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Bennett CL, Gibbons JB, Trujillo A, Carson KR, Knopf K, Nabhan C, Rosen ST, Aboulafia DM. Congressional Investigation of RevAssist-Linked and General Pricing Strategies for Lenalidomide. JCO Oncol Pract 2024:OP2300579. [PMID: 38412398 DOI: 10.1200/op.23.00579] [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] [Received: 09/11/2023] [Revised: 12/07/2023] [Accepted: 01/05/2024] [Indexed: 02/29/2024] Open
Affiliation(s)
- Charles L Bennett
- SmartState Center for Medication Safety and Efficacy at the University of South Carolina, Columbia, SC
- Department of Health Systems Management and Policy, Colorado School of Public Health, Denver, Colorado
| | - Jason B Gibbons
- Department of Health Systems Management and Policy, Colorado School of Public Health, Denver, Colorado
| | - Antonio Trujillo
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kenneth R Carson
- Department of Hematology/Hematopoietic Cell Transplantation, The City of Hope Comprehesive Cancer Center, Duarte, CA
| | - Kevin Knopf
- SmartState Center for Medication Safety and Efficacy at the University of South Carolina, Columbia, SC
| | - Chadi Nabhan
- SmartState Center for Medication Safety and Efficacy at the University of South Carolina, Columbia, SC
| | - Steven T Rosen
- Department of Hematology/Hematopoietic Cell Transplantation, The City of Hope Comprehesive Cancer Center, Duarte, CA
- Floyd and Delores Jones Cancer Institute at Virginia Mason, Seattle, WA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute at Virginia Mason, Seattle, WA
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Haigentz M, Lee JY, Chiao EY, Aboulafia DM, Ratner L, Ambinder RF, Baiocchi RA, Mitsuyasu RT, Wachsman W, Sparano JA, Rudek MA. Phase I Trial of the Multi-kinase Inhibitor Cabozantinib, a CYP3A4 Substrate, plus CYP3A4-Interacting Antiretroviral Therapy in People Living with HIV and Cancer (AMC-087). Clin Cancer Res 2023; 29:5038-5046. [PMID: 37523145 PMCID: PMC10829065 DOI: 10.1158/1078-0432.ccr-23-1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/01/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To evaluate the safety, pharmacokinetics, and pharmacodynamic effects of cabozantinib, a CYP3A4 substrate, in people living with human immunodeficiency virus and cancer receiving antiretrovirals (ARV). PATIENTS AND METHODS Patients received a reduced dose of cabozantinib (20 mg orally daily) with strong CYP3A4 inhibitors (ARV ritonavir or non-ARV cobicistat, stratum A), or a standard 60 mg dose with ARVs that are CYP3A4 inducers (efavirenz or etravirine, stratum B) or noninteracting ARVs (stratum C). Initial dose escalation in stratum A and stratum B was performed on the basis of tolerability. RESULTS 36 patients received cabozantinib plus ARVs, including 20 in stratum A, 9 in B, and 7 in C. The recommended initial cabozantinib doses for stratum A, B, and C were 20, 60, and 60 mg, respectively. Doses of 40 or 60 mg plus CYP3A4 inhibitors in stratum A and 100 mg plus CYP3A4 inducers in stratum B were associated with excessive toxicity, whereas 60 mg with noninteracting ARVs was not. The steady state minimal concentrations were lower at 20 mg in stratum A or 60 mg in stratum B compared with 60 mg in stratum C, while total exposure was only lower in 60 mg in stratum B compared with 60 mg in stratum C. Activity was observed in Kaposi sarcoma and an AXL-amplified sarcoma. CONCLUSIONS Cabozantinib as a single agent should be initiated at 20 mg daily and 60 mg daily when taken concurrently with ARVs that are strong CYP3A4 inhibitors and inducers, respectively, with consideration for subsequent escalation per current cabozantinib guidelines. See related commentary by Eisenmann and Sparreboom, p. 4999.
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Affiliation(s)
- Missak Haigentz
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ
| | | | | | - David M. Aboulafia
- The Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center and the University of Washington, Seattle, Washington
| | - Lee Ratner
- Siteman Cancer Center, University of Washington in Saint Louis, St. Louis, MO
| | - Richard F. Ambinder
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | | | - Ronald T. Mitsuyasu
- University of California, Los Angeles, UCLA Clinical AIDS Research and Education Center, Los Angeles, CA
| | - William Wachsman
- University of California San Diego Moores Cancer Center, San Diego, CA
| | - Joseph A. Sparano
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY
| | - Michelle A. Rudek
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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3
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Nagaraj G, Vinayak S, Khaki AR, Sun T, Kuderer NM, Aboulafia DM, Acoba JD, Awosika J, Bakouny Z, Balmaceda NB, Bao T, Bashir B, Berg S, Bilen MA, Bindal P, Blau S, Bodin BE, Borno HT, Castellano C, Choi H, Deeken J, Desai A, Edwin N, Feldman LE, Flora DB, Friese CR, Galsky MD, Gonzalez CJ, Grivas P, Gupta S, Haynam M, Heilman H, Hershman DL, Hwang C, Jani C, Jhawar SR, Joshi M, Kaklamani V, Klein EJ, Knox N, Koshkin VS, Kulkarni AA, Kwon DH, Labaki C, Lammers PE, Lathrop KI, Lewis MA, Li X, Lopes GDL, Lyman GH, Makower DF, Mansoor AH, Markham MJ, Mashru SH, McKay RR, Messing I, Mico V, Nadkarni R, Namburi S, Nguyen RH, Nonato TK, O'Connor TL, Panagiotou OA, Park K, Patel JM, Patel KG, Peppercorn J, Polimera H, Puc M, Rao YJ, Razavi P, Reid SA, Riess JW, Rivera DR, Robson M, Rose SJ, Russ AD, Schapira L, Shah PK, Shanahan MK, Shapiro LC, Smits M, Stover DG, Streckfuss M, Tachiki L, Thompson MA, Tolaney SM, Weissmann LB, Wilson G, Wotman MT, Wulff-Burchfield EM, Mishra S, French B, Warner JL, Lustberg MB, Accordino MK, Shah DP. Clinical characteristics, racial inequities, and outcomes in patients with breast cancer and COVID-19: A COVID-19 and cancer consortium (CCC19) cohort study. eLife 2023; 12:e82618. [PMID: 37846664 PMCID: PMC10637772 DOI: 10.7554/elife.82618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/18/2023] [Indexed: 10/18/2023] Open
Abstract
Background Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations. Methods This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity. Results 1383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32-1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70-6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83-12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63-3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20-2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66-3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89-22.6]). Hispanic ethnicity, timing, and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status. Conclusions Using one of the largest registries on cancer and COVID-19, we identified patient and BC-related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to non-Hispanic White patients. Funding This study was partly supported by National Cancer Institute grant number P30 CA068485 to Tianyi Sun, Sanjay Mishra, Benjamin French, Jeremy L Warner; P30-CA046592 to Christopher R Friese; P30 CA023100 for Rana R McKay; P30-CA054174 for Pankil K Shah and Dimpy P Shah; KL2 TR002646 for Pankil Shah and the American Cancer Society and Hope Foundation for Cancer Research (MRSG-16-152-01-CCE) and P30-CA054174 for Dimpy P Shah. REDCap is developed and supported by Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH). The funding sources had no role in the writing of the manuscript or the decision to submit it for publication. Clinical trial number CCC19 registry is registered on ClinicalTrials.gov, NCT04354701.
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Affiliation(s)
| | - Shaveta Vinayak
- Fred Hutchinson Cancer Research CenterSeattleUnited States
- University of WashingtonSeattleUnited States
- Seattle Cancer Care AllianceSeattleUnited States
| | | | - Tianyi Sun
- Vanderbilt University Medical CenterNashvilleUnited States
| | - Nicole M Kuderer
- University of WashingtonSeattleUnited States
- Advanced Cancer Research GroupKirklandUnited States
| | | | - Jared D Acoba
- University of Hawaii Cancer CenterHonoluluUnited States
| | - Joy Awosika
- University of Cincinnati Cancer CenterCincinnatiUnited States
| | | | | | - Ting Bao
- Memorial Sloan Kettering Cancer CenterNew YorkUnited States
| | - Babar Bashir
- Sidney Kimmel Comprehensive Cancer Center, Thomas Jefferson UniversityPhiladelphiaUnited States
| | | | - Mehmet A Bilen
- Winship Cancer Institute, Emory UniversityAtlantaUnited States
| | - Poorva Bindal
- Beth Israel Deaconess Medical CenterBostonUnited States
| | - Sibel Blau
- Northwest Medical SpecialtiesTacomaUnited States
| | - Brianne E Bodin
- Herbert Irving Comprehensive Cancer Center, Columbia UniversityNew YorkUnited States
| | - Hala T Borno
- Helen Diller Family Comprehensive Cancer Center, University of California, San FranciscoSan FranciscoUnited States
| | | | - Horyun Choi
- University of Hawaii Cancer CenterHonoluluUnited States
| | - John Deeken
- Inova Schar Cancer InstituteFairfaxUnited States
| | | | | | - Lawrence E Feldman
- University of Illinois Hospital & Health Sciences SystemChicagoUnited States
| | | | | | - Matthew D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
| | - Cyndi J Gonzalez
- Rogel Cancer Center, University of Michigan-Ann ArborAnn ArborUnited States
| | - Petros Grivas
- Fred Hutchinson Cancer Research CenterSeattleUnited States
- University of WashingtonSeattleUnited States
- Seattle Cancer Care AllianceSeattleUnited States
| | | | - Marcy Haynam
- The Ohio State University Comprehensive Cancer CenterColumbusUnited States
| | - Hannah Heilman
- University of Cincinnati Cancer CenterCincinnatiUnited States
| | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia UniversityNew YorkUnited States
| | - Clara Hwang
- Henry Ford Cancer Institute, Henry Ford HospitalDetroitUnited States
| | | | - Sachin R Jhawar
- The Ohio State University Comprehensive Cancer CenterColumbusUnited States
| | - Monika Joshi
- Penn State Health St Joseph Cancer CenterReadingUnited States
| | - Virginia Kaklamani
- Mays Cancer Center, The University of Texas Health San Antonio MD Anderson Cancer CenterSan AntonioUnited States
| | | | - Natalie Knox
- Stritch School of Medicine, Loyola UniversityMaywoodUnited States
| | - Vadim S Koshkin
- Helen Diller Family Comprehensive Cancer Center, University of California, San FranciscoSan FranciscoUnited States
| | - Amit A Kulkarni
- Masonic Cancer Center, University of MinnesotaMinneapolisUnited States
| | - Daniel H Kwon
- Helen Diller Family Comprehensive Cancer Center, University of California, San FranciscoSan FranciscoUnited States
| | | | | | - Kate I Lathrop
- Mays Cancer Center, The University of Texas Health San Antonio MD Anderson Cancer CenterSan AntonioUnited States
| | - Mark A Lewis
- Intermountain HealthcareSalt Lake CityUnited States
| | - Xuanyi Li
- Vanderbilt University Medical CenterNashvilleUnited States
| | - Gilbert de Lima Lopes
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of MedicineMiamiUnited States
| | - Gary H Lyman
- Fred Hutchinson Cancer Research CenterSeattleUnited States
- University of WashingtonSeattleUnited States
- Seattle Cancer Care AllianceSeattleUnited States
| | - Della F Makower
- Montefiore Medical Center, Albert Einstein College of MedicineBronxUnited States
| | | | - Merry-Jennifer Markham
- Division of Hematology and Oncology, University of Florida Health Cancer CenterGainesvilleUnited States
| | | | - Rana R McKay
- Moores Cancer Center, University of California, San DiegoSan DiegoUnited States
| | - Ian Messing
- Division of Radiation Oncology, George Washington UniversityWashingtonUnited States
| | - Vasil Mico
- Sidney Kimmel Comprehensive Cancer Center, Thomas Jefferson UniversityPhiladelphiaUnited States
| | | | | | - Ryan H Nguyen
- University of Illinois Hospital & Health Sciences SystemChicagoUnited States
| | | | | | | | - Kyu Park
- Loma Linda University Cancer CenterLoma LindaUnited States
| | | | | | | | - Hyma Polimera
- Penn State Health St Joseph Cancer CenterReadingUnited States
| | | | - Yuan James Rao
- Division of Radiation Oncology, George Washington UniversityWashingtonUnited States
| | - Pedram Razavi
- Moores Cancer Center, University of California, San DiegoSan DiegoUnited States
| | - Sonya A Reid
- Vanderbilt University Medical CenterNashvilleUnited States
| | - Jonathan W Riess
- UC Davis Comprehensive Cancer Center, University of California, DavisDavisUnited States
| | - Donna R Rivera
- Division of Cancer Control and Population Sciences, National Cancer InstituteRockvilleUnited States
| | - Mark Robson
- Memorial Sloan Kettering Cancer CenterNew YorkUnited States
| | - Suzanne J Rose
- Carl & Dorothy Bennett Cancer Center, Stamford HospitalStamfordUnited States
| | - Atlantis D Russ
- Division of Hematology and Oncology, University of Florida Health Cancer CenterGainesvilleUnited States
| | | | - Pankil K Shah
- Mays Cancer Center, The University of Texas Health San Antonio MD Anderson Cancer CenterSan AntonioUnited States
| | | | - Lauren C Shapiro
- Montefiore Medical Center, Albert Einstein College of MedicineBronxUnited States
| | | | - Daniel G Stover
- The Ohio State University Comprehensive Cancer CenterColumbusUnited States
| | | | - Lisa Tachiki
- Fred Hutchinson Cancer Research CenterSeattleUnited States
- University of WashingtonSeattleUnited States
- Seattle Cancer Care AllianceSeattleUnited States
| | | | | | | | - Grace Wilson
- Masonic Cancer Center, University of MinnesotaMinneapolisUnited States
| | - Michael T Wotman
- Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
| | | | - Sanjay Mishra
- Vanderbilt University Medical CenterNashvilleUnited States
| | | | | | - Maryam B Lustberg
- Yale Cancer Center, Yale University School of MedicineNew HavenUnited States
| | - Melissa K Accordino
- Herbert Irving Comprehensive Cancer Center, Columbia UniversityNew YorkUnited States
| | - Dimpy P Shah
- Mays Cancer Center, The University of Texas Health San Antonio MD Anderson Cancer CenterSan AntonioUnited States
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4
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Atkinson TM, Lensing S, Lee JY, Chang D, Kim SY, Li Y, Lynch KA, Webb A, Holland SM, Lubetkin EI, Goldstone S, Einstein MH, Stier EA, Wiley DJ, Mitsuyasu R, Rosa-Cunha I, Aboulafia DM, Dhanireddy S, Schouten JT, Levine R, Gardner E, Logan J, Dunleavy H, Barroso LF, Bucher G, Korman J, Stearn B, Wilkin TJ, Ellsworth G, Pugliese JC, Arons A, Burkhalter JE, Cella D, Berry-Lawhorn JM, Palefsky JM. Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03. Qual Life Res 2023:10.1007/s11136-023-03391-4. [PMID: 37020153 PMCID: PMC10330891 DOI: 10.1007/s11136-023-03391-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI). METHODS The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization. RESULTS Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness. CONCLUSION A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.
