Belatacept for Simultaneous Calcineurin Inhibitor and Chronic Corticosteroid Immunosuppression Avoidance

Immunosuppressive therapy in kidney transplantation is associated with numerous toxicities. CD28-mediated T cell costimulation blockade using belatacept may reduce long-term nephrotoxicity, compared with calcineurin inhibitor-based immunosuppression. The efficacy and safety of simultaneous calcineurin inhibitor avoidance and rapid steroid withdrawal were tested in a randomized, prospective, multi-center study. Methods All kidney transplants were performed using rapid steroid withdrawal immunosuppression. Recipients were randomized to 1:1:1 to receive belatacept with alemtuzumab induction, belatacept with rabbit antithymocyte globulin (rATG) induction, or tacrolimus with rATG induction. The composite endpoint consisted of death, kidney allograft loss, or an MDRD calculated eGFR of <45 ml/min/1.73m² at 2 years. Results The composite endpoint was observed for 11/107 (10%) participants assigned to belatacept/alemtuzumab, 13/104 (13%) assigned to belatacept /rATG, and 21/105 (21%) assigned to tacrolimus/rATG (belatacept/alemtuzumab vs tacrolimus/rATG p = 0.99: belatacept/rATG vs tacrolimus/rATG p = 0.66). Patient and graft survival rates were similar between all groups. eGFR <45 ml/min/1.73m² was observed for 9/107 (8%) participants assigned to belatacept/alemtuzuab, 8/104 (8%) participants assigned to belatacept/rATG, and 20/105 (19%) participants assigned to tacrolimus/rATG (p<0.05 for each belatacept group vs tacrolimus/rATG). Biopsy-proven acute rejection was observed for 20/107 (19%) participants assigned to belatacept/alemtuzuab, 26/104 (25%) participants assigned to belatacept/rATG, and 7/105 (7%) participants assigned to tacrolimus/rATG (belatacept/alemtuzumab vs tacrolimus/rATG p = 0.006: belatacept/rATG vs tacrolimus/rATG p < 0.001). Gastrointestinal and neurologic adverse events were less frequent with belatacept versus calcineurin based immunosuppression. Conclusions Overall two-year outcomes were similar comparing maintenance immunosuppression based on belatacept versus tacrolimus, each protocol with rapid steroid withdrawal. The incidence of eGFR <45 ml/min/1.73m² was significantly lower but the incidence of biopsy proven acute rejection significantly higher with belatacept compared with tacrolimus.

Belatacept-based immunosuppression with simultaneous calcineurin inhibitor avoidance and early corticosteroid withdrawal: A prospective, randomized multicenter trial

Simultaneous calcineurin inhibitor avoidance (CNIA) and early corticosteroid withdrawal (ESW) have not been achieved primarily due to excessive acute rejection. This trial compared 2 belatacept-based CNIA/ESW regimens with a tacrolimus-based ESW regimen. Kidney transplant recipients were randomized to receive alemtuzumab/belatacept, rabbit anti-thymocyte globulin (rATG)/belatacept, or rATG/tacrolimus. The combinatorial primary endpoint consisted of patient death, renal allograft loss, or a Modification of Diet in Renal Disease-calculated eGFR of <45 mL/min/1.73 m² at 12 months. Results are reported by treatment group (alemtuzumab/belatacept, rATG/belatacept, and rATG/tacrolimus). Superiority was not observed at 1 year for the primary endpoint (9/107 [8.4%], 15/104 [14.4%], and 14/105 [13.3%], respectively; P = NS) for either belatacept-based regimen. Differences were not observed for secondary endpoints (death, death-censored graft loss, or estimated glomerular filtration rates < 45 mL/min/1.73 m² ). Differences were observed in biopsy-proved acute cellular rejection (10.3%, 18.3%, and 1.9%, respectively) (P < .001), but not in antibody-mediated rejection, mixed acute rejection, or de novo donor-specific anti-HLA antibodies. Neurologic and electrolyte abnormality adverse events were less frequent under belatacept. Belatacept-based CNIA/ESW regimens did not prove to be superior for the primary or secondary endpoints. Belatacept-treated patients demonstrated an increase in biopsy-proved acute cellular rejection and reduced neurologic and metabolic adverse events. These results demonstrate that simultaneous CNIA/ESW is feasible without excessive acute rejection.

