We report on the feasibility of outpatient transplant in 716 patients undergoing autologous stem cell transplant for multiple myeloma at Mayo Clinic's site in Rochester, MN, from January 1, 2000, ...through October 31, 2007. We also report on the development and effect of a multidisciplinary quality initiative implemented by the Mayo Clinic Blood and Marrow Transplant Program involving physicians, nurses, pharmacists, dietitians, and financial specialists for outpatient management of patients undergoing stem cell transplant. This approach uses an electronic ordering system for diagnostic tests and chemotherapy to minimize medical errors. Analysis of hospitalization trends since inception of the program showed that 278 (39%) of the 716 patients treated completed the transplant procedure as outpatients. The median duration of hospitalization for all patients was 4 days; age and serum creatinine levels were predictive of the need for and duration of hospitalization. We also assessed recent treatment-related mortality rates during a 33-month period after implementation of the program (between January 1, 2005, and October 1, 2007). The 100-day survival rate was 99.5% for patients with low-risk myeloma (transplant during first plateau; n=201) and 97.2% for patients with high-risk myeloma (refractory, relapsing or second or greater plateau; n=71). The overall 100-day survival rate was 98.9%. Our experience shows that outpatient transplant is feasible for all patients with multiple myeloma and results in shorter hospital stays and low treatment-related mortality rates.
OBJECTIVE To identify and assess the clinical features and treatment response of light chain (AL) amyloidosis diagnosed in patients with previous diagnosis of multiple myeloma (MM). PATIENTS AND ...METHODS From a prospectively maintained database, we identified 47 patients seen between January 1, 1990, and August 31, 2008, with a diagnosis of AL amyloidosis that was made at least 6 months after MM diagnosis; these patients form the study group. RESULTS Among the 47 patients, 36 developed typical features, 3 had atypical features, and 8 had an incidental finding of amyloidosis. Amyloid deposits were demonstrated in bone marrow, subcutaneous fat aspirate, or organ biopsy in 24, 19, and 12 patients, respectively. One organ was involved in 29 patients (62%), whereas 11 patients (23%) had involvement in more than one organ. At diagnosis of AL amyloidosis, treatment was changed or started in 22 patients, whereas the same treatment was continued in 21 patients, and no treatment data were available for the rest. The best hematologic response included partial response or better in 11 patients (23%) and stable disease in 18 patients (38%). Improvement in an organ was seen in 3 of the 21 evaluable patients. The median overall survival from diagnosis of AL amyloidosis was 9.1 months (95% confidence interval, 4-14). Of the 6 patients still alive, 2 underwent peripheral blood stem cell transplant, and none had cardiac involvement or involvement in more than one organ. CONCLUSION Delayed onset of AL amyloidosis is rarely seen in patients with MM and requires a high index of suspicion for prompt diagnosis. Outcome of these patients is poor, especially in the presence of cardiac involvement.
Overall survival (OS) has improved with increasing use of novel agents in multiple myeloma (MM). However, the disease course remains highly variable, and the heterogeneity largely reflects different ...genetic abnormalities. We studied the impact of the Mayo risk-stratification model of MM on patient outcome in the era of novel therapies, evaluating each individual component of the model—fluorescence in situ hybridization (FISH), conventional cytogenetics (CG), and the plasma cell labeling index—that segregates patients into high- and standard-risk categories. This report consists of 290 patients with newly diagnosed MM, predominantly treated with novel agents, who were risk-stratified at diagnosis and were followed up for OS. Of these patients, 81% had received primarily thalidomide (n=50), lenalidomide (n=199), or bortezomib (n=79) as frontline or salvage therapies. Our retrospective analysis validates the currently proposed Mayo risk-stratification model (median OS, 37 months vs not reached for high- and standard-risk patients, respectively; P =.003). Although the FISH or CG test identifies a high-risk cohort with hazard ratios of 2.1 ( P =.006) and 2.5 ( P =.006), respectively, the plasma cell labeling index cutoff of 3% fails to independently prognosticate patient risk (hazard ratio, 1.4; P =.41). In those stratified as standard-risk by one of the 2 tests (FISH or CG), the other test appears to be of additional prognostic significance. This study validates the high-risk features defined by FISH and CG in the Mayo risk-stratification model for patients with MM predominantly treated with novel therapies based on immunomodulatory agents.
