AB1265 BIOTECHNOLOGICAL AGENTS IN PEDIATRIC-ONSET SCLERITIS

Background

the term scleritis refers to the inflammation of the sclera, the white outer type I collagen tunic of the eye (1). It may be rarely found in pediatric patients, with the incidence of pediatric scleritis accounting for about 1.2% of all scleritis cases (2). An early diagnosis and an adequate treatment are mandatory to avoid irreversible ocular sequelae (3). In this regard, the experience of biotechnological agents in patients with pediatric scleritis is quite limited at current.

Objectives

To assess the effectiveness of biotechnological agents in terms of scleritis control and glucocorticoid dosage tapering in patients with pediatric-onset scleritis; b) to assess the safety of the biotechnological agents employed and their ability in avoiding new ocular disease complications.

Methods

patients with pediatric-onset scleritis resistant to the conventional therapy and treated with biotechnological agents were retrospectively enrolled and prospectively followed-up. Demographic, clinical, ophthalmologic and therapeutic data were collected. The endpoints of the study consisted in the description of the therapeutic details gathered at the start of the biotechnological agents compared to what was observed at the 6-month, 12-month and last follow-up visits.

Results

5 patients (3 males; 2 females) treated with adalimumab, infliximab, abatacept secukinumab were consecutively enrolled. A remarkable clinical efficacy was observed in 5/5 cases during a 10-to-54 months follow-up period; complete and persistent suppression of ocular inflammation was pointed out in 2/2 patients with active disease at the start of the treatment, while a clinically relevant decrease of scleritis relapses was observed in 5/5 patients after the start of biotechnological treatment, compared to the past years of scleritis activity. In particular, the 5 patients suffered from a total number of 17 scleritis relapses during the 12 months preceding the start of the biologic treatment; the same patients suffered from 2 scleritis relapses within the first 12 months from the start of the treatment and 4 scleritis relapses during the entire follow-up period (median time of 28 months, interquartile range=118 months). These results were obtained despite the progressive and persistent glucocorticoid sparing effect, with a median daily dosage of prednisone or equivalent ranging from 15 (interquartile range =21.75) mg/day at the start of treatment to 2.5 (interquartile range =8.75) mg/day at the 3-month assessment, 2.5 (interquartile range=0) mg/day at 6 month visit, and 0.0 (interquartile range =2.5) mg/day at the last assessment. Regarding the safety profile, one out of five patients experienced an adverse event represented by oral candidiasis, presumably related to the concomitant use of glucocorticoids.

Conclusion

biotechnological agents have shown to be highly effective in controlling pediatric-onset scleritis, allowing a remarkable glucocorticoids sparing effect in patients previously resistant to conventional treatment and recalcitrant to a glucocorticoid-sparing approach. The safety profile was excellent.

References

[1]Yanoff M, Duker JS. Ophthalmology 5th ed. New York: Elsevier; 2019.

[2]Majumder PD, Ali S, George A, et al. Clinical Profile of Scleritis in Children. Ocul Immunol Inflamm 2019;27:535-539. doi: 10.1080/09273948.2017.

[3]Murthy SI, Sabhapandit S, Balamurugan S, et al. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020; 68:1818-1828. doi: 10.4103/ijo.IJO_2032_20.

Disclosure of Interests

None declared

POS1373 THE DIAGNOSTIC ROLE OF PATHERGY TEST IN PATIENTS WITH BEHÇET’S DISEASE FROM WESTERN EUROPE

Background

pathergy is the term used to describe the hyper-reactivity of the skin in response to a minimal trauma, as the consequence of an exacerbated response of the innate immune system [1]. Pathergy test has a central role for the diagnosis of Behçet’s disease (BD), especially in doubtful and atypical cases. However, while its incidence has been decreasing over the past few decades, there are significant variations in the frequency of pathergy among different geographic contexts [2]. These aspects affect the diagnostic role of pathergy test for patients with suspected BD.

Objectives

to evaluate the frequency and features of positive pathergy test (PPT) in Italy, its role in the diagnosis of BD, and any association with other BD-related manifestations.

Methods

29 BD patients, 15 patients with spondyloarthritis (SpA) and 19 healthy controls (HCs) underwent two types of pathergy test, which were performed on the hairless part of the volar forearm ipsilaterally: intradermal injection of 0.5 ml normal saline and intradermally needle soaked with fresh self-saliva. Both pricks were done with a monouse 25 gauge hypodermic needle inserted with a vertical approach at a depth of 5 mm into the skin. The needle was withdrawn with a twisting movement. Skin reactions were observed 48 hours after prick. The results of pathergy tests were statistically analysed in the light of demographic, clinical, and therapeutic features of subjects enrolled. The BD activity at the time of the pathergy test was assessed with the Behçet’s Disease Current Activity Form (BDCAF) [3].

