Current Management and Future Perspectives in Metastatic HER2-Positive Breast Cancer

OBJECTIVE

Metastatic HER2-positive breast cancer remains a significant clinical challenge with a poor prognosis. The introduction of anti-HER2 therapies has significantly improved survival in early and advanced stages. However, patients with metastatic HER2-positive breast cancer eventually experience progression due to de novo or acquired resistance. This review article comprehensively analyzes the current management of metastatic HER2-positive breast cancer, addressing the complexities in determining the optimal HER2-targeted therapy sequence.

DATA SOURCES

Discussion of selected peer-reviewed articles and expert opinion.

CONCLUSIONS

We explore the actual standard of care and the emerging therapeutic options that hold promise for further improving patient care and survival in this aggressive breast cancer subtype. This article highlights vital toxicities linked to anti-HER2 therapies, emphasizing their recognition across treatments as interstitial lung disease, diarrhea, or left ventricular dysfunction.

IMPLICATIONS FOR NURSING PRACTICES

Oncology nurses have a key role to play in detecting potential adverse effects of anti-HER2 therapies. The development of new drugs, as antibody-drug conjugates, with a distinct toxicity profile makes it necessary for us to be updated on the management of these new toxicities.

Safety and efficacy of endoscopic vacuum therapy for the treatment of perforations and anastomotic leaks of the upper gastrointestinal tract

AIM

To evaluate the efficacy and safety of endoscopic vacuum therapy (EVT) in the management of perforations and anastomotic leaks of the upper gastrointestinal tract.

PATIENTS AND METHODS

This is a retrospective observational study which included patients who underwent EVT due to any upper gastrointestinal defect between April 2017 and February 2019 in three Spanish Hospitals. To this end, we used the only medical device approved to date for endoscopic use (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Germany).

RESULTS

11 patients were referred for EVT of an anastomotic leak after esophagectomy (n=7), gastrectomy (n=2), esophageal perforation secondary to endoscopic Zenker's septomiotomy (n=1) and Boerhaave syndrome (n=1). The median size of the cavity was 8×3cm. The median delay between surgery and EVT was 7 days. The median of EVT duration was 28 days. The median number of sponges used was 7 and the mean period replacement was 3.7 days. In 10 cases (91%), the defect was successfully closed. In 9 cases (82%) clinical resolution of the septic condition was achieved. 5 patients presented some adverse event: 3 anastomotic strictures, 1 retropharyngeal pain and 1 case of new-onset pneumonia. The median hospital stay from the start of EVT was 45 days. 1 patient died owing to septic complications secondary to the anastomotic leak.

CONCLUSION

EVT was successful in over 90% of perforations and anastomotic leaks of the upper gastrointestinal tract. Moreover, this is a safe therapy with only mild adverse events associated.

Efficacy and safety of trabectedin in metastatic uterine leiomyosarcoma: A retrospective multicenter study of the Spanish ovarian cancer research group (GEICO)

•

Trabectedin confers clinical benefit in patients with recurrent/metastatic uterine leiomyosarcoma.

•

Our data are similar to those previously reported in clinical studies.

•

Trabectedin is especially effective when administered in earlier lines.

•

Trabectedin has a manageable safety profile.

Objective

We assessed trabectedin in patients with advanced uterine leiomyosarcoma (uLMS) in real-life clinical practice given according to the marketing authorization.

Methods

Thirty-six women from 11 tertiary hospitals across Spain who received trabectedin after anthracycline-containing regimen/s were retrospectively analyzed. The primary endpoint was progression-free survival (PFS).

Results

Median PFS and overall survival (OS) since starting trabectedin treatment were 5.4 (95%CI: 3.5–7.3) and 18.5 months (95%CI: 11.5–25.6), respectively. Median OS was significantly higher (P = 0.028) in patients receiving trabectedin in ≤ 2nd line (25.3 months) than in ≥ 3rd (15.1 months) and with ECOG performance status ≤ 1 at trabectedin start (19.8 months) than ECOG 2–3 (6.0 months, P = 0.013). When calculating OS since diagnosis, patients had longer OS with localized disease at diagnosis (87.4 months) vs. locally advanced (30.0 months) or metastatic (44.0 months, P = 0.041); and patients who received adjuvant therapy (87.4 months) compared with those who did not (30.0 months, P = 0.003), especially when receiving radiochemotherapy (106.7 months, P = 0.027). One patient (2.8%) had a complete response (CR) and nine patients (25.0%) achieved a partial response (PR) for an objective response rate of 27.8% with median response duration of 11 months (range: 4–93). Eighteen patients (50.0%) had disease stabilization for a disease control rate (DCR) of 77.8%. More patients receiving trabectedin in 1st-line of advanced disease achieved CR (16.7%) and PR (50.0%) than those in ≥ 2nd line/s (0.0% and 20.0%), whereas the DCR was similar across treatment lines. Reversible neutropenia was the most common grade 3/4 laboratory abnormality (19.4%).

