Placenta-derived mesenchymal-like cells (PDA-001) as therapy for chronic pulmonary sarcoidosis: a phase 1 study

BACKGROUND

Placental derived mesenchymal-like cells have been found to have immunosuppressive effects on T cell function. We studied mesenchymal-like cells as immunomodulators in chronic pulmonary sarcoidosis.

METHODS

PDA-001 cells were culture-expanded in vitro as a plastic-adherent, undifferentiated cell population that expresses the nominal phenotype CD34-, CD10+, CD105+ and CD200+. Four patients with refractory pulmonary sarcoidosis received two infusions of 150 million PDA-001 cells in 240 ml dextran-40 solution one week apart. During and for two hours after the first infusion, the pulmonary artery pressure was monitored. Prior to first infusion and within 24 hours after the second infusion, bronchoscopy and bronchoalveolar lavage (BAL) were performed. Patients underwent initial and serial pulmonary function testing and were followed for two years.

RESULTS

After the first infusion, all patients had a mild, non-clinically significant increase in mean pulmonary artery pressure, but none exhibited right heart failure or volume overload. In the year following treatment, there was no significant change in the FVC, but two patients had improvement in their chest x-ray and had prednisone withdrawn. BAL samples after the second infusion were sufficiently viable to undergo FACS analysis in three cases and in two patients, CD10+CD49c+C105+ cells (indicative of PDA-001 cells) were found.

CONCLUSION

The use of placental derived mesenchymal-like cells led to a mild increase in pulmonary artery pressure. In some cases, these cells were found in the BAL 24 hours after the second dose. Two of four patients demonstrated some steroid sparing benefit, including one patient with prolonged remission.

Abstract P3-05-16: The effect of HER-2/neu inhibition on prolonging clinical benefit with fulvestrant treatment for metastatic estrogen receptor positive breast cancer patients treated with trastuzumab

Background: Fulvestrant is a well-established treatment for postmenopausal patients with estrogen receptor (ER) positive metastatic breast cancer, and some patients experience prolonged clinical benefit exceeding one year. HER2 activation is a major cause of endocrine resistance, and cross-talk between HER2/neu and ER coactivator MED1 regulates tamoxifen resistance in breast cancer cells. (Cancer Res 2012 1;72(21):5625-34.). In a xenograft mouse model, suppression of MED1 enhanced tumor growth inhibition by fulvestrant in HER2/neu overexpressing breast cancer cells (PLoS One 20123 30;8(7)). Objective of study: To determine if blocking the HER2/neu receptor with trastuzumab can improve response to fulvestrant. Methods: This was an IRB approved record review of patients from three medical oncologists with biopsy-proven ER+ metastatic breast cancer treated with fulvestrant. Demographic data collected included age at diagnosis, type and stage of cancer, original and metastatic ER, progesterone receptor (PR), and HER2/neu biomarkers, and site(s) of metastasis, and primary local and systemic treatment. All patients with HER2/neu positive primary tumors received trastuzumab. The duration of fulvestrant therapy was calculated. Time to clinical disease progression on fulvestrant was measured as a surrogate for duration of clinical benefit. Based on the median duration of therapy of 425 days, patients were divided into two groups: Short Treatment (< 425 days) versus Prolonged Treatment (>425 days). Results: One hundred metastatic ER+ fulvestrant treated breast cancer patients with documented duration of therapy were identified. There was no difference between the Short and Prolonged Treatment Groups in regards to age, sites of metastases, or use of adjuvant endocrine or chemotherapy. Eighty five patients had recorded HER2/neu tumor status. All 11 of 85 (13%) patients with documented HER2/neu positive primary tumors received trastuzumab. Patients with HER2/neu positive tumors tended to have longer durations of fulvestrant therapy (772 (51-1911) days (median (range)) compared to HER2/neu negative patients (360 (60-2739) days, p=0.059). Only 2 of 45 (4%) tumors from the Short Treatment Group were HER2/neu positive, while 9 of 40 Prolonged Treatment Group patients with documented HER2/neu status were positive (Fisher’s exact test p<0.021). Patients with HER2/neu positive tumors were more likely to experience prolonged responses to therapy with an odds ratio of 6.2 (1.26 to 30.92 95% confidence interval, p=0.0249). Conclusion: Overexpression of HER2/neu in tumors from ER+ metastatic breast cancer patients treated with trastuzumab was associated with a prolonged response to fulvestrant therapy.