Results

pathergy test performed with saline solution resulted always negative in all groups. Skin prick test using self-saliva resulted in the occurrence of a papule in 2 (6.9%) BD patients and in 1 (6.7%) patient with SpA. A ≥15 mm erythematous area surrounding the needle prick site was observed in 12 (41.4%) BD patients, in 4 (26.7%) patients with SpA (including the patient with the papule), and in 1 (5.6%) HCs (p=0.022). The frequency of skin erythema was significantly higher among BD patients compared to HCs (p=0.015); no statistically significant differences were observed between BD and SpA patients (p=0.53) as well as between SpA patients and HC (p=0.21). The occurrence of skin erythema was not associated with any of the BD-related clinical manifestations. No statistically significant differences were observed between BD patients with positive and negative pathergy test according to sex (p=0.873); HLA-B51 positivity (p-value=0.461); age at the pathergy test (p=0.929); and disease duration at the pathergy test (p=0.487). The mean BDCAF was 1.33±0.65 among patients with PPT and 0.82±0.72 among patients with negative pathergy test (p=0.092). Erythema at self-saliva prick test showed a sensitivity of 41.4% (C.I. 23.52%-61.06%) and a specificity of 85.3% (C.I. 68.94%-95.05%); the positive likelihood ratio was 2.81 (C.I. 1.12-7.05) and the negative likelihood ratio was 0.69 (C.I. 0.49-0.96).

Conclusion

this study confirms the lower frequency of PPT in Western European BD patients if considering the development of a papule or a pustule in the site of pathergy test. Conversely, the onset of a ≥15 mm erythematous area surrounding the prick site could be sufficient to unveil the hyper-reactivity of the innate immune system in BD patients from Western Europe. Pathergy test is not pathognomonic of BD, as its positivity can be also observed in other innate immune system disorders, as observed for SpA patients.

References

[1]Gül A, Esin S, Dilsen N, Koniçe M, Wigzell H, Biberfeld P. Immunohistology of skin pathergy reaction in Behçet’s disease. Br J Dermatol 1995;132:901-7. doi: 10.1111/j.1365-2133.1995.tb16946.x.

[2]Davatchi F, Chams-Davatchi C, Ghodsi Z, Shahram F, Nadji A, Shams H, et al. Diagnostic value of pathergy test in Behcet’s disease according to the change of incidence over the time. Clin Rheumatol. 2011;30:1151–1155. doi: 10.1007/s10067-011-1694-5.

[3]Lawton G, Bhakta BB, Chamberlain MA, Tennant A. The Behcet’s disease activity index. Rheumatology (Oxford) 2004;43:73-8. doi: 10.1093/rheumatology/keg453.

Disclosure of Interests

None declared

Abstract P4-10-09: The impact of Charlson comorbidity index on survival of triple negative breast cancer

Background

Patients with cancer and comorbidities have been found to have poorer survival since they may be unable to receive or complete treatments. It is not clear if comorbid conditions impact survival of patients in all stages of disease and all ER/PR/HER2 subtypes.

Purpose

The purpose of this study was to determine how the Charlson Comorbidity Index (CCI) affected the risk of mortality of triple negative breast cancer (TNBC) within each stage of disease.

Methods

We accessed 22,503 cases of TNBC and documented CCI from the California Cancer Registry 2000-2015. The CCI is a weighted index based on the presence of certain comorbid conditions twelve months prior through six months following the cancer diagnosis and weighted by the severity of those conditions. A score of 0 is interpreted as no significant comorbidity burden and scores of 3 or more are generally interpreted as a high comorbidity burden.

Kaplan-Meier Survival Analysis and the Log Rank test were used to compare differences in breast cancer specific survival between patients with a CCI of 1, 2 or higher (2+) versus a CCI of 0. Cox Regression Analysis was used to estimate risk of mortality of CCI after adjusting for age, race/ethnicity, socioeconomic status, grade, and treatment. Analyses were conducted separately for each stage. Hazard ratios and 95% confidence intervals (CIs) were reported.

Results

There 16,664 (74.1%) cases with a CCI of 0; 3,915 (17.4%) with a CCI of 1; 1,055 (4.7%) had a CCI of 2, and the remaining 869 (3.9%) cases of TNBC had a CCI of 3 or higher.

Unadjusted survival analysis indicated that for stages 2 and 3, there was increased survival with decreasing CCI score. For stages 1 and 4, survival was only better for patients with a CCI of 0 versus a CCI of 2+.

Cox regression analysis indicated that the CCI made no difference in risk of mortality for patients with stage 1 disease. Patients with a CCI of 2+ had an increased risk of mortality when compared with a CCI of 0 for stage 2 (HR = 1.48, CI: 1.25-1.77), stage 3 (HR=1.25, CI: 1.03-1.52) and stage 4 (HR = 1.53; CI: 1.22-1.92).

Conclusion

Comorbidity as measured by the CCI does not increase the risk of mortality for patients with stage 1 TNBC and only increases risk of mortality in higher stages for patients with a CCI score of 2 or higher.

Citation Format: Parise C, Caggiano V. The impact of Charlson comorbidity index on survival of triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-09.

Abstract P4-10-04: Assessment of clinical trial participation on breast cancer survival

Background

Accredited cancer treatment centers offer clinical trials for patients since it is universally accepted that participation in these trials is advantageous.

