Effect of induction intensity on survival in patients with acute myeloid leukemia

e19004

Background: Acute Myeloid Leukemia (AML) has traditionally been treated frontline with intensive induction chemotherapy in patients fit enough for this treatment. The FDA has approved several oral targeted therapies for AML in recent years. The survival impact of these agents vs induction chemotherapy is unknown. Methods: In this single-center, retrospective study, patients diagnosed with AML from 2015-2020 were included if they received treatment with either high intensity chemotherapy (HiC) or lower intensity targeted therapy (LITT). HiC was defined as a regimen containing cytarabine + anthracycline given on a “7+3” based schedule. Patients treated with liposomal cytarabine-daunorubicin were excluded. LITT was defined as venetoclax, gilteritinib, enasidenib, or ivosidenib alone or in combination with a hypomethylating agent. Patients fell into four groups: HiC only, LITT only, HiC followed by LITT, and LITT followed by HiC with assignment censored at transplant. Overall survival (OS) was estimated using Kaplan-Meier method and patients receiving any HiC vs LITT only were compared using log-rank test. Results: A total of 332 patients were included: 177 received HiC only, 116 LITT only, 32 HiC before LITT, and 7 LITT before HiC. Baseline characteristics and OS data are outlined in the table. The any HiC group had a lower median age and more patients with WBC >10 K/µL at diagnosis, as well as more patients receiving allogeneic hematopoietic cell transplant (HCT). OS was superior in the any HiC group vs LITT only group. Receipt of any HiC remained predictive of OS after adjusting for age (HR 0.65, 95% CI 0.44-0.96, p = 0.03); however, was no longer predictive of OS after adjusting for age and receipt of HCT. Conclusions: While HiC was associated with superior OS compared to LITT only treatment in univariable analysis, the survival benefit was no longer apparent after adjusting for age and receipt of HCT. The results suggest that intensity of AML treatment is less impactful on prognosis than ability to receive HCT. Differences in age were likely confounded by clinical trial eligibility and prescribing information specifically affecting patients receiving LITT. In the era of LITT, prospective randomized studies of intensity of AML therapy, particularly in non-favorable risk disease, are imperative to striking a balance between toxicity and cure for patients of all ages.[Table: see text]

Association of post-transplant outcomes with induction intensity in patients with acute myeloid leukemia

e19026

Background: The USFDA has recently approved several oral targeted therapies for the treatment of acute myeloid leukemia (AML). The relative survival impact of these agents vs standard induction chemotherapy in the frontline setting is unknown, especially in patients who undergo allogeneic hematopoietic cell transplant (HCT). Methods: This is a retrospective, single-institution study of 125 patients with AML diagnosed 2015-2020 who received HCT. Patients were included if induced with high intensity chemotherapy (HiC) or lower intensity targeted therapy (LITT). HiC was defined as cytarabine + anthracycline given on a “7+3” based schedule. LITT was defined as venetoclax, gilteritinib, enasidenib, or ivosidenib alone or combined with hypomethylating agent. Patients receiving liposomal cytarabine-daunorubicin were excluded. Outcomes of interest were overall survival (OS), non-relapse mortality (NRM), and cumulative incidence of relapse (CIR). Between-groups analysis was conducted comparing receipt of any HiC to LITT only. OS was analyzed by Kaplan-Meier method and compared using log-rank test; NRM and CIR was estimated through cumulative incidence function and compared by Fine-Gray test. Results: Of 125 HCT recipients, 108 received any HiC and 17 LITT only. Two patients received HiC after suboptimal response to LITT. Median age at HCT was 61 years, 48% were female, and 90% were in complete remission at HCT. Population characteristics and outcomes as well as between-groups comparison are presented in the table. LITT only group was older with longer time to HCT and exclusively received RIC. With median follow-up of 23 months, median OS had not been reached. There were no statistically significant differences in median OS or one-year NRM or CIR between groups. Conclusions: Despite differences in age, conditioning regimen, and time to HCT in patients receiving any HiC vs LITT only, we have shown similar OS, CIR, and NRM. Difference in age is in contrast to lack of difference in HCT-CI and KPS, but is partially explained by limited access to LITT for younger patients. Longer time to HCT among LITT only recipients represents a major opportunity for pre-HCT optimization of recipient health. Prospective study from time of diagnosis will be important to understanding the appropriate use of LITT in HCT-eligible patients.[Table: see text]