Citation Format: Mahmoud Charif, Elyse E Lower, Diane Kennedy, Harriet Kumar, Shugufta Khan, Neetu Radhakrishnan, Xiaoting Zhang. The effect of HER-2/neu inhibition on prolonging clinical benefit with fulvestrant treatment for metastatic estrogen receptor positive breast cancer patients treated with trastuzumab [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-05-16.

Features of sarcoidosis associated with chronic disease

BACKGROUND

The clinical outcome of sarcoidosis is variable. Several features have been proposed as predictive of chronic sarcoidosis.

OBJECTIVES

To examine the predictive role of clinical features on the clinical outcome score (COS) of sarcoidosis patients five years after initial diagnosis.

METHODS

A cohort of newly diagnosed sarcoidosis patients seen at one clinic were re-evaluated five years after initial diagnosis. The COS was determined at this five year time point and compared to initial age, race, sex, forced vital capacity (FVC) and chest roentgenogram. We also compared COS to whether patients had Lofgrens syndrome, lupus pernio, or cardiac disease and what treatment they received during the five years of observation. Patients with neurologic disease were divided into those with seventh cranial nerve paralysis alone versus those with other neurologic disease (CNS).

RESULTS

Of the 335 newly diagnosed patients seen over a three year period, 213 (64%) were evaluated five years after initial diagnosis. Of these patients 168 (79%) were still requiring systemic therapy at five years (COS 7, 8, or 9). Seven features were associated with chronic disease: CNS alone (Odds Ratio (OR)=19.24, p<0.05); CNS, cardiac, and/or lupus pernio (OR=5.86, p<0.02); FVC<80% (OR=7.04, p<0.02); treatment with prednisone (OR=6.35, p<0.0001); methotrexate (OR=7.2, p<0.0001); azathioprine (OR=19.24, p<0.05); anti-tumor necrosis therapy (OR=13.98, p>0.05).

CONCLUSION

In our study, the majority of sarcoidosis patients were receiving systemic therapy five years after initial diagnosis. Patients with reduced lung function, neurologic disease, lupus pernio, and cardiac disease were more likely to require prolonged treatment.

The effect of trastuzumab therapy on clinical benefit from fulvestrant treatment for metastatic estrogen receptor-positive breast cancer patients

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Background: Overexpression of HER2/neu is associated with tamoxifen resistance in breast cancer (Osborne CK et al. J Natl Canc Inst 2003; 95:353-361). However pts may present with both estrogen receptor (ER) and HER2/neu + tumors. The benefit of adding fulvestrant to trastuzumab is unclear. The objective of the study was to determine the effect of trastuzumab on fulvestrant therapy. Methods: This was an IRB approved record review of patients (pts) from three medical oncologists with biopsy-proven ER+ metastatic breast cancer treated with fulvestrant who also had their primary tumor tested for HER2/neu. Demographic data collected included age at diagnosis, type and stage of cancer, original and metastatic ER, progesterone receptor (PR), and HER-2/neu biomarkers, and site(s) of metastasis, and primary local and systemic treatment. All pts with HER-2/neu + primary tumors received trastuzumab. The duration of fulvestrant therapy was calculated. Time to clinical disease progression on fulvestrant was measured as a surrogate for duration of clinical benefit. Results: Eighty-five metastatic ER+ fulvestrant treated breast cancer pts with known primary tumor HER2/neu status were identified and the duration of therapy calculated. All eleven (13%) pts with documented HER2/neu + primary tumors received trastuzumab. The duration of therapy for HER2/neu + pts (772 (51-1911) days (median (range)) was longer than HER2/neu negative pts (360 (60-2,739) days, p=0.059). The median duration of fulvestrant therapy was 425 days. Pts with HER2/neu + tumors were more likely to be treated beyond the median fulvestrant therapy with an odds ratio of 6.2 (1.26 to 30.92 95% confidence interval, p=0.0249). Conclusions: Trastuzumab plus fulvestrant therapy was associated with a more prolonged clinical response than fulvestrant alone in pts with metastatic breast cancer. This synergism may be due to the effect of trastuzumab inhibiting the activation of transcriptional coactivator MED1, a recently discovered key crosstalk point between HER2/neu and ER signaling pathways in mediating endocrine resistance (Cancer Res 2012;72(21):5625;PLoS One 2013; 8:e70641).

