Methotrexate in sarcoidosis: hematologic and hepatic toxicity encountered in a large cohort over a six year period

BACKGROUND

Methotrexate (MTX) is a second line agent for treatment of sarcoidosis. Its long term safety and efficacy in sarcoidosis remains unclear.

METHODS

This was a retrospective review of patients seen at the University of Cincinnati Sarcoidosis Clinic over a six year period. For each visit, complete blood count, liver function testing, and dosing and outcome of MTX was noted. For efficacy, we compared the outcome of therapy of a matching subgroup of patients treated with either MTX or infliximab for one year and results scored as improved, stable, or worse based on response of the target organ.

RESULTS

Over six years, 1606 sarcoidosis patients were seen with a total of 13,576 clinical visits. During the study period, 607 patients (38% of total) were receiving MTX and had available blood work. Moderate elevation of alanine aminotransferase (ALT) (>3 times upper limit normal) was seen in nine (1.6%) patients. White blood count of <1500 cells per cu mm was seen in one patient. At six months, over half of the 44 patients initiated on infliximab and with at least six months of follow-up were better, while only 23% of the 44 of a matched subset of MTX treated patients were better (Chi square=10.566, p=0.0143). At the 12 month assessment, the infliximab treated patients were still more likely to be better than those treated with MTX (Chi square=10.033, p=0.0183). Only 23% of those treated with MTX were worse at twelve months.

CONCLUSION

In our study, MTX therapy was associated with very few hepatic or hematologic complications. MTX was less likely than infliximab to improve clinical status. However, only 20% were worse after one year of MTX. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (3): e2020001).

Use of third-line therapies in advanced sarcoidosis

OBJECTIVES

Patients with advanced sarcoidosis often require third-line therapies including infliximab, adalimumab, rituximab, and repository corticotropin injection (RCI). Over time, some patients discontinue therapy.

METHODS

In a retrospective review of patients at the University of Cincinnati Sarcoidosis Clinic, we identified patients who received one or more third-line treatments. Age, race, gender, organ involvement, and initial date of therapy were collected. For patients in whom a drug was discontinued, the last date of treatment, reason for drug discontinuation, and outcome of drug withdrawal were noted.

RESULTS

Of the 2109 patients identified, 317 (15%) had received one or more third-line therapies (infliximab: 258 patients; adalimumab: 52 patients; rituximab: 34 patients; RCI: 101 patients). Patients with neurologic, cutaneous, or ocular sarcoidosis involvement were more likely to have received third-line therapy. Overall, 225 (50.6%) of treatment regimens were discontinued. Rate of discontinuation was higher for infliximab (55%), adalimumab (58%), or RCI (43%) than for rituximab (29%, Chi square=11.959, p=0.0075). Compared to RCI, the hazard ratio (HR) for discontinuing therapy due to infection was increased for infliximab (HR=12.14, p=0.0134) and adalimumab (HR=9.71, p=0.0356). The hazard ratio was higher for drug discontinuation due to allergic reactions to infliximab (HR=9.40, p=0.0017) or adalimumab (HR=5.83, p=0.0273). For patients receiving at least two years of therapy, drug survival was significantly shorter for infliximab compared to other therapies (Chi square=5.4054, p=0.0201).

CONCLUSIONS

While third-line therapies are often initially effective, a significant number of patients discontinued individual treatments and initiated an alternative third-line therapy.

Balancing Altered Calcium Metabolism with Bone Health in Sarcoidosis

Abnormal calcium metabolism in sarcoidosis patients can lead to hypercalcemia, hypercalciuria, and kidney stones. Hypercalcemia in sarcoidosis is usually due to increased activity of 1α-hydroxylase in macrophages of pulmonary granulomata, resulting in low levels of 25-hydroxyvitamin D and high levels of calcitriol. Vitamin D supplementation may be dangerous for some sarcoidosis patients and is recommended only for those with decreased 25-hydroxyvitamin D and reduced or normal calcitriol level. Diagnosis, treatment of osteoporosis, and maintenance of bone health are complex issues for sarcoidosis patients. An approach to diagnosis and treatment of bone fragility is presented.

