David Westerman

University of Melbourne, Melbourne, Victoria, Australia

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Publications (76)386.25 Total impact

  • Denise Lee · George Grigoriadis · David Westerman ·
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    ABSTRACT: Flow cytometry is the most accessible method for minimal residual disease (MRD) detection due to its availability in most haematological centres. Using a precise combination of different antibodies, immunophenotypic detection of MRD in acute leukaemia can be performed by identifying abnormal combinations or expressions of antigens on malignant cells at diagnosis, during and post treatment. These abnormal phenotypes, referred to as leukaemia-associated immunophenotypes (LAIPs) are either absent or expressed at low frequency in normal bone marrow (BM) cells and are used to monitor the behaviour and quantitate the amount of residual disease following treatment. In paediatric acute lymphoblastic leukaemia (ALL), the level of MRD by multiparametric flow cytometry (MPFC) during therapy is recognised as an important predictor of outcome. Although less extensively studied, adult ALL and adult and paediatric acute myeloid leukaemia (AML) have also demonstrated similar findings. The challenge now is incorporating this information for risk-stratification so that therapy can be tailored individually and ultimately improve outcome while also limiting treatment-related toxicity. In this review we will elaborate on the current and future role of MPFC in MRD in acute leukaemia while also addressing its limitations.
    Pathology 10/2015; 47(7). DOI:10.1097/PAT.0000000000000319 · 2.19 Impact Factor
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    ABSTRACT: Despite its efficacy in prospective trials, full dose fludarabine, cyclophosphamide and rituximab (FCR) may be too toxic for elderly patients with chronic lymphocytic leukemia (CLL) in clinical practice. We retrospectively reviewed the impact of dose reductions in FCR therapy on the outcomes of 42 consecutive patients aged 65 - 87 (median 72) years. Despite a median cumulative fludarabine dose reduction of 50% from full dose, the objective response and complete response rates were 86% and 38% respectively (frontline 94%/59%; previously treated 80%/24%). Dose reductions of 25 - 75% were not significantly associated with inferior progression free survival compared to minimal reductions (≤25%) (p=0.49), and did not preclude deep responses, including six cases (14%) of minimal residual disease negativity. Although hematological and infectious toxicities were common, treatment limiting adverse effects were infrequent. Dose attenuated FCR appears to have preserved efficacy and may be a viable therapeutic option for elderly patients with CLL.
    Leukemia & lymphoma 10/2015; DOI:10.3109/10428194.2015.1096353 · 2.89 Impact Factor
  • Neil Came · Vuong Nguyen · David Westerman · Simon Harrison ·

    British Journal of Haematology 10/2015; DOI:10.1111/bjh.13655 · 4.71 Impact Factor
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    ABSTRACT: MYC rearrangements with or without BCL2 rearrangements have been shown to be associated with poor prognosis and inferior survival in diffuse large B-cell lymphomas (DLBCL). Most of these cases are still diagnosed by fluorescent in situ hybridisation (FISH) testing, which is expensive, requires expertise and is not routinely available in all laboratories. Immunohistochemistry (IHC) is widely available and has the potential to be used as a screening test to identify cases with increased protein expression and select cases that require confirmatory testing. We correlated the expression of MYC and BCL2 by IHC with FISH studies in an attempt to define a cut-off value, which can be used by laboratories to select cases requiring confirmatory FISH testing. The prevalence of MYC-positive DLBCL and double-hit lymphoma (DHL) has also been studied. 209 cases comprising of 15 cases of Burkitt lymphoma (BL), 13 cases of intermediate BL/DLBCL and 181 cases of DLBCL were included. IHC and FISH for MYC and BCL2 were performed and the results were correlated. The prevalence of MYC-positive DLBCL and MYC/BCL2DHL was 13.4% and 7.4%, respectively, in our study. Germinal-centre subtype was more common in MYC-positive DLBCL and DHL. MYC-positive DLBCL also showed higher median Ki-67 (>90%) and CD10 positivity as compared with MYC-negative cases. IHC can be used for screening cases, which require further confirmatory FISH testing. We recommend a cut-off value of ≥30% for MYC by IHC; however, international standardisation of these values is necessary to provide uniformity among laboratories. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Journal of Clinical Pathology 08/2015; DOI:10.1136/jclinpath-2015-203002 · 2.92 Impact Factor
  • Neil Came · David Westerman · Surender Juneja ·
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    ABSTRACT: Acute myeloid leukemia;minimal residual disease;flow cytometry
    American Journal of Hematology 08/2015; 90(11). DOI:10.1002/ajh.24142 · 3.80 Impact Factor
  • Kate L Burbury · Michael Dickinson · David A Westerman · H Miles Prince ·

