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1 day ago · In the Halls of Hematology: Meet Dr. Kenderian

Dr. Kenderian Editorial_1

Saad Kenderian, M.B., Ch.B., is a Mayo Clinic hematologist, Senior Associate Consultant, and an Assistant Professor of Medicine, Immunology & Oncology. He specializes in bone marrow transplant and has a K award from the National Institutes of Health for research on chimeric antigen receptor t-cell therapy (CAR T). He is an inventor on several CAR T cell therapies that are being currently used and investigated for the treatment of blood cancer. His current laboratory program is focused on developing new CARs and creating more ways of fighting cancers.

Dr. Kenderian is a well-respected provider and researcher. His passion for working with cancer patients and groundbreaking research on new ways to treat blood cancers are part of what makes Mayo Clinic special. What makes his story unique is how difficult and dangerous his journey to practicing medicine was:

Your patients, and coworkers, may not know that you grew up in Bagdad, Iraq and you studied medicine during wartime. Would you mind sharing more about what that was like?

I am originally Armenian, but I was born and spent most of my life in Iraq. During the 2003 war, I was a medical student at the University of Bagdad School of Medicine. It was quite an interesting… and unique experience. School was only interrupted for a few months due to the war, but life always had a way of continuing on.

How dangerous was it practicing medicine during the war?

Practicing medicine at that time was difficult. I was a medical student, and later I was briefly an intern before leaving Iraq. We had extremely limited resources and high patient volume due to the trauma that was happening all around us. The medical students and interns played a large role in helping care for the traumas caused by war. When there was an accident, they would call every physician to the ER, and too often it still wasn’t enough. Most of the trauma we treated was not caused by U.S. and Iraqi soldier confrontations, but by terror attacks and suicide bombers on innocent citizens.

Our daily life included a bombing here, an explosion there, and kidnappings happening everywhere. There were things we never took for granted. We simply went off to school, not sure if we were coming back home or not… I remember once when I was on call, a suicide bomber attacked a floor on our hospital. Their main motive was to just destroy medicine, destroy healthcare, and simply destroy education.


Dr. Kenderian Medical School

Dr. Kenderian (left) in medical school

How did you and the other medical staff handle an attack like that in the moment?

We all ran to the scene without hesitation. People there were so used to these incidents they would just run to the scene to use their medical expertise and training to help as best they could. At that time we had no government, little protection, but we just kept going.

Despite all of these obstacles, you completed medical school.

I finished in 2004. I always wanted to come to the United States. When I left Iraq in 2005, there were no embassies or airports at the time. I, along with many others, had to take a 24-hour road trip to Jordan. It was an extremely risky road to travel. Not only was it all desert with nothing around, but we had to be concerned with bombs and being stopped along the way. Fortunately, we were lucky to never be in any danger during the trip .

What happened when you made it to Jordan?

I obtained a student visa to come to the United States to pursue a Masters Degree. At that same time I studied for my boards. That was a way for me to get to the US. I passed boards and did my residency program with Michigan State University, McLaren Hospital

You said you always knew you wanted to practice medicine in the United States, was there any part of you that thought you should stay?

If you are physician there, you are a target to be kidnapped, or worse. It was always a concern, even as a medical student. So it was a combination of the opportunities in the United States, but also that it was not safe in Iraq.

Dr. Kenderian & his brother

Dr. Kenderian (right) and his brother

How did you stay focused on medical school despite all of the dangers around you?

You just get used to it and try to do your best each day. I also give a lot of the credit to my mom. My dad passed away in a car accident when I was only a year old and my mom helped direct me in to medicine. My mom is a great role model for my brother and I and continues to push us to do our best.

How has growing up in Iraq, going to medical school during a war, and taking a dangerous journey across the desert molded how you care for patients today?

My whole perspective is different. If you look at third-world countries, there is often such a lack of access to healthcare compared to the west. I hope that is something we can continue to improve. I have an appreciation for the access to resources we have here, especially at Mayo Clinic, and I strive to take full advantage of that access to help patients as best I can.

Did your family also come to the United States?

A few years after I came, my mom and brother both joined me here. My now wife also moved two years later. My wife and I now have two kids and we love it in Minnesota. My mom lives only about a mile away from me and is a great help with my kids and family.