Purpose

The purpose of this study was to assess whether clinical trial participation was associated with a survival advantage.

Methods

We identified 308,291 cases of first primary female invasive breast cancer from the California Cancer Registry 2000-2015. Participation in a clinical trial was documented. Clinical trials were defined as National Cancer Institute (NCI) sponsored studies such as National Surgical Adjuvant Breast and Bowel Project (NSABP) and Southwest Oncology Group (SWOG); pharmaceutical trials; and local investigator initiated studies.

The distribution of age, race/ethnicity, socioeconomic status (SES), and stage between clinical trial participants and non-participants was compared using contingency tables and the χ2 Test.

Kaplan-Meier Survival Analysis and the Log Rank test were used to compare differences in breast cancer specific survival between participants and non-participants. Cox Regression Analysis was used to estimate the risk of mortality between participants and non-participants after adjusting for age, race/ethnicity, SES, grade, and treatment. Analyses were conducted separately for each stage. Hazard ratios (HR) and 95% confidence intervals (CIs) were reported.

Results

There were 3,517 (1.1%) patients who participated in a clinical trial. Almost 50% of participants were enrolled in an NCI trial, 38% in a local/investigator initiated study, and 13% were in a trial sponsored by a pharmaceutical company. Trial participation was highest for patients less than 45 years of age (21.9%) and lowest in patients 70 years of age and older (12.3%). Most participants were in stage 2 (44.6%). Participation increased with increasing SES. Only 8.5% of participants were in the lowest SES whereas 35.4% were in the highest SES.

Unadjusted survival analysis indicated that there was no survival advantage for stage 1 patients (χ2 = 0.41, p=0.52) whereas study participants in stages 2, 3, and 4 had statistically significantly better survival. Adjusted hazard ratios indicated that stage 2 patients participating in a trial had a 23% reduced risk of mortality (HR=0.77; CI: 0.65 - 0.94). For patients in stage 4, the risk of mortality was reduced by 36% (HR=0.64; CI: 0.47 - 0.87). There was no risk reduction for patients in stages 1 and 3.

Conclusion

Only a small percent of patients enroll in breast cancer clinical trials and participation is correlated with age and SES. There is a survival advantage for participation in a clinical trial for stages 2 and 4 patients.

Citation Format: Parise C, Caggiano V. Assessment of clinical trial participation on breast cancer survival [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-04.

Abstract P5-12-08: Survival differences by stage and race/ethnicity using the Nottingham prognostic index

Background

It is well documented that race/ethic disparities in breast cancer survival exist. The Nottingham Prognostic Index (NPI), based on tumor size, lymph node status, and histologic grade, is a well established method of predicting survival of operable breast cancer. The purpose of this investigation is to determine if race/ethnic disparities also exist among the NPI categories.

Method

We identified 157, 865 cases of stages 1-3 first primary female invasive breast cancer from the California Cancer Registry diagnosed between January 1, 2000 and December 31, 2010. The NPI was computed and cases were stratified as having good (NPI <3.4), moderate (3.4-5.4) and poor (> 5.4) prognosis. Kaplan Meier Survival analysis (95% CIs) was used to compare survival at eight years for patients who were white, black, Hispanic, or Asian/Pacific Islander (API) within each AJCC stage and NPI category.

Results

The distribution of cases by stage, race/ethnicity and good, moderate, and poor NPI categories is seen in the table.

Distribution of cases by stage, race/ethnicity and NPI categories WhiteBlackHispanicAPITotalStage 1     Good15,8287442,4432,16921,184Moderate28,9841,8025,1954,20040,181Poor9,7701,0152,4351,85515,075Stage 2     Good237234842350Moderate4,0872567315155,589Poor37,1094,00710,8937,18659,195Stage 3     Good803112Moderate56216983Poor9,4511,2793,7021,76416,196Total    157,865

Stage 1: There were no significant differences in survival within the good category. In the moderate category, APIs (95.5; 94.5, 96.6) had better survival than whites (93.6; 93.2, 94.0) whereas blacks (90.1; 87.8; 92.3) had worse survival. In the poor NPI category, APIs (92.6; 90.8, 94.4) also had better survival than whites (88.7; 87.8, 89.6).

Stage 2: In the moderate NPI category, blacks (92.8; 89.0, 96.7) had worse survival than whites (94.0; 93.0, 95.1) and in the poor category, blacks (73.8; 71.9, 75.8) and Hispanics (80.7; 79.5, 81.8) both had worse survival than whites (81.8; 81.2, 82.3) while APIs had better survival (84.6; 83.3, 85.8).

Stage 3: There were too few patients in the good and moderate NPI categories. In the poor category, blacks (47.8, 43.4, 52.1) had worse survival than whites (60.1; 58.4, 61.8) while APIs (64.2; 60.2, 68.2) had better survival.

Conclusion

The NPI provides further refinement of the disparities in survival among race/ethnicity. It appears that APIs have better survival than whites in all stages of disease.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-12-08.

