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McMillan A, Basu S, Karunanithi K, Parkins E, Lau EYM, Cook G, Parrish C, Al-Kaisi F, Pratt G, Shafeek S, Jenkins S, Memon D, Bygrave C, Papanikolaou X, Maisel T, Hassan S, Moosai S, Chander G, Rakesh P, Kishore B, Karim F, Talbot G, Wandroo F, Yong K, Popat R. Daratumumab, bortezomib and dexamethasone at first relapse for patients with multiple myeloma: A real-world multicentre UK retrospective analysis. Br J Haematol 2023; 201:682-689. [PMID: 36822820 DOI: 10.1111/bjh.18703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/15/2023] [Accepted: 02/07/2023] [Indexed: 02/25/2023]
Abstract
Daratumumab, bortezomib and dexamethasone (DVd) is approved for patients with relapsed multiple myeloma following the CASTOR phase 3 clinical trial. This retrospective multicentre analysis assesses the overall response rate (ORR) and progression-free survival (PFS) in routine clinical practice for patients at first relapse treated with DVd incorporating weekly bortezomib. Data were collected from 296 sequential patients treated across 15 UK centres. After a median follow-up of 21 months, the ORR was 82% (26% partial response, 56% very good partial response or better) and the median PFS was 16 months [95% confidence interval (CI) 12-20 months]. Results were similar regardless of prior lenalidomide exposure. The median time to next treatment was 20 months (95% CI 15-25 months) and the estimated overall survival at two years was 74%. Patients with high-risk features (by cytogenetics, International Staging System or extramedullary disease) and those treated within 18 months of initiation of progression-free treatment, or within 12 months of autologous stem cell transplant, had significantly inferior outcomes. The grade 2 and 3 peripheral neuropathy rate was 7%. DVd with weekly bortezomib was effective in a heterogenous real-world population at first relapse with a low rate of peripheral neuropathy. However, high-risk patients had inferior outcomes and should be considered for alternative treatments.
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Affiliation(s)
- Annabel McMillan
- University College London Hospitals NHS Foundation Trust, London, UK.,Whittington Health NHS Trust, London, UK
| | - Supratik Basu
- The Royal Wolverhampton Hospitals NHS Trust and University, Wolverhampton, UK.,West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK
| | - Kamaraj Karunanithi
- West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK.,University Hospitals of North Midlands NHS Trust, Staffordshire, UK
| | | | | | - Gordon Cook
- CRUK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Christopher Parrish
- CRUK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Guy Pratt
- West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Salim Shafeek
- West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK.,Worcestershire Royal Hospital, Worcestershire, UK
| | - Stephen Jenkins
- West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK.,Russell Hall Hospital, Dudley, UK
| | - Danish Memon
- West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK.,Russell Hall Hospital, Dudley, UK
| | | | - Xenofon Papanikolaou
- University College London Hospitals NHS Foundation Trust, London, UK.,The Lister Hospital, London, UK
| | | | | | - Shivir Moosai
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gurvin Chander
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Pallav Rakesh
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bhuvan Kishore
- West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Farheen Karim
- The Royal Wolverhampton Hospitals NHS Trust and University, Wolverhampton, UK.,West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK
| | - Georgina Talbot
- The Royal Wolverhampton Hospitals NHS Trust and University, Wolverhampton, UK.,West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK
| | - Farooq Wandroo
- West Midlands Research Consortium (WMRC, CRN-West Midlands), Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Kwee Yong
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Rakesh Popat
- University College London Hospitals NHS Foundation Trust, London, UK
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2
