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Klein EJ, Karim M, Kushner CJ, Marji JS, Adotama P, Lo Sicco K, Shapiro J. Enlarging alopecic patch in an African American woman with central centrifugal cicatricial alopecia: A case of concomitant tinea incognito. JAAD Case Rep 2022; 23:67-69. [PMID: 35445146 PMCID: PMC9014319 DOI: 10.1016/j.jdcr.2022.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Elizabeth J. Klein
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Maria Karim
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Carolyn J. Kushner
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Jackleen S. Marji
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Prince Adotama
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Kristen Lo Sicco
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Jerry Shapiro
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
- Correspondence to: Jerry Shapiro, MD, The Ronald O. Perelman Department of Dermatology, 240 E 38th Street, New York, NY 10016.
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Tovanabutra N, Bax CE, Feng R, Kushner CJ, Payne AS. Temporal outcomes after rituximab therapy for pemphigus vulgaris. J Invest Dermatol 2021; 142:1058-1064.e7. [PMID: 34710389 DOI: 10.1016/j.jid.2021.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/23/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022]
Abstract
Pemphigus vulgaris is an autoimmune blistering disease characterized by autoantibodies that target desmoglein adhesion proteins. Rituximab and corticosteroids are FDA-approved therapies for pemphigus vulgaris. As newer treatments for pemphigus enter clinical trials, analysis of clinical and serologic outcomes after rituximab therapy as a function of time is essential to guide clinical trial design. Here, we report detailed temporal and serological outcomes of rituximab treatment of pemphigus vulgaris. The maximal prevalence of complete remission off oral systemic therapy after a single cycle of rituximab was 32.4% at 12 months, or 43.1% by 36 months including additional rituximab cycles. Using receiver operating characteristic curves to develop prediction models for complete remission after a single cycle of rituximab, >90.7% reduction in average desmoglein 3 ELISA titers from baseline to months 3-9 was 94% sensitive, and an average absolute titer ≤130 RU/mL between months 3-9 was 96% specific, for achievement of complete remission off oral systemic therapy. All patients with negative titers at 6-9 months ultimately achieved complete remission off oral systemic therapy. This dataset of clinical and serological outcomes for pemphigus vulgaris patients after rituximab therapy will facilitate clinical trial planning and also guide clinician and patient expectations after rituximab therapy.
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Affiliation(s)
- Napatra Tovanabutra
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA; Department of Internal Medicine, Division of Dermatology, Chiang Mai University, Chiang Mai, Thailand
| | - Christina E Bax
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
| | - Rui Feng
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, USA
| | - Carolyn J Kushner
- Department of Dermatology, New York University Langone Health, New York City, USA
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA.
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Kushner CJ, Wang S, Tovanabutra N, Tsai DE, Werth VP, Payne AS. Factors Associated With Complete Remission After Rituximab Therapy for Pemphigus. JAMA Dermatol 2021; 155:1404-1409. [PMID: 31642878 DOI: 10.1001/jamadermatol.2019.3236] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Rituximab has emerged as a front-line therapy for pemphigus, but prognostic factors for achieving complete remission off therapy (CROT) with oral systemic agents remain unknown. Objectives To describe rates of CROT and relapse and identify prognostic factors for achieving CROT after rituximab therapy for pemphigus. Design, Setting, and Participants A single-center, retrospective, cohort study was conducted at the University of Pennsylvania including 112 patients with pemphigus treated with rituximab with at least 12 months' clinical follow-up after the start of rituximab therapy. Multivariate regression analysis of factors predictive of CROT and Kaplan-Meier analysis of disease relapse were conducted. The study included patients treated with rituximab from March 15, 2005, until December 19, 2016. Data analysis was performed from December 2017 to June 2018. Main Outcomes and Measures The primary study outcome was CROT after 1 cycle. Secondary study outcomes included rate of CROT or the composite end point of CROT or complete remission on minimal therapy after 1 or more cycle, and median time to relapse. Multivariate regression analysis for prognostic variables for CROT, including age, sex, pemphigus subtype, body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), disease duration, and dosing regimen, was performed. Results A total of 112 patients with pemphigus with median 37.8 months (range, 12.1-130.7) follow-up after rituximab therapy