When Dr. Kenderian is not practicing medicine, his favorite thing to pass the time is traveling with his family and seeing different parts of the world.

In the fall I like to go to the northeast, New Hampshire area to see the color change. I have a large extended family as well that tries to get together in a unique place once a year. We tend to get about 100 people together each year. We pretty much take over wherever we are staying and it tends to be a great time.

Dr. Kenderian reflected on his journey over the past 15 years and had this to say:

I’m really happy. Where I was just over a decade ago in the middle of a war and now being here at Mayo Clinic as a clinician and researcher, I’m grateful for the whole transition.

Dec 20, 2017 · International research team identifies genetic-based model for predicting outcomes in primary Myelofibrosis


Original post by Joe Dangor in the News Network

A group of investigators from Mayo Clinic and multiple academic research centers in Italy have identified a genetic model for predicting outcomes in patients with primary myelofibrosis who are 70 years or younger and candidates for stem cell transplant to treat their disease. The group’s findings were presented today at the 59th American Society of Hematology annual meeting in Atlanta by lead authors Alessandro Vannucchi, M.D. from the University of Florence and Ayalew Tefferi, M.D., a hematologist at Mayo Clinic.

“Myelofibrosis is a rare type of chronic leukemia that disrupts the body’s normal production of blood cells,” says Dr. Tefferi. “Prior to this study, the most comprehensive predictive model for outcomes in myelofibrosis, utilized mostly clinical variables, such as age, hemoglobin level, symptoms, white blood cell count and the percentage of immature cells in the peripheral blood.”

Dr. Tefferi says he and his colleagues incorporated new genetic tests in the model for gene mutations including JAK2CALR, and MPL, which are known to drive myelofibrosis. He says the new model also tests for the presence or absence of high-risk mutations such as ASXL1 and SRSF2. “Our model is also unique in that we developed it for patients who are age 70 years or younger who may still be candidates for a stem cell transplant to treat their disease,” Dr. Tefferi says.

Researchers studied 805 patients with primary myelofibrosis who were 70 years of age or younger. Patients were recruited from multiple centers in Italy and from Mayo Clinic in Minnesota. The Italian and Minnesota groups formed two independent learning and validation cohorts. “We were surprised by how similar the predictive models performed in two completely separate patient databases,” Dr. Tefferi says.

Dr. Tefferi says that genetic information is increasingly being used as a prognostic biomarker in patients with primary myelofibrosis and he anticipates the potential use of such an approach along with relevant clinical, cytogenetic and mutational data for other hematologic and non-hematologic cancers.


Want to continue the discussion with Connect members who also live with this condition? Join the following conversations:

Dec 13, 2017 · Study identifies barriers to transplant therapy to treat multiple myeloma among racial minority groups


Original story by Joe Dangor in the Mayo Clinic News Network

A study by researchers at Mayo Clinic’s campus in Jacksonville, Florida has found that barriers to patients receiving stem cell therapy as part of their treatment for multiple myeloma include income, education, insurance status and access to care at an academic center or facility that treats a high volume of patients.

“Stem cell transplants are a standard treatment for patients with multiple myeloma and have been shown to benefit patients by delaying the recurrence of disease and, in some cases, improving patient survival,” says Sikander Ailawadhi, M.D., a hematologist at Mayo Clinic in Florida and the lead investigator of this study. “While stem cell transplant utilization for patients with multiple myeloma has increased for all racial and ethnic subgroups over time, population-based studies have repeatedly shown that certain racial minorities are less likely to receive it.”

Dr. Ailawadhi and his colleagues decided to explore factors that determine stem cell transplant utilization among patients from minority communities to better understand the issue and come up with solutions to eliminate barriers and improve access for all patients.

Researchers reviewed medical records for approximately 112,000 patients with a multiple myeloma diagnosis from the National Cancer Database between 2004 and 2013. Of those, 15,000 patients received a stem cell transplant as part of their treatment.

“We found that there was an overall increase in the use of stem cell transplant for multiple myeloma over time for all races except Asians,” says Dr. Ailawadhi. “We also found there was greater use of stem cell therapy among Whites and Hispanics with higher income levels and greater use among Whites and Blacks with higher education levels.”

