Intrathecal Infusion Research Articles

In Vivo Intrathecal Tracer Dispersion in Cynomolgus Monkey Validates Wide Biodistribution Along Neuraxis.

It is commonly believed that in intrathecal (IT) drug delivery, agent distribution is confined to a narrow region close to the injection site, thereby undermining the efficacy of the method. To test the claim, multimodal in vivo imaging was used to experimentally observe the effects of IT infusion in cynomolgus monkey, looking at cerebrospinal fluid flow, anatomy, and dispersion of a radiolabeled tracer. At high infusion rates, the tracer reached the cervical region after only 2 h, demonstrating rapid and wide distribution. The same in vivo nonhuman primate imaging data also provided evidence in support of a computational fluid dynamic model for the prediction of drug distribution following IT injection. Tracer dispersion was predicted in two specimens matching the distribution acquired with positron emission tomography (PET). For the third specimen, tracer dispersion simulations were conducted as a blind study: predictions were made before in vivo biodistribution data was known. In all cases, the computational fluid dynamics (CFD) predictions of drug dispersion after IT administration showed close spatio-temporal agreement with tracer biodistribution in vivo. Validation by in vivo nonhuman primate data confirms our ability to predict the biodistribution of intrathecally administered agents in subject-specific models of the central nervous system from first principles. The experiments reinstate IT delivery as a viable administration method when targeting molecules to the whole spine or the brain. The proposed computational methodology enables rational design of novel therapies for neurological diseases that require reliable, efficient, and safe delivery of therapeutic agents to specific target sites in the central nervous system.

Case Report: Morphine withdrawal induced convulsions in an adult male patient

This case report describes a possible unknown complication of morphine withdrawal in a patient with persistent back pain, treated with intrathecal morphine pump infusion. The patient presented with left lower extremity edema. After excluding deep vein thrombosis by Doppler ultrasound and worsening of the swelling despite oral antibiotics, peripheral edema caused by intrathecal morphine was suspected. Twelve hours following the termination of his intrathecal morphine pump and initiation of inequivalent doses of oral morphine and tramadol, he developed convulsions. After metabolic and structural causes of convulsion were ruled out by blood tests and head imaging, equivalent doses of morphine were given. Then the patient regained full consciousness, and no additional seizures occurred. After that, opioid withdrawal emerged as the most likely explanation. Seizure is a life-threating condition; therefore, an awareness of this case is important and further studies are warranted to explore the potential association of opioid withdrawal and seizure.

Mast Cell Degranulation and Fibroblast Activation in the Morphine-induced Spinal Mass: Role of Mas-related G Protein-coupled Receptor Signaling.

As the meningeally derived, fibroblast-rich, mass-produced by intrathecal morphine infusion is not produced by all opiates, but reduced by mast cell stabilizers, the authors hypothesized a role for meningeal mast cell/fibroblast activation. Using the guinea pig, the authors asked: (1) Are intrathecal morphine masses blocked by opiate antagonism?; (2) Do opioid agonists not producing mast cell degranulation or fibroblast activation produce masses?; and (3) Do masses covary with Mas-related G protein-coupled receptor signaling thought to mediate mast cell degranulation? In adult male guinea pigs (N = 66), lumbar intrathecal catheters connected to osmotic minipumps (14 days; 0.5 µl/h) were placed to deliver saline or equianalgesic concentrations of morphine sulfate (33 nmol/h), 2',6'-dimethyl tyrosine-(Tyr-D-Arg-Phe-Lys-NH2) (abbreviated as DMT-DALDA; 10 pmol/h; μ agonist) or PZM21 (27 nmol/h; biased μ agonist). A second pump delivered subcutaneous naltrexone (25 µg/h) in some animals. After 14 to 16 days, animals were anesthetized and perfusion-fixed. Drug effects on degranulation of human cultured mast cells, mouse embryonic fibroblast activation/migration/collagen formation, and Mas-related G protein-coupled receptor activation (PRESTO-Tango assays) were determined. Intrathecal infusion of morphine, DMT-DALDA or PZM21, but not saline, comparably increased thermal thresholds for 7 days. Spinal masses proximal to catheter tip, composed of fibroblast/collagen type I (median: interquartile range, 0 to 4 scale), were produced by morphine (2.3: 2.0 to 3.5) and morphine plus naltrexone (2.5: 1.4 to 3.1), but not vehicle (1.2: 1.1 to 1.5), DMT-DALDA (1.0: 0.6 to 1.3), or PZM21 (0.5: 0.4 to 0.8). Morphine in a naloxone-insensitive fashion, but not PZM21 or DMT-DALDA, resulted in mast cell degranulation and fibroblast proliferation/collagen formation. Morphine-induced fibroblast proliferation, as mast cell degranulation, is blocked by cromolyn. Mas-related G protein-coupled receptor activation was produced by morphine and TAN67 (∂-opioid agonist), but not by PZM21, TRV130 (mu biased ligand), or DMT-DALDA. Opiates that activate Mas-related G protein-coupled receptor will degranulate mast cells, activate fibroblasts, and result in intrathecal mass formation. Results suggest a mechanistically rational path forward to safer intrathecal opioid therapeutics.

