POS0253 RITUXIMAB-BIOSIMILAR FOR ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODIES-ASSOCIATED VASCULITIS: EXPERIENCE OF A SINGLE ITALIAN CENTER

Background:

Rituximab (RTX), an anti-CD20 monoclonal antibody, represents a valuable treatment for anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV). RTX biosimilar CT-P10 (RTX-B) has been approved in Europe in all indications held by RTX originator (RTX-O). As stated by recent international consensus-based recommendations, 1 there is evidence regarding safety and efficacy of biosimilars in the context of rheumatic diseases, but it is encouraged to gather additional data. 2,3

Objectives:

To report the experience of a single Italian center with RTX-B in AAV in terms of safety and efficacy.

Methods:

We retrospectively reviewed the charts of all AAV patients followed up in our Small Vessel Vasculitis Clinic and we selected those who received RTX-B between October 2017 and May 2020, both naïve to RTX (RTX-Bn) or already treated with ≥1 course of RTX-O and switched to RTX-B (RTX-Bs). Baseline features, disease outcome, concomitant therapy and adverse events 6 (T6), 12 (T12) and 24 (T24) months after RTX-B introduction, when available, were collected. Non-parametric statistic tests were used.

Results:

Fifty-six AAV patients (44 [78.6%] granulomatosis with polyangiitis (GPA), 12 [21.4%)] microscopic polyangiitis (MPA)) received RTX-B with a median follow up of 20 (IQR 10-24) months. ANCA were positive in 49 (87.5%) patients. Ten (17.9%) patients were newly diagnosed with AAV, while 23 (41.1%) had refractory disease and another 23 had relapsing disease.

Thirty-three (58.9%) patients were RTX-Bs, whereas 23 (41.1%) RTX-Bn. In 29 (51.8%) patients RTX was decided because of remission induction, while in 27 (48.2%) as maintenance regimen. Median cumulative RTX-B dose was 2.5 (2-3.875) grams with 3 (IQR 2-4) median courses. AAV activity, adverse events and concomitant therapy at T6, T12 and T24 are shown in Table 1. One GPA patient died of severe infection 3 months after a single infusion of RTX-B 500 mg as maintenance therapy.

Table 1.

AAV activity, concomitant therapy and adverse events at T0, T6, T12 and T24.

T0T6T12T24n (%)56 (100)52 (92.6)40 (71.4)18 (32.1)Dose RTX-B, median (IQR) grams1.75 (0.5-2)0.5 (0.5-1)0.5 (0.5-1)0.5 (0.5-1)Concomitant prednisone therapy, n (%)42 (75)27 (48.2)13 (32.5)4 (22.2)Dose prednisone, median (IQR) milligrams/day5 (5-15.625)2.5 (2.5-5)3.75 (2.75-7.5)2.75 (1.56-4.5)Concomitant bDMARDs, n (%)10 (17.9)5 (9.6)3 (7.5)1 (5.6)RefractorinessNA4 (7.7)2 (5)1 (5.6)RelapseNA0 (0)3 (7.5)2 (11.1)RemissionNA48 (92.3)35 (87.5)15 (83.3)SuspensionNA10 (19.2)9 (22.5)4 (22.2)Infusion reaction, n (%)1 (1.8)1 (1.9)0 (0)0 (0)Infectious adverse events, n (%)NA10 (19.2)6 (15)3 (16.7)Severe infectious adverse events, n (%)NA2 (3.8)1 (2.5)0 (0)

Considering the 52 (92.6%) patients who reached a 6 months-follow up, we marked a significant decrease of number of patients on steroid therapy (39 [75%] vs 27 [51.9%]; p=0.003), of median prednisone daily dose (5 [IQR 5-25] vs 2.5 [IQR 1.25-5 mg; p=0.001) and of number of patient on concomitant bDMARDs (10 [19.2%] vs 5 [9.6%]; p=0.003).