Prognostic value of early imaging following CAR T-cell therapy in DLBCL

e19559

Background: Chimeric antigen receptor T-cell (CART) therapies lead to durable disease control in patients (pts) with relapsed/refractory (R/R) Diffuse Large B-cell Lymphoma (DLBCL). We assessed the prognostic value of response on first staging scan, and whether pts with progression of disease (PD) convert to a response on second scan. Methods: We conducted a retrospective analysis of pts with R/R DLBCL treated with CART at our institute. Baseline characteristics were assessed at apheresis. We included staging scans (CT, PET-CT and MRI) that occurred up to 6 months (mos) after CART infusion. Responses were determined via the Lugano 2014 criteria. Overall survival (OS) was calculated from first scan to last follow-up. Kaplan Meier method and Cox model were used to correlate first scan result with OS. Results: Of the 118 pts who received CART, 111 pts had evaluable staging scans (7 passed prior to first scan). Of the 111 pts, median age was 61 years (range, 23-84), and median number of prior therapies was 3 (range, 1-7). 61 pts received tisagenlecleucel, and 50 pts received axicabtagene ciloleucel. 22% of pts had MYC rearrangement by FISH. The majority of pts were stage 3/4 (91%), with an IPI score ≥2 (82%). 32%, 66% and 2% of pts had a CT, PET-CT or MRI as their first scan respectively. After a median follow-up of 16.2 mos, median OS from first scan was not reached (NR) (95% CI, 17-NR). 37%, 5%, 32%, 25% of pts had PD, SD, PR, and CR on first scan respectively. Median time to first scan was 59 days (range, 13-115). Median OS for pts who had PD was 3 mos (95% CI 2-8), and the median OS for those who attained SD, PR or CR was NR (95% CI NR-NR). Accounting for statistically important factors on multivariate analysis, PD on first scan was an independent predictor of OS (p<.001, HR 10.1 (95% CI 4.7-22)). We observed no evidence that pts with PD on first scan convert to a response on second scan without intervention. 26 of 41 pts who had PD did not start new treatment, 17 passed without follow-up scan, 1 is in follow-up, and 8 continued to show PD on subsequent scans. Conclusions: PD on first staging scan is a strong prognostic marker for survival for pts with R/R DLBCL who receive CART. There is no evidence to suggest conversion to a response will occur for patients who have PD. Performing staging scans at an earlier time-point has value, allowing for earlier treatment changes and goals of care conversations in this pt population.[Table: see text]

Feedback Recommendation System Based on Structured Feedback Acquisition

Users’ feedback are increasingly becoming a vital factor during the software evolution process. Users’ feedback are widely considered to be an indication of how satisfied are the system’s users. It was found that large percentage of feedback represents problems reported by users who face problems in using the system. Users’ feedback are usually communicated in an ad-hoc manner with no defined structure. The ad-hoc nature of the feedback makes it difficult to study and analyse feedback. Also, it usually happens that similar problems are reported by different users, so engineers spend wasted time and effort in duplicate issues. In this paper we propose a recommendation system which recommends to the user reported problems that are similar to his from prevoius feedback threads to reuse existing solutions. We based our work on a structured feedback system to ensure we get better results. Structured feedback ensures minimum level of useful and meanigful information that helps enhance the analysis results. Initial evaluation was conducted and the results are promising.

Allogeneic transplantation in elderly patients ≥65 years with non-Hodgkin lymphoma: a time-trend analysis

Allogeneic hematopoietic cell transplantation (allo-HCT) is a curative therapy for relapsed/refractory and high-risk non-Hodgkin lymphoma (NHL). However, no large studies have evaluated allo-HCT utilization in elderly NHL patients (≥65 years). Using the CIBMTR registry, we report a time-trend analysis of 727 NHL patients (≥65 years) undergoing the first allo-HCT from 2000 to 2015 in the United States (US). Study cohorts were divided by time period: 2000-2005 (N = 76) vs. 2006-2010 (N = 238) vs. 2011-2015 (N = 413). Primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS), relapse/progression (R/P), and non-relapse mortality (NRM). Median age at transplant, use of reduced-intensity conditioning, and graft source remained stable, while use of unrelated donors increased in the most current era. The 1-year probabilities of NRM from 2000 to 2005 vs. 2006-2010 vs. 2011-2015 were 24% vs. 19% vs. 21%, respectively (p = 0.67). Four-year probability of R/P was similar among the three cohorts: 48% (2000-2005), 40% (2006-2010), and 40% (2011-2015) (p = 0.39). The 4-year probabilities of PFS and OS (2000-2005 vs. 2006-2010 vs. 2011-2015) showed significantly improved outcomes in more recent time periods: 17% vs. 31% vs. 30% (p = 0.02) and 21% vs. 42% vs. 44% (p < 0.001), respectively. Utilization of allo-HCT increased in elderly NHL patients in the US since 2000 with improving survival outcomes.

A phase II study of myeloablative allogeneic hematopoietic stem cell transplantation (aHSCT) for acute lymphoblastic leukemia (ALL) in older patients using fludarabine and total body irradiation (Flu/TBI)