were identified. Of these, 65 were women (58.0%). At the time of first rituximab infusion, median age was 52.3 years (range, 20.0-89.3). Including patients who received multiple cycles of rituximab, 79 patients (70.5%) achieved CROT after a median time of 10.5 months (range, 2.0-49.8), and 36 of 72 patients (50.0%) subsequently experienced relapse after a median of 23.3 months (interquartile range, 10.8-50.4 months). Considering only the first cycle of rituximab, 54 patients (48.2%) achieved CROT. Controlling for age, sex, pemphigus subtype, BMI, and disease duration, patients who received lymphoma vs rheumatoid arthritis dosing were 2.70-fold more likely to achieve CROT (odds ratio [OR], 2.70; 95% CI, 1.03-7.12; P = .04). Increasing age was associated with significant increases in achieving CROT (Wald test for trend, P = .01), whereas BMI greater than or equal to 35 was associated with a 0.14 OR (95% CI, 0.03-0.63; P = .01) for achieving CROT, regardless of the dosing regimen. In multivariate analysis, there was no significant difference in CROT rates with sex (OR, 1.01; 95% CI, 0.42-2.50; P = .97), pemphigus subtype (OR, 0.37; 95% CI, 0.09-1.51; P = .17), or disease duration (OR, 0.99; 95% CI, 0.98-1.00; P = .09). Conclusions and Relevance Lymphoma dosing and older age may be associated with CROT and BMI greater than or equal to 35 may be a negative prognostic factor for CROT after rituximab therapy for pemphigus. These findings help inform clinical expectations and merit evaluation in future prospective clinical trials.
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Affiliation(s)
- Carolyn J Kushner
- Department of Dermatology, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Shiyu Wang
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Napatra Tovanabutra
- Department of Dermatology, University of Pennsylvania, Philadelphia.,Division of Dermatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Donald E Tsai
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania, Philadelphia
| | - Victoria P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia
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Bax CE, Ravishankar A, Yan D, Concha J, Kushner CJ, Zamalin D, Feng R, Payne AS, Werth VP. Identifying the required degree of disease clearance to improve quality of life in pemphigus vulgaris. Br J Dermatol 2020; 184:573-575. [PMID: 33090460 DOI: 10.1111/bjd.19625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- C E Bax
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - A Ravishankar
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - D Yan
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - J Concha
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - C J Kushner
- Department of Dermatology, New York University, New York City, NY, USA
| | - D Zamalin
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - R Feng
- Department of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - A S Payne
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - V P Werth
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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Tarazi M, Gaffney RG, Kushner CJ, Chakka S, Werth VP. Cutaneous Lupus Erythematosus Patients With a Negative Antinuclear Antibody Meeting the American College of Rheumatology and/or Systemic Lupus International Collaborating Clinics Criteria for Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 71:1404-1409. [PMID: 31058462 DOI: 10.1002/acr.23916] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/30/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) is a disorder that is heterogeneous and can be difficult to diagnose. One hallmark of the disease is the presence of antinuclear antibodies (ANAs), a feature that has been incorporated into multiple classification criteria over the years. In this study, we used a database of patients with cutaneous lupus erythematosus (CLE) to determine how many had a negative ANA and met criteria for SLE using the American College of Rheumatology (ACR) and/or Systemic Lupus International Collaborating Clinics (SLICC) criteria. METHODS We used a database of 301 biopsy-proven CLE patients that contained information including ANA status and the presence of features of SLE. The database was searched for patients who had a negative ANA result and whether or not they met SLE criteria using the ACR and/or SLICC criteria. RESULTS Of the 301 patients with biopsy-proven CLE and a known ANA, 111 had a negative ANA test (36.9%) and 27 had an ANA test that fluctuated (33.3%). In all, 20 ANA-negative patients met SLE criteria (18.0%), and 12 patients with a fluctuating ANA test met SLE criteria (44.4%). Of all patients who had either a negative or fluctuating ANA result and who met criteria for SLE (n = 32), 27 patients had involvement of ≥1 organ system other than skin (84.4%), and 13 patients had involvement of ≥2 organ systems other than skin (40.6%). CONCLUSION Our results show that an ANA is not always present in patients with systemic disease. This fact should be taken into consideration when devising SLE classification criteria to be used for clinical trials.
