Musculoskeletal symptoms in chronic myeloid leukemia patients after stopping tyrosine kinase inhibitors

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Background: TKIs have revolutionized outcomes for CML patients (pts) but are not without cost or side effects. For pts with a prolonged response to treatment, discontinuing (d/c) treatment is appealing and has been investigated in a number of trials. In pts in whom treatment was stopped, musculoskeletal (MSK) symptoms were reported that were shown in some cases to resolve with resuming TKIs. Methods: Records of pts with chronic phase CML who stopped TKIs were reviewed. Results: We report 8 pts with chronic phase CML whose TKI was stopped following a prolonged molecular remission. 5 pts were receiving imatinib and 3 dasatinib. 5 pts were experiencing intolerable side effects of TKIs and agreed to a trial of d/c; 2 pts requested d/c; a third pt was planning for pregnancy. The median duration of therapy with TKI before d/c was 10 years. 6/8 pts developed MSK complaints with arthralgias and joint stiffness after cessation. Involved joints included the cervical spine, shoulders, elbows, small joints of the hand, hips and knees. Arthralgia was Grade 1 in 3 pts, and Grades 2 and 3 in 1 and 2 pts, respectively. Joints were not swollen, erythematous or tender to touch. The median time from cessation of TKIs to the onset of symptoms was 2.25 mos (range: < 1-6 months). 3 pts with symptoms underwent rheumatologic work up that was nonrevealing. 5/8 pts remain in molecular remission. Of the 3 with molecular relapse, 2 had arthralgias that improved with resuming TKIs; the third remained asymptomatic. Of those who did not relapse, 1 remains symptom-free and 2 had resolution of their MSK symptoms. 1 had little benefit with corticosteroid therapy and imatinib was resumed. However, this retreatment was d/c due to side effects and she continues to experience mild arthralgias. 1 pt did not benefit from resuming TKIs, which was therefore d/c. Conclusions: The etiology of the so-called TKI “withdrawal syndrome” remains unclear. The incidence of this syndrome has not been fully elucidated, and it seems to be underappreciated and perhaps under-reported by patients. Although most symptoms are relatively mild and self-limited, this should be discussed with patients considering stopping TKIs.

Metabolomic profiling in patients undergoing Off-Pump or On-Pump coronary artery bypass surgery

Background

Coronary artery bypass surgery can be performed without (Off-Pump) or with cardiopulmonary bypass (On-Pump). Extracorporeal circulation and cardioplegic arrest may cause alterations in the plasma metabolome. We assessed metabolomic changes in patients undergoing On-Pump or Off-Pump coronary artery bypass surgery.

Methods

We assessed five analyte classes (41 acylcarnitines, 14 amino acids, 92 glycerophospholipids, 15 sphingolipids, sugars, lactate) using a mass-spectrometry-based kit (Biocrates AbsoluteIDQ® p150) in paired arterial and coronary sinus blood obtained from 10 consecutive On-Pump and 10 Off-Pump patients. Cardioplegia for On-Pump was warm blood Calafiore. On-Pump outcomes were corrected for hemodilution through crystalloid priming.

Results

Demographic data were equal in both groups with normal ejection fraction, renal and liver function. Patients received 2.25 ± 0.64 bypass grafts. All postoperative courses were uneventful. Of 164 measured metabolites, only 13 (7.9%) were altered by cardiopulmonary bypass. We found more long-chain acylcarnitines Off-Pump and more short-chain acylcarnitines On-Pump. Glycerophospholipids showed lower concentrations On-Pump and arginine (as the only different amino acid) Off-Pump. Interestingly, plasma arginine (nitric oxide precursor) concentration at the end of surgery correlated inversely with postoperative vasopressor need (r = −0.7; p < 0.001). Assessing arterial/venous differences revealed phosphatidylcholine-production and acylcarnitine-consumption. These findings were unaffected by cardiopulmonary bypass, cardioplegia or temporary vessel occlusion during Off-Pump surgery.

Conclusions

Cardiopulmonary bypass and warm blood cardioplegia cause only minor changes to the metabolomic profile of patients undergoing coronary artery bypass surgery. The observed changes affected mainly acylcarnitines. In addition, there appears to be a relationship between arginine and vasopressor need after bypass surgery.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0518-1) contains supplementary material, which is available to authorized users.

