Showing posts with label Rituxan. Show all posts
Showing posts with label Rituxan. Show all posts

Wednesday, July 3, 2013

Hairy Cell Leukemia: A Pleasant Surprise...

It's been a week since my restaging appointment at NIH.  Those of you in the trial know the routine:  CBC bloodraw in Phlebotomy, MRI and ultrasound in Imaging, then bone marrow biopsy and aspiration (my tenth) in Out-patient Procedures.  Get an X-ray and EKG in between those appointments. 

Waiting for results over the past week was nerve-wracking.  I got the CBC results that day.  My platelets were down slightly.  All white counts were normal, but looked like they were trending down too.  Red counts were fine, and they had certainly been pulling their share during all the recent hikes I've taken. 

Recovering from a head cold, I thought maybe that could account for the slight dip I perceived in the platelets and neutrophils.  Last year, 18 months after my final Rituxan treatment, my bone marrow aspirate came back slightly positive (.08%) for HCL.  At the time, Dr. K indicated that it might come back negative in a year, but I didn't think it would.  I assumed the cells would double every 3 weeks, and I'd have 60 to 80 weeks before I would need to be retreated.  Enough time to maybe let me get into an inhibitor trial and avoid chemo, which suppressed my marrow much longer than expected when I was first treated.  Thinking about going back for retreatment and the possibility of another chemo was starting to wear on me. 

Well, I'm pleased to report that both my peripheral blood and bone marrow aspirate flow results were negative for hairy cell leukemia - providing further data to show that using Rituxan to treat minimal residual disease (MRD) may allow the body to get an upper hand in keeping the disease in check.  In my case, chemo didn't get me into a partial or complete remission (CR), and a first cycle of Rituxan at 6 months post chemo to treat continued HCL infiltration allowed me to get a short-term CR.  A year later, when MRD first appeared, the second cycle of Rituxan had the opportunity to knock out what remained.

I've been in CR ever since that final treatment, and now there's no evidence of HCL at all!  My body is keeping it in check and appears to have eliminated the small amount that was detected last year.  Although the PCR lab was never able to clone my hairy cells to perform the hyper-sensitive MRD test and determine if HCL is completely eradicated from my body, I'm elated that I appear to have the upper-hand at this point.  The only supplement I take is 1000 IU of Vitamin D in the winter.  My diet is relaxed and normal, just no junk food or soda.  My ultrasound tech said my liver was now "textbook" and no longer fatty like it was when I was first diagnosed.

I couldn't have gotten to this point had I not participated in the NIH trial for newly diagnosed HCL patients.  I'm eternally grateful to Dr. K, Rita and the fantastic team at NIH.

Sunday, January 20, 2013

It's Been Awhile...

It's hard to believe my last post dates back to July, 2011.  So much has happened since then.  Shortly after my last post, I experienced a significant drop in a type of white blood cell known as neutrophils, which I attribute to an effect known as Rituxan-related late-onset-neutropenia (LON).  I quickly recovered with the help of the expert staff at NIH, where I am being treated.  The neutrophil count of 700 that I alluded to in my last post was just the beginning.  I dipped all the way down to 0 but recovered quickly with the help of neupogen (aka: Neulasta), a hormone that induces the marrow to produce neutrophils.  Everything worked out fine in just a few days.  I'm grateful for everyone at NIH who treated me and helped me recover.  They are fantastic!

Otherwise, I've been working hard and just enjoying life.  Great progress has been made with respect to early treatments using Vemurafenib  (aka PLX-4032), the BRAF V-600E inhibitor that targets the mutation specific to nearly 100% of hairy cell classic cases.  UVA rays from sunlight induce the mutation (the same one that causes 50% of melanoma cases).  In other words, the cause of hairy cell leukemia is sun exposure.  A refractory patient in Germany was the first I know of to receive Vemurafenib, and now a patient in England -- an incredibly courageous individual who has seen more hardship over the past two years than I can imagine.  He's a pathfinder and an inspiration to many of us.  Both patients had given up hope of achieving a meaningful remission with the known chemotherapies (Cladribine, Pentostatin, and Bendamustine) and tried the Vemurafenib as a last hope.  I believe one of them got down to a platelet count of 10 (out of 160,000) when he started treatment.  This new drug appears to be working well -- melting away the refractory hairy cells, and also is being investigated to treat papillary thyroid cancer, which is also associated with the BRAF V600 mutations (thus probably caused by excess UVA exposure). 