Refractory granulomas of breast: Benign or malignant disease

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Background: Idiopathic granulomatous mastitis (IGM) is an uncommon benign inflammatory breast disease of unknown etiology that may mimic malignancy, infectious diseases, or autoimmune conditions requiring a diagnosis of exclusion. Because the differential diagnosis includes benign as well as malignant disease, an organized approach to the diagnosis and its symptom management is needed. Treatment may include corticosteroids, immunosuppression, or in severe refractory cases, surgery. Methods: This IRB-approved single tertiary referral center study was performed to better characterize the presentation, risk factors, differential diagnosis, and treatment options for IGM. All patients identified in a pathology database with a biopsy consistent with IGM were studied. Data collected included demographics, duration and quality of symptoms, imaging results, microbiology, pathology, systemic and surgical therapies, and outcomes. Results: Between 2006 and 2014, 16 eligible patients were identified. Patients with a prior history of IGM, cancer, or other granulomatous diseases were excluded. Twelve patients were evaluable, and four patients were excluded due to insufficient records. The mean age was 31.9 years (23 to 54) with 50% of patients black and 25% Hispanic. Pregnancy occurred within 5 years of biopsy in 67% of patients. The most common presenting symptom was mass (83%) with focal pain (75%), and the mean duration of symptoms was 5.1 months (0.5 to 16). All microbial cultures were negative. Following diagnosis, systemic treatment included antibiotics (58%), corticosteroids (25%), and methotrexate (17%). Due to refractory symptoms and toxicity despite steroids and methotrexate, surgical intervention was necessary in 67%. Partial mastectomy was performed in 50% and total mastectomy in 17%, with one patient requesting mastectomy for palliation. Conclusions: Although rare, IGM is difficult to diagnose and manage, and an accurate diagnosis must exclude malignancy and other granulomatous processes. Despite the benign nature of the disease, surgical intervention may be required. Systemic treatment with corticosteroids and methotrexate may decrease the need for surgical intervention.

Medical therapy of sarcoidosis

For treatment of sarcoidosis, one should develop a long-term management plan. Factors to be considered include the organ involvement and severity of symptoms. Different organ manifestations may require different treatments. Intensity of treatment is usually based on severity of disease or potential for organ failure or death. Glucocorticoids are quite effective as initial therapy for most forms of sarcoidosis. However, the toxicity associated with long-term treatment often leads to the use of alternative treatments. These include cytotoxic agents such as methotrexate, biologic agents such as the antitumor necrosis factor antibody infliximab, and other anti-inflammatory drugs such as hydroxychloroquine. In some cases, anti-inflammatory drugs may not help. Examples include pulmonary hypertension and fibrosis.

Bosentan for sarcoidosis-associated pulmonary hypertension: a double-blind placebo controlled randomized trial

BACKGROUND

Sarcoidosis-associated pulmonary hypertension (SAPH) is a common problem in patients with persistent dyspneic sarcoidosis. The objective of this study was to determine the effect of bosentan therapy on pulmonary arterial hemodynamics in patients with SAPH.

METHODS

This 16-week study was a double-blind, placebo-controlled trial of either bosentan or placebo in patients with SAPH confirmed by right-sided heart catheterization. Patients were enrolled from multiple academic centers specializing in sarcoidosis care. They were stable on sarcoidosis therapy and were receiving no therapy for pulmonary hypertension. The cohort was randomized two to one to receive bosentan at a maximal dose of 125 mg or placebo bid for 16 weeks. Pulmonary function studies, 6-min walk test, and right-sided heart hemodynamics, including pulmonary artery mean pressure and pulmonary vascular resistance (PVR), were performed before and after 16 weeks of therapy.