Researchers found that White, Black and Hispanic patients with private insurance and those treated at academic medical centers or centers that treat a high volume of patients were more likely to get a stem cell transplant to treat multiple myeloma. They also observed some other variables that contributed to disparities including, patient comorbidities, distance from a treating facility and geographic isolation.

“This is the largest analysis exploring socio-demographic factors affecting stem cell transplant use in multiple myeloma treatment,” says Dr. Ailawadhi. “We noted significant disparities among races for regarding who receives a stem cell transplant as a part of their initial care for multiple myeloma and who does not. Furthermore, we found that the socio-demographic factors that affect receipt of stem cell transplant for myeloma are variable from patients of one race to another.”

Dr. Ailawadhi says that while some of these factors are non-modifiable, others including access to healthcare, income, insurance and literacy levels, proximity to treatment center, treating facility type as well as volumes are modifiable.


Want to meet others discussing multiple myeloma? Check out the following discussions taking place on Connect:

Nov 30, 2017 · Lego ICU built for dad is more than just child's play

Lego ICU

This story originally appeared on the In the Loop blog.

Haines and Colter Gauzens missed their dad. It had been more than two weeks since they’d last seen him — an eternity in kid years. “When’s Dad coming home?” the 9-year-old twins kept asking their mother, Isis. “I’m not really sure,” she’d tell them. “Dad is really, really sick.”

Dad — Joe Gauzens — has Erdheim-Chester disease, a rare disorder that can cause a host of symptoms throughout the body. Joe’s primary symptom is chronic, debilitating pain that keeps him at home most of the time. But he’d developed pneumonia, and was lying in the intensive care unit at Mayo Clinic’s Arizona campus. Isis wasn’t eager to take the couple’s sons to the ICU, but as the days passed she decided it was time for a visit. “I would never have let the kids into the ICU, but Joe had been there so long,” she says.

Before she took Haines and Colter to visit their father, Isis wanted to prepare them for what they’d see. To do that, she decided to speak to them in a language they’d understand: Legos.

Together, Isis and the boys built a replica of Joe’s room in the ICU. There’s a panel with buttons, representing his medications; a tower representing his monitor; and even a bed that tilts, just like the rotating bed that was used to help reposition Joe. The model also showcases the many, many staff involved in Joe’s care. They’re represented by Lego mini-figures inside Joe’s room and standing watch, like tiny guardians, on top of the model’s walls. At the center is Joe himself, outfitted in a dual-purpose cape. “The boys wanted their dad to be a superhero,” Isis says. “It’s also their interpretation of a hospital gown.”

When Isis brought Haines and Colter to the ICU, the Lego model came with them. It was placed near a glass wall in Joe’s room, along with a thank-you sign for the staff, including Ayan Sen, M.D., an intensivist, and nurse Natalie Marquez, who had done so much for Joe…

Read the rest of the story on  In the Loop

Meet more members on Connect talking about living with rare blood disease and disorders in the Blood Cancers & Disorders group.

Nov 14, 2017 · Mayo Clinic to offer CAR T-cell therapy for relapsed non-Hodgkin lymphoma

Lin, Yi M

Original post by Joe Dangor in the News Network

Mayo Clinic announced today that its Rochester campus is one of 16 cancer centers nationally selected to provide chimeric antigen receptor T-cell therapy (CAR T-cell therapy) for adults with B-cell non-Hodgkin lymphoma who have not responded to, or have relapsed, after two or more lines of treatment. The therapy, called axicabtagene ciloleucel (Yescarta), is approved to treat subtypes of lymphoma, including diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, diffuse large B-cell lymphoma arising from follicular lymphoma, and high-grade B-cell lymphoma.