Abstract P3-09-01: Odds of the triple negative subtype and survival of stages 1–3 breast cancer: Variation by race/ethnicity

Background: Triple negative (TN) breast cancer is known to be more common in black and Hispanic women and associated with poor survival. This study assesses the differences in the odds and survival of the TN versus the ER+/PR+/HER2− (the most common subtype) by race/ethnicity separately for AJCC stages 1, 2, and 3.

Methods: Using the California Cancer Registry for years 2000–2010, we examined 91,393 cases of stages 1–3 TN and ER+/PR+/HER2− first primary female invasive breast cancer. Race/ethnicity was defined as white, black, Hispanic, and Asian/Pacific Islander (API). Logistic regression was used to assess the association of race with odds of the TN subtype. Kaplan-Meier was used to compute 6-year survival. Cox proportional hazards was used to assess the risk of mortality of the TN subtype by race adjusting for age, grade, year of diagnosis, and socioeconomic status. All analyses were run separately for stages 1, 2, and 3.

Results: The table shows the distribution of the TN and ER+/PR+/HER2-subtypes by stage and race/ethnicity.

Abstract P3-09-02: The HER2 –positive subtypes by stage and race/ethnicity

HER2-positivity is often associated with poor survival. The purpose of this study is to determine if there are differences in mortality among the HER-positive subtypes when stratified by stage and race/ethnicity.

Methods: Using the California Cancer Registry for years 2000–2010, we examined 99,897 cases of stages 1–3 ER+/PR+/HER2− and all HER2-positive first primary female invasive breast cancers. Race/ethnicity was defined as white, black, Hispanic, and Asian/Pacific Islander (API). Kaplan-Meier (KM) and the Log-Rank test were used to compute 6-year survival. Cox proportional hazards was used to assess the risk of mortality of each of the HER2-positive subtypes when compared with the ER+/PR+/HER2− subtype (the most common subtype). All analyses were adjusted for age, grade, year of diagnosis (<2007, 2007+), and socioeconomic status and run separately by race for stages 1, 2, and 3.

Survival variation of the ER/PR/HER2 subtypes by race in a single institution

183

Background: We have investigated breast cancer in California noting variation in survival among race/ethnicity, age, and the ER/PR/HER2 subtypes. The purpose of this study is to determine if similar variation exists in a single institution in California.

Methods: We indentified 994 cases of first primary invasive breast cancer between January 2004 and December 2007. Descriptive statistics were used to assess the distributions of race/ethnicity, ER/PR/HER2 subtype, age, and treatment status. Kaplan-Meier survival estimates were computed and the Log-Rank Test used to compare 5-year survival.

Results: The most common subtype was ER+/PR+/HER2- (49.6%). There were 221 cases of the HER2-positive subtype; 25% of these were the HER2 over-expressed subtype (ER-/PR-/HER2+). There were 113 cases of ER-/PR-/HER2- (14.0%) and only 3 cases of the ER-positive/PR-positive subtype. The distributions of race and subtype were similar to statewide data for this region. Of the 994 cases, 81% were White, 5.9% Black, 6.5% Asian, 6.2% Hispanic, and 0.3% were American-Indian. For all subtypes and stages combined, 5-year survival was worse for African-Americans (70%) when compared with White patients (83%) Χ2 = 15.29, p < 0.001. There were no statistically significant differences in mean age of diagnosis among the eight subtypes. Of the 113 cases of ER-/PR-/HER2-, 80 were White, 15 Black, 8 Asian, and 8 Hispanic. Only one Black patient with ER-/PR-/HER2- was younger than age 45. African-American patients with ER+/PR+/HER2+ and ER+/PR-/HER2- were more often diagnosed in stages 3 and 4. The ER-/PR-/HER2- subtype had worse 5-year survival (64%) than both the ER+/PR+/HER2+ (88%) and the ER+/PR+/HER2- (85%) subtypes (p < 0.001). There was no difference in survival by race for the ER-/PR-/HER2- subtype. For ER-positive patients, African-Americans had worse 5-year survival than whites (66% versus 86%) Χ2 = 16.18, p < 0.001 despite comparable hormonal and chemotherapy regimens.

Conclusions: The ER+/PR+/HER2+ subtype does not always mean poor survival. The triple-negative subtype has the worst survival for both Black and White patients. African-American patients with any ER-positive subtype fare poorly. Referral bias and small sample sizes are study limitations.