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Affiliation(s)
- Thomas M Atkinson
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA.
| | - Shelly Lensing
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeannette Y Lee
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Di Chang
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Soo Young Kim
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Yuelin Li
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Kathleen A Lynch
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
- School of Global Public Health, New York University, New York, NY, USA
| | - Andrew Webb
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Susan M Holland
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | | | | | | | | | - Dorothy J Wiley
- University of California, Los Angeles School of Nursing, Los Angeles, CA, USA
| | - Ronald Mitsuyasu
- UCLA Center for Clinical AIDS Research and Education, Los Angeles, CA, USA
| | | | | | | | - Jeffrey T Schouten
- Virginia Mason Medical Center, Seattle, WA, USA
- Harborview Medical Center, Seattle, WA, USA
| | | | - Edward Gardner
- Public Health Institute at Denver Health, Denver, CO, USA
| | - Jeffrey Logan
- Public Health Institute at Denver Health, Denver, CO, USA
| | | | - Luis F Barroso
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Gary Bucher
- Anal Dysplasia Clinic MidWest, Chicago, IL, USA
| | - Jessica Korman
- Metropolitan Gastroenterology Group, Washington, DC, USA
| | | | | | | | - Julia C Pugliese
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Abigail Arons
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Jack E Burkhalter
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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5
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Nagaraj G, Vinayak S, Khaki AR, Sun T, Kuderer NM, Aboulafia DM, Acoba JD, Awosika J, Bakouny Z, Balmaceda NB, Bao T, Bashir B, Berg S, Bilen MA, Bindal P, Blau S, Bodin BE, Borno HT, Castellano C, Choi H, Deeken J, Desai A, Edwin N, Feldman LE, Flora DB, Friese CR, Galsky MD, Gonzalez CJ, Grivas P, Gupta S, Haynam M, Heilman H, Hershman DL, Hwang C, Jani C, Jhawar SR, Joshi M, Kaklamani V, Klein EJ, Knox N, Koshkin VS, Kulkarni AA, Kwon DH, Labaki C, Lammers PE, Lathrop KI, Lewis MA, Li X, de Lima Lopes G, Lyman GH, Makower DF, Mansoor AH, Markham MJ, Mashru SH, McKay RR, Messing I, Mico V, Nadkarni R, Namburi S, Nguyen RH, Nonato TK, O’Connor TL, Panagiotou OA, Park K, Patel JM, Patel KG, Peppercorn J, Polimera H, Puc M, Rao YJ, Razavi P, Reid SA, Riess JW, Rivera DR, Robson M, Rose SJ, Russ AD, Schapira L, Shah PK, Shanahan MK, Shapiro LC, Smits M, Stover DG, Streckfuss M, Tachiki L, Thompson MA, Tolaney SM, Weissmann LB, Wilson G, Wotman MT, Wulff-Burchfield EM, Mishra S, French B, Warner JL, Lustberg MB, Accordino MK, Shah DP. Clinical Characteristics, Racial Inequities, and Outcomes in Patients with Breast Cancer and COVID-19: A COVID-19 and Cancer Consortium (CCC19) Cohort Study. medRxiv 2023:2023.03.09.23287038. [PMID: 37205429 PMCID: PMC10187350 DOI: 10.1101/2023.03.09.23287038] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations. Methods This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity. Results 1,383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32 - 1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70 - 6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83 - 12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63 - 3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20 - 2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66 - 3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89 - 22.6]). Hispanic ethnicity, timing and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status. Conclusions Using one of the largest registries on cancer and COVID-19, we identified patient and BC related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to Non-Hispanic White patients.
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Affiliation(s)
| | - Shaveta Vinayak
- Fred Hutchinson Cancer Research Center, Seattle, WA
- University of Washington, Seattle, WA
- Seattle Cancer Care Alliance, Seattle, WA
| | | | - Tianyi Sun
- Vanderbilt University Medical Center, Nashville, TN
| | - Nicole M. Kuderer
- University of Washington, Seattle, WA
- Advanced Cancer Research Group, Kirkland, WA
| | | | | | - Joy Awosika
- University of Cincinnati Cancer Center, Cincinnati, OH
| | | | | | - Ting Bao
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Babar Bashir
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | | | | | | | - Sibel Blau
- Northwest Medical Specialties, Tacoma, WA
| | - Brianne E. Bodin
- Herbert Irving Comprehensive Cancer Center at Columbia University, New York, NY
| | - Hala T. Borno
- UCSF Helen Diller Family Comprehensive Cancer Center at the University of California at San Francisco, San Francisco, CA
| | | | - Horyun Choi
- University of Hawaii Cancer Center, Honolulu, HI
| | | | | | | | | | | | | | - Matthew D. Galsky
- Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Petros Grivas
- Fred Hutchinson Cancer Research Center, Seattle, WA
- University of Washington, Seattle, WA
- Seattle Cancer Care Alliance, Seattle, WA
| | | | - Marcy Haynam
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Dawn L. Hershman
- Herbert Irving Comprehensive Cancer Center at Columbia University, New York, NY
| | - Clara Hwang
- Henry Ford Cancer Institute, Henry Ford Hospital, Detroit, MI
| | | | - Sachin R. Jhawar
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Virginia Kaklamani
- Mays Cancer Center at UT Health San Antonio MD Anderson Cancer Center, San Antonio, TX
| | | | - Natalie Knox
- Stritch School of Medicine at Loyola University, Maywood, IL
| | - Vadim S. Koshkin
- UCSF Helen Diller Family Comprehensive Cancer Center at the University of California at San Francisco, San Francisco, CA
| | - Amit A. Kulkarni
- Masonic Cancer Center at the University of Minnesota, Minneapolis, MN
| | - Daniel H. Kwon
- UCSF Helen Diller Family Comprehensive Cancer Center at the University of California at San Francisco, San Francisco, CA
| | | | | | - Kate I. Lathrop
- Mays Cancer Center at UT Health San Antonio MD Anderson Cancer Center, San Antonio, TX
| | | | - Xuanyi Li
- Vanderbilt University Medical Center, Nashville, TN
| | - Gilberto de Lima Lopes
- Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, Miami, FL
| | - Gary H. Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA
- University of Washington, Seattle, WA
- Seattle Cancer Care Alliance, Seattle, WA
| | - Della F. Makower
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | | | - Merry-Jennifer Markham
- University of Florida, Division of Hematology and Oncology, UF Health Cancer Center, Gainesville, FL
| | | | - Rana R. McKay
- Moores Cancer Center, University of California, San Diego, CA
| | - Ian Messing
- Division of Radiation Oncology, George Washington University, Washington, DC
| | - Vasil Mico
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | | | | | - Ryan H. Nguyen
- University of Illinois Hospital & Health Sciences System, Chicago, IL
| | | | | | | | - Kyu Park
- Loma Linda University Cancer Center, Loma Linda, CA
| | | | | | | | | | | | - Yuan James Rao
- Division of Radiation Oncology, George Washington University, Washington, DC
| | - Pedram Razavi
- Moores Cancer Center, University of California, San Diego, CA
| | | | - Jonathan W. Riess
- UC Davis Comprehensive Cancer Center at the University of California at Davis, CA
| | - Donna R. Rivera
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, USA
| | - Mark Robson
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Suzanne J. Rose
- Carl & Dorothy Bennett Cancer Center at Stamford Hospital, Stamford, CT
| | - Atlantis D. Russ
- University of Florida, Division of Hematology and Oncology, UF Health Cancer Center, Gainesville, FL
| | | | - Pankil K. Shah
- Mays Cancer Center at UT Health San Antonio MD Anderson Cancer Center, San Antonio, TX
| | | | - Lauren C. Shapiro
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | | | - Daniel G. Stover
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Lisa Tachiki
- Fred Hutchinson Cancer Research Center, Seattle, WA
- University of Washington, Seattle, WA
- Seattle Cancer Care Alliance, Seattle, WA
| | | | | | | | - Grace Wilson
- Masonic Cancer Center at the University of Minnesota, Minneapolis, MN
| | - Michael T. Wotman
- Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | | | | | - Dimpy P. Shah
- Mays Cancer Center at UT Health San Antonio MD Anderson Cancer Center, San Antonio, TX
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Bakouny Z, Labaki C, Grover P, Awosika J, Gulati S, Hsu CY, Alimohamed SI, Bashir B, Berg S, Bilen MA, Bowles D, Castellano C, Desai A, Elkrief A, Eton OE, Fecher LA, Flora D, Galsky MD, Gatti-Mays ME, Gesenhues A, Glover MJ, Gopalakrishnan D, Gupta S, Halfdanarson TR, Hayes-Lattin B, Hendawi M, Hsu E, Hwang C, Jandarov R, Jani C, Johnson DB, Joshi M, Khan H, Khan SA, Knox N, Koshkin VS, Kulkarni AA, Kwon DH, Matar S, McKay RR, Mishra S, Moria FA, Nizam A, Nock NL, Nonato TK, Panasci J, Pomerantz L, Portuguese AJ, Provenzano D, Puc M, Rao YJ, Rhodes TD, Riely GJ, Ripp JJ, Rivera AV, Ruiz-Garcia E, Schmidt AL, Schoenfeld AJ, Schwartz GK, Shah SA, Shaya J, Subbiah S, Tachiki LM, Tucker MD, Valdez-Reyes M, Weissmann LB, Wotman MT, Wulff-Burchfield EM, Xie Z, Yang YJ, Thompson MA, Shah DP, Warner JL, Shyr Y, Choueiri TK, Wise-Draper TM, Gandhi R, Gartrell BA, Goel S, Halmos B, Makower DF, O' Sullivan D, Ohri N, Portes M, Shapiro LC, Shastri A, Sica RA, Verma AK, Butt O, Campian JL, Fiala MA, Henderson JP, Monahan RS, Stockerl-Goldstein KE, Zhou AY, Bitran JD, Hallmeyer S, Mundt D, Pandravada S, Papaioannou PV, Patel M, Streckfuss M, Tadesse E, Gatson NTN, Kundranda MN, Lammers PE, Loree JM, Yu IS, Bindal P, Lam B, Peters MLB, Piper-Vallillo AJ, Egan PC, Farmakiotis D, Arvanitis P, Klein EJ, Olszewski AJ, Vieira K, Angevine AH, Bar MH, Del Prete SA, Fiebach MZ, Gulati AP, Hatton E, Houston K, Rose SJ, Steve Lo KM, Stratton J, Weinstein PL, Garcia JA, Routy B, Hoyo-Ulloa I, Dawsey SJ, Lemmon CA, Pennell NA, Sharifi N, Painter CA, Granada C, Hoppenot C, Li A, Bitterman DS, Connors JM, Demetri GD, Florez (Duma) N, Freeman DA, Giordano A, Morgans AK, Nohria A, Saliby RM, Tolaney SM, Van Allen EM, Xu WV, Zon RL, Halabi S, Zhang T, Dzimitrowicz H, Leighton JC, Graber JJ, Grivas P, Hawley JE, Loggers ET, Lyman GH, Lynch RC, Nakasone ES, Schweizer MT, Vinayak S, Wagner MJ, Yeh A, Dansoa Y, Makary M, Manikowski JJ, Vadakara J, Yossef K, Beckerman J, Goyal S, Messing I, Rosenstein LJ, Steffes DR, Alsamarai S, Clement JM, Cosin JA, Daher A, Dailey ME, Elias R, Fein JA, Hosmer W, Jayaraj A, Mather J, Menendez AG, Nadkarni R, Serrano OK, Yu PP, Balanchivadze N, Gadgeel SM, Accordino MK, Bhutani D, Bodin BE, Hershman DL, Masson C, Alexander M, Mushtaq S, Reuben DY, Bernicker EH, Deeken JF, Jeffords KJ, Shafer D, Cárdenas AI, Cuervo Campos R, De-la-Rosa-Martinez D, Ramirez A, Vilar-Compte D, Gill DM, Lewis MA, Low CA, Jones MM, Mansoor AH, Mashru SH, Werner MA, Cohen AM, McWeeney S, Nemecek ER, Williamson SP, Peters S, Smith SJ, Lewis GC, Zaren HA, Akhtari M, Castillo DR, Cortez K, Lau E, Nagaraj G, Park K, Reeves ME, O'Connor TE, Altman J, Gurley M, Mulcahy MF, Wehbe FH, Durbin EB, Nelson HH, Ramesh V, Sachs Z, Wilson G, Bardia A, Boland G, Gainor JF, Peppercorn J, Reynolds KL, Rosovsky RP, Zubiri L, Bekaii-Saab TS, Joyner MJ, Riaz IB, Senefeld JW, Shah S, Ayre SK, Bonnen M, Mahadevan D, McKeown C, Mesa RA, Ramirez