    Leukemia & lymphoma 06/2015; 56(12):1-9. DOI:10.3109/10428194.2015.1055487 · 2.89 Impact Factor
  • Eric Wong · Victoria Ling · David Westerman · Susan Morgan · Surender Juneja ·
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    ABSTRACT: Pure erythroid leukaemia (PEL) is a rare subtype of acute myeloid leukaemia (AML) and its clinicopathological features are not well-defined. The aim of this study was to describe the immunophenotypic, cytogenetic and clinical features of PEL and to compare these with cases of AML with ≥50% erythroblasts. Cases of PEL according to WHO morphological criteria diagnosed at three institutions from 1997 to 2013 were included. A comparison cohort comprised of AML with ≥50% erythroblasts. The clinical, histopathology, immunophenotypic and cytogenetic features of cases were analysed. We also reviewed the existing literature on PEL, and combined our cohort with previously reported cases of PEL in a pooled analysis. There were seven cases of PEL diagnosed at our institutions. There was a high incidence of either prior chemoradiotherapy exposure or evolution from pre-existing myelodysplastic syndrome (MDS) (71%). The leukaemic blasts frequently expressed glycophorin C (100%), CD117 (83%) and were myeloperoxidase negative (83%). Complex karyotypes were present in 83% of cases. Median overall survival was 2.9 months. Compared with AML with ≥50% erythroblasts, cases of PEL demonstrated a higher incidence of adverse-risk cytogenetics (p=0.01) and prior exposure to chemoradiotherapy (p=0.01). PEL appears to be a unique entity that is often secondary or therapy related, commonly features a complex karyotype and has a poor prognosis. It is morphologically and immunophenotypically distinct from other cases of AML with erythroid hyperplasia. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Journal of Clinical Pathology 01/2015; 68(4). DOI:10.1136/jclinpath-2014-202740 · 2.92 Impact Factor

  • Clinical Lymphoma Myeloma and Leukemia; 12/2014
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    ABSTRACT: Numerous systemic treatments options exist for patients with Mycosis Fungoides (MF) and Sézary Syndrome (SS) but no large comparative studies are published. In order to study the efficacy of treatments, a retrospective analysis of our cutaneous lymphoma database was undertaken, with 198 MF/SS patients undergoing systemic therapies. The primary endpoint was time to next treatment (TTNT). Patients with advanced-stage disease made up 53%. The median follow-up time from diagnosis for all alive patients was 4.9 years (range, 0.3-39.6 years), with a median survival of 11.4 years. Patients received a median of three lines of therapy (range, 1-13), resulting in a total of 709 treatment episodes. 28 treatment modalities were analyzed. The median TTNT for single- or multi-agent chemotherapy was only 3.9 months (95% confidence interval (CI): 3.2-5.1), with few durable remissions. Alfa interferon gave a median TTNT of 8.7 months (95% CI: 6.0-18.0) and histone deacetylase inhibitors (HDACi) gave a median 4.5 months TTNT (95% CI: 4.0-6.1). When compared directly to chemotherapy, interferon and HDACi both had greater TTNT (P < .00001 and P = .01, respectively). This study confirms that all chemotherapy regimens assessed have very modest efficacy; we recommend their use be restricted until other options are exhausted.
    Blood 10/2014; 125(1). DOI:10.1182/blood-2014-07-588236 · 10.45 Impact Factor
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    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 07/2014; 111(6). DOI:10.1038/bjc.2014.405 · 4.84 Impact Factor
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    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.
    Bone Marrow Transplantation 06/2014; 49(8). DOI:10.1038/bmt.2014.112 · 3.57 Impact Factor
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    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; 93(7). DOI:10.1007/s00277-014-2040-1 · 2.63 Impact Factor
  • David A Westerman · Denise Lee · Kate L Burbury ·
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    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.).
    Pathology 02/2014; 46 Suppl 1:S33-4. DOI:10.1097/01.PAT.0000443476.74421.bf · 2.19 Impact Factor
  • Rishu Agarwal · Michelle McBean · Chelsee Hewitt · David A Westerman ·

