Toxicity and Efficacy of Concurrent Androgen Deprivation Therapy, Pelvic Radiotherapy, and Radium-223 in Patients with De Novo Metastatic Hormone-Sensitive Prostate Cancer

PURPOSE

Radium-223 is an alpha-emitting radionuclide associated with overall survival (OS) improvement in metastatic castration-resistant prostate cancer (mCRPC). External beam radiotherapy (EBRT) to prostate extends OS in men with metastatic hormone-sensitive prostate cancer (mHSPC) limited to less than 4 metastases. We hypothesized that combination radium-223 + pelvic EBRT could safely deliver maximal radiotherapy doses to primary and metastatic prostate cancer and may improve disease control.

PATIENTS AND METHODS

Thirty patients with de novo bone metastatic mHSPC who had commenced androgen deprivation therapy (ADT) and docetaxel were recruited to this single-arm, open-label, prospective clinical trial: Neo-adjuvant Androgen Deprivation Therapy, Pelvic Radiotherapy and RADium-223 (ADRRAD; for new presentation T1-4 N0-1 M1B adenocarcinoma of prostate). Study treatments were: ADT, 6 cycles of radium-223 q28 days, conventionally fractionated prostate radiotherapy (74 Gy) and simultaneous integrated boost to pelvic lymph nodes (60 Gy).

RESULTS

No grade 4/5 toxicity was observed. Three patients experienced grade 3 leukopenia, and 1 each experienced grade 3 neutropenia and thrombocytopenia; all were asymptomatic. One patient each experienced grade 3 dysuria and grade 3 urinary infection. No grade 3 gastrointestinal (GI) toxicity was observed. On treatment completion, there was a signal of efficacy; 24 (80%) patients had whole-body MRI evidence of tumor response or stability. Twenty-seven (90%) patients showed a reduction in alkaline phosphatase (ALP) compared with pretreatment levels. Median progression-free survival was 20.5 months.

CONCLUSIONS

This is the first trial of combination ADT, radium-223, and EBRT to pelvis, post docetaxel. The combination was safe, with an efficacy signal. Multicenter randomized controlled trials (RCT) are warranted.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Results of the ADRRAD Trial of pelvic IMRT plus radium-223 in men with mHSPC metastatic to bone

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Background: Radiotherapy to the Prostate in mHSPC improves overall survival (OS) and Progression free survival (PFS) for patients with low-volume-disease[1]. Radium-223 in metastatic castration resistant prostate cancer (mCRPC) improves OS [2]. We conducted a prospective phase 1/2 clinical trial in mHSPC, testing the combination of with LHRHa, concurrent pelvic radiotherapy and radium-223. Methods: Thirty patients were recruited with mHSPC; they had a minimum of 3 bone metastases (majority had > 20 bone mets), nil visceral metastases, PS0-1. Patients were encouraged to receive up front docetaxel. They were treated with ongoing LHRHa, pelvic radiotherapy aiming for 74Gy in 37 fractions to prostate PTV with 60Gy concomitantly delivered to pelvic nodal PTV. Concurrently, patients received radium-223, 55kBq/kg for 6 cycles q28 days; fraction 1 radiotherapy was synchronous with cycle 1 day 1 radium-223. Results: Median age was 63 years and 28 (93%) received at least 4 cycles of docetaxel. One patient received prostate only radiotherapy due to bowel constraints. Three patients had cycle 6 radium-223 omitted. At a median follow-up of 28 months, there have been 415 Adverse events, (3% Grade >3), and 6 serious adverse events (SAEs) ( 2 episodes of UTI, 1 each of cystitis non-infective, cardiac chest pain, pyrexia and AKI). Commonest AEs by number were: leucopenia, neutropenia, and diarrhoea. Ten SSE’s have occurred including 8 courses of palliative radiotherapy for bone pain, 1 course of radiotherapy for impending MSCC and 1 pathological fracture. At median follow up 28.0 months, median biochemical PFS is 17.9 months, median OS not yet reached. Conclusions: This trial shows clear tolerability and promising early efficacy data requiring further exploration in a randomised phase 3 trial. Clinical trial information: 2014-000273-39.