Analysing the 40 (71.4%) patients who reached a 12 months-follow up, we confirmed the tendency with a decrease of number of patients on steroid therapy (29 [72.5%] vs 13 [32.5%]; p=0.007), of median prednisone daily dose (5 [IQR 5-12.5] vs 3.75 [IQR 2.75-7.5]; p=0.008) and of number of patient on concomitant bDMARDs (9 [22.5%] vs 3 [7.5%]; p=0.009).

No statistically significant difference was found for the same variables comparing T0 versus T24.

Conclusion:

Our experience with RTX-B is limited; however, it represents an extensive report about the use of RTX-B in AAV patients and confirmed that it may be a well-tolerated and effective therapy in AAV setting, in agreement with previous evidence on RTX-O. Prospective and larger studies are needed to confirm this preliminary evidence.

References:

[1]Kay J, et al. Ann Rheum Dis 2018;77:165–74.

[2]Kwon HC, et al. Yonsei Med J 2020;61:712-9.

[3]Mittal S, et al. Clin Rheumatol 2021;40:645-51.

Disclosure of Interests:

Silvia Sartorelli: None declared, adriana cariddi: None declared, Luca Moroni: None declared, Elena Baldissera Speakers bureau: Pfizer, Roche, Sanofi-Genzyme, Consultant of: Novartis, Enrica Bozzolo: None declared, Lorenzo Dagna Consultant of: Abbvie, Amgen, Biogen, BristolMyers Squibb, Celltrion, Galapagos, GlaxoSmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI., Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unrestricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI.

AB0512 ALLERGIC PROFILE AND ALLERGEN-SPECIFIC IMMUNOTHERAPY IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA): A SINGLE CENTER OBSERVATIONAL STUDY

Background:

Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome, is a systemic disease characterized by late onset asthma associated with small- and/or medium-size vessel vasculitis, besides eosinophil-mediated cytotoxic organ damage. About 20-30% of patients with EGPA displays allergic manifestations related with inhalant sensitization, while prevalence of food and drug allergy is unknown in this context. Moreover, some authors in the past hypothesized in favor of a possible role of allergen-specific immunotherapy (ASIT) as a trigger of disease.

Objectives:

Aim of the present study is to establish the prevalence of each category allergen sensitization and to determine whether atopy or specific immunotherapy could influence clinical expression of the disease.

Methods:

Our study consisted in a retrospective demographic and clinical data collection regarding EGPA history (including age at diagnosis, organ and tissue involvement, autoantibody profile) and the presence of allergic comorbidities or previous drug hypersensitivity reactions. Patients without either proven allergic reactions or positive tests have been excluded.

Results:

Fifty-three (53) patients with definitive diagnosis of EGPA have been included in the analysis among which 25 (47.2%) with chronic respiratory allergy or previous acute allergic reaction. Among allergic patients 15 (60%) resulted sensitized towards inhalants and among them 13 (86.7%) displayed multiple sensitization. Drug allergy affected 13 patients (52%), food 4 (16%). Among 15 patients with respiratory allergy, 13 were eligible to allergen-specific immunotherapy (ASIT). Seven (7) subjects underwent ASIT prior EGPA diagnosis with an average time-to-EGPA of 16.2 years. No statistically significant difference was found in terms of sex, age at diagnosis, positivity for or specificity of anti-neutrophil cytoplasm antibodies (ANCA), eosinophil count at onset, pattern of clinical manifestations comparing allergic vs. non-allergic, ASIT vs. non-ASIT, ASIT vs. allergic, ASIT vs. eligible.

Conclusion:

Among patients with EGPA allergies are highly prevalent, particularly towards inhalants and drugs. In the great majority of patients multiple sensitization profile is found. Atopy doesn’t seem to be associated with specific patterns of disease presentation. The absence of correlation between inhalant ASIT exposure and variation in mode and time of EGPA onset doesn’t support the hypothesis of a its potential role in triggering the disease.