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Affiliation(s)
- Meera Tarazi
- Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rebecca G Gaffney
- Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Carolyn J Kushner
- Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Srita Chakka
- Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Victoria P Werth
- Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia
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6
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Krain RL, Kushner CJ, Tarazi M, Gaffney RG, Yeguez AC, Zamalin DE, Pearson DR, Feng R, Payne AS, Werth VP. Assessing the Correlation Between Disease Severity Indices and Quality of Life Measurement Tools in Pemphigus. Front Immunol 2019; 10:2571. [PMID: 31781098 PMCID: PMC6851056 DOI: 10.3389/fimmu.2019.02571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 10/16/2019] [Indexed: 11/13/2022] Open
Abstract
Pemphigus, an autoimmune blistering disease that affects the skin and mucous membranes, adversely impacts patients' quality of life (QOL). While there are various QOL measurement tools that can be used in this disease, few studies have assessed how a patient's change in disease severity can affect their QOL. This study aims to identify which disease severity index correlates best with the change in QOL. Fifty pemphigus patients completed QOL surveys with disease severity scored over two visits. QOL was assessed with the Autoimmune Bullous Disease Quality of Life (ABQOL), Dermatology Life Quality Index (DLQI), Skindex-29, and Short Form Survey 36 (SF-36). Disease severity was scored with the Pemphigus Disease Area Index (PDAI) and Autoimmune Bullous Skin Disorder Intensity Score (ABSIS). Correlations between the change in QOL scores and change in disease severity were analyzed using Spearman's coefficient (r). The change in PDAI showed a strong correlation (r = 0.60–0.79) with changes in the ABQOL, Skindex-29 symptoms (Skindex-S), and Skindex-29 functioning (Skindex-F) subscales for all patients (n = 50). For patients with mucosal disease (n = 24), the change in PDAI showed a strong correlation with changes in the ABQOL and Skindex-S subscale. For patients without mucosal disease, the change in PDAI showed a strong correlation with the Skindex-S. The change in ABSIS showed a strong correlation with Skindex-S for all patients and patients with no mucosal involvement, but showed no strong correlations for patients with mucosal involvement. The changes in PDAI always had a stronger correlation than the changes in ABSIS scores to changes in the ABQOL, DLQI, and Skindex-29 subscales, except where the PDAI and ABSIS scores were about the same for the Skindex-S subscale in patients with no mucosal involvement (r = 0.76 and r = 0.77, respectively). PDAI is superior to ABSIS in its correlation with validated QOL tools. The QOL tools that appear to be of most use in clinical trials and patient management are the Skindex-S and ABQOL.
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Affiliation(s)
- Rebecca L Krain
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Carolyn J Kushner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Meera Tarazi
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca G Gaffney
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Andrea C Yeguez
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Danielle E Zamalin
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - David R Pearson
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States.,Department of Dermatology, University of Minnesota, Minneapolis, MN, United States
| | - Rui Feng
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Victoria P Werth
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
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Concha JSS, Pena S, Gaffney RG, Patel B, Tarazi M, Kushner CJ, Merola JF, Fiorentino D, Dutz JP, Goodfield M, Nyberg F, Volc-Platzer B, Fujimoto M, Ang CC, Werth VP. Developing classification criteria for skin-predominant dermatomyositis: the Delphi process. Br J Dermatol 2019; 182:410-417. [PMID: 31049930 DOI: 10.1111/bjd.18096] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The European League Against Rheumatism/American College of Rheumatology classification criteria for inflammatory myopathies are able to classify patients with skin-predominant dermatomyositis (DM). However, approximately 25% of patients with skin-predominant DM do not meet two of the three hallmark skin signs and fail to meet the criteria. OBJECTIVES To develop a set of skin-focused classification criteria that will distinguish cutaneous DM from mimickers and allow a more inclusive definition of skin-predominant disease. METHODS An extensive literature review was done to generate items for the Delphi process. Items were grouped into categories of distribution, morphology, symptoms, antibodies, histology and contextual factors. Using REDCap™, participants rated these items in terms of appropriateness and distinguishing ability from mimickers. The relevance score ranged from 1 to 100, and the median score determined a rank-ordered list. A prespecified median score cut-off was decided by the steering committee and the participants. There was a pre-Delphi and two rounds of actual Delphi. RESULTS There were 50 participating dermatologists and rheumatologists from North America, South America, Europe and Asia. After a cut-off score of 70 during the first round, 37 of the initial 54 items were retained and carried over to the next round. The cut-off was raised to 80 during round two and a list of 25 items was generated. CONCLUSIONS This project is a key step in the development of prospectively validated classification criteria that will create a more inclusive population of patients with DM for clinical research. What's already known about this topic? Proper classification of patients with skin-predominant dermatomyositis (DM) is indispensable in the appropriate conduct of clinical/translational research in the field. The only validated European League Against Rheumatism/American College of Rheumatology criteria for idiopathic inflammatory myopathies are able to classify skin-predominant DM. However, a quarter of amyopathic patients still fail the criteria and does not meet the disease classification. What does this study add? A list of 25 potential criteria divided into categories of distribution, morphology, symptomatology, pathology and contextual factors has been generated after several rounds of consensus exercise among experts in the field of DM. This Delphi project is a prerequisite to the development of a validated classification criteria set for skin-predominant DM.