Toxicity results from a novel phase I/II trial of VMAT radiotherapy to prostate and pelvic nodes plus six cycles of radium-223 in mCSPC metastatic to bone post ADT and docetaxel

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Background: Recent data has shown an overall survival (OS) benefit for up front Docetaxel or Abiraterone combined with androgen deprivation therapy (ADT) in metastatic castration sensitive prostate cancer (mCSPC). Data from STAMPEDE also suggests an additional OS benefit for radiotherapy to the prostate in men with low volume metastases. We hypothesised that Radium-223 + Radiotherapy to prostate and pelvic nodes following docetaxel (DOC) would be well tolerated and potentially improve OS in men with mCSPC involving bone. Methods: Men with mCSPC involving bone were treated in a single arm phase 1/2 study in which they received radical dose radiotherapy (74Gy/37) to prostate and pelvic nodes using Volumetric Modulated Arc Therapy (VMAT) radiotherapy and 6 cycles of Radium-223, 55kBq/kg following up front ADT and DOC. The primary endpoint was toxicity with secondary endpoints including time to PSA and ALP progression and radiological response. Results: We report the results of 27 men, median age 67 years treated in the study with a median follow up of 25 months post 1st ADT. 81% of men had high volume disease. The schedule was well tolerated with grade ≥3 toxicity occurring in 5 patients (18.5%). Most toxicity was short lived thrombocytopenia and leucopenia. No unexpected toxicity was observed. All but 2 patients received all 6 cycles of Radium-223. One patient died of progressive disease before completion of the course of Radium-223. To date, 6 out of 27 patients have died, actuarial survival at 24 months is 83%. To date 9 out of 27 (33%) patients have developed PSA progression. Only 1 patient had a progressive alkaline phosphatase levels during the course of Radium-223 treatment. Conclusions: In men with mCSPC involving bone, a schedule of radical dose radiotherapy to prostate and pelvis + 6 cycles of Radium-223 is well tolerated post ADT + DOC. This treatment schedule will now join as a new arm of the STAMPEDE trial with OS as primary endpoint. Clinical trial information: 2014-000273-39.

Should we prescribe calcium or vitamin D supplements to treat or prevent osteoporosis?

Systematic reviews of randomized, controlled trials (RCTs) are considered the highest level of evidence to inform clinical practice. Meta-analyses of large RCTs of calcium and/or vitamin D supplements completed in the last 15 years provide strong evidence for clinical recommendations. These meta-analyses with data for > 50,000 older adults reported that calcium with or without vitamin D has only weak, inconsistent effects on fracture, and that vitamin D without calcium has no effect on fracture. Only one RCT of co-administered calcium and vitamin D in frail, institutionalized, elderly women with low dietary calcium intake and vitamin D levels showed significant reductions in fracture risk. These RCTs have also reported previously unrecognized adverse events of calcium supplements including kidney stones, myocardial infarction, hypercalcemia, and hospitalization with acute gastrointestinal symptoms. The small risk of these important adverse effects, together with the moderate risk of minor side-effects such as constipation, probably outweighs any benefits of calcium supplements on fracture. These data suggest the role for calcium and vitamin D supplements in osteoporosis management is very limited. Neither calcium nor vitamin D supplements should be recommended for fracture prevention in community-dwelling adults, although vitamin D should be considered for prevention of osteomalacia in at-risk individuals.

Bone density is normal and does not change over 2 years in sarcoidosis

SUMMARY

Small studies have previously suggested that sarcoidosis may be associated with low bone mineral density. In this observational study of 64 patients with sarcoidosis, bone mineral density was within the normal range at baseline, and there was no evidence of accelerated bone loss over 1-2 years.

INTRODUCTION

Several small studies have suggested that sarcoidosis may be associated with low bone mineral density (BMD).

METHODS

We undertook a cross-sectional study of BMD in 64 patients with sarcoidosis. Of these, 27 with 25-hydroxyvitamin D<50 nmol/L entered a 1-year intervention study of vitamin D supplements, and 37 entered a 2-year longitudinal study of BMD, with the primary endpoint of the change in lumbar spine BMD.

RESULTS

The mean age of participants was 58 years, 68% were female, and 8% were currently using oral glucocorticoids. At baseline, BMD for the entire cohort was greater than the expected values for the population at the lumbar spine (mean Z-score 0.7, P<0.001) and total body (0.5, P<0.001) and similar to expected values at the femoral neck (0.2, P=0.14) and total hip (0.2, P=0.14). BMD did not change at any of these four sites (P>0.19) over 2 years in the longitudinal study. In the intervention study, vitamin D supplements had no effect on BMD, and therefore we pooled the data from all participants. BMD did not change over 1 year at the spine, total hip, or femoral neck (P>0.3), but decreased by 0.7% (95% confidence interval 0.3-1.1) at the total body (P=0.019).

CONCLUSIONS

BMD was normal at baseline, and there was no consistent evidence of accelerated bone loss over 1-2 years, regardless of baseline vitamin D status. Patients with sarcoidosis not using oral glucocorticoids do not need routine monitoring of BMD.

Bone density in healthy men after cessation of calcium supplements: 20-month follow-up of a randomized controlled trial

Bone density has been followed up for 20 months following completion of a trial which compared calcium 1,200 mg/day with placebo, in normal older men. Following cessation of calcium supplements, there is a small residual benefit in total body bone density, but not at the hip or spine.

INTRODUCTION

Calcium supplements, or supplements of calcium-rich foods, have a positive effect on bone mineral density (BMD). However, it is uncertain whether there are any residual benefits of calcium on BMD following cessation of supplementation.

