Edward A Stadtmauer

University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (205)1440.54 Total impact

  • Leukemia. 11/2014;
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    ABSTRACT: Recombinant herpes zoster (HZ) vaccines may be an alternative to the live-attenuated HZ vaccine for immunocompromised individuals.This was a phase 1/2, randomized, observer-blind, placebo-controlled study in adults with multiple myeloma, non-Hodgkin lymphoma (B- or T-cell), Hodgkin lymphoma, or acute myeloid leukemia who had undergone autologous hematopoietic stem-cell transplant 50-70 days earlier. Subjects (N=121) were randomized 1:1:1:1 to receive (at months 0, 1, 3) three doses of 50 µg VZV glycoprotein E (gE) adjuvanted with AS01B, three doses of gE adjuvanted with AS01E, one dose of saline followed by two doses of gE/AS01B, or three doses of saline. One month after the last dose (6 months after transplant), frequencies of CD4(+) T cells expressing ≥2 activation markers following induction with gE and anti-gE antibody concentrations were higher with all gE/AS01 regimens than with saline. Both responses persisted up to one year in subjects vaccinated with gE/AS01. Immune responses were higher in the gE/AS01B 3-dose group than in the gE/AS01B 2-dose group but not higher than in the gE/AS01E 3-dose group. One serious adverse event (pneumonia) was considered vaccine-related. Both formulations and both schedules were immunogenic and well tolerated in this population. This study was registered at Clinicaltrials.gov as #NCT00920218.
    Blood 09/2014; · 9.78 Impact Factor
  • Leukemia & lymphoma. 09/2014;
  • Bone marrow transplantation. 07/2014;
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    ABSTRACT: The success of hematopoietic stem-cell transplantation (HSCT) with reduced-intensity conditioning (RIC) is limited by a high rate of disease relapse. Early risk assessment could potentially improve outcomes by identifying appropriate patients for pre-emptive strategies that may ameliorate this high risk. Using a series of landmark analyses, we investigated the predictive value of early (day-30) donor chimerism measurements on disease relapse, graft-versus-host disease and survival in a cohort of 121 patients who were allografted with a uniform RIC regimen. Chimerism levels were analyzed as continuous variables. In multivariate analysis, day-30 whole blood chimerism levels were significantly associated with relapse (HR=0.90, p<0.001), relapse-free survival (HR=0.89, p<0.001) and overall survival (HR=0.94, p=0.01). Day-30 T-cell chimerism levels were also significantly associated with relapse (HR=0.97, p=0.002), relapse-free survival (HR=0.97, p<0.001) and overall survival (HR=0.99, p=0.05). Multivariate models that included T-cell chimerism provided a better prediction for these outcomes compared to whole blood chimerism. Day-30 chimerism levels were not associated with acute or chronic graft-versus-host disease. We found that high donor chimerism levels were significantly associated with a low lymphocyte count in the recipient prior to transplant, highlighting the impact of pre-transplant lymphopenia on the kinetics of engraftment after RIC HSCT. In summary, low donor chimerism levels are associated with relapse and mortality and can potentially be used as an early predictive and prognostic marker. These findings can be used to design novel approaches to prevent relapse and to improve survival after RIC HSCT.
    Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation 07/2014; · 3.15 Impact Factor
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    ABSTRACT: The efficacy of proteasome inhibition for myeloma is limited by therapeutic resistance, which may be mediated by activation of the autophagy pathway as an alternative mechanism of protein degradation. Preclinical studies demonstrate that autophagy inhibition with hydroxychloroquine augments the antimyeloma efficacy of the proteasome inhibitor bortezomib. We conducted a phase I trial combining bortezomib and hydroxychloroquine for relapsed or refractory myeloma. We enrolled 25 patients, including 11 (44%) refractory to prior bortezomib. No protocol-defined dose-limiting toxicities occurred, and we identified a recommended phase 2 dose of hydroxychloroquine 600 mg twice daily with standard doses of bortezomib, at which we observed dose-related gastrointestinal toxicity and cytopenias. Of 22 patients evaluable for response, 3 (14%) had very good partial responses, 3 (14%) had minor responses, and 10 (45%) had a period of stable disease. Electron micrographs of bone marrow plasma cells collected at baseline, after a hydroxychloroquine run-in, and after combined therapy showed therapy-associated increases in autophagic vacuoles, consistent with the combined effects of increased trafficking of misfolded proteins to autophagic vacuoles and inhibition of their degradative capacity. Combined targeting of proteasomal and autophagic protein degradation using bortezomib and hydroxychloroquine is therefore feasible and a potentially useful strategy for improving outcomes in myeloma therapy.