RESULTS

Thirty-five patients completed 16 weeks of therapy (23 treated with bosentan, 12 with placebo). For those treated with bosentan, repeat hemodynamic studies at 16 weeks demonstrated a significant mean±SD fall in PA mean pressure (-4±6.6 mm Hg, P=.0105) and PVR (-1.7±2.75 Wood units, P=.0104). For the patients treated with placebo, there was no significant change in either PA mean pressure (1±3.7 mm Hg, P>.05) or PVR (0.1±1.42 Wood units, P>.05). There was no significant change in 6-min walk distance for either group. Two patients treated with bosentan required an increase of supplemental oxygen by >2 L after 16 weeks of therapy.

CONCLUSIONS

This study demonstrated that bosentan significantly improved pulmonary hemodynamics in patients with SAPH.

TRIAL REGISTRY

ClinicalTrials.gov; No: NCT00581607; URL: www.clinicaltrials.gov.

Accuracy of Serial PET-CT Imaging in Systemic Sarcoidosis

Positron emission tomography (PET) in combination with computed tomography (PET-CT) is commonly used to identify malignant lesion in the lung. Despite there being only a few reports in literature, PET-CT imaging may have many advantages in the study of sarcoidosis, being useful in the diagnosis as well as in monitoring the response to treatment. The object of this case report is to highlight the clinical utility of integrated PET-CT imaging for evaluation of patients with systemic sarcoidosis and for comparing baseline findings to follow-up readings.

The WASOG Sarcoidosis Organ Assessment Instrument: An update of a previous clinical tool

INTRODUCTION

A Case Control Etiology of Sarcoidosis Study (ACCESS) sarcoidosis organ assessment instrument has been used for more than a decade to establish uniform standards for the probability of sarcoidosis organ involvement. The ACCESS instrument has become increasingly outdated as new technologies have been developed. Furthermore, the ACCESS instrument failed to address all possible organs involved with sarcoidosis. For these reasons, the World Association of Sarcoidosis and Other Granulomatous Diseases (WASOG) developed a new sarcoidosis organ assessment instrument.

METHODS

Clinical sarcoidosis experts assessed various clinical manifestations for the probability of sarcoidosis organ involvement. Two criteria were required to apply this assessment: 1) histologic evidence of granulomatous inflammation of unknown cause in an organ that was not being assessed; 2) the clinical manifestation being addressed required that alternative causes other than sarcoidosis had been reasonably excluded. Clinical manifestations were assessed as either: a) highly probable: likelihood of sarcoidosis causing this manifestation of at least 90%.; b) probable: likelihood of sarcoidosis causing this manifestation of between 50 and 90%; c) possible: likelihood of sarcoidosis causing this manifestation of less than 50%. The sarcoidosis experts voted on the likelihood of sarcoidosis causing each manifestation using Delphi study methodology where at least 70% agreement of the experts was needed for consensus.

RESULTS

Various clinical manifestations were classified as highly probable, at least probable, possible, or indeterminate when no consensus could be reached.

CONCLUSION

An instrument was developed by expert opinion that may be useful for the clinician and researcher in establishing criteria for sarcoidosis organ involvement.

Biomarker discordance: why it occurs and why it is important

Although the analysis of hormone receptors and HER-2/neu has usually been performed on primary tumors only, a growing body of evidence suggests that substantial discordance exists between primary and metastatic disease for estrogen receptors (30-40%) and HER-2/neu (10-30%). This discordance may reflect alterations in pathologic assessment techniques, changes between primary and metastatic breast cancer, differences within a heterogenous tumor, or the effect of treatment. The etiology of discordance is poorly understood and frequently may reflect tumor heterogeneity along with lack of standardized preanalytic and analytic variables. Standardization of diagnostic variables can improve diagnostic reproducibility. Because of the emergence of targeted hormonal and HER-2/neu therapies, tumor biomarkers assume a pivotal role in treatment decisions. The loss of sensitivity to hormones or HER-2/neu may suggest tumor resistance; whereas, the acquisition of hormone receptors and HER-2/neu provides potential new treatment targets which can improve overall patient outcomes.