METHODS

In a previously published study, 323 healthy men were randomized to receive elemental calcium 600 mg/day (n = 108), calcium 1,200 mg/day (n = 108), or placebo (n = 107) over 2 years. Consenting men from the placebo and calcium 1,200 mg/day groups (85 and 87, respectively) were followed over the next 1-2 years (mean 20 months), off trial medication.

RESULTS

In the core trial, BMD increased at all sites by 1.0-1.5% at 2 years in the group receiving calcium 1,200 mg/day, compared to the group receiving placebo. In post-trial follow-up, the calcium group has some residual benefit at the total body (0.41% above placebo; P = 0.04) but there was no significant between-group differences at other sites.

CONCLUSION

Following cessation of calcium supplements in healthy men, there is a small residual benefit in total body BMD, but not at the hip or spine. This is unlikely to confer a clinically significant dividend in terms of ongoing fracture prevention.

A study of erosive phenotypes in lupus arthritis using magnetic resonance imaging and anti-citrullinated protein antibody, anti-RA33 and RF autoantibody status

OBJECTIVES

The aims of this study were to investigate the extent of MRI-determined joint disease (erosion and synovitis) in SLE and to link this to autoantibody profiles known to be relevant to SLE, including ACPA, RF and anti-RA33 antibodies.

METHODS

Contrast-enhanced MRI of the hand and wrist was performed in 34 symptomatic SLE patients and in 15 RA patients with similar disease duration. Images were scored by two observers using the OMERACT rheumatoid arthritis MRI scoring (RAMRIS) system. Findings were correlated with clinical examination and autoantibody status.

RESULTS

Erosions were present at the wrist in 93% of SLE patients and at the MCP joints in 61% of SLE patients. Despite the high prevalence of MRI-determined erosion, only 8.8% of SLE patients were ACPA positive, although these patients had a higher burden of erosive disease. There was no positive correlation with anti-RA33 titres and erosion scores in the SLE patients, but there was a negative correlation with anti-RA33 titres and total bone oedema scores in the SLE patients. Ninety-three per cent of SLE patients had at least grade 1 synovitis at one or more MCP joints, and wrist joint synovitis was present in all the SLE patients.

CONCLUSION

An MRI-determined joint erosive phenotype is common in SLE, even in ACPA-negative cases. The conventional radiographic observation that anti-RA33 is not positively associated with erosion in patients with RA was also found to be the case in SLE patients.

The Auckland calcium study: 5-year post-trial follow-up

Five years after completion of a randomised placebo-controlled trial of calcium supplements, there was no effect of calcium on total fracture incidence, a significant reduction in vertebral and forearm fractures and, in a subset, no effect on bone density. There was no increased risk of cardiovascular events after discontinuation of calcium.

INTRODUCTION

The Auckland calcium study was a 5-year randomised controlled trial of 1 g/day calcium citrate in 1,471 postmenopausal women. Calcium did not reduce total, vertebral or forearm fracture incidence, increased hip fracture incidence and had beneficial effects on bone mineral density (BMD). A secondary analysis raised concerns about the cardiovascular safety of calcium. The purpose of this study was to determine whether the effects of calcium on fracture incidence, BMD and cardiovascular endpoints persisted after supplement discontinuation.

METHODS

Approximately 5-years post-trial, we collected information on the 1,408 participants alive at trial completion from the national databases of hospital admissions and deaths. We contacted 1,174 women by phone, and from these we obtained information on medical events and post-trial calcium use. We undertook BMD measurements at 10 years in a selected subset of 194 women who took study medication for 5 years in the original trial, and did not take bone-active medications post-trial.

RESULTS

Over the 10-year period, there was no effect on total fracture (HR 0.90, 95% CI 0.75-1.07) or hip fracture incidence (1.40, 0.89-2.21), but significant reductions in forearm (0.62, 0.43-0.89) and vertebral fractures (0.52, 0.32-0.85) in those assigned to calcium. There were no between-group differences in BMD at 10 years at any site. The adverse cardiovascular outcomes observed in the 5-year trial did not persist post-trial.

CONCLUSION

Calcium supplementation for 5 years had no effect on total fracture incidence at 10 years. The positive benefits on BMD and the adverse cardiovascular effects did not persist once supplements were stopped.

The effect of treatments for osteoporosis on mortality

The incidence of osteoporotic fractures increases exponentially in later life, in parallel with the progression of frailty and the risk of dying. Several pharmacologic therapies are now available that reduce the risk of fragility fractures. Data from observational studies report that osteoporotic fractures are associated with an increased risk of dying, particularly in the first few years after an event, and that, in osteoporotic populations, bisphosphonate therapy is associated with a reduced risk of death. Data emerging from randomised controlled trials suggest that drugs which significantly reduce fracture risk might also prolong survival in osteoporotic populations. Further research into the nature, magnitude and mechanisms of the effects of osteoporosis treatments on mortality is required, but in the interim, clinicians and their patients should consider the available data in their deliberations about the use of these medications.

