Update on the use of erythropoiesis-stimulating agents (ESAs) for the management of anemia of multiple myeloma and lymphoma

Preoperative hemoglobin-to-red cell distribution width ratio as a prognostic factor in pulmonary large cell neuroendocrine carcinoma: a retrospective cohort study

Background

The hemoglobin (Hgb)/red cell distribution width (RDW) ratio (HRR) is a simple prognostic marker for small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), but no data are available for pulmonary large cell neuroendocrine carcinoma (PLCNEC). This study aimed to assess the potential prognostic role of preoperative HRR in PLCNEC.

Methods

This single-center retrospective study included patients with PLCNEC who underwent surgery at Shanghai Pulmonary Hospital from January 2012 to August 2016. The follow-up was censored in August 2020. The participants were grouped as low/high HRR according to their optimal value calculated using a receiver operating characteristic (ROC) curve. Univariable and multivariable Cox analysis were performed to identify the risk factors for overall survival (OS).

Results

A total of 80 patients with PLCNEC were included. The optimal cutoff values were 0.969 for HRR. Compared with the high HRR group, the low HRR group had a lower mean Hgb (12.1 vs. 14.1 g/dL, P<0.001), lower mean albumin-globulin ratio (AGR) (1.4 vs. 1.6, P=0.017), and higher median RDW (14.5% vs. 12.9%, P<0.001). The median OS was 30.0 months [95% confidence interval (CI): 13.4 to 46.5 months]. Participants in the low HRR group exhibited a poorer OS than those with high HRR (20.3 months, 95% CI: 14.5 to 26.1 months vs. not reached, P<0.001). The multivariable analysis showed that low HRR was significantly associated with poor OS [hazard ratio (HR) =3.16, 95% CI: 1.69 to 5.93, P<0.001].

Conclusions

Low HRR is associated with poor OS in patients with PLCNEC and can be used as an inexpensive prognostic factor in patients undergoing PLCNEC resection.

A proposed index of diffuse bone marrow [18F]-FDG uptake and PET skeletal patterns correlate with myeloma prognostic markers, plasma cell morphology, and response to therapy

PURPOSE

The investigation of a semi-quantitative index in the pelvis to assess for diffuse bone marrow (BM) [18F]-FDG uptake and the investigation of PET skeletal patterns in multiple myeloma (MM) patients, in accordance with prognostic markers, clonal plasma cell (cPC) morphology, and response to therapy.

METHODS

We prospectively analyzed [18F]-FDG PET/CT in 90 MM patients (newly diagnosed, 60; relapsed/refractory, 30). Among other PET/CT parameters, we calculated the ratio SUVmax pelvis/liver and examined for correlations with known MM prognostic parameters, cPC morphology (good vs. low/intermediate differentiation), and response to therapy.

RESULTS

SUVmax pelvis/liver ratio was significantly lower for the group of good differentiation vs. intermediate/low differentiation cPCs (p < 0.001) and showed a positive correlation with BM infiltration rate, β2 microglobulin, serum ferritin, international staging system (ISS), and revised ISS; no significant correlation was found with hemoglobin. A cutoff value of 1.1 showed an excellent specificity (99%) and high sensitivity (76%) for diffuse BM involvement (AUC 0.94; p < 0.001). Mixed pattern and appendicular involvement correlated with poor prognostic features while normal pattern, found in 30% of patients, correlated with good prognostic features. Presence of ≥ 10 focal lesions negatively predicted for overall response (p < 0.05; OR 4.8). The CT component improved the diagnostic performance of PET.

CONCLUSION

This study showed, for the first time, that cPC morphology and markers related with MM biology, correlate with SUVmax pelvis/liver index, which could be used as a surrogate marker for BM assessment and disease prognosis; PET patterns correlate with MM prognostic features and response rates.

Prognostic value of baseline hemoglobin-to-red blood cell distribution width ratio in small cell lung cancer: A retrospective analysis

Background

This study aimed to investigate the prognostic value of baseline hemoglobin‐to‐red blood cell distribution width ratio (HRR) in patients with small cell lung cancer (SCLC).

Methods

We retrospectively analyzed the medical records of patients with newly diagnosed SCLC who had received first‐line chemotherapy at the Department of Pulmonary Oncology of the PLA 307 Hospital between January 2008 and October 2018. The optimal cutoff value of the continuous variables was determined using the X‐tile software. Univariate and multivariate analyses were conducted using Cox proportional hazard models. The Kaplan‐Meier method was used for survival analysis, with differences tested using the log‐rank test.