We examined the potential role of Doppler myocardial imaging for early detection of systolic dysfunction in patients with systemic amyloidosis (AL) but without evidence of cardiac involvement by ...standard echocardiography. We identified 42 patients without 2-dimensional echocardiographic or Doppler evidence of cardiac involvement. These patients had normal ventricular wall thickness and normal velocity of the medial mitral annulus. Myocardial images were obtained in these patients and in 32 age- and gender-matched healthy controls. Peak longitudinal systolic tissue velocity (sTVI), systolic strain rate (sSR), and systolic strain (sS) were determined for 16 left ventricular segments. Radial and circumferential sSR and sS were also measured. Compared with controls in this group of patients with AL, peak longitudinal sSR (−1.0 ± 0.2 vs −1.4 ± 0.2, p <0.001) and peak longitudinal sS (−15.6 ± 3.3 vs −22.5 ± 2.0 p <0.001) were significantly decreased. In conclusion, the mean sS from all 6 basal segments, or from all 16 left ventricular segments differentiated patients with AL with normal echocardiography from controls, with similar accuracy for the mean sSR from the 6 basal segments. This distinction was not apparent from peak longitudinal sTVI or from radial or circumferential sSI or sSR.
Acute Lung Toxicity Related to Pomalidomide Geyer, Holly L., MD; Viggiano, Robert W., MD, FCCP; Lacy, Martha Q., MD ...
Chest,
08/2011, Letnik:
140, Številka:
2
Journal Article
Recenzirano
Pomalidomide is an immunomodulatory derivative (IMiD) active in multiple myeloma. In this report, we review the course of two patients receiving pomalidomide therapy who subsequently developed ...dyspnea, fever, hypoxia, and ground-glass opacities on CT scan. An extensive workup for infectious causes was negative. Both patients improved with discontinuation of the medication and/or treatment with corticosteroids. Both patients were restarted on pomalidomide therapy at a lower dose, with one patient experiencing an immediate recurrence of pulmonary symptoms. The combination of symptoms, radiographic findings, clinical course, and response to treatment strongly supports the diagnosis of acute pulmonary toxicity secondary to pomalidomide. We then review previously published pulmonary toxicity data on thalidomide and lenalidomide and compare the described clinical courses, radiographic findings, and responses to treatment with those observed in our patients. We conclude that pulmonary toxicity is a potential adverse effect of pomalidomide therapy and encourage physicians to remain cognizant of its clinical presentation.
OBJECTIVE To determine the prognostic value of serum uric acid (UA) in patients with primary systemic (light chain) amyloidosis (AL). PATIENTS AND METHODS A cohort of 1977 patients with newly ...diagnosed AL seen at our institution between April 1, 1960, and August 1, 2006, and 293 patients with AL who underwent peripheral blood stem cell transplant between March 1, 1996, and October 1, 2006, were studied retrospectively to examine the value of serum UA. The prognostic value of several variables was examined using Cox proportional hazards models, and the survival time was estimated using Kaplan-Meier analysis; curves were compared using the log-rank test. RESULTS Patients with UA levels greater than 8 mg/dL had a median overall survival of 9 months from diagnosis compared with 20.3 months for the remaining patients ( P <.001). The prognostic value of UA was independent of the known cardiac prognostic markers cardiac troponin T (cTnT) and N-terminal propeptide of brain-type natriuretic peptide (NTProBNP). Addition of UA to these factors allows us to classify patients into 4 groups with significantly different outcomes. Patients with none, 1, 2, or 3 of these risk factors (UA, >8 mg/dL; cTnT, >0.035 ng/mL; and NTProBNP, >332 pg/mL) had a median overall survival of 36.6, 29.2, 11.1, and 3.6 months, respectively ( P <.001). Similarly, UA levels helped predict overall survival in patients undergoing peripheral blood stem cell transplant for AL and added to the value of cTnT and NTProBNP. CONCLUSION The data confirm the prognostic utility of cTnT and NTProBNP in a large group of patients and highlight the value of serum UA in allowing better forecasting of probable outcomes for patients with AL.
Highlights • In high-risk (HR) patients by FISH, post-ASCT sCR leads to superior PFS but not OS. • Post-ASCT MRD-negativity leads to a superior PFS and OS. • sCR and MRD- status did not impact PFS/OS ...in del(17p) and ≥2 HR subgroups. • In the subgroup with t(4;14), post-ASCT MRD negativity improved PFS and OS.
Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), are part of a growing cancer care workforce. Current hematology-specific education provided by ...most graduate NP and PA school educations is limited. Mayo Clinic School of Health Sciences launched a hematology-specific fellowship in 2018 to provide APPs with the skills and knowledge required to deliver high-quality specialty care in hematology and blood and marrow transplant (BMT). The fellowship curriculum was developed based on a needs-based assessment study as well as the qualitative reported experiences of current hematology-specific APPs. The curriculum contains didactic in-class education, research opportunities, and mentored clinical rotations in both inpatient and outpatient practice in hematology and BMT. This 12-month fellowship, one of the only postgraduate training programs dedicated to benign and malignant hematology practice, provides structured training for highly qualified graduate APPs interested in developing a rewarding career in hematology.
PDF
