[Show abstract][Hide abstract] ABSTRACT: Background:Central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) is a devastating complication; the optimal prophylactic strategy remains unclear.Methods:We performed a multicentre, retrospective analysis of patients with DLBCL with high risk for CNS relapse as defined by two or more of: multiple extranodal sites, elevated serum LDH and B symptoms or involvement of specific high-risk anatomical sites. We compared three different strategies of CNS-directed therapy: intrathecal (IT) methotrexate (MTX) with (R)-CHOP 'group 1'; R-CHOP with IT MTX and two cycles of high-dose intravenous (IV) MTX 'group 2'; dose-intensive systemic antimetabolite-containing chemotherapy (Hyper-CVAD or CODOXM/IVAC) with IT/IV MTX 'group 3'.Results:Overall, 217 patients were identified (49, 125 and 43 in groups 1-3, respectively). With median follow-up of 3.4 (range 0.2-18.6) years, 23 CNS relapses occurred (12, 10 and 1 in groups 1-3 respectively). The 3-year actuarial rates (95% CI) of CNS relapse were 18.4% (9.5-33.1%), 6.9% (3.5-13.4%) and 2.3% (0.4-15.4%) in groups 1-3, respectively (P=0.009).Conclusions:The addition of high-dose IV MTX and/or cytarabine was associated with lower incidence of CNS relapse compared with IT chemotherapy alone. However, these data are limited by their retrospective nature and warrant confirmation in prospective randomised studies.British Journal of Cancer advance online publication, 29 July 2014; doi:10.1038/bjc.2014.405 www.bjcancer.com.
[Show abstract][Hide abstract] ABSTRACT: The safety, kinetics and efficacy of plerixafor+pegfilgrastim for hematopoietic stem and progenitor cell (HSPC) mobilization are poorly understood. We treated 12 study patients (SP; lymphoma n=10 or myeloma n=2) with pegfilgrastim (6 mg SC stat D1) and plerixafor (0.24 mg/kg SC nocte from D3). Six SP were 'predicted poor-mobilizers' and six were 'predicted adequate-mobilizers'. Peripheral blood (PB) CD34(+) monitoring commenced on D3. Apheresis commenced on D4. Comparison was with 22 historical controls (HC; lymphoma n=18, myeloma n=4; poor mobilizers n=4), mobilized with pegfilgrastim alone. Eight (67%) SP had PB CD34(+) count ⩽5 × 10(6)/L D3 post pegfilgrastim; all SP surpassed this threshold the morning after plerixafor. In SP, PBCD34(+) counts peaked D4 6/12 (50%), remaining ⩾5 × 10(6)/L for 4 days in 8/12 (67%). All SP successfully yielded target cell numbers (⩾2 × 10(6)/kg) within four aphereses. After maximum four aphereses, median total CD34+ yield was higher in SP than HC; 8.0 (range 2.4-12.9) vs 4.8 (0.4-14.0) × 10(6)/kg (P=0.04). Seven of twelve (58%) SP achieved target yield after one apheresis. Flow cytometry revealed no tumor cells in PB or apheresis product of SP. Plerixafor+pegfilgrastim was well tolerated with bone pain (n=2), diarrhoea (n=2) and facial paraesthesiae (n=3). Plerixafor+pegfilgrastim is a simple, safe and effective HSPC mobilization regimen in myeloma and lymphoma, in both poor and good mobilizers, and is superior to pegfilgrastim alone.Bone Marrow Transplantation advance online publication, 2 June 2014; doi:10.1038/bmt.2014.112.
