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Nilius H, Hamzeh-Cognasse H, Hastings J, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt AE, Wuillemin WA, Gerber B, Vishnu P, Graf L, Kremer Hovinga JA, Bakchoul T, Cognasse F, Nagler M. Proteomic profiling for biomarker discovery in heparin-induced thrombocytopenia. Blood Adv 2024:bloodadvances.2024012782. [PMID: 38588487 DOI: 10.1182/bloodadvances.2024012782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/10/2024] Open
Abstract
New analytical techniques can assess hundreds of proteins simultaneously with high sensitivity, facilitating the observation of their complex interplay and role in disease mechanisms. We hypothesized that proteomic profiling targeting proteins involved in thrombus formation, inflammation, and the immune response would identify potentially new biomarkers for heparin-induced thrombocytopenia (HIT). Four existing panels of the Olink proximity extension assay covering 356 proteins involved in thrombus formation, inflammation, and immune response were applied to randomly selected patients with suspected HIT (confirmed HIT, n=32; HIT ruled-out, n=38; positive heparin/PF4 [H/PF4] antibodies, n=28). The relative difference in protein concentration was analyzed using a linear regression model adjusted for sex and age. To confirm the test results, soluble P-selectin was determined using ELISA in above mentioned patients and an additional second dataset (n=49). HIT was defined as a positive heparin-induced platelet aggregation test (HIPA; washed platelet assay). Among 98 patients of the primary dataset, the median 4Ts score was 5 in patients with HIT, 4 in patients with positive heparin/PF4 antibodies, and 3 in patients without HIT. The median OD of a polyspecific heparin/PF4 ELISA was 3.0, 0.9, and 0.3, respectively. Soluble P-selectin remained statistically significant after multiple test adjustments. The area under the receiver-operating-characteristics-curve was 0.81 for Olink and 0.8 for ELISA. Future studies shall assess the diagnostic and prognostic value of soluble P-selectin in the management of HIT.
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Affiliation(s)
- Henning Nilius
- Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | | | | | | | | | | | | | - Walter A Wuillemin
- Division of Hematology and Laboratory of Hematology, Luzern 16, Switzerland
| | - Bernhard Gerber
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Prakash Vishnu
- St. Michael Medical Center, Virginia Mason Franciscan Health, United States
| | - Lukas Graf
- Centre for Laboratory Medicine St. Gallen, St. Gallen, Switzerland
| | | | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen, Tübingen, Germany
| | | | - Michael Nagler
- Inselspital University Hospital, Center for Laboratory Medicine, Switzerland
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Larsen EL, Nilius H, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Vishnu P, Graf L, Kremer Hovinga JA, Goetze JP, Bakchoul T, Nagler M. Accuracy of Diagnosing Heparin-Induced Thrombocytopenia. JAMA Netw Open 2024; 7:e243786. [PMID: 38530310 DOI: 10.1001/jamanetworkopen.2024.3786] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
Importance Heparin-induced thrombocytopenia (HIT) is a life-threatening condition that requires urgent diagnostic clarification. However, knowledge of the diagnostic utility of the recommended diagnostic tests is limited in clinical practice. Objective To evaluate the current diagnostic practice for managing the suspicion of HIT. Design, Setting, and Participants This prospective diagnostic study was conducted from January 2018 to May 2021 among consecutive patients with suspected HIT from 11 study centers in Switzerland, Germany, and the United States. Detailed clinical data and laboratory information were recorded. Platelet factor 4/heparin antibodies were quantified using an automated chemiluminescent immunoassay (CLIA). A washed-platelet heparin-induced platelet activation (HIPA) test was used as a reference standard to define HIT. Exposures Suspicion of HIT. Main Outcomes and Measures The primary outcome was the diagnostic accuracy of the 4Ts score, the CLIA, and the recommended algorithm serially combining both tests. Results Of 1448 patients included between 2018 and 2021, 1318 were available for the current analysis (median [IQR] age, 67 [57-75] years; 849 [64.6%] male). HIPA was positive in 111 patients (prevalence, 8.4%). The most frequent setting was intensive care unit (487 [37.0%]) or cardiovascular surgery (434 [33.0%]). The 4Ts score was low risk in 625 patients (46.8%). By 2 × 2 table, the numbers of patients with false-negative results were 10 (9.0%; 4Ts score), 5 (4.5%; CLIA), and 15 (13.5%; recommended diagnostic algorithm). The numbers of patients with false-positive results were 592 (49.0%; 4Ts score), 73 (6.0%; CLIA), and 50 (4.1%; recommended diagnostic algorithm), respectively. Conclusions and Relevance In this diagnostic study of patients suspected of having HIT, when the recommended diagnostic algorithm was used in clinical practice, antibody testing was required in half the patients. A substantial number of patients were, however, still misclassified, which could lead to delayed diagnosis or overtreatment. Development of improved diagnostic algorithms for HIT diagnosis should be pursued.
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Affiliation(s)
- Emil List Larsen
- Department of Clinical Biochemistry, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Department of Transfusion Medicine, Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Prakash Vishnu
- Fred Hutchinson Cancer Center, University of Washington, Seattle
| | - Lukas Graf
- Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Jens P Goetze
- Department of Clinical Biochemistry, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health, Copenhagen University, Copenhagen, Denmark
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
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Hammerer-Lercher A, Nilius H, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Kremer Hovinga JA, Vishnu P, Graf L, Bakchoul T, Nagler M. Limited concordance of heparin/platelet factor 4 antibody assays for the diagnosis of heparin-induced thrombocytopenia: an analysis of the TORADI-HIT study. J Thromb Haemost 2023; 21:2559-2568. [PMID: 37247669 DOI: 10.1016/j.jtha.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/26/2023] [Accepted: 05/17/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Anecdotal reports suggest that the correlation between heparin/platelet factor 4 (PF4) antibody assays for the diagnosis of heparin-induced thrombocytopenia (HIT) is limited. OBJECTIVES To investigate the correlation between widely used assays and examine possible factors contributing to variability. METHODS This is a large, prospective cohort study with 10 participating tertiary care hospitals including 1393 patients with suspected HIT in clinical practice. HIT was defined by a positive heparin-induced platelet activation (HIPA) assay (washed platelet reference standard test). Three different immunoassays were used to measure heparin/PF4 antibodies: chemiluminescent immunoassay, enzyme-linked immunosorbent assay, and particle gel immunoassay. Various factors that could influence the assays were examined: sex (male or female), age (<65 years or ≥65 years), unfractionated heparin exposure, presence of thrombosis, cardiovascular surgery, and intensive care unit. Spearman's correlation coefficients were calculated. Z-scores and diagnostic odds ratios were determined in the aforementioned subgroups of patients. RESULTS Among 1393 patients, 119 were classified as HIT-positive (prevalence, 8.5%). The median 4Ts score was 5 (IQR, 4-6) in patients with HIT compared with 3 (IQR, 2-4) in patients without HIT. Correlations (rs) between immunoassays were weak (0.53-0.65). Inconsistencies between immunoassays could not be explained by further analyses of z-scored test results and diagnostic odds ratios in subgroups of patients. CONCLUSION The correlation between widely used heparin/PF4 antibody assays was weak, and key factors could not explain this variability. Standardization of immunoassays is requested to improve comparability.
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Affiliation(s)
- Angelika Hammerer-Lercher
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Institute of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, USA
| | - Lukas Graf
- Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Nilius H, Cuker A, Haug S, Nakas C, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Kremer Hovinga JA, Vishnu P, Graf L, Kashev A, Sznitman R, Bakchoul T, Nagler M. A machine-learning model for reducing misdiagnosis in heparin-induced thrombocytopenia: A prospective, multicenter, observational study. EClinicalMedicine 2023; 55:101745. [PMID: 36457646 PMCID: PMC9706528 DOI: 10.1016/j.eclinm.2022.101745] [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: 07/01/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Diagnosing heparin-induced thrombocytopenia (HIT) at the bedside remains challenging, exposing a significant number of patients at risk of delayed diagnosis or overtreatment. We hypothesized that machine-learning algorithms could be utilized to develop a more accurate and user-friendly diagnostic tool that integrates diverse clinical and laboratory information and accounts for complex interactions. METHODS We conducted a prospective cohort study including 1393 patients with suspected HIT between 2018 and 2021 from 10 study centers. Detailed clinical information and laboratory data were collected, and various immunoassays were conducted. The washed platelet heparin-induced platelet activation assay (HIPA) served as the reference standard. FINDINGS HIPA diagnosed HIT in 119 patients (prevalence 8.5%). The feature selection process in the training dataset (75% of patients) yielded the following predictor variables: (1) immunoassay test result, (2) platelet nadir, (3) unfractionated heparin use, (4) CRP, (5) timing of thrombocytopenia, and (6) other causes of thrombocytopenia. The best performing models were a support vector machine in case of the chemiluminescent immunoassay (CLIA) and the ELISA, as well as a gradient boosting machine in particle-gel immunoassay (PaGIA). In the validation dataset (25% of patients), the AUROC of all models was 0.99 (95% CI: 0.97, 1.00). Compared to the currently recommended diagnostic algorithm (4Ts score, immunoassay), the numbers of false-negative patients were reduced from 12 to 6 (-50.0%; ELISA), 9 to 3 (-66.7%, PaGIA) and 14 to 5 (-64.3%; CLIA). The numbers of false-positive individuals were reduced from 87 to 61 (-29.8%; ELISA), 200 to 63 (-68.5%; PaGIA) and increased from 50 to 63 (+29.0%) for the CLIA. INTERPRETATION Our user-friendly machine-learning algorithm for the diagnosis of HIT (https://toradi-hit.org) was substantially more accurate than the currently recommended diagnostic algorithm. It has the potential to reduce delayed diagnosis and overtreatment in clinical practice. Future studies shall validate this model in wider settings. FUNDING Swiss National Science Foundation (SNSF), and International Society on Thrombosis and Haemostasis (ISTH).
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Affiliation(s)
- Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sigve Haug
- Mathematical Institute, University of Bern, Bern, Switzerland
- Albert Einstein Center for Fundamental Physics and Laboratory for High Energy Physics, University of Bern, Bern, Switzerland
| | - Christos Nakas
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Laboratory of Biometry, School of Agriculture, University of Thessaly, Volos, Greece
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, United States
| | - Lukas Graf
- Cantonal Hospital of St Gallen, Switzerland
| | | | - Raphael Sznitman
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Corresponding author. Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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Vishnu P, Mahesh R, Madan Kumar PD, Sharna N. Oral health status and treatment needs of children with sensory deficits in Chennai, India-A cross-sectional study. Indian J Dent Res 2021; 32:236-242. [PMID: 34810396 DOI: 10.4103/ijdr.ijdr_809_18] [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] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose The negligence of oral health combined with barriers in accessing adequate oral care is more commonly encountered in children with sensory deficits. In a developing country like India, there is a severe lacuna in data regarding the oral health status and treatment needs in this group of population. The purpose of this study is to assess the oral health status and treatment needs of children with sensory deficits, using WHO criteria of Basic Oral Health Survey Methods, 1997. Materials and Methods A descriptive cross-sectional study was conducted using the WHO criteria (Basic Oral Health Survey, 1997); questionnaire data regarding the demographic profile, oral hygiene status, degree of sensory impairment were recorded and tabulated. The Chi-square test was used to determine whether there existed a significant difference in the oral health status. The confidence interval was set at 95% and alpha error was assumed at 0.05. Results Among the 742 sensory deficit children examined, 371 children are visually impaired and 371 are hearing impaired. Gingival bleeding and poor oral hygiene is diagnosed in more than 70% of the visually impaired children. The prevalence of trauma is estimated to be 8% in children, who are visually impaired. In the hearing impairment group, gingival bleeding because of inadequate oral hygiene is seen in 58% of the population examined. There is no statistically significant difference in the dental caries status between visually impaired and hearing impaired children (P > 0.05). There is also no statistically significant difference in the restorative treatment need and trauma status between visually impaired and hearing impaired children (P > 0.05). Conclusion The present study shows a high prevalence of gingival diseases and dental caries in the special health care group children. The study signifies a wide spread presence of unmet treatment needs among children in this study population.