References:

[1]Berti A et al. Severe/uncontrolled asthma and overall survival in atopic patients with eosinophilic granulomatosis with polyangiitis. Respiratory Medicine 2018; DOI: 10.1016/j.rmed.2018.07.017

[2]Cottin V et al. Respiratory manifestations of eosinophilic granulomatosis with polyangiitis (Churg–Strauss). European Respiratory Journal 2016; DOI: 10.1183/13993003.00097-2016

Disclosure of Interests:

Luca Moroni: None declared, adriana cariddi: None declared, Silvia Sartorelli: None declared, Emanuel Della Torre: None declared, Tommaso Germanò: None declared, Giuseppe Alvise Ramirez: None declared, Enrica Bozzolo: None declared, Mona-Rita Yacoub: None declared, Lorenzo Dagna Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unresctricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI., Consultant of: Prof Lorenzo Dagna received consultation honoraria from Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI.

AB0336 IMPACT OF SUBJECTIVE INTOLERANCE TO METHOTREXATE ON THE QUALITY OF LIFE OF PATIENTS WITH RHEUMATOID ARTHRITIS: SIDE EFFECTS AND AVOIDANCE COPING STRATEGIES THROUGH SELF-ADMINISTRATION IN THE EVENING OR DURING THE WEEKEND

Background:

Methotrexate (MTX) represents theanchor drugfor the treatment of rheumatoid arthritis (RA), as well as other rheumatological diseases such as psoriatic arthritis (PsA) and spondyloarthritides (SpA). Despite consolidated clinical efficacy, the use of MTX suffers from relevant limitations. Common issues include subjective intolerance, nausea, malaise, and fatigue, which negatively impact on quality of life and work/social participation.

Objectives:

In this study, we evaluated the frequency with which patients on MTX therapy opt for self-administration over the weekend or in the evening hours, in order to minimize interference with daily activities, work productivity, and social participation.

Methods:

A cross-sectional, prospective study was performed in two tertiary referral Rheumatology clinics, which included consecutive patients with RA, PsA, or SpA on MTX therapy. Enrolled patients had not previously received instructions by their healthcare provider as to when during the week or day MTX ought to be administered, and were free to choose or change the weekday and time for self-administration. Data on the route and timing of MTX self-administration was collected using dedicated questionnaires, which included queries on the dose and route of administration, day of the week and time of self-administration, reasons for the patient’s choice, use of folic acid supplementation, and concomitant therapies. Statistical analyses were conducted using a chi-square test; a p-value <0.05 was considered significant.

Results:

A total of 275 consecutive patients treated with MTX were included, mostly with RA (86%). Patients had an average age of 59.8 years (SD 14.0) and an average disease duration of 134.5 months (SD 127.3). The average MTX dose was 15 mg/wk (SD 4.4); MTX was administered subcutaneously in 68.2% of cases, orally in 17.8%, and intramuscularly in 5%. Regarding the timing of MTX self-administration, 157 patients (57.1%) took MTX in the evening and 119 patients (44.3%) took it during the weekend; even among patients taking MTX in the evening, weekend administration was preferred (93/157, 59.2%, p <0.001). The most frequent reasons leading to MTX self-administration during the evening or weekend were gastrointestinal side effects/nausea (85% of cases), fatigue (63%), interference with work activities (36%) and interference with social activities (29%). Patients who opted for MTX self-administration in the evening or over the weekend were significantly younger (p <0.001), with no significant gender differences or disease duration.

Conclusion:

The majority of patients with inflammatory arthritis opt for self-administration of MTX in the evening (absolute majority) or during the weekend (relative majority). This choice is dictated by the need to avoid side effects and detrimental repercussions on the individual’s social or working life. The adoption of these strategies for minimizing the adverse effects of MTX is more frequent among younger patients, and provides an indirect, yet powerful indicator of the impact of MTX therapy on patients’ quality of life.