AG, Salazar M, Shah PK, Wang CP, Bouganim N, Papenburg J, Sabbah A, Tagalakis V, Vinh DC, Nanchal R, Singh H, Bahadur N, Bao T, Belenkaya R, Nambiar PH, O’Cearbhaill RE, Papadopoulos EB, Philip J, Robson M, Rosenberg JE, Wilkins CR, Tamimi R, Cerrone K, Dill J, Faller BA, Alomar ME, Chandrasekhar SA, Hume EC, Islam JY, Ajmera A, Brouha SS, Cabal A, Choi S, Hsiao A, Jiang JY, Kligerman S, Park J, Razavi P, Reid EG, Bhatt PS, Mariano MG, Thomson CC, Glace M(G, Knoble JL, Rink C, Zacks R, Blau SH, Brown C, Cantrell AS, Namburi S, Polimera HV, Rovito MA, Edwin N, Herz K, Kennecke HF, Monfared A, Sautter RR, Cronin T, Elshoury A, Fleissner B, Griffiths EA, Hernandez-Ilizaliturri F, Jain P, Kariapper A, Levine E, Moffitt M, O'Connor TL, Smith LJ, Wicher CP, Zsiros E, Jabbour SK, Misdary CF, Shah MR, Batist G, Cook E, Ferrario C, Lau S, Miller WH, Rudski L, Santos Dutra M, Wilchesky M, Mahmood SZ, McNair C, Mico V, Dixon B, Kloecker G, Logan BB, Mandapakala C, Cabebe EC, Jha A, Khaki AR, Nagpal S, Schapira L, Wu JTY, Whaley D, Lopes GDL, de Cardenas K, Russell K, Stith B, Taylor S, Klamerus JF, Revankar SG, Addison D, Chen JL, Haynam M, Jhawar SR, Karivedu V, Palmer JD, Pillainayagam C, Stover DG, Wall S, Williams NO, Abbasi SH, Annis S, Balmaceda NB, Greenland S, Kasi A, Rock CD, Luders M, Smits M, Weiss M, Chism DD, Owenby S, Ang C, Doroshow DB, Metzger M, Berenberg J, Uyehara C, Fazio A, Huber KE, Lashley LN, Sueyoshi MH, Patel KG, Riess J, Borno HT, Small EJ, Zhang S, Andermann TM, Jensen CE, Rubinstein SM, Wood WA, Ahmad SA, Brownfield L, Heilman H, Kharofa J, Latif T, Marcum M, Shaikh HG, Sohal DPS, Abidi M, Geiger CL, Markham MJ, Russ AD, Saker H, Acoba JD, Choi H, Rho YS, Feldman LE, Gantt G, Hoskins KF, Khan M, Liu LC, Nguyen RH, Pasquinelli MM, Schwartz C, Venepalli NK, Vikas P, Zakharia Y, Friese CR, Boldt A, Gonzalez CJ, Su C, Su CT, Yoon JJ, Bijjula R, Mavromatis BH, Seletyn ME, Wood BR, Zaman QU, Kaklamani V, Beeghly A, Brown AJ, Charles LJ, Cheng A, Crispens MA, Croessmann S, Davis EJ, Ding T, Duda SN, Enriquez KT, French B, Gillaspie EA, Hausrath DJ, Hennessy C, Lewis JT, Li X(L, Prescott LS, Reid SA, Saif S, Slosky DA, Solorzano CC, Sun T, Vega-Luna K, Wang LL, Aboulafia DM, Carducci TM, Goldsmith KJ, Van Loon S, Topaloglu U, Moore J, Rice RL, Cabalona WD, Cyr S, Barrow McCollough B, Peddi P, Rosen LR, Ravindranathan D, Hafez N, Herbst RS, LoRusso P, Lustberg MB, Masters T, Stratton C. Interplay of Immunosuppression and Immunotherapy Among Patients With Cancer and COVID-19. JAMA Oncol 2023; 9:128-134. [PMID: 36326731 PMCID: PMC9634600 DOI: 10.1001/jamaoncol.2022.5357] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/11/2022] [Indexed: 11/06/2022]
Abstract
Importance Cytokine storm due to COVID-19 can cause high morbidity and mortality and may be more common in patients with cancer treated with immunotherapy (IO) due to immune system activation. Objective To determine the association of baseline immunosuppression and/or IO-based therapies with COVID-19 severity and cytokine storm in patients with cancer. Design, Setting, and Participants This registry-based retrospective cohort study included 12 046 patients reported to the COVID-19 and Cancer Consortium (CCC19) registry from March 2020 to May 2022. The CCC19 registry is a centralized international multi-institutional registry of patients with COVID-19 with a current or past diagnosis of cancer. Records analyzed included patients with active or previous cancer who had a laboratory-confirmed infection with SARS-CoV-2 by polymerase chain reaction and/or serologic findings. Exposures Immunosuppression due to therapy; systemic anticancer therapy (IO or non-IO). Main Outcomes and Measures The primary outcome was a 5-level ordinal scale of COVID-19 severity: no complications; hospitalized without requiring oxygen; hospitalized and required oxygen; intensive care unit admission and/or mechanical ventilation; death. The secondary outcome was the occurrence of cytokine storm. Results The median age of the entire cohort was 65 years (interquartile range [IQR], 54-74) years and 6359 patients were female (52.8%) and 6598 (54.8%) were non-Hispanic White. A total of 599 (5.0%) patients received IO, whereas 4327 (35.9%) received non-IO systemic anticancer therapies, and 7120 (59.1%) did not receive any antineoplastic regimen within 3 months prior to COVID-19 diagnosis. Although no difference in COVID-19 severity and cytokine storm was found in the IO group compared with the untreated group in the total cohort (adjusted odds ratio [aOR], 0.80; 95% CI, 0.56-1.13, and aOR, 0.89; 95% CI, 0.41-1.93, respectively), patients with baseline immunosuppression treated with IO (vs untreated) had worse COVID-19 severity and cytokine storm (aOR, 3.33; 95% CI, 1.38-8.01, and aOR, 4.41; 95% CI, 1.71-11.38, respectively). Patients with immunosuppression receiving non-IO therapies (vs untreated) also had worse COVID-19 severity (aOR, 1.79; 95% CI, 1.36-2.35) and cytokine storm (aOR, 2.32; 95% CI, 1.42-3.79). Conclusions and Relevance This cohort study found that in patients with cancer and COVID-19, administration of systemic anticancer therapies, especially IO, in the context of baseline immunosuppression was associated with severe clinical outcomes and the development of cytokine storm. Trial Registration ClinicalTrials.gov Identifier: NCT04354701.
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Affiliation(s)
- Ziad Bakouny
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Chris Labaki
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Punita Grover
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Joy Awosika
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Shuchi Gulati
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Chih-Yuan Hsu
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Saif I Alimohamed
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina
| | - Babar Bashir
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Mehmet A Bilen
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | | | - Aakash Desai
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arielle Elkrief
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Omar E Eton
- Hartford Healthcare Cancer Institute, Hartford, Connecticut
| | | | | | | | | | | | | | | | | | | | | | - Mohamed Hendawi
- Aurora Cancer Center, Advocate Aurora Health, Milwaukee, Wisconsin
| | - Emily Hsu
- Hartford Healthcare Cancer Institute, Hartford, Connecticut
| | - Clara Hwang
- Henry Ford Cancer Institute, Detroit, Michigan
| | - Roman Jandarov
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | | | | | - Monika Joshi
- Penn State Cancer Institute, Hershey, Pennsylvania
| | - Hina Khan
- Brown University and Lifespan Cancer Institute, Providence, Rhode Island
| | - Shaheer A Khan
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Natalie Knox
- Loyola University Medical Center, Maywood, Illinois
| | - Vadim S Koshkin
- UCSF, Helen Diller Comprehensive Cancer Center, San Francisco
| | | | - Daniel H Kwon
- UCSF, Helen Diller Comprehensive Cancer Center, San Francisco
| | - Sara Matar
- Hollings Cancer Center, MUSC, Charleston
| | - Rana R McKay
- Moores Cancer Center, UCSD, San Diego, California
| | - Sanjay Mishra
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Feras A Moria
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Nora L Nock
- Case Comprehensive Cancer Center, Department of Population and Quantitative Health Sciences, Cleveland, Ohio
| | | | - Justin Panasci
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | - Yuan J Rao
- George Washington University, Washington, DC
| | | | | | - Jacob J Ripp
- University of Kansas Medical Center, Kansas City
| | - Andrea V Rivera
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Andrew L Schmidt
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Gary K Schwartz
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | | | - Justin Shaya
- Moores Cancer Center, UCSD, San Diego, California
| | - Suki Subbiah
- Stanley S. Scott Cancer Center, LSU, New Orleans, Louisiana
| | - Lisa M Tachiki
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | | | | | - Zhuoer Xie
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Michael A Thompson
- Aurora Cancer Center, Advocate Aurora Health, Milwaukee, Wisconsin.,Tempus Labs, Chicago, Illinois
| | - Dimpy P Shah
- Mays Cancer Center, UT Health, San Antonio, Texas
| | | | - Yu Shyr
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Toni K Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Trisha M Wise-Draper
- Division of Hematology/Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Omar Butt
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ang Li
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eric Lau
- for the COVID-19 and Cancer Consortium
| | | | - Kyu Park
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ting Bao
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ji Park
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Erin Cook
- for the COVID-19 and Cancer Consortium
| | | | - Susie Lau
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Anup Kasi
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Li C Liu
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | - Chris Su
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tan Ding
- for the COVID-19 and Cancer Consortium
| | | | | | | | | | | | | | | | | | | | | | - Sara Saif
- for the COVID-19 and Cancer Consortium
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Naveed Ahmad JA, Schroeder BA, Yun JPT, Aboulafia DM. Mixed Diffuse and Tumoral Form of Bing-Neel Syndrome Successfully Treated with Ibrutinib. Case Rep Oncol 2023; 16:1353-1361. [PMID: 37946745 PMCID: PMC10631778 DOI: 10.1159/000534528] [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: 04/20/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023] Open
Abstract
Introduction Bing-Neel syndrome (BNS) is a rare and heterogenous manifestation of Waldenström macroglobulinemia (WM) involving central nervous system (CNS) infiltration by malignant lymphoplasmacytic cells. Efforts to standardize diagnostic criteria have improved in recent years, as have treatment options including the use of the Bruton tyrosine kinase inhibitor (BTKI) ibrutinib. Case Presentation Here, we present the case of a 70-year-old male with a remote history of WM previously treated with bendamustine and rituximab, who presented to medical attention with several months of left-sided weakness, headache, and ataxia. Brain magnetic resonance imaging revealed numerous enhancing masses in the bilateral cerebral hemispheres, inferior medulla, and upper cervical spine. Laboratory studies showed serum IgM lambda monoclonal gammopathy and elevated free serum kappa and lambda light chains, while cerebrospinal fluid flow cytometry revealed CD19+ B cells. Stereotactic brain biopsy of a right frontal brain lesion was consistent with lymphoplasmacytic lymphoma, confirmed by a positive MYD88 L265P mutation. He received ibrutinib 420 mg orally daily, and this resulted in appreciable clinical and radiologic responses, which have persisted over a 31-month period. Conclusion The advent of molecularly targeted agents and novel therapies for WM has provided patients and clinicians with additional therapeutic options. The use of BTK inhibitors with their high-level CNS penetrance, in particular, offers a novel way to treat BNS and improve patient overall survival while maintaining a high level of quality of life. We discuss the importance of MYD88 L265P testing in the context of BNS as well as the expanding role of BTKIs in treating this disease.