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Affiliation(s)
- P Vishnu
- Department of Community and Preventive Dentistry, Karpaga Vinayaka Dental College, Chennai, India
| | - R Mahesh
- Department of Pediatric Dentistry, Saveetha Dental College & Hospitals, Saveetha University, Chennai, India
| | - P D Madan Kumar
- Department of Community and Preventive Dentistry, Ragas Dental College, Chennai, India
| | - N Sharna
- Department of Pediatric, Dentistry, Jawaharlal Nehru Institute of Dental Sciences, Manipur, India
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Abstract
Background Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has emerged as a deadliest global pandemic after its identification in December 2019 in Wuhan, China resulting in more than three million deaths worldwide. Recently FDA issued emergency authorization for three vaccines for prevention of COVID-19. Here in, we report three cases of severe immune thrombocytopenia (ITP) following COVID-19 vaccination and their clinical course. Case presentations Case #1: 53 year old male with past medical history of Crohn’s disease was admitted for myalgias and diffuse petechial rash 8 days after receiving second dose of Pfizer-BioNTech COVID-19 vaccine. A complete blood test showed a platelet count of 2 × 109/L. Patient did not have a prior history of thrombocytopenia and other causes of thrombocytopenia were ruled out by history and pertinent lab data. He received two doses of intravenous immunoglobulin and oral dexamethasone for 4 days resulting in normalization of platelet counts. Case #2: 67 year male with past medical history of chronic ITP in remission was admitted for melena 2 days after receiving his first dose of Pfizer-BioNTech COVID-19 vaccine. A complete blood test showed a platelet count of 2 × 109/L. Physical exam showed generalized petechiae. There was no history of recent flares of ITP and patient had normal platelet counts following his splenectomy 4 years ago. He received two doses of IVIG and oral dexamethasone for 4 days with gradual improvement in platelet counts. Case #3: 59 year old female with past medical history of chronic ITP secondary to SLE was admitted for bloody diarrhea 2 days after receiving her first dose of Johnson and Johnson COVID-19 vaccine. Physical exam was unremarkable. A complete blood test showed platelet count of 64 × 109/L which dropped to 27 × 109/L during hospital course. She received oral dexamethasone for 4 days with improvement in platelet counts. Conclusion COVID-19 vaccination induced ITP has been recently acknowledged. However, given very few cases and limited data, currently there are no guidelines for management of ITP caused by COVID-19 vaccine as well as vaccination of people with predisposing conditions.
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Affiliation(s)
- Syed Raza Ali Shah
- Departments of Hospital Medicine, St. Michael Medical Center, Virginia Mason Franciscan Health, Silverdale, WA, USA. .,, 4655 Olivine Dr SW, Port Orchard, WA, 98367, USA.
| | - Sherpa Dolkar
- Departments of Hospital Medicine, St. Michael Medical Center, Virginia Mason Franciscan Health, Silverdale, WA, USA
| | - Jacob Mathew
- Departments of Hematology, St. Michael Medical Center, Virginia Mason Franciscan Health, Silverdale, WA, USA
| | - Prakash Vishnu
- Departments of Hematology, St. Michael Medical Center, Virginia Mason Franciscan Health, Silverdale, WA, USA
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Rose LM, DeBerg HA, Vishnu P, Frankel JK, Manjunath AB, Flores JPE, Aboulafia DM. Incidence of Skin and Respiratory Immune-Related Adverse Events Correlates With Specific Tumor Types in Patients Treated With Checkpoint Inhibitors. Front Oncol 2021; 10:570752. [PMID: 33520695 PMCID: PMC7844139 DOI: 10.3389/fonc.2020.570752] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/03/2020] [Indexed: 12/19/2022] Open
Abstract
Checkpoint inhibitors (CPIs) increase antitumor activity by unblocking regulators of the immune response. This action can provoke a wide range of immunologic and inflammatory side effects, some of which can be fatal. Recent studies suggest that CPI-induced immune-related adverse events (irAEs) may predict survival and response. However, little is known about the mechanisms of this association. This study was undertaken to evaluate the influence of tumor diagnosis and preexisting clinical factors on the types of irAEs experienced by cancer patients treated with CPIs. The correlation between irAEs and overall survival (OS) was also assessed. All cancer patients treated with atezolizumab (ATEZO), ipilimumab (IPI), nivolumab (NIVO), or pembrolizumab (PEMBRO) at Virginia Mason Medical Center between 2011 and 2019 were evaluated. irAEs were graded according to the Common Terminology Criteria for Adverse Events (Version 5) and verified independently. Statistical analyses were performed to assess associations between irAEs, pre-treatment factors, and OS. Of the 288 patients evaluated, 59% developed irAEs of any grade, and 19% developed irAEs of grade 3 or 4. A time-dependent survival analysis demonstrated a clear association between the occurrence of irAEs and OS (P < 0.001). A 6-week landmark analysis adjusted for body mass index confirmed an association between irAEs and OS in non-Small Cell Lung Cancer (NSCLC) (P < 0.03). An association between melanoma and skin irAEs (P < 0.01) and between NSCLC and respiratory irAEs (P = 0.03) was observed, independent of CPI administered. Patients with preexisting autoimmune disease experienced a higher incidence of severe irAEs (P = 0.01), but not a higher overall incidence of irAEs (P = 0.6). A significant association between irAEs and OS was observed in this diverse patient population. No correlation was observed between preexisting comorbid conditions and the type of irAE observed. However, a correlation between skin-related irAEs and melanoma and between respiratory irAEs and NSCLC was observed, suggesting that many irAEs are driven by a specific response to the primary tumor. In patients with NSCLC, the respiratory irAEs were associated with a survival benefit.
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Affiliation(s)
- Lynn M Rose
- Scientific Administration, Benaroya Research Institute at Virginia Mason, Seattle, WA, United States
| | - Hannah A DeBerg
- Systems Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, United States
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, WA, United States
| | - Jason K Frankel
- Section of Urology, Virginia Mason Medical Center, Seattle, WA, United States
| | - Adarsh B Manjunath
- Systems Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, United States
| | - John Paul E Flores
- Department of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, United States
| | - David M Aboulafia
- Department of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, United States.,Division of Hematology, University of Washington, Seattle, WA, United States
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Vishnu P, Duncan J, Connell N, Cooper N, Lim W, Rodeghiero F, Tomiyama Y, Grace RF, Bakchoul T, Arnold DM. International survey on Helicobacter pylori testing in patients with immune thrombocytopenia: Communication of the platelet immunology scientific and standardization committee. J Thromb Haemost 2021; 19:287-296. [PMID: 33070448 DOI: 10.1111/jth.15136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 01/08/2023]
Abstract
Essentials When to test and treat H pylori among patients with ITP is controversial. We report the results of an international survey administered to physicians with experience treating ITP across 39 countries. The decision to test for H pylori was influenced by country, country of origin, and concomitant gastrointestinal symptoms. Testing and treating for H pylori among patients with ITP varied across geographic regions. ABSTRACT: Background Investigations for patients suspected of immune thrombocytopenia (ITP) lack standardization. A controversial issue is whether such patients should be tested for Helicobacter pylori, a known cause of secondary ITP. Objectives This Scientific and Standardization Committee Communication reports the results of an international survey to describe patterns of practice with respect to screening and treatment of H pylori among patients with ITP. Patients/Methods A 17-item scenario-based questionnaire was delivered to hematologists in countries across the world. The questionnaire was pilot tested before use. We used snowball sampling and a contact list of physicians from the Platelet Disorders Support Association to identify survey respondents. Data were analyzed descriptively. Results A total of 186 respondents from 39 countries completed the survey. Response rate from the snowball sample was 53.6%. Twenty-nine percent (n = 55) of respondents always tested ITP patients for H pylori, and 53% (n = 98) sometimes tested. Of the 37 respondents from Asia and the Middle East, 51.4% (n = 19) always tested for H pylori for the stated reasons of high local prevalence and perceived benefit of treatment on platelet count levels. Respondents were more likely to test patients who were from Asia (145/177, 80%) and who had concomitant gastrointestinal symptoms (133/183, 72%). For eradication therapy, 71 of 118 (60.2%) respondents used the combination of a proton pump inhibitor, clarithromycin, and amoxicillin for 14 days. Conclusions This international survey showed that testing for H pylori was most common in Asia and in patients from Asia. Testing and treating practices varied across geographic regions.