TPS7069

Background: Older adults with ALL have poor survival outcomes. Although aHSCT can be curative when used as consolidation after complete remission (CR), advanced age, limited performance status, and comorbidities are risk factors for increased non-relapse mortality (NRM) after myeloablative aHSCT. The 1-year disease free survival (DFS) for patients ≥ 40 years who receive an aHSCT for ALL is often estimated to be 40-50%. Previous studies have demonstrated the efficacy of TBI-based regimens in adults with ALL when combined with cyclophosphamide (Cy). Reduced intensity conditioning for ALL patients has fallen out of favor due to high relapse rate forfeiting the benefit of reduced NRM. High-dose Cy is, however, associated with cardiac, hemorrhagic and hepatic toxicities. Fludarabine (Flu) has emerged as a safer substitute of Cy (e.g. Flu/Bu replacing Bu/Cy) with favorable toxicity profile. Given the efficacy of TBI-based regimens in ALL, we hypothesized that a myeloablative regimen of Flu/TBI (12 Gy) is almost as effective as Cy/TBI 12 Gy in older adults with ALL undergoing aHSCT, but with less NRM confering survival benefit over Cy/TBI 12 Gy. Methods: This study is a single center, single-arm phase II clinical trial of Flu 40 mg/m2 IV daily (days -7 to -4) and TBI 2 Gy X2 (days -3 to -1) as myeloablative conditioning for older adults (≥40 years old) or younger adults with significant comorbidities with ALL. Patients aged 40-65 years with ALL in CR, KPS ≥ 70, adequate organ function, and having HLA-matched sibling or unrelated donor will be eligible. The primary endpoint of the study is 1-year DFS post-transplant. Secondary endpoints include 1-year overall survival (OS), incidence and severity of acute and chronic GVHD, immune reconstitution and regimen related toxicity. The study has just finished accrual (January 2019) enrolling a total of 16 patients. This number of patients was pre-determined to give a probability ≤ 0.05 of concluding that the 1-year DFS rate exceeds 45%, and a probability of at least 0.80 of concluding that the 1-year DFS rate exceeds 45% (expecting 1-year DFS of 75%). Clinical trial information: NCT01991457.

Peripheral Blood versus Bone Marrow from Unrelated Donors: Bone Marrow Allografts Have Improved Long-Term Overall and Graft-versus-Host Disease-Free, Relapse-Free Survival

Peripheral blood (PB) and bone marrow (BM) from unrelated donors can serve as a graft source for hematopoietic cell transplantation (HCT). Currently, PB is most commonly used in roughly 80% of adult recipients. Determining the long-term impact of graft source on outcomes would inform this decision. Data collected by the Center for International Blood and Marrow Transplant Research from 5200 adult recipients of a first HCT from an 8/8 or 7/8 HLA antigen-matched unrelated donor for treatment of acute leukemia, chronic myelogenous leukemia, or myelodysplastic syndrome between 2001 and 2011 were analyzed to determine the impact of graft source on graft-versus-host disease (GVHD) relapse-free survival (GRFS), defined as freedom from grade III/IV acute GVHD, chronic GVHD requiring immunosuppressive therapy, relapse, and death, and overall survival. GRFS at 2 years was superior in BM recipients compared with PB recipients (16%; 95% confidence interval [CI], 14% to 18% versus 10%; 95% CI, 8% to 11%; P <.0001) in the 8/8 HLA-matched cohort and 7/8 HLA-matched cohort (11%; 95% CI, 8% to 14% versus 5%; 95% CI, 4% to 7%; P = .001). With 8/8 HLA-matched unrelated donors, overall survival at 5 years was superior in recipients of BM (43%; 95% CI, 40% to 46% versus 38%; 95% CI, 36% to 40%; P = .014). The inferior 5-year survival in the PB cohort was attributable to a higher frequency of deaths while in remission compared with the BM cohort. For recipients of 7/8 HLA-matched grafts, survival at 5 years was similar in BM recipients and PB recipients (32% versus 29%; P = .329). BM grafts are associated with improved long-term GRFS and overall survival in recipients of matched unrelated donor HCT and should be considered the unrelated allograft of choice, when available, for adults with acute leukemia, chronic myelogenous leukemia, and myelodysplastic syndrome.

Myeloid Growth Factors, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

Myeloid growth factors (MGFs) are given as supportive care to patients receiving myelosuppressive chemotherapy to reduce the incidence of neutropenia. This selection from the NCCN Guidelines for MGFs focuses on the evaluation of regimen- and patient-specific risk factors for the development of febrile neutropenia (FN), the prophylactic use of MGFs for the prevention of chemotherapy-induced FN, and assessing the risks and benefits of MGF use in clinical practice.

Country-Level Macroeconomic Indicators Predict Early Post-Allogeneic Hematopoietic Cell Transplantation Survival in Acute Lymphoblastic Leukemia: A CIBMTR Analysis

For patients with acute lymphoblastic leukemia (ALL), allogeneic hematopoietic cell transplantation (alloHCT) offers a potential cure. Life-threatening complications can arise from alloHCT that require the application of sophisticated health care delivery. The impact of country-level economic conditions on post-transplantation outcomes is not known. Our objective was to assess whether these variables were associated with outcomes for patients transplanted for ALL. Using data from the Center for Blood and Marrow Transplant Research, we included 11,261 patients who received a first alloHCT for ALL from 303 centers across 38 countries between the years of 2005 and 2013. Cox regression models were constructed using the following macroeconomic indicators as main effects: Gross national income per capita, health expenditure per capita, and Human Development Index (HDI). The outcome was overall survival at 100 days following transplantation. In each model, transplants performed within lower resourced environments were associated with inferior overall survival. In the model with the HDI as the main effect, transplants performed in the lowest HDI quartile (n = 697) were associated with increased hazard for mortality (hazard ratio, 2.42; 95% confidence interval, 1.64 to 3.57; P < .001) in comparison with transplants performed in the countries with the highest HDI quartile. This translated into an 11% survival difference at 100 days (77% for lowest HDI quartile versus 88% for all other quartiles). Country-level macroeconomic indices were associated with lower survival at 100 days after alloHCT for ALL. The reasons for this disparity require further investigation.