Conclusions

Trabectedin confers clinical benefit in patients with recurrent/metastatic uLMS, given after failure to an anthracycline-based regimen being comparable to those reported in clinical trials and with a manageable safety profile.

Combination of pegylated liposomal doxorubicin plus gemcitabine in heavily pretreated metastatic breast cancer patients: Long-term results from a single institution experience

The combination of Pegylated Liposomal Doxorubicin (PLD) plus Gemcitabine (GEM) has been previously investigated in the treatment of metastatic breast cancer (MBC). PLD is a doxorubicin formulation with prolonged circulation time and better tissue distribution. GEM is a nucleoside analog with nonoverlapping toxicity compared to PLD. The aim of our study was to assess efficacy, toxicity, and long-term outcome of this combination. Patients with heavily treated MBC were retrospectively analyzed. Chemotherapy consisted of PLD 25 mg/m² and GEM 800 mg/m² day 1, on a three-week schedule. Cardiac function was evaluated baseline and during treatment. Radiological response was graded according to RECIST criteria v1.1. Toxicity was scored according to CTCAE v4.0. Progression-free survival (PFS) and overall survival (OS) were evaluated. From 2001 to 2014, 122 pts were included. Median age was 55 (range: 28-84). Median previous treatment schedules in the metastatic scenario were 3 (range: 1-15). Most patients received prior anthracyclines (85%). Median number of metastatic sites was 2 (range: 1-7). Median number of cycles delivered was 5 (range: 1-36). Overall response rate was 31% (5% complete responses; 26% partial responses). Stable and progressive diseases were observed in 32% and 26% of patients. Grade ≥3 neutropenia was observed in 29 patients (24%). Grade ≥3 hand-foot syndrome was detected in 17 patients (14%), mostly since cycle 3 (88%). Median cumulative PLD dose was 125 mg/m² . At a median follow-up of 101 months, median PFS and OS were 7 and 22 months, respectively. PLD-GEM combination achieves remarkable long-term outcomes with an acceptable toxicity profile in patients with MBC.

A phase II trial of autologous dendritic cell vaccination and radiochemotherapy following fluorescence-guided surgery in newly diagnosed glioblastoma patients

Background

Prognosis of patients with glioblastoma multiforme (GBM) remains dismal, with median overall survival (OS) of about 15 months. It is therefore crucial to search alternative strategies that improve these results obtained with conventional treatments. In this context, immunotherapy seems to be a promising therapeutic option. We hypothesized that the addition of tumor lysate-pulsed autologous dendritic cells (DCs) vaccination to maximal safe resection followed by radiotherapy and concomitant and adjuvant temozolomide could improve patients’ survival.

Methods

We conducted a phase-II clinical trial of autologous DCs vaccination in patients with newly diagnosed patients GBM who were candidates to complete or near complete resection. Candidates were finally included if residual tumor volume was lower than 1 cc on postoperative radiological examination. Autologous DCs were generated from peripheral blood monocytes and pulsed with autologous whole tumor lysate. The vaccination calendar started before radiotherapy and was continued during adjuvant chemotherapy. Progression free survival (PFS) and OS were analyzed with the Kaplan–Meier method. Immune response were assessed in blood samples obtained before each vaccines.

Results

Thirty-two consecutive patients were screened, one of which was a screening failure due to insufficient resection. Median age was 61 years (range 42–70). Karnofsky performance score (KPS) was 90–100 in 29%, 80 in 35.5% and 60–70 in 35.5% of cases. MGMT (O⁶-methylguanine-DNA-methyltransferase) promoter was methylated in 45.2% of patients. No severe adverse effects related to immunotherapy were registered. Median PFS was 12.7 months (CI 95% 7–16) and median OS was 23.4 months (95% CI 16–33.1). Increase in post-vaccination tumor specific immune response after vaccines (proliferation or cytokine production) was detected in 11/27 evaluated patients. No correlation between immune response and survival was found.