[Show abstract][Hide abstract] ABSTRACT: The optimum follow-up of patients with transformed indolent lymphoma (TrIL) is not well defined. We sought to determine the utility of surveillance positron emission tomography-computed tomography (PET-CT) in patients with TrIL achieving complete metabolic remission (CMR) after primary therapy. We performed a retrospective analysis of patients with TrIL treated at Peter MacCallum Cancer Centre between 2002 and 2012 who achieved CMR after primary therapy who had ≥1 subsequent surveillance PET-CT. Of 55 patients with TrIL, 37 (67 %) received autologous stem cell transplantation as consolidation following chemoimmunotherapy. After a median follow-up of 34 (range 3-101) months, the actuarial 3-year progression-free (PFS) and overall survival (OS) were 77 % (95 %CI 62-86 %) and 88 % (75-94 %), respectively. Of 180 surveillance PET-CT scans, there were 153 true negatives, 4 false positives, 1 false negative, 7 indeterminate and 15 true positives. Considering indeterminate scans as false positives, the specificity of PET-CT for detecting relapse was 94 %, sensitivity was 83 %, positive predictive value was 63 % and negative predictive value was 98 %. All seven subclinical (PET detected) relapses were of low-grade histology; in contrast, all nine relapses with diffuse large B cell lymphoma (DLBCL) were symptomatic. In our cohort of patients with TrIL achieving CMR, PET-CT detected subclinical low-grade relapses but all DLBCL relapses were accompanied by clinical symptoms. Thus, surveillance imaging of patients with TrIL achieving CMR is of limited clinical benefit. PET-CT should be reserved for evaluation of clinically suspected relapse.
Annals of Hematology 03/2014; · 2.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML) are the predominant myeloid neoplasms where FCM has both a diagnostic and prognostic role in addition to minimal residual disease (MRD) testing in AML. Criteria for the diagnosis and classification of MDS have been refined and proposed in a consensus International MDS Working Group publication (2007) with immunophenotyping recommended as a co-criterion for diagnosis.Utilising our understanding and delineation of normal antigen maturation and expression patterns of myelomonocytic precursors enables the detection of aberrancy in mature and immature populations. This forms the basis of reporting MDS and AML MRD FCM. There is a large body of literature supporting the routine utility of immunophenotyping in the diagnostic workup of MDS and provocative data in patients treated serially with hypomethylating agents. However, further validation and definitions of aberrancy and flow scoring systems are required to enable the introduction of immunophenotyping into mainstream diagnostic laboratories. Standardisation efforts are underway within the European LeukemiaNet.FCM is routinely used for the diagnosis of AML, however MRD testing requires significant expertise. Despite numerous publications demonstrating prognostic significance in MRD at both post induction and post consolidation time points, most are single institution studies highlighting the sophistication required by laboratories.(Figure is included in full-text article.).
[Show abstract][Hide abstract] ABSTRACT: In a phase I study of autologous chimeric antigen receptor (CAR) anti-LeY T cell therapy of acute myeloid leukemia (AML), we examined the safety and post-infusion persistence of adoptively transferred T cells. Following fludarabine-containing pre-conditioning four patients received up to 1.3 x 10(9) total T cells, of which 14% to 38% expressed the CAR. Grade 3 or 4 toxicity was not observed. One patient achieved a cytogenetic remission, whilst another with active leukemia had a reduction in peripheral blood blasts and a third showed a protracted remission. Using an aliquot of (111)In-labeled CAR-T cells we demonstrated trafficking to the bone marrow in those patients with the greatest clinical benefit. Furthermore, in a patient with leukemia cutis, CAR-T cells infiltrated proven sites of disease. Serial PCR of peripheral blood and bone marrow for the LeY transgene demonstrated that infused CAR-T cells persisted for up to 10 months. Our study supports the feasibility and safety of CAR-T cell therapy in high-risk AML, and demonstrates durable in vivo persistence.Molecular Therapy (2013); doi:10.1038/mt.2013.154.
[Show abstract][Hide abstract] ABSTRACT: Abstract Myelodysplastic syndromes (MDS) are a heterogeneous group of myeloid neoplasms. With the emergence of therapeutic options, attempts to standardise diagnostic, prognostic and response criteria to guide treatment decisions are increasingly important. This has been achieved in part by the revised 2008 WHO classification and consensus guidelines outlining refined definitions and standards. Conventional criteria have limitations in terms of sensitivity and specificity. Multiparameter flow cytometry (FC) can be used real-time and is a highly reproducible and objective way of assessing the pattern of expression of multiple antigens on a single hematopoietic cell and defined subpopulations. By comparing antigen expression within maturing myelomonocytic populations, with that identified on the equivalent normal cells, abnormalities identified may provide a diagnostic indication of stem cell dysmaturation. There is now increasingly robust data demonstrating the capacity of FC to discriminate MDS from non-clonal cytopenias and dysplasia, as well as further refine disease classification and prognostication, which will be reviewed here.