Abstract P3-09-17: One year of adjuvant hormone therapy does not increase patient fatigue: Results of a prospective early stage breast cancer trial

INTRODUCTION: The diagnosis and treatment of breast cancer may alter a patient's mental and physical quality of life. Estrogen effects on the brain may be neuroprotective or detrimental, and adjuvant endocrine therapy may influence cognitive functions including fatigue. We previously reported that three months of adjuvant hormone therapy was not associated with change in fatigue. The purpose of this study was to prospectively determine the incidence of fatigue in early stage breast cancer patients during one year of adjuvant hormone therapy. METHODS: Seventy-four consecutive patients of a single medical oncologist with newly diagnosed hormone dependent breast cancer prescribed adjuvant hormone therapy enrolled in this prospective study. Data collected included age, race, menopausal status, breast cancer stage, body mass index, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT)-F, Fatigue Assessment Scale (FAS), short form 36 (SF-36), and cognitive failure questionnaire (CFQ). All tests were administered by one nurse prior to hormone initiation (0 mo) and after 3, 6, 9, and 12 months (mo) of therapy. Statistical analysis was performed using Student t test for paired data with a p value of <0.05 considered significant. RESULTS: Prior to starting therapy, a third of patients had a FAS score of >22, consistent with moderate to severe fatigue. After 12 months of therapy, 52 patients (13 premenopausal, 39 postmenopausal) were still receiving adjuvant hormone therapy and had completed serial testing. Twenty patients received chemotherapy prior to institution of hormone treatment. There were no significant changes in FACIT-F, FAS, SF-36, or CFQs scores during the first 12 months of treatment.

 0 mo3 mo6 mo9 mo12 moFACIT-F44 (7-52)*42 (3-52)43 (3-52)43 (2-52)44 (6-52)FAS17 (10-43)18 (10-48)17 (10-48)20 (10-48)19 (10-50)Weight, lb.159 (102-256)162 (102-258)161 (102-258)163 (102-263)164 (101-258)SF-36 Total72 (12-100)68 (15-99)83 (15-99)76 (15-99)82 (7-100)CFQ70 (39-94)69 (34-92)68 (34-94)67 (28-96)70 (20-96)* Median (Range)

Although during the first six months, a small but significant increase in body weight occurred, there was no significant difference between the initial and 12 month body weight. CONCLUSION: Prior to adjuvant hormone therapy institution, breast cancer patients often have significant problems with fatigue. However, the first 12 months of adjuvant hormone therapy does not appear to affect fatigue or cognitive failure.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-17.

Effect of obesity on patient-reported outcomes in sarcoidosis

OBJECTIVES

To assess the impact of high body mass index (BMI) on patient-reported outcomes in sarcoidosis patients and healthy persons.

METHODS

In this case-control study, we investigated symptoms of fatigue and dyspnoea, health status, BMI and spirometric tests in 184 sarcoidosis patients and the same number of sex- and age-matched healthy subjects. Fatigue was assessed using the fatigue scale (FS), dyspnoea was determined by the baseline dyspnoea index (BDI) and health status was measured using the respiratory-specific St George's Respiratory Questionnaire (SGRQ).

RESULTS

There were significantly more subjects with increased BMI (≥25 kg/m(2)) among the sarcoidosis patients than among the healthy volunteers ((2) 37.675, P < 0.01). Sarcoidosis patients also had a greater probability of having a higher BMI (P < 0.01, OR 1.18, 95%CI 1.071.3). We found significantly lower BDI scores and forced expiratory volume in 1 s/forced vital capacity, as well as higher total SGRQ and total FS scores in sarcoidosis patients than in healthy individuals (P < 0.01 for all differences).

CONCLUSION

Sarcoidosis significantly reduces patients' health status, both independently and also due to increased BMI. Reduction in BMI may contribute to improved spirometry results and health status of patients with sarcoidosis.

Calcium and vitamin D metabolism in sarcoidosis

BACKGROUND

Sarcoidosis associated hypercalcemia (SAHC) may be secondary to excessive levels of 1,25-(OH)2 vitamin D3 produced by autonomous 1-alpha-hydroxylase activity within the granulomas.  The frequency, treatment, and consequences of hypercalcemia remain unclear.

