Successful long-term treatment of systemic lupus erythematosus with rituximab maintenance therapy

Systemic lupus erythematosus(SLE) is a chronic, inflammatory autoimmune disease that may involve multiple organ systems. Treatment consists of immunosuppression, cytotoxic treatment, plasmapheresis and immunoglobuline therapy. Treatment of patients refractory to standard treatment approaches is difficult and results are poor. We describe a 39-year old patient with SLE sufferingfrom grand mal epilepsy due to cerebralvasculopathywith positivelupus anticoagulant, who was refractory to standard treatment modalities. The patient was treated with the anti-CD20 monoclonal antibody rituximab (375 mg/m2 ×4, repeated at weekly intervals). Rituximab applications were delivered in October 2000, March 2001 and October 2001. Since March 2002 she has received maintenance therapy with rituximab 375 mg/m2 every three months. A second female with refractory SLE was treated successfully in April 2002 and receives maintenance therapy every three months. Both patients responded well to rituximab therapy. The first patient showed a major improvement of her clinical condition, and 30 months after the beginning of the rituximab therapy she is free of any symptoms. inflammation parameters, ANA and lupus anticoagulantdeclined significantly after the treatment. The clinical conditionof the second patient improved dramatically, all inflammation parameters normalized and her circulating immunocomplexes disappeared. In conclusion, rituximab maintenance treatment may be a new effective therapy in SLE.

Follow-up Reality for Breast Cancer Patients - Standardised Survey of Patients and Physicians and Analysis of Treatment Data

Introduction: Currently, about 360 000 breast cancer patients who could, after completion of their primary therapy, take advantage of follow-up options are living in Germany. Up to now very little is known about the extent to which the available options are used and as to how the follow-up reality is experienced and evaluated. Thus, an explorative examination among the patients and their physicians was undertaken. Patients and Methods: All patients who underwent surgery in a certified breast centre between 2007 and 2013 received a standardised questionnaire; at the same time the physicians responsible for the follow-up were invited to answer a standardised questionnaire. Results: 920 patients (response rate: 61 %) with a median age of 65 years (32-95) could be analysed. 99 % of the participants stated that they regularly attended follow-ups. The personal contact with the physician (mean value: 4.4) and the reassurance that the cancer disease had not recurred (mean value: 4.5) were described on a scale of 0 to 5 to be two of the most important factors of the follow-up. Deficits were expressed with regard to psychosocial care (70 %) and the perception and treatment of physical complaints (55 %). In addition, 105 physicians returned completed questionnaires (response rate: 12 %). For asymptomatic patients the physicians performed the following examinations most frequently: anamnesis (92 %), physical examination (87 %) as well as laboratory tests (63 %) and tumour marker determinations (40 %). Conclusion: On the whole it became clear that the vast majority of the patients took advantage of the follow-up options. From the patient's perspective the importance of the follow-up lies in contact to the physician and the comforting assurance that the breast cancer has not relapsed. Deficits are seen in the psychosocial care and the perception and treatment of physical impairments. Not recommended examinations were employed by a significant proportion of the surveyed physicians.

Abstract P4-10-13: Follow-up care of breast cancer patients who were treated in a German breast cancer centre - Survey of patients and attending physicians and analysis of treatment data

Introduction: Breast cancer treatment leads to long-lasting impairments which, according to international guidelines, have to be identified and treated in follow-up care. It remains unclear how follow-up care is perceived by patients and if all needs are met in routine care.

Methods: All breast cancer patients who underwent surgery in a German breast cancer centre from 2007 to 2013 were asked to fill out a standardized scanner-readable questionnaire. Medical data were retrieved from their charts and statistically analyzed together with the questionnaire responses. Physicians who could possibly care for breast cancer patients after primary therapy were invited to fill out a standardized scanner-readable questionnaire as well.

Results: 920 questionnaires were filled out and returned (response rate: 61%) by patients. Median age at the time of the survey was 65 years (32-95). 58% of patients still received some form of therapy, 94% of them hormonal therapy. 94% were still in follow-up care, 5% stopped and 1% never went. Intervals of follow-up visits suggested by international guidelines were assessed as "quite right" in 93%. The following examinations were conducted throughout the whole follow-up period at least once: physical examination (93%), mammography (90%), sonography of breast (81%) and liver (22%), laboratory (56%), tumor marker (23%), bone scan (21%), MRI (20%) and CT (15%). Different items were rated on a 6-point scale ranging from "0" "not true at all" to "5" "completely true". Follow-up care was regarded as very important for the own health (4.7), reassuring and calming (4.5), well-being to be looked after (4.4) and well cared for (4.4). A continuous contact between patient and doctor was appreciated (4.4). Visits were connected only to a part with distress (2.1), the median score on the NCCN distress thermometer was 4 (0-10).

105 questionnaires were answered by healthcare professionals (response rate 12%), most of them general practitioners (51%) or gynecologists (30%). Doctors carried out or referred asymptomatic patients most often to the following examinations: medical history taking (92%), physical examination (87%), blood chemistry (63%) and tumor markers (40%). Mammography was mentioned in 45%, sonographic examinations of breast, liver and axilla in 49%, 45% and 38%, respectively. 55% were (very) satisfied with international guidelines on follow-up care. Intervals and duration of follow-up visits were assessed as "quite right" in 88% and 60%, respectively. Different items were rated on a 6-point scale ranging from "0" "not important at all" to "5" "very important". Detection of disease recurrence and secondary tumors (4.8), reassurance of patients (4.7) and detection of treatment toxicities (4.5) were assessed as most important aims in follow-up care.

Conclusions: An overwhelming majority of patients makes use of follow-up care. Most important qualities from the patient's perspective are reassurance, a feeling of security, calming and continuous care by their doctor. Examinations which are not recommended in international guidelines are used by a considerable amount of healthcare providers.

Citation Format: Weide R, Feiten S, Friesenhahn V, Heymanns J, Köppler H, Meister R, van Roye C, Thomalla J, Wey D, Dünnebacke J. Follow-up care of breast cancer patients who were treated in a German breast cancer centre - Survey of patients and attending physicians and analysis of treatment data. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-10-13.