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Parry H, McIlroy G, Bruton R, Damery S, Tyson G, Logan N, Davis C, Willett B, Zuo J, Ali M, Kaur M, Stephens C, Brant D, Otter A, McSkeane T, Rolfe H, Faustini S, Richter A, Lee S, Wandroo F, Shafeek S, Pratt G, Paneesha S, Moss P. Impaired neutralisation of SARS-CoV-2 delta variant in vaccinated patients with B cell chronic lymphocytic leukaemia. J Hematol Oncol 2022; 15:3. [PMID: 35000597 PMCID: PMC8743056 DOI: 10.1186/s13045-021-01219-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/03/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Immune suppression is a clinical feature of chronic lymphocytic leukaemia (CLL), and patients show increased vulnerability to SARS-CoV-2 infection and suboptimal antibody responses. METHOD We studied antibody responses in 500 patients following dual COVID-19 vaccination to assess the magnitude, correlates of response, stability and functional activity of the spike-specific antibody response with two different vaccine platforms. RESULTS Spike-specific seroconversion post-vaccine was seen in 67% of patients compared to 100% of age-matched controls. Amongst responders, titres were 3.7 times lower than the control group. Antibody responses showed a 33% fall over the next 4 months. The use of an mRNA (n = 204) or adenovirus-based (n = 296) vaccine platform did not impact on antibody response. Male gender, BTKi therapy, prophylactic antibiotics use and low serum IgA/IgM were predictive of failure to respond. Antibody responses after CD20-targeted immunotherapy recovered 12 months post treatment. Post-vaccine sera from CLL patients with Spike-specific antibody response showed markedly reduced neutralisation of the SARS-CoV-2 delta variant compared to healthy controls. Patients with previous natural SARS-CoV-2 infection showed equivalent antibody levels and function as healthy donors after vaccination. CONCLUSIONS These findings demonstrate impaired antibody responses following dual COVID-19 vaccination in patients with CLL and further define patient risk groups. Furthermore, humoural protection against the globally dominant delta variant is markedly impaired in CLL patients and indicates the need for further optimisation of immune protection in this patient cohort.
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Affiliation(s)
- Helen Parry
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Graham McIlroy
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Rachel Bruton
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sarah Damery
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Grace Tyson
- MRC- University of Glasgow Centre for Virus Research, University of Glasgow, Glasgow, G61 1QH, UK
| | | | - Chris Davis
- MRC- University of Glasgow Centre for Virus Research, University of Glasgow, Glasgow, G61 1QH, UK
| | - Brian Willett
- MRC- University of Glasgow Centre for Virus Research, University of Glasgow, Glasgow, G61 1QH, UK
| | - Jianmin Zuo
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Myah Ali
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Manjit Kaur
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Christine Stephens
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Dawn Brant
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Ashley Otter
- UK Health Security Agency, Porton Down, Salisbury, SP4 OJG, UK
| | - Tina McSkeane
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Hayley Rolfe
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sian Faustini
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Alex Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sophie Lee
- Department of Haematology, The Royal Wolverhampton NHS Trust. Wolverhampton Hospital, Wolverhampton, WV10 0QP, UK
| | - Farooq Wandroo
- Department of Haematology. Sandwell and West Birmingham, NHS Trust, Birmingham, B18 7QH, UK
| | - Salim Shafeek
- Department of Haematology, Worcestershire Acute Hospitals NHS Trust, Worcester, WR5 1DD, UK
| | - Guy Pratt
- Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, B15 2TH, UK
| | - Shankara Paneesha
- Birmingham Heartlands Hospital, University Hospitals Birmingham, Birmingham, B9 5SS, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK.