Abstract P6-19-02: Tumor subtypes and survival in male breast cancer: SEER 2010-2014

Background: Male breast cancer (MaBC) is an uncommon disease, and population-based information regarding prognostic factors is limited. Most MaBC are hormone receptor (HR) positive, however, the association of tumor subtypes with overall survival (OS) and breast cancer-specific survival (BCSS) is unclear. The aim of this study was to analyze the characteristics of each tumor subtype and its impact on OS and BCSS.

Methods: Using Surveillance, Epidemiology, and End Results (SEER) data, we identified men with invasive breast cancer between 2010 and 2014 with known estrogen receptor and progesterone receptor (together HR) status and human epidermal growth factor receptor 2 (HER2) status. Tumor subtypes were classified as: HR+/HER2-, HR+/HER2+, HR-/HER2+ and triple negative (TN). We examined tumor subtypes by patient (pt) characteristics and performed multivariate Cox proportional hazards analyses to determine the associations of each variable with OS and BCSS.

Results: We included 1508 pts with a median follow-up of 24 months (range 0-60). Median age was 65 years (range 26-97). At diagnosis, 86.6% of tumors were ductal, 97.1% HR+, 42.1% T1, 55.7% N0, 7.9% M1. Tumor subtype distribution was: 85.5% HR+/HER2-, 11.6% HR+/HER2+, 0.9% HR-/HER2+ and 2% TN. Compared with other subtypes, pts with TN tumors had higher grade disease, presented with more advanced stage and died more often from breast cancer (all p&lt;0.0001); whereas pts with HR+/HER2- tumors were older (p=0.02) and more often white (p=0.02). In univariate analysis, OS at 5 years for all HER2- and all HER2+ was 74.2% and 64.1%, respectively (p=0.002); while BCSS at 5 years for all HER2- and all HER2+ was 88.4% and 78.8%, respectively (p=0.009). Of all subtypes, TN had the worst OS and BCSS (p&lt;0.0001). Breast cancer was the cause of death in 43.7% of HR+/HER2-, 54.2% of all HER2+ and 100% of TN (p&lt;0.0001). In multivariate analyses for OS, older pts (Hazard ratio [HaR] 3 vs. &lt;50 years; p=0.001), stage IV (HaR 9 vs. stage I; p&lt;0.001), HR+/HER2+ tumors (HaR 1.9 vs. HR+/HER2-; p=0.003), TN tumors (HaR 8.5 vs. HR+/HER2-; p&lt;0.001) and unmarried pts (HaR 1.9 vs. married; p=0.002) had significantly worse survival. In multivariate analyses for BCSS, stage IV (HaR 25.7 vs. stage I; p&lt;0.001), HR+/HER2+ tumors (HaR 2.1 vs. HR+/HER2-; p=0.019), TN tumors (HaR 17 vs. HR+/HER2-; p&lt;0.001) and unmarried pts (HaR 2.2 vs. married; p=0.009) had significantly worse survival.

Conclusion: We observed significant differences in outcomes by tumor type in men with breast cancer which mirror those previously observed for women with breast cancer. Among the limited numbers of men with HER2+ and TN disease in our sample, outcomes were poor, suggesting possible under-treatment, aggressive tumor biology, and/or more advanced of disease at presentation. Studies to better understand the inferior survival for men with these subtypes are warranted and efforts to ensure appropriate treatment are paramount.