[Immunoglobulin substitution in patients with indolent non-Hodgkin's lymphoma]

BACKGROUND

Infections are major complications in chronic lymphoproliferative disorders, among them indolent non-Hodgkin's lymphoma (iNHL) including chronic lymphocytic leukemia, follicular lymphoma and multiple myeloma.We report on a retrospective cohort analysis of outpatients with indolent non-Hodgkin's lymphoma who were treated in an oncology / hematology group practice and received intravenous polyvalent immunoglobulin G (IVIG) as supportive care. The aim was to describe the treated iNHL population, the course of therapy and the effects of IVIG administrations on the levels of immunoglobulin G (IgG), the incidence of infections and the survival time.

PATIENTS AND METHOD

57 patients with secondary iNHL antibody deficiencies (n = 46) or IgG subclass deficiencies (n = 11) who received IVIG substitution were included. Patients received median 11 IVIG doses with a mean dose of 28 g over a period of median 9.5 months.

RESULTS

Mean IgG levels increased with IVIG substitution at about twice and then remained within the normal range. The incidence of infections decreased in 46 % of treated patients. Effects on survival could not be observed. Median overall survival was in the group of substituted patients 124 months (range 7-124), the control group had a median survival time of 96 months (range 3-129) (p = 0.537).

CONCLUSION

IgG levels should be reviewed during IVIG substitution on a regular basis and dosage and intervals should be adjusted individually.

Abstract P6-08-08: Adjuvant breast cancer therapy: Correlation of treatment data with patient reported outcomes in a German breast cancer centre

Objectives: Clinical diagnosis and treatment data lack a subjective perspective of the affected patients. Patient reported outcomes on the other hand often provide only basic information of the medical background. In this analysis we matched treatment data from clinical files and subjective experiences of breast cancer patients.

Methods: Identification of breast cancer patients who had their primary surgery between 2006 and 2010 at a breast cancer centre followed by systemic adjuvant treatment. Relevant medical data were transferred from clinical files into a database and patients were asked to fill in a standardized paper pencil interview. Statistical analyses were conducted using SPSS 19.

Results: 1044 unselected female patients who suffered from invasive breast cancer were contacted, 740 responded (return rate 70.9%) and 734 questionnaires could be analyzed. Non-responders showed no systematic differences in diagnosis or treatment. Median age at the time of the interview was 65 (30-91) for responders and 66 (33-96) for non-responders respectively (p = .412). Further analyses were conducted for the 734 responders only. Distribution according to UICC criteria at initial diagnosis was as follows: stage I 46%, stage II 42%, stage III 12%. 78% received breast-preserving surgery, 22% mastectomy. 3% received neo-adjuvant chemotherapy, 85% radiotherapy and 85% anti-hormonal therapy. 49% received adjuvant chemotherapy with taxane containing regimens in 60%. 91% were “satisfied” or “very satisfied” with the surgical result, in which patients with breast-preserving surgery were more satisfied than patients after mastectomy. 66% indicated a complete freedom of pain, 65% reported no limitations of arm or shoulder function. In both cases the results improved with increasing age. In frequency of antihormonal therapy a correspondence of 91% between data from medical records and subjectively reported treatment could be observed. Psychological distress, cognitive limitations and physical consequences were rated on a scale from 1 - “not at all” to 4 - “very much”. The highest average values were found for the items sleep disturbances (2.3) and exhaustion (2.3), the lowest for depression (1.7). Patients up to 60 years suffered more from the psychological consequences than older patients. 44% were in employment before the disease, 66% of them could return to their workplace. The return to work was as easier the younger the patients were. For 75% their partnership did not change, 12% experienced deterioration, 12% improvement. No effect of surgery or systemic treatment could be found here. Before the illness 9% consulted a psychiatrist / psychotherapist, after the illness 19%. Before the diagnosis of breast cancer 14% received antipsychotic drugs, after the disease 26%. In both cases is the increase in frequency stronger for younger patients and for patients who had received chemotherapy. Multivariate analyses will be presented.

Conclusions: Adjuvant breast cancer therapy leads to long lasting impairment of physical, psychological, social and job-related functioning in a significant number of patients. Depending on age, surgery and systemic treatment patients are affected differently.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-08.

Abstract P2-11-11: Patient Reported Outcomes after Breast Cancer Surgery and Adjuvant Therapy from a German Breast Cancer Centre

Objectives: Evaluation of the subjectively experienced physical, psychological, social and job-related consequences of breast cancer.

Methods: Standardized paper pencil interview of patients with the initial diagnosis of breast cancer who had their primary surgery between 01/2006 and 12/2010 at an accredited breast cancer centre followed by systemic adjuvant treatment. The data collection was conducted with the help of a self-developed scanner-readable questionnaire which had been evaluated in a pretest.

Results: 1260 patients were contacted, 871 completed questionnaires (return rate 72%) were analyzed. Median age of the patients (99.5% women) at the time of the interview was 65 years (30–91). 6% relapsed during the observation period. 91% were “satisfied” or “very satisfied” with the surgical result. 67% indicated a complete freedom of pain. 23% received lymphatic drainage at the time of the questioning (11/2011), 33% complained about limitations of arm and/or shoulder function. 76% received anti-hormonal therapy, 13% stopped the anti-hormonal medication prematurely. Patients received a mean of 1.3 different anti-hormonal therapies, 54% took Tamoxifen. Psychological distress, cognitive limitations and physical consequences were rated on a scale from 1 – “not at all” to 4 – “very much”. The highest average values were found for the items sleep disturbances (2.3) and exhaustion (2.3), the lowest for depression (1.7) and word-finding difficulties (1.8). After therapy only 39% described a complete recovery of their physical capacity, 62% regained their previous mental capacity. 44% were in employment before their disease. 67% returned to their workplace but only 65% of them with their previous number of hours. 15% indicated disadvantages in their workplace due to the breast cancer disease. For 75% their partnership did not change, 12% experienced a deterioration, 13% an improvement. Before the illness 9% consulted a psychiatrist/psychotherapist, after the illness 18%. Before the diagnosis of breast cancer 13% received antipsychotic drugs, after the disease 25%.

