HCT, but in most patients it fell during the next 3 months, such that 1-year median myeloid chimerism was 14% (range, 2% to 100%). Six of 10 patients had full T and B cell reconstitution, despite myeloid chimerism as low as 3%. Three patients have not recovered B cell function at over 2 years post-HCT, 2 of them in the setting of treatment with rituximab for post-HCT autoimmunity. Low-exposure busulfan was well tolerated and achieved sufficient myeloid chimerism for full immune reconstitution in over 50% of patients. However, other factors beyond busulfan exposure may also play critical roles in determining long-term myeloid chimerism and full T and B cell reconstitution.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California.
| | - Janel Long-Boyle
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California; Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Jasmeen Dara
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California; Division of Pediatric Hematology and Oncology, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - James N Huang
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California; Division of Pediatric Hematology and Oncology, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - Jennifer M Puck
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - Morna J Dorsey
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - Janelle Facchino
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - Catherine K Chang
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - Morton J Cowan
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, California
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21
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Dvorak CC, Higham C, Shimano KA. Transplant-Associated Thrombotic Microangiopathy in Pediatric Hematopoietic Cell Transplant Recipients: A Practical Approach to Diagnosis and Management. Front Pediatr 2019; 7:133. [PMID: 31024873 PMCID: PMC6465621 DOI: 10.3389/fped.2019.00133] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/21/2019] [Indexed: 01/04/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial damage syndrome that is increasingly identified as a complication of both autologous and allogeneic hematopoietic cell transplantation (HCT) in children. If not promptly diagnosed and treated, TA-TMA can lead to significant morbidity (e.g., permanent renal injury) or mortality. However, as the recognition of the early stages of TA-TMA may be difficult, we propose a TA-TMA "triad" of hypertension, thrombocytopenia (or platelet transfusion refractoriness), and elevated lactate dehydrogenase (LDH). While not diagnostic, this triad should prompt further evaluation for TA-TMA. There is increased understanding of the risk factors for the development of TA-TMA, including those which are inherent (e.g., race, genetics), transplant approach-related (e.g., second HCT, use of HLA-mismatched donors), and related to post-transplant events (e.g., receipt of calcineurin inhibitors, development of graft-vs. -host-disease, or certain infections). This understanding should lead to enhanced screening for TA-TMA signs and symptoms in high-risk patients. The pathophysiology of TA-TMA is complex, resulting from a cycle of activation of endothelial cells to produce a pro-coagulant state, along with activation of antigen-presenting cells and lymphocytes, as well as activation of the complement cascade and microthrombi formation. This has led to the formulation of a "Three-Hit Hypothesis" in which patients with either an underlying predisposition to complement activation or pre-existing endothelial injury (Hit 1) undergo a toxic conditioning regimen causing endothelial injury (Hit 2), and then additional insults are triggered by medications, alloreactivity, infections, and/or antibodies (Hit 3). Understanding this cycle of injury permits the development of a specific TA-TMA treatment algorithm designed to treat both the triggers and the drivers of the endothelial injury. Finally, several intriguing approaches to TA-TMA prophylaxis have been identified. Future work on the development of a single diagnostic test with high specificity and sensitivity, and the development of a robust risk-scoring system, will further improve the management of this serious post-transplant complication.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Christine Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
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22
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Grace RF, Despotovic JM, Bennett CM, Bussel JB, Neier M, Neunert C, Crary SE, Pastore YD, Klaassen RJ, Rothman JA, Hege K, Breakey VR, Rose MJ, Shimano KA, Buchanan GR, Geddis A, Haley KM, Lorenzana A, Thompson A, Jeng M, Neufeld EJ, Brown T, Forbes PW, Lambert MP. Physician decision making in selection of second-line treatments in immune thrombocytopenia in children. Am J Hematol 2018; 93:882-888. [PMID: 29659042 DOI: 10.1002/ajh.25110] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/02/2018] [Accepted: 04/06/2018] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder which presents with isolated thrombocytopenia and risk of hemorrhage. While most children with ITP promptly recover with or without drug therapy, ITP is persistent or chronic in others. When needed, how to select second-line therapies is not clear. ICON1, conducted within the Pediatric ITP Consortium of North America (ICON), is a prospective, observational, longitudinal cohort study of 120 children from 21 centers starting second-line treatments for ITP which examined treatment decisions. Treating physicians reported reasons for selecting therapies, ranking the top three. In a propensity weighted model, the most important factors were patient/parental preference (53%) and treatment-related factors: side effect profile (58%), long-term toxicity (54%), ease of administration (46%), possibility of remission (45%), and perceived efficacy (30%). Physician, health system, and clinical factors rarely influenced decision-making. Patient/parent preferences were selected as reasons more often in chronic ITP (85.7%) than in newly diagnosed (0%) or persistent ITP (14.3%, P = .003). Splenectomy and rituximab were chosen for the possibility of inducing long-term remission (P < .001). Oral agents, such as eltrombopag and immunosuppressants, were chosen for ease of administration and expected adherence (P < .001). Physicians chose rituximab in patients with lower expected adherence (P = .017). Treatment choice showed some physician and treatment center bias. This study illustrates the complexity and many factors involved in decision-making in selecting second-line ITP treatments, given the absence of comparative trials. It highlights shared decision-making and the need for well-conducted, comparative effectiveness studies to allow for informed discussion between patients and clinicians.