NIH is preparing to start a trial in March, 2013 for refractory and relapsed patients that will investigate two other BRAF V600 inhibitors to treat HCL.  I will post a link to that trial and protocol when it becomes available.  Interested individuals should contact Dr. Kreitman at NIH. He always welcomes direct calls from patients (see his number in the blog sidebar). 

Personally, everything is well with me.  My counts are still great, and I had a peripheral blood flow cytometry test last week which was negative for hairy cells.  My last bone marrow biopsy was in June, 2012.  The core was negative for hairy cells, and the aspirate only showed 0.08% hairies, if I recall correctly.  I've started rowing 2 to 4 miles every day and hope to join a local rowing club soon.  The only daily supplement I take is 1000 IU of Vitamin D in the winter and early Spring.

I continue to highly endorse NIH for both new and refractory/relapsed patients.  The Cladribine + Rituxan trial has had a 100% remission rate for new patients (over 70 now), which is amazing.  I know I'd be in a very different position right now had I not received both rounds of Rituxan when I did -- to treat minimal residual disease instead of relapse.  My participation in the trial made all the difference in the world between achieving a CR (complete remission) and being among the 20% of patients who do not with just standard chemotherapy. 

All first time HCL patients should call Dr. Kreitman at NIH to discuss treatment options and submit research samples before proceeding with treatment, regardless of whether they decide to seek treatment at their local hemoncologist or NIH.

Just one more thing:  Here is a link to 15-year-old Jack Andraka's TED talk.  At 3-cents, his carbon nanotube antibody-based sensor (patent pending) costs 1/26000th that of the $800, 60-year-old ELISA test for pancreatic cancer and is 100 times more sensitive.  The possible applications cover a broad spectrum -- from water contamination to HIV detection, and will improve the lives of billions.  He's showing us that innovation can bridge the gap between providing services and cutting costs.  Glad Intel and the school systems are still supporting and promoting science fairs.  This is one helluva return on investment!!!


Happy New Year to All!

- Jon

Here are some articles related to the BRAF V600E mutation and HCL Classic:

The BRAF V600E Mutation in Hairy Cell Leukemia

BRAF Inhibition in Refractory Hairy-Cell Leukemia

Sunday, January 23, 2011

Hairy Cell Leukemia Trivia

Thought I'd put together a few trivia questions for those of you who want to test your hairy cell leukemia knowledge:

Questions:
1) What causes hairy cell leukemia?
2) Who discovered hairy cell leukemia?
3) In what year was hairy cell leukemia discovered?
4) Where was hairy cell leukemia discovered?
5) What is the formal name of hairy cell leukemia?
6) What protein is overexpressed on hairy cells and the main target of monoclonal antibody therapy?
7) What does the "CD" in "CD20" stand for?
8) Name the primary chemotherapies for hairy cell leukemia?
9) When is Pentostatin typically used in lieu of Cladribine?
10) What's the term for treatment with a monoclonal antibody (mAb)?
11) What is the primary mAb used to treat hairy cell?
12) What other surface proteins are also targeted in hairy cell?
13) Name a well known HCL immunotoxin?
14) Who is Ira Pastan?
15) What is the bacterial toxin used in HA22, and what's its origin?
16) What is the typical cause of fever after treatment with Cladribine (commonly misdiagnosed as "a mystery infection")?
17) What are the three modes of cell death mediated by Rituxan?
18) Who invented Cladribine?
19) Which is the more effective approach for administering Cladribine?
              5 day x 2 hour IV
              or 24x7 drip?
20) At what stage of cellular development is the malignant mutation of hairy cell believed to occur?
21) What is the median age of an HCL patient at diagnosis?
22) Is HCL more prevalent in men or women?
23) What type of cells are hairy cells from?
24) What is the average period of remission for HCL after Cladribine chemotherapy?
25) What percentage of patients receiving Cladribine have a complete remission, partial remission, and no response?
26) How rare is hairy cell leukemia?
27) What does MRD stand for?
28) Is there a cure for hairy cell leukemia?
29) The first case of patient/doctor genetic rights involved hairy cell leukemia and what university?
30) What's the life expectancy of the average hairy cell leukemia patient?
31) When should hairy cell leukemia be treated?
32) What is Hairy Cell Leukemia?
33) What is Bruton's Tyrosine Kinase (BTK)?
34) What Hairy Cell Leukemia (HCL) treatment options are available to multiply relapsed and refractory patients who don't respond to chemotherapy?