Citation Format: Leone J, Freedman RA, Zwenger AO, Lin NU, Tolaney SM, Vallejo CT, Leone BA, Winer EP, Leone JP. Tumor subtypes and survival in male breast cancer: SEER 2010-2014 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-19-02.

Abstract P5-23-06: Metastatic pattern in stage IV male breast cancer at initial diagnosis: A population-based study

Background: Male breast cancer (MaBC) is a relatively uncommon disease, representing less than 1% of all breast cancers. Although men tend to present at more advanced stages, the prognostic influence of metastatic pattern (MP), sites of metastases and factors associated with specific organ involvement are unknown. The primary aim of this study was to analyze the influence of MP compared with other biologic and clinical factors in the survival of patients (pts) with stage IV breast cancer at initial diagnosis (BCID). Secondary aims were to describe sites of metastases and evaluate factors associated with specific sites of metastatic spread.

Methods: We evaluated men with microscopically confirmed stage IV BCID with known metastatic sites, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program from 2010 to 2014. Pts with other primary tumor either before or after breast cancer were excluded. MP was categorized as bone only, visceral (lung, liver or brain), bone and visceral and other. Pt characteristics were compared between MP. Univariate and multivariate analyses determined the effects of each variable on overall survival (OS). Logistic regression examined factors associated with specific sites of metastases.

Results: We included 136 pts. Median age was 63 years (range 28-91). At diagnosis, bone only metastases represented 31.6% of pts, visceral 16.2%, bone and visceral 38.2% and other 14%. Median OS for the entire cohort was 33 months (95% CI 19 months – not reached). Bone was the most common site of metastases (69.9%), followed by lung (44.9%), liver (14%) and brain (8.1%). OS rate at 3 years by MP was: bone only 46.05%, visceral 53.57%, bone and visceral 37.23% and other 70.56% (p=0.41). There were no significant differences in pt or tumor characteristics between MP. However, in adjusted logistic regression, triple negative (TN) and ER/PR+/HER2+ tumors had higher odds of brain metastases than ER/PR+/HER2- (all p&lt;0.05). Also, ER/PR+/HER2+ tumors had higher odds of liver metastases (p=0.027). Univariate analysis showed that older age (HR 1.7; p=0.03), no surgery (HR2.5; p=0.005), TN tumors (HR 5.6; p&lt;0.001) and pts with brain metastases (HR 4.2; p&lt;0.001) had worse prognosis. In multivariate analysis, TN subtype (HR 4.2; p=0.001) and pts with brain metastases (HR 3.44; p=0.012) had significantly shorter OS.

Conclusions: To our knowledge, this is the first study of MP in MaBC. The cohort had an acceptable median OS which did not differ significantly according to MP. Although brain metastases were less common, it is important to recognize their worse prognosis. Independent predictors of OS included tumor subtype and brain metastases. Tumor subtype had a clear influence on specific sites of metastases, particularly for brain and liver involvement.

Citation Format: Leone JP, Leone BA, Zwenger AO, Vallejo CT, Romero AO, Machiavelli MR, Perez JE, Leone J. Metastatic pattern in stage IV male breast cancer at initial diagnosis: A population-based study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-23-06.

Abstract P1-12-02: Prognostic factors and survival according to tumor subtype in women presenting with breast cancer brain metastases at initial diagnosis

Background: Breast cancer represents one of the most common causes of brain metastases. The occurrence of this event is a catastrophic complication of metastatic breast cancer, associated with poor prognosis. However, the presence of brain metastases at the time of initial breast cancer diagnosis (BMIBCD) is uncommon. Because of this, the prognostic assessment and management of patients (pts) who present with BMIBCD is very challenging. The aim of this study was to analyze the influence of tumor subtype compared with other prognostic factors in the survival of pts who present with BMIBCD.

Methods: We evaluated women with brain metastases at the time of initial diagnosis of microscopically confirmed breast cancer, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program from 2010 to 2013. Pts with other primary malignancy either before or after breast cancer were excluded. Pt characteristics were compared between tumor subtypes. Univariate and multivariate analyses were performed to determine the effects of each variable on overall survival (OS).