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Affiliation(s)
| | - Joanne Duncan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Nathan Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Nichola Cooper
- Department of Haematology, Imperial College London, London, UK
| | - Wendy Lim
- Hematology & Thromboembolism, McMaster University, Hamilton, ON, Canada
| | - Francesco Rodeghiero
- Hematology Project Foundation, Hematology Department, San Bortolo Hospital, Vicenza, Italy
| | | | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Tamam Bakchoul
- Medical Faculty of Tubingen, Institute for Clinical and Experimental Transfusion Medicine, Tubingen, Germany
| | - Donald M Arnold
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
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Arnold DM, Heddle NM, Cook RJ, Hsia C, Blostein M, Jamula E, Sholzberg M, Lin Y, Kassis J, Larratt L, Tinmouth A, Amini S, Schipperus M, Lim W, Vishnu P, Warner M, Carruthers J, Li N, Lane S, Kelton JG. Perioperative oral eltrombopag versus intravenous immunoglobulin in patients with immune thrombocytopenia: a non-inferiority, multicentre, randomised trial. Lancet Haematol 2020; 7:e640-e648. [PMID: 32853584 DOI: 10.1016/s2352-3026(20)30227-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with immune thrombocytopenia are at risk of bleeding during surgery, and intravenous immunoglobulin is commonly used to increase the platelet count. We aimed to establish whether perioperative eltrombopag was non-inferior to intravenous immunoglobulin. METHODS We did a randomised, open-label trial in eight academic hospitals in Canada. Patients were aged at least 18 years, with primary or secondary immune thrombocytopenia and platelet counts less than 100 × 109 cells per L before major surgery or less than 50 × 109 cells per L before minor surgery. Previous intravenous immunoglobulin within 2 weeks or thrombopoietin receptor agonists within 4 weeks before randomisation were not permitted. Patients were randomly assigned to receive oral daily eltrombopag 50 mg from 21 days preoperatively to postoperative day 7 or intravenous immunoglobulin 1 g/kg or 2 g/kg 7 days before surgery. Eltrombopag dose adjustments were allowed weekly based on platelet counts. The randomisation sequence was generated by a computerised random number generator, concealed and stratified by centre and surgery type (major or minor). The central study statistician was masked to treatment allocation. The primary outcome was achievement of perioperative platelet count targets (90 × 109 cells per L before major surgery or 45 × 109 cells per L before minor surgery) without rescue treatment. We did intention-to-treat and per-protocol analyses using an absolute non-inferiority margin of -10%. This trial is registered with ClinicalTrials.gov, NCT01621204. FINDINGS Between June 5, 2013, and March 7, 2019, 92 patients with immune thrombocytopenia were screened, of whom 74 (80%) were randomly assigned: 38 to eltrombopag and 36 to intravenous immunoglobulin. Median follow-up was 50 days (IQR 49-55). By intention-to-treat analysis, perioperative platelet targets were achieved for 30 (79%) of 38 patients assigned to eltrombopag and 22 (61%) of 36 patients assigned to intravenous immunoglobulin (absolute risk difference 17·8%, one-sided lower limit of the 95% CI 0·4%; pnon-inferiority=0·005). In the per-protocol analysis, perioperative platelet targets were achieved for 29 (78%) of 37 patients in the eltrombopag group and 20 (63%) of 32 in the intravenous immunoglobulin group (absolute risk difference 15·9%, one-sided lower limit of the 95% CI -2·1%; pnon-inferiority=0·009). Two serious adverse events occurred in the eltrombopag group: one treatment-related pulmonary embolism and one vertigo. Five serious adverse events occurred in the intravenous immunoglobulin group (atrial fibrillation, pancreatitis, vulvar pain, chest tube malfunction and conversion to open splenectomy); all were related to complications of surgery. No treatment-related deaths occurred. INTERPRETATION Eltrombopag is an effective alternative to intravenous immunoglobulin for perioperative treatment of immune thrombocytopenia. However, treatment with eltrombopag might increase risk of thrombosis. The decision to choose one treatment over the other will depend on patient preference, resource limitations, cost, and individual risk profiles. FUNDING GlaxoSmithKline and Novartis.
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Affiliation(s)
- Donald M Arnold
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; Canadian Blood Services, Ancaster, ON, Canada.
| | - Nancy M Heddle
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard J Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Cyrus Hsia
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Mark Blostein
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Erin Jamula
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jeannine Kassis
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Loree Larratt
- Division of Hematology, University of Alberta, Edmonton, AB, Canada
| | - Alan Tinmouth
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sufia Amini
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands
| | - Martin Schipperus
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands; Department of Hematology, University Medical Centre Groningen, Groningen, Netherlands
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Prakash Vishnu
- Division of Hematology, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | | | - Julie Carruthers
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Na Li
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon Lane
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John G Kelton
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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10
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Dholaria B, Vanegas YAM, Diehl N, Spaulding AC, Visscher S, Tun HW, Ailawadhi S, Vishnu P. Cost Analysis of R-CHOP Versus Dose-Adjusted R-EPOCH in Treatment of Diffuse Large B-Cell Lymphoma with High-Risk Features. Clin Hematol Int 2020; 2:117-124. [PMID: 34595452 PMCID: PMC8432333 DOI: 10.2991/chi.d.200410.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/07/2020] [Indexed: 11/12/2022] Open
Abstract
Dose-adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA.R-EPOCH) is used for upfront treatment of high-risk diffuse large B cell lymphoma (DLBCL). In this study, we compared the outcomes in patients with high-risk DLBCL who received frontline rituximab, cycophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) or DA.R-EPOCH immunochemotherapy. Outcomes and treatment-related cost were analyzed. DLBCL with one of the following features were included in the study: MYC ± BCL2 or BCL6 rearrangement by FISH or MYC overexpression by immunohistochemistry, Ki67 index ≥ 80% or nongerminal center immunophenotype, tumor measuring ≥5 cm and NCCN- IPI score ≥4. A total of 80 patients were treated with R-CHOP (n = 52, 65%) or DA.R-EPOCH (n = 28, 35%), with a median follow-up of 11.2 months (range: 0.7–151.3 months). The hazard ratios (HRs) for progression-free survival and overall survival were 0.79 [95% confidence interval (CI) 0.28%–2.29%, p = 0.67] and 0.86 (95% CI 0.26%–2.78%, p = 0.80), respectively for DA.R-EPOCH compared to R-CHOP. The total mean cost was USD106,940 ± USD39,351 and USD58,509 ± 24,588 for DA.R-EPOCH and R-CHOP respectively (p < 0.001). In our analysis, DA.R-EPOCH resulted comparable clinical outcomes and increased treatment-related expenses compared to R-CHOP in high-risk DLBCL.
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Affiliation(s)
- Bhagirathbhai Dholaria
- Department of Hematology-Oncology, Pierce Ave, Preston Research Building, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Department of Hematology and Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Yenny Alejandra Moreno Vanegas
- Department of Hematology and Oncology, Mayo Clinic Florida, Jacksonville, FL, USA.,Department of Internal Medicine, St. Elizabeth Medical Center, Boston, MA, USA
| | - Nancy Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA
| | - Sue Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Han W Tun
- Department of Hematology and Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- Department of Hematology and Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Prakash Vishnu
- Department of Hematology and Oncology, Mayo Clinic Florida, Jacksonville, FL, USA.,Harrison Health Partners Hematology and Oncology, Bremerton, WA, USA
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11
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Kumar V, Alhaj-Moustafa M, Bojanini L, Sher T, Roy V, Manochakian R, Vishnu P, Bodepudi S, Shareef Z, Ahmed S, Jani P, Paulus A, Grover A, Alegria VR, Ailawadhi M, Chanan-Khan A, Ailawadhi S. Timeliness of Initial Therapy in Multiple Myeloma: Trends and Factors Affecting Patient Care. JCO Oncol Pract 2020; 16:e341-e349. [DOI: 10.1200/jop.19.00309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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
Multiple myeloma (MM) treatment has advanced significantly over the last 2 decades. In most patients, the disease course has been altered from early fatality to chronic morbidity with multiple lines of treatment. The MM treatment paradigm has shifted toward treating patients before end-organ damage occurs. Thus, timeliness of treatment initiation in this era might improve patient outcomes. This is the first report to our knowledge analyzing disparities and trends in treatment timeliness of patients with MM using the National Cancer Database. Multiple factors affected the timing of treatment initiation in MM and disparities were found. We noted that initiation of treatment was delayed in women (odds ratio [OR], 1.15; 95% CI, 1.1 to 1.2) and blacks (OR, 1.21; 95% CI, 1.14 to 1.28; reference, whites) and in patients diagnosed in more recent years (2012-2015; OR, 1.15; 95% CI, 1.1 to 1.22; reference, 2004-2007). Patients were likely to start treatment earlier if they were age ≥ 80 years (OR, 0.83; 95% CI, 0.76 to 0.9; reference, age < 60 years), were uninsured (OR, 0.81; 95% CI, 0.72 to 0.91; reference, private insurance), had Medicaid (OR, 0.87; 95% CI, 0.79 to 0.95; reference, private insurance), were treated in a comprehensive community cancer program (OR, 0.7; 95% CI, 0.65 to 0.77; reference, community cancer program), lived in a location other than the US Northeast, or had a higher Charlson comorbidity score. Patient education and income levels did not affect time to treatment initiation. Particular aspects of these disparities could be explained by our current health care system and insurance rules, whereas others need to be investigated more deeply.
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Affiliation(s)
| | | | - Leyla Bojanini
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Vivek Roy
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Rami Manochakian
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Prakash Vishnu
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | | | - Zan Shareef
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Salman Ahmed
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Prachi Jani
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Aneel Paulus
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL
| | - Ashna Grover
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | | | - Meghna Ailawadhi
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
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12
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Lou Y, Marin-Acevedo JA, Vishnu P, Manochakian R, Dholaria B, Soyano A, Luo Y, Zhang Y, Knutson KL. Hypereosinophilia in a patient with metastatic non-small-cell lung cancer treated with antiprogrammed cell death 1 (anti-PD-1) therapy. Immunotherapy 2020; 11:577-584. [PMID: 30943864 DOI: 10.2217/imt-2018-0128] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Immune checkpoint inhibitors have changed the treatment paradigm for patients with cancer. Though a majority of patients tolerate treatment, some develop hematologic toxicities, including eosinophilia. Eosinophilia has been associated with better responses in some patients with melanoma, but this has not been investigated in non-small-cell lung cancer. We present a case of a woman with metastatic lung adenocarcinoma who developed asymptomatic hypereosinophilia after initiation of nivolumab. Her eosinophil count temporarily decreased after transiently stopping the medication, but increased again after re-initiation. She had a favorable tumor response to therapy. This exemplifies the potential role of eosinophilia as a peripheral, readily available biomarker of favorable response to immunotherapy in patients with lung cancer. Awareness of this manifestation is important.
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Affiliation(s)
- Yanyan Lou
- Division of Hematology & Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | | | - Prakash Vishnu
- Division of Hematology & Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Rami Manochakian
- Division of Hematology & Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Bhagirathbhai Dholaria
- Division of Hematology & Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA.,Division of Hematology & Oncology, Vanderbilt University Medical Center, Nashville, TN 32224 , USA
| | - Aixa Soyano
- Division of Hematology & Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA.,Division of Hematology & Oncology, Moffitt Cancer Center, Tampa, FL 32224, USA
| | - Yan Luo
- Department of Immunology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Yan Zhang
- Department of Immunology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Keith L Knutson
- Department of Immunology, Mayo Clinic, Jacksonville, FL 32224, USA
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13
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McBane RD, Wysokinski WE, Le-Rademacher JG, Zemla T, Ashrani A, Tafur A, Perepu U, Anderson D, Gundabolu K, Kuzma C, Perez Botero J, Leon Ferre RA, Henkin S, Lenz CJ, Houghton DE, Vishnu P, Loprinzi CL. Apixaban and dalteparin in active malignancy-associated venous thromboembolism: The ADAM VTE trial. J Thromb Haemost 2020; 18:411-421. [PMID: 31630479 DOI: 10.1111/jth.14662] [Citation(s) in RCA: 321] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/14/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Low-molecular-weight heparin is the guideline-endorsed treatment for cancer-associated venous thromboembolism (VTE). While apixaban is approved for the treatment of acute VTE, limited data support its use in cancer patients. OBJECTIVES The primary outcome was major bleeding. Secondary outcomes included VTE recurrence and a composite of major plus clinically relevant non-major bleeding (CRNMB). PATIENTS/METHODS Patients with cancer-associated VTE were randomly assigned to receive either apixaban 10 mg twice daily for seven days followed by 5 mg twice daily for six months or subcutaneous dalteparin (200 IU/kg for one month followed by 150 IU/kg once daily). RESULTS Of 300 patients randomized, 287 were included in the primary analysis. Metastatic disease was present in 66% of subjects; 74% were receiving concurrent chemotherapy. Major bleeding occurred in 0% of 145 patients receiving apixaban, compared with 1.4% of 142 patients receiving dalteparin [P = .138; hazard ratio (HR) not estimable because of 0 bleeding event in apixaban group]. Recurrent VTE occurred in 0.7% of apixaban, compared to 6.3% of dalteparin patients [HR 0.099, 95% confidence interval [CI], 0.013-0.780, P = .0281). Major bleeding or CRNMB rates were 6% for both groups. CONCLUSIONS Oral apixaban was associated with low major bleeding and VTE recurrence rates for the treatment of VTE in cancer patients.