    Autophagy 05/2014; 10(8). · 12.04 Impact Factor
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    ABSTRACT: Allogeneic hematopoietic cell transplantation (alloHCT) with reduced intensity conditioning is an appealing option for patients with high risk multiple myeloma (MM). However, progression after alloHCT remains a challenge. Maintenance therapy after alloHCT may offer additional disease control and allow time for a graft-versus-myeloma effect. The primary objective of this clinical trial was to determine the tolerability and safety profile of maintenance lenalidomide (LEN) given on days 1-21 of 28 days cycles, with intra-patient dose escalation during 12 months/cycles after alloHCT. Thirty alloHCT recipients (median age 54 years) with high risk MM were enrolled at 8 centers between 2009 -2012. The median time from alloHCT to LEN initiation was 96 days (66-171 days). Eleven patients (37%) completed maintenance and 10 mg daily was the most commonly delivered dose (44%).Most common reasons for discontinuation were aGVHD (37%) and disease progression (37%). Cumulative incidence of grades III-IV acute GVHD from time of initiation of Len was 17%. . Outcomes at 18 months after initiation of maintenance were MM progression, 28%; transplant related mortality, 11%; and progression-free and overall survival, 63% and 78%, respectively. The use of LEN post alloHCT is feasible at lower doses, although associated with a 38% incidence of aGVHD. Survival outcomes observed in this high risk MM population warrant further study of this approach.
    Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation 04/2014; · 3.15 Impact Factor
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    ABSTRACT: Myeloma-directed cellular immune responses after autologous stem cell transplantation (ASCT) may reduce relapse rates. We studied whether coinjecting the TLR-3 agonist and vaccine adjuvant Poly-ICLC with a MAGE-A3 peptide vaccine was safe and would elicit a high frequency of vaccine-directed immune responses when combined with vaccine-primed and costimulated autologous T cells.EXPERIMENTAL DESIGN: In a phase II clinical trial (NCT01245673), we evaluated the safety and activity of ex vivo expanded autologous T cells primed in vivo using a MAGE-A3 multipeptide vaccine (compound GL-0817) combined with Poly-ICLC (Hiltonol), granulocyte macrophage colony-stimulating factor (GM-CSF) ± montanide. Twenty-seven patients with active and/or high-risk myeloma received autografts followed by anti-CD3/anti-CD28-costimulated autologous T cells, accompanied by MAGE-A3 peptide immunizations before T-cell collection and five times after ASCT. Immune responses to the vaccine were evaluated by cytokine production (all patients), dextramer binding to CD8(+) T cells, and ELISA performed serially after transplant.RESULTS: T-cell infusions were well tolerated, whereas vaccine injection site reactions occurred in >90% of patients. Two of nine patients who received montanide developed sterile abscesses; however, this did not occur in the 18 patients who did not receive montanide. Dextramer staining demonstrated MAGE-A3-specific CD8 T cells in 7 of 8 evaluable HLA-A2(+) patients (88%), whereas vaccine-specific cytokine-producing T cells were generated in 19 of 25 patients (76%). Antibody responses developed in 7 of 9 patients (78%) who received montanide and only weakly in 2 of 18 patients (11%) who did not. The 2-year overall survival was 74% [95% confidence interval (CI), 54%-100%] and 2-year event-free survival was 56% (95% CI, 37%-85%).CONCLUSIONS: A high frequency of vaccine-specific T-cell responses were generated after transplant by combining costimulated autologous T cells with a Poly-ICLC/GM-CSF-primed MAGE-A3 vaccine. Clin Cancer Res; 1-11. ©2013 AACR.