Answers:
1) Most cases of classic HCL have a BRAF V600E DNA mutation, caused by a photon from sunlight inducing an RNA translation error in a B-cell (a type of white blood cell) during replication.  This mutation is also common to 50% of melanoma cases, but in that case, it affects a skin cell.  The causes of other variants of HCL are unknown.
2) Bertha A. Bouroncle, MD
3) 1958
4) Ohio State University
5) Reticuloendotheliosis
6) CD20
7) "Cluster of Differentiation"
8) Cladribine and Pentostatin
9) When a patient's counts are so low or health is so weak that a less sudden drop in counts is needed; however, it is sometimes used if a patient doesn't respond to Cladribine.  Pentostatin is administered over several weeks whereas Cladribine is administered in 5 or 7 days.
10) mAb therapy
11) Rituximab (aka: Rituxan)
12) CD25, CD22
13) HA22
14) Head of NCI laboratory of molecular biology and immunotoxin development
15) Pseudomonas Exotoxin from Pseudomonas aeruginosa
16) Tumor Lysis (hairy cells dying)
17) Apoptosis (cell suicide), antibody-dependent cell-mediated cytotoxicity (ADCC), complement-dependent cytotoxicity (CDC)
18) Dr. Dennis Carson
19) Both are considered equally effective
20) Later in the differentiation process at the level of the germinal center B-cells, likely in the process of differentiating to a Memory B-cell (per Basso, et al, p.62, col 1).
21) 52
22) Men, by a ratio of 4:1
23)  B-cells, a type of lymphocyte.
24) Ten years.
25) 80%, 15% and 5% respectively.
26) HCL accounts for only 2% of diagnosed/reported cases of leukemia.  However, it may be more prevelant since it can remain "in-check" in many people without ever being diagnosed.
27) Minimal Residual Disease.
28) Not yet, but there are hairy cell clinical trials trying to establish a cure curve.
29) UCLA (link to court case)
30) The average patient will have a normal life expectancy.
31) In general, HCL should be treated when blood counts indicate one of the following conditions:
                 Platelets (PLT) < 100 K/uL
                 Hemoglobin (HGB) < 10 g/dL
                 Absolute Neutrophils (ANC) < 1.0 K/uL
       however, Dr. Michael Grever, in his paper "How I treat Hairy Cell Leukemia (Blood, 10/2009)" states the following:
                   "Therefore, I recommend that therapy be initiated when a declining trajectory predicts that the patient will reach a platelet count less than 100,000/uL or an absolute granulocyte count consistently below 1,000/uL."
32)  HCL is an uncommon, chronic, neoplastic (malignant) disorder of B lymphocytes (a type of white blood cell) that predominantly afflicts middle-aged men. The patient usually presents with pancytopenia (broad spectrum reduction in blood counts -- low platelets, low white blood cells, low red blood cells). In the U.S., there are 500 to 800 cases of HCL annually, representing just 2% of all leukemias. Although it is incurable, it is highly treatable, with an average remission of 10 years.
33) BTK is an enzyme that's critical to the maturation of B-cells.  Inhibiting it, with drugs like Ibrutinib, has proven to be a well-tolerated and effective means of targeting a variety of leukemias and lymphomas.  Clinical trials using Ibrutinib to target hairy cell leukemia in relapsed and refractory patients are now underway.
34)  Multiply relapsed and refractory Hairy Cell Leukemia (HCL) patients should consider the moxetumomab (moxe) clinical trial at NIH.  A majority of patients have achieved complete remissions and in many cases eliminated MRD.