[Show abstract][Hide abstract] ABSTRACT: Background:The usefulness of positron emission tomography with computed tomography (PET-CT) in the surveillance of patients with diffuse large B-cell lymphoma (DLBCL) in complete metabolic remission after primary therapy is not well studied.Methods:We performed a retrospective review of our database between 2002 and 2009 for patients with de novo DLBCL who underwent surveillance PET-CT after achieving complete metabolic response (CMR) following primary therapy.Results:Four-hundred and fifty scans were performed in 116 patients, with a median follow-up of 53 (range 8-133) months from completion of therapy. Thirteen patients (11%) relapsed: seven were suspected clinically and six were subclinical (all within first 18 months). The positive predictive value in patients with international prognostic index (IPI) <3 was 56% compared with 80% in patients with IPI3. Including indeterminate scans, PET-CT retained high sensitivity 95% and specificity 97% for relapse.Conclusion:Positron emission tomography with computed tomography is not useful in patients for the majority of patients with diffuse large B-cell lymphoma in CMR after primary therapy, with the possible exception of patients with baseline IPI 3 in the 18 months following completion of primary therapy. This issue could be addressed by a prospective clinical trial.British Journal of Cancer advance online publication, 27 June 2013; doi:10.1038/bjc.2013.338 www.bjcancer.com.
British Journal of Cancer 06/2013; · 5.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pain during bone marrow biopsy (BMB) under local anaesthesia (LA) is reported in 70% of patients, of whom 35% rate the pain as severe. Pain is experienced during both the biopsy and the marrow aspiration. Many medical centres use conscious sedation involving benzodiazepines and/or opioids administered orally or intravenously for BMB analgesia. Methoxyflurane (MEOF) is self-administered by a handheld device (the Penthrox inhaler), which is licensed in Australia for the relief of pain associated with short surgical procedures.
To evaluate the efficacy and safety of MEOF analgesia in patients with cancer undergoing BMB.
Patients received LA plus either MEOF or placebo. The primary endpoint was worst pain intensity measured with the Numerical Rating Scale. Anxiety was assessed with the State Trait Anxiety Inventory (STAI-Y-1). Patients, operators and the research nurse rated global medication performance using a 5-point Likert scale.
Forty-nine of the 50 patients randomised to MEOF and 48 of the 50 patients randomised to placebo effectively received the allocated intervention. Mean±SD worst pain overall was 4.90±2.07 in MEOF group and 6.0±2.24 in placebo group (p=0.011). Worst pain during the aspiration was 3.3±2.0 in MEOF group and 5.0±2.4 in placebo group (p<0.001). 49% of patients treated with MEOF rated the medication as very good or excellent compared with 16.5% of the patients treated with placebo (p=0.005). 20.4% of patients treated with MEOF had an adverse event (AE) compared with 4.2% in the placebo arm (p=0.028). All AEs were grade 1.
MEOF was safe and performed better than placebo for analgesia in BMB procedures.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The JAK2 V617F mutation is the most frequent somatic change in myeloproliferative neoplasms, making it an important tumour-specific marker for diagnostic purposes and for the detection of minimal residual disease. Sensitive quantitative assays are required for both applications, particularly for the monitoring of minimal residual disease, which requires not only high sensitivity but also very high specificity. METHODS: We developed a highly sensitive probe-free quantitative mutant-allele detection method, Quantitative Threefold Allele-Specific PCR (QuanTAS-PCR) that is performed in a closed-tube system, thus eliminating the manipulation of PCR products. QuantTAS-PCR uses a threefold approach to ensure allele-specific amplification of the mutant sequence: (i) a mutant allele-specific primer, (ii) a 3'dideoxy blocker to suppress false-positive amplification from the wild-type template and (iii) a PCR specificity enhancer, also to suppress false-positive amplification from the wild-type template. Mutant alleles were quantified relative to exon 9 of JAK2. RESULTS: We showed that the addition of the 3'dideoxy blocker suppressed but did not eliminate false-positive amplification from the wild-type template. However, the addition of the PCR specificity enhancer near eliminated false-positive amplification from the wild-type allele. Further discrimination between true and false positives was enabled by using the quantification cycle (Cq) value of a single mutant template as a cut-off point, thus enabling robust distinction between true and false positives. As 10,000 JAK2 templates were used per replicate, the assay had a sensitivity of 1/10-4 per replicate. Greater sensitivity could be reached by increasing the number of replicates analysed. Variation in replicates when low mutant-allele templates were present necessitated the use of a statistics-based approach to estimate the load of mutant JAK2 copies. QuanTAS-PCR showed comparable quantitative results when validated against a commercial assay. CONCLUSIONS: QuanTAS-PCR is a simple, cost-efficient, closed-tube method for JAK2 V617F mutation quantification that can detect very low levels of the mutant allele, thus enabling analysis of minimal residual disease. The approach can be extended to the detection of other recurrent single nucleotide somatic changes in cancer.