“CAR T-cell therapy is a cell-based regenerative immunotherapy, and it is one of the most promising new areas of cancer treatment,” says Yi Lin, M.D., Ph.D., a hematologist and chair of the Cellular Therapeutics Cross-Disciplinary Group at Mayo Clinic. “This therapy uses genetically modified versions of a patient’s own immune cells to fight their cancer. I like to describe these modified T-cells as super RoboCops designed to seek out and destroy a particular cancer.” 3D-illustration of CART-Cell Therapy

CAR T-cell therapy begins by collecting a patient’s white blood cells (T-cells) and sending them to a central manufacturing facility where they are genetically modified to direct them against a patient’s cancer. Once processed, the CAR T-cells are frozen and sent back to the hospital for IV infusion back into the patient.

Before the patients receives their CAR T-cells, they undergo a short chemotherapy regimen to condition their body to receive the cells. Once infused, the CAR T-cells proliferate inside the body, and begin to recognize and attack cancer cells.

Mayo Clinic has successfully participated in CAR T-cell clinical trials with Kite (a Gilead company) and other manufacturers of T-cell therapies. “As one of the first treatment centers in the country, patients will be under the care of a team of experts trained in CAR T-cell therapy for cancer treatment,” Dr. Lin says.

Patients with diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, diffuse large B-cell lymphoma arising from follicular lymphoma, and high-grade B-cell lymphoma who have not responded to, or have relapsed, after two or more lines of treatment and are interested in CAR T-cell therapy may contact the Mayo Clinic Hematology Patient Appointment office at 507-284-5363 to request an appointment for evaluation and assessment for eligibility for  chimeric antigen receptor T-cell therapy. In the future, Mayo Clinic plans to offer chimeric antigen receptor T-cell therapy for adult non-Hodgkin lymphoma at its campuses in Arizona and Florida.

Check out Dr. Lin’s original post on CAR T

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Oct 26, 2017 · Clotting disorders: Factor V Leiden and blood clots

Dr. Marshall Editorial_2

As many as 1 in 20 Caucasians carry a gene mutation called factor V Leiden. This mutation can increase your chance of developing abnormal blood clots (thrombophilia) ─ usually in your veins.

Factor V Leiden is an inherited, heterozygous disorder, where one gene comes from dad and one comes from mom.

“Factor V Leiden may increase the risk of a blood clot from anywhere from two to five times, but it is important to compare that to the general population’s risk,” says Ariela Marshall, M.D., a Mayo Clinic hematologist. “If you take someone in their 30s or 40s, the risk of a blood clot is about 1 in 10,000, so you multiply that by four or five times, it is still only 4 or 5 in 10,000.”

However, Dr. Marshall explains the risk number changes with age. Adults in their 50s and 60s have a baseline blood clot risk of 1 in 1,000, so someone with factor V Leiden would be 4 or 5 in 1,000. For adults in their 70s and 80s, the normal risk for a blood clot may be as high as 1 in 100.

Age is just one risk factor for blood clots. Others include:

  • Smoking
  • Being overweight
  • Sedentary lifestyle
  • Estrogen-containing birth control pills
  • Pregnancy
  • Flying
  • Previous blood clot

According to Dr. Marshall, each risk factor a person has compounds the chance of getting a blood clot.

“Say, for instance, you have a smoker who is over 35 but skinny, you have a slightly increased risk of blood clots,” Dr. Marshall says. “But if you take someone who is 70, overweight and smokes, they are at a much higher increased risk of blood clots. If a person also has factor V Leiden, you then multiply all of these risk factors by another four or five times.”

Legs and lungs are the two most common areas for blood clots.

To recognize when you have a blood clot, note these warning signs:

  • New pain and swelling in the legs ─ ongoing pain that is typically in one leg
  • Redness
  • Sudden onset of shortness of breath not related to exercise

“If you have had a previous clot, you are more likely to get another blood clot in the same spot because of the remaining blood vessels abnormality,” Dr. Marshall says.

Treating a clotting disorder may not be as worrisome as you’d expect.

“We do not actively treat clotting disorders, unless they have had a blood clot,” Dr. Marshall says. “What we do want to do, is council our patients about how to mitigate the other risk factors like smoking, weight management and living healthy lifestyles.”

Patients with clotting disorders are actively managed during major surgical procedures with low doses of blood thinners.

“It is important to know our patients have a clotting disorder so they can be properly managed during procedures or trauma,” Dr. Marshall says. “But the best thing a person can do is manage the controllable risk factors as best they can.”

