Impact of individualized treatment on recovery from fatigue and return to work in survivors of advanced-stage Hodgkin's lymphoma: results from the randomized international GHSG HD18 trial

BACKGROUND

Persisting cancer-related fatigue impairs health-related quality of life (HRQoL) and social reintegration in patients with Hodgkin's lymphoma (HL). The GHSG HD18 trial established treatment de-escalation for advanced-stage HL guided by positron emission tomography after two cycles (PET-2) as new standard. Here, we investigate the impact of treatment de-escalation on long-term HRQoL, time to recovery from fatigue (TTR-F), and time to return to work (TTR-W).

PATIENTS AND METHODS

Patients received European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and life situation questionnaires at baseline, interim, end of treatment, and yearly follow-up. TTR-F was defined as time from the end of chemotherapy until the first fatigue score <30. TTR-W was analyzed in previously working or studying patients and measured from the end of treatment until the first documented work or education. We compared duration of treatment on TTR-F and TTR-W using Cox proportional hazards regression adjusted for confounding variables.

RESULTS

HRQoL questionnaires at baseline were available in 1632 (83.9%) of all randomized patients. Overall, higher baseline fatigue and age were significantly associated with longer TTR-F and TTR-W and male sex with shorter TTR-W. Treatment reduction from eight to four chemotherapy cycles led to a significantly shorter TTR-F [hazard ratio (HR) 1.41, P = 0.008] and descriptively shorter TTR-W (HR 1.24, P = 0.084) in PET-2-negative patients. Reduction from six to four cycles led to non-significant but plausible intermediate accelerations. The addition of rituximab caused significantly slower TTR-F (HR 0.70, P = 0.0163) and TTR-W (HR 0.64, P = 0.0017) in PET-2-positive patients. HRQoL at baseline and age were the main determinants of 2-year HRQoL.

CONCLUSIONS

Individualized first-line treatment in patients with advanced-stage HL considerably shortens TTR-F and TTR-W in PET-2-negative patients. Our results support the use of response-adapted shortened treatment duration for patients with HL.

Visualization of fibroblast activation after myocardial infarction using 68Ga-FAPI-PET

Introduction

Fibroblast activation protein (FAP) alpha specifically expressed by activated fibroblasts has been shown to be significantly involved in processes of tissue healing after injury, including fibrotic remodeling after myocardial infarction (MI). Positron-emission tomography (PET) with the tracer FAP-inhibitor (FAPI) is a novel diagnostic tool primarily described in oncologic patients for tumor stroma detection. We present data from a pilot study investigating patients after MI who underwent subsequent 68Ga-FAPI-PET for assessment of potential FAP-related myocardial remodeling.

Methods

In this retrospective study we analyzed a cohort of 10 post-MI patients who underwent 68Ga-FAPI-PET imaging with respect to cardiac tracer pattern. Standardized maximum and mean uptake values and total volume of tracer enrichment (fibroblast activation volume, FAV) of the infarcted area were calculated. A visual grading scale was established to assess the level of agreement between maximum localized tracer uptake and segments belonging to the supply area of the culprit vessel. Tracer uptake was correlated to clinical variables, with readers blinded to the clinical characteristics.

Results

Focal 68Ga-FAPI uptake was detected in all 10/10 patients after MI. According to our grading system for visual agreement of polar map segments and culprit lesion, we observed a very good (in 37.5% of patients) and a moderate (62.5% of patients) match between tracer uptake and the culprit lesion, respectively. We demonstrated a negative correlation of FAV uptake and left ventricular systolic function (R2=−0.69, p&lt;0.05) and a very strong positive correlation of FAV and peak creatinine kinase level (R2=0.90, p&lt;0.01).

Conclusion

Increased myocardial 68Ga-FAPI uptake, serving as a surrogate for FAP expression after MI, corresponds well to the supply area of the culprit coronary vessel as well as to biomarker levels of myocardial injury. This imaging technique represents a highly promising, novel bio-signal in the assessment of myocardial injury and consecutive remodeling. Large controlled studies are warranted to further evaluate the prognostic impact of this novel imaging technique.

Funding Acknowledgement

Type of funding sources: None.

Cardiac fibroblast activation detected by Ga-68 FAPI PET imaging as a potential novel biomarker of cardiac injury/remodeling

BACKGROUND

Fibroblast activation protein (FAP) as a specific marker of activated fibroblasts can be visualized by positron emission tomography (PET) using Ga-68-FAP inhibitors (FAPI). Gallium-68-labeled FAPI is increasingly used in the staging of various cancers. In addition, the first cases of theranostic approaches have been reported. In this work, we describe the phenomenon of myocardial FAPI uptake in patients who received a Ga-68 FAPI PET for tumor staging.

METHOD AND RESULTS

Ga-68 FAPI PET examinations for cancer staging were retrospectively analyzed with respect to cardiac tracer uptake. Standardized uptake values (SUV) were correlated to clinical covariates in a univariate regression model. From 09/2018 to 11/2019 N = 32 patients underwent FAPI PET at our institution. Six out of 32 patients (18.8%) demonstrated increased localized myocardial tracer accumulation, with remote FAPI uptake being significantly higher in patients with vs without localized focal myocardial uptake (SUVmax 2.2 ± .6 vs 1.5 ± .4, P < .05 and SUVmean 1.6 ± .4 vs 1.2 ± .3, P < .05, respectively). Univariate regression demonstrated a significant correlation of coronary artery disease (CAD), age and left ventricular ejection fraction (LVEF) with remote SUVmean uptake, the latter with a very strong correlation with remote uptake (R2 = .74, P < .01).

CONCLUSION

Our study indicates an association of CAD, age, and LVEF with FAPI uptake. Further studies are warranted to assess if fibroblast activation can be reliably measured and may be used for risk stratification regarding early detection or progression of CAD and left ventricular remodeling.

Hypermagnesemia as a cause of refractory hypotension, respiratory depression, and coma

Hypermagnesemia developed in a patient as a result of excess antacid ingestion, bowel obstruction, and renal failure. Before the diagnosis was considered, refractory hypotension, respiratory depression, and coma developed, all of which were eventually reversed through the lowering of the serum magnesium concentration by hemodialysis.

Selective inhibition of bacterial enzymes by free fatty acids

Octanoic acid inhibits, in vitro, the bacterial enzymes glucose-6-phosphate dehydrogenase, phosphofructokinase, pyruvate kinase, fumarase, lactate dehydrogenase, and the malic enzyme of Arthrobacter crystallopoietes. The free fatty acid appears to act as an inhibitor of lipogenesis, although it does not affect the rate of gluconeogenesis. To demonstrate that this inhibition may be of physiological significance in vivo, those enzymes not involved in lipogenesis, such as fructose-1, 6-diphosphatase, phosphoglucomutase, phosphohexoisomerase, aconitase, nicotinamide adenine dinucleotide phosphate (NADP) isocitrate dehydrogenase, NADP glutamate dehydrogenase, malate dehydrogenase, and isocitrate lyase, were assayed and found not to be inhibited by the free fatty acid.