BMC Cancer 04/2013; 13(1):206. · 3.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Next generation sequencing techniques are powerful high throughput methods that have enabled the comprehensive documentation of genetic lesions in numerous hematological malignancies. In recent times, the genome of multiple different B-cell lymphoproliferative disorders including chronic lymphocytic leukemia, diffuse large B-cell lymphoma, Burkitt lymphoma, splenic marginal zone lymphoma, mantle cell lymphoma, hairy cell leukemia and Waldenström macroglobulinemia have been documented. Between them, these studies have reinforced and provided insight into the mechanisms for the dysregulation of known pathways (e.g. NF-κB), uncovered the importance of new pathways for oncogenesis (e.g. mRNA processing), identified disease-defining mutations, and provided meaningful new targets which are already being translated into therapeutic interventions. This review summarises the molecular lesions that have been discovered in B-cell lymphoproliferative disorders thus far by studies utilising high-throughput sequencing techniques and the aberrations in the numerous intracellular pathways that have been shown to be involved.
[Show abstract][Hide abstract] ABSTRACT: : A number of clinicopathological features have been attributed to the CD20 positive subset of plasma cell myeloma (PCM). CD20 is an appealing therapeutic target given the success with monoclonal antibody regimens in a spectrum of B cell lymphomas. To date, a small number of reports have described CD20 PCM as a unique subset, and these are not conclusive, especially taking into consideration reporting bias. This study aims to further identify the clinicopathological features of CD20 PCM.
: A retrospective analysis of all newly diagnosed PCM between 2003 and 2010 was undertaken. Trephine material was retrieved and reviewed for CD20, and for positive cases an extended immunohistochemical (IHC) panel including cyclin D1 was subsequently performed.
: The review of our 40 cases and those described in the literature demonstrated that these are heterogeneous with regard to clinical features, morphology, biochemical features, immunophenotype, and cytogenetics.
: Based on our study and review of the literature, CD20 PCM cases represent a heterogeneous disease and not a unique clinicopathological entity.
[Show abstract][Hide abstract] ABSTRACT: Hairy cell leukemia has been shown to be strongly associated with the BRAF V600E mutation. We screened 59 unenriched archived bone marrow aspirate and peripheral blood samples from 51 patients with hairy cell leukemia using high resolution melting analysis and confirmatory Sanger sequencing. The BRAF V600E mutation was detected in 38 samples (from 36 patients). The BRAF V600E mutation was detected in all samples with disease involvement above the limit of sensitivity of the techniques used. Thirty-three of 34 samples from other hematologic malignancies were negative for BRAF mutations. A BRAF K601E mutation was detected in a patient with splenic marginal zone lymphoma. Our data support the recent finding of a disease defining point mutation in hairy cell leukemia. Furthermore, high resolution melting with confirmatory Sanger sequencing are useful methods that can be employed in routine diagnostic laboratories to detect BRAF mutations in patients with hairy cell leukemia and related lymphoproliferative disorders.