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Affiliation(s)
- J S S Concha
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - S Pena
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - B Patel
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M Tarazi
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - C J Kushner
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J F Merola
- Department of Dermatology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - D Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA, U.S.A
| | - J P Dutz
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - M Goodfield
- Department of Dermatology, Leeds General Infirmary, Leeds, U.K
| | - F Nyberg
- Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - B Volc-Platzer
- Department of Dermatology, Wiener Krankenanstaltenverbund, Vienna, Austria
| | - M Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - C C Ang
- Department of Dermatology, Changi General Hospital, Singapore
| | - V P Werth
- Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, U.S.A
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Kushner CJ, Tarazi M, Gaffney RG, Feng R, Ardalan K, Brandling-Bennett HA, Castelo-Soccio L, Chang JC, Chiu YE, Gmuca S, Hunt RD, Kahn PJ, Knight AM, Mehta J, Pearson DR, Treat JR, Wan J, Yeguez AC, Concha JSS, Patel B, Okawa J, Arkin LM, Werth VP. AB002. Evaluation of the reliability and validity of the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) in pediatric cutaneous lupus among pediatric dermatologists and rheumatologists. Ann Transl Med 2019. [DOI: 10.21037/atm.2019.ab002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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9
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Tarazi M, Gaffney RG, Pearson D, Kushner CJ, Werth VP. AB001. Fatigue in systemic lupus erythematosus and other autoimmune skin diseases. Ann Transl Med 2019. [DOI: 10.21037/atm.2019.ab001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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10
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Concha JSS, Tarazi M, Kushner CJ, Gaffney RG, Werth VP. The diagnosis and classification of amyopathic dermatomyositis: a historical review and assessment of existing criteria. Br J Dermatol 2019; 180:1001-1008. [PMID: 30561064 DOI: 10.1111/bjd.17536] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Diagnostic criteria are used to identify a patient having a disease in a clinical setting, whereas classification criteria create a well-defined population for research purposes. The diagnosis and classification of amyopathic dermatomyositis (ADM) have not been recognized by most existing criteria for idiopathic inflammatory myopathies (IIMs). To address this, several criteria were proposed to define ADM either as a distinct disease entity or as a subset of the spectrum of IIMs. OBJECTIVES To discuss the diagnosis and classification of ADM and to assesses the available criteria in identifying cases of ADM and/or distinguishing it from dermatological mimickers such as lupus erythematosus. METHODS We conducted an extensive literature search using the PubMed database from June 2016 to August 2018, using the search terms 'amyopathic dermatomyositis', 'diagnosis' and 'classification'. RESULTS The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) criteria, which are the only validated classification criteria for adult and juvenile IIM and their major subgroups, include three cutaneous items (Göttron sign, Göttron papules, heliotrope rash) to be able to classify ADM. This international and multispecialty effort is a huge step forward in the classification of skin-predominant disease in dermatomyositis. However, about 25% of the population with ADM do not meet two out of the three skin features and are misdiagnosed or classified as having a different disease entity, most commonly lupus erythematosus. CONCLUSIONS These gaps rationalize the continuous assessment and improvement of existing criteria and/or the development of validated, separate and skin-focused criteria for DM.