Triple-negative receptor status and the 2007 St. Gallen consensus guidelines for early breast cancer

547

Background: The 2007 St Gallen consensus statement describes three risk categories and provides guidelines for treatment. We previously described the distribution of ER/PR/HER2 in breast cancer and analyzed the triple-negative subtype. We now examine the 2007 St Gallen consensus-risk categories with respect to the ER/PR/HER2 subtypes. Methods: Using the population-based California Cancer Registry from 2000 through 2006, we identified 63,925 cases of stages I-III first primary invasive female breast cancer with known status of ER, PR, and HER2. We retrospectively assigned cases to risk categories using pathologic tumor size and grade, age, and status of ER, PR, HER2, and lymph nodes. Extensive peritumoral vascular invasion was not readily available and could not be utilized. We determined the ER/PR/HER2 subtypes for each risk category and performed five-year relative survival. Results: Five year relative survival was 95% or greater for the low risk (LR), node-negative intermediate risk (NNIR), and node positive (1–3) intermediate risk (NPIR) categories. The 5-year relative survival for the node positive (1–3) high-risk (NPHR) category was 85% and 74% for the node positive (> 3) high-risk (NPHR4) category; both had significantly worse survival than the low- and intermediate-risk categories. Classification of the risk categories by ER/PR/HER2 subtype showed no differences between the subtypes in the low risk category and clear differences in all other risk categories. All ER-negative subtypes had the worst survival within the NNIR, NPHR, and NPHR4 categories. The triple negative subtype had the worst survival in all of these risk categories. The greatest differences in 5-year relative survival were noted in the NPHR4 category with survival ranging from 85% in the ER+/PR+/HER2- subtype to 50% in the triple negative subtype. Conclusions: The St Gallen risk model clearly separates early breast cancer into three risk categories and helps with treatment decisions. Use of the ER/PR/HER2 subtypes within these categories clearly illustrates the heterogeneity of the intermediate and high risk categories and may prove to be important in this era of tailored therapy.

No significant financial relationships to disclose.

The impact of age on delivered dose intensity and hospitalizations for febrile neutropenia in patients with intermediate-grade non-Hodgkin's lymphoma receiving initial CHOP chemotherapy: a risk factor analysis

The purpose of this historical case series study was to evaluate the association of age on delivered dose intensity of initial CHOP (cyclophosphamide/doxorubicin/ vincristine/prednisone) chemotherapy and the occurrence of hospitalizations for febrile neutropenia for patients with intermediate-grade non-Hodgkin's lymphoma (NHL). Findings are reported for 12 managed community and academic practices. Medical records of 930 NHL patients not enrolled on clinical trial protocols were reviewed. We reported on 577 of the study patients (62%) who received initial CHOP chemotherapy. Median age of the patients was 65.1 years. Older patients (age > or = 65 years) had more hospitalizations for febrile neutropenia (28% vs. 16%; P < 0.05) than younger patients (age, 18-64 years). In patients with advanced-stage NHL (stage III/IV), older patients received fewer cycles of CHOP (< 6 cycles, 35% vs. 22%; P < 0.05) than younger patients. Older patients were planned for lower average relative dose intensity (ARDI < or = 80%; P < 0.05) and had more heart disease and comorbid conditions (P < 0.05) than younger patients. Multiple logistic regression models showed that older patients were more likely to receive a lower dose intensity (ARDI < or = 80%; odds ratio = 2.46, 95% confidence interval [CI]: 1.62-3.72) during their first 3 cycles of therapy and to experience more hospitalizations for febrile neutropenia (odds ratio = 2.17, 95% CI: 1.43-3.30). We found the dose intensity of delivered CHOP chemotherapy for elderly patients to be less than standard CHOP therapy and the risk of hospitalizations for febrile neutropenia to be greater than in younger patients. Prospective clinical trials examining supportive care measures, such as colony-stimulating factor, for elderly NHL patients are recommended.

Alternative care. Patient choices for adjunct therapies within a cancer center

PURPOSE

Prompted by an increased interest in and awareness of alternative medicine, the Sutter Cancer Center in Sacramento, California, sponsored a telephone survey of its cancer patients. The primary purpose of this 1994 survey was: 1) to determine patient perceptions and attitudes regarding alternative care providers, and 2) to determine whether the Sutter Cancer Center should provide support for these types of therapies to its patients.

DESCRIPTION OF STUDY

The Center conducted a 95-item telephone survey of its patients with cancer, using an independent professional research firm. A random sample of 503 adult patients completed the 15-minute telephone survey between January 27 and March 8, 1994. The sample included more women than men (62%, 38%, respectively), and patients ranged in age from 18 to 88 years. All respondents had been treated for cancer at the Center within the past 2 years. Survey questions included areas such as cancer diagnosis, awareness of alternative therapies, attitude toward alternative therapies, and perception of oncologists' attitude toward alternative therapies. The analysis of the survey results contained two phases: descriptive analysis and comparative analysis. The descriptive aspect is included in this report.

RESULTS

Of the 503 respondents, 82 (16%) had considered utilizing alternative therapy for cancer after a diagnosis was made. Most respondents were moderately familiar with alternative therapy, such as nutrition therapy (59%), herbal therapy (63%), and acupuncture (62%). Only 6% of respondents actually saw a provider of alternative therapies; providers were most frequently nutritionists, counselors, herbalists, and massage therapists. The user patient profile clearly indicates that usage is highest in patients with a diagnosis of at least 1 year. Seventy-five percent reported that they would prefer to receive a referral from their doctors, while 20% would prefer to use a telephone referral line. Two thirds of patients felt that alternative care providers should be encouraged by the medical profession, and 85% indicated that alternative care should be offered at the cancer center as part of oncology treatment.