Management of repository corticotrophin injection therapy for pulmonary sarcoidosis: a Delphi study

In patients treated with repository corticotrophin injection (RCI) for pulmonary sarcoidosis, effective management of adverse events may improve adherence. However, management of adverse events may be challenging due to limitations in real-world clinical experience with RCI and available published guidelines.

We surveyed 12 physicians with a modified Delphi process using three questionnaires. Questionnaire 1 consisted of open-ended questions. Panellists' answers were developed into a series of statements for Questionnaires 2 and 3. In these, physicians rated their agreement with the statements using a Likert scale.

Key consensus recommendations included a starting dose of 40 units twice a week for patients with less severe disease, continued at a maintenance dose for patients who responded, particularly those with chronic refractory sarcoidosis. Panellists reached consensus that concomitant steroids should be quickly tapered in patients receiving RCI, but that concomitant use of immunosuppressive medications should be continued. Panellists developed consensus recommendations for adverse event management, and reached consensus that RCI should be down-titrated or discontinued if other interventions for the adverse effects fail or if the adverse effect is severe.

In the absence of clinical evidence, our Delphi consensus opinions may provide practical guidance to physicians on the management of RCI to treat pulmonary sarcoidosis.

In this paper, a modified Delphi method was used to develop an expert consensus on the use of repository corticotrophin injection therapy for pulmonary sarcoidosis, including dosing, concomitant medications, contraindications and adverse event management.http://bit.ly/2TyauZp

Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis

Pulmonary sarcoidosis presents substantial management challenges, with limited evidence on effective therapies and phenotypes. In the absence of definitive evidence, expert consensus can supply clinically useful guidance in medicine. An international panel of 26 experts participated in a Delphi process to identify consensus on pharmacological management in sarcoidosis with the development of preliminary recommendations.

The modified Delphi process used three rounds. The first round focused on qualitative data collection with open-ended questions to ensure comprehensive inclusion of expert concepts. Rounds 2 and 3 applied quantitative assessments using an 11-point Likert scale to identify consensus.

Key consensus points included glucocorticoids as initial therapy for most patients, with non-biologics (immunomodulators), usually methotrexate, considered in severe or extrapulmonary disease requiring prolonged treatment, or as a steroid-sparing intervention in cases with high risk of steroid toxicity. Biologic therapies might be considered as additive therapy if non-biologics are insufficiently effective or are not tolerated with initial biologic therapy, usually with a tumour necrosis factor-α inhibitor, typically infliximab.

The Delphi methodology provided a platform to gain potentially valuable insight and interim guidance while awaiting evidenced-based contributions.

Expert consensus recommendations for a pulmonary sarcoidosis treatment algorithm from a modified Delphi process include corticosteroids as initial therapy, immunomodulators for steroid-sparing or severe disease, and biologics for very severe diseasehttp://bit.ly/2SmP3uG

Physiological predictors of survival in patients with sarcoidosis-associated pulmonary hypertension: results from an international registry

Introduction

Sarcoidosis-associated pulmonary hypertension (SAPH) is associated with reduced survival in single-centre studies. The international Registry for SAPH (ReSAPH) with long-term follow-up was established to enrich our knowledge of this complication of sarcoidosis. This analysis aims to elucidate factors associated with reduced transplant-free survival in SAPH patients.

Methods

ReSAPH contains prospectively collected outcomes of SAPH patients since the time of registry enrolment. Information analysed includes right heart catheterisation data, pulmonary function testing, chest radiography, Scadding stage and 6-min walk distance (6MWD), among others. Cox regression models were used to identify independent predictors of transplant-free survival.

Results

Data from 215 patients followed for a mean±sd 2.5±1.9 years were available for analysis. In the 159 precapillary patients, the Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival was 89.2%, 71.7% and 62.0%, respectively. Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival in the incident group was 83.5%, 70.3% and 58.3%, respectively, and in the prevalent group was 94.7%, 72.2% and 66.3%, respectively. Patients with reduced diffusing capacity of the lung for carbon monoxide (DLCO) (<35% predicted) and 6MWD <300 m in the precapillary cohort had significantly worse transplant-free survival. Reduced 6MWD and preserved forced expiratory volume (FEV1)/forced vital capacity (FVC) ratio were identified as independent risk factors for reduced transplant-free survival in the precapillary cohort.