NCCN Guidelines Insights: Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Version 1.2017

Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are different manifestations of the same disease and managed in much the same way. The advent of novel CD20 monoclonal antibodies led to the development of effective chemoimmunotherapy regimens. More recently, small molecule inhibitors targeting kinases involved in a number of critical signaling pathways and a small molecule inhibitor of the BCL-2 family of proteins have demonstrated activity for the treatment of patients with CLL/SLL. These NCCN Guidelines Insights highlight important updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for CLL/SLL for the treatment of patients with newly diagnosed or relapsed/refractory CLL/SLL.

Outcomes after Umbilical Cord Blood Transplantation for Myelodysplastic Syndromes

For patients with hematologic malignancies undergoing allogeneic hematopoietic cell transplantation, umbilical cord blood transplantation (UCBT) has become an acceptable alternative donor source in the absence of a matched sibling or unrelated donor. To date, however, there have been few published series dedicated solely to describing the outcomes of adult patients with myelodysplastic syndrome (MDS) who have undergone UCBT. Between 2004 and 2013, 176 adults with MDS underwent UCBT as reported to the Center for International Blood and Marrow Transplant Research. Median age at the time of transplantation was 56 years (range, 18-73 years). The study group included 10% with very low, 23% with low, 19% with intermediate, 19% with high, and 13% with very high-risk Revised International Prognostic Scoring System (IPSS-R) scores. The 100-day probability of grade II-IV acute graft-versus-host disease (GVHD) was 38%, and the 3-year probability of chronic GVHD was 28%. The probabilities of relapse and transplantation-related mortality (TRM) at 3 years were 32% and 40%, respectively, leading to a 3-year disease-free survival (DFS) of 28% and an overall survival (OS) of 31%. In multivariate analysis, increasing IPSS-R score at the time of HCT was associated with inferior TRM (P = .0056), DFS (P = .018), and OS (P = .0082), but not with GVHD or relapse. The presence of pretransplantation comorbidities was associated with TRM (P = .001), DFS (P = .02), and OS (P = .001). Reduced-intensity conditioning was associated with increased risk of relapse (relative risk, 3.95; 95% confidence interval, 1.78-8.75; P < .001), and although a higher proportion of myeloablative UCBTs were performed in patients with high-risk disease, the effect of conditioning regimen intensity was the same regardless of IPSS-R score. For some individuals who lack a matched sibling or unrelated donor, UCBT can result in long-term DFS; however, the success of UCBT in this population is hampered by a high rate of TRM.

Does FLT3 mutation impact survival after hematopoietic stem cell transplantation for acute myeloid leukemia? A Center for International Blood and Marrow Transplant Research (CIBMTR) analysis

BACKGROUND

Patients with FMS like tyrosine kinase 3 (FLT3)-mutated acute myeloid leukemia (AML) have a poor prognosis and are referred for early allogeneic hematopoietic stem cell transplantation (HCT).

METHODS

Data from the Center for International Blood and Marrow Transplant Research (CIBMTR) were used to evaluate 511 adult patients with de novo AML who underwent HCT during 2008 through 2011 to determine whether FLT3 mutations had an impact on HCT outcomes.

RESULTS

In total, 158 patients (31%) had FLT3 mutations. Univariate and multivariate analyses revealed an increased risk of relapse at 3 years in the FLT3 mutated group compared with the wild-type (WT) group (38% [95% confidence interval (CI), 30%-45%] vs 28% [95% CI, 24%-33%]; P = .04; relative risk, 1.60 [95% CI, 1.15-2.22]; P = .0048). However, FLT3 mutation status was not significantly associated with nonrelapse mortality, leukemia-free survival, or overall survival. Although more patients in the FLT3 mutated group died from relapsed primary disease compared with those in the WT group (60% vs 46%), the 3-year overall survival rate was comparable for the 2 groups (mutated group: 49%; 95% CI, 40%-57%; WT group: 55%, 95% CI, 50%-60%; P = .20).

CONCLUSIONS

The current data indicate that FLT3 mutation status did not adversely impact overall survival after HCT, and about 50% of patients with this mutation who underwent HCT were long-term survivors. Cancer 2016;122:3005-3014. © 2016 American Cancer Society.