    Clinical Cancer Research 02/2014; · 7.84 Impact Factor
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    ABSTRACT: Advances in the past decade and a half have led to unprecedented improved outcomes for patients with multiple myeloma (MM), and this disease appears to be transitioning to one more characteristic of a chronic disease in large part due to rapid translation of clinical insights into practice at the community level. Although evidence-based guidelines and consensus recommendations remain an important resource for managing cancer patients, they do not fill the gap between the principles of disease management today and the translation of tailoring treatment for individual patient needs. Thus, there is a continuing need for concise, focused educational activities and resources that facilitate improved knowledge and understanding of appropriate, individualized therapeutic strategies for assessing and caring for patients with MM. The next several years will truly be a time of shifting paradigms in the treatment of MM in which new agents will be approved, response criteria will be updated, and new approaches to risk assessment and monitoring minimal residual disease will evolve and enter practice. New groundbreaking therapeutic approaches, such as immunotherapy, might result in significant changes in how MM is treated and managed over the entire life cycle of the disease. Even the definition of the disease might be further amended as insights grow regarding who should be treated and who might benefit more from observation. As such, oncology clinicians will have to carefully review and update their management approaches accordingly even as they begin to focus even more on the survivorship needs of their MM patients.
    Clinical Lymphoma Myeloma and Leukemia. 01/2014;
  • Clinical Lymphoma Myeloma and Leukemia. 01/2014;
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    ABSTRACT: Background While intensive induction and ASCT prolong survival in younger patients with mantle cell lymphoma (MCL), benefit in older patients remains uncertain as data supporting these approaches come almost exclusively from younger cohorts. Patients and Methods We reviewed outcomes for 38 patients age ≥60 with MCL receiving R-CHOP (n=19) or R-HyperCVAD (n=19) with or without ASCT. Results Median progression free survival (PFS) of R-CHOP+ASCT (3.2 years) and R-HyperCVAD alone (4.0 years) was longer than for R-CHOP alone (1.6 years, p=0.013 and 0.009, respectively). R-CHOP+ASCT and R-HyperCVAD have similar PFS (p=0.66). R-HyperCVAD induction led to a higher incidence of toxicity including therapy discontinuation and need for transfusions as compared to R-CHOP, although rates of adverse events were similar for R-HyperCVAD alone vs. R-CHOP+ASCT. Conclusion R-CHOP alone is less effective therapy for fit older patients with MCL. Intensifying therapy with R-HyperCVAD induction or ASCT consolidation following R-CHOP is associated with prolonged PFS and similar rates of toxicity. Consideration should be given to individual preferences regarding the differing method of administration and relative timing of toxicity with each regimen.
    Clinical Lymphoma Myeloma and Leukemia. 01/2014;
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    ABSTRACT: Patients with multiple myeloma (MM) who relapse after autologous transplantation have limited therapeutic options. We conducted a prospective, multicenter, Phase IIa study to investigate the safety and efficacy of intravenous (IV) busulfan (Bu) in combination with bortezomib as a conditioning regimen for a second autotransplant. Because a safe Bu exposure was unknown in patients receiving this combination, Bu was initially targeted to a total area under the concentration–time curve (AUC) of 20,000 μM*min. As no concentration-limiting toxicity was observed in six patients, this Bu exposure was utilized in the following treatment cohort (n=24). Individualized Bu dose, based on test dose 0.8 mg/kg pharmacokinetics [PK], was administered daily for 4 consecutive days starting 5 days before transplant, followed by a single dose of bortezomib (1.3 mg/m2) 1 day before transplantation. The total mean dose of IV Bu (including the test dose and 4-day administration) was 14.2 mg/kg (standard deviation=2.48; range 8.7–19.2). Confirmatory PK demonstrated that only 2 of 30 patients who underwent transplantation were dosed outside the Bu AUC target and dose adjustments were made for the last two doses of IV Bu. The median age was 59 years (range, 48–73). Median time from first to second transplant was 28.0 months (range, 12–119). Of 26 evaluable patients, 10 patients attained a partial response (PR) or better at 3 months post-transplantation, with two patients attaining a complete response. At 6 months post-transplantation, five of 12 evaluable patients had maintained or improved their disease status. Median progression-free survival was 191 days, whereas median overall survival was not reached during the study period. The most common grade 3–4 toxicities were febrile neutropenia (50.0%) and stomatitis (43.3%). One transplant-related death was observed. A combination of dose-targeted IV Bu and bortezomib induced PR or better in a third of patients with MM who underwent a second autotransplant, with acceptable toxicity.
    Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 01/2014;
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    ABSTRACT: Various translocations and mutations have been identified in myeloma and certain aberrations, such as t(4;14) and del17, are linked with disease prognosis. To investigate mutational prevalence in myeloma and associations between mutations and patient outcomes, we tested a panel of 41 known oncogenes and tumor suppressor genes in tumor samples from 133 relapsed myeloma patients participating in phase 2 or 3 clinical trials of bortezomib. DNA mutations were identified in 14 genes. BRAF as well as RAS genes were mutated in a large proportion of cases (45.9%) and these mutations were mutually exclusive. New recurrent mutations were also identified, including in the PDGFRA and JAK3 genes. NRAS mutations were associated with a significantly lower response rate to single-agent bortezomib (7% versus 53% in patients with mutant versus wild-type NRAS, P = .00116, Bonferroni-corrected P = .016), as well as shorter time-to-progression in bortezomib-treated patients (P = .0058, Bonferroni-corrected P = .012). However, NRAS mutation did not impact outcome in patients treated with high-dose dexamethasone. KRAS mutation did not reduce sensitivity to bortezomib or dexamethasone. These findings identify a significant clinical impact of NRAS mutation in myeloma and demonstrate a clear example of functional differences between the KRAS and NRAS oncogenes.
    Blood 12/2013; · 9.78 Impact Factor
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    ABSTRACT: CD74, expressed in multiple myeloma (MM), was evaluated as a target for immunotherapy with milatuzumab (a humanized anti-CD74 antibody). In a multicentre dose escalation study, 25 patients with advanced MM received milatuzumab doses of 1·5 (N = 8), 4·0 (N = 9), 8·0 (N = 4) or 16·0 mg/kg (N = 4) administered twice weekly x 4. They had a median of 5 prior treatments (17 post ≥1 stem cell transplantation) and were refractory (N = 7) or relapsed (N = 18) with generally short-lived responses to last treatment (median 4·0 months). After increasing prophylactic medications and slowing administration, infusions were well tolerated (National Cancer Institute-Common Terminology Criteria v3 toxicity Grades 1-2) with no dose-limiting toxicity at higher doses. Only one patient developed borderline positive human anti-milatuzumab antibody titres of uncertain clinical significance. Although milatuzumab was rapidly cleared from circulation with little serum accumulation and low trough levels, B-cell levels were moderately decreased with treatment (median decrease, 34%). There were no objective responses by European Group for Blood and Marrow Transplantation criteria, but 5 of 19 patients (26%) who completed treatment in this heavily pretreated and generally refractory group had stable disease for ≥3 months post-treatment (one continuing for 17 months). Disease stabilization and evidence of pharmacodynamic activity support further development for use in combination with other agents or as a drug conjugate. (Clinicaltrials.gov identifier: NCT00421525).
    British Journal of Haematology 09/2013; · 4.94 Impact Factor
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    ABSTRACT: MAGE A3, which belongs to the family of cancer-testis antigens, is an attractive target for adoptive therapy given its reactivation in various tumors and limited expression in normal tissues. We developed an affinity-enhanced T cell receptor (TCR) directed to a human leukocyte antigen (HLA)-A*01-restricted MAGE A3 antigen (EVDPIGHLY) for use in adoptive therapy. Extensive preclinical investigations revealed no off-target antigen recognition concerns; nonetheless, administration to patients of T cells expressing the affinity-enhanced MAGE A3 TCR resulted in a serious adverse event (SAE) and fatal toxicity against cardiac tissue. We present a description of the preclinical in vitro functional analysis of the MAGE A3 TCR, which failed to reveal any evidence of off-target activity, and a full analysis of the post-SAE in vitro investigations, which reveal cross-recognition of an off-target peptide. Using an amino acid scanning approach, a peptide from the muscle protein Titin (ESDPIVAQY) was identified as an alternative target for the MAGE A3 TCR and the most likely cause of in vivo toxicity. These results demonstrate that affinity-enhanced TCRs have considerable effector functions in vivo and highlight the potential safety concerns for TCR-engineered T cells. Strategies such as peptide scanning and the use of more complex cell cultures are recommended in preclinical studies to mitigate the risk of off-target toxicity in future clinical investigations.