Disclosure of Interests:

Giulio Cavalli Consultant of: SOBI, Pfizer, Sanofi, Novartis, Paid instructor for: SOBI, Novartis, Speakers bureau: SOBI, Novartis, Martina Biggioggero: None declared, adriana cariddi: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, Pfizer, MSD, Elena Agape: None declared, nicola boffini: None declared, Elena Baldissera Speakers bureau: Novartis, Pfizer, Roche, Alpha Sigma, Sanofi, Lorenzo Dagna: None declared, Ennio Giulio Favalli Consultant of: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Speakers bureau: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie

FRI0183 DISTINCTIVE TRAITS OF MYOCARDIAL INFLAMMATION IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A MULTICENTRE STUDY

Background:

Myocarditis is an infrequent but potentially life-threatening inflammatory disorder and might be part of the spectrum of systemic lupus erythematosus (SLE). Little is known about the clinical and histologic features of myocarditis in SLE, especially compared to other forms of myocarditis.

Objectives:

to test for potential distinctive traits among myocarditis in SLE (MyoSLE), SLE without myocarditis (OnlySLE) and myocarditis without SLE (OnlyMyo)

Methods:

Patients with MyoSLE were identified from three centres and compared with 231 cross-sectionally enrolled patients with OnlySLE and 87 patients with OnlyMyo. MyoSLE patients were split into two groups based on myocarditis onset within (early onset) vs after (late onset) the first year from SLE diagnosis. OnlySLE patients were dichotomised in the same way based on disease duration at time of enrolment. Demographics and general clinical features were collected retrospectively. SLE disease activity index 2000 (SLEDAI-2K), SLE International Collaborating Clinics/American College of Rheumatology damage index (SDI), clinical and laboratory features were collected at time of myocarditis onset in MyoSLE and at enrolment in OnlySLE. Quantitative data are expressed as median [interquartile range].

Results:

Fourteen MyoSLE patients were identified, 50% with early onset. Women were equally frequent among MyoSLE (71%) and OnlySLE patients (87%) and less frequent in the OnlyMyo group (43%; p<0.001). Age was comparable among groups. Clinical features at presentation, including left ventricular ejection fraction, were similar between MyoSLE and OnlyMyo, although the former had higher levels of pro-brain natriuretic peptide (1.1 [0.4-1.8] vs 0.1 [0.1-0.5] ng/ml; p=0.004). Patients with MyoSLE also had a lower frequency of left ventricle lateral wall involvement (36 vs 68%; p=0.035) and of oedema (20 vs 71%; p=0.036) and necrosis (0 vs 64%; p=0.009) at biopsy. Antiphospholipid antibodies (aPL) were more frequent in MyoSLE (57%) compared to both OnlyMyo (16%; p=0.003) and OnlySLE (28%; p=0.031). Compared to OnlySLE, patients with MyoSLE also had a higher prevalence of aPL-syndrome (APS: 36 vs 7%; p=0.003), neuropsychiatric (NPSLE: 43 vs 19%; p=0.039) and gastrointestinal manifestations (21 vs 5%; p=0.045). Early and late onset patients had similar demographics and clinical features and did not differ from patients with OnlySLE with similar disease duration in terms of SLEDAI-2K and SDI. Late onset MyoSLE patients had a higher prevalence of NPSLE (57 vs 18%; p=0.026) and APS (57 vs 7%; p=0.001) and higher C-reactive protein levels (6 [2-12] vs 1[0-4] mg/l; p=0.024) compared to OnlySLE patients with the same disease duration.

Conclusion:

Demographics of patients with MyoSLE are more similar to patients with OnlySLE than to OnlyMyo patients. MyoSLE might have distinct histological and pathogenic features compared to OnlyMyo. Patients with MyoSLE show similar patterns of disease activity and accrued damage at time of myocarditis onset compared to patients with OnlySLE with the same disease duration but might diverge later on in SLE course. aPL are frequent in MyoSLE and might both contribute to the pathogenesis of myocardial inflammation and account for the high prevalence of NPSLE and APS, especially in late onset cases.