Hematopoietic Cell Transplantation Outcomes in Monosomal Karyotype Myeloid Malignancies

The presence of monosomal karyotype (MK+) in acute myeloid leukemia (AML) is associated with dismal outcomes. We evaluated the impact of MK+ in AML (MK+AML, n = 240) and in myelodysplastic syndrome (MDS) (MK+MDS, n = 221) on hematopoietic cell transplantation outcomes compared with other cytogenetically defined groups (AML, n = 3360; MDS, n = 1373) as reported to the Center for International Blood and Marrow Transplant Research from 1998 to 2011. MK+ AML was associated with higher disease relapse (hazard ratio, 1.98; P < .01), similar transplantation-related mortality (TRM) (hazard ratio, 1.01; P = .90), and worse survival (hazard ratio, 1.67; P < .01) compared with those outcomes for other cytogenetically defined AML. Among patients with MDS, MK+ MDS was associated with higher disease relapse (hazard ratio, 2.39; P < .01), higher TRM (hazard ratio, 1.80; P < .01), and worse survival (HR, 2.02; P < .01). Subset analyses comparing chromosome 7 abnormalities (del7/7q) with or without MK+ demonstrated higher mortality for MK+ disease in for both AML (hazard ratio, 1.72; P < .01) and MDS (hazard ratio, 1.79; P < .01). The strong negative impact of MK+ in myeloid malignancies was observed in all age groups and using either myeloablative or reduced-intensity conditioning regimens. Alternative approaches to mitigate disease relapse in this population are needed.

Chronic lymphocytic leukemia/small lymphocytic lymphoma, version 1.2015

Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are different manifestations of the same disease, which are managed in the same way. The advent of novel monoclonal antibodies (ofatumumab and obinutuzumab) led to the development of effective chemoimmunotherapy regimens. The recently approved small molecule kinase inhibitors (ibrutinib and idelalisib) are effective treatment options for CLL in elderly patients with decreased tolerance for aggressive regimens and in patients with poor prognostic features who do not benefit from conventional chemoimmunotherapy regimens. This portion of the NCCN Guidelines for Non-Hodgkin's Lymphomas describes the recent specific to the incorporation of recently approved targeted therapies for the management of patients with newly diagnosed and relapsed or refractory CLL/SLL.

Serum Th17 cytokines in leprosy: correlation with circulating CD4(+) CD25 (high)FoxP3 (+) T-regs cells, as well as down regulatory cytokines

Leprosy is not only a bacteriological disease but also an immunological disease, in which T helper17 and CD4(+) CD25(high)FoxP3(+) regulatory T cells (T-regs), among others, may play a role. We aimed to evaluate serum levels of interleukin (IL)-17, IL-22 (Th17 cytokines), IL-10 and transforming growth factor (TGF)-β (down regulatory cytokines) in 43 untreated leprosy patients and 40 controls by enzyme-linked immunosorbent assay, and to assess circulating CD4(+) CD25(high)FoxP3(+)T-regs in patients using flow cytometry. Patients were grouped into tuberculoid, pure neural, borderline, lepromatous, type 1 reactional leprosy, and erythema nodosum leprosum. IL-10 and TGF-β were significantly higher in patients as compared to controls (p < 0.001), while IL-17, but not IL-22, was significantly lower (p < 0.001), with no significant difference comparing patients' subgroups. Significantly higher CD4(+) CD25(high)FoxP3(+)T-regs levels was detected in tuberculoid, type 1 reaction and pure neural leprosy, while the lowest levels in erythema nodosum leprosum (p < 0.001). TregsFoxP3 expression% was significantly lower in pure neural leprosy than other patients' subgroups (p < 0.05). T-regs/T-effs was lowest in erythema nodosum leprosum (p < 0.05). TGF-β correlated negatively with TregsFoxP3 expression% and T-effs% (p = 0.009 and 0.018 respectively). Leprosy is associated with defective IL-17 and overproduction of IL-10 and TGF-β. Tuberculoid, type 1 reaction and pure neural leprosy express significantly higher circulating T-regs, consistent with effector immune mechanisms activation, but with lower TregsFoxP3 expression (in pure neural leprosy). Erythema nodosum leprosum is characterized by deficient T-regs and increased TregsFoxP3 expression%. The present study pinpointed a potential role of Th17, CD4(+) CD25(high)FoxP3(+)T-regs, and probably CD4(+) CD25(+)IL-10(+) T regulatory cells 1 (Tr1), and Th3 in leprosy.

Serum YKL-40 in psoriasis with and without arthritis; correlation with disease activity and high-resolution power Doppler ultrasonographic joint findings

BACKGROUND

YKL-40 may be involved in angiogenesis in psoriasis and psoriatic arthritis (PsA). High-resolution power Doppler ultrasound (PDUS) can detect angiogenesis of synovium in PsA.

AIM

To assess serum YKL-40 in psoriasis patients with or without PsA, and to correlate its levels with disease activity and high-resolution PDUS findings.

METHODS

In this case-control study, 48 patients with psoriasis (26 of them also had PsA) and 30 controls were assessed by high-resolution PDUS, and assayed for serum levels of YKL-40 by ELISA. Patients were clinically assessed using Composite Psoriatic Disease Activity Index (CPDAI). Total joint score (TJS) was used to assess joint involvement in PsA.