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Affiliation(s)
- Robert D McBane
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Hematology Division, Mayo Clinic, Rochester, Minnesota
- Cardiovascular Department, Mayo Clinic, Rochester, Minnesota
| | - Waldemar E Wysokinski
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Hematology Division, Mayo Clinic, Rochester, Minnesota
- Cardiovascular Department, Mayo Clinic, Rochester, Minnesota
| | - Jennifer G Le-Rademacher
- Health Science Research Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Tyler Zemla
- Health Science Research Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Aneel Ashrani
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Hematology Division, Mayo Clinic, Rochester, Minnesota
| | | | - Usha Perepu
- Medical Oncology, University of Iowa, Iowa City, Iowa
| | - Daniel Anderson
- Department of Hematology, Oncology and Transplantation, University of Minnesota, Regions Hospital, St Paul, Minnesota
| | - Krishna Gundabolu
- Department of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Charles Kuzma
- Department of Hematology and Oncology, First Health of the Carolinas, Pinehurst, North Carolina
| | | | | | - Stanislav Henkin
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Charles J Lenz
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Cardiovascular Department, Mayo Clinic, Rochester, Minnesota
| | - Damon E Houghton
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Hematology Division, Mayo Clinic, Rochester, Minnesota
- Cardiovascular Department, Mayo Clinic, Rochester, Minnesota
| | - Prakash Vishnu
- Department of Oncology and Hematology, Mayo Clinic, Jacksonville, Florida
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14
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Jamali SA, Turnbull MT, Kanekiyo T, Vishnu P, Zubair AC, Raper CC, Tawk RG, Freeman WD. Elevated Neutrophil-Lymphocyte Ratio is Predictive of Poor Outcomes Following Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104631. [PMID: 31964576 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104631] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 12/02/2019] [Accepted: 12/22/2019] [Indexed: 02/09/2023] Open
Abstract
Background Recent studies of patients with intracerebral hemorrhage suggest an association between peripheral blood neutrophil-lymphocyte ratio and neurologic deterioration. We aimed to study the prognostic utility of neutrophil-lymphocyte ratio in predicting inpatient mortality in aneurysmal subarachnoid hemorrhage. Methods We conducted a retrospective electronic medical record review of the clinical, laboratory, and radiographic data of patients with aneurysmal subarachnoid hemorrhage 18 years of age or older presenting to the neuroscience intensive care unit from January 1, 2011, to December 31, 2017. Patients with aneurysmal subarachnoid hemorrhage were divided into 2 groups (group 1, alive at discharge; group 2, deceased prior to discharge), and neutrophil-lymphocyte ratio laboratory mean values were recorded for each patient. Our primary outcome measure was inpatient mortality, and our secondary measure was incidence of pneumonia with hospitalization. Results We identified 403 patients with aneurysmal subarachnoid hemorrhage for the study. After exclusion criteria, 44 eligible patients were divided into the 2 groups (group 1, n = 32; group 2, n = 12). Mean neutrophil-lymphocyte ratio for group 1 was 11.53, and for group 2, 17.85 (P < .01). The mean neutrophil-lymphocyte ratio of those who developed pneumonia compared to those who did not was 15.28 versus 12.81, respectively (P = .39). A Kaplan-Meier plot demonstrated increased mortality among patients with a neutrophil-lymphocyte ratio equal to or greater than 12.5 compared to those with a neutrophil-lymphocyte ratio less than 12.5. Conclusions These preliminary data demonstrate that a neutrophil-lymphocyte ratio equal to or greater than 12.5 at admission predict higher inpatient mortality in patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
| | | | | | - Prakash Vishnu
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
| | - Abba C Zubair
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Jacksonville, Florida
| | - Carol C Raper
- Quality Management Services, Mayo Clinic, Jacksonville, Florida
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida; Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida.
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15
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Sinit RB, Hwang DG, Vishnu P, Peterson JF, Aboulafia DM. B-cell acute lymphoblastic leukemia in an elderly man with plasma cell myeloma and long-term exposure to thalidomide and lenalidomide: a case report and literature review. BMC Cancer 2019; 19:1147. [PMID: 31775673 PMCID: PMC6882354 DOI: 10.1186/s12885-019-6286-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/24/2019] [Indexed: 04/04/2023] Open
Abstract
Background The advent of the immunomodulatory imide drugs (IMiDs) lenalidomide and thalidomide for the treatment of patients with plasma cell myeloma (PCM), has contributed to more than a doubling of the overall survival of these individuals. As a result, PCM patients join survivors of other malignancies such as breast and prostate cancer with a relatively new clinical problem – second primary malignancies (SPMs) – many of which are a result of the treatment of the initial cancer. PCM patients have a statistically significant increased risk for acute myeloid leukemia (AML) and Kaposi sarcoma. IMiD treatment has also been associated with an increased risk of myelodysplastic syndrome (MDS), AML, and squamous cell carcinoma of the skin. However, within these overlapping groups, acute lymphoblastic leukemia (ALL) is much less common. Case presentation Herein, we describe an elderly man with PCM and a 14-year cumulative history of IMiD therapy who developed persistent pancytopenia and was diagnosed with B-cell acute lymphoblastic leukemia (B-ALL). He joins a group of 17 other patients documented in the literature who have followed a similar sequence of events starting with worsening cytopenias while on IMiD maintenance for PCM. These PCM patients were diagnosed with B-ALL after a median time of 36 months after starting IMiD therapy and at a median age of 61.5 years old. Conclusions PCM patients with subsequent B-ALL have a poorer prognosis than their de novo B-ALL counterparts, however, the very low prevalence rate of subsequent B-ALL and high efficacy of IMiD maintenance therapy in PCM should not alter physicians’ current practice. Instead, there should be a low threshold for bone marrow biopsy for unexplained cytopenias.
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Affiliation(s)
- Ryan B Sinit
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, 1100 Ninth Avenue (C2-HEM), Seattle, WA, 98101, USA
| | - Dick G Hwang
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Prakash Vishnu
- Department of Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jess F Peterson
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, 1100 Ninth Avenue (C2-HEM), Seattle, WA, 98101, USA. .,Division of Hematology, University of Washington School of Medicine, Seattle, WA, USA.
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16
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Hammond WA, Vishnu P, Rodriguez EM, Li Z, Dholaria B, Shreders AJ, Rivera CE. Sequence of Splenectomy and Rituximab for the Treatment of Steroid-Refractory Immune Thrombocytopenia: Does It Matter? Mayo Clin Proc 2019; 94:2199-2208. [PMID: 31685150 DOI: 10.1016/j.mayocp.2019.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/05/2019] [Accepted: 05/01/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the impact of the sequence of treatment with rituximab and/or splenectomy on time to relapse for patients with steroid-refractory immune thrombocytopenia (ITP). PATIENTS AND METHODS Patients 18 years or older with steroid-refractory immune thrombocytopenia who underwent treatment with splenectomy or rituximab from January 1, 2002, through December 31, 2015, at Mayo Clinic. Evaluation included freedom from relapse (FFR) and response rates after treatment with rituximab or splenectomy as single or sequential interventions. RESULTS A total of 218 eligible patients with ITP who were treated according to standard of care were included in this analysis. Patients failing steroids treated with splenectomy had a higher 5-year FFR than did those treated with rituximab (67.4% vs 19.2%; P<.001, propensity-score matched). Patients who failed splenectomy and were then treated with rituximab had a 2-year FFR similar to that of patients who failed rituximab and were then treated with splenectomy (73.4% vs 59.9%; P=.52). Patients treated with rituximab after splenectomy had a longer 2-year FFR than did patients treated with rituximab as a second-line treatment (73.4% vs 29.0%; P<.001). CONCLUSION For patients with ITP that relapse after treatment with steroids, splenectomy provides longer FFR than rituximab as a second-line therapy. Among patients who fail second-line treatment with splenectomy or rituximab, those who end up receiving sequential splenectomy-rituximab or rituximab-splenectomy therapy seem to derive similar benefit in the long term. Patients who received rituximab after splenectomy seem to derive superior benefit than do those who are treated with rituximab with an intact spleen.
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Affiliation(s)
- William A Hammond
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL; Division of Hematology Medical Oncology, Baptist MD Anderson Cancer Center, Jacksonville, FL
| | - Prakash Vishnu
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL
| | | | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Bhagirathbhai Dholaria
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL; Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Amanda J Shreders
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL; Division of Hematology Medical Oncology, Baptist MD Anderson Cancer Center, Jacksonville, FL
| | - Candido E Rivera
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL.
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17
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Alfayez M, Richard‐Carpentier G, Jabbour E, Vishnu P, Naqvi K, Sasaki K, Cortes J, Pemmaraju N. Sudden blastic transformation in treatment‐free remission chronic myeloid leukaemia. Br J Haematol 2019; 187:543-545. [DOI: 10.1111/bjh.16245] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mansour Alfayez
- Department of Leukemia University of Texas M. D. Anderson Cancer Center Houston TX USA
| | | | - Elias Jabbour
- Department of Leukemia University of Texas M. D. Anderson Cancer Center Houston TX USA
| | - Prakash Vishnu
- Department of Hematology Mayo Clinic Jacksonville FL USA
| | - Kiran Naqvi
- Department of Leukemia University of Texas M. D. Anderson Cancer Center Houston TX USA
| | - Koji Sasaki
- Department of Leukemia University of Texas M. D. Anderson Cancer Center Houston TX USA
| | - Jorge Cortes
- Department of Leukemia University of Texas M. D. Anderson Cancer Center Houston TX USA
| | - Naveen Pemmaraju
- Department of Leukemia University of Texas M. D. Anderson Cancer Center Houston TX USA
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Hsieh RW, Ravindran A, Hook CC, Begna KH, Ashrani AA, Pruthi RK, Marshall AL, Hogan W, Litzow M, Hoyer J, Oliveira JL, Vishnu P, Call TG, Al-Kali A, Patnaik M, Gangat N, Pardanani A, Tefferi A, Go RS. Etiologies of Extreme Thrombocytosis: A Contemporary Series. Mayo Clin Proc 2019; 94:1542-1550. [PMID: 31378229 DOI: 10.1016/j.mayocp.2019.01.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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] [Received: 11/13/2018] [Revised: 12/25/2018] [Accepted: 01/23/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe the multifactorial etiologies of extreme thrombocytosis (EXT) in different care settings and the frequency of finding an occult malignancy. PATIENTS AND METHODS We conducted a retrospective chart review at Mayo Clinic from January 1, 2011, through December 31, 2016. Adult patients who had at least 2 readings of platelet counts greater than 1000×109/L within 30 days of each other were included. We determined the causes of EXT on the basis of preset definitions of precipitating factors and identified the dominant causes on the basis of the trend of platelet counts. RESULTS A total of 44,490 patients had thrombocytosis, and 305 patients (0.7%) had EXT. In 242 patients (79.3%), EXT was multifactorial. Surgical complications (54.1%) and hematologic malignancies (27.9%) were the 2 most dominant causes. Thirty-eight patients (12.5%) had new diagnoses of malignancies, mostly myeloproliferative neoplasms. In inpatients, surgical complications (71.9%), concurrent/previous splenectomy (50.5%), and infections (44.9%) were the most common causes, whereas hematologic malignancies (56.9%), iron deficiency (36.7%), and previous splenectomy (28.4%) were the most common causes in outpatients. Hematologic malignancy was 3.4 times more likely to be the cause of EXT in outpatients than in inpatients (56.9% vs 16.8%), and a new diagnosis of hematologic malignancy was 1.9 times more likely to be made in outpatients (15.6% vs 8.2%). Eighty-four percent of patients had resolution of EXT within 30 days. One patient died during the period of EXT. Nonsurgical patients with hematologic malignancies had the most prolonged period of EXT. CONCLUSION Extreme thrombocytosis is a multifactorial hematologic condition, and its etiology differs substantially between inpatients and outpatients. Occult hematologic malignancies are uncommon in EXT when other major causes are present.