Pharmaceutical care for a patient with refractory cancer pain treated by intrathecal infusion of hydromorphone

Pharmaceutical care for a patient with refractory cancer pain treated by intrathecal infusion of hydromorphone

PS946 BLINATUMOMAB + PONATINIB FOR RELAPSED PH1‐POSITIVE ACUTE LYMPHOBLASTIC LEUKEMIA: THE FRENCH EXPERIENCE

Background:Despite the progress achieved with the combination of BCR‐ABL1 tyrosine kinase inhibitors (TKI) and chemotherapy, the prognosis of patients with a refractory/relapsed Philadelphia chromosome‐positive acute lymphoblastic leukemia (Ph1+ ALL) is still very dismal. However, new drugs have recently improved outcomes of these patients: ponatinib has shown some efficacy in this context and a recent study has reported very encouraging results of the anti‐CD3/CD19 monoclonal antibody blinatumomab as single‐agent. Data regarding the efficacy and tolerance of a combination of blinatumomab+ponatinib (blina/pona) are still scarce.Aims:Methods:This was a retrospective study in 12 French centers: 23 patients with a relapsed/refractory Ph1+ ALL have concomitantly received blinatumomab (28 mg/day by continuous infusion for 28 days every 6 weeks) and daily orally ponatinib.Results:There were 13 males and 10 females, with a median age of 58 years (range:17–72). All patients, but 3 with blast crisis of chronic myeloid leukemia, had de novo Ph1+ ALL. Seven cases (30.4%) had BCR‐ABL1 T315I mutation. Patients received the blina/pona combination, either after a first (n = 10) or a second or more (n = 11) cytologic relapse. There was one refractory patient. One patient received blina/pona in consolidation, after serious side effects from front‐line chemotherapy. Previous allograft and autograft has been performed in 9 and 4 patients, respectively. The majority of patients (n = 15) had previously received 3 2 or more lines of TKI. The median number of blinatumomab cycle administered per patient was 3 (range: 1–5) while ponatinib was administered continuously at an initial dose of 45 mg once daily in 17 pts (74%) and 30 mg in 6 pts (26%) during a median time of 5 months (range: 1–41) from first blinatumomab cycle. The toxicity profile was safe: blinatumomab was stopped in 48% of cases because of neurologic events in 4, infections in 4 and cytokine release syndrome in 3 patients; ponatinib was stopped in 22% of cases because of neurologic events in 3, hepatobiliary disorder in 1 and severe arteriopathy in 1 patient who had others vascular disease risk factors. All neurologic events resolved after stopping involved drug. All but one patient (95.6%) obtained a cytologic complete remission (CR), of whom 19/22 (86%) achieved a complete molecular response (CMR). However, 2 patients were documented with CNS relapse, treated with intrathecal infusion of chemotherapy. Then, 7 patients underwent allogeneic transplant (including 3 patients already allotransplanted before blina/pona). With a median follow‐up of 29 months (range: 17.5–66.7) for the alive patients (74%), median overall survival from first cycle of blina/pona was not reached and leukemia‐free survival was 18.2 months (range: 1.3–41). At last follow‐up (February 2019), 7 relapses had occurred at a median of 7 months (range: 1.3–41) from first blina/pona cycle and 1 patient had refractory disease. 6 patients (26%) had died of 2 bacterial infections, 2 fungal infections, 1 secondary cancer and 1 progressive refractory ALL. Among the 17 patients alive, one had relapsed and 16 are still in CMR, but 2 with CNS relapse. Twelve patients are still under ponatinib medication.Summary/Conclusion:The combination of blinatumomab+ponatinib appears effective and tolerable in relapsed Ph1+ALL patients. It could replace chemotherapy salvage regimens and allow a brigde to allogeneic transplantation, or may be tested in first‐line therapy in the future. Our results have to be confirmed prospectively on a larger cohort of patients.