Conclusions: Breast cancer diagnosis and therapy leads to long lasting impairment of physical, psychological, social and job-related functioning in a significant number of patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-11.

Evaluation of psychosocial distress in patients treated in a community-based oncology group practice in Germany

Background: Systematic evaluation of psychosocial distress in oncology outpatients is an important issue. We assessed feasibility and benefit of standardized routine screening using the Distress Thermometer (DT) and Problem List (PL) in all patients of our community-based hematooncology group practice.

Patients and methods: One thousand four hundred forty-six patients were screened between July 2008 and September 2008. Five hundred randomly selected patients were sent a feedback form.

Results: The average distress level was 4.7, with 37% indicating a distress level >5. Patients with nonmalignant diseases (81% autoimmune diseases or hereditary hemochromatosis) showed the highest distress level of 5.2. Most distressed were patients who just learned about relapse or metastases (6.4), patients receiving best supportive care (5.4) and patients receiving adjuvant antihormonal therapy (5.4). Ninety-seven percent of patients appreciated to speak to their doctor about their distress. Fifty-six percent felt better than usual after this consultation.

Conclusion: DT and PL are feasible instruments to measure distress in hematooncology outpatients receiving routine care. DT and PL are able to improve doctor–patient communication and thus should be implemented in routine patient care. The study shows that distress is distributed differently between individuals, disease groups and treatment phases.

Evaluation of Important Contact Persons and Their Helpfulness in Coping with Metastatic Breast Cancer Induced Psycho-Social Distress. A Prospective Study at a Community-Based Oncology Group Practice in Germany

Introduction: Since psycho-social distress is a prevalent condition in metastatic breast cancer patients, it is important to find out which contact persons are called on most frequently to find help in dealing with this situation. In addition to the significance of these contact persons we wanted to find out to what extend they were actually helpful for the patients when contacted.Methods: 57 patients with metastatic breast cancer visiting the practice in April and May 2009 were administered the Distress Thermometer (DT) and Problem List (PL). Thereafter a standardized personal interview was held concerning their important contact persons where patients were asked to name their important contact persons freely. After this additionally a list of possible contact persons was read to the patients to complete the set of persons the patient has contacted. For each contact person the patient was asked to indicate if this contact was helpful or not.Results: The mean distress level observed in this population of 57 metastatic breast cancer patients was 4.9. 36% showed a distress level > 5. Physical problems as a source of distress were stated by 93%, emotional, familial, practical or spiritual problems were causing distress in 72%, 26%, 21% and 4% respectively. 88% of patients named their oncologist as an important person to help them with their distress. Children, partner, friends and general practitioner were important persons for 70%, 65%, 60% and 54% respectively. Regarding only the free answers the order of the most important persons was partner (60%), children (54%), friends (42%), other family members (35%), oncologist (28%), general practitioner (14%). All patients (100%) who sought help from their oncologist described this as helpful. Children, partner, friends and general practitioner were helpful in 90%, 86%, 94% and 94% of cases. 10 patients (18%) had contacted a psychiatrist. This was helpful for 8 (80%) of these patients.There is a positive and statistically significant correlation between distress level and number of persons contacted. (r=.283; p=0.033).Conclusions: Psycho-social distress in patients with metastatic breast cancer is mostly caused by physical and emotional problems. Patients treated in an oncology practice reported a network of care-giving persons as helpful in the coping process. Persons described as being most helpful were oncologists, partner, children, friends an general practitioner. Patients with higher distress levels tend to contact more different persons in trying to find help.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1072.

Evaluation of psycho-social distress in patients treated in a community-based oncology group practice in Germany

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Background: Systematic evaluation of psycho-social distress in oncology outpatients is an important issue. Therefore we assessed feasibility and benefit of standardized routine screening using the Distress Thermometer (DT) and the Problem List (PL) in daily practice. Methods: All patients attending the practice between July and September 2008 were administered the DT and the PL. Patients were classified into the disease groups solid tumors, hematological neoplasms, benign hematological diseases and other non-malignant diseases. The individual treatment phase was evaluated additionally. Participants in a mammography screening programme were assessed as a control group. 500 randomly selected patients were sent a feedback-form to describe how they experienced the DT's influence on the doctor-patient-communication. Results: The 1,446 patients reported an average distress level of 4.7 with 37% indicating a distress level > 5. Patients with other non-malignant diseases (81% autoimmune diseases or hereditary hemochromatosis) showed the highest average distress level of 5.2. Regarding the treatment phases, the most distressed patients were patients who just learned about their diagnosis of relapsed or metastatic disease (6.4), patients receiving Best Supportive Care (5.4) and patients receiving adjuvant anti-hormonal therapy (5.4). The most frequently indicated problems causing distress were exhaustion/fatigue (49%), pain (44%), impaired mobility (41%) and sleep disorders (39%) respectively. Breast cancer patients stated a distress level of 5.2. The average distress level in 474 mammography screening participants was 3.3. 37% of 190 patients who returned the feedback-form indicated that the DT and PL were useful tools to speak to their doctor about their distress more precisely. 38% felt better than usual after this conversation. Conclusions: The study shows that cancer patients do not necessarily show higher distress than patients with severe non-malignant diseases. The problems patients most frequently indicate as distressing are somatic disorders. DT and PL are applicable for routine screening in an outpatient setting. Physicians as well as patients stated that the use of the DT improved the quality of their communication.

No significant financial relationships to disclose.

[Lymphomas: new therapeutic options]

Malignant lymphomas are differentiated clinically, morphologically and molecular-biologically, into aggressive (formerly high-grade malignant) and indolent (formerly low-grade malignant) lymphomas. In the meantime, virtually all patients can be diagnosed and treated on an ambulatory basis. The introduction of the monoclonal antibody rituximab (R) in combination with chemotherapeutic agents, has led to the development of highly potent forms of chemoimmunotherapy. In the case of aggressive lymphomas, R-CHOP has been shown to be significantly superior to CHOP alone, both in elderly and younger patients. In stage III and IV indolent (follicular) lymphomas, rituximab/chemotherapy combinations achieve response rates in excess of 90%, and prolonged progression-free survival rates which, for the first time hold out hope of a cure. Monoclonal antibodies that can be coupled to radioisotopes open up new possibilities for potent radioimmunotherapy which look promising for effecting a cure or long-lasting palliation in additional proportion of the patients.