Conclusions

Our results suggest that the addition of tumor lysate-pulsed autologous DCs vaccination to tumor resection and combined radio-chemotherapy is feasible and safe. A multicenter randomized clinical trial is warranted to evaluate the potential survival benefit of this therapeutic approach.

Trial registration This phase-II trial was registered as EudraCT: 2009-009879-35 and ClinicalTrials.gov Identifier: NCT01006044 retrospectively registered

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-017-1202-z) contains supplementary material, which is available to authorized users.

Eribulin and carboplatin in heavily pretreated patients with metastatic breast cancer: A single institution experience

122

Background: In recent years many drug combinations have demonstrated clinical activity in heavily pretreated patients (pts) with metastatic breast cancer (MBC). Eribulin (E) in monotherapy has shown a beneficial effect in overall survival (OS) with slight rate of objective responses (OR) and poor effect in progression free survival (PFS). The Eribulin – Carboplatin (Cb) combination has been studied in other types of tumors in a phase Ib with promising results. We initiated an exploratory program with an off-label combination of E – Cb in pts with visceral disease and ECOG < 2. Methods: We retrospectively analyzed pts with MBC previously treated with anthracyclines, taxanes, and Capecitabine. Chemotherapy regimen consisted of E 1.1mg/m2 on days 1 and 8 and Cb AUC: 5 on day 1 every 21 days. Toxicity was assessed according to CTC criteria v 4.0. OR, PFS and OS rates were also evaluated. RECIST criteria were used to appraise radiological response. Results: Treatment was delivered in 10 pts. Median (M) age was 56 (range, 39-65). Pts characteristics were defined as follows: ECOG 0 (1 pt), 1 (6 pts) and 2 (3 pts); histological subtypes: luminal 9 pts and Her-2, 1 pt. M of previous lines was 7 (3-11). M of metastatic localizations were 3 (1-4). M of administered cycles was 6’5 (1-10). Grade 2 toxicity was asthenia 40%, peripheral neuropathy 10% and nausea - vomiting 10%. G 3 anemia and thrombopenia were noted in 20%. G 3-4 neutropenia was observed in 5 pts. Two pts required hospital admission due to febrile neutropenia. OR rate: complete response 10%, partial response 50% and stable disease 40%. Biochemical response rate was 80%. M of follow-up was 11 months, with M PFS and OS of 8 (4-11) and 18 months (4-18) respectively. Conclusions: Eribulin and Carboplatin is feasible, achieving remarkable response and survival rates with an acceptable toxicity profile in heavily pretreated patients with metastatic breast cancer. Preliminary results are promising and encourage us to continue recruiting patients.

Abstract P4-13-04: Autologous dendritic cells vaccines combined with neoadjuvant chemotherapy increase total pCR in stages II-III non-overexpressing HER2 breast cancer patients and induce phenotypic changes in peripheral blood