Adjacent intact nociceptive neurons drive the acute outburst of pain following peripheral axotomy

Injury of peripheral nerves may quickly induce severe pain, but the mechanism remains obscure. We observed a rapid onset of spontaneous pain and evoked pain hypersensitivity after acute transection of the L5 spinal nerve (SNT) in awake rats. The outburst of pain was associated with a rapid development of spontaneous activities and hyperexcitability of nociceptive neurons in the adjacent uninjured L4 dorsal root ganglion (DRG), as revealed by both in vivo electrophysiological recording and high-throughput calcium imaging in vivo. Transection of the L4 dorsal root or intrathecal infusion of aminobutyrate aminotransferase inhibitor attenuated the spontaneous activity, suggesting that retrograde signals from the spinal cord may contribute to the sensitization of L4 DRG neurons after L5 SNT. Electrical stimulation of low-threshold afferents proximal to the axotomized L5 spinal nerve attenuated the spontaneous activities in L4 DRG and pain behavior. These findings suggest that peripheral axotomy may quickly induce hyperexcitability of uninjured nociceptors in the adjacent DRG that drives an outburst of pain.

Anti-Neurofascin-155 IgG4 antibodies prevent paranodal complex formation in vivo.

Neurofascin-155 (Nfasc155) is an essential glial cell adhesion molecule expressed in paranodal septate-like junctions of peripheral and central myelinated axons. The genetic deletion of Nfasc155 results in the loss of septate-like junctions and in conduction slowing. In humans, IgG4 antibodies against Nfasc155 are implicated in the pathogenesis of chronic inflammatory demyelinating polyneuropathy (CIDP). These antibodies are associated with an aggressive onset, a refractoriness to intravenous immunoglobulin, and tremor of possible cerebellar origin. Here, we examined the pathogenic effects of patient-derived anti-Nfasc155 IgG4. These antibodies did not inhibit the ability of Nfasc155 to complex with its axonal partners contactin-1/CASPR1 or induce target internalization. Passive transfer experiments revealed that IgG4 antibodies target Nfasc155 on Schwann cell surface, and diminished Nfasc155 protein levels and prevented paranodal complex formation in neonatal animals. In adult animals, chronic intrathecal infusions of antibodies also induced the loss of Nfasc155 and of paranodal specialization and resulted in conduction alterations in motor nerves. These results indicate that anti-Nfasc155 IgG4 perturb conduction in absence of demyelination, validating the existence of paranodopathy. These results also shed light on the mechanisms regulating protein insertion at paranodes.