Results: Seven hundred forty pts were included. Median age was 60 years (range 26-93). After a median follow-up of 6 months (range 1-48), median OS for the whole population was 10 months and 20.7% of pts were alive at 36 months. At diagnosis, brain was the only site of metastasis in 125 pts, whereas 66.2% of pts had metastases in bone, 33.2% in liver and 44.7% in lung. Tumor subtype distribution was: 46.6% hormone receptor (HR)+/HER2-, 17% HR+/HER2+, 14.1% HR-/HER2+ and 22.3% triple negative (TN). Pts with TN brain metastases had higher grade (p&lt;0.0001), higher rate of brain only (p=0.001) and lung metastases (p=0.03), had lower rates of bone metastases (p&lt;0.0001) and were more likely to die from breast cancer (p&lt;0.0001). Univariate analysis showed that older age (p=0.0002), black race (p=0.004), lobular histology (p=0.01), unmarried pts (p=0.01), the presence of liver (p&lt;0.0001) and lung metastases (p=0.002) and TN pts (median OS 6 months; p&lt;0.0001) had worse prognosis. The HR+/HER2+ subtype had the longest OS with a median of 22 months. In multivariate analysis, older age (hazard ratio 1.8; p=0.001), lobular histology (hazard ratio 2.08; p=0.006), TN subtype (hazard ratio 2.25; p&lt;0.001), liver metastases (hazard ratio 1.6; p=0.001) and unmarried pts (hazard ratio 1.39; p=0.04) had significantly shorter OS. Race, tumor grade, bone metastases, lung metastases and brain only metastases had no association with OS.

Conclusions: To our knowledge, this is the largest study of BMIBCD. Although the prognosis of these pts is generally poor, it is important to notice that 20.7% of pts were still alive 3 years after diagnosis. There were substantial differences in OS according to tumor subtype, TN pts had the shortest OS. HR+/HER2- represented the largest proportion of cases, therefore these pts should not be ignored when designing clinical trials for pts with brain metastases. In addition to tumor subtype, other independent predictors of OS are age at diagnosis, marital status, histology and liver metastases.

Citation Format: Leone JP, Leone J, Zwenger AO, Iturbe J, Leone BA, Vallejo CT. Prognostic factors and survival according to tumor subtype in women presenting with breast cancer brain metastases at initial diagnosis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-12-02.

Abstract P6-09-21: Prognostic impact of metastatic pattern in stage IV breast cancer at initial diagnosis

Background: Stage IV breast cancer at initial diagnosis (BCID) can be recognized in approximately 5% of all breast neoplasms. Clinical outcomes of these patients (pts) are highly variable and depend on tumor biology and pt characteristics. The prognostic influence of metastatic pattern (MP) at initial presentation and factors associated with specific organ involvement have been understudied. The primary aim of this study was to analyze the influence of MP compared with other biologic and clinical factors in the survival of pts with stage IV BCID. The secondary aim was to evaluate factors associated with specific sites of metastatic spread.

Methods: We evaluated women with microscopically confirmed stage IV BCID with known metastatic sites, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program from 2010 to 2013. Pts with other primary tumor either before or after breast cancer were excluded. MP was categorized as bone only, visceral (lung, liver or brain), bone and visceral and other. Pt characteristics were compared between MP. Univariate and multivariate analyses determined the effects of each variable on overall survival (OS). Logistic regression examined factors associated with specific sites of metastases.