CLINICAL IMPLICATIONS

The results of this survey clearly reflect the patients' desires to integrate mainstream medicine with some forms of alternative/complementary medicine. Consequently, the Sutter Cancer Center has established a multidisciplinary group of healthcare professionals, including oncologists, nurses, social workers, and alternative practitioners, to evaluate the clinical, psychosocial, and financial impact of integrating wellness/complementary medicine into the existing treatment model at this facility. Providing alternative therapy within a cancer center ensures the availability of both the most advanced conventional treatment and care as well as accurate information and guidance with regard to alternative therapies. This service allows the patient and the cancer care team to focus not only on the patient's physical symptoms, but also on his or her overall quality of life.

Increased intensification and total dose of cyclophosphamide in a doxorubicin-cyclophosphamide regimen for the treatment of primary breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-22

PURPOSE

The National Surgical Adjuvant Breast and Bowel Project (NSABP) initiated a randomized trial (B-22) to determine if intensifying but maintaining the total dose of cyclophosphamide (Cytoxan, Bristol-Myers Squibb Oncology, Princeton, NJ) in a doxorubicin (Adriamycin, Pharmacia, Kalamazoo, MI)-cyclophosphamide combination (AC), or if intensifying and increasing the total dose of cyclophosphamide improves the outcome of women with primary breast cancer and positive axillary nodes.

PATIENTS AND METHODS

Patients (N = 2,305) were randomized to receive either four courses of standard AC therapy (group 1); intensified therapy, in which the same total dose of cyclophosphamide was administered in two courses (group 2); or intensified and increased therapy, in which the total dose of cyclophosphamide was doubled (group 3). The dose and intensity of doxorubicin were similar in all groups. Disease-free survival (DFS) and overall survival were determined using life-table estimates.

RESULTS

There was no significant difference in DFS (P = .30) or overall survival (P = .95) among the groups through 5 years. At 5 years, the DFS of women in group 1 was similar to that of women in group 2 (62% v 60%, respectively; P = .43) and to that of women in group 3 (62% v 64%, respectively; P = .59). The 5-year survival of women in group 1 was similar to that of women in group 2 (78% v 77%, respectively; P = .86) and to that of women in group 3 (78% v 77%, respectively; P = .82). Grade 4 toxicity increased in groups 2 and 3. Failure to note a difference in outcome among the groups was unrelated to either differences in amount and intensity of cyclophosphamide or to dose delays and intervals between courses of therapy.

CONCLUSION

Intensifying or intensifying and increasing the total dose of cyclophosphamide failed to significantly improve either DFS or overall survival in any group. It was concluded that, outside of a clinical trial, dose-intensification of cyclophosphamide in an AC combination represents inappropriate therapy for women with primary breast cancer.

Factors affecting the in vitro evolution of a myeloma cell line

A continuously growing plasma cell line has been established from the bone marrow of a multiple myeloma patient. Initial growth of the cells was dependent on the presence of bone marrow stromal cells. Following initial outgrowth the cells were maintained by transfer onto non-autocthonous bone marrow stromal cultures. Following approximately one year of continuous growth, a subline was derived which could be grown independently of feeder cells. These stromal-cell-independent myeloma cells nevertheless retained dependence for a growth factor present in stromal-cell-conditioned media. The relevant factor in the conditioned media was determined to be interleukin-6 (IL-6). The cells also ultimately became independent of the conditioned media. These latter cells were shown to contain mRNA for IL-6 and eventually began to secrete IL-6. This cell line has thus progressed from complete dependence on stromal cells to IL-6-dependent growth in the absence of stromal cells to complete self sufficient growth. This in vitro progression may reflect an in vivo pattern of myeloma development.

Abnormalities in immune regulation precede the development of multiple myeloma

Immunosuppression of immunoglobulin synthesis seen in patients with multiple myeloma is in part due to immunosuppressive CD5 positive B cells. In a 13 year longitudinal study of an IgA-deficient blood donor who developed multiple myeloma, the presence of immunosuppressive CD5 positive B cells and T cells preceded the diagnosis of overt multiple myeloma and the appearance of immunosuppressive monocytes. These data argue that certain immune defects may be involved in the development of myeloma and are not simply a consequence of overt malignancy.

CD5 positive immunoregulatory B cells in spleen populations from multiple myeloma patients

CD19+CD5+ lymphocytes constitute a minority of peripheral blood B cells. In view of the importance of these cells in the pathogenesis of the immunoregulation of myeloma, their incidence in another lymphoid organ was determined. CD5+ B cells were studied in 9 spleens from patients with multiple myeloma and in 10 spleens from normal individuals removed secondary to trauma. The total number of CD19+ B cells were increased in myeloma spleens (44.4% +/- 12.6%) as compared to normal spleens (20.4% +/- 7.4%). Likewise, the percentage of CD19 cells which co-expressed CD5 were increased in myeloma (25.3% +/- 12.4%) versus normal (4.4% +/- 2.3%) spleen. CD5+ B cells isolated from myeloma spleens, but not normal spleens, inhibit production of immunoglobulin in a pokeweed mitogen driven assay. Thus the spleen appears to be an important source of immunoregulatory B cells in multiple myeloma.