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Affiliation(s)
- Ronan W Hsieh
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA
| | - Aishwarya Ravindran
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - James Hoyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | - Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN.
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Ailawadhi S, Azzouqa AG, Hodge D, Cochuyt J, Jani P, Ahmed S, Sher T, Roy V, Ailawadhi M, Alegria VR, Manochakian R, Vishnu P, Grover A, Abdulazeez MF, Paulus A, Chanan-Khan A. Survival Trends in Young Patients With Multiple Myeloma: A Focus on Racial-Ethnic Minorities. Clin Lymphoma Myeloma Leuk 2019; 19:619-623. [PMID: 31377212 DOI: 10.1016/j.clml.2019.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/05/2019] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Outcomes in multiple myeloma (MM) have improved significantly over time. This is true overall for all patients as well as patient subgroups based on age and race/ethnicity. Despite this, disparities are noted in outcomes when looking at racial subgroups. MATERIALS AND METHODS We performed an analysis from the population-based Surveillance, Epidemiology, and End Results (SEER) database to evaluate improvement in relative survival rates (RSRs) for young (≤ 40 years at the time of MM diagnosis) and older (> 40 years at the time of MM diagnosis) over time by race/ethnicity, specifically focusing on Hispanic patients with MM. Expected survival was estimated using the age- and gender-specific death rates from the United States population. RSR was provided as the ratio of the observed to expected survival at individual time points. Five-year and 10-year RSRs were calculated for patients based on treatments modalities available in various time periods. RESULTS We identified a total of 89,451 patients with MM in SEER, of which 1460 patients formed the young patients with MM (≤ 40 years) cohort. Five- and 10-year RSR improved significantly over time for all patients and older patients (> 40 years) by race (all P < .001). Evaluating the younger patients, RSR improved significantly for non-Hispanic whites and non-Hispanic blacks, but not for Hispanics. This was true for the 5-year (P = .08) and 10-year (P = .13) RSRs. CONCLUSION We report a lack of significant benefit in long-term outcomes for younger Hispanic patients with MM over time. This could be owing to multifactorial causes that need to be addressed to mitigate outcome disparities.
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Affiliation(s)
| | | | - David Hodge
- Department of Health Sciences and Research, Mayo Clinic, Jacksonville, FL
| | - Jordan Cochuyt
- Department of Health Sciences and Research, Mayo Clinic, Jacksonville, FL
| | - Prachi Jani
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL
| | - Salman Ahmed
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL
| | - Vivek Roy
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Prakash Vishnu
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL
| | - Ashna Grover
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL
| | | | - Aneel Paulus
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL
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20
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Ghoz HM, Kröner PT, Stancampiano FF, Bowman AW, Vishnu P, Heckman MG, Diehl NN, McLeod E, Nikpour N, Palmer WC. Hepatic iron overload identified by magnetic resonance imaging-based T2* is a predictor of non-diagnostic elastography. Quant Imaging Med Surg 2019; 9:921-927. [PMID: 31367546 DOI: 10.21037/qims.2019.05.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Magnetic resonance elastography (MRE) is a non-invasive test used to assess liver stiffness and fibrosis in chronic liver disease, which includes systemic iron overload. However, iron deposition by itself is associated with technical failure of MRE of the liver which necessitates the use of invasive liver biopsy as an alternative monitoring method for these patients. T2*-weighted magnetic resonance imaging (T2*) is a reliable modality to asses for hepatic as well as total body iron overload. Therefore, we aimed to determine a cutoff value on the T2* reading at which MRE would no longer provide accurate stiffness measurements in patients with iron overload. Methods Ninety-five patients with iron overload who underwent MRE at our institution, between 2010 and 2017 were reviewed retrospectively. We compared T2* values between patients with adequate elastography (N=63) versus those with non-diagnostic elastography (N=32). We additionally examined the ability of T2* to predict the likelihood of non-diagnostic elastography by estimating area under the ROC curve (AUC). Results T2* was significantly different between patients with and without an adequate elastography (P<0.0001) and predicted occurrence of non-diagnostic elastography with an AUC of 0.95. All patients with a non-diagnostic elastography had a T2* value below 20 milliseconds (ms), and correspondingly 55% of the patients with a T2* value below 20 ms had a non-diagnostic elastography. The subgroups of patients with a T2* value ≤10, ≤8, and ≤6 ms, had a higher likelihood of non-diagnostic elastography (87%, 92%, and 95%, respectively). Conclusions T2* can be used to accurately predict which patients are most likely to have a non-diagnostic elastography reading. T2* of 20 ms or lower reflects a higher likelihood of non-diagnostic elastography.
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Affiliation(s)
- Hassan M Ghoz
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Paul T Kröner
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Prakash Vishnu
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Ethan McLeod
- Clinical Research Internship Study Program (CRISP), Mayo Clinic, Jacksonville, FL, USA
| | - Naveed Nikpour
- Clinical Research Internship Study Program (CRISP), Mayo Clinic, Jacksonville, FL, USA
| | - William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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21
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Abstract
AbstractThere is an association between Helicobacter pylori infection and immune thrombocytopenia (ITP), and few studies have suggested that eradicative treatment of H. pylori infection may improve platelet counts in patients with ITP. Conventional treatments for ITP include immunosuppressive agents, and more recently thrombopoietic agents. However, based on clinical reports of association between H. pylori and ITP, several medical societies increasingly suggest detection and eradication of H. pylori as a treatment for ITP. In this article, we reappraise recent medical literature to determine the effectiveness of platelet response after treatment of H. pylori infection in patients with ITP. We searched two online databases (MEDLINE and Google Scholar) for full articles published between January 2008 and May 2018, and found a total of 11 studies that presented data and outcomes of treatment of H. pylori infection in ITP patients. All the studies administered triple therapy (amoxicillin 500 mg, clarithromycin 250 mg and a proton-pump inhibitor each given twice daily for either 7- or 14-day course) for eradication of H. pylori. Median overall platelet response ranged from 27 to 69.2% with a complete response rate ranging from 0 to 65.4% and a partial response rate ranging from 0 to 29.4%. Although there is variability in the effectiveness between different populations, it appears to be of benefit to ITP patients with concomitant H. pylori infection when treated with triple therapy. However, further studies to understand the pathogenesis of H. pylori-associated ITP is necessary for the development of new therapeutic approaches for ITP.
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Affiliation(s)
| | - Prakash Vishnu
- Division of Hematology and Medical Oncology, Mayo Clinic Florida, Jacksonville, Florida, United States
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22
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Palmer WC, Vishnu P, Sanchez W, Aqel B, Riegert-Johnson D, Seaman LAK, Bowman AW, Rivera CE. Diagnosis and Management of Genetic Iron Overload Disorders. J Gen Intern Med 2018; 33:2230-2236. [PMID: 30225768 PMCID: PMC6258594 DOI: 10.1007/s11606-018-4669-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 11/09/2017] [Revised: 05/23/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022]
Abstract
Iron overload disorders lead to excess iron deposition in the body, which can occur as a result of genetic or secondary causes. Genetic iron overload, referred to as hereditary hemochromatosis, may present as a common autosomal recessive mutation or as one of several uncommon mutations. Secondary iron overload may result from frequent blood transfusions, exogenous iron intake, or certain hematological diseases such as dyserythropoietic syndrome or chronic hemolytic anemia. Iron overload may be asymptomatic, or may present with significant diseases of the liver, heart, endocrine glands, joints, or other organs. If treated appropriately prior to end-organ damage, life expectancy has been shown to be similar compared to matched populations. Alongside clinical assessment, diagnostic studies involve blood tests, imaging, and in some cases liver biopsy. The mainstay of therapy is periodic phlebotomy, although oral chelation is an option for selected patients.
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Affiliation(s)
- William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.
| | - Prakash Vishnu
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - William Sanchez
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Bashar Aqel
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Doug Riegert-Johnson
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Candido E Rivera
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
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23
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Tsamalaidze L, Stauffer JA, Vishnu P, Elli EF, Asbun HJ. Incidence of Postsplenectomy Thrombosis of Splenic, Mesenteric and Portal Vein (PST-SMPv) in 953 Patients at a Multi-Site Single-Institution and Validation of PST-SMPv Classification. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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24
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Vanegas YAM, Azzouqa AGM, Menke DM, Foran JM, Vishnu P. Myelodysplasia-related acute myeloid leukemia and acute promyelocytic leukemia: concomitant occurrence of two molecularly distinct diseases. Hematol Rep 2018; 10:7658. [PMID: 30283621 PMCID: PMC6151345 DOI: 10.4081/hr.2018.7658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/24/2018] [Indexed: 12/18/2022] Open
Abstract
Concurrent presentation of acute promyelocytic leukemia (APL) with other hematologic diseases in the absence of previous chemotherapy or ionizing radiotherapy treatment is very rare. We present a case of simultaneous occurrence of APL with myelodysplastic syndrome (MDS)-related acute myeloid leukemia (AML). A 43-yearold female presented with 3 month of history fatigue, night sweats, chills and pancytopenia. Bone marrow aspirate and biopsy demonstrated 20% myeloid blasts with dysplastic changes admixed with abnormal promyelocytes. Cytogenetic analysis showed tetraploidy and deletion in chromosomes 5q and 7q and polymerase chain reaction showed presence of PML/RARA mRNA transcripts, confirming the presence of concurrent APL and MDS-related AML. Induction chemotherapy with cytarabine and daunorubicin was initiated along with all-trans retinoic acid. This is the first case to be reported in the literature of concurrent occurrence of APL with MDS-related AML. Treatment with 7 + 3 regimen and ATRA was successful in inducing complete remission.