Background Based on the synergistic effect between immuno- and chemotherapy (CT), we have elaborated an autologous vaccine with dendritic cells loaded with patients´ own tumor antigens (lysate), and we have already demonstrated that the addition of the vaccines to a standard neoadjuvant CT schedule has increased total pCR (breast+ axilla) in stages II-III non-overexpressing HER2 breast cancer patients (Santisteban M, SABCS 2012). Both cohorts, the control (C) and the vaccinated (V) were well balanced related to demographic characteristics. Toxicity has been similar in both the C and the V cohorts. Moreover, we have analyzed the phenotypic changes in peripheral blood induced by the vaccine and its correlation with pathologic responses. Indeed, we have studied if the amount of lysate used to load the dendritic cells or the total dendritic cell numbers received by the patients in the first five doses (before surgery) is correlated with pCR Methods Twenty-eight patients with stage II-III HER2 negative breast cancer have started on sequential neoadjuvant CT based on dose dense antracyclines (E 100mg/m2 and C 600 mgr/m2) x4 cycles plus GM-CSF followed by taxanes (DOC 75-100 mgr/m2) x4 cycles plus vaccination. The C historic cohort was composed of thirty patients who received the same treatment except for the absence of the vaccines. Vaccine calendar was started after the 4th EC and alternated with DOC and as maintenance up to a maximum of a 2 year-period. The first 5 vaccines were administered before breast surgery. Changes in different lymphocytes populations were measured in peripheral blood of patients at different points by flow cytometry (absolute cell counts). To date, twenty-one patients have both determinations of lymphocyte subpopulations before the 1st and the 6th vaccine. Paired samples t-tests and Fisher exact were used Results pCR was superior in the V cohort (24% versus 3.3%, p = 0.04). Lymphocyte subpopulations were measured in peripheral blood (cells/uL) and a stimulation of the immune system was found after the 5 vaccines schedule at the time of surgery as follows: NK (p&lt;0.001), T cytotoxic CD8 (p = 0.018), T helper CD4 (p = 0.04), CD19 (p = 0.001), HLADRCD8 (p = 0.007), CD16CD8 (p = 0.003), HLADRCD4 (p&lt;0.001), CD16CD4 (p = 0.008) and T regulators lymphocytes (p = 0.004). We did not find any differences among CD57CD8 (p = 0.17), CD56CD8 (p = 0.11), CD57CD4 (p = 0.45) and CD56CD4 (p = 0.65). We neither see correlation among the amount of lysate to load dendritic cells and the tpCR (p = 0.09) nor the amount of dendritic cells (summatory of 5 vaccines) administered intradermally and the pCR (p = 0.59) Conclusions Immunotherapy added to standard neoadjuvant CT could improve total pCR in stage II-III non-overexpressing HER2 breast cancer patients. After 5 doses of vaccination plus chemotherapy, we can observe phenotypic changes in peripheral blood: some immune system subpopulations increased statistically after the treatment in vaccinated patients. Neither the amount of lysate nor the number of dendritic cells used in the five first vaccines significantly correlated with the pRC.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-13-04.

A new rapid desensitization protocol for chemotherapy agents

BACKGROUND

Desensitization has been used for some decades to treat patients with the allergenic drug when an alternative drug with similar efficacy and safety is not available. We present the results from a series of oncology patients desensitized at our hospital during the last 2 years.

OBJECTIVE

To assess the efficacy of a new desensitization protocol in patients allergic to chemotherapy drugs.

METHODS

We performed an observational retrospective study of 11 women (6 breast cancer and 5 ovarian cancer) who underwent our desensitization protocol. Four patients had immediate reactions to carboplatin, 3 to docetaxel, 3 to paclitaxel, and 1 to both docetaxel and paclitaxel. Premedication was administered in all cases. A 5-step protocol based on 5 different dilutions of the drugs was used.

RESULTS

We performed 39 desensitization procedures: 14 to carboplatin, 3 to oxaliplatin, 16 to docetaxel, and 6 to paclitaxel. Eight patients tolerated the full dose in 36 procedures. One patient suffered an anaphylactic reaction to carboplatin that reverted with treatment. One patient had dyspnea after a paclitaxel cycle. One patient experienced dyspnea due to chronic pulmonary thromboembolism related to her disease.

CONCLUSION

Desensitization is a useful procedure in patients who are allergic to their chemotherapy agents.

Hepatic breast cancer dissemination after an iatrogenic hepatic laceration during talc pleurodesis: a case report

Background

Talc pleurodesis is an effective treatment for malignant pleural effusion. We present a case of an asymptomatic hepatic laceration that occurred during pleurodesis in a breast cancer patient and led to hepatic tumor dissemination.

Discussion

Pleurodesis is a relatively safe procedure, although previous studies have described malignant invasion of scar tissue.

Conclusion

To our knowledge, this is the first case report of tumor spread due to a liver puncture during talc pleurodesis in a breast cancer patient.

A phase II trial of less than 7 weeks of concomitant cisplatin-paclitaxel chemoradiation in locally advanced cervical cancer

OBJECTIVES

This study was undertaken to determine the tolerability of a 7-week schedule of external beam radiation therapy, high-dose-rate brachytherapy, and weekly cisplatin and paclitaxel in patients with locally advanced carcinoma of the cervix.

METHODS

Twenty-nine patients with International Federation of Gynecology and Obstetrics stages IB2 to IVa cervical cancer were treated with 40 mg/m per week of intravenous (i.v.) cisplatin and 50 mg/m per week of i.v. paclitaxel combined with 45 Gy of pelvic external beam radiation therapy and 30 Gy of high-dose-rate brachytherapy.