On Novermber 2nd, 2017, we discuss how clotting disorders affect women differently than men.


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Oct 15, 2017 · Leukemia Diagnosis Changes Life, Career Path, for Mayo Physician

Dr. Rosenthal

Allison Rosenthal, D.O., went to medical school for the sole purpose of becoming an orthopedic surgeon. All of that changed, however, when she was diagnosed with acute promyelocytic leukemia at the age of 24.

Original story from In the Loop

Allison Rosenthal, D.O., has wanted to be a doctor for as long as she can remember. “Ever since I was a kid,” she tells us. “I don’t know where I got it from, but it’s just something I wanted to do.”

More specifically, she wanted to become an orthopedic surgeon. “That’s why I went to medical school in the first place,” Dr. Rosenthal tells us. But then came spring break of her second year of medical school. “I was planning to meet some friends from college after I’d finished finals, but then I got pretty sick,” she says. “I just thought I’d overdone it by studying and not sleeping all week. I thought I had the flu.”

A trip to a local emergency department would tell another story. “The ER doctor who assessed me got some fluids going, drew some labs, and then didn’t even come back to see me,” Dr. Rosenthal tells us. “The next person I met was a hematologist because my labs were so out of whack.”

Leukemia Cells

Dr. Rosenthal — just 24 at the time — was diagnosed with acute promyelocytic leukemia, a rare form of the disease. Over the next two-plus years, she received treatments that would save her life. She also received unsolicited and unexpected advice that would change her career path. “My oncologist kept saying, ‘This is what you’re going to do. You’re going to become an oncologist,'” she tells us. “And I was like, ‘You’re out of your mind. I’m just trying to survive this, never mind having to be around it every day!'”

But life, as they say, has a funny way of working out. Today, Dr. Rosenthal is a physician in Hematology/Oncology at Mayo Clinic’s Arizona campus. And she was recently named the 2017 “Woman of the Year” by the Arizona chapter of the Leukemia & Lymphoma Society. The honor, in part, recognized her work to help raise more than $140,000 for the organization’s continued blood cancer research work, as well as financial aid programs for blood cancer patients and their families.

It’s also an honor that came with Dr. Rosenthal’s likeness being featured on a billboard above an Arizona freeway — something she doesn’t seem particularly thrilled about. “It’s actually quite horrifying to me, but it’s temporary,” she tells us with a laugh.

What’s not temporary, however, are the effects that Dr. Rosenthal’s work, and career change, are having on her patients at Mayo Clinic. “I don’t know why I ended up with leukemia, and I don’t know why I was able to survive it when other people don’t,” she tells us. “But I do know that it affords me a unique perspective in taking care of my patients, because the best way to develop empathy for someone is to have gone through what they’re going through.”

Give us your unique perspective by sharing your comments below before using the handy media tools atop this page to share this story with others.


Want to meet others with leukemia to share experiences and get support from someone who understands? Check out these discussions on Connect:

Oct 4, 2017 · Bleeding disorders in women - complications

Dr. Marshall Editorial_1

Women with bleeding disorders face many complications during their lifetime. In addition to the usual symptoms associated with bleeding disorders in both men and women, women face challenges such as heavy bleeding with menstruation and pregnancy.

Ariela Marshall, M.D., a Mayo Clinic hematologist, researches bleeding disorders such as hemophilia and von Willebrand disease in women. Dr. Marshall explains women with very severe bleeding disorders may be diagnosed in childhood, as they may display symptoms such as nosebleeds, bleeding in the brain, or bleeding from the gastrointestinal tract. However, if a bleeding disorder is not diagnosed in childhood, women may start having symptoms when they start having menstrual periods.

Women_3 Generations

“Not all women with heavy periods suffer from bleeding disorders, but women who have heavy periods are more likely to have a bleeding disorder than women who do not have heavy periods,” Dr. Marshall says.

According to Dr. Marshall, due to a lack of awareness that heavy periods can be the sign of a bleeding disorder and sometimes should be worked up further. Bleeding disorders are sometimes not diagnosed as early as they could be.