RESULTS

A statistically significant elevation was found in YKL-40 levels in psoriatics with or without PsA compared with controls (P < 0.001), as well as in PsA (group II) compared to patients without arthritis (group I) (P = 0.002). CPDAI, synovial thickness score and colour Doppler ultrasound (CDUS) score were highly significantly higher in group II vs. group I (P < 0.001). In all patients, CPDAI, synovial thickness and CDUS score were positively correlated to each other, and each of them was positively correlated to serum YKL-40 levels (P < 0.05). In either group I or II, serum YKL-40 levels correlated positively with CPDAI (P < 0.05). In group II, TJS, synovial thickness and CDUS score were positively correlated to each other (P < 0.05).

CONCLUSIONS

Serum YKL-40 can be used as a new biological marker for angiogenesis and disease activity in psoriasis with or without PsA. High-resolution PDUS is a non-invasive tool for the evaluation of angiogenesis in PsA patients as well as for the detection of early synovial changes in psoriasis patients without arthritis.

Platelet activation: a link between psoriasis per se and subclinical atherosclerosis--a case-control study

BACKGROUND

Pathomechanisms of both psoriasis and atherosclerosis may involve platelet activation. Activated platelets show increased P-selectin; CD62 expression, and mean platelet volume (MPV). Impaired brachial artery flow-mediated dilatation (FMD) is related to atherosclerosis.

OBJECTIVES

To determine the presence of subclinical atherosclerosis in patients with psoriasis (without overt cardiovascular complications or traditional cardiovascular disease risk factors), compared with controls.

METHODS

In this case-control study, 25 patients with psoriasis and 25 age- and gender-matched healthy individuals were subjected to assessment of MPV, CD62 expression using flow cytometry, and brachial artery FMD and transthoracic echocardiography by cardiac ultrasound scanner.

RESULTS

A statistically highly significant increased CD62 expression, but not MPV, was found in cases compared with controls, and in patients with moderate/severe psoriasis compared with either mild cases or controls (P < 0.001). CD62 expression was statistically significantly positively correlated with the Psoriasis Area and Severity Index (PASI) score (P < 0.001), baseline brachial artery diameter (P = 0.03) but not FMD and aortic root diameter (ARD; P = 0.03). ARD was statistically significantly higher in patients with moderate/severe psoriasis compared with controls (P = 0.017). Stepwise simple linear regression analysis revealed that PASI score was the most important factor affecting CD62 expression (P < 0.001).

CONCLUSIONS

Our study showed increased atherosclerosis risk in patients with psoriasis, particularly those with moderate/severe disease, as evidenced by increased expression of platelet CD62 compared with healthy controls. Moreover, we found a positive correlation between CD62 expression and ARD (another possible marker of atherosclerosis), with positive correlation to the PASI score; the most important factor influencing CD62 expression. However, our data on MPV and FMD do not support the use of either value for diagnosing subclinical atherosclerosis in patients with psoriasis in further studies.

Association of cyclin D1 A870G polymorphism with two malignancies: acute lymphoblastic leukemia and breast cancer

PURPOSE

To study the association between cyclin D1 (CCND1) polymorphic variants and acute lymphoblastic leukemia (ALL) and breast cancer cases and the possibility of having different (CCND1) polymorphic variants in the development of ALL and breast cancer. In addition, to study the association between the different CCND1 polymorphic variants and the response to induction chemotherapy in ALL cases and clinicobiological parameters in breast cancer.

METHODS

We evaluated the association of CCND1 G870A polymorphism with ALL risk in 25 ALL patients and 15 healthy controls and with breast cancer risk in 30 newly diagnosed breast cancer female patients and in 25 healthy controls. Restriction Fragment Length Polymorphism (RFLP) polymerase chain reaction (PCR) was used for analysis of G870A polymorphism of CCND1 on anticoagulated whole blood of both the ALL and breast cancer cases and control groups.

RESULTS

The frequency of the AA genotype was significantly increased in the ALL cases while GG genotype was significantly increased in the control group. Furthermore, there was a highly statistically significant association between the A allele in the homozygous state AA and the ALL cases. Furthermore, there was a positive risk of developing ALL when having the AA genotype and the results were highly significant for AA genotype compared to GG genotype. For breast cancer, the results revealed that there was a positive risk association for those carrying the CCND1 A allele in the development of breast cancer.

CONCLUSION

Homozygosity for CCND1 A allele was associated with ALL patients and was a risk factor for ALL development, while the presence of the A allele, whether in homozygous or heterozygous state was associated with breast cancer cases and was a risk for breast cancer .Homozygosity for CCND1 G allele was associated with the control group.

Assessment of serum leptin, insulin resistance and metabolic syndrome in patients with skin tags

BACKGROUND

Skin tags are common cutaneous lesions with an indefinite aetiology.

OBJECTIVES

To assess serum leptin, insulin resistance and metabolic syndrome in different body mass index (BMI) patients with skin tags.

METHODS

Three equally distributed groups of patients with multiple skin tags: 30 normal BMI, 30 overweight and 30 obese were included. Controls were age-, gender- and BMI-matched healthy subjects. Serum leptin, insulin resistance based on homeostasis model assessment of insulin resistance (HOMA-IR) and metabolic syndrome were assessed in all groups.