Successful treatment of Epstein-Barr virus associated central nervous system diseases after allogeneic hematopoietic stem cell transplantation with intrathecal donor lymphocytes infusion: three cases report and literatures review

Successful treatment of Epstein-Barr virus associated central nervous system diseases after allogeneic hematopoietic stem cell transplantation with intrathecal donor lymphocytes infusion: three cases report and literatures review

Protocolo diagnóstico y terapéutico de la espasticidad

Spasticity is a motor disorder caused by several conditions of the nervous central system (cerebral or spinal cord origin) (NCS). Symptomatology encompass contractures, pain, stiffness and, in general, deterioration of neurological status. In patients with spasticity after spinal cord injury, removing all aggravating factors and stablishing a physical rehabilitation treatments to reduce spastic component are mandatory. Treatment schedule is as follows: prevention of complications that may worse spascticity, physical rehabilitation, orthosis, oral pharmacologic interventions, botulinum toxin injection for focal spasticity and continuous intrathecal baclofen infusion

Application of Hepatocyte Growth Factor for Acute Spinal Cord Injury: The Road from Basic Studies to Human Treatment.

Hepatocyte growth factor (HGF) was first identified as a potent mitogen for mature hepatocytes, and has also gained attention as a strong neurotrophic factor in the central nervous system. We found that during the acute phase of spinal cord injury (SCI) in rats, c-Met, the specific receptor for HGF, increases sharply, while the endogenous HGF up-regulation is relatively weak. Introducing exogenous HGF into the spinal cord by injecting an HGF-expressing viral vector significantly increased the neuron and oligodendrocyte survival, angiogenesis, and axonal regeneration, to reduce the area of damage and to promote functional recovery in rats after SCI. Other recent studies in rodents have shown that exogenously administered HGF during the acute phase of SCI reduces astrocyte activation to decrease glial scar formation, and exerts anti-inflammatory effects to reduce leukocyte infiltration. We also reported that the intrathecal infusion of recombinant human HGF (intrathecal rhHGF) improves neurological hand function after cervical contusive SCI in the common marmoset, a non-human primate. Based on these collective results, we conducted a phase I/II clinical trial of intrathecal rhHGF for patients with acute cervical SCI who showed a modified Frankel grade of A/B1/B2 72 h after injury onset, from June 2014 to May 2018.

Abstract #137: Opioid Induced Hyperalgesia with Intrathecal Infusion of High Dose Fentanyl

Abstract #137: Opioid Induced Hyperalgesia with Intrathecal Infusion of High Dose Fentanyl

Subpial AAV Delivery for Spinal Parenchymal Gene Regulation in Adult Mammals.

The use of adeno-associated virus (AAV) vectors has become an attractive method for treatment of a variety of neurodegenerative disorders by permitting targeted gene upregulation or silencing in the CNS. Systemic and intrathecal infusion, while preferable routes of vector delivery, have shown encouraging but variable efficacy due to the poor permeability of AAV into spinal cord and brain parenchyma in adult mammals. Recently we have developed a novel and relatively noninvasive technique of spinal subpial vector delivery. This technique confers widespread transgene expression throughout the spinal parenchyma, including both white and gray matter. We have demonstrated that this technique can be performed safely, with a high level of accuracy, and is effective in both small (mouse or rat) and large preclinical (adult pig or nonhuman primate) animal models. In this chapter we provide a comprehensive description of the subpial vector delivery technique in adult rodents (mouse and rat) and large preclinical animals (adult pig and nonhuman primates).

Melatonin regulation of transcription in the reversal of morphine tolerance: Microarray analysis of differential gene expression.