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Affiliation(s)
| | | | - David M Menke
- Department of Laboratory Medicine and Pathology, Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
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25
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Baldeo C, Vishnu P, Mody K, Kasi PM. Uridine triacetate for severe 5-fluorouracil toxicity in a patient with thymidylate synthase gene variation: Potential pharmacogenomic implications. SAGE Open Med Case Rep 2018; 6:2050313X18786405. [PMID: 30013790 PMCID: PMC6041857 DOI: 10.1177/2050313x18786405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 06/11/2018] [Indexed: 11/15/2022] Open
Abstract
Adverse drug reactions can be unpredictable. However, pharmacogenomic testing can help identify patients who may be more susceptible to the toxic effects of certain drugs. Genetic variations in the dihydropyrimidine dehydrogenase and thymidylate synthase genes have been shown to increase the risk of 5-fluorouracil toxicity. 5-Fluorouracil toxicity can be life threatening. Fortunately, there is treatment available for 5-fluorouracil toxicity, called uridine triacetate. Although, the indications for its use limit its administration to within 96 h of receiving 5-fluorouracil, we report a case of effective therapy in a patient started on uridine triacetate beyond the recommended 96 h, who was found to carry a thymidylate synthase gene variation but no dihydropyrimidine dehydrogenase mutations. This provides important implications for pharmacogenomic testing.
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Affiliation(s)
- Candice Baldeo
- Division of Hematology and Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Prakash Vishnu
- Division of Hematology and Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Kabir Mody
- Division of Hematology and Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Pashtoon Murtaza Kasi
- Division of Hematology and Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
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26
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Vishnu P, Moreno Vanegas Y, Wadei HM, Rivera CE. Post-transplant erythrocytosis refractory to ACE inhibitors and angiotensin receptor blockers. BMJ Case Rep 2018; 2018:bcr-2018-224622. [PMID: 29954763 DOI: 10.1136/bcr-2018-224622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-transplant erythrocytosis (PTE) is a condition with elevated haematocrit (hct) in renal allograft recipients. The mainstay of treatment is ACE inhibitors (ACEi) or angiotensin II receptor blockers (ARB), but seldom phlebotomy. PTE must be recognised early to prevent major thromboembolic events. We present a case of PTE that was refractory to blockade of renin-angiotensin system (RAS) by ACEi and ARB and required phlebotomy for control of hct. Our review of medical literature about prevalence and pathophysiology of PTE suggests that approximately 22% of patients with PTE are refractory to ACEi/ARB treatment. There are four plausible pathways that appear to play a role in causing PTE: disruption of erythropoietin regulation, mitogenic effect of the RAS on erythroid lineage, insulin-like growth factor 1 and androgenic stimulation. Presently, there is no unifying hypothesis involving these factors, but refractoriness to ACEi/ARB may represent a distinct subcategory of PTE.
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Affiliation(s)
- Prakash Vishnu
- Department of Hematology and Oncology, Mayo Clinic, Florida, US
| | | | - Hani M Wadei
- Department of Transplant Nephrology, Mayo Clinic, Florida, US
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27
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Dholaria BR, Hammond WA, Roy V, Sher T, Vishnu P, Soyano A, Finn LE, Tun H. Allogeneic hematopoietic cell transplant for relapsed-refractory, marginal zone lymphoma: a single-center experience. Leuk Lymphoma 2018; 59:2727-2730. [PMID: 29566563 DOI: 10.1080/10428194.2018.1452220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Bhagirathbhai R Dholaria
- a Department of Blood and Marrow Transplant and Cellular Immunotherapy , Moffitt Cancer Center , Tampa , FL , USA
| | - William A Hammond
- b Department of Malignant Hematology , Baptist M.D. Anderson Cancer Center , Jacksonville , FL , USA
| | - Vivek Roy
- c Department of Hematology and Oncology , Mayo Clinic , Jacksonville , FL , USA
| | - Taimur Sher
- c Department of Hematology and Oncology , Mayo Clinic , Jacksonville , FL , USA
| | - Prakash Vishnu
- c Department of Hematology and Oncology , Mayo Clinic , Jacksonville , FL , USA
| | - Aixa Soyano
- c Department of Hematology and Oncology , Mayo Clinic , Jacksonville , FL , USA
| | - Laura E Finn
- d Division of Hematology and Oncology , Ochsner Medical Center , New Orleans , LA , USA
| | - Han Tun
- c Department of Hematology and Oncology , Mayo Clinic , Jacksonville , FL , USA
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28
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Vishnu P, Roy U, Guru P, Thomas C, Rivera C, Foran J, Roy V. Long-Term Outcomes of Critically Ill Adult Allogeneic Hematopoietic Stem Cell Recipients. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
von Willebrand disease (VWD) is a common bleeding disorder caused by defective or low levels of von Willebrand factor (VWF). Although most cases of VWD are caused by genetic mutations, some are acquired due to various disease states. In managing VWD, the aim is to normalize plasma levels of both VWF and factor VIII (FVIII), as this aids in hemostasis. Desmopressin usually corrects VWF level in type 1 VWD by inducing the release of endogenous VWF. In cases where desmopressin is ineffective or cannot be used, transfusion of virally inactivated, plasma-derived VWF/FVIII concentrate or infusion of recombinant VWF (Vonvendi) is indicated. Treatment of acquired von Willebrand syndrome (AVWS) aims to control the underlying disease while regulating life-threatening hemorrhages with infusions of VWF/FVIII concentrate. Wide intrasubject variability in VWF and FVIII levels, particularly in AVWS, necessitates verification of response to treatment by frequent monitoring of the plasmatic VWF level. Clinical pharmacokinetics of VWF may facilitate calculation of the necessary loading and maintenance doses of VWF/FVIII concentrate in the management of AVWS patients undergoing surgery, thereby avoiding unnecessary infusion of coagulation factor concentrate.
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Affiliation(s)
- Candice M Baldeo
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Candido E Rivera
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Han W Tun
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Prakash Vishnu
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
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30
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Qiu Y, Li Z, Pouzoulet F, Vishnu P, Copland JA, Knutson KL, Soussain C, Tun HW. Immune checkpoint inhibition by anti-PDCD1 (anti-PD1) monoclonal antibody has significant therapeutic activity against central nervous system lymphoma in an immunocompetent preclinical model. Br J Haematol 2017; 183:674-678. [DOI: 10.1111/bjh.15009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yushi Qiu
- Department of Cancer Biology; Mayo Clinic; Jacksonville FL USA
| | - Zhimin Li
- Department of Cancer Biology; Mayo Clinic; Jacksonville FL USA
| | - Frederic Pouzoulet
- Department of Hematology; Rene-Huguenin Hospital-Curie Institute; Saint Cloud France
| | - Prakash Vishnu
- Division of Hematology and Medical Oncology; Mayo Clinic; Jacksonville FL USA
| | - John A. Copland
- Department of Cancer Biology; Mayo Clinic; Jacksonville FL USA
| | | | - Carole Soussain
- Department of Hematology; Rene-Huguenin Hospital-Curie Institute; Saint Cloud France
| | - Han W. Tun
- Department of Cancer Biology; Mayo Clinic; Jacksonville FL USA
- Division of Hematology and Medical Oncology; Mayo Clinic; Jacksonville FL USA
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31
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Vishnu P, Wingerson A, Lee M, Mandelson MT, Aboulafia DM. Utility of Bone Marrow Biopsy and Aspirate for Staging of Diffuse Large B Cell Lymphoma in the Era of Positron Emission Tomography With 2-Deoxy-2-[Fluorine-18]fluoro-deoxyglucose Integrated With Computed Tomography. Clin Lymphoma Myeloma Leuk 2017; 17:631-636. [PMID: 28684378 DOI: 10.1016/j.clml.2017.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 05/11/2017] [Accepted: 06/08/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND About one-third of patients with diffuse large B cell lymphoma (DLBCL) have lymphomatous bone marrow involvement (BMI) at the time of diagnosis, and bone marrow aspirate/biopsy (BMAB) is considered the gold standard to detect such involvement. [18F] fluorodeoxyglucose positron emission tomography combined with computed tomography (PET-CT), has become standard pretreatment imaging in DLBCL and may be a noninvasive alternative to BMAB to ascertain BMI. Prior studies have suggested that PET-CT scan may obviate the need for BMAB as a component for staging patients with newly diagnosed DLBCL, but this is not yet a standard of practice. The aim of this retrospective study was to determine the accuracy of PET-CT in detecting BMI in DLBCL and to define 2-year and 5-year overall survival based on BMI by BMAB versus PET-CT. METHODS We reviewed institutional records of all patients with newly diagnosed DLBCL between January 2004 and December 2013 who underwent pretreatment PET-CT and BMAB. PET-CT images were visually assessed for BMI, including the posterior iliac crest. Patients with primary mediastinal DLBCL, previous history or coexistence of another lymphoma subtype, and those with a nondiagnostic BMAB, and in whom the PET-CT did not show marrow signal abnormality, were excluded from the analysis. Ann Arbor stage was determined using PET-CT with and without the contribution of BMAB, and the proportion of stage IV cases by each method was measured. RESULTS Among 99 eligible patients, the median age was 62 years (range, 24-88 years), 62 (63%) were male, 53 (53%) had elevated serum lactate dehydrogenase, and 17 (16%) had an Eastern Community Oncology Group performance status of > 2. Thirteen (12%) patients had more than 1 extra-nodal site of lymphoma involvement. Revised International Prognostic Index score was 1 in 39 (37%) patients, 2 in 42 (40%) patients, 3 in 20 (19%) patients, and 4 in 4 (4%) patients. A total of 38 (36%) patients had BMI established by either PET-CT (n = 24; 24%), BMAB (n = 14; 14%), or by both modalities (n = 12; 12%). Twelve (50%) of the 24 patients with positive PET-CT had BMI by DLBCL, whereas only 2 (3%) of the 75 patients with negative PET-CT showed BMI. BMAB upstaged 1 (2%) of the 53 stage I/II patients to stage IV. The sensitivity and specificity of PET-CT scan to detect BMI by DLBCL was 86% (95% confidence interval, 51.9%-95.7%) and 87% (95% confidence interval, 76%-92%), respectively. Eighty-five (86%) patients had concordant results between lymphomatous BMAB and PET-CT (12 patients were positive for both; 73 patients were negative for both), and 14 (14%) patients had a discordant interpretation (2 patients were positive by BMAB and negative by PET-CT, and 12 patients were negative by BMAB and positive by PET-CT). The positive predictive value of PET-CT was only 50%, whereas the negative predictive value was 98%. The accuracy of PET-CT was 86%. Although patients with positive BMAB had inferior 5-year overall survival estimates compared with those with negative BMAB (66% vs. 85%; P = .08), no such difference was demonstrated between PET-CT-positive and PET-CT-negative patients (79% vs. 83%; P = .30). CONCLUSIONS In patients with newly diagnosed DLBCL, PET-CT is accurate in detecting BMI by DLBCL. Although PET-CT has a very high negative predictive value for BMI, it overestimates the number of cases with marrow involvement by DLBCL. In clinical practice, routine BMAB may no longer be necessary for all patients with DLBCL who are staged by PET-CT, unless the results would change both staging and therapy. The prognostic implication of BMI identified by PET-CT compared with BMAB remains unknown. Whether a PET-CT precludes the need for a BMAB in patients with DLBCL remains to be evaluated in a prospective study.