RESULTS

Number and extent of skin tags increase with the increase in BMI. Highest leptin levels were found in obese patients, with significant differences when compared to normal BMI and overweight patients. Similar findings existed in controls. Significantly higher leptin levels were found in obese patients compared to obese controls. HOMA-IR was significantly higher in all groups of patients compared to BMI-counterpart controls. Seventy-one per cent of patients fulfilled criteria of metabolic syndrome. Number of skin tags, leptin and HOMA-IR were significantly higher in patients with metabolic syndrome compared to patients without the syndrome. Positive correlations were found between serum leptin and HOMA-IR in obese patients and obese controls. Positive correlations were also found between number of skin tags and waist circumference in all groups of patients.

CONCLUSIONS

Serum leptin displays an association with obesity and insulin resistance. Assessment of HOMA-IR in patients with skin tags may serve as a useful approach for diagnosis of insulin resistance. Waist circumference is the only criteria of metabolic syndrome that correlates with number of skin tags.

Biological activity resulting from exposure to aquatic environmental genotoxic pollutants in northern Egypt

We estimated pollution in Lake Edku and the Mediterranean Sea, El-Maadiya Region, with 3 aromatic amines (1-naphthylamine, 2-naphthylamine and benzidine) in the muscle tissue of fish. There were marked seasonal variations in the aromatic amine levels. We also determined oxidative stress (blood glutathione, and catalase activity) and genotoxic effects (chromosomal aberrations and urinary metabolites) in fishermen from each area. The fishermen suffered from oxidative stress and had high levels of the urinary metabolite sulfanilamide [mean (microg/mg creatinine): Lake Edku 20.7, Mediterranean 14.5, controls 5.3]. Frequencies for total chromosomal aberrations were significantly raised in the peripheral blood lymphocytes of fishermen in both areas [frequency (per 100 metaphases): Mediterranean 67, Lake Edku 45, controls 14].

Oncology: Treatment of Multiple Myeloma in the Targeted Therapy Era

Objective:

To review the clinical trials that have impacted treatment standards of multiple myeloma (MM).

Data Source:

A PubMed search (1980–June 2008) restricted to English-language publications was conducted using the key words multiple myeloma, clinical trials, targeted therapy, thalidomide, lenalidomide, bortezomib, dexamethasone, melphalan, autologous stem-cell transplantation, and tumor biology. Abstracts emanating from the meetings of the American Society of Clinical Oncology and American Society of Hematology from June 2002 to June 2008 were also reviewed.

Data Synthesis:

Although hematopoietic stem-cell transplantation has improved the response rate and duration of overall survival, MM remains an incurable disease. However, focused research aimed at the molecular basis of the disease has led to a number of new treatment strategies. Evidence from clinical trials indicates that each of the 3 novel agents, thalidomide, lenalidomide, and bortezomib, is remarkably effective as first-line therapy. The data also suggest that clinicians may need to reevaluate the role of stem-cell transplantation in the disease.

Conclusions:

Thalidomide, lenalidomide, or bortezomib in combination with dexamethasone have replaced traditional chemotherapy such as melphalan, doxorubicin, and vincristine as initial therapy of patients with MM who are eligible for stem-cell transplantation. Furthermore, these novel drugs can be incorporated into regimens used to treat transplant-ineligible patients or those with relapsing disease.

Glutathione S-transferase M1, T1 and P1 polymorphisms and bladder cancer risk in Egyptians

Previous studies suggest that bladder cancer risk may vary with GST genotype but these results are inconsistent. The aim of this study was to explore whether GSTM1, GSTT1 and GSTP polymorphisms were associated with increased bladder cancer risk in an Egyptian population. GSTM1, GSTT1 and GSTP1 genotype frequencies were determined in bladder cancer cases (n=72) and healthy controls with no history of malignancies (n=82) using PCR-based techniques. The GSTT1*2 genotype was particularly associated with increased risk (OR 2.71, 95%CI 1.27-5.73) and the GSTM1*2 genotype to a lesser extent (OR 1.63, 95%CI 0.85-3.10). 18.1% of cases but only 7.3% of controls were GSTP1*B*B homozygotes (OR 2.38, 95%CI 0.83-6.87). The presence of two or more a priori at-risk genotypes was associated with increased bladder cancer risk (OR 2.42; 95%CI 1.47-3.97). These results suggest that polymorphisms in the GST genes are associated with increased risk of bladder cancer among Egyptians.

Biochemical effects of vinyl chloride monomer on the liver of occupationally exposed workers

We investigated the effects of vinyl chloride monomer exposure on the liver of 86 workers by measuring beta-glucuronidase, arylsulfatase A, adenosine deaminase, 5'-nucleotidase and routine liver function enzymes in the sera of the workers. In 21 of them, three or more of these parameters were raised, with a significant decrease in the level of blood glutathione and a significant increase in the enzyme activity level of glutathione S-transferase. Of these 21 workers, 14 had fatty liver infiltration, 8 of whom were also suffering from liver enlargement. Also, 4 workers had liver enlargement without fatty infiltration and 3 had enlarged spleens. The study highlights the need for vigilance in environmental monitoring and medical surveillance of workers exposed to this chemical.