Outpatient therapy in metastatic breast cancer. A retrospective study of 90 patients treated in an oncology group practice

BACKGROUND

Whenever possible, treatment of breast cancer should be performed in an outpatient setting, but only few data about patients being treated exclusively on an outpatient basis are available.

PATIENTS AND METHODS

A retrospective analysis was performed in 90 unselected patients who were treated consecutively in our oncology group practice between 6/95 and 8/99.

RESULTS

Median age at detection of metastases was 55 years (30-90) and performance status ranged from 0 to 2. 83 patients (92.2%) received chemotherapy, 7 (7.8%) received endocrine therapy only. CMF was used in 27.7%, anthracyclines in 71.1% and taxanes in 43.3%. 855 chemotherapy cycles were performed and the observed toxicity was mild. Reversible grade 3 and 4 hematotoxicity was seen after 27 cycles (3.2%). Neurotoxicity or mucositis grade 3 and 4 were seen in 6 patients (6.6%). Therapy-associated hospitalization occurred in 1 patient thrice due to febrile neutropenia. Complete remissions were seen in 5 patients (5.6%) during first-line therapy. Median survival of the whole cohort until the end of the follow-up period (2/03) was 28 months (2-259). Overall survival after 1, 2, 3 and 5 years was 83, 56, 33 and 18% respectively. 50% could die at home.

CONCLUSIONS

Treatment of metastatic breast cancer can be performed with minimal toxicity and a high patient acceptance in the outpatient setting. Overall survival and median survival are comparable to historical results achieved in specialized academic hospitals. Hospitalization could be avoided in the majority of patients and half of them could die at home.

Palliative treatment of advanced pancreatic carcinoma in community-based oncology group practices

This study was aimed at evaluating the feasibility, effectiveness, and toxicity of palliative chemotherapy/supportive care in patients with advanced pancreatic cancer being treated on an outpatient basis. A retrospective analysis was performed on 127 consecutive, unselected patients with advanced pancreatic cancer in four community-based oncology group practices. Median age was 63 years and WHO performance status ranged from 0 to 3. Forty-three patients (34%) had locally advanced disease, and 84 patients (66%) had distant metastases; 94 patients (74%) received cytotoxic treatment during the course of their disease, and 33 (26%) received best supportive care only. First-line treatment consisted of gemcitabine (1,000 mg/m2 on days 1, 8, and 15 of a 28-day cycle) in 81 patients (86%), 5-fluorouracil (5-FU) in 8 patients (9%), radiochemotherapy in 4 patients (4%), and radiation therapy only in 1 patient (1%). A total of 1,501 gemcitabine treatments were given during the study period. Toxicity was moderate. Four patients (3%) required hospitalization for treatment-related side effects, and 111 patients (88%) died during the observation period. Symptom control, as measured by reduction of pain medication, was seen in 25% of patients receiving gemcitabine, whereas no reduction in pain medication was seen in the best supportive care group. The median survival of patients receiving cytotoxic treatment (mainly gemcitabine) was 42 weeks, and the median survival of patients receiving best supportive care was 21 weeks. The overall survival rate at 6, 12, 24, and 36 months was 65%, 32%, 14%, and 7%, respectively. Based on these outcomes, it appears that patients with locally advanced and metastatic pancreatic cancer benefit from adequate palliative treatment, including cytotoxic chemotherapy with gemcitabine, and this can be accomplished on an outpatient basis.

[Severe lead poisoning due to Ayurvedic indian plant medicine]

HISTORY AND CLINICAL FINDINGS

A 39-year-old woman with a history of slowly progressive muscular dystrophia was transferred to us for further evaluations of a hypochromic, microcytic anaemia. The patient complained about progressive muscle weakness, loss of appetite and constipation, sleep disorders as well as muscle and back pain. Clinical examination revealed a tetraparesis without any detectable muscle reflexes and atrophic muscles of the extremities. A bilateral radial paresis was found with a loss of power.

INVESTIGATIONS

She presented with a hypochromic, microcytic anaemia with a haemoglobin of 7.9 g/dl. Re-evaluation of her peripheral blood smear showed basophilic stippling of the erythrocytes. Bone marrow biopsy revealed a marked dyserythropoiesis with 50% ring sideroblasts. After the examination of the bone marrow, the blood lead level was found to be grossly elevated up to 880 microg/l.

DIAGNOSIS

Re-evaluation of the patient's history revealed that she had been to India for an Ayurvedic treatment approach to improve her muscle dystrophia. She had taken regularly 4 different natural plant pills which she had bought in an Ayurvedic health centre. Toxicologic analysis of these pills revealed one to have a lead concentration of 50.4 mg/g.

TREATMENT AND COURSE

The patient was treated with 16 infusions of sodium-EDTA followed by a 4-week treatment with dimercaptopropionic acid orally. Her neurological condition improved and the radial paresis resolved gradually so that she could return to work. Her haematological parameters normalized.

CONCLUSION

This case report underscores the importance, while asking patients for their drug history, to ask additionally if natural plant medicine is taken or applied regularly. The report reveals that Ayurvedic pills from India may have a high concentration of lead and may cause severe poisoning.

Dose reduction of steroid premedication for paclitaxel: no increase of hypersensitivity reactions

BACKGROUND

Premedication with dexamethasone, ranitidine and clemastine is mandatory for patients receiving paclitaxel to avoid hypersensitivity reactions. The proposed dexamethasone dose is 20 mg orally 12 and 6 h prior to paclitaxel infusion. With this premedication severe hypersensitivity reactions are reduced to 1-2% of the treated patients. Besides this oral schedule a single dose of dexamethasone, 40 mg given i.v., just prior to paclitaxel has been shown to be equally effective. In an attempt to reduce steroid-induced side effects, especially for patients receiving weekly paclitaxel protocols, we reduced the dexamethasone dose.