STUDY DESIGN AND METHODS

Two patient cohorts were studied.  In Cohort 1, the prevalence of hypercalcemia in 1606 sarcoidosis patients seen during a six year period was analyzed along with treatment and outcome. Cohort 2 consisted of  261 sarcoidosis patients with measured 25-(OH) vitamin D3 and 1,25-(OH) vitamin D3 levels. In forty patients, serial levels of 25-(OH) vitamin D3 and 1,25-(OH) vitamin D3 were measured at least three months apart without change in therapy.

RESULTS

SAHC was identified in 97 of 1606 (6%) of patients studied and additional nine (0.6%) patients had primary hyperparathyroidism. Post treatment follow up was available in 86 SAHC patients. Hypercalcemia improved in &gt;90% of patients, including eight patients treated solely with vitamin D supplement withdrawal. Renal insufficiency, documented in 41 (42%) of SAHC patients, improved with hypercalcemia treatment.  In 80% of Cohort 2 patients low 25-(OH) vitamin D3 levels were measured with only one patient having a low 1,25(OH)2 vitamin D3 level. Elevated 1,25(OH)2 vitamin D3 levels, which were measured in 11% of patients, were higher for those with a history of hypercalcemia.

CONCLUSION

Sarcoidosis associated hypercalcemia, which is often accompanied by renal insufficiency, responds to treatment of sarcoidosis and withdrawal of vitamin D supplementation. Measurement of serum vitamin 1,25(OH)2 vitamin D3 appears to best evaluate vitamin D status in sarcoidosis patients.

Established and experimental medical therapy of pulmonary sarcoidosis

The treatment options for pulmonary sarcoidosis have increased over the past 10 years. As new treatments have been introduced, the best way to assess and compare treatments remains unknown. The goal of this review is to discuss the standard treatments for pulmonary sarcoidosis, including glucocorticoids, and cytotoxic agents, such as methotrexate, azathioprine and leflunomide, and compare them to the newer biological agents, such as infliximab and adalimumab. We also discuss some novel treatments which are currently being evaluated. To compare these different regimens, we look at the measures used to assess response. These include pulmonary function, chest imaging, steroid sparing potential and, more recently, improvements in quality of life measures. While there is, as yet, no standard assessment for response, there is a growing consensus that response to treatment may include improvement of one or more of the following: forced vital capacity, chest imaging and steroid sparing. Several drugs used for pulmonary sarcoidosis have demonstrated improvement in one or more of these measures.

Armodafinil for sarcoidosis-associated fatigue: a double-blind, placebo-controlled, crossover trial

CONTEXT

Fatigue has been identified in more than one-half of patients with sarcoidosis. Although fatigue is not synonymous with impaired quality of life, most studies of sarcoidosis identify fatigue as a major cause of impaired quality of life.

OBJECTIVES

To test the hypothesis that stimulants may have a role in the treatment of fatigued sarcoidosis patients, even without objective evidence of daytime sleepiness.

METHODS

This was a double-blind, placebo-controlled, crossover study of sarcoidosis patients followed up in one sarcoidosis clinic Sarcoidosis patients with fatigue received either armodafinil or placebo with eight weeks of therapy for each arm and a two week washout period before crossover to the other treatment. Initial armodafinil dose was 150mg and increased to 250mg after four weeks. Patients underwent polysomnography and multiple sleep latency testing (MSLT) the following day. Patients with an apnea/hypopnea index <6/hour received either armodafinil or placebo. Polysomnography with MSLT was repeated after each treatment arm.

RESULTS

Fifteen patients received the study drug. Fatigue was assessed using the Fatigue Assessment Scale (the lower the score, the less the fatigue) and the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) (the higher the score, the less the fatigue). After eight weeks of therapy, there was a significant improvement in the Fatigue Assessment Scale during armodafinil treatment (median -4.5, range -20, 5) compared with placebo treatment (median 3.5, range -9, 14, P<0.05) and for the FACIT-F (armodafinil: median 9, range -12, 26 vs. placebo: median -5, range -17, 11, P<0.005). This improvement in fatigue was seen for both those with and without shortened sleep onset latency time during the MSLT.