Tolerance and associated hyperalgesia induced by long-term morphine administration substantially restrict the clinical use of morphine in pain treatment. Melatonin, a neurohormone released by the pineal gland, has been demonstrated to attenuate anti-nociceptive morphine tolerance. The present study investigates differentially expressed genes in the process of morphine tolerance and altered gene expression subsequent to melatonin treatment in chronic morphine-infused ratspinal cords. Morphine tolerance was induced in male Wistar rats by intrathecal morphine infusion (the MO group). Melatonin (the MOMa group) was administered to overcome the effects derived by morphine. The mRNA collected from L5-S3 of the spinal cord was extracted and analysed by rat expression microarray. Principal component analysis and clustering analysis revealed that the overall gene profiles were different in morphine and melatonin treatments. Subsequent to Gene Ontology analysis, the biological processes of differentially expressed genes of MO and MOMa compared with the control group were constructed. Furthermore, a panel of genes exclusively expressed following melatonin treatment and another panel of genes with inverse expression between the MO and MOMa group were also established. Subsequent to PANTHER pathway analysis, a group of genes with inverse expression following melatonin administrated compared with morphine alone were identified. The expression levels of genes of interest were also confirmed using a reverse transcription-quantitative polymerase chain reaction. The gene panel that was constructed suggests a potential signaling pathway in morphine tolerance development and is valuable for investigating the mechanism of morphine tolerance and the regulatory gene profiles of melatonin treatment. These results may contribute to the discovery of potential drug targets in morphine tolerance treatments in the future.

Systemic Rapamycin Attenuates Morphine-Induced Analgesic Tolerance and Hyperalgesia in Mice.

Previous studies showed that repeated intrathecal morphine injection activated the mammalian target of rapamycin complex 1 (mTORC1) in spinal dorsal horn neurons and that blocking this activation by intrathecal infusion of rapamycin, a specific mTORC1 inhibitor, prevented the initiation of morphine-induced tolerance and hyperalgesia. However, in clinic, rapamycin is usually administrated orally. In this study, we examined whether systemic administration of rapamycin had the effect on morphine-induced tolerance and hyperalgesia in mice. Repeatedly intraperitoneal injection of morphine led to morphine analgesic tolerance on day 5 post-injection evidenced by a marked decrease in morphine's maximal possible analgesic effect and hyperalgesia on day 6 post-injection demonstrated by significant increases in paw withdrawal frequency in response to mechanical stimulation and decreases in paw withdrawal latency in response to cold stimulation on bilateral sides. Co-intraperitoneal injection with rapamycin prevented the development of morphine analgesic tolerance and hyperalgesia. Moreover, on day 6 after morphine injection, co-intraperitoneal injection with rapamycin reduced the established morphine tolerance and hyperalgesia. Co-intraperitoneal injection of rapamycin also attenuated the morphine-induced increases in the levels of phosphorylated mTOR and its downstream target phosphorylated 4E-BP1 in the spinal cord dorsal horn. Our findings indicate that, like intrathecal injection, systemic administration of rapamycin has significant effects on both induction and maintenance of morphine tolerance and hyperalgesia. Systemic mTOR inhibitors could serve as promising medications for use as adjuvants with opioids in clinical chronic pain management.

Kinetics and MR-Based Monitoring of AAV9 Vector Delivery into Cerebrospinal Fluid of Nonhuman Primates

Here we evaluated the utility of MRI to monitor intrathecal infusions in nonhuman primates. Adeno-associated virus (AAV) spiked with gadoteridol, a gadolinium-based MRI contrast agent, enabled real-time visualization of infusions delivered either via cerebromedullary cistern, lumbar, cerebromedullary and lumbar, or intracerebroventricular infusion. The kinetics of vector clearance from the cerebrospinal fluid (CSF) were analyzed. Our results highlight the value of MRI in optimizing the delivery of infusate into CSF. In particular, MRI revealed differential patterns of infusate distribution depending on the route of delivery. Gadoteridol coverage analysis showed that cerebellomedullary cistern delivery was a reliable and effective route of injection, achieving broad infusate distribution in the brain and spinal cord, and was even greater when combined with lumbar injection. In contrast, intracerebroventricular injection resulted in strong cortical coverage but little spinal distribution. Lumbar injection alone led to the distribution of MRI contrast agent mainly in the spinal cord with little cortical coverage, but this delivery route was unreliable. Similarly, vector clearance analysis showed differences between different routes of delivery. Overall, our data support the value of monitoring CSF injections to dissect different patterns of gadoteridol distribution based on the route of intrathecal administration.