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Affiliation(s)
| | - Brett A. Schroeder
- Virginia Mason Medical Center, Cancer Institute, Seattle, WA, USA
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - John Paul T. Yun
- National University of Ireland School of Medicine, Galway, Ireland
| | - David M. Aboulafia
- Virginia Mason Medical Center, Cancer Institute, Seattle, WA, USA
- Division of Hematology, University of Washington, Seattle, WA, USA
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8
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Palefsky JM, Lee JY, Jay N, Goldstone SE, Darragh TM, Dunlevy HA, Rosa-Cunha I, Arons A, Pugliese JC, Vena D, Sparano JA, Wilkin TJ, Bucher G, Stier EA, Tirado Gomez M, Flowers L, Barroso LF, Mitsuyasu RT, Lensing SY, Logan J, Aboulafia DM, Schouten JT, de la Ossa J, Levine R, Korman JD, Hagensee M, Atkinson TM, Einstein MH, Cracchiolo BM, Wiley D, Ellsworth GB, Brickman C, Berry-Lawhorn JM. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med 2022; 386:2273-2282. [PMID: 35704479 PMCID: PMC9717677 DOI: 10.1056/nejmoa2201048] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence of anal cancer is substantially higher among persons living with the human immunodeficiency virus (HIV) than in the general population. Similar to cervical cancer, anal cancer is preceded by high-grade squamous intraepithelial lesions (HSILs). Treatment for cervical HSIL reduces progression to cervical cancer; however, data from prospective studies of treatment for anal HSIL to prevent anal cancer are lacking. METHODS We conducted a phase 3 trial at 25 U.S. sites. Persons living with HIV who were 35 years of age or older and who had biopsy-proven anal HSIL were randomly assigned, in a 1:1 ratio, to receive either HSIL treatment or active monitoring without treatment. Treatment included office-based ablative procedures, ablation or excision under anesthesia, or the administration of topical fluorouracil or imiquimod. The primary outcome was progression to anal cancer in a time-to-event analysis. Participants in the treatment group were treated until HSIL was completely resolved. All the participants underwent high-resolution anoscopy at least every 6 months; biopsy was also performed for suspected ongoing HSIL in the treatment group, annually in the active-monitoring group, or any time there was concern for cancer. RESULTS Of 4459 participants who underwent randomization, 4446 (99.7%) were included in the analysis of the time to progression to cancer. With a median follow-up of 25.8 months, 9 cases were diagnosed in the treatment group (173 per 100,000 person-years; 95% confidence interval [CI], 90 to 332) and 21 cases in the active-monitoring group (402 per 100,000 person-years; 95% CI, 262 to 616). The rate of progression to anal cancer was lower in the treatment group than in the active-monitoring group by 57% (95% CI, 6 to 80; P = 0.03 by log-rank test). CONCLUSIONS Among participants with biopsy-proven anal HSIL, the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT02135419.).
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Affiliation(s)
- Joel M Palefsky
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeannette Y Lee
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Naomi Jay
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Stephen E Goldstone
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Teresa M Darragh
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Hillary A Dunlevy
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Isabella Rosa-Cunha
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Abigail Arons
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Julia C Pugliese
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Don Vena
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Joseph A Sparano
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Timothy J Wilkin
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Gary Bucher
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Elizabeth A Stier
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Maribel Tirado Gomez
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Lisa Flowers
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Luis F Barroso
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Ronald T Mitsuyasu
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Shelly Y Lensing
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeffrey Logan
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - David M Aboulafia
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeffrey T Schouten
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Juan de la Ossa
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Rebecca Levine
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jessica D Korman
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Michael Hagensee
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Thomas M Atkinson
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Mark H Einstein
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Bernadette M Cracchiolo
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Dorothy Wiley
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Grant B Ellsworth
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Cristina Brickman
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - J Michael Berry-Lawhorn
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
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Goff CB, Stapleton A, Aboulafia DM, Dasanu CA. Necrotizing leg gangrene from invasive cutaneous Kaposi sarcoma, reversed by pegylated liposomal doxorubicin. J Oncol Pharm Pract 2022; 28:1003-1008. [PMID: 35037777 DOI: 10.1177/10781552211073532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Although rare, Kaposi sarcoma is the most common malignant neoplasm associated with human immunodeficiency virus (HIV) infection. Several agents have now been approved in the treatment of this malignancy and are used with varying degrees of success. CASE REPORT We present a unique case of a 64-year-old man with well-controlled HIV infection who developed necrotizing leg gangrene from invasive cutaneous Kaposi sarcoma. He responded very well to systemic chemotherapy, thereby avoiding limb amputation. MANAGEMENT AND OUTCOME Pegylated liposomal doxorubicin (PLD) at a dose of 20 mg/m2 every 3 weeks was utilized, with a near-complete response after six cycles of therapy. The patient continues to receive maintenance treatment with PLD. His HIV infection remains in excellent control, with a high-normal CD4 T-cell count. Periodic echocardiogram evaluations have not shown any decline in left ventricular ejection fraction (LVEF) over time. CONCLUSION Most patients with Kaposi sarcoma achieve partial responses to treatment with PLD. Our case illustrates that near complete and complete responses are possible with this agent, leading to potential limb salvage in necrotizing gangrene.
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Affiliation(s)
- Catherine B Goff
- Department of Internal Medicine, 541618Eisenhower Health, Rancho Mirage, CA, USA
| | - Ann Stapleton
- Department of Internal Medicine, 541618Eisenhower Health, Rancho Mirage, CA, USA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute, 7289Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, 12353University of Washington School of Medicine, Seattle, WA, USA
| | - Constantin A Dasanu
- Lucy Curci Cancer Center, 541618Eisenhower Health, Rancho Mirage, CA, USA.,Department of Medical Oncology and Hematology, 21814University of California in San Diego Health System, San Diego, CA, USA
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10
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Sinit RB, Leung JH, Hwang WS, Woo JS, Aboulafia DM. An Unusual Case of Hashimoto's Thyroiditis Presenting as Impending Cardiac Tamponade in a Patient with Acquired Immune Deficiency Syndrome (AIDS). Am J Case Rep 2021; 22:e929249. [PMID: 34039947 PMCID: PMC8165493 DOI: 10.12659/ajcr.929249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patient: Male, 52-year-old Final Diagnosis: Hashimoto’s thyroiditis Symptoms: Acute epigastric pain • confusion • diarrhea • episodic gastrointestinal discomfort • fatigue • nausea • vomiting Medication: — Clinical Procedure: Radiographic-assisted pericardiocentesis Specialty: Hematology
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Affiliation(s)
- Ryan B Sinit
- Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Janet H Leung
- Department of Endocrinology, Virginia Mason Medical Center, Seattle, WA, USA.,Department of Transgender Health, Virginia Mason Medical Center, Seattle, WA, USA
| | - Wayne S Hwang
- Department of Cardiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - J Susie Woo
- Department of Cardiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, University of Washington School of Medicine, Seattle, WA, USA
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11
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Hwang CS, Hwang DG, Aboulafia DM. A Clinical Triad with Fatal Implications: Recrudescent Diffuse Large B-cell Non-Hodgkin Lymphoma Presenting in the Leukemic Phase with an Elevated Serum Lactic Acid Level and Dysregulation of the TP53 Tumor Suppressor Gene - A Case Report and Literature Review. Clin Med Insights Blood Disord 2021; 14:2634853521994094. [PMID: 33679144 PMCID: PMC7897840 DOI: 10.1177/2634853521994094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/17/2021] [Indexed: 12/18/2022]
Abstract
Despite representing 30% to 40% of newly diagnosed cases of adult non-Hodgkin lymphoma, diffuse large B-cell lymphoma (DLBCL) rarely presents (1) in the leukemic phase (2) with dysregulation of the TP53 tumor suppressor gene and (3) an elevated serum lactic acid level. In this case report and literature review, we highlight this unfortunate triad of poor prognostic features associated with an aggressive and fatal clinical course in a 53-year-old man with recrudescent DLBCL. A leukemic presentation of de novo or relapsed DLBCL is rare and may be related to differential expressions of adhesion molecules on cell surfaces. In addition, TP53 gene mutations are present in approximately 20% to 25% of DLBCL cases and foreshadow worse clinical outcomes. Finally, an elevated serum lactic acid level in DLBCL that is not clearly associated with sepsis syndrome is a poor prognostic factor for survival and manifests as type B lactic acidosis through the Warburg effect.
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Affiliation(s)
- Catherine S Hwang
- Department of Medicine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Dick G Hwang
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, University of Washington School of Medicine, Seattle, WA, USA
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12
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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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13
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Bennett CL, Schoen MW, Hoque S, Witherspoon BJ, Aboulafia DM, Hwang CS, Ray P, Yarnold PR, Chen BK, Schooley B, Taylor MA, Wyatt MD, Hrushesky WJ, Yang YT. Improving oncology biosimilar launches in the EU, the USA, and Japan: an updated Policy Review from the Southern Network on Adverse Reactions. Lancet Oncol 2021; 21:e575-e588. [PMID: 33271114 DOI: 10.1016/s1470-2045(20)30485-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022]
Abstract
The EU, the USA, and Japan account for the majority of biological pharmacotherapy use worldwide. Biosimilar regulatory approval pathways were authorised in the EU (2006), in Japan (2009), and in the USA (2015), to facilitate approval of biological drugs that are highly similar to reference products and to encourage market competition. Between 2007 and 2020, 33 biosimilars for oncology were approved by the European Medicines Agency (EMA), 16 by the US Food and Drug Administration (FDA), and ten by the Japan Pharmaceuticals and Medical Devices Agency (PMDA). Some of these approved applications were initially rejected because of manufacturing concerns (four of 36 [11%] with the EMA, seven of 16 [44%] with the FDA, none of ten for the PMDA). Median times from initial regulatory submission before approval of oncology biosimilars were 1·5 years (EMA), 1·3 years (FDA), and 0·9 years (PMDA). Pharmacists can substitute biosimilars for reference biologics in some EU countries, but not in the USA or Japan. US regulation prohibits substitution, unless the biosimilar has been approved as interchangeable, a designation not yet achieved for any biosimilar in the USA. Japan does not permit biosimilar substitution, as prescribers must include the product name on each prescription and that specific product must be given to the patient. Policy Reviews published in 2014 and 2016 in The Lancet Oncology focused on premarket and postmarket policies for oncology biosimilars before most of these drugs received regulatory approval. In this Policy Review from the Southern Network on Adverse Reactions, we identify factors preventing the effective launch of oncology biosimilars. Introduction to the market has been more challenging with therapeutic than for supportive care oncology biosimilars. Addressing region-specific competition barriers and educational needs would improve the regulatory approval process and market launches for these biologics, therefore expanding patient access to these products in the EU, the USA, and Japan.