High-dose cisplatin and mitomycin C in advanced non-small cell lung cancer: a phase II study of the Northern California Oncology Group

To investigate chemotherapeutic dose intensity in advanced non-small-cell lung cancer (NSCLC), we evaluated a pharmacokinetically designed schedule of high-dose cisplatin (200 mg/m2 per 28-day cycle) plus mitomycin C. Between March 1987 and March 1989, 62 patients were registered for a phase II study of the Northern California Oncology Group (NCOG). The treatment schedule consisted of cisplatin in hypertonic saline given on a divided days 1 and 8 schedule (100 mg/m2 on each day) plus mitomycin C given at a dose of 8 mg/m2 on day 1 of each cycle. In 61 patients evaluable for response analysis, the overall response rate was 39% (24/61), with a complete response being achieved in 6% (4/61) of cases and a partial response, in 33% (20/61). The response according to reviewed histologic subtype included squamous, 53% of patients (10/19); large cell, 31% (4/13); and adenocarcinoma, 34% (10/29). The median survival for all patients was 29.3 weeks. The mean cisplatin and mitomycin C delivered dose intensities in this study were 45 mg/m2 per week (90% of the projected dose) and 1.5 mg/m2 per week (75%). The toxicity of this combination regimen in the 62 enrolled patients was significant but manageable. Leukopenia (WBC, less than 1,000/mm3) and thrombocytopenia (platelets, less than 25,000/mm3) occurred in 3% and 8% of patients treated, respectively. Dose-limiting renal toxicity and clinically significant ototoxicity developed in 8 patients each (13%), and a peripheral sensory neuropathy was observed in 17 cases (27%). Whether this type of dose-intensive therapy results in an improved therapeutic index in NSCLC is currently being evaluated in a randomized comparative trial versus standard-dose cisplatin therapy.

CD5 positive immunoregulatory B cell subsets

B-chronic lymphocytic leukemia (B-CLL) is a heterogeneous disease often expressed as a clonal expansion of CD5+ B cells. We report the characterization of CD5+ B cells from two unique B-CLL patients. Cells from patient 1 coexpressed CD5 (leu-1), CD19 (Leu-12), CD20 (B1), and HLA-DR; they were CD10 (J5), CD21 (B2), CD22 (Leu-14), CD25 (IL2-R1), PCA-1, surface, and cytoplasmic Ig negative. They suppressed normal peripheral blood lymphocyte (PBL) pokeweed mitogen (PWM) -stimulated immunoglobulin (Ig) synthesis greater than 80%. Cells from patient 2 were CD5 (Leu-1), CD19 (Leu-12), CD20 (B1), CD21 (B2), CD22 (Leu-14), HLA-DR, IgM, and kappa positive. They were negative for CD10 (J5), CD25 (IL2-R1), and PCA-1. These cells did not suppress normal PBL PWM-stimulated Ig synthesis but produced a monoclonal IgM kappa protein with rheumatoid factor-like activity. These observations suggest that there are different CD5+ B cell subsets, one immunosuppressive and the other autoreactive.

Effects of plasmapheresis on peripheral blood mononuclear cell populations from patients with macroglobulinemia

Effects of plasmapheresis on peripheral blood T-cell, B-cell, monocyte, and natural-killer-cell populations were studied in ten macroglobulinemia patients with hyperviscosity syndrome. Following plasmapheresis, there was a transient decrease in the number of T4+ helper cells and a longer-lasting decrease in the number of Leu-7+ natural killer cells and Mo2+ monocytes. In addition, there was a greater than 50% decrease in the in vitro ingestion capacity of monocytes. Although no significant changes in the numbers of IgM+, B1+, B4+, or PCA+ B cells (P greater than .05) were detected, there was a highly significant (P less than .01) increase in I2 antigen density on the surface of IgM+ B cells and in the bromodeoxyuridine uptake by these cells 7-9 days after plasmapheresis. These findings suggest that following plasmapheresis, IgM+ B cells are activated. Using flow cytometry to determine when maximum IgM+ B cell activation occurs by measuring I2 antigen density on the cell surface may be useful in determining the postplasmapheresis timing of chemotherapy in macroglobulinemia patients with hyperviscosity syndrome who require more aggressive treatment.

Peripheral T-cell lymphoma. A clinicopathologic study of a morphologically diverse entity

We analyzed the clinicopathologic features of 13 patients with immunologically confirmed peripheral T-cell lymphoma. The lymphomas were classified into poorly differentiated lymphocytic, mixed cell, and large cell types. Marked morphologic heterogeneity was noted within the mixed cell and large cell categories, and the various subtypes are described. Twelve of the 13 patients received multiagent chemotherapy. Only three of the nine patients with poorly differentiated or mixed cell lymphomas achieved a complete remission, and the median survival for this group was 11 months. In contrast, all three of the treated patients with large cell lymphomas achieved a complete remission, two of whom are alive without disease (14 and 29 months, respectively). Classification of peripheral T-cell lymphomas into lymphocytic, mixed cell, and large cell types, as well as further subclassification within the heterogeneous groups, is suggested so that pathologic features of prognostic significance can be identified.

