Increased risk of leukaemia in patients with juvenile chronic arthritis treated with chlorambucil

The role of biologic agents in the management of non-infectious uveitis

INTRODUCTION

Uveitis is an intriguing group of disorders characterized by inflammation of the uveal tract. Due to the potential grave consequences of the disease process, it is important to assess the various therapeutic options available for treating uveitis, and their outcomes.

AREAS COVERED

This review discusses the use of conventional agents in the management of uveitis, including discussion of the molecular and clinical properties of corticosteroids, antimetabolites, calcineurin inhibitors and alkylating agents and their side effects. In addition, it also discusses the molecular and clinical properties of novel biologic agents and their side effects. Moreover, recommendations as to when biologic agents should be employed are also discussed.

EXPERT OPINION

We recommend that in general (except in selected cases of Adamantiades-Behçet's disease) biologics should not be used as a first-line therapy for uveitis due to inconvenience, high cost, and potential immunosuppressive effects. However, many biologics are potent in inducing drug-free remission of uveitis and may be employed to manage recurrent diseases or diseases not responsive to conventional agents.

Risk of cancer with metal-on-metal hip replacements: population based study

OBJECTIVE

To assess the risk of cancer associated with modern primary metal-on-metal hip replacements.

DESIGN

Population based study.

SETTING

Nationwide retrospective comparative register.

PARTICIPANTS

10,728 patients who underwent metal-on-metal total hip arthroplasty and 18,235 patients who underwent conventional metal-on-polyethylene, ceramic-on-polyethylene, and ceramic-on-ceramic total hip arthroplasty (the non-metal-on-metal cohort) in the Finnish Arthroplasty Register 2001-10. Data on cancer cases up to 2010 for these cohorts were extracted from the Finnish Cancer Registry.

MAIN OUTCOME MEASURES

The relative risk of cancer was expressed as the ratio of observed to expected number of cases from the Finnish population--that is, the standardised incidence ratio. The relative risk of cancer in the metal-on-metal cohort compared with the non-metal-on-metal cohort was estimated with analyses of these ratios and Poisson regression.

RESULTS

The overall risk of cancer in patients with metal-on-metal hip implants was similar to that in the Finnish population (378 observed v 400 expected, standardised incidence ratio 0.95, 95% confidence interval 0.85 to 1.04). The overall risk of cancer in patients with metal-on-metal hip implants was also no higher than in patients who had received non-metal-on-metal hip implants (relative risk 0.92, 0.81 to 1.05).

CONCLUSIONS

Metal-on-metal hip replacements are not associated with an increased overall risk of cancer during a mean follow-up of four years.

Comparative tolerability of treatments for juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) includes several forms of chronic arthritis in children. Treatments are chosen according to the type and severity of the disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids remain the mainstays of therapy. Traditional slower acting anti-rheumatic drugs, such as gold therapy, penicillamine, sulfasalazine, tiopronin and hydroxychloroquine, are usually poorly active in children. In addition, adverse effects are common, including severe macrophage activation syndrome with gold therapy or sulfasalazine. Low dose, once weekly methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to the administration of an NSAID, especially in those with the extended oligoarticular subtype of the disease. Other immunosuppressive agents, such as cyclosporin, are sometimes combined with methotrexate. In recent years, novel treatments have been developed. Autologous hematopoietic stem cell transplantation is effective in a number of children with severe JIA, whose disease has been refractory to conventional therapy. However, only short term follow-up data are currently available for this novel therapy. In addition, severe infections complicated by macrophage activation syndrome and death have been reported. Finally, anti-tumour necrosis factor-alpha therapy has shown efficacy in more than two-thirds of children with JIA and polyarthritis, and other cytokine inhibitors may be soon available.

Uveitis associated with pediatric behçet disease in the american midwest

PURPOSE

To describe demographics, clinical course, treatment, and visual prognosis of uveitis in pediatric patients with Behçet disease, and to compare childhood-onset with adult-onset Behçet uveitis.

DESIGN

Retrospective, observational case series.

METHODS

setting: Uveitis service, University of Illinois at Chicago and private office of one of the authors (H.H.T.). study population: Patients diagnosed with Behçet uveitis using International Study Group criteria between January 1, 1973 to December 31, 2007. main outcome measures: Demographics, symptoms, clinical course, management, laboratory tests, complications, and visual prognoses were recorded.

RESULTS

Thirty-three patients had available records with at least one month follow-up; four were children and 29 were adults. All children and 19 adults were male. The most common initial symptom was oral ulcers and the most common uveitis type was panuveitis with retinal vasculitis in both groups. There was an average delay of one year among children and 1.8 years among adults between onset of uveitis and disease diagnosis. Immunosuppressive therapy was employed in all children and 23 of 29 adults. Treatment response was variable in both groups. Maculopathy was the most common cause of permanent visual impairment, both in children and in adults. Six of eight pediatric eyes (75%) and 13 of 25 adult eyes (52%) retained a visual acuity better than 20/200 at three years.