PATIENTS AND METHODS

A total of 132 patients were treated on an outpatient basis with paclitaxel-containing protocols. Paclitaxel was given in doses of 135-175 mg/m(2) once every 3 weeks in 76 patients and/or with 100 mg/m(2) weekly in 70 patients. Dexamethasone premedication was given in a single dose (40, 20, 10 mg) as an infusion directly before paclitaxel.

RESULTS

0/46 patients receiving 40 mg dexamethasone premedication in 235 cycles and 0/48 patients receiving 20 mg dexamethasone premedication in 186 cycles experienced a severe hypersensitivity reaction. 1/52 patients receiving 10 mg dexamethasone in 480 applications developed a severe hypersensitivity reaction with bronchospasm, hypotension and supraventricular tachycardia shortly after her first paclitaxel infusion started.

CONCLUSION

No increase of severe hypersensitivity reactions is seen when dexamethasone premedication is reduced to doses of 20 or even 10 mg prior to paclitaxel infusion.

The polyneuropathy associated with Waldenström's macroglobulinaemia can be treated effectively with chemotherapy and the anti-CD20 monoclonal antibody rituximab

A 50-year-old male developed headache, impaired balance, visual defects and severe deafness. Ten months later he presented with markedly reduced power and tremor of his right arm. Waldenström's macroglobulinaemia (WM) with accompanying polyneuropathy was diagnosed. The patient received chemotherapy, which resulted in a partial improvement of the arm tremor. Subsequently, he was treated with rituximab (4 x 375 mg/m2), leading to complete resolution of the tremor and the paresis of his arm. Additionally, his headache and imbalance disappeared. Fifteen months after rituximab therapy he remained free of any neurological symptoms. This is the first report showing that WM-associated polyneuropathy can be treated effectively with a combination of chemotherapy and the anti-CD20 monoclonal antibody rituximab.

Induction of complete haematological remission after monotherapy with anti-CD20 monoclonal antibody (RITUXIMAB) in a patient with alkylating agent resistant Waldenström's macroglobulinaemia

Response of Waldenström's macroglobulinaemia to chemotherapy with alkylating agents is usually only transient. We report a case with marked bone marrow involvement and resistance to chemotherapy with alkylating agents. The patient was red cell and platelet transfusion dependent. Three weeks after rituximab-monotherapy, he achieved a complete haematological remission which is continuing 6 months after the end of therapy. Our case demonstrates that treatment with the unconjugated anti-CD20-monoclonal antibody (rituximab) may be a new powerful tool for a better treatment of Waldenström's macroglobulinaemia.

Immediate and long-term results of ATG induction therapy for delayed graft function compared to conventional therapy for immediate graft function

The use of polyclonal antibodies for delayed graft function (DGF) was tested in 83 renal allograft recipients. Conventional immunosuppression (CI) was given to 52 patients with immediate graft function (IGF) while 31 patients with DGF received the polyclonal antibody ATG. Administration of OKT3 was restricted to steroid-resistant acute rejections in both groups. The incidence and severity of acute rejections, graft survival rate, CMV infections, and lymphocyte subsets were examined. ATG patients experienced a total of 0.6 acute rejections per patient, whereas CI patients had 0.9 on the average (P < 0.05). Second and third acute rejections occurred less frequently and later in the ATG group than in the CI group (P < 0.01). Steroid-resistant acute rejections occurred in 20 of the CI patients (38 %) but in only 7 of ATG patients (23 %). One-year graft survival in the CI and ATG groups was 98.1% and 93.2%, respectively. A decreased CD4 + to CD8 + T-lymphocyte ratio of about 0.5 was still detectable 5 years after the initial ATG administration. Hence, patients with DGF appear to benefit from induction therapy with ATG.

Soluble intercellular adhesion molecule-1 in patients with lung cancer and benign lung diseases

Intercellular adhesion molecule-1 (ICAM-1) expression correlates with tumour progression in patients with malignant melanoma or renal cell carcinoma. To assess the value of soluble ICAM-1 (sICAM-1) for lung cancer patients, sICAM-1 was determined by means of an enzyme-linked immunosorbent assay. Sera from 147 patients with lung cancer, from 75 patients with benign lung diseases and from 108 healthy adults were investigated for sICAM-1 expression. Significant differences in sICAM-1 levels were detected in lung cancer patients (387 +/- 176 ng/ml) and patients with benign lung diseases (365 +/- 110 ng/ml) compared to the group of healthy adults (310 +/- 90 ng/ml). There was no difference in sICAM-1 level among the subtypes of lung cancer. Advanced tumour stages and patients with progressive disease tended to be associated with higher sICAM-1 levels, the site of metastasis being relevant for the level attained. Patients with liver metastasis had the highest sICAM-1 levels (547 +/- 295 ng/ml) compared to patients with cerebral metastasis (317.8 +/- 92.2 ng/ml). An increase of sICAM-1 expression during the progression of the disease coincided with a poorer survival prognosis for the patients compared to patients with stable or falling sICAM-1 levels.

Persistent long-term changes in lymphocyte subsets induced by polyclonal antibodies

BACKGROUND

Clinicians are well aware of the short-term effects of immunosuppression by mono- or polyclonal antibodies. Little is known about long-term changes induced by these therapies.

METHODS

Forty-three renal allograft recipients were selected according to their initial postoperative immunosuppression: (1) BI group=basic immunosuppression with steroids and cyclosporine, n=16; (2) ATG group=basic immunosuppression plus polyclonal antibody antithymocyte globulin (ATG), n=11; and (3) OKT3 group=basic immunosuppression plus monoclonal antibody OKT3, n=16 patients. At intervals of 6 months, the following parameters were measured prospectively: lymphocyte surface antigens (HLA-DR, CD3, CD4, CD8, CD16, CD19, CD56, and CD57); serum and urine neopterin; serum amyloid A; and indirect and direct tests for herpes viruses.

RESULTS

The mean period of observation was 58.4 months. The most significant differences between the groups occurred for CD4+ and CD8+ T cells. The ratios of CD4+ to CD8+ cells (n=278 measurements) were significantly and persistently lower in the ATG group (P<0.001, Brown-Mood test). Five years after transplantation, the ATG group had a CD4+ to CD8+ cell ratio of x=0.6 versus x=1.7 in the OKT3 group and x=2.0 in the BI group. This inversion was due to a persistent depletion of the CD4+ cells and an increased regeneration of the CD8+ cells, in particular of the CD8+brightCD57+ subpopulation. Extent and duration of CD4+ depletion correlated with the cumulative ATG dose (r=0.7, P<0.05, Spearman rank correlation test).