Conclusion

Reduced DLCO (<35% pred) and 6MWD (<300 m) at the time of registry enrolment were associated with reduced transplant-free survival in the overall precapillary cohort. Preserved FEV1/FVC ratio was identified as an independent risk factor for worsened outcomes.

Presence of onconeural antibodies in sarcoidosis patients with parasarcoidosis syndrome

Background

Bothersome symptoms from sarcoidosis can develop in the absence of identified granulomas. These parasarcoidosis complaints can include small fiber neuropathy, diaphoresis, dysautonomia, and fatigue. Similar issues are also encountered in some cancer patients, especially those with onconeural antibodies.

Methods

Serum was obtained for onconeural antibody testing from sarcoidosis patients with parasarcoidosis symptoms seen at the University of Cincinnati Sarcoidosis clinic during a six month period. Detection of antibodies was performed using an onconeural antibody panel.

Results

A total of 268 patients with sarcoidosis and one or more features suggesting parasarcoidosis symptoms were enrolled in the study. Of these, 60 (22.4%) had one or more positive onconeural antibodies. In a control group of 46 non sarcoidosis patients seen in the interstitial lung disease clinic, there were only three patients with a positive antibody (Chi square=6.143, p=0.0132). A subgroup of sarcoidosis and control patients completed the small fiber neuropathy screening list. Sarcoidosis patients had a significantly higher score than the control patients (sarcoidosis: 7 [0-49] (Median [range] versus non sarcoidosis: 3 [0-31], p=0.0074). However, no significant differences were measured in the SFNL scores for sarcoidosis patients with an onconeural antibody (9 [3-36]) versus without (7 [0-49]).

Conclusion

In patients with parasarcoidosis symptoms, approximately 30% have evidence of onconeural antibody production. This may be a potential cause for parasarcoidosis symptoms in some patients.

Breast cancer risk in premalignant lesions: osteopontin splice variants indicate prognosis

BACKGROUND

Premalignant breast lesions pose variable risks for transformation, raising the question who should receive treatment to counteract the potential progression to breast cancer. Because the secreted metastasis mediator Osteopontin (OPN) is a marker for breast cancer aggressiveness, its presence in these lesions may reflect progression risk.

METHODS

By immunohistochemistry, we analyse the association of Osteopontin variant expression in healthy breasts, hyperplasias, papillomas, and carcinomas in situ from 434 women to assess a) staining for OPN exon 4 (present in OPN-a and OPN-b) or OPN-c in low-risk to high-risk lesions b) correlations between staining and progression (DCIS with invasion, invasive cancer) or survival.

RESULTS

The markers correlate with risk, and they are prognostic for ensuing invasive disease and survival. About 10% of OPN-c pathology score 0-1 (intensity), vs. 40% of score 3 experience cancer over 5 years. More than 90% of women, who progress, had pathology scores of 2-3 for OPN-c intensity at the time of initial diagnosis. When combining OPN-c and OPN exon 4 staining, all of the low intensity patients are alive after 5 years, whereas women in the high category have a close to 30% chance to die within 5 years. Of patients who succumb, close to 80% had a high combined score at the time of initial diagnosis.

CONCLUSION

The combined information of OPN splice variant immunohistochemistry can provide a foundation for very reliable prognostication and has the potential to aid decision making in the treatment of early breast lesions.