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Affiliation(s)
- Prakash Vishnu
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Centre, Seattle, WA
| | - Andrew Wingerson
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Centre, Seattle, WA
| | - Marie Lee
- Department of Radiology, Virginia Mason Medical Center, Seattle, WA
| | - Margaret T Mandelson
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Centre, Seattle, WA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Centre, Seattle, WA; Division of Hematology, University of Washington, Seattle, WA.
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Vishnu P. Needle-track Tumor Seeding Consequent to Renal Biopsy. JMSH 2016. [DOI: 10.46347/jmsh.2016.v02i02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
Inhibition of platelet production and mediated by antiplatelet antibodies is a well-known mechanism causing low platelet counts in immune thrombocytopenia (ITP). Use of thrombopoietin receptor agonists increases platelet counts and decreases the risk of bleeding in patients with ITP. Two such thrombopoietin receptor agonists, romiplostim and eltrombopag, are approved by the US Food and Drug Administration to treat thrombocytopenia in adults, and most recently, children with persistent or chronic ITP. This review focuses on the efficacy data and safety analysis of the pooled data from the clinical trials evaluating romiplostim for treatment of adults with ITP. The rates of hemorrhage, thrombosis, hematologic and nonhematologic cancers, and myelodysplastic syndrome were not overrepresented among the groups who received romiplostim versus placebo or other standard-of-care treatments. Yet, as after-market experience with thrombopoietin receptor agonists increases, there are emerging reports of increased incidence of thrombosis and bone marrow reticulin among patients who are treated with long-term use of these agents. Ongoing clinical research will continue to evaluate romiplostim's efficacy and safety in other primary and secondary thrombocytopenic states.
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Affiliation(s)
- Prakash Vishnu
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, University of Washington, Seattle, WA, USA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, University of Washington, Seattle, WA, USA; Division of Hematology, University of Washington, Seattle, WA, USA
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Gulvin JM, Lin BS, Robinson N, Malpass TW, Picozzi VJ, Vishnu P, Taylor LP, Chatta GS, Goetsch CM, Aboulafia DM, Rosales JK. Using a QOPI-based template to monitor appropriate evaluation of constipation. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.7_suppl.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
94 Background: A common symptom in patients being treated with opioid analgesics is constipation, which is often underreported by patients and therefore undertreated by providers. The Quality Oncology Project Initiative (QOPI) has identified constipation as one of the benchmark symptoms to be monitored in order to obtain certification. At Virginia Mason Medical Center, we had previously identified constipation as a symptom which was not adequately addressed in the medical record, and implemented a template-based initiative to increase its evaluation. Methods: We identified consecutive patients with advanced cancer undergoing systemic therapy who were also receiving opioid analgesic treatments. These patients were surveyed for constipation, and answered a questionnaire regarding its severity and whether they felt it was adequately handled. We then reviewed the encounter notes for the visit to correlate the provider’s documentation of constipation and its treatment and the patient experience. Results: Results will be presented at the symposium. Conclusions: We aim to describe whether or not the symptom of constipation was adequately captured and/or treated in patients receiving opioid therapy.
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Abstract
Early in the human immunodeficiency virus (HIV) epidemic, infected patients presented to medical attention with striking abnormalities in each of the major blood cell lineages. The reasons for these derangements remain complex and multifactorial. HIV infects multipotent haematopoietic progenitor cells and establish latent cellular reservoirs, disturbs the bone marrow microenvironment and also causes immune dysregulation. These events lead to cytokine imbalances and disruption of other factors required for normal haematopoiesis. Activation of the reticulo-endothelial system can also result in increased blood cell destruction. The deleterious effects of medications, including first and second generation anti-retroviral agents, on haematopoiesis were well documented in the early years of HIV care; in the current era of HIV-care, the advent of newer and less toxic anti-retroviral drugs have had a more beneficial impact on haematopoiesis. Due to impaired regulation of the immune system and potential side effects of one or more anti-retroviral agents, there is also an increase in coagulation abnormalities such as thromboembolism, and less frequently, acquired disorders of coagulation including thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura and acquired inhibitors of coagulation. In this article we review the epidemiology and aetiology of select non-oncological haematological disorders commonly seen in people living with HIV-acquired immune deficiency syndrome.
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Affiliation(s)
- Prakash Vishnu
- Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, University of Washington, Seattle, WA, USA
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Chatta GS, Aboulafia DM, Brockmeyer A, Bumpus M, Dimitrova I, Goetsch C, Jacobs A, Lin BS, Malpass TW, Nichols CR, Picozzi VJ, Robinson N, Vishnu P, Rosales JGF. Quality Oncology Practice Initiative (QOPI) participation as a means to physician engagement, performance improvement, and delivery of safe and high-quality cancer care. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.30_suppl.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
80 Background: High quality and safe medical care has been a consistent goal of the medical community at Virginia Mason Medical Center (VMMC). The Am Soc of Clinical Oncology (ASCO) has set out a list of criteria as part of Its Quality Oncology Practice Initiative (QOPI), which are increasingly being adopted as standards for quality measurement in the Oncology community. Our practice at VMMC participated in the QOPI quality metric survey, with the intent of measuring and enhancing cancer care delivery. Methods: We participated in the web-based QOPI quality metric during the September, 2013 and April, 2014 sessions. Chart abstraction was shared by the providers. Following the Sept session, our performance was analyzed, and targeted areas of improvement were collectively identified by all providers. Following the April session, the clinical note format was changed to incorporate a standard template, addressing areas of underperformance. Results: In the September 2013 session, the primary areas of underperformance were assessment of: a) pain, b) emotional distress, c) performance status (PFS), and d) documentation of staging. Following the April 2014 session, we noted improved performance in all these assessments. Thus, pain reporting rates improved from 40.6 to 61.2%; emotional distress screening from 37.3% to 42.8%; PFS documentation from 42.6 to 53.7%; and staging at initial diagnosis from 74.6% to 80.9%. However our areas of underperformance continued to lag 10 to 30% behind QOPI aggregate reporting rates. With the introduction of a structured note in the electronic medical record (EMR), further improvements are expected the results of which will be reported at the time of the meeting. On the positive side, chemotherapy education and discussion of risk/benefit were consistently areas of superior performance in our practice with our reporting rates being 10 to 40% higher than the QOPI aggregate. Conclusions: QOPI participation is a useful tool for improving and sustaining a high level of practice performance in oncology. Structured notes in the EMR maybe indispensable for maintaining a high level of compliance with performance measures.
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Affiliation(s)
| | | | | | | | | | | | - Andrew Jacobs
- Virginia Mason Community Clinical Oncology Program, Seattle, WA
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Vishnu P, Dorer RP, Aboulafia DM. Immune reconstitution inflammatory syndrome-associated Burkitt lymphoma after combination antiretroviral therapy in HIV-infected patients. Clin Lymphoma Myeloma Leuk 2014; 15:e23-9. [PMID: 25458079 DOI: 10.1016/j.clml.2014.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/25/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Prakash Vishnu
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA.
| | - Russell P Dorer
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA; Division of Hematology, University of Washington, Seattle, WA
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Vishnu P, Dorer RK, Aboulafia DM. Immune reconstitution inflammatory syndrome (IRIS)-associated Burkitt lymphoma. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e19529] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Granulocytic sarcoma (GS) is a rare extramedullary manifestation of acute myeloid leukemia (AML). It may also represent blastic transformation of myelodysplastic syndromes or myeloproliferative neoplasms. Although usually seen in the context of advanced and poorly controlled disease, it may also present as the first manifestation of illness, without concurrent bone marrow or blood involvement. In the medical literature, chloroma and GS are terms that have been used interchangeably with myeloid sarcoma. GS usually manifests as soft tissue or bony masses in several extracranial sites, such as bone, periosteum, and lymph nodes; involvement of the head and neck region is uncommon. We report a case of a woman with insidious onset of progressive nasal congestion and diminished hearing who was diagnosed with an isolated GS of the nasopharynx. With involved field radiotherapy, she achieved a complete remission of 12-months duration before being diagnosed with overt AML. She has remained disease-free for greater than 18 months following induction and consolidation chemotherapy. Through a MEDLINE®/PubMed® search we identified an additional 13 cases of nasopharyngeal GS. The median age was 37 years (range 1 to 81 years). The cases were equally distributed among the sexes. The most common presenting symptoms were conductive hearing loss and sinonasal congestion. Isolated GS was identified in six cases, and the median time from diagnosis of GS to AML was 12 months (range 3 to 48 months). The treatment varied, but responses were seen in all the patients who received chemotherapy with or without radiotherapy.
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Affiliation(s)
- Prakash Vishnu
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA
| | - Ravindra Reddy Chuda
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Dick G Hwang
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA ; Division of Hematology, University of Washington, Seattle, WA, USA
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Tan WW, Heckman MG, Vishnu P, Crook JE, Younkin LH, Covil EG, Ferman TJ, Graff-Radford NR, Younkin SG, Smallridge RC, Wehle MJ, Buskirk SJ. Effect of leuprolide on serum amyloid-β peptide levels and memory in patients with prostate cancer with biochemical recurrence. Urology 2013; 81:150-4. [PMID: 23273081 DOI: 10.1016/j.urology.2012.08.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 07/30/2012] [Accepted: 08/02/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate whether prostate cancer patients receiving leuprolide demonstrated objective cognitive decline accompanied by a change in plasma levels of amyloid-β. METHODS Between November 19, 2003, and July 21, 2008, we prospectively enrolled 50 patients with biochemical recurrence of prostate cancer and measured plasma amyloid-β peptide 40 and amyloid-β peptide 42 levels with sandwich enzyme-linked immunosorbent assay at baseline before the first leuprolide injection and at 2, 4, and 12 months. The Mini-Mental State Examination was used to assess 49 patients at baseline and at subsequent visits, and 24 were also assessed by the California Verbal Learning Test-Short Form. RESULTS Patients were a median age of 71 years (range, 59-89 years). Compared with baseline levels, plasma amyloid-β peptide 40 levels were increased at 2 months (P=.04) and 4 months (P=.02). Age was correlated with plasma amyloid-β peptide 40 levels (P=.003) and likely accounted for this relationship. Plasma amyloid-β peptide 42 and performance on cognitive tasks did not differ from baseline, but memory measures improved slightly after baseline, most likely due to a practice effect. CONCLUSION Leuprolide therapy was not associated with a decline in cognition or memory function or with elevated plasma amyloid short-term. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Winston W Tan
- Division of Hematology, Oncology, Cancer Center, GU Oncology, Department of Neurology, Mayo Clinic, Jacksonville, FL 32224, USA.