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Affiliation(s)
- Charles L Bennett
- College of Pharmacy, University of South Carolina, Columbia, SC, USA; WJB Dorn VA Medical Center, Columbia, SC, USA; Department of Comparative Medicine and Evidence Based Medicine, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
| | - Martin W Schoen
- Saint Louis University School of Medicine, Saint Louis, MO, USA; John Cochran VA Medical Center, Saint Louis, MO, USA
| | - Shamia Hoque
- College of Engineering and Computing, University of South Carolina, Columbia, SC, USA; WJB Dorn VA Medical Center, Columbia, SC, USA
| | | | | | | | - Paul Ray
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Paul R Yarnold
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Brian K Chen
- The Arnold School of Public Health, University of South Carolina, Columbia, SC, USA; WJB Dorn VA Medical Center, Columbia, SC, USA
| | - Benjamin Schooley
- College of Engineering and Computing, University of South Carolina, Columbia, SC, USA
| | - Matthew A Taylor
- School of Medicine, University of South Carolina, Columbia, SC, USA
| | - Michael D Wyatt
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | | | - Y Tony Yang
- School of Nursing and Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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14
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Sinit RB, Dorer RK, Flores JP, Aboulafia DM. Rare Causes of Isolated and Progressive Splenic Lesions: Challenges in Differential Diagnosis, Evaluation, and Treatment of Primary Splenic Lymphomas. Clin Med Insights Blood Disord 2020; 13:1179545X20926188. [PMID: 32565679 PMCID: PMC7288794 DOI: 10.1177/1179545x20926188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/23/2020] [Indexed: 12/20/2022]
Abstract
The spleen is among the most common extranodal sites for Hodgkin and non-Hodgkin lymphomas (NHLs); however, among lymphomas arising from the spleen, primary splenic lymphomas (PSLs) are rare. The group of PSLs includes primary splenic diffuse large B-cell lymphoma (PS-DLBCL), splenic red pulp small B-cell lymphoma, splenic marginal zone lymphoma (SMZL), and a splenic hairy cell leukemia variant. Delineating between the PSL variants can be challenging, especially as fine-needle aspirate and core needle biopsy of the spleen are not routinely offered at most medical centers. Herein, we describe the clinical course of 2 representative patients who presented with non-specific gastrointestinal symptoms, the first who was diagnosed with PS-DLBCL and the second who was diagnosed with SMZL. We review and contrast the clinical presentations, imaging techniques, and laboratory findings of these discrete lymphoma variants and offer strategies on how to delineate between these varied splenic processes. We also examine the use of splenectomy and splenic needle biopsy as diagnostics and, in the case of splenectomy, a therapeutic tool. Finally, we also briefly review treatment options for these varied lymphoma sub-types while acknowledging that randomized trials to guide best practices for PSLs are lacking.
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Affiliation(s)
- Ryan B Sinit
- Floyd & Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Russell K Dorer
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA, USA
| | - John Paul Flores
- Floyd & Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Floyd & Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, School of Medicine, University of Washington, Seattle, WA, USA
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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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Burkhalter JE, Aboulafia DM, Botello-Harbaum M, Lee JY. Participant characteristics and clinical trial decision-making factors in AIDS malignancy consortium treatment trials for HIV-infected persons with cancer (AMC #S006). HIV Clin Trials 2019; 19:235-241. [PMID: 30890062 DOI: 10.1080/15284336.2018.1537349] [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] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Overall, people living with HIV/AIDS (PLWHA) are living longer, but compared with the general population, they are at elevated risk for numerous AIDS-defining and non-AIDS-defining cancers. The AIDS Malignancy Consortium (AMC) is dedicated to conducting clinical trials aimed at prevention and treatment of cancers among PLWHA. OBJECTIVE To examine patient-level characteristics and perceptions that influence decision-making regarding AMC treatment trial participation. METHODS PLWHA diagnosed with cancer or anal high-grade intraepithelial neoplasia who were ≥18 years old and offered participation on a therapeutic AMC clinical trial were eligible. Participants completed a 17-item survey assessing sociodemographic and other factors potentially influencing decision-making regarding trial participation. RESULTS The sample of 67 participants was mainly male (n = 62, 92.5%), non-Hispanic (89.5%) and white (67.2%), with a mean age of 48.3 years. About half of participants were screened for lymphoma studies. Nearly all (98.5%) of the participants learned about AMC clinical trials from a medical provider, most (73.1%) knew little about clinical trials in general, and half decided on trial participation on their own. Altruism was the most frequently cited reason for trial participation. Participant recommendations for improving AMC trial accrual included systems changes to speed access to clinical trials and reduce participant burden. CONCLUSIONS This formative study highlights the perceived benefits to others, i.e. altruism, as an important factor in trial decision-making, little knowledge about clinical trials in general, and the role of physicians in informing participants about clinical trials. Future research should address knowledge barriers and explore systems- and provider-level factors affecting accrual to AMC trials.
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Affiliation(s)
- Jack E Burkhalter
- a Department of Psychiatry & Behavioral Sciences , Memorial Sloan Kettering Cancer Center , New York , NY, USA
| | - David M Aboulafia
- b Department of Hematology/Oncology , Virginia Mason Medical Center , Seattle , WA, USA (Retired)
| | | | - Jeannette Y Lee
- d AIDS Malignancy Center Statistical Center , University of Arkansas for Medical Sciences , Little Rock , AR, USA
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17
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Sinit RB, Horan KL, Dorer RK, Aboulafia DM. Epstein-Barr Virus-Positive Mucocutaneous Ulcer: Case Report and Review of the First 100 Published Cases. Clin Lymphoma Myeloma Leuk 2018; 19:e81-e92. [PMID: 30442566 DOI: 10.1016/j.clml.2018.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/06/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Ryan B Sinit
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA
| | - Kathleen L Horan
- Department of Pulmonary and Critical Care Medicine, Virginia Mason Medical Center, Seattle, WA
| | - Russell K Dorer
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA; Division of Hematology, University of Washington School of Medicine, Seattle, WA.
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18
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Whooley PD, Dorer RK, Aboulafia DM. The fear of lymphadenopathy: A cautionary case of sarcoidosis masquerading as recurrent diffuse large b-cell lymphoma (DLBCL). Leuk Res Rep 2018; 9:48-53. [PMID: 29892550 PMCID: PMC5993354 DOI: 10.1016/j.lrr.2018.04.003] [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: 01/23/2018] [Accepted: 04/07/2018] [Indexed: 12/01/2022] Open
Abstract
We describe the cautionary case of a patient with advanced-stage large B-cell lymphoma (DLBCL). After combination chemotherapy, CT-PET revealed a persistent focus of likely DLBCL for which he received radiotherapy. Follow-up CT-PET showed diffuse hypermetabolic adenopathy and recurrent DLBCL was presumed. As part of clinical trial assessment, multiple biopsies showed non-caseating lymphadenitis consistent with sarcoidosis. No treatment for asymptomatic sarcoidosis was required and 18 months later he remains cancer-free. The presentation of sarcoidosis masquerading as recurrent DLBCL highlights the importance of tissue sampling prior to engaging in toxic and potentially life-threatening chemotherapy and the interesting link between DLBCL and sarcoidosis.
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Affiliation(s)
- Peter D Whooley
- Division of General Internal Medicine, Virginia Mason Medical Center, Seattle, WA, United States
| | - Russell K Dorer
- Section of Pathology, Virginia Mason Medical Center, Seattle, WA, United States
| | - David M Aboulafia
- Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, United States.,Division of Hematology, University of Washington, United States
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19
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Poston JN, Dorer R, Aboulafia DM. The Diving Bell and the Butterfly Revisited: A Fatal Case of Locked-in Syndrome in a Man With Epstein-Barr Virus-Positive Diffuse Large B-Cell Lymphoma, Not Otherwise Specified. Clin Med Insights Blood Disord 2018; 11:1179545X18762799. [PMID: 29623003 PMCID: PMC5881979 DOI: 10.1177/1179545x18762799] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 02/08/2018] [Indexed: 11/16/2022]
Abstract
Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) is a rare variant of DLBCL. The natural history of this subtype is poorly understood. Incomplete literature in the era of rituximab suggests that patients with EBV-positive DLBCL have similar outcomes to patients with EBV-negative DLBCL when treated with rituximab and anthracycline-based chemotherapy regimens; however, there are few prospective studies on this subtype and little is known about the risk of central nervous system (CNS) relapse with EBV-positive DLBCL. Herein, we describe the case of a 64-year-old man who presented with stage IIA EBV-positive DLBCL. His international age-adjusted International Prognostic Index (IPI) was 2. He achieved a complete response to 6 cycles of rituximab combined with chemotherapy consisting of dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin. After 10 days of completion of chemotherapy, he had a fulminant neurologic decline manifested by diffuse weakness followed by a locked-in syndrome; he could only communicate by moving his eyes. He had been deemed at low risk for CNS relapse based on the application of the recently developed CNS-IPI score of 2 (1 point for age >60 years and 1 point for lactate dehydrogenase higher than normal) and consequently did not receive therapy for CNS prophylaxis. A limited postmortem autopsy revealed extensive lymphoma throughout the brain, particularly in the deep basal nuclei, midbrain, pons, centrum semiovale, and corpus callosum. This presentation of CNS relapse is rare and has not yet been described in EBV-positive DLBCL. We discuss some of the unique aspects of this case including the clinical manifestations of locked-in syndrome and its differential diagnosis and the uncertain benefits of CNS prophylaxis in this clinical context.
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Affiliation(s)
| | - Russell Dorer
- Department of Pathology and Laboratory Medicine, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Division of Hematology, University of Washington, Seattle, WA, USA
- Floyd & Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA
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20
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Abstract
The number of women living with HIV continues to increase. Thirty years into the
AIDS epidemic, we now expect those with access to highly active antiretroviral
to survive into their seventh decade of life or beyond. Increasingly, the focus
of HIV care is evolving from preventing opportunistic infections and treating
AIDS-defining malignancies to strategies that promote longevity. This holistic
approach to care includes detection of malignancies that are associated with
certain viral infections, with chronic inflammation, and with lifestyle choices.
The decision to screen an HIV-infected women for cancer should include an
appreciation of the individualized risk of cancer, her life expectancy, and an
attempt to balance these concerns with the harms and benefits associated with
specific cancer screening tests and their potential outcome. Here, we review
cancer screening strategies for women living with HIV/AIDS with a focus on
cancers of the lung, breast, cervix, anus, and liver.
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Affiliation(s)
- David M Aboulafia
- 1 Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA.,2 Division of Hematology, University of Washington, Seattle, WA, USA
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21
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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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22
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Bischin AM, Dorer R, Aboulafia DM. Transformation of Follicular Lymphoma to a High-Grade B-Cell Lymphoma With MYC and BCL2 Translocations and Overlapping Features of Burkitt Lymphoma and Acute Lymphoblastic Leukemia: A Case Report and Literature Review. Clin Med Insights Blood Disord 2017; 10:1179545X17692544. [PMID: 28579851 PMCID: PMC5428247 DOI: 10.1177/1179545x17692544] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 10/11/2016] [Accepted: 01/16/2017] [Indexed: 12/16/2022]
Abstract
Most commonly, histologic transformation (HT) from follicular lymphoma (FL) manifests as a diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS). Less frequently, HT may result in a high-grade B-cell lymphoma (HGBL) with MYC and B-cell lymphoma protein 2 (BCL2) and/or BCL6 gene rearrangements, also known as “double-hit” or “triple-hit” lymphomas. In the 2016 revision of the World Health Organization (WHO) classification of lymphoid neoplasms, the category B-cell lymphoma, unclassifiable was eliminated due to its vague criteria and limiting diagnostic benefit. Instead, the WHO introduced the HGBL category, characterized by MYC and BCL2 and/or BCL6 rearrangements. Cases that present as an intermediate phenotype of DLBCL and Burkitt lymphoma (BL) will fall within this HGBL category. Very rarely, HT results in both the intermediate DLBCL and BL phenotypes and exhibits lymphoblastic features, in which case the WHO recommends that this morphologic appearance should be noted. In comparison with de novo patients with DLBCL, NOS, those with MYC and BCL2 and/or BCL6 gene rearrangements have a worse prognosis. A 63-year-old woman presented with left neck adenopathy. Laboratory assessments, including complete blood count, complete metabolic panel, serum lactate dehydrogenase, and β2-microglobulin, were all normal. A whole-body computerized tomographic (CT) scan revealed diffuse adenopathy above and below the diaphragm. An excisional node biopsy showed grade 3A nodular FL. The Ki67 labeling index was 40% to 50%. A bone marrow biopsy showed a small focus of paratrabecular CD20+ lymphoid aggregates. She received 6 cycles of bendamustine (90 mg/m2 on days +1 and +2) and rituximab (375 mg/m2 on day +2), with each cycle delivered every 4 weeks. A follow-up CT scan at completion of therapy showed a partial response with resolution of axillary adenopathy and a dramatic shrinkage of the large retroperitoneal nodes. After 18 months, she had crampy abdominal pain in the absence of B symptoms. Positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-d-glucose integrated with CT (18F-FDG PET/CT) scan showed widespread adenopathy, diffuse splenic involvement, and substantial marrow involvement. Biopsy of a 2.4-cm right axillary node (SUVmax of 16.1) showed involvement by grade 3A FL with a predominant nodular pattern of growth. A bone marrow biopsy once again showed only a small focus of FL. She received idelalisib (150 mg twice daily) and rituximab (375 mg/m2, monthly) beginning May 2015. After 4 cycles, a repeat CT scan showed a complete radiographic response. Idelalisib was subsequently held while she received corticosteroids for immune-mediated colitis. A month later, she restarted idelalisib with a 50% dose reduction. After 2 weeks, she returned to clinic complaining of bilateral hip and low lumbar discomfort but no B symptoms. A restaging 18F-FDG PET/CT in January 2016 showed dramatic marrow uptake. A bone marrow aspirate showed sheets of tumor cells representing a spectrum from intermediate-sized cells with lymphoblastic features to very large atypical cells with multiple nucleoli. Two distinct histologies were present; one remained consistent with the patient’s known FL with a predominant nodular pattern and the other consistent with HT (the large atypical cells expressed PAX5, CD10, BCL2, and c-MYC and were negative for CD20, MPO, CD34, CD30, and BCL6). Focal areas showed faint, heterogeneous expression of terminal deoxynucleotidyl transferase best seen on the clot section. Ki67 proliferation index was high (4+/4). Fluorescence in situ hybridization analysis showed 2 populations with MYC amplification and/or rearrangement and no evidence of BCL6 rearrangement; a karyotype analysis showed a complex abnormal female karyotype with t(14;18) and multiple structural and numerical abnormalities. She started dose-adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin with concomitant prophylactic intrathecal methotrexate and cytarabine. She had but a short-lived response before dying in hospice from progressive lymphoma. Whether idelalisib could provide a microenvironment for selection of more aggressive clones needs to be addressed. Our patient’s clinical course is confounded by the incorporation of idelalisib while being further complicated by the complexity of HT and the mechanisms in which first-line chemotherapy regimens affect double-hit lymphoma.