“Sometimes, when teens tell people that they have very heavy periods, they get told things like, ‘things are different for every woman’ or even ‘it’s something you have to deal with’,” Dr. Marshall says. “If a doctor doesn’t ask more questions about the bleeding and see if further workup is needed, it can be a missed opportunity to diagnose and treat a bleeding disorder and improve the woman’s quality of life.”

As a result, some women have even gone on to have hysterectomies because of very heavy menstrual periods that happen because of their bleeding disorder.

“Had they been diagnosed earlier on, they may have been able to get treatment for their heavy periods and other bleeding symptoms and in some cases may have been able to avoid needing the hysterectomy,” Dr. Marshall says.

One of Dr. Marshall’s specific interests is how to manage pregnancy in patients with inherited bleeding disorders and extra methods of caution that are practiced to keep the mother and the baby safe before, during and after delivery. Below, she shares some of the complications a woman with a bleeding disorder might experience during pregnancy.

“Every pregnancy is different, but for all women with bleeding disorders we need to take special precautions, especially starting at about 36 weeks, so that we are prepared by the time the woman goes into labor,” Dr. Marshall says.

When a woman with hemophilia is pregnant with a male child, extra caution must be exercised around the time of delivery to prevent increased bleeding risk.Pregnant Mother

“If a woman who is a carrier of hemophilia is having a baby, and the baby is male, there’s a good chance that the child could be affected by hemophilia,” Dr. Marshall says. “Because of this, we want to be very careful for the baby’s health and this means not doing things like using forceps or vacuums for delivery.”

For a lot of women, the choice to get an epidural is a big decision. According to Dr. Marshall, extra consideration goes into this decision for women with bleeding disorders because an epidural represents a high risk for bleeding. Further caution and preparation must be taken to ensure the mother’s factor levels are at a safe level. .

The same precautions come into play if the mother must undergo a cesarean section delivery (C-section).

Though women with bleeding disorders are mostly at a disadvantage during the course of their lifetime, Dr. Marshall explains they do have one advantage. Levels of von Willebrand proteins naturally go up during the course of pregnancy, and while a woman without von Willebrand disease is at a higher risk for blood clots during those nine months, a woman with the disease reaches an ideal level.

“Factor VIII levels and von Willebrand proteins naturally increase during pregnancy for all women,” Dr. Marshall says. “The reason for this is that women lose blood during delivery and the body is naturally trying to protect itself from bleeding by increasing the levels of Von Willebrand and factor VIII, which helps decrease bleeding.”

Therefore, women with Von Willebrand disease and hemophilia A are relatively protected from bleeding during pregnancy.

“Many of our patients with Von Willebrand disease and hemophilia A don’t need any treatment at all during the course of their pregnancy,” Dr. Marshall says. “We don’t even need to check their levels throughout most of the pregnancy, until around week 36, because we know that the levels increase in all women as the body prepares itself for delivery.”

However, immediately after delivery, a woman’s Von Willebrand levels must be closely monitored and the natural rise in protein levels ceases to exist.

“Von Willebrand levels crash back to normal anywhere from a couple of hours to a couple of days following delivery,” Dr. Marshall says. “We closely monitor the patient for excessive blood loss to guard against a postpartum hemorrhage.”

While many people dread getting older, aging calls for a sigh of relief among some women with bleeding disorders. Women with von Willebrand disease may see improvements with their disease as they age, since von Willebrand levels naturally increase in all people as they age.

“Sometimes, the normal ageing process is treatment enough,” Dr. Marshall says.

As for hemophilia, Dr. Marshall says that there may be some increase in factor levels as a person ages, though complete normalization is not as common as with von Willebrand disease. For hemophilia A, Dr. Marshall says that factor 8 levels may increase with inflammation in the body and somewhat with aging, but for hemophilia B increases in factor 9 levels are not as common.

Menstruation, pregnancy, and aging are complicated enough for all women. Add bleeding disorders into the mix, and they are faced with even more obstacles throughout the course of their lives. Dr. Marshall hopes that by raising awareness about bleeding disorders in women specifically, there will be a global increase in diagnoses early on to better care for women throughout their lives.

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Read these related blog posts, “Bleeding disorders in women,” and “Hemophilia: from Mayo Clinic patient, to employee, to Connect moderator.