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Vishnu P, Colon-Otero G, Kennedy GT, Marlow LA, Kennedy WP, Wu KJ, Santoso JT, Copland JA. Corrigendum to “RhoB mediates antitumor synergy of combined ixabepilone and sunitinib in human ovarian serous cancer” [Gynecol. Oncol. 124 (2012) 589–597]. Gynecol Oncol 2012. [DOI: 10.1016/j.ygyno.2012.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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R. Chuda R, Vishnu P, Aboulafia D. Ofatumumab: A Novel Anti-CD20 Monoclonal Antibody for the Treatment of Chronic Lymphocytic Leukemia. CDTH 2012. [DOI: 10.2174/157488512804999091] [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: 11/22/2022]
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Colon-Otero G, Albertie M, Lesperance M, Weis JA, Coles A, Smith N, Mills L, Woodward T, Aspitia AM, Vishnu P, Willis F, Isley A, Fonseca R, Vachon C, Rajkumar SV. A pilot program in collaboration with African American churches successfully increases awareness of the importance of cancer research and participation in cancer translational research studies among African Americans. J Cancer Educ 2012; 27:294-8. [PMID: 22072126 PMCID: PMC3736846 DOI: 10.1007/s13187-011-0288-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
African Americans are underrepresented in cancer research. We evaluate whether collaboration with African American churches can improve cancer awareness and increase participation in translational research protocols among African Americans. From February to April 2010, the Mayo Clinic partnered with African American Jacksonville churches to provide educational programs focused on cancer research and healthy behaviors. Education on multiple myeloma and on-site access to a translational cancer research pilot project evaluating the prevalence of monoclonal gammopathies and t(14,18) in African Americans was offered. Seventy-four percent, 236 out of 318 participants, returned the questionnaires. The majority of participants had never received information on multiple myeloma (67%), had never received clinical research study information (57%), and were enrolled in the translational research studies (55%). Partnerships with African American churches in community education projects that bring research to church venues are effective in improving cancer awareness and in increasing research participation among African Americans.
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Affiliation(s)
- Gerardo Colon-Otero
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL 32224, USA.
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Vishnu P, Colon-Otero G, Kennedy GT, Marlow LA, Kennedy WP, Wu KJ, Santoso JT, Copland JA. RhoB mediates antitumor synergy of combined ixabepilone and sunitinib in human ovarian serous cancer. Gynecol Oncol 2011; 124:589-97. [PMID: 22115851 DOI: 10.1016/j.ygyno.2011.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [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: 09/21/2011] [Revised: 11/10/2011] [Accepted: 11/14/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim was to evaluate antitumor activity of the combination of ixabepilone and sunitinib in pre-clinical models of chemotherapy naïve and refractory epithelial ovarian tumors, and to investigate the mechanism of synergy of such drug combination. METHODS HOVTAX2 cell line was derived from a metastatic serous papillary epithelial ovarian tumor (EOC) and a paclitaxel-resistant derivative was established. Dose response curves for ixabepilone and sunitinib were generated and synergy was determined using combination indexes. The molecular mechanism of antitumor synergy was examined using shRNA silencing. RESULTS The combination of ixabepilone and sunitinib demonstrated robust antitumor synergy in naïve and paclitaxel-resistant HOVTAX2 cell lines due to increased apoptosis. The GTPase, RhoB, was synergistically upregulated in cells treated with ixabepilone and sunitinib. Using shRNA, RhoB was demonstrated to mediate antitumor synergy. These results were validated in two other EOC cell lines. CONCLUSIONS Ixabepilone plus sunitinib demonstrated antitumor synergy via RhoB in naïve and paclitaxel-resistant cells resulting in apoptosis. This study demonstrates a novel mechanism of action leading to antitumor synergy and provides 'proof-of-principle' for combining molecular targeted agents with cytotoxic chemotherapy to improve antitumor efficacy. RhoB could be envisioned as an early biomarker of response to therapy in a planned Phase II clinical trial to assess the efficacy of ixabepilone combined with a receptor tyrosine kinase inhibitor such as sunitinib. To the best of our knowledge, this is the first demonstration of antitumor synergy between these two classes of drugs in EOC and the pivotal role of RhoB in this synergy.
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Affiliation(s)
- Prakash Vishnu
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
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Vishnu P, Jiang L, Cortese C, Menke D, Tun H. Plasmacytoma-like Posttransplant Lymphoproliferative Disorder Following Orthotopic Liver Transplantation: A Case Report. Transplant Proc 2011; 43:2806-9. [DOI: 10.1016/j.transproceed.2011.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 07/18/2011] [Indexed: 10/17/2022]
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Abstract
BACKGROUND Bladder cancer is one of the most common cancers in Europe, the United States, and Northern African countries. Muscle-invasive bladder cancer is an aggressive epithelial tumor, with a high rate of early systemic dissemination. Superficial, noninvasive bladder cancer can most often be cured; a good proportion of invasive cases can also be cured by a combined modality approach of surgery, chemotherapy, and radiation. Recurrences are common and mostly manifest as metastatic disease. Those with distant metastatic disease can sometime achieve partial or complete remission with combination chemotherapy. RECENT DEVELOPMENTS Better understanding of the biology of the disease has led to the incorporation of molecular and genetic features along with factors such as tumor grade, lympho-vascular invasion, and aberrant histology, thereby allowing identification of 'favorable' and 'unfavorable' cancers which helps a more accurate informed and objective selection of patients who would benefit from neoadjuvant and adjuvant chemotherapy. Gene expression profiling has been used to find molecular signature patterns that can potentially be predictive of drug sensitivity and metastasis. Understanding the molecular pathways of invasive bladder cancer has led to clinical investigation of several targeted therapeutics such as anti-angiogenics, mTOR inhibitors, and anti-EGFR agents. CONCLUSION With improvements in the understanding of the biology of bladder cancer, clinical trials studying novel and targeted agents alone or in combination with chemotherapy have increased the armamentarium for the treatment of bladder cancer. Although the novel biomarkers and gene expression profiles have been shown to provide important predictive and prognostic information and are anticipated to be incorporated in clinical decision-making, their exact utility and relevance calls for a larger prospective validation.
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Affiliation(s)
- Prakash Vishnu
- Division of Hematology Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jacob Mathew
- Division of Hematology Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Winston W Tan
- Division of Hematology Oncology, Mayo Clinic, Jacksonville, FL, USA
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Abstract
Breast cancer is the most common type of cancer diagnosed in women. Anthracyclines and taxanes are the most active and widely used chemotherapeutic agents in the treatment of both early-stage and advanced breast cancer. In the past decade, novel formulations of these cytotoxic agents have been developed to improve efficacy and decrease toxicity. nab-paclitaxel is a solvent-free, albumin-bound 130-nm particle form of paclitaxel (Abraxane, Abraxis Bioscience, CA, USA), which was developed to avoid toxicities associated with the Cremophor vehicle used in solvent-based paclitaxel. In a Phase III study, nab-paclitaxel demonstrated higher response rates, a better safety profile compared with conventional paclitaxel, and improved survival in patients receiving it as second-line therapy. Based on this pivotal trial, nab-paclitaxel is now approved in the USA for treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 months of adjuvant therapy where prior therapy included an anthracycline unless clinically contraindicated. Recently, several Phase II studies have suggested a role for nab-paclitaxel as a single agent and in combination with other agents for first-line treatment of metastatic breast cancer. Studies are ongoing to explore the use of nab-paclitaxel in other solid tumors such as non-small-cell lung cancer, ovarian cancer and malignant melanoma.
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Affiliation(s)
- Prakash Vishnu
- Mayo Clinic, Division of Hematology Oncology, Jacksonville, FL, USA
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Vishnu P, Roy V, Paulsen A, Zubair AC. Efficacy and cost-benefit analysis of risk-adaptive use of plerixafor for autologous hematopoietic progenitor cell mobilization. Transfusion 2011; 52:55-62. [PMID: 21658047 DOI: 10.1111/j.1537-2995.2011.03206.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Plerixafor (P) reduces mobilization failure rates but it is very expensive. For better utilization of P, we employed a risk-adaptive strategy of using it only in patients who are at high risk of mobilization failure, defined by peripheral blood (PB) CD34+ cell count of fewer than 10×10(6)/L after 4 days of filgrastim (F) alone. STUDY DESIGN AND METHODS Herein, we present the results of efficacy and cost-benefit analysis of this risk-adaptive approach for hematopoietic progenitor cell (HPC) collection. All patients received daily F for 4 days, and P was added for those "at-risk" patients from Day 4 with apheresis commencing the following morning. F and P were continued daily for up to a maximum of 4 days or until more than 5×10(6) CD34+ cells/kg were collected. Forty-two transplant-eligible patients underwent HPC mobilization. RESULTS Eighteen patients mobilized with F alone and 24 patients required P with F. Two patients failed adequate HPC mobilization after F+P. Addition of P increased the PB CD34+ count by 6.8-fold with a mean yield of 4.9×10(6) CD34+ cells/kg. Decision-analysis model estimated cost-effectiveness for this risk-adaptive approach of using P with savings of $19,300/patient. Engraftment after HPC infusion was similar among the patients regardless of mobilization regimens. CONCLUSION These results suggest that addition of P to F based on a risk-adaptive strategy significantly reduces the frequency of mobilization failures and is also cost-effective.
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Affiliation(s)
- Prakash Vishnu
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida 32224, USA
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Mathew J, Vishnu P, Perez EA. Highlights from the 3rd Breast-Gynecological International Cancer Conference 2011. Expert Rev Anticancer Ther 2011; 11:701-4. [PMID: 21554044 DOI: 10.1586/era.11.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The 3rd Breast-Gynecological International Cancer Conference, supported by the European Society of Medical Oncology (ESMO), was held in Cairo (Egypt) on 13-14 January 2011. The meeting was conducted under the patronage of Egypt's Ministry of Health, with the scientific committee led by Heba El Zawahry from the National Cancer Institute (Cairo, Egypt), and Yasser Abdel Kader from Cairo University (Cairo, Egypt). Several important updates and multifaceted issues in the management of various breast and gynecological cancers were addressed in this conference. Leading physicians and scientists from 12 different countries shared their expertise and views. This meeting was a good opportunity to meet fellow professionals from all parts of the world and discuss complex and interesting case studies. In this article, we highlight pertinent sessions and important topics discussed in this meeting.
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Affiliation(s)
- Jacob Mathew
- Mayo Clinic, Division of Hematology and Oncology, 4500 San Pablo Road, Jacksonville, FL, USA
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50
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Abstract
Taxanes are highly active chemotherapeutic agents in the treatment of early-stage and metastatic breast cancer. Novel formulations have been developed to improve efficacy and decrease toxicity associated with these cytotoxic agents. nab-paclitaxel is a solvent free, albumin-bound 130-nanometer particle formulation of paclitaxel (Abraxane(®), Abraxis Bioscience), which was developed to avoid toxicities of the Cremophor vehicle used in solvent-based paclitaxel. In a phase III clinical trial, nab-paclitaxel demonstrated higher response rates, better safety and side-effect profile compared to conventional paclitaxel, and improved survival in patients receiving it as second line therapy. Higher doses can be administered over a shorter infusion time without the need for special infusion sets or pre-medications. It is now approved in the US for treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 months of adjuvant therapy, where prior therapy included an anthracycline. Recently, several phase II studies have suggested a role for nab-paclitaxel as a single agent and in combination with other agents for first-line treatment of metastatic breast cancer.
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Affiliation(s)
- Prakash Vishnu
- Division of Hematology Oncology, Mayo Clinic, Jacksonville, FL, USA
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