CONCLUSIONS

Behçet disease is an uncommon cause of uveitis in the United States, with a male predominance. Although the clinical picture of Behçet uveitis was similar among both groups, the visual prognosis appeared worse in adults. Awareness of this disease should be increased in nonendemic areas to prevent blindness resulting from delays in diagnosis.

Incidence of second neoplasia in patients with B-cell chronic lymphocytic leukemia treated with chlorambucil maintenance chemotherapy

The aim of this retrospective study was to examine the impact of prolonged chlorambucil (CLB) therapy on the development of second neoplasia (SN) in 389 patients with B-CLL, comparing untreated cases with those receiving CLB as induction plus maintenance therapy. Fifty-nine SN cases were observed (15.1%) at a median follow-up of 79 months. SN occurrence was significantly related to Binet stage. No difference was detected between untreated and CLB treated cases neither in terms of SN incidence (12.2% vs 18.1%) nor in the median follow-up (81 vs 79.1 months). Moreover, SN free survival was not different between these two groups. Four out of 13 CLB treated patients (30.8%) developed s-MDS after a subsequent treatment with fludarabine plus cyclophosphamide (F + C). In conclusion, SN development is dependent on the length of follow-up rather than on therapy duration. F + C should be administered with caution after prolonged CLB therapy.

Cancer after Total Joint Arthroplasty: A Meta-analysis

BACKGROUND

Some epidemiologic and laboratory studies have suggested that total joint arthroplasty could increase the risk of cancer. In this meta-analysis, we attempt to clarify the association of joint arthroplasty with subsequent cancer incidence.

METHODS

We identified population-based studies reporting standardized incidence ratios (SIR) for cancer following large joint arthroplasty. After summing the observed and expected numbers of cases across all qualifying studies, we calculated SIRs for all cancers, and for those at 28 anatomic sites. Latency analysis involving 175,166 patients characterized short-term and long-term cancer associations.

RESULTS

The analyses included 1,435,356 person-years of follow-up and 20,045 cases of cancer. Overall cancer risk among patients with arthroplasty was equal to that for the general population. The relative risk of lung cancer, reduced in the first 5 years after arthroplasty, increased significantly over time to approach that of the general population. Risks for all sites in the luminal gastrointestinal tract were significantly reduced by 10% to 20%; with relative risks that were generally stable over time. Increased risks were seen for cancer of the prostate (SIR, 1.12; 95% confidence interval, 1.08-1.16); similar relative risks were seen in each time period after the procedure. For melanoma, relative risks increased with follow-up to a SIR of 1.43 (95% confidence interval, 1.13-1.79) for 10 or more years after arthroplasty. There was a similar delayed emergence of increased risks for cancers of the urinary tract and oropharynx. The relative risk for bone cancer decreased with time after the procedure.

CONCLUSIONS

There does not seem to be an overall increased risk of cancer following total joint arthroplasty. Although the risks of prostate cancer and melanoma seem to be elevated, there is no obvious mechanism for these associations. Reductions in risk for some malignancies may not be causal.

Immunomodulatory therapy for ocular inflammatory disease: a basic manual and review of the literature

Corticosteroids are used as first-line treatment for many ocular inflammatory conditions. The risk of adverse effects, however, necessitates conversion to steroid-sparing immunomodulatory therapy (IMT) for disease that is recurrent, chronic, or poorly responsive to treatment. Combination drug treatments with multiple agent 'recipes' are also considered. Immunomodulatory agents include the broad categories of antimetabolites (azathioprine, methotrexate, mycophenolate mofetil), alkylating agents (cyclophosphamide, chlorambucil), T-cell inhibitors (cyclosporine, tacrolimus), and cytokines (interferon alfa). This article reviews and summarizes the evidence for IMT agent use in the treatment of various forms of ocular inflammation.