Results: We included 9143 pts. Median age was 61 years (range 19-102). Median OS for the entire cohort was 28 months (95% CI 27-29 months). At diagnosis, bone only metastases represented 37.5% of pts, visceral 21.9%, bone and visceral 28.8% and other 11.9%. Median OS by MP was: bone only 38 months, visceral 21 months, bone and visceral 19 months and other 33 months (p&lt;0.0001). Bone was the most common site of metastases (66.2%), followed by lung (30.5%), liver (26.2%) and brain (7.4%). Pts with visceral metastases were more often black race, had higher grade, less likely to be lobular histology and more likely to be triple negative (TN) (all p&lt;0.0001). Univariate analysis showed that older age, black race, grade 3/4 tumors, TN pts, bone and visceral MP, higher number of metastatic sites and unmarried pts had worse prognosis (all p&lt;0.0001). In multivariate analysis, older age (HR 1.9; p&lt;0.001), black race (HR 1.17; p=0.002), grade 3/4 tumors (HR 1.6; p&lt;0.001), TN subtype (HR 2.24; p&lt;0.001), bone and visceral MP (HR 2.07, p&lt;0.001) and unmarried pts (HR 1.25; p&lt;0.001) had significantly shorter OS. In adjusted logistic regression, as compared with ER/PR+/HER2- tumors, TN and ER/PR-/HER2+ had higher odds of brain, liver, lung and other metastases (all p&lt;0.05). ER/PR+/HER2+ had higher odds of liver metastases (p&lt;0.001). All three subtypes had lower odds of bone metastases (p&lt;0.001).

Conclusions: To our knowledge, this is the largest study of MP in stage IV BCID. There were substantial differences in prognosis according to MP, bone only was the most common MP and had the best OS, whereas bone and visceral MP had the worst prognosis. We observed significant differences in pt characteristics according to MP. Independent predictors of OS included age at diagnosis, race, marital status, tumor grade, tumor subtype and MP. There was a clear influence of tumor subtype among other factors on specific sites of metastases. Our study identified several prognostic factors that could guide therapy selection in treatment naïve pts.Background: Stage IV breast cancer at initial diagnosis (BCID) can be recognized in approximately 5% of all breast neoplasms. Clinical outcomes of these patients (pts) are highly variable and depend on tumor biology and pt characteristics. The prognostic influence of metastatic pattern (MP) at initial presentation and factors associated with specific organ involvement have been understudied. The primary aim of this study was to analyze the influence of MP compared with other biologic and clinical factors in the survival of pts with stage IV BCID. The secondary aim was to evaluate factors associated with specific sites of metastatic spread.

Methods: We evaluated women with microscopically confirmed stage IV BCID with known metastatic sites, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program from 2010 to 2013. Pts with other primary tumor either before or after breast cancer were excluded. MP was categorized as bone only, visceral (lung, liver or brain), bone and visceral and other. Pt characteristics were compared between MP. Univariate and multivariate analyses determined the effects of each variable on overall survival (OS). Logistic regression examined factors associated with specific sites of metastases.

Results: We included 9143 pts. Median age was 61 years (range 19-102). Median OS for the entire cohort was 28 months (95% CI 27-29 months). At diagnosis, bone only metastases represented 37.5% of pts, visceral 21.9%, bone and visceral 28.8% and other 11.9%. Median OS by MP was: bone only 38 months, visceral 21 months, bone and visceral 19 months and other 33 months (p&lt;0.0001). Bone was the most common site of metastases (66.2%), followed by lung (30.5%), liver (26.2%) and brain (7.4%). Pts with visceral metastases were more often black race, had higher grade, less likely to be lobular histology and more likely to be triple negative (TN) (all p&lt;0.0001). Univariate analysis showed that older age, black race, grade 3/4 tumors, TN pts, bone and visceral MP, higher number of metastatic sites and unmarried pts had worse prognosis (all p&lt;0.0001). In multivariate analysis, older age (HR 1.9; p&lt;0.001), black race (HR 1.17; p=0.002), grade 3/4 tumors (HR 1.6; p&lt;0.001), TN subtype (HR 2.24; p&lt;0.001), bone and visceral MP (HR 2.07, p&lt;0.001) and unmarried pts (HR 1.25; p&lt;0.001) had significantly shorter OS. In adjusted logistic regression, as compared with ER/PR+/HER2- tumors, TN and ER/PR-/HER2+ had higher odds of brain, liver, lung and other metastases (all p&lt;0.05). ER/PR+/HER2+ had higher odds of liver metastases (p&lt;0.001). All three subtypes had lower odds of bone metastases (p&lt;0.001).