RESULTS

Eleven patients (37.9%) were able to complete the 6 scheduled cycles of chemotherapy. The median number of weekly chemotherapy cycles administered was 5 (range, 2-7). Thirty-five (20.1%) of 174 cycles of chemotherapy were not given because of toxicity. The median dose intensity of cisplatin was 31 mg/m per week (95% confidence interval [CI], 25.2-36.8); that of paclitaxel was 44 mg/m per week (95% CI, 39.9-48.3). Twenty-two patients (78.6%) were able to complete the planned radiation course in less than 7 weeks. Median radiation treatment length was 45 days (95% CI, 43.4-46.6). After a median follow-up of 48 months, 7 patients (24.1%) experienced severe (Radiation Therapy Oncology Group grade 3 or higher) late toxicity. No fatal events were observed. Seven patients have failed, 1 locally and 6 at distant sites. The 8-year local/pelvic control rate was 95.7%, and the 8-year freedom from systemic failure rate was 76.1%. Eight-year actuarial disease-free survival and overall survival were 63.1% and 75.9%, respectively.

CONCLUSIONS

This study demonstrated unacceptable toxicity of combining the stated doses of concurrent cisplatin and paclitaxel chemotherapy with definitive radiotherapy for patients with advanced cervical cancer. Additional phase I/II trials are recommended to clearly establish the recommended phase II dose for these drugs.

Preliminary results of the combination of bevacizumab and weekly Paclitaxel in advanced melanoma

BACKGROUND

Pretreated advanced melanoma is a poor prognosis scenario with few, if any, active therapeutic options. The antibody against vascular endothelial growth factor, bevacizumab, has demonstrated increased activity in combination with chemotherapy in many tumors. We intended to evaluate the activity of the combination of weekly paclitaxel and bevacizumab in previously treated metastatic melanoma.

PATIENTS AND METHODS

Patients with previously treated metastatic melanoma received paclitaxel 70 mg/m(2) weekly and bevacizumab 10 mg/kg biweekly for 5 consecutive weeks every 6 weeks.

RESULTS

Twelve patients were treated. Two patients (16.6%) achieved a partial response and 7 patients (58.3%) stable disease. Responses were seen in soft tissue, lung and brain metastases. Median disease-free and overall survival times were 3.7 and 7.8 months, respectively. Treatment was well tolerated. Main toxicities were grade 3 asymptomatic lymphopenia in 6 patients, grade 3 leucopenia in 2 patients, and grade 3 thrombocytopenia in 1 patient.

CONCLUSIONS

Our preliminary results suggest that the combination of bevacizumab and weekly paclitaxel is active and safe in patients with metastatic melanoma, warranting further investigation.

Diagnostic value of duodenal antitissue transglutaminase antibodies in gluten-sensitive enteropathy

BACKGROUND

In gluten-sensitive enteropathy, antitissue transglutaminase antibodies are synthesized in the duodenum.

AIM

To compare the diagnostic yield of these autoantibodies in cultured duodenal biopsies, duodenal aspirate and serum.

METHODS

Patients (n = 315, 135 female, 180 male; age: 37.3 +/- 1.1 years) referred for duodenal biopsies, were recruited and HLA-DQ2/DQ8 haplotyped. Histological measurements were made from duodenal biopsies and cultured duodenal biopsies were used for antitissue transglutaminase antibodies analysis by enzyme-linked immunosorbent assay. Duodenal aspirate was collected in a subgroup of 81 patients. Patients were classified, according to their histology, response to a gluten-free diet and DQ2/DQ8 status, as definite, likely or nongluten-sensitive enteropathy.

RESULTS

Histology was normal in 59% of patients; 28% had lymphocytic enteritis, 1% had crypt hyperplasia and 13% showed atrophy. In Marsh III patients, there was complete agreement between duodenal and serological antitissue transglutaminase antibodies measurements. Marsh I patients showed a slight antitissue transglutaminase antibodies sensitivity improvement in cultured duodenal biopsy compared to serum in definite (22% vs. 19%) and likely gluten-sensitive enteropathy (20% vs. 14%) patients. Combined serum and cultured duodenal biopsy antitissue transglutaminase antibodies assessment increased serological sensitivity from 19% to 30% in Marsh I patients.

CONCLUSION

Duodenal antitissue transglutaminase antibodies detection improves serological determination sensitivity in Marsh I patients, providing diagnostic value and therapeutic impact.