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3
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Shields AM, Venkatachalam S, Shafeek S, Paneesha S, Ford M, Sheeran T, Kelly M, Qureshi I, Salhan B, Karim F, De Silva N, Stones J, Lee S, Khawaja J, Kaudlay PK, Whitmill R, Kakepoto GN, Parry HM, Moss P, Faustini SE, Richter AG, Drayson MT, Basu S. SARS-CoV-2 vaccine responses following CD20-depletion treatment in patients with haematological and rheumatological disease: a West Midlands Research Consortium study. Clin Exp Immunol 2021; 207:3-10. [PMID: 35020852 PMCID: PMC8767851 DOI: 10.1093/cei/uxab018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/23/2021] [Revised: 10/29/2021] [Accepted: 11/08/2021] [Indexed: 12/15/2022] Open
Abstract
B-cell-depleting agents are among the most commonly used drugs to treat haemato-oncological and autoimmune diseases. They rapidly induce a state of peripheral B-cell aplasia with the potential to interfere with nascent vaccine responses, particularly to novel antigens. We have examined the relationship between B-cell reconstitution and SARS-CoV-2 vaccine responses in two cohorts of patients previously exposed to B-cell-depleting agents: a cohort of patients treated for haematological B-cell malignancy and another treated for rheumatological disease. B-cell depletion severely impairs vaccine responsiveness in the first 6 months after administration: SARS-CoV-2 antibody seroprevalence was 42.2% and 33.3% in the haemato-oncological patients and rheumatology patients, respectively and 22.7% in patients vaccinated while actively receiving anti-lymphoma chemotherapy. After the first 6 months, vaccine responsiveness significantly improved during early B-cell reconstitution; however, the kinetics of reconstitution was significantly faster in haemato-oncology patients. The AstraZeneca ChAdOx1 nCoV-19 vaccine and the Pfizer BioNTech 162b vaccine induced equivalent vaccine responses; however, shorter intervals between vaccine doses (<1 m) improved the magnitude of the antibody response in haeamto-oncology patients. In a subgroup of haemato-oncology patients, with historic exposure to B-cell-depleting agents (>36 m previously), vaccine non-responsiveness was independent of peripheral B-cell reconstitution. The findings have important implications for primary vaccination and booster vaccination strategies in individuals clinically vulnerable to SARS-CoV-2.
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Affiliation(s)
- Adrian M Shields
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Clinical Immunology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK,Correspondence: Adrian M. Shields, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | | | - Salim Shafeek
- Department of Haematology, Worcestershire Acute NHS Trust, Worcester, UK
| | - Shankara Paneesha
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Ford
- Department of Rheumatology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Tom Sheeran
- Department of Rheumatology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Melanie Kelly
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Iman Qureshi
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Beena Salhan
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Farheen Karim
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Neelakshi De Silva
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Jacqueline Stones
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Sophie Lee
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Jahanzeb Khawaja
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Richard Whitmill
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Helen M Parry
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sian E Faustini
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Alex G Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Clinical Immunology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark T Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Clinical Immunology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK,Mark T. Drayson, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | - Supratik Basu
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK,Faculty of Science & Engineering, University of Wolverhampton, Wolverhampton, UK,Supratik Basu, The Royal Wolverhampton NHS Trust, Wolverhampton, UK.
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4
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Jackson GH, Davies FE, Pawlyn C, Cairns DA, Striha A, Collett C, Waterhouse A, Jones JR, Kishore B, Garg M, Williams CD, Karunanithi K, Lindsay J, Allotey D, Shafeek S, Jenner MW, Cook G, Russell NH, Kaiser MF, Drayson MT, Owen RG, Gregory WM, Morgan GJ. Lenalidomide before and after autologous stem cell transplantation for transplant-eligible patients of all ages in the randomized, phase III, Myeloma XI trial. Haematologica 2021; 106:1957-1967. [PMID: 32499244 PMCID: PMC8252959 DOI: 10.3324/haematol.2020.247130] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/28/2020] [Indexed: 01/28/2023] Open
Abstract