The impact of low-dose busulfan on clonal dynamics in nonhuman primates

An understanding of the number and contribution of individual pluripotent hematopoietic stem cells (HSCs) to the formation of blood lineages has important clinical implications for gene therapy and stem cell transplantation. We have been able to efficiently mark rhesus macaque long-term repopulating stem and progenitor cells with retroviral vectors, and track their in vivo contributions to hematopoiesis using the linear amplification mediated-polymerase chain reaction (LAM-PCR) technique of insertion site analysis. We assessed the impact of busulfan on contributions of individual retrovirally marked clones to hematopoiesis. There were 2 macaques that received transplants of retrovirally transduced CD34(+) cells 2 years previously that were then treated with 4 mg/kg busulfan. Despite only transient and mild suppression of peripheral blood counts, the numbers of individual stem/progenitor clones contributing to granulocyte production decreased dramatically, by 80% in the first monkey and by 60% in the second monkey. A similar impact was seen on clones contributing to T cells. The clone numbers recovered gradually back toward baseline by 5 months following busulfan in the first monkey and by 3 months in the second monkey, and have remained stable for more than one year in both animals. Tracking of individual clones with insertion-site-specific primers suggested that clones contributing to hematopoiesis prior to busulfan accounted for the majority of this recovery, but that some previously undetected clones began to contribute during this recovery phase. These results indicate that even low-dose busulfan significantly affects stem and progenitor cell dynamics. The clonal diversity of hematopoiesis was significantly decreased after even a single, clinically well-tolerated dose of busulfan, with slow but almost complete recovery over the next several months, suggesting that true long-term repopulating stem cells were not permanently deleted. However, the prolonged period of suppression of many clones suggests that transplanted HSCs may have a marked competitive advantage if they can engraft and proliferate during this time period, and supports the use of this agent in nonmyeloablative regimens

Therapy-related myeloid leukemias are observed in patients with chronic lymphocytic leukemia after treatment with fludarabine and chlorambucil: results of an intergroup study, cancer and leukemia group B 9011

PURPOSE

Patients with chronic lymphocytic leukemia (CLL) may have disease transformation to non-Hodgkin's lymphoma or prolymphocytic leukemia; however, development of therapy-related acute myeloid leukemia (t-AML) is unusual. A series of patients enrolled onto an intergroup CLL trial were examined for this complication.

PATIENTS AND METHODS

A total of 544 previously untreated B-cell CLL patients were enrolled onto a randomized intergroup study comparing treatment with chlorambucil, fludarabine, or fludarabine plus chlorambucil. Case report forms from 521 patients were reviewed for t-AML.

RESULTS

With a median follow-up of 4.2 years, six patients (1.2%) to date have developed therapy-related myelodysplastic syndrome (t-MDS; n = 3), t-AML (n = 2), or t-MDS evolving to t-AML (n = 1), from 27 to 53 months (median, 34 months) after study entry. This included five (3.5%) of 142 patients treated with fludarabine plus chlorambucil and one (0.5%) of 188 receiving fludarabine; no chlorambucil-treated patients developed t-MDS or t-AML (P =.007). At study entry, the median age among these six patients was 56 years (range, 44 to 72 years); three were male; the CLL Rai stage was I/II (n = 4) or III/IV (n = 2). Response to CLL therapy was complete (n = 4) or partial remission (n = 1) and stable disease (n = 1). Marrow cytogenetics, obtained in three of six cases at diagnosis of t-MDS or t-AML, were complex, with abnormalities in either or both chromosomes 5 and 7. Other abnormalities involved chromosomes X, 1, 8, 12, 17, and 19. Median survival after diagnosis of t-MDS/AML was 3.5 months (range, 0.5 to 10.1 months).

CONCLUSION

Our findings raise the possibility that alkylator-purine analog combination therapy may increase the risk of therapy-related myeloid malignancies, which is of particular relevance with regard to ongoing trials using these combination therapies.

Long-term follow-up of patients treated with short-term high-dose chlorambucil for sight-threatening ocular inflammation

PURPOSE

To determine the effectiveness of short-term high-dose chlorambucil in the treatment of sight-threatening uveitis and to ascertain the incidence of severe side effects, particularly late malignancy.

DESIGN

Retrospective, noncomparative interventional case series.

PARTICIPANTS

Fifty-three patients treated at the University of Illinois at Chicago Eye and Ear Infirmary and the private office of one of the authors for severe sight-threatening uveitis.

METHODS

Treatment with short-term high-dose chlorambucil (2-9 months of therapy).

MAIN OUTCOME MEASURE

Visual acuity and degree of inflammation were assessed at every visit. The development of systemic side effects, including malignancy, was assessed using a detailed questionnaire.

RESULTS

Total cumulative dose of chlorambucil ranged from 392 to 5200 mg with an average of 1429 mg. The maximum daily dose ranged from 10 to 30 mg with an average of 20 mg. Average duration of treatment was 16 weeks with a range of 7 to 40 weeks. Seventy-seven percent of patients treated were in remission with an average follow-up of 4 years (range: 6 months to 24 years). Forty-seven percent had at least two lines of improvement in Snellen visual acuity after treatment, with an average gain of 3.5 lines. Adverse effects include secondary amenorrhea, nonophthalmic herpes zoster, testicular atrophy, and erectile dysfunction. None of the patients had developed a malignancy as of their last follow-up.

CONCLUSION

Short-term high-dose chlorambucil therapy may be a reasonable option in patients with intractable sight-threatening uveitis.