The effect of dimethylnitrosamine on the activities of renal prenolsulfotransferase and arylsulfatases A and B in Schistosona mansoni infected mice

The activities of renal phenolsulfotransferase and arylsulfatases A and B were estimated in 400 male Swiss albino mice classified into four groups: Normal controls, Schistosoma mansoni infected group, Dimethylnitrosamine (DMN) treated group and infected treated group. The activity levels of the studied enzymes were significantly increased in all groups when compared with the control group, also the statistical analyses showed a high significant increase of the three enzymes levels in the infected treated group; when compared separately with treated or infected groups. It was concluded, therefore, that schistosomal infection is implicated in the development of kidney cancer which may arise from the pattern of hepatic mixed-function oxidase induction characterized for schistosomiasis and its temporal relationship with the procarcinogenic initiating events. Furthermore, the striking significant increase in the enzymatic activity levels of the acid hydrolases arylsulfatases due to the lesion of both cytotoxic effects of dimethylnitrosamine as well as pathological change of schistosomiasis which may play an active role in the initiation of the malignant process by detoxifying endogenous sulfated aromatic metabolites.

Effects of groove placement on retention/resistance of maxillary anterior resin-bonded retainers

Debonding of resin-bonded fixed partial dentures has been partly resolved with modification of tooth preparations. Tooth preparations for resin-bonded retainers were completed on a maxillary central incisor, a lateral incisor, and a canine. Fifteen metal replicas were constructed (five of each tooth morphotype). The three tooth morphotypes were then modified with proximal grooves prepared parallel to the long axes, and another 15 metal replicas were prepared. Cast metal retainers were constructed and cemented to the replicas with a resin cement. Tensile shearing dislodging loads were applied at 20 degrees to the long axes of the teeth with a testing machine. The addition of proximal grooves made statistically significant differences in resistance to debonding forces for all three tooth morphotypes (p < 0.01). An increase of 76.7% was seen in dislodging forces for lateral incisors with proximal grooves compared with incisors without grooves.

Studies on serum beta-glucuronidase activity and urinary tryptophan metabolites in human fascioliasis

In the last few years, human fascioliasis has been reported more frequently from different parts of the world including Egypt. The present work aimed to study the ability of fascioliasis affected patients to metabolize tryptophan and to explore how this disease can affect the activity of the hydrolytic lysosomal enzyme beta-glucuronidase. Liver and kidney functions and complete blood pictures of the studied patients were considered. Eleven tryptophan metabolites together with 4-pyridoxic acid, the major metabolite of vitamin B6, were determined. Fascioliasis showed an abnormal pattern of tryptophan metabolism which resembled that described earlier by Kupke and Knapp and which indicated that those patients were suffering from vitamin B6 deficiency. This conclusion was proved by the decreased levels of 4-pyridoxic acid. Abnormally high levels of beta-glucuronidase were also encountered in the fascioliasis cases which points to the liver damage caused by the fluke.

Malignant childhood neoplasms in the western region of Saudi Arabia

In a sample of 8 cases of solid malignant neoplasms occurring in children resident in the Western Region of Saudi Arabia the most important finding was a remarkable preponderance of lymphomas when compared with Western series. Other notable differences were the prevalence of Hodgkin's disease in the first decade of life, the different proportions of its subtype, and the occurrence of well-differentiated lymphocytic lymphoma. Included is a case of lympho-epithelioid cellular lymphoma (Lennert's lymphoma) which, as far as we can ascertain, is the youngest reported case. There was a relatively large number of embryonal rhabdomyosarcomas and a paucity of neuroblastomas. Our study, which is concerned with proportional rates (population studies are not yet completed), contributes to the interesting ethnic and geographical differences which exist in the prevalence of childhood lymphomas and other solid malignant neoplasms. The biases that affect studies such as ours are stressed.

Malignant neoplasms in Saudi Arabia

In a sample of 1000 consecutive malignant neoplasms in Saudis resident in the Western Region of Saudi Arabia, malignant lymphoma was the commonest of the life-threatening malignancies. The differences between malignant lymphoma in this sample and Western series include the greater frequency of lymphoma; the tendency for reticulum cell and poorly differentiated lymphomas to present as abdominal lesions; the earlier peak of prevalence of Hodgkin's disease, and the dissimilar proportions of its subtypes. The distribution of cancers in the gastrointestinal tract in our sample is almost the reverse of that encountered in the West in that cancer of the mouth and esophagus were more common than cancer of the lower intestinal tract. Lung cancer was relatively uncommon. The smoking habit is not so prevalent in Saudi Arabia as in the West and there is a need to maintain this situation by discouraging smoking. Cancer of the breast was by far the commonest major malignancy in the female, although most Saudi women have their first child early in their reproductive life. Skin cancers proved to be the most prevalent malignancy, and of these squamous cell carcinoma was the most common. The biases that affect studies such as ours in Saudi Arabia are stressed.