CONCLUSION

Armodafinil treatment led to a significant reduction in fatigue in sarcoidosis patients. This effect was seen even in patients who did not have excessive daytime somnolence.

Abstract P6-08-08: Three months of adjuvant hormone therapy does not increase fatigue or cognitive failure: results of a prospective early stage breast cancer trial

INTRODUCTION: The diagnosis and treatment of breast cancer may alter a patient's mental and physical quality of life. Fatigue and impaired cognition have been reported after chemotherapy and hormone therapy. The purpose of this study was to prospectively determine the incidence of fatigue and cognitive changes in early stage breast cancer patients during adjuvant hormone therapy and to evaluate the relationship of dysfunction with other risk factors.

METHODS: Fifty-four consecutive patients of a single medical oncologist with newly diagnosed hormone dependent breast cancer prescribed adjuvant hormone therapy enrolled in this prospective study. Data collected included age, race, menopausal status, breast cancer stage, body mass index, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT)-F, Fatigue Assessment Scale (FAS), short form 36 (SF-36), cognitive failure questionnaire (CFQ), Beck depression inventory (BDI-2), Epworth sleepiness scale, and facial recognition (FR) and sheep dash time (SDT) to assess executive functioning. All tests were administered by one nurse prior to hormone initiation (0 mo) and after 3 months (3 mo) of therapy. Statistical analysis was performed using Student t test for paired data with a p value of &lt;0.05 considered significant.

RESULTS: After 3 months of therapy, 52 of 54 patients were reevaluated (1 patient dropped out and 1 excluded for metastatic disease). Of the remaining 52 patients, the mean age was 54 years (range 30–76) with self-reported race of white 38, black 13 and Indian 1 patient and 39 (75%) patients were postmenopausal. Initial tumor stage was 0 in 8 patients, 1 in 23, 2 in 20, and 3 in 1. Although the baseline mental health of patients assessed by SF-36 mental health (MH) domain was low (70 ±22.0 [mean ±SD]) after 3 months it improved to 55 ±8.1, P &lt; 0.0001. No change was found in the SF-36 domains of physical health or vitality. At baseline, 15 of 52 patients (36%) reported significant fatigue (FAS score ≥22). After 3 months of therapy fatigue as measured by either the FACIT-F (0 mo:30 ±11.2; 3 mo:31 ±9.5, p = 0.37) or FAS (0 mo:20 ±8.5; 3 mo: 20 ±7.6, p = 0.53) remained unchanged. No change was noted in depression as determined by the BDI-2 score (0 mo: 9 ±8.1 versus 3 mo:9 ± 9, p = NS) or Epworth sleepiness scores (0 mo:7 ±4.5 versus 3 mo:8 ±4.7, p = NS). The initial CFQ was considered positive (&gt;43) in 48 (92%) of patients. There was no significant change in the CFQ, SDT, or FR (CFQ 0 mo:67±12.9, 3 mo:67±13.0, p = 0.453; SDT: 0 mo:0.56±0.292 secs, 3 mo:0.52±0.223 secs, p = 0.144). BMI rose minimally after hormone therapy (0 mos:28.8 ±6.41; 3 mo:29.1 ±6.43, p = 0.0498).

CONCLUSION: Prior to adjuvant hormone therapy institution, breast cancer patients often have significant problems with fatigue, cognitive failure, and overall mental health. Overall mental health improved during the first three months of hormone therapy. However, there was no significant change in fatigue, cognitive failure, depression score, reaction time, or facial recognition. Longer follow–up will be performed to assess the possible cumulative effects of hormone therapy on fatigue or cognitive function. Supported by Ride Cincinnati

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-08-08.

Rituximab for refractory granulomatous eye disease

OBJECTIVE

To determine the effectiveness of rituximab therapy for patients with granulomatous disease of the eye.

METHODS

Retrospective review was undertaken of cases seen at a single institution for ocular antineutrophil cytoplasmic antibody-associated vasculitis or sarcoidosis with persistent ocular disease despite systemic therapy. All patients were treated with rituximab and followed for at least 6 months.