The optimal way to use immunomodulatory drugs as components of induction and maintenance therapy for multiple myeloma is unresolved. We addressed this question in a large phase III randomized trial, Myeloma XI. Patients with newly diagnosed multiple myeloma (n = 2042) were randomized to induction therapy with cyclophosphamide, thalidomide, and dexamethasone (CTD) or cyclophosphamide, lenalidomide, and dexamethasone (CRD). Additional intensification therapy with cyclophosphamide, bortezomib and dexamethasone (CVD) was administered before ASCT to patients with a suboptimal response to induction therapy using a response-adapted approach. After receiving high-dose melphalan with autologous stem cell transplantation (ASCT), eligible patients were further randomized to receive either lenalidomide alone or observation alone. Co-primary endpoints were progression-free survival (PFS) and overall survival (OS). The CRD regimen was associated with significantly longer PFS (median: 36 vs. 33 months; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.75-0.96; P = 0.0116) and OS (3-year OS: 82.9% vs. 77.0%; HR, 0.77; 95% CI, 0.63-0.93; P = 0.0072) compared with CTD. The PFS and OS results favored CRD over CTD across all subgroups, including patients with International Staging System stage III disease (HR for PFS, 0.73; 95% CI, 0.58-0.93; HR for OS, 0.78; 95% CI, 0.56-1.09), high-risk cytogenetics (HR for PFS, 0.60; 95% CI, 0.43-0.84; HR for OS, 0.70; 95% CI, 0.42-1.15) and ultra high-risk cytogenetics (HR for PFS, 0.67; 95% CI, 0.41-1.11; HR for OS, 0.65; 95% CI, 0.34-1.25). Among patients randomized to lenalidomide maintenance (n = 451) or observation (n = 377), maintenance therapy improved PFS (median: 50 vs. 28 months; HR, 0.47; 95% CI, 0.37-0.60; P < 0.0001). Optimal results for PFS and OS were achieved in the patients who received CRD induction and lenalidomide maintenance. The trial was registered with the EU Clinical Trials Register (EudraCT 2009-010956-93) and ISRCTN49407852.
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Affiliation(s)
- Graham H. Jackson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Faith E. Davies
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Charlotte Pawlyn
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - David A. Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alina Striha
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Corinne Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anna Waterhouse
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - John R. Jones
- King’s College Hospital NHS Foundation Trust, London, UK
| | | | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
| | - Cathy D. Williams
- Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | | | | | - David Allotey
- Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Salim Shafeek
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Matthew W. Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gordon Cook
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Nigel H. Russell
- Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | - Martin F. Kaiser
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Mark T. Drayson
- Clinical Immunology, School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - Roger G. Owen
- St James's University Hospital, Haematological Malignancy Diagnostic Service (HMDS), Leeds, UK
| | - Walter M. Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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5
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Nilak YD, Nilak A, Shafeek S, Rudzki DZ, Chapman J. Benign histiocyte-rich pseudotumor in post treatment mediastinal Hodgkin's lymphoma. Radiol Case Rep 2019; 15:156-160. [PMID: 31871516 PMCID: PMC6911874 DOI: 10.1016/j.radcr.2019.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 08/12/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 10/31/2022] Open
Abstract
Benign xanthomatous pseudotumors are rare, mass forming lesions composed of lipid laden histiocytes and tumor necrosis following chemotherapy. We present a rare case of young 36 year old male with primary mediastinal Hodgkin's lymphoma who developed xanthomatous pseudotumor mimicking relapse at the site of original disease on positron emission tomography. This scenario places emphasis on histologic confirmation of suspected treatment failure or relapse.
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Affiliation(s)
- Yash Dilip Nilak
- Department of Medicine, Worcester Royal Hospital, Worcester WR5 1DD, UK
| | - Anjumara Nilak
- Department of Radiology, Worcester Royal Hospital Worcester, WR5 1DD, UK
| | - Salim Shafeek
- Worcestershire Acute Hospitals NHS trust, Worcester, WR5 1DD, UK.,Hon Sen Lecturer in Clinical Haematology, University of Birmingham, Birmingham, UK
| | - Dr Zbigniew Rudzki
- Heartlands Hospital, Birmingham, B9 5SS, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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6
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Gibbins J, Pankhurst T, Murray J, McCafferty I, Baiden-Amissahk K, Shafeek S, Lipkin GW. Extramedullary haematopoiesis in the kidney: a case report and review of literature. ACTA ACUST UNITED AC 2006; 27:391-4. [PMID: 16307541 DOI: 10.1111/j.1365-2257.2005.00724.x] [Citation(s) in RCA: 18] [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] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a 47-year-old man with myelofibrosis who presented with bilateral nephromegaly secondary to extramedullary haematopoiesis. We discuss diagnosis and treatment of this rare case and review the literature.
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Affiliation(s)
- J Gibbins
- Department of Nephrology, University Hospital Birmingham, Birmingham, UK
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