Treatment of Epstein-Barr Virus Associated Central Nervous System Diseases after Allogeneic Hematopoietic Stem Cell Transplantation with Intrathecal Donor Lymphocyte Infusion

▪Allogeneic hematopoietic stem cell transplantation(allo-HSCT) is an effective measure for the treatment of hematological disease. With the progress and widespread use of allo-HSCT, Epstein-Barr virus(EBV) related central nervous system(CNS) diseases have gotten more and more attention because of its poor prognosis and overall survival. Since currently there is no standard treatment for patients with EBV-associated CNS diseases and reported therapies are heterogeneous with mixed results, we attempted to develop a novel therapeutic method. We have applied a regimen of intrathecal donor lymphocyte infusion(IDLI) in 3 patients with EBV-associated CNS diseases after allo-HSCT in addition to immunosuppressants reduction and combined antiviral therapy. All of 3 patients were responsive to this therapy: all clinical symptoms and EBV load in CSF resolved 10, 17 and 12 days after initial IDLI respectively, and magnetic resonance imaging (MRI) showed lesions of case 1 and 2 disappeared 15 and 19 days after initial IDLI respectively. Even more appealing, there were no acute or chronic adverse reactions during the infusion and up to 23 months of follow-up. In conclusion, IDLI seems to be an effective and safe method for EBV-associated CNS diseases in allo-HSCT recipients. We recommend this treatment modality for further investigation. DisclosuresNo relevant conflicts of interest to declare.

Piggybac CD19 CAR T Cells Eradicate CNS Leukemia By Direct Delivery into Cerebral Ventricle of Xenograft Mice Model

