Arthralgia and aromatase inhibitors

Rheumatic aspects of arthralgias associated with aromatase inhibitor therapy (analysis of a clinical case series)

Objective: to describe the rheumatic aspects of arthralgia associated with aromatase inhibitor therapy in a clinical case series.Material and methods. The article presents a series of clinical cases – 16 patients (mean age 61±14 years) with histologically verified breast cancer (BC) and the onset of musculoskeletal pathology during hormone therapy with aromatase inhibitors (letrozole, anastrozole, exemestane). The laboratory and instrumental examination data, including ultrasound, joint X-rays, general and immunological blood tests with the determination of rheumatoid factor (RF), antibodies to cyclic citrullinated peptide (ACCP), CRP and antinuclear factor (ANF) are presented. The detected musculoskeletal pathology was compared with valid classification and/or diagnostic criteria for rheumatic diseases.Results and discussion. In 10 (63%) cases, musculoskeletal pathology debuted in the first 3 months of therapy with aromatase inhibitors and in all patients it was represented by inflammatory manifestations, including clinically significant synovitis (n=13), tenosynovitis (n=12), enthesitis (n=5), morning stiffness in the joints >30 min (n=6) and inflammatory rhythm lower back pain (n=1). In 15 (94%) patients, ultrasound showed signs of synovitis (with increased vascularization in 5 cases), tenosynovitis in 15 (94%), and erosions in 1 (6%). X-rays showed osteoarthritis in 12 patients, and chronic erosive arthritis in 2. Increased ESR >30 mm/h and CRP level >5 mg/l were present in 6 (38%) and 7 (44%) patients, respectively; ANF (Hеp2) titer 1/160 was found in 8 (53%) out 15 examined patients. RF and ACCP were not detected in any case. During rheumatological examination, the following were diagnosed: polymyalgia rheumatica (n=1), undifferentiated arthritis (n=6), psoriatic arthritis (n=1), rheumatoid arthritis (n=1), recurrent proliferative synovitis of the knee joints with a pronounced exudative component (n=3), inflammatory lesions of periarticular tissues (n=4).Conclusion. Based on the obtained data, it can be assumed that arthralgias induced by breast cancer hormone therapy may be a manifestation of inflammatory diseases of the musculoskeletal system. Given the heterogeneity of manifestations of musculoskeletal pathology in such patients, a complete rheumatological examination is necessary to establish the diagnosis and conduct adequate therapy.

Exploration of tumour-infiltrating lymphocytes as a predictive biomarker for adjuvant endocrine therapy in early breast cancer

PURPOSE

Tumour-infiltrating lymphocytes (TILs) have been shown to be prognostic for disease-free survival and predictive for the benefit of chemotherapy in patients with early breast cancer, but have not been studied for endocrine therapy.

EXPERIMENTAL DESIGN

The number of CD8-positive TILs was assessed in a subcohort of 236 patients in the Intergroup Exemestane Study. AQ After 2-3 years of adjuvant tamoxifen, AQpatients were randomized between the schemes of continuation for 5 years on tamoxifen and switching to exemestane. The numbers of CD8-positive TILs were analysed for correlations with disease-free survival (DFS) and overall survival (OS). A similar analysis was performed on 2596 patients in the TEAM trial who were randomized between the sequential scheme and the exemestane monotherapy.

RESULTS

In the first cohort, patients with low (below median) numbers of CD8-positive TILs had a univariate hazard ratio (HR) for DFS of 0.27 (95% CI 0.13-0.55) in favour of treatment with exemestane, whereas this benefit was not observed in patients with high numbers of CD8-positive TILs (HR 1.34, 95% CI 0.71-2.50, HR for interaction 5.02, p = 0.001). In the second cohort, patients with low numbers of CD8-positive TILs showed a benefit of exemestane treatment on recurrence-free survival (RFS HR 0.67, 95% CI 0.45-0.99), and not with above-median numbers of CD8-positive TILs (HR 0.86, 95% CI 0.59-1.26, HR for interaction 1.29, p = 0.36).

CONCLUSIONS

This study is the first to propose the number of CD8-positive TILs as potential predictive markers for endocrine therapy, with the low presence of CD8-positive TILs associated to benefit for exemestane-inclusive therapy. However, treatment-by-marker interactions were only significant in one cohort, indicating the need for further validation.

Influence of aromatase inhibitors therapy on the occurrence of rheumatoid arthritis in women with breast cancer: results from a large population-based study of the Italian Society for Rheumatology

Objectives

The purpose of this study was to evaluate the risk of developing rheumatoid arthritis (RA) in a population of patients with breast cancer treated with aromatase inhibitors (AIs) compared with tamoxifen.

Methods

Data were collected from the administrative healthcare database of Lombardy Region, Italy, from 2004 to 2013. This study follows a nested cohort design, including women with a diagnosis of breast cancer starting treatment with tamoxifen, anastrozole, exemestane or letrozole. The risk of RA related to the prescription of the different drugs was estimated by survival models for competing risks and the results are presented as hazard ratios (HRs) and 95% confidence intervals (95% CI), adjusted for age and cancer severity.

Results

Out of total 10 493 women with breast cancer with a median (IQR) age of 66 (57–74), 7533 (71.8%) started an active treatment with AIs or tamoxifen. In this subgroup a total of 113 new cases of RA developed during the 26 105.9 person-year of 10 186 exposure periods, including time varying exposures in the same patient. Using tamoxifen as reference category, AIs therapy was associated with an increased risk of RA (adjusted HR 1.62 (95%1.03–2.56)), in particular in patients receiving anastrozole, even after adjusting for age and level of neoplasia: (adjusted HR 1.75 (95%1.07–2.86)).

Conclusions

In a large population-based sample of women with breast cancer, exposure to AIs compared with tamoxifen is associated with a significantly increased risk of RA, which is not influenced by the cancer severity and the relationship of age with indication to specific drugs.