[Hormonal therapy in breast cancer]

Hormonal therapy has been the first systemic treatment against breast cancer. Up to now Tamoxifen and ovarian supression/ablation were the best optionts we had to treat early breast cancer as advancer disease. The advent of aromatase inhibitors, new SERMS and antistrogen Fulvestrant have supoused a great advance in the treatment of this disease and at the same time have complicated the election of the optimal drug for each patient. This article tries to review the aviable treatment options insiting on its indications.

[Von Willebrand factor as an intermediate between hemostasis and angiogenesis of tumor origin]

Cancer patients often show an imbalance condition between coagulation system and fibrinolysis which causes a prothrombotic state. Different molecular factors like von Willebrand factor (vWf), presenting higher plasmatic rates in these patients, play an important role in this situation. During active angiogenesis taking place in tumor growth, the vascular endothelial growth factor (VEGF) and the fibroblast growth factor (FGF-2) contribute to the proliferation and differentiation of endothelial tissue, the main vWf producer, promoting increased rates of vWf in the serum of neoplastic patients. Recently vWf's contribution to tumor cells and platelet adhesion has been described. In this process, the discovery of platelet, endothelial and tumor cell membrane integrins and their implication in cellular adhesion has represented a major step in demonstrating how blood clotting and platelet aggregation are mediated by tumor cell and platelet linkage. Migration properties acquired by tumor cells as a result of this binding have been also pointed out. Clinical trials show higher rates of plasmatic vWf in cancer patients the more advanced clinical and radiological stage they present (metastasic versus localized). Moreover, higher pre-surgical serum vWf rates in patients can be used to predict poorer survival after resection surgery. vWf high molecular weight multimers have been also related to a cleavage protease deficiency in the serum of the oncologic population. The promising results of antiaggregation/anticoagulation therapies in these patients permit us to envisage new therapeutic targets.

Must ERCP Be routinely performed if choledocholithiasis is suspected?

OBJECTIVE

To evaluate the results of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of those patients suspected of harboring bile duct stones before laparoscopic cholecystectomy (LC).

PATIENTS AND METHODS

A total of 1,235 consecutive LCs performed between 1991 and 1997 were studied prospectively. ERCP was performed to explore the common bile duct (CBD) preoperatively when choledocholithiasis was suspected on the basis of clinical, analytical or echographical data.

RESULTS

ERCPs were performed in 268 patients: unsuccessful CBD evaluation in 3%; dilated CBD without lithiasis in 13%, and normal exploration in 37% (99 patients). CBD stones were found in 46% (124 patients), and endoscopic sphincterotomy was then performed and stone extraction attempted. Endoscopic therapy achieved 92.8% successful removal of CBD stones (115 patients). There was no ERCP-related mortality and the morbidity rate was 6%. Retained CBD stones have been observed in 7 cases after ERCP-LC; all of them have been successfully treated by ERCP.

CONCLUSIONS

A combined approach to bile duct stones with selective use of ERCP followed by LC is a good therapeutical alternative. Nevertheless, the usual selection criteria for ERCP may lead to unnecessary exploration. It appears to be necessary to modify the current diagnostic and therapeutic strategy.

[Echo-endoscopy: the clinical implications after a period of more than 16 years of its existence]

Endosonography is an imaging diagnostic technique recently introduced in our country. It allows us to perform an ultrasound from within the digestive tube. Because of the transducer proximity to the gut wall and the high frequency of emission we are able to visualize with great resolution small lesions as well as differentiate the five layers of the gastric wall and examine structures close to the digestive lumen with a 7 to 8 cm penetration. This is a brief introduction to the basic pillars of endosonography and its main indications, well defined after sixteen years of clinical practice.

Incidence of collagenous and lymphocytic colitis: a 5-year population-based study

OBJECTIVE

The incidence of collagenous and lymphocytic colitis is not well known. We sought to assess the incidence of collagenous and lymphocytic colitis in a well-defined population during a 5-yr study period.

METHODS

From January 1, 1993, to December 31, 1997, all new patients diagnosed with collagenous or lymphocytic colitis living in the catchment area of the Hospital Mutua de Terrassa (Barcelona, Spain) were identified. Since 1993 all patients with chronic diarrhea were referred for a diagnostic colonoscopy. Multiple biopsy sampling of the entire colon was performed when appearance of the colonic mucosa was grossly normal.