CONCLUSION

Therapy with polyclonal antibody ATG induces dose-dependent long-term changes in T-cell lymphocyte subsets, which persist over a period of years.

Storage of noncryopreserved periphered blood stem cells for transplantation

Mobilized peripheral blood stem cells (PBSC) were collected in autologous plasma and acid-citrate-dextrose formula A (ACD-A) by leukaphereses using the CS3000 cell separator (Baxter) and stored at 4 degrees C in a refrigerator for 8 days. We have looked at the viability of the nucleated cells with the trypan blue test and the proliferation and differentiation capacity using a standardized progenitor cell cloning assay. The changes in viability, granulocyte-macrophage colony-forming units (CFU-GM), erythroid burst-forming units (BFU-E), and mixed-lineage colony-forming units (CFU-GEMM) were determined daily during the storage period. Viability was 90.8% (SD 8%) at day 0 and declined to a mean of 69.5% (SD 15.5%) at day 8. CFU-GM decreased to 47% (SD 28.7%), CFU-GEMM to 48% (SD 42.2%), and BFU-E to 40.1% (SD 18.4%) after 6 days. After 5 days of storage the mean viability was 79.7% (SD 17.8%), whereas the mean CFU-GM were 65.3% (SD 28.4%) the mean CFU-GEMM were 61.8% (SD 30.4%) and the mean BFU-E were 55.1% (SD 18.2%). At day 4 viability was still 82.5% (SD 17.0%), recovery of CFU-GM was 78.5% (SD 28.8%), recovery of CFU-GEMM was 70.7% (SD 40.4%) and recovery of BFU-E was 65.0% (SD 17.5%). These data show, that PBSC can be stored safely over at least 5 days at 4 degrees C while the patient receives high-dose chemotherapy.

Successful treatment of neutropenia in T-LGL leukemia (T gamma-lymphocytosis) with granulocyte colony-stimulating factor

Severe neutropenia is a common feature in patients with T-large granular lymphocytic (LGL) leukemia. Neutropenia often causes severe infections and septicemia, thus representing a major cause of morbidity and mortality in this disease. We have treated two outpatients with T-LGL leukemia who had severe neutropenia (neutrophils < 0.2 x 10(9)/l) successfully with G-CSF (5 micrograms/kg daily, s.c.). After 10 days of treatment the neutrophil count was within the normal range and a severe oral infection healed rapidly. We conclude that G-CSF therapy is able to normalize the neutrophil count in T-LGL leukemia within a few days and that it can be used to treat severe infections in these patients even on an outpatient basis.

Peri-operative changes of cellular and humoral components of immunity with brain tumour surgery

Nosocomial infections, which are not uncommon in neurosurgical intensive care medicine, may possibly be favoured by an impairment of immunological competence of the patient. In a prospective observational trial, we investigated several parameters of cellular and humoral immunity in 32 patients before and after resection of an intracranial tumour. We quantified the effects of operative procedure, dexamethasone pretreatment, and tumour type. Dexamethasone alone causes an increase of neutrophilic granulocyte count and monocytes, whereas IgG and eosinophilic granulocytes decrease as well as lymphocytes. CD4+ T lymphocytes (T helper cells) and CD8+ T lymphocytes (T cytotoxic/suppressor cells) were more severely affected than B lymphocytes. Dexamethasone and operation in combination act synergistically on T lymphocytes and IgG, while no synergism is obvious in other clinical test parameters. The skin sensitivity reaction was depressed accordingly. With intracerebral tumours (gliomas WHO grades II to IV), levels of T helper cells and eosinophilic granulocytes were lower, and levels of IgM and neutrophilic granulocytes were higher than with benign extracerebral neoplasms. Postoperative nosocomial infections of the lower respiratory tract occurred almost exclusively in patients subject to severe depression of T helper cells.

Anemia with LDH-elevation in a patient with aortic valve replacement

In a 63-year old patient with a history of aortic valve replacement in 1986, a reduced hemoglobin of 91 g/l was found by a family physician. Since serum LDH was also increased, the patient was diagnosed to suffer from mechanically induced, hemolytic anemia and presented at our hospital for further diagnosis and evaluation of the aortic valve prosthesis.

Differential expression of the intercellular adhesion molecule-1 (ICAM-1) in lung cancer cell lines of various histological types

Ten small cell lung carcinoma and 12 non-small cell lung carcinoma cell lines of various histological types were studied for constitutive expression of the intercellular adhesion molecule-1 (ICAM-1). ICAM-1 was present in all squamous and large cell carcinoma cell lines whereas two out of five adenocarcinoma and all small cell lung cancer (SCLC) cell lines showed no basal ICAM-1 expression. ICAM-1 expression was upregulated by tumour necrosis factor-alpha (TNF-alpha) in a time- and dose-dependent manner in cell lines with basal ICAM-1 expression. Western blot analysis revealed a molecular size of 85 kDa for ICAM-1 in all but one cell line. The TNF-alpha-induced upregulation of ICAM-1 occurs on the transcriptional level. Adhesion of peripheral blood mononuclear cells to lung tumour cell lines could be inhibited by monoclonal antibodies (MAb) (CD11a;CD18) against the receptor of ICAM-1, the leukocyte function-associated antigen-1 (LFA-1), but not by a MAb (CD54) against ICAM-1 itself.

Immobilization and light-dark cycle-induced modulation of serotonin metabolism in rat brain and of lymphocyte subpopulations: in vivo voltammetric and FACS analyses

The effect of immobilization and light-dark cycle on the serotoninergic system of the n. raphe dorsalis and on the distribution of blood lymphocyte subpopulations was studied in the rat. As was shown by in vivo voltammetry, 10 min immobilization enhanced serotonin metabolism with a maximum 15 min after immobilization. The distribution of the blood lymphocytes into subpopulations was also affected: pan-T and T helper lymphocytes were reduced during immobilization and reached minimum values after 20 min recovery. The circadian rhythms of serotonin metabolism and the distribution of pan-T and T helper cells exhibited a slight phase shift if compared with each other.