Results

A total of 146 patients were included. The cutoff value for HRR was determined as 0.985. Statistically significant differences were observed in sex, smoking history, stage, radiotherapy combination, neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio, hemoglobin, and red blood cell distribution width between the high and low HRR groups. The median overall survival (OS) was nine and 17.5 months in the low and high HRR groups, respectively (P < 0.001). The median progression‐free survival (PFS) was five and 8.5 months, respectively (P < 0.001). Univariate and multivariate analyses showed low HRR to be an independent predictor of a poor prognosis for OS (hazard ratio = 3.782; 95% confidence interval, 2.151–6.652; P < 0.001) and PFS (hazard ratio = 2.112; 95% confidence interval, 1.195–3.733; P = 0.01) in SCLC.

Conclusion

Low HRR was associated with poorer OS and PFS in patients with SCLC and can be a potentially valuable prognostic factor for these patients.

Key points

The prognostic value of the baseline hemoglobin‐to‐red blood cell distribution width ratio was evaluated in patients with small cell lung cancer.

In this population, this ratio was an independent predictor of overall survival and progression‐free survival. This ratio, an inexpensive and routine parameter, can be used as a prognostic factor in small cell lung cancer.

Proposal for a Quantitative 18F-FDG PET/CT Metabolic Parameter to Assess the Intensity of Bone Involvement in Multiple Myeloma

Many efforts have been made to standardize the interpretation of ¹⁸F-FDG PET/CT in multiple myeloma (MM) with qualitative visual analysis or with quantitative metabolic parameters using various methods for lesion segmentation of PET images. The aim of this study was to propose a quantitative method for bone and bone marrow evaluation of ¹⁸F-FDG PET/CT considering the extent and intensity of bone ¹⁸F-FDG uptake: Intensity of Bone Involvement (IBI). Whole body ¹⁸F-FDG PET/CT of 59 consecutive MM patients were evaluated. Compact bone tissue was segmented in PET images using a global threshold for HU of the registered CT image. A whole skeleton mask was created and the percentage of its volume with ¹⁸F-FDG uptake above hepatic uptake was calculated (Percentage of Bone Involvement - PBI). IBI was defined by multiplying PBI by mean SUV above hepatic uptake. IBI was compared with visual analysis performed by two experienced nuclear medicine physicians. IBI calculation was feasible in all images (range:0.00–1.35). Visual analysis categorized PET exams into three groups (negative/mild, moderate and marked bone involvement), that had different ranges of IBI (multi comparison analysis, p < 0.0001). There was an inverse correlation between the patients’ hemoglobin values and IBI (r = −0.248;p = 0.02). IBI score is an objective measure of bone and bone marrow involvement in MM, allowing the categorization of patients in different degrees of aggressiveness of the bone disease. The next step is to validate IBI in a larger group of patients, before and after treatment and in a multicentre setting.

The optimum hematocrit

The hematocrit (Hct) determines the oxygen carrying capacity of blood, but also increases blood viscosity and thus flow resistance. From this dual role the concept of an optimum Hct for tissue oxygenation has been derived. Viscometric studies using the ratio Hct/blood viscosity at high shear rate showed an optimum Hct of 50-60% for red blood cell (RBC) suspensions in plasma. For the perfusion of an artificial microvascular network with 5-70μm channels the optimum Hct was 60-70% for high driving pressures. With lower shear rates or driving pressures the optimum Hct shifted towards lower values. In healthy, well trained athletes an increase of the Hct to supra-normal levels can increase exercise performance. These data with healthy individuals suggest that the optimum Hct for oxygen transport may be higher than the physiological range (35-40% in women, 39-50% in men). This is in contrast to clinical observations. Large clinical studies have repeatedly shown that a correction of anemia in a variety of disorders such as chronic kidney disease, heart failure, coronary syndrome, oncology, acute gastrointestinal bleeding, critical care, or surgery have better clinical outcomes when restrictive transfusion strategies are applied. Actual guidelines, therefore, recommend a transfusion threshold of 7-8 g/dL hemoglobin (Hct 20-24%) in stable, hospitalized patients. The discrepancy between the optimum Hct in health and disease may be due to factors such as decreased perfusion pressures (low cardiac output, vascular stenoses, change in vascular tone), endothelial cell dysfunction, leukocyte adhesion and others.