[Introduction]Despite the improvement in the treatment for childhood acute lymphoblastic leukemia (ALL), a central nervous system (CNS) involvement is still a risk factor for mortality. Moreover, CNS-directed treatments can cause acute and late adverse complications. Therefore, more effective and less toxic treatment strategy for CNS-ALL is needed.Recent clinical trials show that the anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapy have an excellent effect against refractory and relapsed ALL. In these trials, some clinical effect of systemic intravenous (i.v.) delivery of CAR-T cells against CNS-ALL were reported and these reports implied clinical possibility and necessity for optimization of CAR-T therapy against CNS-ALL.The superior effect of direct delivery of CAR-T cells into solid tumors has been published, and we and others have shown the feasibility of intrathecal (IT) donor lymphocyte infusion for CNS-ALL without severe adverse events (Yanagisawa et al, IJH 2016). These reports inspired us to apply direct CAR-T cells infusion into CNS as a new therapeutic approach against CNS-ALL. However, as the lethally neurotoxicity has been reported in CAR-T clinical trials, preclinical study is a crucial step for clinical use of IT administration of CD19 CAR-T cells.We have previously reported ALL patient-derived xenograft (PDX) model with CNS infiltration in NOD/SCID/γc Null (NOG) mouse (Kato et al, ASH 2010). With this model, we have revealed the unique characteristics of CNS infiltrated leukemic cells and proposed new strategy targeting the CNS-ALL (Kato et al, Blood, 2018).In this study, we established an isolated CNS-ALL xenograft model with the intra-cerebroventricular (i.c.v.) injection of ALL cells and tested the feasibility and safety of the i.c.v. delivery of CAR-T cells into this model.[Method]CD19 CAR-T cells were generated with the piggyBac transposon system from isolated PBMCs donated from a healthy volunteer and expanded in the presence of IL-7 and IL-15 (Morita et al, Mol Ther Methdos Clin Dev 2018). SUSR cells, BCR-ABL fusion gene positive pre-B ALL cells, were genetically engineered to express GFP-FFLuc (SUSRGFP/luc).2×105 SUSRGFP/luc cells were injected by i.c.v. into 8-10 weeks old male NOG mice. Seven days after injection, confirming that SUSRGFP/luc cells were detected by IVIS imaging system only in CNS region, 2×106 piggyBac CD19 CAR-T cells injected by i.c.v. (CAR-T i.c.v.) (n=6), or i.v via tail-vein (CAR-T i.v) (n=5). As control groups, non-transduced T-cells from the same donor (Mock-T i.c.v.) (n=5) or vehicle (Medium i.c.v.) (n=5) were injected by i.c.v. No treatment group (n=4) received no i.c.v. injection. ALL invasion was followed by IVIS imaging. To assess the safety, we serially measured body weight, rectal temperature and scores of clinical symptoms of each mouse every morning after treatment.[Results]All mice in the Medium i.c.v. and no treatment group died by day 45. Both in the CAR-T i.v. and i.c.v. group, all mice were alive at day 45. Regardless of the route of injection, CAR-T administration prolonged the survival period. IVIS imaging revealed that 3/5 mice both in Mock-T i.c.v. and CAR-T i.v group failed to eliminate CNS-ALL at day 40. On the other hand, CAR-T i.c.v. completely eradicated ALL in all mice. Histopathological and flowcytometry analysis at day 4 after treatment also showed decrease of ALL cells and expansion of human CD3 positive T-cells in CAR-T i.c.v. mouse.Regarding clinical symptoms, weight loss, decrease in rectal temperature and elevation of clinical scores were observed only in SUSR transplanted CAR-T i.c.v. group during a few days after treatment. These changes were transient and not fatal. No neurological symptoms were observed in all mice. Histopathological analysis of CNS at day 4 showed slightly thickened epithelium of choroid plexus and edema localized around the lateral ventricle only in CAR-T i.c.v. mouse. Any other abnormalities associated neurotoxicity was not detected.[Discussion]In this preclinical study, we demonstrated that i.c.v. delivery of CD19 CAR-T cells had superior effect to i.v. delivery without any additional side effects. Our data suggests that IT administration of CD19 CAR-T cells would be an effective and feasible therapeutic approach against CNS-ALL. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Blinatumomab + Ponatinib for Relapsed Ph1-Positive Acute Lymphoblastic Leukemia: The French Experience