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Affiliation(s)
- Rachael F. Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center; Boston Massachusetts
| | - Jenny M. Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine; Houston Texas
| | - Carolyn M. Bennett
- Emory University School of Medicine; Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center; Atlanta Georgia
| | | | | | - Cindy Neunert
- Columbia University Medical School; New York New York
| | - Shelley E. Crary
- University of Arkansas for Medical Sciences; Little Rock Arkansas
| | | | | | | | - Kerry Hege
- Riley Hospital at IU Health, Indiana University School of Medicine; Indianapolis Indiana
| | | | - Melissa J. Rose
- Nationwide Children's Hospital, The Ohio State University College of Medicine; Columbus Ohio
| | | | | | - Amy Geddis
- University of Washington, Seattle Children's Hospital; Seattle Washington
| | | | | | - Alexis Thompson
- Ann and Robert H. Lurie Childrens Hospital of Chicago, Northwestern University, Feinberg School of Medicine; Chicago Illinois
| | - Michael Jeng
- Stanford School of Medicine; Palo Alto California
| | | | - Travis Brown
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center; Boston Massachusetts
| | - Peter W. Forbes
- Boston Children's Hospital, Clinical Research Center; Boston Massachusetts
| | - Michele P. Lambert
- Division of Hematology; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania
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23
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Czechowicz JA, Long-Boyle JR, Rosbe KW, Mathes EF, Frieden IJ, Shimano KA. Sirolimus for management of complex vascular anomalies - A proposed dosing regimen for very young infants. Int J Pediatr Otorhinolaryngol 2018; 105:48-51. [PMID: 29447818 DOI: 10.1016/j.ijporl.2017.11.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/12/2017] [Accepted: 11/29/2017] [Indexed: 12/12/2022]
Abstract
Neonates with vascular anomalies causing airway compromise and other complications require early initiation of medical therapy. Sirolimus has emerged as a safe and effective treatment, but standard recommendations for dosing start at seven months. Guidelines are needed for dosing in very young infants, who have reduced hepatic metabolism of sirolimus. We present our experience treating six neonates (mean age 14.8 days) with complicated vascular anomalies. Standard dosing caused supratherapeutic levels in this population. Our modified dosing regimen has resulted in safe therapeutic concentrations. Properly dosed, sirolimus is a viable and potentially lifesaving option for neonates with severe morbidity from vascular anomalies.
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Affiliation(s)
| | | | - Kristina W Rosbe
- UCSF-Benioff Children's Hospital, San Francisco, CA, United States
| | - Erin F Mathes
- UCSF-Benioff Children's Hospital, San Francisco, CA, United States
| | - Ilona J Frieden
- UCSF-Benioff Children's Hospital, San Francisco, CA, United States
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24
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Delgado-Martin C, Meyer LK, Huang BJ, Shimano KA, Zinter MS, Nguyen JV, Smith GA, Taunton J, Winter SS, Roderick JR, Kelliher MA, Horton TM, Wood BL, Teachey DT, Hermiston ML. JAK/STAT pathway inhibition overcomes IL7-induced glucocorticoid resistance in a subset of human T-cell acute lymphoblastic leukemias. Leukemia 2017; 31:2568-2576. [PMID: 28484265 PMCID: PMC5729333 DOI: 10.1038/leu.2017.136] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 03/09/2017] [Accepted: 04/24/2017] [Indexed: 12/27/2022]
Abstract
While outcomes for children with T-cell acute lymphoblastic leukemia (T-ALL) have improved dramatically, survival rates for patients with relapsed/refractory disease remain dismal. Prior studies indicate that glucocorticoid (GC) resistance is more common than resistance to other chemotherapies at relapse. In addition, failure to clear peripheral blasts during a prednisone prophase correlates with an elevated risk of relapse in newly diagnosed patients. Here we show that intrinsic GC resistance is present at diagnosis in early thymic precursor (ETP) T-ALLs as well as in a subset of non-ETP T-ALLs. GC-resistant non-ETP T-ALLs are characterized by strong induction of JAK/STAT signaling in response to interleukin-7 (IL7) stimulation. Removing IL7 or inhibiting JAK/STAT signaling sensitizes these T-ALLs, and a subset of ETP T-ALLs, to GCs. The combination of the GC dexamethasone and the JAK1/2 inhibitor ruxolitinib altered the balance between pro- and anti-apoptotic factors in samples with IL7-dependent GC resistance, but not in samples with IL7-independent GC resistance. Together, these data suggest that the addition of ruxolitinib or other inhibitors of IL7 receptor/JAK/STAT signaling may enhance the efficacy of GCs in a biologically defined subset of T-ALL.
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Affiliation(s)
- C Delgado-Martin
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - L K Meyer
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - B J Huang
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - K A Shimano
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - M S Zinter
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - J V Nguyen
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - G A Smith
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - J Taunton
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - S S Winter
- Department of Pediatric Hematology/Oncology, University of New Mexico, Albuquerque, NM, USA
| | - J R Roderick
- Department of Cancer Biology, University of Massachusetts, Worcester, MA, USA
| | - M A Kelliher
- Department of Cancer Biology, University of Massachusetts, Worcester, MA, USA
| | - T M Horton
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - B L Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - D T Teachey
- Department of Pediatrics, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
| | - M L Hermiston
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
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25
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Neely J, Dvorak CC, Pantell MP, Shimano KA. Autoimmune Cytopenias in Pediatric Hematopoietic Cell Transplant (HCT) Patients. Biol Blood Marrow Transplant 2016. [DOI: 10.1016/j.bbmt.2015.11.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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