Malignant acrospiroma: a case report in the era of next generation sequencing

Background

Malignant acrospiroma is a rare tumor of the eccrine sweat glands accounting for around 6% of all malignant eccrine tumors. Typically, it presents as large ulcerated nodules, and diagnosis can be challenging as it has great overlap with its benign counterpart.

Case presentation

We herein report a case of acral malignant acrospiroma, initially treated with surgical excision and adjuvant radiotherapy. After metastatic disease was confirmed, subject received multiple lines of chemo- as well as targeted therapy. Genomic testing was also done using next generation sequencing.

Conclusion

To the best of our knowledge, this is the first case of acral malignant acrospiroma with reported next generation sequencing results.

Operative treatment of calcaneal fractures: improved outcomes and low complications rates with a strict management protocol

This is a retrospective review of 80 intra-articular calcaneal fractures treated with open reduction and internal fixation by a specialist team under supervision of a single surgeon in a tertiary centre between 2005 and 2014. The fractures were evaluated with plain radiography and computed tomography, and graded using the Eastwood-Atkins classification. A lateral approach was used and all fractures were fixed with calcaneal plates. All patients had clinical and radiological follow-up. Clinical assessment included foot and ankle disability index, SF-36^® and Kerr-Atkins scores. The mean follow-up duration was 72 months (range: 12-130 months). The mean age of patients was 49 years (range: 17-73 years). There were three open fractures and eight patients had other injuries. The mean Bohler's angle improved from 6° preoperatively to 26° postoperatively. The mean foot and ankle disability index score was 78.62, the mean SF-36^® scores were 45.5 (physical component) and 52.6 (mental component), and the mean Kerr-Atkins score was 72 (range: 36-100). Early complications included one case of screw protrusion in the subtalar joint (which warranted a repeat procedure), one sural nerve injury and one wound breakdown, which healed with non-operative measures. Twelve patients had symptomatic subtalar joint osteoarthritis. Four of these had subtalar fusion. We believe that our strict protocols of patient selection, intraoperative and postoperative management produced long-term results comparable with those in the peer reviewed literature.

Production and characterization of monoclonal antibodies specific for canine CD138 (syndecan-1) for nuclear medicine preclinical trials on spontaneous tumours

We isolated 11 antibodies specific for canine CD138 (cCD138) to validate the interest of CD138 antigen targeting in dogs with spontaneous mammary carcinoma. The affinity of the monoclonal antibodies in the nanomolar range is suitable for immunohistochemistry and nuclear medicine applications. Four distinct epitopes were recognized on cCD138 by this panel of antibodies. CD138 expression in canine healthy tissues is comparable to that reported in humans. CD138 is frequently expressed in canine mammary carcinomas corresponding to the human triple negative breast cancer subtype, with cytoplasmic and membranous expression. In canine diffuse large B-cell lymphoma, CD138 expression is associated with the 'non-germinal center' phenotype corresponding to the most aggressive subtype in humans. This homology of CD138 expression between dogs and humans confirms the relevance of tumour-bearing dogs as spontaneous models for nuclear medicine applications, especially for the evaluation of new tumour targeting strategies for diagnosis by phenotypic imaging and radio-immunotherapy.

Major Pulmonary Complications After Hematopoietic Stem Cell Transplant

Both autologous and allogeneic hematopoietic stem cell transplants are important therapeutic options for several benign and malignant disorders. Pulmonary complications, although they have become less frequent, remain a significant cause of morbidity and mortality after hematopoietic stem cell transplant. These complications range from bacterial, fungal, and viral pulmonary infections to noninfectious conditions such as diffuse alveolar hemorrhage and idiopathic pneumonia syndrome. Bronchiolitis obliterans syndrome is the primary chronic pulmonary complication, and treatment of this condition remains challenging. This report highlights the advances in the diagnosis and management of the major pulmonary complications after hematopoietic stem cell transplant. It also underscores the need for prospective and multicenter research to have a better understanding of the mechanisms behind these complications and to obtain more effective diagnostic tool and therapeutic options.