Prognosis of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph1+ ALL) has been considerably improved since the beginning of the BCR-ABL1 tyrosine kinase inhibitors (TKI) era 20 years ago. However, the prognosis of patients with a refractory/relapsed (including molecular relapse) disease is still very dismal. New drugs or combination of new drugs may improve outcomes of these patients. For example, ponatinib, a 3rd-generation oral TKI, known to have activity against BCR-ABL1 T315I mutations, has shown some efficacy in this context. Similarly, a recent study has reported very encouraging results of the bispecific anti-CD3/CD19 monoclonal antibody blinatumomab as single-agent in refractory/relapsed Ph1+ ALL. Data regarding the efficacy and tolerance of a combination of blinatumomab+ponatinib (blina/pona) are still scarce.This was a retrospective study with the aim to report outcomes of patients receiving a combination of blina/pona for refractory/relapsed Ph1+ ALL in France. Fifteen adults from 8 French centers were identified and data were collected by physicians of each centers, then gathered for the purpose of this study.There were 9 males and 6 females, with a median age of 53 years (range:17-72). All patients, but 2 with blast crisis of chronic myeloid leukemia, had de novo Ph1+ ALL. Four cases had BCR-ABL1 T315I mutation. Patients received the blina/pona combination, either after a first (n=8) or a second (n=7) cytologic relapse. There was no refractory patient in theses series. Previous allograft and autograft has been performed in 7 and 2 patients, respectively. The majority of patients (n=12) had previously received 2 or more lines of TKI. The median time between the first cycle of blina/pona and diagnosis was 14 months (range: 8-40). The median number of blinatumomab cycle (28 mg/day by continuous infusion for 28 days every 6 weeks) administered per patient was 3 (range: 1-6) while ponatinib was concomittantly administered continuously at an initial dose of 45 mg once daily in 11 pts (73%) and 30 mg in 4 pts (27%). Median duration of ponatinib administration was 4 months (range: 1.1-10.9) from first blinatumomab cycle. The toxicity profile was safe: all patients received a complete first cycle without grade 3-4 adverse events. After cycle 1, blinatumomab was stopped in 47% of cases because of neurologic events in 4 and infections in 3; ponatinib was stopped in 33% of cases because of neurologic events in 3, fluid retention in 1 and severe arteriopathy in 1 patient with other vascular disease risk factors. All neurologic events resolved after stopping blinatumomab or ponatinib.The majority of patients were evaluated after one cycle (n=11, after cycle 2 n=3, after cycle 3 n=1). All but one patients (93%) obtained a cytologic complete remission (CR), of whom 12/14 (86%) achieved a complete molecular response. However, 2 patients were documented with CNS relapse at the time of blina/pona evaluation although in bone marrow molecular remission. Both obtained clearance of leukemic blasts after intrathecal infusion of chemotherapy. Then, 5 patients underwent allogeneic transplant (including 2 patients already allotransplanted before blina/pona) and 1 patient received donor lymphocyte infusion. Seven cases pursued maintenance therapy with ponatinib as single agent after stopping blinatumomab. With a median follow-up of 8 months (range: 2.6-30.2) for alive patients, median overall and leukemia-free survivals from first cycle of blina/pona were 8.5 months (range: 1.7-30.2) and 8 months (range: 1.3-30.2), respectively.At last follow-up (July 2018), only 4 relapses had occurred at a median of 3.3 months (range: 1.3-8.3) from first blina/pona cycle and 6 patients had died (3 bacterial infections, 1 fungal infection, 1 secondary cancer and 1 ALL relapse). All alive patients (n=9) but one (cytologic CR but detectable minimal residual disease) are in complete molecular response. Four patients are still under ponatinib medication at last follow-up.The combination of blinatumomab+ponatinib appears effective and tolerable in relapsed Ph1+ALL patients and may replace chemotherapy salvage regimens. The combination should be tested in first-line therapy in the future. Our results have also to be confirmed prospectively on a larger cohort of patients. DisclosuresNo relevant conflicts of interest to declare.

Physical positioning markedly enhances brain transduction after intrathecal AAV9 infusion.

Several neurological disorders may benefit from gene therapy. However, even when using the lead vector candidate for intrathecal administration, adeno-associated virus serotype 9 (AAV9), the strength and distribution of gene transfer to the brain are inconsistent. On the basis of preliminary observations that standard intrathecal AAV9 infusions predominantly drive reporter gene expression in brain regions where gravity might cause cerebrospinal fluid to settle, we tested the hypothesis that counteracting vector "settling" through animal positioning would enhance vector delivery to the brain. When rats are either inverted in the Trendelenburg position or continuously rotated after intrathecal AAV9 infusion, we find (i) a significant 15-fold increase in the number of transduced neurons, (ii) a marked increase in gene delivery to cortical regions, and (iii) superior animal-to-animal consistency of gene expression. Entorhinal, prefrontal, frontal, parietal, hippocampal, limbic, and basal forebrain neurons are extensively transduced: 95% of transduced cells are neurons, and greater than 70% are excitatory. These findings provide a novel and simple method for broad gene delivery to the cortex and are of substantial relevance to translational programs for neurological disorders, including Alzheimer's disease and related dementias, stroke, and traumatic brain injury.

Stability study of hydromorphone and bupivacaine mixture by HPLC-UV

ObjectivesThe objective of this study was to evaluate the physical and chemical stability of hydromorphone hydrochloride and bupivacaine hydrochloride in concentrations of 15 mg.ml-1 and 10 mg.mL-1 in 0.9% sodium...