HER2-Driven Breast Tumorigenesis Relies upon Interactions of the Estrogen Receptor with Coactivator MED1

Studies of the estrogen receptor (ER) coactivator protein Mediator subunit 1 (MED1) have revealed its specific roles in pubertal mammary gland development and potential contributions to breast tumorigenesis, based on coamplification of MED1 and HER2 in certain breast cancers. In this study, we generated a mouse model of mammary tumorigenesis harboring the MMTV-HER2 oncogene and mutation of MED1 to evaluate its role in HER2-driven tumorigenesis. MED1 mutation in its ER-interacting LxxLL motifs was sufficient to delay tumor onset and to impair tumor growth, metastasis, and cancer stem-like cell formation in this model. Mechanistic investigations revealed that MED1 acted directly to regulate ER signaling through the downstream IGF1 pathway but not the AREG pathway. Our findings show that MED1 is critical for HER2-driven breast tumorigenesis, suggesting its candidacy as a disease-selective therapeutic target.Significance: These findings identify an estrogen receptor-binding protein as a critical mediator of HER2-driven breast tumorigenesis, suggesting its candidacy as a disease-selective therapeutic target. Cancer Res; 78(2); 422-35. ©2017 AACR.

Discordance of the estrogen receptor and HER-2/neu in breast cancer from primary lesion to first and second metastatic site

BACKGROUND

Hormone receptor and HER-2/neu discordance between the primary lesion and first metastasis has been reported. This study was performed to determine further biomarker discordance rates between the first and subsequent metastatic breast cancer lesions.

METHODS

We performed a retrospective review of paired biomarkers from primary breast cancers compared to first reported and subsequent metastases from 103 patients with breast cancer. The estrogen receptor (ER), progesterone receptor (PR), and HER-2/neu status were reported at all three time points. In addition, hormone, cytotoxic, and targeted treatments were recorded for primary and metastatic disease, and survival was determined.

RESULTS

Between the primary and first metastases, discordance rates for ER, PR, and HER-2/neu were 15.8%, 33.7%, and 14.3%, respectively. There was discordance between the first and second metastases for the ER receptor in 18.8%, PR receptor in 19.8%, and HER-2/neu in 10.7%. Overall, there was discordance between the primary tumor and either the first or second metastases for ER in 27.7%, PR receptor in 40.7%, and HER-2/neu in 19.6% of cases. Discordance of either ER or PR affected survival, with worse survival experienced by those patients with all three hormone receptors remaining negative, and intermediate survival reported for those with discordant tumors (ER χ2=14.27, p=0.0008; PR χ2=11.31, p=0.0035). There was no difference in survival for patients whose HER-2/neu tumors were discordant.

CONCLUSION

This study demonstrated that continued metastatic disease evolution may be associated with different tumor biology and that studies of metastatic lesions appear warranted, especially if targeted therapy is an option.

HGFL-mediated RON signaling supports breast cancer stem cell phenotypes via activation of non-canonical β-catenin signaling

Breast cancer stem cells (BCSCs), which drive tumor progression, recurrence, and metastasis, are considered a major challenge for breast cancer treatments, thus the discovery of novel pathways regulating BCSC maintenance remains essential to develop new strategies to effectively target this population and combat disease mortality. The HGFL-RON signaling is overexpressed in human breast cancers and is associated with increased breast cancer progression, metastasis, and poor prognosis. Here, we report that overexpression of RON/MST1R and HGFL/MST1 in cell lines and primary tumors increases BCSC self-renewal, numbers, and tumorigenic potential after syngeneic transplantation. Transcriptome analyses also reveal that the HGFL-RON signaling pathway regulates additional BCSC functions and supports an immunosuppressive microenvironment to stimulate tumor formation and progression. Moreover, we show that genetic and chemical downregulation of HGFL-RON signaling disrupts BCSC phenotypes and tumor growth by suppressing the RON-mediated phosphorylation/activation of β-CATENIN/CTNNB1 and its effector NF-κB/RELA. These studies indicate that HGFL-RON signaling regulates BCSC phenotypes and the tumor microenvironment to drive tumorigenesis and present HGFL/RON as novel therapeutic targets to effectively eradicate BCSCs in patients.

Predictors of Mortality in Pulmonary Sarcoidosis

OBJECTIVE

The goal of this study was to assess the prognostic strength of factors in predicting respiratory death in a large cohort of patients with sarcoidosis with at least 8 years' follow-up.

METHODS

Data were collected on age, sex, self-declared race, time of death, spirometry findings, diffusing capacity for carbon monoxide, chest radiograph stage, extent of fibrosis on high-resolution CT (HRCT) scanning, and presence of precapillary pulmonary hypertension (PH). The Gender-Age-Physiology (GAP) index and Walsh model criteria for high vs low risk were calculated.