T cell receptor gamma delta bearing cells are decreased in the peripheral blood of patients with atopic diseases

The biological role of T cell receptor (TCR) gamma delta bearing cells is currently not fully understood. Recently, a monoclonal antibody (TCR delta 1) reacting against the whole molecule became available which facilitates the direct analysis of TCR-gamma delta+ cells. We studied 11 children with atopic dermatitis, 20 children with atopic asthma, 18 adults with atopic dermatitis and 38 healthy age matched controls aged 4-51 years. Lymphocytes were isolated from heparinized peripheral blood and the proportion of TCR-gamma delta+ lymphocytes was determined by FACS analysis. Patients with atopic diseases yielded a significantly (P less than 0.01) lower proportion of TCR-gamma delta+ cells compared with normal controls (median 4.8% versus 7.1%). The percentage of TCR-gamma delta+ cells showed an age-dependent decline in both the patient group (r = -0.49, P less than 0.01) and the control group (r = -0.40, P less than 0.01). In addition, the proportion of cells which expressed CD8, TCR-gamma delta or CD4, TCR-gamma delta simultaneously was determined by double labelling immunofluorescence. Whereas CD4+, TCR-gamma delta+ cells could be identified in only a few individuals, CD8+, TCR-gamma delta+ cells were found in nearly all controls (median 2.4%, range 0.0-10.8%); atopic patients displayed significantly (P less than 0.01) lower proportions of CD8+, TCR-gamma delta+ cells.

Imbalance of CD4+CD45R+ and CD4+CD29+ T helper cell subsets in patients with atopic diseases

To evaluate the proportion of helper cell subsets we studied 18 children with atopic dermatitis, 30 patients with asthma, 27 healthy age-matched controls aged 1 to 17 years and 11 atopic controls without symptoms related to atopy, aged 9-22 years. Lymphocytes were isolated from heparinized peripheral blood and the proportion of CD4+CD29+ and CD4+CD45R+ cells was determined by double-labelling immunofluorescence. Children with atopic dermatitis yielded a significantly (P less than 0.01) higher proportion of CD4+CD45R+ (median 75%) cells compared with normal controls (median 66.6%), whereas the proportion of CD4+CD29+ cells was significantly (P less than 0.01) lower in patients with atopic dermatitis (median 20.4 versus 29.6%). Interestingly, the percentage of CD4+CD45R+ cells shows an age-dependent decline (r = -0.67, P less than 0.01) in the control group, which is not found in the patient group.

Flow-cytometric analysis of lymphocyte subsets in patients with advanced periodontitis

Peripheral blood lymphocytes from 36 patients with advanced periodontitis and from 34 healthy subjects were examined using a panel of monoclonal antibodies and fluorescence flow cytometry. The absolute and relative counts of B-cells, T-cells, T-helper (TH), T-suppressor/cytotoxic (TS) cells, activated T-cells and natural killer cells were assessed and the TH/S ratio was calculated. In the periodontitis patients, the TH/S ratio was 1.56 +/- 0.62 and in the controls 1.35 +/- 0.55. This was not statistically significant. A classification on the basis of sex also did not show significant differences in the TH/S ratio. B-cells and activated T-cells were slightly increased in the periodontitis group. However, all determined lymphocyte subpopulations revealed no significant differences between the groups. These results indicate that local inflammatory reactions and immunoregulatory dysfunction are limited to the periodontium in the patients with advanced periodontitis, with no significant quantitative effects on the peripheral lymphocyte subpopulations.

A cytofluorometric method to quantify membrane antigens on individual alveolar macrophages

An immunofluorescence method for assaying membrane-bound antigens on individual alveolar macrophages (AM) collected by bronchoalveolar lavage (BAL) is described. Cells were labelled with FITC-conjugated anti-HLA-DR antibodies in a single (direct) step. Quantification of the fluorescence was performed by computer-assisted cytophotometry. Alveolar macrophages, especially when obtained from cigarette smokers, exhibited an autofluorescence which interfered with the measurement of specific fluorescence. The specific fluorescence was calculated by determination of total fluorescence in the wave-length optimal for FITC and the non-specific fluorescence in a different wavelength during a second measurement. Specificity and reproducibility testing confirmed the reliability of the method.

A randomized controlled trial of ciamexon versus placebo in the immunomodulatory treatment of rheumatoid arthritis

To determine the efficacy of the new immunosuppressive agent ciamexon in patients with rheumatoid arthritis (RA), we conducted a 6-month, prospective, double-blind, placebo-controlled study. The study included 21 outpatients with confirmed RA, who were randomized into 3 treatment groups of 7 patients each. Group 1 received 400 mg/day of ciamexon, group 2 received 100 mg/day of ciamexon, and group 3 received placebo. We investigated the influence of ciamexon on the clinical course, the systemic inflammatory activity, and the lymphocyte subsets in the peripheral blood. Significant, dose-dependent improvement was seen in both the clinical and the biochemical activity indexes at the end of the treatment period (P = 0.02 to P = 0.05). The proportion of activated T lymphocytes was significantly decreased (P = 0.05), and the proportion of CD8-positive lymphocytes was significantly increased (P = 0.03) in patients taking ciamexon. The major adverse effects were hepatotoxicity (2 patients) and rash (2 patients). This study documents the clinical efficacy of ciamexon therapy in RA patients and identifies the agent's potential toxicity.

[Immunomodulating basic therapy of rheumatoid arthritis using ciamexone]

Ciamexone, a 2-cyanoaziridine derivative, had been shown previously in animal studies to inhibit the proliferation of autoreactive lymphocytes dose dependently, without affecting the reaction against foreign antigens. To extend the experimental models of ciamexone's in vitro effects to the clinical level, we performed a pilot study to evaluate the clinical efficacy of ciamexone therapy. We further studied its influence on the systemic inflammatory activity and T-lymphocyte subsets in the peripheral blood of 10 patients with active rheumatoid arthritis (RA). Following 6 months' treatment with ciamexone all patients showed a significant decrease of both the clinical and biochemical scores. Concerning the T-lymphocyte subsets analysis, a relatively decreased rate of the activated T-lymphocytes was observed concurrently. Minor side effects included rash (n = 1), hepatotoxicity (n = 1) and diarrhea (n = 1). The study thus documents the clinical efficacy of ciamexone in patients with RA, but also indicates the agent's potential toxicity.