The impact of dietary calcium intake and vitamin D status on the effects of zoledronate

We investigated whether baseline dietary calcium intake or vitamin D status modified the effects of zoledronate. Neither variable influenced the effect of zoledronate on bone mineral density, bone turnover, or risk of acute phase reaction, suggesting that co-administration of calcium and vitamin D supplements with zoledronate may not always be necessary.

INTRODUCTION

Calcium and vitamin D supplements are often co-administered with bisphosphonates, but it is unclear whether they are necessary for therapeutic efficacy or minimizing side effects of bisphosphonates. We investigated whether baseline dietary calcium intake or vitamin D status modified the effect of zoledronate on bone mineral density (BMD) or bone turnover at 1 year, or the risk of acute phase reactions (APR).

METHODS

Data were pooled from two trials of zoledronate in postmenopausal women without vitamin D deficiency in which calcium and vitamin D were not routinely administered. The cohort (zoledronate n = 154, placebo n = 68) was divided into subgroups by baseline dietary calcium intake (<800 vs. ≥800 mg/day) and vitamin D status [25-hydroxyvitamin D (25OHD) <50 vs. ≥50 nmol/L, and <75 nmol/L vs. ≥75 nmol/L] and treatment × subgroup interactions tested.

RESULTS

There were 52, 86, and 36 % of the zoledronate group and 64, 94, and 46 % of the placebo group that had dietary calcium intake ≥800 mg/day, 25OHD ≥50 nmol/L, and 25OHD ≥75 nmol/L, respectively. There were no significant interactions between treatment and either baseline dietary calcium or baseline vitamin D status for lumbar spine BMD, total hip BMD, the bone turnover markers P1NP and β-CTx, or the risk of an APR. There was also no three-way interaction between baseline dietary calcium intake, baseline vitamin D status, and treatment for any of these variables.

CONCLUSIONS

Baseline dietary calcium intake and vitamin D status did not alter the effects of zoledronate, suggesting that co-administration of calcium and vitamin D with zoledronate may not be necessary for individuals not at risk of marked vitamin D deficiency.

Differing perceptions of intervention thresholds for fracture risk: a survey of patients and doctors

This survey suggests that patients are prepared to accept higher absolute fracture risk than doctors, before considering pharmacological therapy to be justified. Patients require that drug treatments confer substantial fracture risk reductions in order to consider long-term therapy.

INTRODUCTION

Absolute fracture risk estimates are now incorporated into osteoporosis treatment guidelines. At present, little is known about how patients regard fracture risk and its management. We set out to describe and compare the views of patients and doctors on the level of fracture risk at which drug treatment is justified.

METHODS

A cross-sectional survey was conducted on 114 patients referred for bone density measurement and 161 doctors whose practice includes management of osteoporosis. Participants were asked about fracture risk thresholds for pharmacological intervention.

RESULTS

The absolute risk of both major osteoporotic fracture and hip fracture at which drug treatment was considered by patients to be justifiable was higher than that reported by doctors [major osteoporotic fracture, median (interquartile range): patients, 50% (25 to 60); doctors, 10% (10 to 20); P < 0.0001; hip fracture: patients, 50% (25 to 60); doctors, 10% (5 to 20); P < 0.0001]. Patients required that a drug provide a median 50% reduction in relative risk of fracture in order to consider taking long-term therapy, irrespective of the treatment mode or dosing schedule. Among doctors, there was an inverse relationship between the number of osteoporosis consultations conducted each month and threshold of risk for recommending drug treatment (r = -0.22 and r = -0.29 for major osteoporotic fracture and hip fracture, respectively, P < 0.01 for both)

CONCLUSIONS

Patients are prepared to accept higher absolute fracture risk than doctors, before considering pharmacological therapy to be justified. Patients require that drug treatments confer substantial fracture risk reductions in order to consider long-term therapy.

Assessing the image quality of pelvic MR images acquired with a flat couch for radiotherapy treatment planning

OBJECTIVES

To improve the integration of MRI with radiotherapy treatment planning, our department fabricated a flat couch top for our MR scanner. Setting up using this couch top meant that the patients were physically higher up in the scanner and, posteriorly, a gap was introduced between the patient and radiofrequency coil.

METHODS

Phantom measurements were performed to assess the quantitative impact on image quality. A phantom was set up with and without the flat couch insert in place, and measurements of image uniformity and signal to noise were made. To assess clinical impact, six patients with pelvic cancer were recruited and scanned on both couch types. The image quality of pairs of scans was assessed by two consultant radiologists.