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Affiliation(s)
- J S S Concha
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - M Tarazi
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - C J Kushner
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
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Kushner CJ, Concha JSS, Pearson DR, Werth VP. Lichen Planus Pigmentosus and Frontal Fibrosing Alopecia Mimicking Discoid Lupus Erythematosus. Arthritis Rheumatol 2019; 71:478. [DOI: 10.1002/art.40779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Carolyn J. Kushner
- Corporal Michael J. Crescenz VAMC and University of Pennsylvania Philadelphia PA
| | | | - David R. Pearson
- Corporal Michael J. Crescenz VAMC and University of Pennsylvania Philadelphia PA
- University of Minnesota Minneapolis MN
| | - Victoria P. Werth
- Corporal Michael J. Crescenz VAMC and University of Pennsylvania Philadelphia PA
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12
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Tarazi M, Gaffney RG, Pearson D, Kushner CJ, Werth VP. Fatigue in systemic lupus erythematosus and other autoimmune skin diseases. Br J Dermatol 2018; 180:1468-1472. [PMID: 30269332 DOI: 10.1111/bjd.17257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fatigue is a well-established symptom in systemic lupus erythematosus (SLE), but has not been well characterized in other skin-limited autoimmune diseases such as cutaneous lupus erythematosus (CLE), amyopathic dermatomyositis (ADM) or autoimmune blistering diseases (AIBD). OBJECTIVES In this retrospective study, we compared fatigue in controls (n = 84) with that in patients enrolled in prospective longitudinal databases with SLE (n = 165), CLE (n = 226), ADM (n = 136) and AIBD (n = 79). METHODS We used the 36-Item Short Form Survey (SF-36) vitality scale to analyse median scores and the percentages of patients with clinically significant fatigue (defined as a score ≤ 35) between experimental groups and controls. RESULTS Median and interquartile range (IQR) vitality scores demonstrated greater fatigue in the experimental groups (SLE 35, IQR 20-55; CLE 50, IQR 30-70; ADM 50, IQR 30-65; AIBD 55, IQR 35-70) than in controls (73, IQR 65-85) (P < 0·05 for each experimental group vs. control). The SLE group had worse fatigue than all of the other groups (P < 0·05 SLE vs. each group), but there was no difference between the CLE, ADM or AIBD groups (all P > 0·05). In addition, the experimental groups had more clinically significant fatigue (score ≤ 35) (SLE 44·2%, CLE 25·2%, ADM 31·6%, AIBD 24·1%) than controls (2%) (P < 0·01 for each experimental group vs. control). The SLE group had more clinically significant fatigue than the CLE group (P < 0·01); however, there was no difference in clinically significant fatigue between SLE and either ADM (P = 0·17) or AIBD (P = 0·055). CONCLUSIONS These findings demonstrate that patients with skin-limited autoimmune disease experience more fatigue than controls. Fatigue is an important symptom that negatively affects quality of life for patients. It should be addressed by clinicians and measured in future clinical trials.
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Affiliation(s)
- M Tarazi
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, U.S.A
| | - D Pearson
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A
| | - C J Kushner
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, U.S.A
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Kushner CJ, Tarazi M, Gaffney RG, Feng R, Ardalan K, Brandling-Bennett HA, Castelo-Soccio L, Chang JC, Chiu YE, Gmuca S, Hunt RD, Kahn PJ, Knight AM, Mehta J, Pearson DR, Treat JR, Wan J, Yeguez AC, Concha JSS, Patel B, Okawa J, Arkin LM, Werth VP. Evaluation of the reliability and validity of the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) in paediatric cutaneous lupus among paediatric dermatologists and rheumatologists. Br J Dermatol 2018; 180:165-171. [PMID: 30033560 DOI: 10.1111/bjd.17012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) is a reliable outcome measure for cutaneous lupus erythematosus (CLE) in adults used in clinical trials. However, it has not been validated in children, limiting clinical trials for paediatric CLE. OBJECTIVES This study aimed to validate the CLASI in paediatrics. METHODS Eleven paediatric patients with CLE, six dermatologists and six rheumatologists participated. The physicians were trained to use the CLASI and Physician's Global Assessment (PGA), and individually rated all patients using both tools. Each physician reassessed two randomly selected patients. Within each physician group, the intraclass correlation coefficient (ICC) was calculated to assess the reliability of each measure. RESULTS CLASI activity scores demonstrated excellent inter- and intrarater reliability (ICC > 0·90), while the PGA activity scores had good inter-rater reliability (ICC 0·73-0·77) among both specialties. PGA activity scores showed excellent (ICC 0·89) and good intrarater reliability (ICC 0·76) for dermatologists and rheumatologists, respectively. Limitations of this study include the small sample size of patients and potential recall bias during the physician rerating session. CONCLUSIONS CLASI activity measurement showed excellent inter- and intrarater reliability in paediatric CLE and superiority over the PGA. These results demonstrate that the CLASI is a reliable and valid outcome instrument for paediatric CLE.