RESULTS

Twenty-three cases of collagenous colitis and 37 of lymphocytic colitis were diagnosed. The female:male ratios were 4.75:1 and 2.7:1 for collagenous and lymphocytic colitis, respectively. The mean age at onset of symptoms was 53.4+/-3.2 (range, 29-82) yr for collagenous colitis, and 64.3+/-2.7 (range, 28-87) yr for lymphocytic colitis (p = 0.012). The mean annual incidence per 100,000 inhabitants based on the year of onset of symptoms was 1.1 (95% confidence interval [CI], 0.4-1.7) for collagenous colitis, and 3.1 (95% CI, 2.0-4.2) for lymphocytic colitis. A peak incidence was observed in older women in both diseases. A rate of microscopic colitis of 9.5 per 100 normal-looking colonoscopies performed in patients with chronic watery diarrhea was observed. Normal rectal biopsies were found in 43 % and 8% of patients with collagenous and lymphocytic colitis, respectively.

CONCLUSIONS

The incidence of lymphocytic colitis is three times higher than that of collagenous colitis. Microscopic colitis should be considered as a major possibility in the work-up of chronic diarrhea in older women.

[Endoscopic ligation with elastic bands in the prevention of hemorrhage recurrence caused by esophageal varices. Study of 45 patients]

The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence by esophageal varices. Forty-five patients without known hepatocarcinoma who had survived a hemorrhagic variceal episode were included in the study. Seventeen patients (38%) were Child-Pugh A, 22 (49%) B, and 6 (13%) C, with the hepatitis C virus and alcohol being the etiology of cirrosis in 55 and 20% of the cases, respectively. The first ligation session was performed between the third and fifth days after the hemorrhagic episode and the posterior sessions were carried out at intervals of 2-4 weeks. The ligation sessions were performed without antibiotic prophylaxis and with placement of an overtube. A mean of 4 +/- 2 bands were placed per session (range, 1-8) and the mean number of sessions required per patient to achieve erradication of the varices was 3.5 +/- 1.5 (range, 2-8). The rate of bleeding recurrence was 17.7% (9 episodes, five by variceal rupture and four by ulcer secondary to ligation). All the episodes of bleeding recurrence occurred between the sessions, with the mortality being 11% (5/45 patients). In the 40 remaining patients the varices were erradicated although 19 (47.5%) required one or two additional sessions of sclerotherapy. The accumulated percentage of patients free of bleeding recurrence was 82% during a mean follow-up of 10.2 +/- 6.7 months. Ten lesions of dislaceration of the esophageal mucosa caused by placement of the were observed overtube. In conclusion, endoscopic elastic band ligation is a useful technique for the erradication of esophageal varices an in the prevention of bleeding recurrence.

Low dose alpha interferon therapy can be effective in chronic active hepatitis C. Results of a multicentre, randomised trial

BACKGROUND

There is some controversy concerning the efficacy of low dose alpha interferon therapy in chronic hepatitis C.

AIMS

To evaluate the effectiveness of treatment with low doses of alpha interferon in chronic hepatitis C.

PATIENTS

One hundred and forty one patients with anti-HCV positive chronic active hepatitis C from six hospitals were enrolled in the study.

METHODS

Patients were randomised to treatment with 5 MU (group A) or 1.5 MU (group B) injections. The dose was reduced in responders from group A or increased in non-responders from group B to maintain treatment with the minimal effective dose. Patients were treated for 48 weeks and followed up for 24 additional weeks with no treatment. Normalisation of alanine aminotransferase (ALT) was used to evaluate response.

RESULTS

A sustained response was seen in eight patients from group A (12%) and in 15 (21%) from group B. This difference was not statistically significant. Increasing the dose of interferon led to sustained response in only five of 58 patients (9%) from group B who did not respond to 1.5 MU injections. In contrast, 15 of 21 patients (71%) in whom ALT remained normal with 1.5 MU injections developed a sustained response. By multivariate analysis sustained response seemed associated with young age and was more frequent in patients with genotype 3 HCV infection. Sustained response was preceded by a rapid normalisation of ALT and was inversely related to the amount of alpha interferon necessary to maintain ALT at low values during treatment.

CONCLUSIONS

Some patients with chronic hepatitis C are very sensitive to alpha interferon and can be successfully treated with low doses. Treatment with higher doses may be effective in a minority of patients who do not respond to low doses.