RESULTS

The use of the flat couch insert led to a drop in image signal to noise of approximately 14%. Uniformity in the anteroposterior direction was affected the most, with little change in right-to-left and feet-to-head directions. All six patients were successfully scanned on the flat couch, although one patient had to be positioned with their arms by their sides. The image quality scores showed no statistically significant change between scans with and without the flat couch in place.

CONCLUSION

Although the quantitative performance of the coil is affected by the integration of a flat couch top, there is no discernible deterioration of diagnostic image quality, as assessed by two consultant radiologists. Although the flat couch insert moved patients higher in the bore of the scanner, all patients in the study were successfully scanned.

Cardiovascular effects of calcium supplementation

Trials in normal older women and in patients with renal impairment suggest that calcium supplements increase the risk of cardiovascular disease. To further assess their safety, we recently conducted a meta-analysis of trials of calcium supplements, and found a 27-31% increase in risk of myocardial infarction and a 12-20% increase in risk of stroke. These findings are robust because they are based on pre-specified analyses of randomized, placebo-controlled trials and show consistent risk across the trials. The fact that cardiovascular events were not primary endpoints of any of these studies will introduce noise but not bias into the data. A recent re-analysis of the Women's Health Initiative suggests that co-administration of vitamin D with calcium does not lessen these adverse effects. The increased cardiovascular risk with calcium supplements is consistent with epidemiological data relating higher circulating calcium concentrations to cardiovascular disease in normal populations. There are several possible pathophysiological mechanisms for these effects, including effects on vascular calcification, on the function of vascular cells, and on blood coagulation. Calcium-sensing receptors might mediate some of these effects. Because calcium supplements produce small reductions in fracture risk and a small increase in cardiovascular risk, there may be no net benefit from their use. Food sources of calcium appear to produce similar benefits on bone density, although their effects on fracture are unclear. Since food sources have not been associated with adverse cardiovascular effects, they may be preferable. Available evidence suggests that other osteoporosis treatments are still effective without calcium co-administration.

Twisted tail: spinal epidural lipomatosis responding to chemotherapy in a patient with non-small-cell lung cancer

Spinal epidural lipomatosis is a rare condition, described in corticoadrenal hyperactivity. It is most commonly seen in association with steroid administration and occasionally with Cushing's syndrome. This is the first case report of spinal epidural lipomatosis as presenting finding in a patient with non-small-cell lung carcinoma without any evidence of endogenous or exogenous hypercortisolism. The additional interesting feature is the paraneoplastic behaviour of this condition and even more interestingly its resolution following chemo-treatment of the primary cancer. Spinal epidural lipomatosis is a benign condition, which must be considered in the differential diagnosis of spinal cord compression in this category of patients. Its pathophysiology remains to be discovered in future.

Effect of calcium supplementation on hip fractures

There have been numerous studies of the effects of calcium supplementation, with or without vitamin D, on fractures. Individually, they have not provided clarity regarding calcium's anti-fracture efficacy, though they have established that calcium does have beneficial effects on bone density throughout the skeleton in women. Meta-analysis of these data suggests that total fracture numbers are diminished. However, the data from the 5,500 women involved in trials of calcium monotherapy show consistent adverse trends in numbers of hip fractures (relative risk 1.50, 95% CI 1.06-2.12). Observational data from the Study of Osteoporotic Fractures show a similar increase in risk of hip fracture associated with calcium use. We hypothesize that reduced periosteal expansion in women using calcium supplementation might account for the differences in anti-fracture efficacy of calcium at the hip, in comparison with other sites. Until there are further trial results to clarify this area, the present findings suggest that reliance on high calcium intakes to reduce the risk of hip fracture in older women is not appropriate. In addition, those at risk should be looking to other agents with a proven capacity to prevent hip fractures, such as bisphosphonates.

Skeletal consequences of thiazolidinedione therapy

Thiazolidinediones (TZDs) are agonists of the peroxisome proliferator-activated receptor gamma (PPARgamma) nuclear transcription factor. Two members of this drug class, rosiglitazone and pioglitazone, are commonly used in the management of type II diabetes mellitus, and play emerging roles in the treatment of other clinical conditions characterized by insulin resistance. Over the past decade, a consistent body of in vitro and animal studies has demonstrated that PPARgamma signaling regulates the fate of pluripotent mesenchymal cells, favoring adipogenesis over osteoblastogenesis. Treatment of rodents with TZDs decreases bone formation and bone mass. Until recently, there were no bone-related data available from studies of TZDs in humans. In the past year, however, several clinical studies have reported adverse skeletal actions of TZDs in humans. Collectively, these investigations have demonstrated that the TZDs currently in clinical use decrease bone formation and accelerate bone loss in healthy and insulin-resistant individuals, and increase the risk of fractures in the appendicular skeleton in women with type II diabetes mellitus. These observations should prompt clinicians to evaluate fracture risk in patients for whom TZD therapy is being considered, and initiate skeletal protection in at-risk individuals.