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Affiliation(s)
- C J Kushner
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - M Tarazi
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - R G Gaffney
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - R Feng
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - K Ardalan
- Department of Pediatrics and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, U.S.A
| | - H A Brandling-Bennett
- Department of Pediatrics and Dermatology, University of Washington School of Medicine, Seattle, WA, U.S.A
| | - L Castelo-Soccio
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - J C Chang
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - Y E Chiu
- Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - S Gmuca
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - R D Hunt
- Departments of Dermatology and Pediatrics, Baylor College of Medicine, Houston, TX, U.S.A
| | - P J Kahn
- Department of Pediatrics, Division of Rheumatology, NYU Langone Medical Center, New York, NY, U.S.A
| | - A M Knight
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - J Mehta
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - D R Pearson
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - J R Treat
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - J Wan
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - A C Yeguez
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A
| | - J S S Concha
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - B Patel
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - J Okawa
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
| | - L M Arkin
- Departments of Dermatology and Pediatrics, University of Wisconsin School of Medicine, Madison, WI, U.S.A
| | - V P Werth
- Department of Dermatology, University of Pennsylvania, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, U.S.A.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, U.S.A
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Abstract
Autoimmune bullous diseases (AIBD), including pemphigus, bullous pemphigoid, epidermolysis bullosa acquisita, mucous membrane pemphigoid, and pemphigoid gestationis, pose significant therapeutic challenges, especially in pregnant and post-partum breastfeeding patients or those planning to conceive. Data on the safety and efficacy of therapeutic interventions during the perinatal period are lacking because randomized controlled trials are typically not performed in this setting. However, many of the treatments for AIBD are also used in other diseases, so data can be extrapolated from studies or case reports in these other patient populations. It appears that many of the treatments for AIBD can adversely affect the fetus or neonate, and alterations in immune status caused by pregnancy-associated hormonal changes can negatively impact disease control. This article summarizes and weighs the risks and benefits of the various agents used to treat AIBD during pregnancy. We also present the available information on lactation as well as effects on male fertility.
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Affiliation(s)
- Carolyn J Kushner
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Josef Symon S Concha
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Section of Dermatology, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.
- Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, 2 East Gates, Room 2075, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
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Kushner CJ, Hwang WT, Wang S, Solin LJ, Vapiwala N. Long-term risk of second malignancies in women after breast conservation therapy for ductal carcinoma in situ or early-stage breast cancer. Breast Cancer Res Treat 2018; 170:45-53. [PMID: 29488126 DOI: 10.1007/s10549-018-4729-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/19/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE Women with ductal carcinoma in situ (DCIS) or early-stage breast cancer have an excellent prognosis, but their risk of developing second malignant neoplasms (SMNs) is not well established. We analyzed SMNs in a large cohort with long follow-up after breast conservation therapy. METHODS The study population comprised 755 women with DCIS (n = 135) or stage I-II breast carcinoma (n = 620). Subjects were aged 25-89 (median 55) years when they underwent breast-conserving surgery followed by radiotherapy to the entire breast (60-68Gray) between 1992 and 2001. Additional treatment included hormonal therapy and/or chemotherapy based on clinical characteristics. SMNs were grouped by site. The rate of SMNs over time was determined using the Kaplan-Meier method. To compare the probability of developing SMNs overall and for specific organs or sites, probability estimates were obtained for a 55-year-old female from the Surveillance, Epidemiology, and End Results Program (SEER). RESULTS Median follow-up from radiotherapy was 13.8 years. The 15-year age-adjusted probability of developing any SMN was 12.0%, close to the SEER rate of 12.1% for a non-breast malignancy. Systemic therapy and higher-dose radiotherapy (> 63 Gray) were not associated with significantly increased risks of SMNs. Compared to SEER, significantly increased risk was noted for gynecologic cancers and melanoma. CONCLUSIONS Most SMNs were unrelated to treatment, and the 15-year incidence was similar to that of cancer in the SEER control group-findings that should be reassuring to patients. Further risk reduction is expected from prophylactic gynecologic surgery. Continued investigations into genetic links with melanoma are warranted.