Thrombotic thrombocytopenic purpura: report of fourteen cases--occurrence during pregnancy and response to plasma exchange

Thrombotic thrombocytopenic purpura (TTP), a syndrome of diverse etiology probably related to factors regulating platelet-vessel wall interaction, is predominantly a disorder of women. We report our experience with 14 patients in an 11-year period. Thirteen were female and aged between 25-69 years. Four were postmenopausal, and of the nine premenopausal women three were pregnant, one was immediately postpartum, and three were taking estrogen-containing oral contraceptives. A review of the literature confirms the two to one female/male preponderance and that TTP is reported in 56 women who are pregnant or recently postpartum. While this association with possible hormonal events has been noted, it has previously received little comment. We stress the similarity between TTP and some occurrences of preeclamptic toxemia, and that this may suggest not only a common etiology but that therapeutic attempts should be similar. While no single therapeutic modality is universally successful, our experience is that plasma exchange is the most effective, with five of seven patients so-treated obtaining prolonged remission; four of five patients responded to splenectomy and corticosteroids, but one died of infection postoperatively. Five patients, including two treated exclusively with antiplatelet aggregating agents, died without achieving remission. The frequency of successful therapy is not changed by the concurrent pregnancy, but the fetal loss is high. There does seem to be an increased risk of recurrence of TTP in a subsequent pregnancy, and this might be considered when counseling premenopausal patients who have achieved remission of TTP.

Immunoglobulin D myeloma: report of a case with unusual neurological complications

Images

Primary hemangiosarcoma of the spleen associated with leukocytosis and abnormal spleen scan

A 60-year-old Filipino man, who presented with left sided abdominal pain and weight loss, was found to have splenomegaly, an abnormal spleen scan and a leukemoid reaction. Primary splenic hemangiosarcoma was found at splenectomy. Metastases first occurred in the cervical lymph nodes two years after diagnosis. Despite treatment with doxorubicin and radiation therapy there was recurrence in lymph nodes and scan evidence of liver and bone metastases. The patient died 38 months after diagnosis. A liver-spleen scan is helpful in establishing an early diagnosis, and splenectomy before rupture occurs is advisable. The role of chemotherapy needs to be defined.

Multiple myeloma: an immunologic profile. II. Bone marrow studies

Bone marrow mononuclear cell populations were studied in 35 patients without myeloma, 39 patients with multiple myeloma, and 15 patients with benign monoclonal gammopathy. Bone marrow mononuclear cell receptors, responses to mitogens or allogeneic stimuli, and suppressive effects on in vitro peripheral blood lymphocyte (PBL) function were studied. In bone marrow cell populations from patients with untreated multiple myeloma, the percent of complement receptor-bearing cells and the pokeweed mitogen- and concanavalin A-stimulated responses were significantly greater than were those in bone marrow cell populations from patients without myeloma. Sheep red blood cell receptor-bearing cells were significantly greater in marrow populations from treated multiple myeloma patients compared to those from untreated multiple myeloma patients. Sheep red blood cell receptor-bearing cells from the bone marrow of multiple myeloma patients suppressed responses of the multiple myeloma patients' PBL's to autologous mitomycin C-treated bone marrow plasma cells and to allogeneic stimuli in one-way mixed leukocyte culture. Complement receptor-bearing cells suppressed the response to pokeweed mitogen. The presence of lymphocytes in the marrow compartment that are capable of suppressing the response of myeloma patients' PBL's to plasma cell antigens may be significant in the pathogenesis of multiple myeloma.

Effects of abnormal cation transport on deformability of desiccytes

We have studied the deformability of subpopulations of red cells from a patient with "desiccytosis," a disorder characterized by increased membrane permeability to potassium and associated with a probable increase in sodium-sodium exchange. Cells become increasingly dehydrated after maturation because of continued potassium loss without compensatory sodium gain, and they exhibit a progressive increase in mean cell hemoglobin concentration (MCHC). This increase in MCHC causes the cells to become underformable at shear stress values which result in extensive deformation of normal cells. Reduction of MCHC to approximately normal levels by suspending the cells in hypotonic medium restores normal deformability to all but 0.1--0.2% of the cells. These results suggest that the major factor leading to premature destruction in this disorder is whole cell rigidity conferred by increased intracellular hemoglobin concentrations, rather than any associated membrane rigidity.

An electromechanical analyzer using histogram techniques

In behavioral studies it is often necessary to classify events and store the number of events occurring in each classification. The classification requirements may be either functions of amplitude (i.e., intensity, force, peaks, etc.) or time (i.e., duration, interval, etc.). The following describes an analyzer capable of classifying events according to their duration, interval, or time of occurrence, and storing and displaying the number of such events in each classification.