Conclusions: To our knowledge, this is the largest study of MP in stage IV BCID. There were substantial differences in prognosis according to MP, bone only was the most common MP and had the best OS, whereas bone and visceral MP had the worst prognosis. We observed significant differences in pt characteristics according to MP. Independent predictors of OS included age at diagnosis, race, marital status, tumor grade, tumor subtype and MP. There was a clear influence of tumor subtype among other factors on specific sites of metastases. Our study identified several prognostic factors that could guide therapy selection in treatment naïve pts.

Citation Format: Leone BA, Vallejo CT, Romero AO, Machiavelli MR, Perez JE, Leone J, Leone JP. Prognostic impact of metastatic pattern in stage IV breast cancer at initial diagnosis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-21.

Abstract P6-19-01: Prognostic factors in male breast cancer: A population-based study

Background: Male breast cancer (MaBC) is a relatively uncommon disease, representing less than 1% of all breast cancers. Given its rarity, information about prognostic factors is unclear and mainly extrapolated from data from female breast cancer. This represents an important challenge for the risk assessment and treatment decisions in men. The aim of this study was to analyze the characteristics of patients with MaBC and factors associated with prognosis over the past decade.

Methods: We evaluated men with microscopically confirmed invasive breast cancer diagnosed between 2003 and 2012, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program. Patients (pts) with other primary malignancy either before or after breast cancer were excluded. Pt characteristics were compared between tumor grades. Univariate and multivariate analyses were performed to determine the effects of each variable on overall survival (OS).

Results: We included 2992 pts. Median age was 65 years (range 23-97). Median follow-up was 36 months (range 0-119). At diagnosis, ductal histology represented 85% of cases, ER positive 95.1% and PR positive 86%. Thirty-one percent were Stage I, 42% stage II, 18% stage III and 9% stage IV. Only 12.8% of pts had breast conservation and 23.7% received adjuvant radiotherapy. Tumor grade distribution was: 12.4% grade 1, 51.5% grade 2 and 36% grade 3/4. Pts with grade 3/4 tumors were more likely mixed ductal and lobular histology (p&lt;0.0001), more often ER and PR negative (p&lt;0.0001), presented with more advanced stage (p&lt;0.0001), were more likely to have mastectomy and radiotherapy (p&lt;0.0001 and p=0.001, respectively) and to die from breast cancer (p&lt;0.0001). Univariate analysis showed that older age, black race, grade 3/4 tumors, stage IV disease, no surgery, no radiotherapy, ER negative tumors, PR negative tumors and unmarried pts had worse prognosis. Most deaths in the ER negative group occurred within the first 5 years (OS rate at 5 years 66.2%). OS rates between ER positive and ER negative groups were similar after 7.5 years (60.9% and 61.9%, respectively). In multivariate analysis, older age, grade 3/4 tumors, stage IV disease, no surgery, no radiotherapy, ER negative tumors and unmarried pts had shorter OS.

 Univariate pMultivariate pAge&lt;0.0001&lt;0.0001Race0.0001NSGrade&lt;0.00010.006Stage&lt;0.0001&lt;0.0001Surgery&lt;0.00010.0001Radiation0.020.004ER0.030.04PR0.005NSMarital status&lt;0.0001&lt;0.0001HistologyNS 

Conclusions: MaBC is most commonly diagnosed at early stages of disease. Tumors are frequently ductal in histology with high rates of ER positivity, however grade 1 is uncommon. We observed significant differences in pt characteristics according to tumor grade. The main difference in OS by ER status is seen during the first 5 years. Age at diagnosis, tumor grade, stage, surgery, radiotherapy, ER and marital status have clear influence on OS in MaBC over the past decade.