Tetanus toxin as a marker for small-cell lung cancer cell lines

Tetanus toxin labeling of human lung cancer cell lines was investigated using direct and indirect immunofluorescence and immunohistochemical staining. Cells of characterized permanent cell lines, eight small-cell lung cancer (SCLC) cell lines of classic subtype, six SCLC cell lines of variant subtype and seven non-small-cell lung cancer (NSCLC) cell lines, were incubated with a saturating concentration of tetanus toxin. For staining, fluorescein-isothiocyanate-(FITC)-conjugated anti-(tetanus toxin) antibodies were used or a mouse monoclonal anti-(fragment C) antibody with subsequent binding of FITC-conjugated anti-(mouse Ig) antibody or peroxidase-anti-peroxidase complex. Only SCLC showed an intense fluorescence/immunoreactivity restricted to the cell membrane. Quantitative analysis of tetanus toxin labeling by flow cytometry revealed the percentage of positive cells to be between 35% and 95% in SCLC without obvious differences between the classic and variant subtypes of SCLC. In NSCLC the percentage of positive cells was lower than 10%. These results demonstrate that SCLC in contrast to NSCLC can be labeled with tetanus toxin, emphasizing the neuroendocrine properties of this tumor, and that tetanus toxin labeling may become a useful diagnostic marker for SCLC cells in cytology.

Peptides and growth factors in small cell lung cancer: production, binding sites, and growth effects

We investigated the production, binding to cell membranes, and influence on cell proliferation of peptides and growth factors in 4 classic, 5 transitional, and 5 variant SCLC cell lines. Glucagon, neurotensin, and TGF-alpha were present in all cell lines. Bombesin was predominantly found in classic cell lines and insulin in variant cell lines. Neurokinin A, calcitonin, CGRP, GHRF, somatostatin, and CNTF were detectable in some cell lines without prevalence for a particular cell type. We could not detect AVP, growth hormone, neuropeptide Y, substance P, VIP, and NGF. Insulin binding sites were present on 11/14 cell lines, and some cell lines specifically bound bombesin, calcitonin, and EGF. Growth effects were detectable for insulin, GRP-related peptides, tachykinins, and VIP. Using serum-free conditions, insulin and VIP had a growth stimulating effect in liquid culture at nanomolar concentrations. Bombesin and neuromedin B stimulated the clonal growth at a concentration of 3-30 nM. The tachykinins neurokinin A, neurokinin B, physalaemin, and eledoisin inhibited the clonal and mass culture growth with a peak effect in the range of 0.1 to 10 pM. Peptide-induced stimulating and inhibiting effects were within a magnitude of 2-fold. All other peptides and growth factors tested, including ACTH, AVP, calcitonin, glucagon, neurotensin, somatostatin, EGF, CNTF, and NGF did not affect the growth of SCLC. We conclude that the growth of SCLC is partly controlled by such peptides in an autocrine/paracrine fashion.

Neuroblastoma cells contain a trophic factor sharing biological and molecular properties with ciliary neurotrophic factor

Ciliary neurotrophic factor (CNTF) is a protein supporting the in vitro survival of a characteristic spectrum of embryonic chicken and rat peripheral neurons. High-speed supernatants of extracts from two neuroblastoma (NB) cell lines--the mouse C 1300 N2a and the human IMR 32--mimic the effects of CNTF on identical target neurons. Promotion of survival is dose-dependent with an ED50 of 80 micrograms (IMR 32) and 140 micrograms (C 1300 N2a) of protein per ml and saturable at plateau values for surviving neurons identical to those achieved with purified CNTF. Small amounts of a CNTF-like material are also detectable in medium conditioned by NB cells. The activity is destroyed by heat and trypsin and not blocked by antibodies to (mouse) nerve growth factor. Unlike the neurite-promoting and neuronal-survival modulating agent laminin, it cannot be depleted on poly(L-alpha-ornithine)-coated plastic surfaces. NB IMR 32 cell extracts were electrophoresed using NaDodSO4/PAGE and transferred to nitrocellulose. Ciliary ganglion neurons seeded on the blotting paper in culture medium lacking CNTF ("cell blot") exclusively survive on two distinct bands with apparent molecular masses of 24 and 48 kDa. Twenty-four kilodaltons is the molecular mass of a CNTF purified from rat sciatic nerve. These results suggest that NB cells may contain a CNTF-like protein and provide further evidence that neurons may store neurotrophic factors. Purified (chicken) CNTF failed to affect proliferation and neurite growth of NB cells. The biological relevance of CNTF for NB cells, therefore, remains to be elucidated.

Comparative studies of mast cells from normal (non-immunized) and actively sensitized dogs

Morphologically and functionally intact mast cells were isolated from the lung and mesentery of normal or actively sensitized dogs using the pronase or collagenase tissue dissociation methods. The latter method yielded about 6 times as many metachromatically staining cells. Electron microscopic examination revealed the presence of both mast cells and basophils in all samples, independent of the enzyme used for tissue dissociation. The average histamine content of the cells obtained with the pronase method was significantly higher (21.8 +/- 3.1 pg) than after collagenase treatment (16.2 +/- 4.2 pg). There was no appreciable difference in the reactivity to secretory stimulation of the cells obtained by the two methods. The cells isolated from actively sensitized dog tissues showed a significantly higher spontaneous histamine release (12.9 +/- 1.2%) than those from non-sensitized animals (7.8 +/- 1.3%) and responded equally well to challenge with both the antigens ovalbumin and horse serum. In contrast to those from normal animals, the mast cells from actively sensitized dogs released histamine on stimulation with acetylcholine, metacholine or atropine. In addition, the response to the threshold concentration of compound 48/80 (10(-6)) was significantly stronger in the sensitized cells. Small molecular polyvinylpyrrolidone (K25) was effective in mast cells from normal and actively sensitized dogs.