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Affiliation(s)
- Alina M Bischin
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Russell Dorer
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Department of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, School of Medicine, University of Washington, Seattle, WA, USA
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23
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Blayney MJ, Nguyen A, Aboulafia DM. Diagnosis and Management of a Pancreaticopleural Fistula in a Patient with AIDS and a Large Pleural Effusion. J Int Assoc Provid AIDS Care 2016; 15:459-462. [PMID: 27655836 DOI: 10.1177/2325957416668578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pleural effusions typically present with nonspecific pulmonary complaints in the setting of either acute or chronic diseases. In the general population, these illnesses include congestive heart failure, infection, and malignancy. However, in people living with HIV/AIDS (PLWHA), pleural effusions often result from opportunistic infections and AIDS-defining malignancies, such as Kaposi sarcoma and non-Hodgkin lymphoma. Since the introduction of highly active antiretroviral therapy, there has been a decline in the frequency of AIDS-defining opportunistic infections and AIDS-defining cancers and an increase in certain non-AIDS-defining malignancies including lung cancer. Throughout this period, longer life expectancy in PLWHA has contributed to an increased risk of those chronic diseases that can result in pleural effusions. This case describes an HIV-infected man who was an active cigarette smoker and alcoholic and who presented with a large pleural effusion of uncertain etiology. The authors review several important noncardiac risk factors associated with pleural effusions in PLWHA. The authors also emphasize the importance of obtaining a detailed medical history and the use of appropriate imaging and laboratory tests in order to identify an underlying cause and to provide optimal treatment.
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Affiliation(s)
- Margaret J Blayney
- Graduate Medical Education, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andy Nguyen
- Graduate Medical Education, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Section of Hematology Oncology, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, University of Washington, Seattle, WA, USA
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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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25
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Foster WR, Bischin A, Dorer R, Aboulafia DM. Human Herpesvirus Type 8-associated Large B-cell Lymphoma: A Nonserous Extracavitary Variant of Primary Effusion Lymphoma in an HIV-infected Man: A Case Report and Review of the Literature. Clin Lymphoma Myeloma Leuk 2016; 16:311-21. [PMID: 27234438 DOI: 10.1016/j.clml.2016.03.013] [Citation(s) in RCA: 14] [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] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/25/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Primary effusion lymphoma (PEL) is a rare non-Hodgkin lymphoma subtype primarily seen in human immunodeficiency virus (HIV)-infected individuals with low CD4(+) cell counts and elevated HIV viral loads. It has always been associated with human herpesvirus type 8 (HHV-8) and in 80% of cases has also been associated with Epstein-Barr virus (EBV). Less commonly, PEL has presented in patients with advanced age and other conditions associated with an altered immunity, including malignancy, liver cirrhosis, and immunosuppressive medications. It is a tumor of B-cell lineage; however, it shows a "null" phenotype, rarely expressing pan-B cell surface antigens. It will usually express CD45, CD30, CD38, CD138, and MUM1 and is characterized by lymphomatous effusions in body cavities but not lymphadenopathy. It is an aggressive lymphoma, with an average median survival of < 1 year. HHV-8-associated large B-cell lymphoma (HHV-8-LBL) is a second variant of PEL that is both solid and extracavitary. It has immunoblastic and/or anaplastic morphologic features and a distinct immunohistochemical staining pattern. It could also have a different clinical presentation than that of classic PEL. MATERIALS AND METHODS We describe the case of a 57-year-old HIV-infected man who presented with a slow-growing and asymptomatic abdominal mass. Examination of an excisional biopsy specimen showed malignant large cells with prominent cytoplasm that were positive for pan-B cell antigen CD20, HHV-8, and EBV and negative for CD138, CD10, BCL-6, CD3, and CD30. The Ki-67 labeling index was 90%. The diagnosis was stage IIIA HHV-8-LBL, and he was treated with 6 cycles of R-EPOCH (rituximab, etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone) infusion chemotherapy. At 12 months after treatment, he was in complete remission. We also performed a Medline and Embase search to better understand the clinical findings of our patient and the unique attributes of HHV-8-LBL. Focusing our search on English language studies, we identified 83 cases of HHV-8-LBL without an effusion component. We compared these 83 cases with 118 reported cases of classic PEL. RESULTS The median age of the patients with HHV-8-LBL was 41 years (range, 24-77), and 96% of the cases were associated with HIV. The median age of the patients with classic PEL was 41 years (range, 26-86), and 96% of the cases were associated with HIV. Of those with HHV-8-LBL, 31 of 61 (51%) had a pre-existing diagnosis of acquired immunodeficiency syndrome (AIDS) and 47 of 63 (75%) were coinfected with EBV. In contrast, 69 of 96 patients (72%) with classic PEL had a pre-existing AIDS diagnosis and 40 of 49 (82%) were coinfected with EBV. The mean CD4(+) count of the HHV-8-LBL patients was 256 cells/μL (range, 18-1126 cells/μL) compared with 139 cells/μL (range, 2-557 cells/μL) in the classic PEL patients. The median survival time for both groups was similar at 5.5 months (range, 25 days to ≥ 25 months) for patients with HHV-8-LBL and 4 months (range, 2 days to ≥ 113 months) for those with classic PEL. More patients with HHV-8-LBL were alive at the last follow-up point (59% vs. 18%). The percentage of patients achieving complete remission was 54% (30 of 56) and 36% (32 of 89) for HHV-8-LBL and classic PEL, respectively. CONCLUSION Our patient's high CD4(+) cell count, the lack of a pre-existing AIDS diagnosis, and the excellent response to chemotherapy highlights that HHV-8-LBL might have distinct clinical features and possibly a better response to chemotherapy than classic PEL. HHV-8-LBL should be included in the differential diagnosis of HIV patients with solid lesions. It is essential that patients' Centers for Disease Control and Prevention HIV clinical status and HIV viral load at the diagnosis of PEL and HHV-8-LBL be reported and that the reported clinical results include longer term follow-up data. Only then will a more complete clinical picture of this little-appreciated and little-understood PEL variant be defined.
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Affiliation(s)
| | - Alina Bischin
- Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA
| | - Russell Dorer
- Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA
| | - David M Aboulafia
- Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA; Division of Hematology, University of Washington, Seattle, WA.
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Gulvin J, Aboulafia DM. Squamous Cell Cancer of Unknown Primary and Primary Breast Cancer in an HIV-Infected Woman: The Importance of Cancer Screening for People Living with HIV/AIDS. J Int Assoc Provid AIDS Care 2016; 15:194-200. [PMID: 26864079 DOI: 10.1177/2325957416629550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 11/15/2022] Open
Abstract
People living with HIV/AIDS (PLWHA) are surviving longer, with an increased risk of cancer. Cancer screening strategies in PLWHA are lacking. We describe the case of a woman with a history of AIDS, who had a nondetectable viral load on treatment. She is an activist, promoting HIV care, but had not undergone routine screening for breast, cervical, or colonic neoplasia. She presented with a left groin mass, which on biopsy proved to be a p16 immuno-histochemical positive squamous cell carcinoma. Anal and cervicovaginal examinations did not show invasive cancer, although high-resolution anoscopy identified high-grade anal dysplasia. A mammogram followed by magnetic resonance imaging showed invasive ductal carcinoma. Her breast cancer was treated with lumpectomy, adjuvant brachytherapy and chemotherapy. The left groin tumor was treated with chemo-radiation. Herein, we also review medical literature concerning anal, cervical, breast, colorectal, and lung cancer screening for PLWHA, which is important for our aging population of PLWHA.
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Affiliation(s)
- Joshua Gulvin
- Division of General Internal Medicine, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, USA Division of Hematology, University of Washington, Seattle, WA, USA
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27
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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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Malhotra U, Aboulafia DM. Cyclophosphamide Treatment for Acquired Factor VIII Inhibitor in a Patient with AIDS-Associated Progressive Multifocal Leukoencephalopathy. J Int Assoc Provid AIDS Care 2015; 15:109-13. [PMID: 26013248 DOI: 10.1177/2325957415586259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia A (AHA) is a severe bleeding disorder with high mortality rates resulting from the development of autoantibodies to factor VIII (FVIII). Patients typically present with hemorrhages in the skin, subcutaneous tissues, and muscles, which are frequently severe. They can also develop life-threatening retroperitoneal hematomas and compartment syndromes. We describe the case of a man with a long history of AIDS complicated by progressive multifocal leukoencephalopathy (PML), who developed AHA while on stable antiretroviral therapy and then presented with new onset bleeding and hypotension. We treated our patient with incrementally increasing doses of cyclophosphamide resulting in resolution of coagulopathy. We review the medical literature for additional cases of HIV-associated AHA and discuss the challenges in the care of our patient, since the immunosuppression needed to eradicate the FVIII inhibitor had the potential to cause recrudescence of his PML.
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Affiliation(s)
- Uma Malhotra
- Divisions of Infectious Diseases, Virginia Mason Medical Center, Seattle, WA, USA Section of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Divisions of Infectious Diseases, University of Washington, Seattle, WA, USA Hematology, University of Washington, Seattle, WA, USA
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29
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Kowalczyk M, Rubinstein PG, Aboulafia DM. Initial Experience with the Use of Thrombopoetin Receptor Agonists in Patients with Refractory HIV-Associated Immune Thrombocytopenic Purpura: A Case Series. J Int Assoc Provid AIDS Care 2014; 14:211-6. [PMID: 25504472 DOI: 10.1177/2325957414557266] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 11/15/2022] Open
Abstract
HIV-associated immune thrombocytopenic purpura (ITP) has decreased in incidence 10-fold since the advent of highly active antiretroviral therapy (HAART). For patients with detectable HIV viral loads, first-line treatment approaches involve optimizing HAART followed by standard ITP options used to treat those without HIV infection. In the general population, the thrombopoetin receptor agonists (TRAs), eltrombopag and romiplostim, are effective when used as salvage ITP therapy. In addition, eltrombopag has been used effectively in patients with thrombocytopenia secondary to hepatitis C--a virus seen commonly in HIV-infected patients, especially in those who also have a history of intravenous drug use. There are, however, few reports or studies of TRAs use in those with HIV infection. Herein, we describe 5 cases of refractory HIV-associated ITP managed with TRAs. Although platelet counts improved for all patients, 2 patients succumbed to thromboembolic complications. Our initial experience, as well as our findings from a Medline review, supports the potential utility of TRA as salvage therapy in the treatment of HIV-related ITP; however, we recommend caution in the use of these agents in those who are at highest risk of thrombosis. Additional studies are needed to determine the efficacy and, more importantly, the safety of TRAs in treatment of HIV-associated ITP.