References:

[1]Gartshteyn Y et al., Lupus, 2020

[2]Thomas G et al., J Rheumatol, 2017

[3]Peretto G et al., Int J Cardiol, 2019

[4]McDonnell T et al., Blood Rev, 2019

Disclosure of Interests:

Giuseppe Alvise Ramirez: None declared, Maria Gerosa: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, Pfizer, MSD, Lorenzo Beretta Grant/research support from: Pfizer, Simone Sala: None declared, Giovanni Peretto: None declared, Luca Moroni: None declared, Francesca Mastropaolo: None declared, adriana cariddi: None declared, Silvia Sartorelli: None declared, Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Enrica Bozzolo: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Lorenzo Dagna Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unresctricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI., Consultant of: Prof Lorenzo Dagna received consultation honoraria from Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI.

SAT0267 ROLE OF AGGRESSIVE IMMUNOSUPPRESSION ON SUBGLOTTIC STENOSIS IN GRANULOMATOSIS WITH POLYANGIITIS: RETROSPECTIVE ANALYSIS OF A MONOCENTRIC COHORT

Background:

Subglottic stenosis (SGS) is defined as airway narrowing below the vocal cords and is a common and potentially life-threatening manifestation of Granulomatosis with Polyangiitis (GPA), with an estimated prevalence of 16-23% (1). Balloon catheter dilation is effective in GPA-related SGS, but relapses are frequent. Little is known about the role of immunosuppression in this setting.

Objectives:

to analyse the clinical characteristics of a monocentric GPA cohort, describe phenotype differences among patients with and without SGS and investigate the role of surgical and medical treatments on relapse risk and general outcome.

Methods:

Biopsy-proven patients with SGS were identified by review of medical charts among a cohort of patients with GPA, classified according to the algorithm of the European Medicine Agency (2). The clinical characteristics of patients with SGS were retrospectively collected over a median follow-up time of 15.9 years and compared to those of patients without SGS.

Results:

Fourteen patients with SGS-GPA were identified, with a female to male ratio of 1:1 and a prevalence of 29.2% among the cohort. The mean ± SD age at GPA onset was 30.8 ± 14.4 years, with a mean time from GPA diagnosis to SGS onset of 4.7 ± 4.2 years. ANCA were positive in 78.6% (54.0% anti-PR3, 18.1% anti-MPO and 27.9% IFI only). The mean Birmingham Vasculitis Activity Score (BVAS) at onset was 10.0 ± 5.6. The main clinical manifestations associated with SGS were crusty rhinitis (100%), sinusitis (78%), pulmonary disease (72.7%), otitis/mastoiditis (50%), glomerulonephritis (42.9%), orbital pseudotumor (28.6%). Six patients (42.9%) received medical treatment only, other six (42.9%) had one to three balloon dilations and two (14.2%) underwent four or more procedures. Eight patients had no SGS relapse (maximum one dilation) and they all received immunosuppression with rituximab (RTX), cyclophosphamide (CYC) or azathioprine (AZA). All patients who received no immunosuppression, methotrexate (MTX) or mycophenolate (MMF) had at least one relapse. Patients treated with MTX or MMF had a mean relapse-free survival of 13.1 months, which was comparable to the one of patients not receiving medical treatment (40.2 months; p=NS) and shorter than the one of patients receiving CYC or RTX (153.2 months; p=0.032). CYC use also inversely correlated with the number of surgical procedures (r=-0.691, p=0.006). Compared to patients without SGS (31 consecutive patients with at least 4 years of follow-up), patients with SGS-GPA had an earlier disease onset (mean age 30.8 vs 50.4 years; p<0.001), but with lower BVAS (mean 10.0 vs 15.3; p=0.013) and showed a higher prevalence of crusty rhinitis (100% vs 67.7%; p=0.019). No difference was observed in damage accrual over time between the two groups.