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Affiliation(s)
- Carolyn J Kushner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Shiyu Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence J Solin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.,Department of Radiation Oncology, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
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16
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Kushner CJ, Hwang WT, Solin LJ, Vapiwala N. Long-term risk of second malignancies in women with ductal carcinoma in situ or early-stage invasive breast cancer after breast conservation treatment. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e12103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12103 Background: Women with ductal carcinoma in situ (DCIS) or early stage breast cancer have a good prognosis after breast conservation treatment (BCT), and are at risk for second malignant neoplasms (SMNs). The long-term risk of SMNs is not well established and carries important public health implications. Methods: A total of 755 women with DCIS or stage I-II invasive breast cancer underwent breast-conserving surgery followed by definitive breast irradiation between 1995 and 2001. Systemic therapy (chemotherapy and/or hormonal therapy) was given to 73% of the patients. We have previously described patient demographics and 15-year oncologic outcomes in detail (Vapiwala, Cancer, 2017). The patient records were reviewed for development of SMNs. SMNs of any anatomic site (other than contralateral breast cancer and basal/squamous cell carcinoma of the skin) were included for analysis. The Kaplan-Meier method was used to determine the rate of SMNs over time. Median follow-up was 13.8 years. Results: The 5-, 10-, and 15-year rates of developing any SMN were 3.6% (95% CI 2.4-5.3%), 7.8% (95% CI 6.0-10.2%), and 12.7% (95% CI 10.2-15.8%). The most common SMNs were uterine (n=12), leukemia/lymphoma (n=11), melanoma (n=10), ovarian (n=9), and lung (n=7). Conclusions: Development of SMNs is a substantial risk for a protracted period of time following BCT. Clinical patterns of specific SMN histologies, locations and time course of development suggest potential opportunities for screening and treatment to guide patient survivorship clinics and protocols.
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Affiliation(s)
- Carolyn J. Kushner
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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17
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Vapiwala N, Hwang WT, Kushner CJ, Schnall MD, Freedman GM, Solin LJ. No impact of breast magnetic resonance imaging on 15-year outcomes in patients with ductal carcinoma in situ or early-stage invasive breast cancer managed with breast conservation therapy. Cancer 2016; 123:1324-1332. [PMID: 27984658 DOI: 10.1002/cncr.30479] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 10/25/2016] [Accepted: 11/07/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND For women undergoing breast conservation therapy (BCT), the added value of breast magnetic resonance imaging (MRI) at the time of initial diagnosis remains controversial. The current study was performed to determine long-term outcomes after BCT for women with and without pretreatment breast MRI. METHODS Between 1992 and 2001, a total of 755 women with ductal carcinoma in situ or early-stage invasive breast cancer underwent breast-conserving surgery (with axillary lymph node staging for invasive carcinoma) followed by definitive breast radiotherapy. Evaluation at the time of the initial diagnosis included conventional mammography in all subjects and breast MRI in 215 women (28%). Clinical, pathologic, and treatment characteristics were comparable for patients with and without breast MRI. Outcomes were determined using the Kaplan-Meier method and compared using the log-rank method. RESULTS At a median follow-up of 13.8 years, there were 49 local failures (15 women with and 34 women without breast MRI, respectively). The 15-year local failure rates were 8% for women with and 8% for women without MRI (P = .59). There also were no differences noted between women with and without breast MRI with regard to 15-year rates of overall survival (77% vs 71%; P = .24), freedom from distant metastases (86% vs 90%; P = .08), and contralateral breast cancer (10% vs 8%; P = .10). Multivariate analysis demonstrated no significant impact of breast MRI on local failure (P = .96). CONCLUSIONS Breast MRI during the initial evaluation for BCT appears to have no significant impact on 15-year rates for local control, overall survival, freedom from distant metastases, or contralateral breast cancer. The routine use of pretreatment breast MRI is not indicated for patients undergoing BCT. Cancer 2017;123:1324-1332. © 2016 American Cancer Society.
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Affiliation(s)
- Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei-Ting Hwang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carolyn J Kushner
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mitchell D Schnall
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary M Freedman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lawrence J Solin
- Department of Radiation Oncology, Albert Einstein Healthcare Network, Philadelphia, Pennsylvania
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Kushner CJ, Vapiwala N, Hwang WT, Freedman GM, Solin LJ. Impact of breast magnetic resonance imaging (MRI) on long-term outcome after breast conservation therapy (BCT). J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.1053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Carolyn J. Kushner
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Wei-Ting Hwang
- University of Pennsylvania, Department of Biostatistics and Epidemiology, Philadelphia, PA
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