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Affiliation(s)
- Mark Kowalczyk
- Department of Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Paul G Rubinstein
- Section of Hematology/Oncology, Stroger Hospital of Cook County, Ruth M. Rothstein CORE Center, Rush University Medical Center, Chicago, IL, USA
| | - David M Aboulafia
- Department of Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA, USA Division of Hematology, The University of Washington School of Medicine, Seattle WA, USA
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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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31
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Ericson S, Shah N, Liberman J, Aboulafia DM. Fatal Bleeding Due to Acquired Factor IX and X Deficiency: A Rare Complication of Primary Amyloidosis; Case Report and Review of the Literature. Clinical Lymphoma Myeloma and Leukemia 2014; 14:e81-6. [DOI: 10.1016/j.clml.2013.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/28/2013] [Indexed: 11/15/2022]
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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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Abstract
PURPOSE OF REVIEW The growing burden of non-AIDS defining malignancies (non-ADMs) among people living with HIV/AIDS (PLWHA) highlights the need for cancer prevention and early detection. In this article, we propose screening guidelines for non-ADMs in PLWHA. RECENT FINDINGS A number of recent findings may help direct cancer screening guidelines in PLWHA. Screening for lung cancer with low-dose helical chest computerized tomography (LDCT) in the National Lung Screening Trial data demonstrated a decrease in lung cancer and all-cause mortality. Recent studies have demonstrated a favorable experience among PLWHA with liver transplantation. Overdiagnosis is common with breast and prostate cancer screening. Anal cancer rates were substantially higher for HIV-infected MSM, other men and women than for HIV-uninfected individuals. SUMMARY Screening recommendations for the general population can be applied to PLWHA patients for breast, colon and prostate cancer. Screening for lung cancer with LDCT could be considered in PLWHA at risk. American Association for the Study of Liver Diseases screening recommendations with biennial ultrasonography may be applied to at-risk PLWHA for hepatocellular carcinoma. All HIV-infected adults should be offered anal cancer screening as part of clinical care at specialized centres.
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Affiliation(s)
- Deepthi Mani
- Division of Internal Medicine, Multicare Good Samaritan Hospital, Puyallup, WA, USA
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Wilkin T, Lee JY, Lensing SY, Stier EA, Goldstone SE, Berry MJ, Jay N, Aboulafia DM, Einstein MH, Saah A, Mitsuyasu RT, Palefsky JM. High-grade anal intraepithelial neoplasia among HIV-1-infected men screening for a multicenter clinical trial of a human papillomavirus vaccine. HIV Clin Trials 2013; 14:75-9. [PMID: 23611828 DOI: 10.1310/hct1402-75] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE High-grade anal intraepithelial neoplasia (HGAIN) is the precursor lesion to invasive anal cancer. Human papillomavirus (HPV) vaccination holds great promise for preventing anal cancer. METHODS We examined 235 HIV-1-infected men screening for participation in a multisite clinical trial of a quadrivalent HPV vaccine. All participants had anal swabs obtained for HPV testing and cytology and high-resolution anoscopy with biopsies of visible lesions to assess for HGAIN. RESULTS HPV types 16 and 18 were detected in 23% and 10%, respectively; abnormal anal cytology was found in 56% and HGAIN in 30%. HGAIN prevalence was significantly higher in those with HPV16 detection compared to those without (38% vs 17%; P = .01). Use of antiretroviral therapy and nadir and current CD4+ cell count were not associated with abnormal anal cytology or HGAIN. CONCLUSION HGAIN is highly prevalent in HIV-infected men. Further studies are needed on treatment and prevention of HGAIN.
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Affiliation(s)
- Timothy Wilkin
- Division of Infectious Diseases, Weill Cornell Medical College, New York, New York 10011, USA.
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35
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Nguyen V, Dorer R, Aboulafia DM. Atypical Cutaneous Lymphoproliferative Disorder: A Fatal Mimic of Cutaneous T-Cell Lymphoma in a Patient with HIV Infection. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/wja.2013.31002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Botello-Harbaum MT, Mosby K, Vena D, Aboulafia DM. The AIDS malignancy clinical trials consortium (AMC) patient navigator (PN) initiative. Infect Agent Cancer 2012. [PMCID: PMC3330067 DOI: 10.1186/1750-9378-7-s1-p24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Affiliation(s)
- David M Aboulafia
- Division of Hematology and Oncology, Virginia Mason Medical Center, and the Division of Hematology, University of Washington, Seattle, WA 98111, USA.
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38
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Auerbach E, Aboulafia DM. Venous and arterial thromboembolic complications associated with HIV infection and highly active antiretroviral therapy. Semin Thromb Hemost 2012; 38:830-8. [PMID: 23041980 DOI: 10.1055/s-0032-1328887] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
With the advent of highly active antiretroviral therapy (HAART), dramatic improvements have been made in the quality and length of life in people living with HIV/AIDS (PLWA). Complications that are seen with increasing frequency in this group include venous thromboembolism events (VTE) and cardiovascular disease. Recent epidemiologic studies suggest PLWA have a 2-fold to 10-fold greater risk of VTE compared with age-matched controls. Several mechanisms associated with HIV infection, coupled with traditional risk factors, including age, opportunistic infections, and lifestyle choices, may contribute to a heightened risk of VTE and cardiovascular disease. It has been challenging to discern which of these complications are related to HAART. Herein, we review the risk of VTE in the pre-HAART and current HAART era. We call attention to particular instances where components of HAART have been associated with acute myocardial infarction, noncirrhotic portal hypertension and portal vein thrombosis. We also highlight potential drug-drug interactions between HAART and anticoagulant therapy. Additional studies are needed to better understand the mechanisms and risks associated with long-term use of HAART and to what extent HAART contributes to or mitigates the risk of VTE and cardiovascular disease.
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Affiliation(s)
- Evan Auerbach
- Division of Hematology and Oncology, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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Bayraktar UD, Ramos JC, Petrich A, Gupta N, Lensing S, Moore PC, Reid EG, Aboulafia DM, Ratner L, Mitsuyasu R, Cooley T, Henry DH, Barr P, Noy A. Outcome of patients with relapsed/refractory acquired immune deficiency syndrome-related lymphoma diagnosed 1999-2008 and treated with curative intent in the AIDS Malignancy Consortium. Leuk Lymphoma 2012; 53:2383-9. [PMID: 22642936 DOI: 10.3109/10428194.2012.697559] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
No comparative studies exist for relapsed/refractory (rel/rfr) acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL). To determine practices over the last decade and to assess the outcomes of salvage chemotherapy with curative intent and autologous stem cell transplant (ASCT), we retrospectively evaluated treatment outcomes in patients with rel/rfr ARL who were treated in 13 national AIDS Malignancy Consortium (AMC) sites between 1999 and 2008 (n = 88). The most commonly used second-line therapies were ICE (ifosfamide/carboplatin/etoposide, n = 34), dose adjusted EPOCH (etoposide/prednisone/vincristine/cyclophosphamide/doxorubicin, n = 17) and ESHAP (etoposide/methylprednisolone/cytarabine/cisplatin, n = 11). The odds of achieving a response were lower for those with non-Hodgkin lymphoma (NHL) than for those with HL and for those with primary refractory disease than for those with relapse. Overall survival (OS) was significantly longer for those with relapsed disease compared to those with refractory disease and for those with non-Burkitt NHL compared to those with Burkitt. OS was longer in patients who underwent ASCT compared to those who did not (1-year OS: 63.2% vs. 37.2%). However, among 32 patients (36%) who achieved a complete or partial response (CR/PR) after second-line therapy, 1-year OS was not different between the two groups (87.5% for ASCT vs. 81.8% for non-ASCT). Long-term survival in some patients with rel/rfr ARL may be possible without transplant, although transplant remains the standard of care for chemotherapy sensitive disease.
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Affiliation(s)
- Ulas D Bayraktar
- Division of Hematology/Oncology, University of Miami, Miami, FL, USA
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Mani D, Guinee DG, Aboulafia DM. Vanishing lung syndrome and HIV infection: an uncommon yet potentially fatal sequela of cigarette smoking. ACTA ACUST UNITED AC 2012; 11:230-3. [PMID: 22564798 DOI: 10.1177/1545109712444755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Persons with HIV infection have a higher risk of infectious pulmonary complications, chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and pulmonary fibrosis than individuals not infected with HIV. Herein, we describe the clinical course of a patient with longstanding and well-controlled HIV infection and multiple previous pneumothoraces who presented to medical attention with insidious onset of shortness of breath and was diagnosed with vanishing lung syndrome (VLS). The VLS or giant bullous emphysema is a distinct clinical syndrome characterized by large bullae, predominantly in the upper lobes, occupying at least one third of the hemithorax and compressing surrounding normal lung parenchyma. It is a progressive disorder that typically occurs in young men, the majority of whom are smokers. As people with HIV/AIDS are now surviving well into middle age and beyond, clinicians are more likely to encounter VLS and severe obstructive lung disease, which are potentially fatal but preventable conditions.
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Affiliation(s)
- Deepthi Mani
- 1Division of Internal Medicine, Multicare Good Samaritan Medical Center, Puyallup, WA, USA
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Abstract
Lung cancer is the most prevalent non-AIDS-defining malignancy in the highly active antiretroviral therapy era. Smoking plays a significant role in the development of HIV-associated lung cancer, but the cancer risk is two to four times greater in HIV-infected persons than in the general population, even after adjusting for smoking intensity and duration. Lung cancer is typically diagnosed a decade or more earlier among HIV-infected persons (mean age, 46 years) compared to those without HIV infection. Adenocarcinoma is the most common histological subtype, and the majority of patients are diagnosed with locally advanced or metastatic carcinoma. Because pulmonary infections are common among HIV-infected individuals, clinicians may not suspect lung cancer in this younger patient population. Surgery with curative intent remains the treatment of choice for early-stage disease. Although there is increasing experience in using radiation and chemotherapy for HIV-infected patients who do not have surgical options, there is a need for prospective studies because this population is frequently excluded from participating in cancer trials. Evidence-based treatments for smoking-cessation with demonstrated efficacy in the general population must be routinely incorporated into the care of HIV-positive smokers.
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Affiliation(s)
- Deepthi Mani
- Division of Internal Medicine, Providence Sacred Heart Medical Center, Spokane, WA 98111, USA
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Tyerman Z, Aboulafia DM. Review of screening guidelines for non-AIDS-defining malignancies: evolving issues in the era of highly active antiretroviral therapy. AIDS Rev 2012; 14:3-16. [PMID: 22297500] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
HIV-associated morbidity and mortality have declined dramatically in the era of HAART. Through direct and indirect benefits of HAART, people with HIV/AIDS are living longer, developing less AIDS-defining cancers and more cancers commonly seen in the seronegative population. Herein, we review cancer screening strategies for people living with HIV and compare and contrast them with those of the general population. The most noticeable differences occur in anal and cervical cancer screening. Although anal cancer is uncommon in the general population, it is more prevalent in men who have sex with men and people at high risk for human papillomavirus infection, especially those infected with HIV. To address this, we recommend that a digital rectal exam and a visual inspection be performed annually. In addition, an anal Pap test should be performed soon after the diagnosis of HIV infection, with follow-up testing every six months until two normal tests. Abnormal cytological results are then investigated with high-resolution anoscopy and biopsy of suspicious lesions. In screening for cervical cancer, a Pap test should be performed during the anogenital exam after initial HIV diagnosis, with a second Pap six months later, then annually if the results are normal. A colposcopy should follow an abnormal result. Human papillomavirus testing as a screening method for cervical cancer in women with HIV can also be efficacious. In lung cancer screening, preliminary data suggest that low-dose computerized tomography may play an important role, but further research is needed. Screening for breast and colon cancer should follow guidelines for the general population. Early screening for prostate cancer based on a diagnosis of HIV lacks clear benefit.
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Affiliation(s)
- Zachary Tyerman
- Division of Hematology and Oncology, Virginia Mason Medical Center, Seattle, WA, USA
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Buskin SE, Barash EA, Scott JD, Aboulafia DM, Wood RW. Hepatitis B and C infection and liver disease trends among human immunodeficiency virus-infected individuals. World J Gastroenterol 2011; 17:1807-16. [PMID: 21528052 PMCID: PMC3080714 DOI: 10.3748/wjg.v17.i14.1807] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Revised: 12/10/2010] [Accepted: 12/17/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine trends in and correlates of liver disease and viral hepatitis in an human immunodeficiency virus (HIV)-infected cohort.