RESULTS

Nine patients were identified (five with antineutrophil cytoplasmic antibody-associated vasculitis, four with sarcoidosis), and all were treated for at least 6 months. Eight experienced improvement of eye disease and were able to reduce prednisone and other drug therapies. One patient remained stable, but still required high dosages of prednisone. All five patients with lung disease improved with rituximab therapy. Rituximab treatment was well tolerated. Two patients discontinued the drug due to leukopenia; however, both patients reinstituted rituximab at modified doses.

CONCLUSION

Rituximab therapy was effective in controlling granulomatous ocular disease in most cases. The drug was corticosteroid-sparing and effective in refractory cases, with no severe adverse events encountered.

Endpoints for clinical trials of sarcoidosis

Over the past few years an increasing number of prospective controlled sarcoidosis treatment trials have been completed. Unfortunately, these studies utilize different endpoints making comparisons between studies difficult. At the recent World Association of Sarcoidosis and other Granulomatous disease (WASOG) meeting, a session was dedicated to the evaluation of clinical endpoints for various disease manifestations. These included pulmonary, pulmonary hypertension, fatigue, cutaneous, and a classification of clinical disease phenotypes. Based on the available literature and our current understanding of the disease, recommendations for clinical evaluation were proposed for each disease category. For example, it was recommended that pulmonary studies should include changes in the forced vital capacity. Additionally, it was recommended that all trials should incorporate measurement of quality of life.

Sarcoidosis-associated fatigue

Sarcoidosis-associated fatigue is globally recognised as a disabling symptom. Fatigue has been reported in up to 50-70% of sarcoidosis patients, causing impaired quality of life. The aetiology of this troublesome problem remains elusive and is usually multifactorial. Fatigue can be a consequence of treatment itself, including as a complication of corticosteroid therapy. The diagnosis of sarcoidosis-associated fatigue requires an extensive evaluation to identify and treat potentially reversible causes. Granuloma formation and cytokine release may be involved in its aetiology. However, despite adequate sarcoidosis treatment, many patients continue to experience fatigue. Comorbidities associated with sarcoidosis, including depression, anxiety, hypothyroidism and altered sleep patterns, may all contribute to fatigue. Despite an exhaustive search for treatable clinical causes of fatigue, most patients' complaints of fatigue are not correlated with clinical parameters of disease activity. Recent studies have demonstrated the effectiveness of various neurostimulants, including methylphenidate, for the treatment of sarcoidosis-associated fatigue. These and other agents may be useful adjuncts for the treatment of sarcoidosis-associated fatigue. Obviously, there is a need for studies evaluating the causes and new therapeutic options of sarcoidosis-associated fatigue. Psychological interventions should also be examined.

Management of ocular sarcoidosis

BACKGROUND

A step wise approach to the use of cytotoxic and anti-tumor necrosis factor (TNF) antibodies has been developed for managing chronic sarcoidosis.

OBJECTIVES

To provide a summary of our experience with immunosuppressive agents especially methotrexate and the anti-tumor necrosis factor antibodies in treating chronic ocular sarcoidosis.

STUDY DESIGN AND METHODS

This was a retrospective review of 1587 sarcoidosis patients seen at one center over a six year period. All patients with definite or probable ocular sarcoidosis were identified.

RESULTS

A total of 465 (29%) of the sarcoidosis patients experienced ocular disease. Of these, 365 patients were treated with methotrexate (MTX) for their eye disease with 281 (77% of those started on MTX) still receiving MTX at the end of the study. Methotrexate was the only systemic therapy prescribed in 115 patients while 101 patients also received concurrent prednisone. Other combinations administered include MTX plus azathioprine and/or leflunomide. A total of 25 patients were treated with the monoclonal anti-TNF antibodies infliximab (19 patients) or adalimumab (6 patients). While all patients initially responded to anti-TNF therapy, only ten patients experienced a sustained response with ongoing therapy or complete remission of ocular disease. Recurrent infections, adverse drug events, or financial constraints were responsible for most drug discontinuations.

CONCLUSION

Most cases of chronic ocular sarcoidosis respond well to immunosuppressive therapy. However, patients may require combination therapy to achieve and maintain disease control. The use of anti-TNF agents for refractory disease is encouraging but can be accompanied by significant toxicity.