    Science translational medicine 08/2013; 5(197):197ra103. · 10.76 Impact Factor
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    ABSTRACT: The efficacy and safety of plerixafor + G-CSF in enhancing hematopoietic stem cell mobilization and collection has been demonstrated in two phase III studies involving patients with NHL or MM. In these pivotal studies, plerixafor + G-CSF significantly increased the proportion of patients achieving target stem cell yields, compared to placebo + G-CSF. In this analysis, we compare the efficacy and safety of plerixafor + G-CSF vs. placebo + G-CSF in patients enrolled in the two phase III studies, stratified by age: ≥60 years of age and <60 years of age. The proportion of older patients who achieved target stem cell yields were significantly higher in the plerixafor group than in placebo group (NHL: 50.9% vs. 25.4%, P<0.001; MM: 69.6% vs. 23.7%, P<0.001). In this older cohort, the median times to neutrophil and to platelet engraftment following autologous stem cell transplant were comparable between the plerixafor and placebo groups. Similar efficacy findings were observed in the younger age group. The most common adverse events (all grades) reported among older patients in the plerixafor group included diarrhea (41.3%), nausea (38.9%), fatigue (30.2%), and injection-site reaction (29.4%). The frequency of adverse events was similar between the older and the younger age groups. Taken together, our subanalysis demonstrate that plerixafor + G-CSF can be safely and effectively used in adult patients of all ages, including those ≥60 years, to support optimal stem cell mobilization for autologous stem cell transplantation.
    American Journal of Hematology 08/2013; · 4.00 Impact Factor
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    ABSTRACT: While the prognosis for older adults diagnosed with acute lymphoblastic leukemia (ALL) is frequently poor, long-term survival can be achieved in patients treated with curative intent. We reviewed the outcomes of 37 patients age ≥60 treated at our institution with either DVP- or hyperCVAD-based chemotherapy regimens from 2003–2011. In this patient population, a complete response rate of 92%, relapse rate of 56% and median overall survival of 18.1 months was experienced. Univariate analysis revealed that receipt of maintenance therapy vs. no maintenance therapy was associated with a statistically-significant impact on overall survival (p = 0.001, HR 0.15 for death), while disease-related characteristics including high-risk white blood cell count at diagnosis and Philadelphia chromosome status as well as treatment-related factors including chemotherapy regimen or completion of intensive therapy were not. Many patients were unable to initiate or remain on maintenance therapy due to toxicities including infections and cytopenias. Our analysis reveals the benefit of prolonged therapy in the treatment of older adults with ALL as well as the high incidence of treatment-related toxicity experienced by these patients. Am. J. Hematol. 88:657–660, 2013. © 2013 Wiley Periodicals, Inc.
    American Journal of Hematology 08/2013; 88(8). · 4.00 Impact Factor
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    ABSTRACT: Salvage chemotherapy followed by autologous stem cell transplant (ASCT) remains the current standard of care for patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) with chemosensitive disease. The addition of rituximab results in improved overall survival (OS) after first-line treatment, but cure rates of salvage therapy with ASCT are inferior when compared to historical controls. Historically, patients with DLBCL with disease progression following ASCT have had an extremely poor prognosis with a median OS of 3 months. However, there are little data regarding outcomes in the rituximab era. We performed a retrospective study of 56 patients with relapsed or refractory DLBCL with prior exposure to rituximab who had disease progression following ASCT. The median OS from progression following ASCT for the cohort was 9.9 months (95% CI: 5.3-13.1 months). Patients who progressed less than 1 year from ASCT had a significantly shorter OS than those who progressed at 1 year or greater from ASCT (8.2 vs. 26.7 months, p=0.01). Patients with at least stable disease following ASCT had a longer OS than those who progressed immediately after ASCT (12.3 vs. 5.3 months, p=0.01). Other factors associated with OS were International Prognostic Index (IPI) (p=0.01) and LDH level (p=0.003) at the time of progression following ASCT. In the rituximab era, the prognosis for patients with disease progression following ASCT remains poor, but is improved when compared with historical controls. Ultimately, more work needs to be done to develop novel therapeutic strategies tailored to individual patients in this heterogeneous population.
