Pleural effusions in patients treated with dasatinib: Results from two institutions, risk factors and management

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Background: Dasatinib (SPRYCEL, formerly BMS354825) is a multi-targeted kinase inhibitor that has been shown to be very effective in the therapy of imatinib-resistant and -intolerant Ph-positive CML/ALL patients, frequently resulting in hematologic and cytogenetic remissions. Therapy with kinase inhibitors has been limited to some extent by fluid retention, the type of which is dependent on the individual drug. Pleural effusions have been relatively more common with dasatinib. We report on the experience at two large teaching hospitals - incidence, risk factors and management. Methods: 27 patients were treated on 5 BMS Phase 2 Studies (2CP, 1AP, 1BP-M, 1BP-L, 1ALL) - 17 CP, 5 AP, 3 BP-M, 2 BP-L/ALL. All patients started on a dose of 70mg BID of dasatinib. Results: In all 13 patients developed effusions. All but 1 were Grade 2; grades 2–4 are symptomatic and require intervention. Of the 14 who did not, 9 were either withdrawn from study because of CML progression (3) or dose-reduced because of hematological toxicity (6). The development of effusions was more common in patients with more advanced disease (BC>AP>CP), in those with previous lung problems (smoking, infections), and in those maintained on starting doses of dasatinib. Effusions could develop even 1–2 years (1>100d, 2>200, 2>300d, 1>500d) after starting therapy often triggered by a lung infection. Effective management included ongoing combinations of diuretics, temporary drug discontinuation, dose reduction, and more recently a once daily drug dosing schedule (Hochhaus et al , Blood 2006, 108: 166a). One patient required thoracentesis and chest tube. Conclusions: Dose monitoring and adjustments and management of the effusions have permitted continuation of the therapy in 10 of the 13 patients with good hematological outcomes. A change in dose schedule will be most effective.

No significant financial relationships to disclose.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

The incidental finding of abnormal cervical histology in postmenopausal patients

A report is supplied on 216 samples of cervical tissue incidentally found in 684 endometrial specimens collected during hysteroscopic examination of postmenopausal women with uterine bleeding and a recent negative Pap smear. We found 43 (19.9%) specimens including cervical tissue with some histologic sign of pathology. Twenty-five (11.6%) had histologic features suggestive for human papillomavirus (HPV) infection, while 18 (8.3%) had cervical intraepithelial neoplasia (CIN). Of the 18 CIN cases, 9 were CIN I, 6 CIN II and 3 CIN III. Altogether, the prevalence of dysplasia in postmenopausal women with recently referred normal cervical cytology was impressive. A significant number of dysplastic lesions (14 out of 18, 77.7%) did not present any histologic sign of HPV. Also, none of the histologic diagnoses of sub-clinical HPV infection was confirmed by the in situ hybridization. Considering the significant prevalence of high grade lesions (9 CIN II and III, 4.2% of the analysed samples) found in this randomly selected patient population, our data strongly suggest the need for a regular follow-up of the transformation zone in all postmenopausal women. Although in women of postmenopausal age some low grade lesions seem to have only a reactive-reparative significance, a more accurate screening procedure, taking into account the peculiar modifications of the menopausal uterine cervix, is advisable.