METHODS: The multi-site adult/adolescent spectrum of HIV-related diseases (ASD) followed 29 490 HIV-infected individuals receiving medical care in 11 U.S. metropolitan areas for an average of 2.4 years, and a total of 69 487 person-years, between 1998 and 2004. ASD collected data on the presentation, treatment, and outcomes of HIV, including liver disease, hepatitis screening, and hepatitis diagnoses.
RESULTS: Incident liver disease, chronic hepatitis B virus (HBV), and hepatitis C virus (HCV) were diagnosed in 0.9, 1.8, and 4.7 per 100 person-years. HBV and HCV screening increased from fewer than 20% to over 60% during this period of observation (P < 0.001). Deaths occurred in 57% of those diagnosed with liver disease relative to 15% overall (P < 0.001). Overall 10% of deaths occurred among individuals with a diagnosis of liver disease. Despite care guidelines promoting screening and vaccination for HBV and screening for HCV, screening and vaccination were not universally conducted or, if conducted, not documented.
CONCLUSION: Due to high rates of incident liver disease, viral hepatitis screening, vaccination, and treatment among HIV-infected individuals should be a priority.
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D'Jaen GA, Pantanowitz L, Bower M, Buskin S, Neil N, Greco EM, Cooley TP, Henry D, Stem J, Dezube BJ, Stebbing J, Aboulafia DM. Human immunodeficiency virus-associated primary lung cancer in the era of highly active antiretroviral therapy: a multi-institutional collaboration. Clin Lung Cancer 2011; 11:396-404. [PMID: 21062730 DOI: 10.3816/clc.2010.n.051] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected individuals are at increased risk for primary lung cancer (LC). We wished to compare the clinicopathologic features and treatment outcome of HIV-LC patients with HIV-indeterminate LC patients. We also sought to compare behavioral characteristics and immunologic features of HIV-LC patients with HIV-positive patients without LC. PATIENTS AND METHODS A database of 75 HIV-positive patients with primary LC in the HAART era was established from an international collaboration. These cases were drawn from the archives of contributing physicians who subspecialize in HIV malignancies. Patient characteristics were compared with registry data from the Surveillance Epidemiology and End Results program (SEER; n = 169,091 participants) and with HIV-positive individuals without LC from the Adult and Adolescent Spectrum of HIV-related Diseases project (ASD; n = 36,569 participants). RESULTS The median age at HIV-related LC diagnosis was 50 years compared with 68 years for SEER participants (P < .001). HIV-LC patients, like their SEER counterparts, most frequently presented with stage IIIB/IV cancers (77% vs. 70%), usually with adenocarcinoma (46% vs. 47%) or squamous carcinoma (35% vs. 25%) histologies. HIV-LC patients and ASD participants had comparable median nadir CD4+ cell counts (138 cells/µL vs. 160 cells/µL). At LC diagnosis, their median CD4+ count was 340 cells/µL and 86% were receiving HAART. Sixty-three HIV-LC patients (84%) received cancer-specific treatments, but chemotherapy-associated toxicity was substantial. The median survival for both HIV-LC patients and SEER participants with stage IIIB/IV was 9 months. CONCLUSION Most HIV-positive patients were receiving HAART and had substantial improvement in CD4+ cell count at time of LC diagnosis. They were able to receive LC treatments; their tumor types and overall survival were similar to SEER LC participants. However, HIV-LC patients were diagnosed with LC at a younger age than their HIV-indeterminate counterparts. Future research should explore how screening, diagnostic and treatment strategies directed toward the general population may apply to HIV-positive patients at risk for LC.
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Affiliation(s)
- Gabriela A D'Jaen
- Division of Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA, USA
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Snyder SM, Siekas L, Aboulafia DM. Initial Experience with Topical Fluorouracil for Treatment of HIV-Associated Anal Intraepithelial Neoplasia. ACTA ACUST UNITED AC 2011; 10:83-8. [PMID: 21266323 DOI: 10.1177/1545109710382578] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Exposure to high-risk strains of human papillomavirus (HPV) promotes cellular dysplasia of the anal canal epithelium, potentially leading to anal intraepithelial neoplasia (AIN), which is in turn a precursor to invasive squamous cell carcinoma of the anus (SCCA). People with HIV infection who engage in anoreceptive intercourse are at heightened risk for acquiring HPV, AIN, and SCCA. Although intravenous 5-fluorouracil (5-FU) is commonly used for treatment of invasive SCCA, there has been little experience with the use of topical 5-FU as therapy for AIN. We retrospectively reviewed records of the first 11 HIV-positive patients treated with topical 5-FU in our anal dysplasia clinic. Six (55%) patients had clinical improvement with reduction in area of dysplasia seen on high-resolution anoscopy (HRA). Three (27%) patients had improvement in AIN pathologic grade. Eight (73%) patients reported mild-to-moderate perianal irritation, which led six to reduce the frequency of 5-FU application. Further study of topical 5-FU for treatment of HIV-associated AIN is warranted.
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Affiliation(s)
- Sean M Snyder
- Department of Graduate Medical Education, Virginia Mason Medical Center, Seattle, WA, USA,
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Eaton C, Dorer R, Aboulafia DM. Human Herpesvirus-8 Infection Associated with Kaposi Sarcoma, Multicentric Castleman's Disease, and Plasmablastic Microlymphoma in a Man with AIDS: A Case Report with Review of Pathophysiologic Processes. Patholog Res Int 2010; 2011:647518. [PMID: 21253546 PMCID: PMC3021860 DOI: 10.4061/2011/647518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Accepted: 12/10/2010] [Indexed: 11/20/2022]
Abstract
Kaposi sarcoma (KS), multicentric Castleman's disease (MCD), and plasmablastic microlymphoma, are all linked to human herpesvirus-8 (HHV-8) infection and HIV-induced immunodeficiency. Herein, we describe the case of a Kenyan man diagnosed with HIV in 2000. He deferred highly active antiretroviral therapy (HAART) and remained in good health until his CD4+ count declined in 2006. He was hospitalized with bacterial pneumonia in 2008, after which he agreed to take HAART but did so sporadically. In 2010, he was hospitalized with fever, lymphadenopathy, pancytopenia, and an elevated HHV-8 viral load. A lymph node biopsy showed findings consistent with KS, MCD, and plasmablastic microlymphoma. Eight months after starting liposomal doxorubicin, Rituximab, and a new HAART regimen, he has improved clinically, and his HIV and HHV-8 viral loads are suppressed. These three conditions, found in the same lymph node, underscore the inflammatory and malignant potential of HHV-8, particularly in the milieu of HIV-induced immunodeficiency.
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Affiliation(s)
- Christian Eaton
- Department of Medicine, Virginia Mason Medical Center, Seattle, WA 98101, USA
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Cianfrocca M, Lee S, Von Roenn J, Tulpule A, Dezube BJ, Aboulafia DM, Ambinder RF, Lee JY, Krown SE, Sparano JA. Randomized trial of paclitaxel versus pegylated liposomal doxorubicin for advanced human immunodeficiency virus-associated Kaposi sarcoma: evidence of symptom palliation from chemotherapy. Cancer 2010; 116:3969-77. [PMID: 20564162 DOI: 10.1002/cncr.25362] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Paclitaxel and pegylated liposomal doxorubicin (PLD) are active cytotoxic agents for the treatment of human immunodeficiency virus (HIV)-associated Kaposi sarcoma (KS). A randomized trial comparing the efficacy and toxicity of paclitaxel and PLD was performed, and the effects of therapy on symptom palliation and quality of life were determined. METHODS Patients with advanced HIV-associated KS were randomly assigned to receive paclitaxel at a dose of 100 mg/m2 intravenously (iv) every 2 weeks or PLD at a dose of 20 mg/m2 iv every 3 weeks. The KS Functional Assessment of HIV (FAHI) quality of life instrument was used before and after every other treatment cycle. RESULTS The study included 73 analyzable patients enrolled between 1998 and 2002, including 36 in the paclitaxel arm and 37 in the PLD arm; 73% of patients received highly active antiretroviral therapy (HAART) and 32% had an undetectable viral load (<400 copies/mL). Treatment was associated with significant improvements in pain (P=.024) and swelling (P<.001). Of the 36 patients who reported that pain interfered with their normal work or activities at baseline, 25 (69%) improved. Of the 41 patients who reported swelling at baseline, 38 (93%) improved. Comparing the paclitaxel and PLD arms revealed comparable response rates (56% vs 46%; P=.49), median progression-free survival (17.5 months vs 12.2 months; P=.66), and 2-year survival rates (79% vs 78%; P=.75), but somewhat more grade 3 to 5 toxicity for paclitaxel (84% vs 66%; P=.077). CONCLUSIONS Treatment with either paclitaxel or PLD appears to produce significant improvements in pain and swelling in patients with advanced, symptomatic, HIV-associated KS treated in the HAART era.
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Affiliation(s)
- Mary Cianfrocca
- Department of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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Snyder SM, Siekas L, Aboulafia DM. Initial experience with topical fluorouracil (5-FU) for treatment of anal intraepithelial neoplasia (AIN) in HIV-positive patients. Infect Agent Cancer 2010. [PMCID: PMC3002701 DOI: 10.1186/1750-9378-5-s1-a41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Ochenrider MG, Patterson DJ, Aboulafia DM. Hepatosplenic T-cell lymphoma in a young man with Crohn's disease: case report and literature review. Clin Lymphoma Myeloma Leuk 2010; 10:144-8. [PMID: 20371449 DOI: 10.3816/clml.2010.n.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hepatosplenic T-cell lymphoma (HSTCL) is a rare form of peripheral T-cell lymphoma. It is associated with an aggressive clinical course, a poor response to conventional treatment, and an exceedingly high mortality rate. Recent reports suggest an excessive number of cases of HSTCL in young patients with Crohn's disease who are treated with thiopurines (azathioprine or 6-mercaptopurine [6-MP]) either in conjunction with or without agents that inhibit tumor necrosis factor-alpha (TNF-alpha). Herein, we describe the case of an 18-year-old man with Crohn's disease who developed HSTCL after 5 years of 6-MP treatment. He died 7 months after diagnosis from chemotherapy-refractory lymphoma. Through a literature review, we identified 28 cases of HSTCL in Crohn's patients. All patients were treated with azathioprine or 6-MP; 22 of 28 (79%) received concomitant treatment with infliximab, and 3 of these 22 patients later received treatment with adalimumab. The median age at diagnosis of HSTCL was 22 years (range, 12-40 years). The median survival for all patients was 8 months (range, 5 days-31+ months), with only 1 patient achieving remission. Additional research is needed to better understand the role of thiopurines and TNF-alpha inhibitors in promoting HSTCL and what can be done to prevent and treat this devastating malignancy in young patients with Crohn's disease.
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Affiliation(s)
- Mark G Ochenrider
- Division of Internal Medicine, Virginia Mason Medical Center, Seattle, WA 98101, USA
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Abstract
In the highly active antiretroviral therapy era, an increasingly large number of HIV-infected patients are developing non- AIDS-defining cancers (NADCs). As patients survive longer, long-term therapy-related complications take on greater importance. Herein, we describe a patient with AIDS who presented to medical attention with pancytopenia 48 months postchemotherapy with etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (R-EPOCH) for diffuse large B-cell lymphoma. Bone marrow biopsy showed a moderately hypocellular marrow; 51% of the nucleated cells were blasts with myelomonocytic differentiation. Cytogenetic studies revealed an abnormal karyotype with deletion of the long arm of chromosome 11 (11q21) and 2 additional copies of the MLL gene attached to the short arms of chromosome 10 in 80% of the metaphase cells examined. With the diagnosis of therapy-related acute myeloid leukemia (AML) secured, he began induction chemotherapy with idarubicin and cytarabine. Two weeks later, he died of fungal septicemia and multiorgan failure. Through a literature search, we were able to identify 4 additional cases of therapy-related AML in AIDS patients following chemotherapy for lymphomas. The median age of these patients at the time of AML diagnosis was 39 years (range, 33-59 years), the median time from the treatment of lymphoma to AML was 18 months (range, 11-48 months), and the median survival following induction chemotherapy was 4 weeks (range, 2-16 weeks). With many HIV-infected patients surviving alkylator and topoisomerase inhibitor-based treatment and radiation therapy for AIDS-defining cancers and NADCs, long-term follow-up for therapy-related complications assumes greater importance.
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Affiliation(s)
- Deepthi Mani
- Division of Internal Medicine, Spokane Medical Centers, WA, USA
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