Conclusion:

Subglottic stenosis is highly prevalent in patients with GPA and may define a milder disease subset occurring more frequently in younger patients. MTX and MMF might be insufficient to prevent SGS relapses requiring balloon dilation. Aggressive immunosuppression (CYC or RTX) might have a non-redundant role in this setting and reduce the risk of relapses.

References:

[1]Quinn KA, et al. Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis. Rheumatology 2019; 58 (12), 2203-2211.

[2]Watts R, et al. Development and validation of a consensus methodology for the classification of the ANCA associated vasculitides and polyarteritis nodosa for epidemiological studies. Ann Rheum Dis 2007; 66: 222-7.

Disclosure of Interests:

Luca Moroni: None declared, Laura Giudice: None declared, Giuseppe Alvise Ramirez: None declared, Silvia Sartorelli: None declared, adriana cariddi: None declared, Angelo Carretta: None declared, Enrica Bozzolo: None declared, Lorenzo Dagna Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unresctricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI., Consultant of: Prof Lorenzo Dagna received consultation honoraria from Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI.

Long-Term Sequelae of Breast Cancer Surgery

Background

Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986.

Patients and Methods

The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed.

Results

Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88).

Conclusions

The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

Histopathologic Classification of Breast Cancer in Sweden and Italy: A Comparison between two Pathologists

Two large series of breast cancers (BC), identified in the Pathology Departments of Malmö (Sweden) and Florence (Italy), were independently reviewed by two experienced pathologists, one from each department. Overall, comparison of diagnoses of 372 BCs according to a simplified WHO histologic classification system (in four combined categories) revealed agreement for 74 % of the cases. Concordance, as measured by the kappa statistic, was relatively good (0.53 overall). Kappa values for specific categories were also acceptable, being highest for « invasive lobular » BC (0.63) and lowest for « other types » (0.45). The kappa value for « noninvasive » versus all other categories of invasive BC was 0.53. Some BCs were systematically classified as « noninvasive » by one pathologist and as « invasive ductal with a predominant intraductal component » by the other. Invasive lobular BCs were also diagnosed more frequently by one pathologist. These findings suggest that when planning geographical or temporal comparisons of distribution for BC histologic categories, standardization of classification and a centralized review may play an important role.

Independent double reading of screening mammograms

OBJECTIVE

To evaluate the cost effectiveness of independent double reading of screening mammograms.

SETTING

Prospective study of 18,817 women undergoing first or repeat screening in a population based programme in the Florence district.

METHODS

Mammograms were independently double read by experienced radiologists. Subjects with mammographic abnormalities reported by at least one reader were recalled for diagnostic assessment. The mean increase in recall rate, cancer detection rate, and screening costs attributable to double reading was calculated.

RESULTS

Eleven of 125 cancers were detected by only one reader. The mean increase in cancer detection rate attributable to double reading compared with single reading was 4.6% (95% confidence interval (CI) 1.1 to 8.9). From a total of 748 cases referred for diagnostic assessment, 196 subjects were referred by one reader only. The mean increase in referral rate attributable to double reading compared with single reading was 15.1% (CI 12.3 to 17.8). Double reading caused a marked increase in the cost for each woman screened -8.5% at the first screening and 6.2% at repeat screening and a more limited increase in the cost for each cancer detected -3.5% at the first screening and 2.7% at repeat screening. Cancers detected by only one screener were at an earlier stage than those detected by both screeners (P = 0.6, not significant).

CONCLUSIONS

Independent double reading results in only a modest increase in the detection of cancers and therefore may not be cost effective.

The efficacy of intensive follow-up testing in breast cancer cases

BACKGROUND

A preliminary inquiry into the follow-up practices of Italian breast cancer centers revealed a considerable diversity of policy. It is clear that accurate follow-up examinations supply important information about the development of metastases, but there is no clinical proof that they extend survival time. It is possible that the effects of early diagnosis are only negative, extending the period over which the patient is aware of her illness and leading to over-diagnosis, overtreatment and increased health-care costs.

PATIENTS AND METHODS

In a study involving the national oncological centers, patients were randomized into two groups: an intensive follow-up group (6 monthly chest X-rays and bone scans) and a control group (clinical examination only).