    American Journal of Hematology 06/2013; · 4.00 Impact Factor
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    ABSTRACT: An obstacle to cancer immunotherapy has been that the affinity of T cell receptors (TCRs) for antigens expressed in tumors is generally low. We initiated clinical testing of engineered T cells expressing an affinity-enhanced T cell receptor against HLA-A*01-restricted MAGE-A3. Open-labeled protocols to test the TCRs for patients with myeloma and melanoma were initiated. The first two treated patients developed cardiogenic shock and died within a few days of T cell infusion, events not predicted by pre-clinical studies of the high-affinity T cell receptors (TCR). Gross findings at autopsy revealed severe myocardial damage and histopathological analysis revealed T cell infiltration. No MAGE-A3 expression was detected in heart autopsy tissues. Robust proliferation of the engineered T cells in vivo was documented in both patients. A beating cardiomyocyte culture generated from induced pluripotent stem cells triggered T cell killing, which was due to recognition of an unrelated peptide derived from the striated muscle specific protein titin. These cases demonstrate that TCR-engineered T cells can have serious and not readily predictable off-target and organ-specific toxicities, and highlight the need for improved methods to define the specificity of engineered TCRs. The protocols were registered at clinicaltrials.gov (NCT01350401 and NCT01352286).
    Blood 06/2013; · 9.78 Impact Factor
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    ABSTRACT: Several cytogenetic abnormalities are associated with poor outcomes in multiple myeloma (MM). We prospectively analyzed the impact of cytogenetic abnormalities on outcomes during the phase 2 PX-171-003-A1 study of single-agent carfilzomib for relapsed and refractory MM. In the response-evaluable population (257/266), fluorescence in situ hybridization (FISH)/conventional cytogenetic profiles were available for 229 patients; 62 (27.1%) had high-risk cytogenetics-del 17p13, t(4;14), or t(14;16) by interphase FISH, or deletion 13 or hypodiploidy by metaphase cytogenetics-and 167 (72.9%) had standard-risk profiles. Generally, baseline characteristics were similar between subgroups, but ISS stage III disease was more common in high- versus standard-risk patients (41.9 vs 27.5%) as was ECOG performance status 1/2 (85.5 vs 68.3%). Overall response was comparable between subgroups (25.8 vs 24.6%, respectively; P=0.85), while time-to-event endpoints showed a trend of shorter duration in high-risk patients, including median duration of response (5.6 months [95% CI 3.7-7.8] vs 8.3 months [95% CI 5.6-12.3]) and overall survival (9.3 [95% CI 6.5-13.0] vs 19.0 months [95% CI 15.4-NE]; P=0.0003). Taken together, these findings demonstrate that single-agent carfilzomib is efficacious and has the potential to at least partially overcome the impact of high-risk cytogenetics in heavily pre-treated patients with MM.Leukemia accepted article preview online, 14 May 2013; doi:10.1038/leu.2013.152.
    Leukemia: official journal of the Leukemia Society of America, Leukemia Research Fund, U.K 05/2013; · 10.16 Impact Factor

Publication Stats

8k Citations
1,440.54 Total Impact Points

Institutions

  • 1992–2014
    • University of Pennsylvania
      • • "Abramson" Cancer Center
      • • Division of Hematology/Oncology
      Philadelphia, Pennsylvania, United States
  • 1989–2014
    • Hospital of the University of Pennsylvania
      • • Division of Hematology/Oncology
      • • Department of Medicine
      • • Division of General Medicine
      Philadelphia, Pennsylvania, United States
  • 2013
    • Washington University in St. Louis
      San Luis, Missouri, United States
    • Mayo Clinic - Rochester
      • Department of Hematology
      Rochester, Minnesota, United States
  • 2012
    • University of Wisconsin–Madison
      Madison, Wisconsin, United States
    • Fred Hutchinson Cancer Research Center
      • Division of Clinical Research
      Seattle, WA, United States
  • 2010
    • Loyola University Maryland
      Baltimore, Maryland, United States
    • Loyola University Chicago
      Chicago, Illinois, United States
  • 2009
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
  • 2005–2007
    • Dana-Farber Cancer Institute
      • Department of Medical Oncology
      Boston, MA, United States
    • University of Maryland Medical Center
      Baltimore, Maryland, United States
  • 2002
    • University of Texas MD Anderson Cancer Center
      Houston, Texas, United States
  • 2000
    • Tufts University
      Georgia, United States
  • 1997
    • New England Baptist Hospital
      Boston, Massachusetts, United States
  • 1994
    • Group Health Cooperative
      Seattle, Washington, United States