[Show abstract][Hide abstract] ABSTRACT: Peri-procedural management of warfarin reflects an intricate balance between the restoration of haemostasis and appropriate thromboprophylaxis. This prospective single-arm study assessed the safety and efficacy of a convenient schedule, incorporating low-dose intravenous vitamin K (vitK(IV) ) for short-term warfarin reversal prior to elective surgery, as well as vitK-dependent factor levels (vitK-Factors) and International Normalized Ratio (INR) pre- and post-vitK(IV) . One seventy eight patients on long-term warfarin received 3mg vitK(IV) 12-18 h pre-procedure with no adverse reactions. 167/178 (94%) achieved an INR≤1·5 post-vitK(IV) on the day of surgery, while all achieved INR≤1·7. Four patients had procedure-associated major bleeding, but importantly had achieved a pre-procedure INR<1·5 and vitK-Factors >0·30iu/ml. No patient suffered a symptomatic thromboembolism during the 6-week follow-up. Median days to re-establish a therapeutic INR were 4 (range 2-11). VitK(IV) near normalized all vitK-Factors, with a uniform pattern of depletion and repletion in association with an increase and decrease in INR, respectively; and from the data, INR<1·5 correlated with vitK-Factors >0·30iu/ml. Low-dose vitK(IV) for short-term warfarin reversal was reliable and safe, and successfully lowered the INR to an acceptable level for planned surgery, with no excess of bleeding, thromboembolism, delayed discharge, or resistance to warfarin. The protocol was simple and convenient for both the patients and the healthcare institution.
British Journal of Haematology 09/2011; 154(5):626-34. · 4.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with multiple myeloma undergoing autologous haemopoietic stem cell transplantation (ASCT) are at high risk for infectious complications. Peri-transplant intravenous immunoglobulin (IVIG) has been used with the aim of reducing these risks. Our retrospective, non-randomised study of peri-transplant IVIG use and effect on infectious complications in 266 ASCTs for myeloma from 2000 to 2009 at a major metropolitan referral centre for haematological malignancies found no difference between those receiving peri-transplant IVIG (0.4 g/kg) (n=130) and those who were not (n=110) with regard to bloodstream infections, pneumonia, urinary tract or gastrointestinal infections. When analysed according to pre-transplant therapy (conventional chemotherapy versus novel agents), there was no significant difference in infectious complications between those who did or did not receive peri-transplant IVIG. In conclusion, our study did not show a benefit for the use of peri-transplant IVIG (0.4 g/kg) to reduce infectious complications in a large cohort of patients with myeloma undergoing ASCT. In the absence of data supporting efficacy in this context, there appears to be no benefit in the routine use of IVIG for this purpose.
Annals of Hematology 06/2011; 90(10):1167-72. · 2.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Correlations between the marrow histopathology and clinical findings in Waldenström macroglobulinaemia (WM) are not well defined, and the pathophysiology of the plasma cell involvement is poorly understood. The authors used a standardised immunohistological approach to the enumeration of B lymphocyte and plasma cell compartments in the bone-marrow trephine to investigate associations between bone-marrow morphology and clinical/laboratory indices.
In 80 newly diagnosed, untreated cases of WM, the authors determined the degree and pattern of B lymphocyte (CD20+) and plasma cell (CD138+) infiltration in the bone-marrow trephine, as defined by immunohistochemistry, and correlated the disease in the marrow with components of the international scoring system for WM (age, serum IgM paraprotein level, haemoglobin, platelet count and β(2) microglobulin). Plasma cell clonality was assessed by κ and λ staining.
Serum IgM paraprotein concentration was related to the plasma cell burden in the bone marrow (coefficient 0.231, p<0.005), but not the B lymphocytic infiltrate. Overall lymphoplasmacytic disease burden weakly correlated with severity of anaemia (coefficient 0.236, p=0.055). In 28/28 evaluated cases, plasma cells exhibited light chain restriction that was concordant with both that of the B lymphocytic infiltrate and paraprotein.
Bone-marrow features, in particular the degree of plasma cell infiltration, correlate with IgM paraprotein concentration at diagnosis in WM. The plasma cell compartment in this condition appears to be part of the neoplastic clone. In WM, specific evaluation of the plasma cell compartment in the bone marrow at baseline and following therapy may be valuable.
Journal of clinical pathology 04/2011; 64(6):520-3. · 2.43 Impact Factor