RESULTS

An excess of isolated bone and intrathoracic metastases were observed in the intensive follow-up group. The survival curves showed no difference between the two groups.

CONCLUSIONS

Six monthly X-rays and bone scans provide occasion for early diagnosis of intrathoracic and bone metastases without, however, influencing overall 5-year survival. Recourse to diagnostic tests only in the presence of symptoms appears to be the most appropriate follow-up procedure. However, other studies considering long term effects of early diagnosis and the effects of considering long term effects of early diagnosis and the effects of new diagnostic tests and/or treatment modalities are clearly needed.

Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up

OBJECTIVE

To evaluate the effectiveness of early detection of intrathoracic and bone metastases in reducing mortality in breast cancer patients.

DESIGN

Randomized clinical trial allocating breast cancer patients to two alternative follow-up protocols (intensive vs clinical) for at least 5 years.

SETTING

Twelve breast clinics (referral centers) in different areas in Italy.

PATIENTS

A total of 1243 consecutive patients (either premenopausal or postmenopausal) surgically treated for unilateral invasive breast carcinoma with no evidence of metastases. The two study groups were well balanced in terms of clinical and prognostic characteristics.

INTERVENTION

Patients in both treatment groups had physical examination and mammography, while patients of the intensive follow-up group had, in addition, chest roentgenography and bone scan every 6 months.

MAIN OUTCOME MEASURES

Vital status at 5 years was the main outcome; information was available for all except five patients (0.4%). Relapse-free survival was also analyzed.

RESULTS

Overall, 393 recurrences (104 local and 289 distant) were observed during the study. Increased detection of isolated intrathoracic and bone metastases was evident in the intensive follow-up group compared with the clinical follow-up group (112 vs 71 cases), while no difference was observed for other sites and for local and/or regional recurrences. The 5-year relapse-free survival rate was significantly higher for the clinical follow-up group, with patients in the intensive follow-up group showing earlier detection of recurrences. No difference in 5-year overall mortality (18.6% vs 19.5%) was observed between the two follow-up groups.

CONCLUSIONS

Periodic chest roentgenography and bone scan allow earlier detection of distant metastases, but anticipated diagnosis appears to be the only effect of intensive follow-up, and no impact on prognosis is evident after 5 years. Periodic intensive follow-up with chest roentgenography and bone scan should not be recommended as a routine policy.

Radial scars of the breast: review of 38 consecutive mammographic diagnoses

The authors report 38 consecutive cases of histologically proved breast radial scars (RSs) detected at mammography. In a retrospective review of mammograms in 30 matched cases of nonpalpable RS and nonpalpable scirrhous cancer, the characteristic mammographic features of RS were confirmed: (a) the absence of a central opacity, often substituted by a radiolucent area; (b) the presence of multiple elongated thin spicules radiating from the center of the lesion; (c) the infrequency of any palpable finding, even for superficial lesions of relatively large size. Microcalcifications with aspecific structure were found in the lesions on mammograms of 14 of the 38 cases and in 24 of the histologic specimens. The typical mammographic features of RS were not specific to RS, being present in a minority of cancer cases. For two blinded readers, sensitivity was 86.7% and 76.7% and specificity was 78% and 80%, respectively. Although some specific mammographic features may suggest the presence of RS, the final differential diagnosis from scirrhous cancer should be based on histologic evidence, and surgical biopsy should be advised for any stellate lesion detected at mammography.