    Leukemia & lymphoma 12/2013; 55(9). DOI:10.3109/10428194.2013.876498 · 2.89 Impact Factor
  • Ir Davis · David A. Westerman ·

    Leukemia & lymphoma 12/2013; 55(7). DOI:10.3109/10428194.2013.876499 · 2.89 Impact Factor
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    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.
    Molecular Therapy 07/2013; 21(11). DOI:10.1038/mt.2013.154 · 6.23 Impact Factor
  • Kate L Burbury · David A Westerman ·
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    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.
    Leukemia & lymphoma 07/2013; 55(4). DOI:10.3109/10428194.2013.820291 · 2.89 Impact Factor
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    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 IPI⩾3. 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 06/2013; 109(2). DOI:10.1038/bjc.2013.338 · 4.84 Impact Factor
  • Odette Spruyt · David Westerman · Alvin Milner · Mathias Bressel · Simon Wein ·
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    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.
    Supportive and Palliative Care 06/2013; 4(4). DOI:10.1136/bmjspcare-2013-000447
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    ABSTRACT: Background: The effectiveness of platelet transfusions to prevent bleeding in patients with hematologic cancers remains unclear. This trial assessed whether a policy of not giving prophylactic platelet transfusions was as effective and safe as a policy of providing prophylaxis. Methods: We conducted this randomized, open-label, noninferiority trial at 14 centers in the United Kingdom and Australia. Patients were randomly assigned to receive, or not to receive, prophylactic platelet transfusions when morning platelet counts were less than 10×10(9) per liter. Eligible patients were persons 16 years of age or older who were receiving chemotherapy or undergoing stem-cell transplantation and who had or were expected to have thrombocytopenia. The primary end point was bleeding of World Health Organization (WHO) grade 2, 3, or 4 up to 30 days after randomization. Results: A total of 600 patients (301 in the no-prophylaxis group and 299 in the prophylaxis group) underwent randomization between 2006 and 2011. Bleeding of WHO grade 2, 3, or 4 occurred in 151 of 300 patients (50%) in the no-prophylaxis group, as compared with 128 of 298 (43%) in the prophylaxis group (adjusted difference in proportions, 8.4 percentage points; 90% confidence interval, 1.7 to 15.2; P=0.06 for noninferiority). Patients in the no-prophylaxis group had more days with bleeding and a shorter time to the first bleeding episode than did patients in the prophylaxis group. Platelet use was markedly reduced in the no-prophylaxis group. A prespecified subgroup analysis identified similar rates of bleeding in the two study groups among patients undergoing autologous stem-cell transplantation. Conclusions: The results of our study support the need for the continued use of prophylaxis with platelet transfusion and show the benefit of such prophylaxis for reducing bleeding, as compared with no prophylaxis. A significant number of patients had bleeding despite prophylaxis. (Funded by the National Health Service Blood and Transplant Research and Development Committee and the Australian Red Cross Blood Service; TOPPS Controlled-Trials.com number, ISRCTN08758735.).
    New England Journal of Medicine 05/2013; 368:1771-1780. DOI:10.1056/NEJMoa1212772 · 55.87 Impact Factor

Publication Stats

784 Citations
386.25 Total Impact Points


  • 2008-2015
    • University of Melbourne
      • • Sir Peter MacCallum Department of Oncology
      • • Department of Pathology
      Melbourne, Victoria, Australia
  • 1999-2015
    • Peter MacCallum Cancer Centre
      • • Division of Haematology and Medical Oncology
      • • Department of Pathology
      • • Department of Cancer Medicine
      • • Peter MacCallum Cancer Center
      Melbourne, Victoria, Australia