Hand arthritis in systemic lupus erythematosus: an ultrasound pictorial essay

A small minority of systemic lupus erythematosus (SLE) patients may develop a deforming arthritis, typically with a non-erosive (Jaccoud's) pattern, although erosive features indistinguishable from rheumatoid arthritis may also occur. High-resolution ultrasonography (HRUS) allows detailed 'real time' imaging of joint and tendon morphostructural changes involving the hand in patients with several rheumatic diseases. The main aim of this pictorial essay is to provide the first descriptive HRUS and power Doppler (PD) findings of joint and tendon involvement of the hand and wrist in patients with SLE arthritis. Seventeen patients with SLE and hand involvement were examined. HRUS of the wrist, 2nd and 3rd MCP joints, 3rd PIP joint and 2nd, 3rd and 4th finger flexor tendons were studied in the dominant hand for each patient. Sixteen (94%) patients had joint effusion or synovial hypertrophy in the wrist. Twelve (71%) patients had joint effusion or synovial hypertrophy in 2nd or 3rd MCPJs. Eight (47%) patients had erosion at 2nd or 3rd MCPJs. In three cases erosions were not present radiologically. Eleven (65%) patients had evidence of tenosynovitis. In SLE, HRUS with PD detects a high prevalence of inflammatory pathology in the tendons and synovium of the hand and wrist, and a high prevalence of MCP joint erosions. HRUS offers a sensitive, real-time and readily repeatable assessment of soft-tissue, inflammatory and bony changes in SLE hands.

Activation of peroxisome proliferator-activated receptor gamma (PPARgamma) by rosiglitazone suppresses components of the insulin-like growth factor regulatory system in vitro and in vivo

Rosiglitazone (Rosi) belongs to the class of thiazolidinediones (TZDs) that are ligands for peroxisome proliferator-activated receptor gamma (PPARgamma). Stimulation of PPARgamma suppresses bone formation and enhances marrow adipogenesis. We hypothesized that activation of PPARgamma down-regulates components of the IGF regulatory system, leading to impaired osteoblast function. Rosi treatment (1 microm) of a marrow stromal cell line (UAMS-33) transfected with empty vector (U-33/c) or with PPARgamma2 (U-33/gamma2) were analyzed by microarray. Rosi reduced IGF-I, IGF-II, IGFBP-4, and the type I and II IGF receptor (IGF1R and IGF2R) expression at 72 h in U-33/gamma2 compared with U-33/c cells (P < 0.01); these findings were confirmed by RT-PCR. Rosi reduced secreted IGF-I from U-33/gamma2 cells by 75% (P < 0.05). Primary marrow stromal cells (MSCs) extracted from adult (8 months) and old (24 months) C57BL/6J (B6) mice were treated with Rosi (1 microm) for 48 h. IGF-I, IGFBP-4, and IGF1R transcripts were reduced in Rosi-treated MSCs compared with vehicle (P < 0.01) and secreted IGF-I was also suppressed (P < 0.05). B6 mice treated with Rosi (20 mg/kg.d) for short duration (i.e. 4 d), and long term (i.e. 7 wk) had reduced serum IGF-I; this was accompanied by markedly suppressed IGF-I transcripts in the liver and peripheral fat of treated animals. To determine whether Rosi affected circulating IGF-I in humans, we measured serum IGF-I, IGFBP-2, and IGFBP-3 at four time points in 50 postmenopausal women randomized to either Rosi (8 mg/d) or placebo. Rosi-treated subjects had significantly lower IGF-I at 8 wk than baseline (-25%, P < 0.05), and at 16 wk their levels were reduced 14% vs. placebo (P = 0.15). We conclude that Rosi suppresses IGF-I expression in bone and liver; these changes could affect skeletal acquisition through endocrine and paracrine pathways.

High-resolution ultrasonography of the first metatarsal phalangeal joint in gout: a controlled study

OBJECTIVE

To compare high-resolution ultrasound (HRUS) with conventional radiography in the detection of erosions in the first metatarsophalangeal joints (1st MTPJs) of patients with gout and to identify the characteristic sonographic features of gout.

METHODS

HRUS examination of the 1st MTPJs of both feet was performed by two independent sonographers. The presence of joint and soft-tissue pathology was recorded. x Ray examination of the feet was performed on the same day and reported by the same radiologist.

RESULTS

39 male patients with gout and 22 age-matched control subjects (14 with an inflammatory arthropathy and 8 disease free) were studied. The agreement on erosion between HRUS and x ray was poor, kappa = 0.229 (non-weighted), with McNemar's test being significant (p<0.001) indicating a large number of false negative x rays. 22 MTPJs in patients with gout had never been subjected to a clinical attack of acute gout. In these MTPJs, there were 10 erosions detected by HRUS and 3 erosions on x ray. HRUS features significantly more prevalent in the patients with gout were hard and soft tophus-like lesions (p<0.01) and the double contour sign (p<0.01).