[Chronobiological study of ischemic attacks in angina pectoris at rest]

The aims of this study were to determine if the hourly distribution of ischaemic episodes differed as regards ST segment elevation or ST segment depression during ischaemic attacks and differed as regards the degree of coronary atherosclerotic involvement. Twenty-four in-patient drug free subjects with angina at rest underwent ECG continuous Holter monitoring for periods varying from 24 to 168 hours. Four groups of patients were identified: group 1A: 6 patients with ST elevation and 0-1 vessel disease; group 1B: 6 patients with ST elevation and 2-3 vessel disease; group 2A: 3 patients with ST depression and 0-1 vessel disease; group 2B: 9 patients with ST depression and 2-3 vessel disease. During Holter monitoring, 301 ischaemic episodes were registered in group 1A during 576 hours; 173 episodes were registered in group 1B during 624 hours; 41 episodes were registered in group 2B during 528 hours. Using the single and population mean cosinor tests on the episodes of each group, considered as a whole, the following results were found: group 1A showed a circadian rhythm with acrophase at 4:03 a.m. (Fig. 2), group 1B showed a circadian rhythm with acrophase at 10:51 a.m. (Fig. 3), group 2A showed a circadian rhythm with acrophase at 11:15 p.m. (Fig. 5), while group 2B showed ultradian rhythms which lasted 7 and 13 hours (Fig. 6). The chronobiologic analysis of the distribution of the ischaemic attacks confirmed the existence of a circadian rhythm of ischaemic episodes in patients with ST elevation.(ABSTRACT TRUNCATED AT 250 WORDS)

Prominent circadian absorption of intranasal salmon calcitonin (SCT) in healthy subjects

In young healthy subjects salmon calcitonin (SCT), intranasally administered, increased in serum as a function of the drug administration time. The serum concentration of a 400 IU SCT dose monitored 10 min after dosing was statistically more significant when inhaled at 0000 than at other, more conventional, administration times (morning or evening). Following dosing at certain times during the day, the serum SCT was less or even questionable with the dose and under the study conditions selected. Dosing without consideration of timing may lead to reduced effect or lack of effect or perhaps ambiguity or controversy regarding the possible circumstance of a "non-absorbent subject". The circadian frequency appears to be a critical determinant of intranasal SCT absorption suggesting administration time to be an important factor in the cost/benefit ratio without the unpleasant side effects sometimes experienced through parenteral routes.

Further steps toward a neonatal chronocardiology

The study of 53 series of blood pressures at half-hour intervals from clinically healthy full-term newborns during the first days of life reveals various classifiers correlating with a history of high blood pressure: the circadian amplitude of diastolic blood pressure, the 50% range of systolic blood pressure and the standard deviation of heart rate.

Serum gastrin and pepsinogen in shift workers

Gastrointestinal complaints, including peptic ulcer, are believed to be associated and enhanced by shift work (SW). However, there are no clear reports in the literature about this acquired pathology. Serum gastrin (G) and group I pepsinogen (PG1) are thought to play a role in the pathogenesis of peptic ulcer and may be considered a useful test of the gastric function. Five adult male foundry shift workers, without any demonstrated gastrointestinal pathology, were studied over a month's span during the following weekly rotating shift schedule: 07.45-16.45, 06.00-14.00, 14.00-22.00, 22.00-06.00. Six adult, day-working males acted as controls. Blood samples drawn at the beginning and at the end of each weekly shift were assayed for G and PG1 utilizing RIA kits. Our data showed that SW causes a prominent change in the gastrin/acidopepsin secretion system.

Toward a medical prolepsis by chronobiology

Medicine today strongly aims at prevention and optimization of diagnosis and therapy Studies tried staging and standardization of clinical trials in diseases and made search of markers for early diagnosis, prognosis and therapy. Moreover, risk factors and other variables such as predictors are now investigated more often in groups or populations of apparently healthy subjects, especially for such diseases as atherosclerosis and neoplasia. This new aspect of increasing interest may be defined as medical prolepsis (from the Greek pi rho ómicron lambda eta psi iota zeta = anticipated idea). It includes early signals of disease (protopathology) as well as other signals the host shows as defence or alarm reaction. Hence, we suggest a chronobiological approach in this field, which allows to quantify health and reveals more subtle differences in many physiological variables. According to these views, we reported studies concerning humoral markers and other parameters considered as risk factors both in atherosclerosis and in some endocrine tumors.