Cancer incidence after total knee arthroplasty: a nationwide Finnish cohort from 1980 to 1996 involving 9,444 patients

A nationwide, computer-based survey of all total joint arthroplasties performed in Finland has been carried out since January 1980. From these records, a cohort of 9,444 patients, with 51,756 person-years, after primary operation with a total polyethylene-on-metal knee arthroplasty (TKA) was followed up for cancer through the Finnish Cancer Register up to December 31, 1996. During the follow-up, 706 cancers were observed. The expected number, based on national rates, was 719; therefore, the standardized incidence ratio (SIR) for all cancers was 0.98. The SIRs for non-Hodgkin's lymphoma (1.40), Hodgkin's disease (1.24) and multiple myeloma (1.54) were increased, but only that of non-Hodgkin's lymphoma was statistically significant 3-10 years after the operation. The numbers of observed cases of prostate cancer exceeded that of expected, with a SIR value of 1.49. A low SIR of lung cancer was observed among men, especially during the first 3 years (0.61), but not in women. The SIR for colon cancer was below unity in women only (SIR 0.70). The SIR for cancer of the urinary organs was close to unity (0.97). SIR relating to soft tissue and bone cancer did not differ significantly from unity, and none of the 6 sarcomas was observed at the site of a prosthesis. The overall cancer risk after TKA done for primary osteoarthrosis seems not to be increased. The increases in lymphoma and prostate cancer risk, however, are observations that could be related to TKA and justify further follow-up of the cohort.

Cancer incidence in Finnish hip replacement patients from 1980 to 1995: a nationwide cohort study involving 31,651 patients

Nationwide, computer-based reporting of all arthroplasties performed in Finland was started in January 1980. Using data from these records, a cohort of 31,651 polyethylene-on-metal total hip arthroplasty (THA) patients was followed up for cancer, using Finnish Cancer Registry data, from 1980 to 1995. During follow-up, 2,367 cancers were observed. There were statistically significantly fewer cancers among the THA patients (standardized incidence ratio [SIR], 0.90; 95% confidence interval [CI], 0.87-0.93). SIRs for cancers of the lung (0.69) and stomach (0.77) were significantly below unity. There was no significantly increased risk at any site. The SIR for cancer overall in male THA patients was below unity during the first 3 years after THA but returned to unity thereafter. The low SIR among men during the first 3 years was largely because the lung cancer SIR was 0.47 (95% CI, 0.35-0.62). In women, the SIR remained around 0.93 throughout follow-up. The SIR for stomach cancer was below unity only in women (SIR, 0.67; 95% CI, 0.51-0.86). For cancer of the urinary bladder, the SIR during the first 3 years after THA was below unity but later slightly above it (SIR, 1.24 in relation to > or =3 years of follow-up; 95% CI, 0.99-1.52). For myeloma and leukemia, SIRs were greater than unity only for THA patients followed up for 3 to 9 years. The study findings, in contrast to previously reported findings, do not indicate that there is any increased risk of hematopoietic cancers after THA using polyethylene-on-metal prostheses. SIRs relating to soft tissue cancers and bone sarcomas did not differ significantly from unity. No sarcoma was observed at the site of a prosthesis. THA seems to play no major role in cancer causation.

Chlorambucil in indolent chronic lymphocytic leukemia. French Cooperative Group on Chronic Lymphocytic Leukemia

BACKGROUND

To determine whether chlorambucil treatment benefits patients with indolent chronic lymphocytic leukemia (CLL), we conducted two randomized trials in 1535 patients with previously untreated stage A CLL.

METHODS

In the first trial, 609 patients were randomly assigned to receive either daily chlorambucil or no treatment; in the second trial, 926 patients were randomly assigned to receive either intermittent chlorambucil plus prednisone or no treatment. Median follow-up for the first and second trials exceeded 11 and 6 years, respectively. The end points were overall survival, response to treatment, and disease progression.

RESULTS

Treatment of indolent CLL did not increase survival in either trial. In the treated group, as compared with the untreated group, the relative risk of death was 1.14 (95 percent confidence interval, 0.92 to 1.41; P=0.23) in the first trial and 0.96 (95 percent confidence interval, 0.75 to 1.23; P=0.74) in the second trial, with 76 percent and 69 percent of patients, respectively, having a response to therapy. Although chlorambucil slowed disease progression, there was no effect on overall survival. In the untreated group in the first trial, 49 percent of patients did not have progression to more advanced disease and did not need therapy after follow-up of more than 11 years; however, 27 percent of patients with stage A CLL died of causes related to the disease.

CONCLUSIONS

Chlorambucil does not prolong survival in patients with stage A CLL. Since deferring therapy until the disease progresses to stage B or C does not compromise survival, treatment of indolent CLL is unnecessary.