CONCLUSIONS

These data show that HRUS may assist in the management of gout in two ways: first, by aiding in the diagnosis by identifying the sonographic features that may be representative of the disease, and, second, by allowing the early detection of erosive joint damage and/or tophaceous deposits even in clinically silent joints.

The diagnostic accuracy of magnetic resonance imaging in detecting cervical involvement in endometrial cancer

OBJECTIVES

The objective of this study was to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting cervical involvement by endometrial cancer.

METHODS

A retrospective accuracy study of 135 consecutive women who underwent preoperative MRI and surgery for endometrial cancer at a single gynaecological cancer centre between 1st February 2003 and 30th November 2004.

RESULTS

For the detection of any cervical involvement by MRI, the sensitivity was 72%, specificity 93.2%, positive predictive value (PPV) 89.8%, negative predictive value (NPV) 80.2%, positive likelihood ratio (+LR) 10.7 and negative likelihood ratio (-LR) 0.3. When cervical stromal invasion was considered alone, the sensitivity was 84.4%, specificity 87.4%, PPV 67.5%, NPV 94.7%, +LR 6.7 and -LR 0.18.

CONCLUSION

We believe that MRI is able to accurately predict cervical involvement in endometrial cancer and allows a decision to be made on the type of hysterectomy to be offered.

Aggressive angiomyxoma of the vulva: Dramatic response to gonadotropin-releasing hormone agonist therapy

BACKGROUND

Aggressive angiomyxoma (AA) is a vulvovaginal mesenchymal neoplasm with a marked tendency to local recurrence but which usually does not metastasise. Most cases exhibit positive immunohistochemical staining with oestrogen receptor (ER) and, or, progesterone receptor (PR).

CASE

We report a case of AA which exhibited positive immunohistochemical staining with ER and in which radiological examination following resection showed extensive residual tumour. The patient was commenced on gonadotropin-releasing hormone (GnRH) agonist therapy which resulted in complete radiological remission with replacement by scar tissue. The patient is currently maintained on a GnRH agonist.

CONCLUSION

The present case, together with several others reported in the literature, suggests that GnRH agonists may be of value in managing cases of AA, either primary or recurrent, which are not amenable to surgical excision. These agents may also be used to effect a reduction in size, so that more conservative surgery can be undertaken.

Non-hyperinsulinemic hypoglycemia in a patient with a gastrointestinal stromal tumor

One of the authors (JvD) recently reported a case of non-islet cell tumor hypoglycemia caused by the production of "big" IGF-II by a gastrointestinal stromal tumor (GIST). Here, we report a patient with a GIST in whom non-hyperinsulinemic hypoglycemia was not attributable to aberrant tumoral IGF-II processing, but instead was caused by a combination of cachexia, renal and hepatic dysfunction, and tumoral glucose consumption.

Calcium supplementation does not affect CRP levels in postmenopausal women--a randomized controlled trial

INTRODUCTION

Epidemiological studies suggest that calcium supplementation may decrease the risk of cardiovascular disease.

METHODS

Since the inflammatory marker C-reactive protein (CRP) is a risk factor for cardiovascular disease, and CRP production is potentially responsive to parathyroid hormone, we measured high-sensitivity CRP at baseline and 12 months in a subset of healthy postmenopausal women participating in a randomized controlled trial of the effects of 1 g of calcium daily on the incidence of fractures.

RESULTS

At baseline, we found that CRP correlated positively with indices of body weight and fat and with bone mineral density (BMD) at the total body and total hip sites, but the associations between CRP and BMD were lost after adjustment for body weight. There were consistent associations between levels of CRP and markers of the metabolic syndrome (fat mass, plasma triglycerides, fasting glucose).

CONCLUSION

After 1 year of calcium supplementation, there was no difference between the groups in levels of CRP. We conclude that levels of CRP correlate with anthropometric and biochemical features of insulin resistance, but that they are neither predictive of BMD nor affected by 1 g of calcium supplementation in healthy postmenopausal women.

Musculoskeletal ultrasound training in rheumatology: the Belfast experience

OBJECTIVES

Despite the increasing use of musculoskeletal ultrasound (MSUS) as a clinical tool in rheumatology, there is no consensus yet regarding the standards required to achieve a basic level of competence in the use of this imaging technique. A number of sonographers worldwide are developing curricula and standardizing teaching methods in order to improve training in MSUS for rheumatologists. In the meantime, clinicians are devising informal means of training in order to acquire these new skills. Here we describe the informal team approach to MSUS training adopted by a group of rheumatologists from the Regional Rheumatology Centre in Belfast, UK.

METHODS

Over a 5-yr period, eight rheumatologists from Musgrave Park Hospital in Belfast used a variety of means to learn the basic skills of MSUS.