RESULTS

A total of 452 patients were identified who had complete pulmonary function testing and chest imaging. The median age at time of entry into the study was 50 years (range, 25-78 years). PH was confirmed by right heart catheterization in 29 (6.4%). Of 452 patients, 42 died during the time of the study, including 38 (8.4%) who died of sarcoidosis-associated respiratory failure and 4 who died of non-sarcoidosis causes. The overall mortality from sarcoidosis was 3.9% and 9.0% at 5 and 10 years, respectively. Alive patients were significantly younger than patients who died from sarcoidosis. Increased mortality was seen for black patients, stage 4 chest radiographs, > 20% fibrosis on HRCT scanning, or PH. The two composite scores (GAP and the Walsh model) were predictive of increased mortality according to univariate analysis. Using the Cox proportional hazards regression model, only age, extent of fibrosis on HRCT scanning, and PH were independent predictors of mortality.

CONCLUSIONS

Although most patients with sarcoidosis do well, increased mortality was seen in those patients who were older, had extensive fibrosis on HRCT scanning, or who had PH.

Idiopathic granulomatous mastitis: A diagnostic and therapeutic challenge

BACKGROUND

Idiopathic granulomatous mastitis is a rare benign breast disease of women of reproductive age. It usually presents as a painful mass. Since the etiology is unclear, directed diagnosis and management is lacking.

METHODS

This is a retrospective chart review of 14 patients, over twelve years (2004-2016), identified through query of pathology findings.

RESULTS

Two asymptomatic patients were diagnosed after oncologic breast resection following neoadjuvant chemotherapy. The remaining twelve patients were young (31.7 years, range 23-43 years), predominantly non-white (50% African/African-American, 36% Hispanic, 7% Asian), pregnant within the last five years (86%), with no prior granulomatous disease. Evaluation included breast imaging, microbial cultures and staining, and biopsy. Treatment included antibiotics (57%), corticosteroids (21%), methotrexate (7%), and/or surgery (71%). Imaging suggests segmental masses, possibly abscess.

CONCLUSION

Granulomatous mastitis is uncommon, and difficult to diagnose and manage. We review our experience, the literature, and propose an algorithm for diagnosis and management.

Repository corticotropin for Chronic Pulmonary Sarcoidosis

Purpose

The dose of repository corticotropin (RCI) and need for a loading dose in sarcoidosis patients receiving chronic corticosteroids are unclear. We performed a single-blind prospective study, comparing two doses of RCI in sarcoidosis.

Methods

Chronic pulmonary sarcoidosis patients receiving prednisone therapy with deterioration by 5% in FVC in the previous year were studied. RCI was administered subcutaneously at a loading dose of 80 units RCI for 10 days. Patients were randomized at day 14 to receive either 40- or 80-unit RCI twice a week. The dose of prednisone was modified by the clinician who was blinded to the patient’s dosage of RCI.

Results

Sixteen patients completed the full 24 weeks of the study. At week 24, there was a decrease in the dose of prednisone, and improvements in DLCO, King’s Sarcoidosis Questionnaire health status and fatigue score. There was no significant change in FVC % predicted. For the PET scan, there was a significant fall in the standard uptake value (SUV) of the lung lesions. Only 3/8 patients remained on 80 units RCI for full 24 weeks. There was no significant difference in the response to therapy for those treated with 40- versus 80-unit RCI.

Conclusions

Repository corticotropin treatment was prednisone-sparing and associated with significant improvement in DLCO, PET scan, and patient-reported outcome measures. A dose of 40-unit RCI twice a week was as effective as 80-unit RCI and was better tolerated.

Clinical characteristics of patients with bone sarcoidosis

OBJECTIVE

To assess the clinical features, diagnosis, and treatment of bone sarcoidosis in the United States.

METHODS

Patients with bone sarcoidosis were identified and matched to sarcoidosis patients based on race, gender, and age. Detailed characteristics were obtained by medical record review.