RESULTS

Seven of the team underwent a formal assessment of their competency in a practical examination devised by an experienced sonographer. All were judged to have attained a basic competency in MSU.

CONCLUSIONS

This Belfast experience shows what can be achieved despite the absence of formal MSUS training. Nevertheless, the development of recognized training programmes and international standards of competency are important goals on the way to achieving more widespread acceptance of MSUS as a useful tool in everyday clinical practice.

Osteoblastic cells express phospholipid receptors and phosphatases and proliferate in response to sphingosine-1-phosphate

Sphingosine-1-phosphate (S1P) is a naturally occurring polar phospholipid that exerts growth-factor--like effects in a number of cell types, potentially by endocrine, paracrine, and intracrine mechanisms. The biological actions of S1P are mediated in part by its specific binding to at least four members of the edg/lp family of G protein-coupled receptors (edg 1, 3, 6, and 8), and further regulated by the actions of specific cell membrane-bound lipid phosphate phosphatases (LPPs). Recent evidence has suggested that S1P may act as an osteoblast growth factor. In the current study, we demonstrate expression in osteoblastic cells of the S1P receptors edg 1, edg 5 and edg 8; the lipid phosphate phosphatases LPP-1, LPP-2, and LPP-3, and the S1P phosphatase mSPP1. S1P exerts dose-dependent mitogenic effects in cultures of primary rat osteoblastic cells and SaOS-2 cells. S1P also activates p42/44 mitogen-activated protein (MAP) kinases in osteoblastic cells, and the proliferative effects of S1P in these cultures are partially abrogated by PD-98059 and U-0126, specific inhibitors of p42/44 MAP kinase signaling. S1P-induced p42/44 MAP kinase activation in osteoblastic cells is dependent on functional Gi proteins and intracellular calcium fluxes, but not on protein kinase A, phospha-tidylinositol-3 kinase, or protein Kinase C. These data demonstrate (1) the expression by osteoblastic cells of several cell membrane-bound components of phospholipid signaling and (2) that S1P is a potent osteoblast mitogen, the proliferative action of which is mediated by a signaling pathway that involves Gi proteins, intracellular calcium, and p42/44 MAP kinases.

A potential role for adrenomedullin as a local regulator of bone growth

Bone remodeling is a complex process of coordinated resorption and formation of bone, which is regulated by systemic hormones and by local factors. We have previously shown that the peptide hormone adrenomedullin is mitogenic to osteoblastic cells in vitro and that it promotes bone growth in vivo. The aim of the present study was to characterize the expression of molecules that may mediate adrenomedullin signaling in osteoblasts and to investigate the expression of adrenomedullin itself in these cells. The first adrenomedullin receptor that was cloned is the seven-transmembrane G protein-coupled receptor, L1. Two additional receptors for adrenomedullin, which arise from interactions between calcitonin receptor-like receptor and receptor activity modifying proteins 2 or 3, have now been described. In the current study, we used RT-PCR and Northern blot analysis to demonstrate that messenger RNA for the three adrenomedullin receptors, as well as for adrenomedullin itself, is expressed in primary rat osteoblasts. Treating primary osteoblasts with transforming growth factor-beta and insulin-like growth factor-I moderately reduced adrenomedullin RNA levels, whereas PTH had no effect. We have shown by immunocytochemistry that adrenomedullin peptide is present in osteoblasts, and by competitive binding assays that (125)I-adrenomedullin binds with high affinity to intact osteoblasts and to osteoblast cell membranes. Coexpression of adrenomedullin and adrenomedullin receptors in osteoblasts, taken together with our previous finding that adrenomedullin is mitogenic to these cells, raises the possibility that this peptide is a local regulator of bone growth.

Parathyroid hormone induces hepatic production of bioactive interleukin-6 and its soluble receptor

Interleukin-6 (IL-6) is an important mediator of parathyroid hormone (PTH)-induced bone resorption. Serum levels of IL-6 and its soluble receptor (IL-6sR) are regulated in part by PTH. The PTH/PTH-related protein type 1 receptor is highly expressed in the liver, and in the current study we investigated whether the liver produces IL-6 or IL-6sR in response to PTH. Perfusion of the isolated rat liver with PTH-(1-84) stimulated rapid, dose-dependent production of bioactive IL-6 and the IL-6sR. These effects were observed at near physiological concentrations of the hormone such that 1 pM PTH induced hepatic IL-6 production at a rate of approximately 0.6 ng/min. In vitro, hepatocytes, hepatic endothelial cells, and Kupffer cells, but not hepatic stellate cells, were each found to produce both IL-6 and IL-6sR in response to higher (10 nM) concentrations of PTH. Our data suggest that hepatic-derived IL-6 and IL-6sR contribute to the increase in circulating levels of these cytokines induced by PTH in vivo and raise the possibility that PTH-induced, liver-derived IL-6 may exert endocrine effects on tissues such as bone.