RESULTS

A total of 64 patients with bone sarcoidosis were enrolled in this study. The female:male ratio was 1.46:1 and the white:black ratio was 3:1. Thirty-eight (59.4%) of 64 patients had bone symptoms. Compared to matched cases, bone sarcoidosis patients have more multi-organ involvement and higher incidence with liver, spleen, and extrathoracic lymph node involvement than controls (P < 0.05). Spine was the most commonly affected bone in 44 (68.8%) of patients, followed by pelvis (35.9%), and hands (15.6%). MRI and PET/CT scan was the common imaging technology, which performed in 36 patients and 32 patients, respectively, and with 97.2% and 93.8% positive bone uptake. Laboratory test indicated anemia was more common in bone sarcoidosis group than controls (P = 0.044). Infliximab was more commonly used in bone sarcoidosis patients than controls (P = 0.009).

CONCLUSION

Bone sarcoidosis was associated with multi-organs affection, and high frequency of liver, spleen, or extrathoracic lymph node involvement. Infliximab should be considered in those patients with aggressive and refractory bone sarcoidosis.

Infliximab for chronic cutaneous sarcoidosis: a subset analysis from a double-blind randomized clinical trial

BACKGROUND

Limited evidence exists demonstrating an effective treatment for chronic cutaneous sarcoidosis.

OBJECTIVE

To determine infliximab's effectiveness in sarcoidosis.

METHODS

We conducted a subset analysis from a randomized, double-blind, placebo-controlled trial for chronic pulmonary sarcoidosis to determine infliximab's effectiveness. Patients with chronic cutaneous sarcoidosis received infliximab (3 or 5 mg/kg) or placebo over 24 weeks. Of 138 patients, the subset analysis evaluated 17 patients with chronic facial and another 9 patients with nonfacial skin involvement. The SASI evaluated lesions for degree of erythema, desquamation, induration, and percentage of area involved. Facial and nonfacial lesions were scored in a blinded manner.

RESULTS

Among 5 placebo-treated and 12 infliximab-treated patients, an improvement was observed with infliximab versus placebo in change from baseline to weeks 12 and 24 in desquamation (P<0.005) and induration (P<0.01) at week 24. Erythema, percentage of area involved and the evaluation of paired photographs did not reveal significant differences.

LIMITATIONS

Sample size; more extensive disease in placebo patients; chronic therapy upon enrollment; lung as primary organ of sarcoidosis involvement; limited investigator experience with SASI.

CONCLUSIONS

Infliximab appears to be a beneficial treatment for chronic cutaneous sarcoidosis. The SASI scoring system demonstrated significant improvement versus placebo in lesion desquamation and induration.

A retrospective pilot study examining the use of Acthar gel in sarcoidosis patients

INTRODUCTION

Acthar was reported as effective for the treatment of pulmonary sarcoidosis in the 1950s. Use of drug waned due to cost and toxicity compared to prednisone. Recent interest has reemerged as an alternative to high dose oral glucocorticoids.

METHODS

Chart review was performed on all advanced sarcoidosis patients seen at two centers who received at least one dose of Acthar gel therapy with at least six months of posttreatment follow up. In all cases prior sarcoidosis therapy and indications for use along with clinical outcome were noted. All patients initially received 80 IU intramuscular or subcutaneous administration twice a week.

RESULTS

A total of 47 patients were treated with Acthar gel therapy during the study period, and 18 (37%) discontinued drug within six months due to cost (four patients), death (two patients), or drug toxicity (eleven patients), or noncompliance (1 patient). Of the remaining 29 patients, eleven experienced objective improvement in one or more affected organs. All but two patients noted disease improvement or oral glucocorticoid reduction. Twenty-one patients were treated for more than six months (Median 274 days). Nineteen patients were on prednisone at time of starting Acthar gel: seventeen had their prednisone dosage reduced by more than fifty percent and one patient discontinued cyclophosphamide therapy.

CONCLUSION

In this group of advanced sarcoidosis patients, Acthar gel treatment for at least three months was associated with objective improvement in a third of patients. A third of patients were unable to take at least a three months of treatment.