Citation Format: Leone JP, Zwenger AO, Iturbe J, Leone J, Leone BA, Vallejo CT, Bhargava R. Prognostic factors in male breast cancer: A population-based study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-19-01.

Achilles tendinitis in systemic lupus erythematosus: search for an associated inflammatory disease

OBJECTIVES

Except for traumatic and iatrogenic causes, Achilles tendinitis (AT) is mostly encountered in the context of inflammatory rheumatic diseases. This study aimed to describe AT in systemic lupus erythematosus (SLE).

PATIENTS AND METHODS

Among 158 SLE patients who fulfilled the SLE criteria of the ACR classification followed between 1980 and 2013, we selected those who experienced at least one episode of AT not caused by traumatic or toxicity factors.

RESULTS

Eight patients (one male, seven females), median age 52 years (range: 35-68), presented with 11 episodes of AT within an average of 10.5 (0-21) years after SLE diagnosis. Clinical presentation of SLE was mainly cutaneous (eight of eight), and articular (seven of eight). Axial symptoms were reported in six patients, two of whom had HLA-B27-positive status, and fulfilled the Amor and European Spondylarthropathy Study Group criteria. Resolution of AT was good with nonsteroidal anti-inflammatory topical or systemic drug therapies, which kept SLE quiescent and avoided any increase of specific treatment.

CONCLUSION

Although the association is rare, when AT occurs in SLE patients, physicians should look for associated spondylarthritis.

[Whipple disease revealed by anti-TNFα therapy]

INTRODUCTION

Whipple disease is a rare infectious disease with protean clinical manifestations. This infection may mimic chronic inflammatory rheumatisms such as rheumatoid arthritis or spondylarthritis. In this context, introduction of a biotherapy after a diagnostic hesitation does not always lead to early complications. Sometimes, the clinical degradation follows an initial improvement, encouraging continuation of the immunosuppressive treatment and leading consequently to a greater diagnostic delay.

CASE REPORTS

We report two cases of Whipple disease diagnosed in the context of an inflammatory disease with anti-TNFα failure. The first patient was a 53-year-old man who presented with an axial and peripheral spondylarthritis who was treated with etanercept and adalimumab. The second was a 42-year-old man who received adalimumab and then etanercept for a peripheral spondylarthritis.

CONCLUSION

Whipple disease should be suspected in all patients who present with a chronic inflammatory rheumatism that is partially or not controlled with anti-TNFα therapy and who had persisting elevated acute phase reactants.

Efficacy of rituximab in primary Sjogren's syndrome with peripheral nervous system involvement: results from the AIR registry

OBJECTIVE

To evaluate rituximab (RTX) in primary Sjögren's syndrome (pSS) with peripheral nervous system (PNS) involvement.

METHODS

Patients with pSS and PNS involvement who were included in the French AIR registry were analysed.

RESULTS

17 patients (age 60 years (44-78 years); 14 were female) were analysed. Neurological improvement was noted in 11 patients (65%) at 3 months. Rankin scale decreased from 3 (1-5) to 2 (1-5), 2 (1-5) and 2 (1-6) after 3, 6 and 9 months (p=0.02). European Sjögren's Syndrome Disease Activity Index decreased from 18 (10-44) to 11 (5-20), 11 (5-29) and 12 (5-30) after 3, 6 and 9 months (p<0.05). RTX was effective in neurological involvement in 9/10 patients with vasculitis or cryoglobulinaemia (90%) (group 1) at 3 months and in 2/7 cases (29%) without cryoglobulinaemia and vasculitis (p=0.03). Rankin and European Sjögren's Syndrome Disease Activity Index scales decreased significantly in group 1.

CONCLUSION

RTX seems effective in cryoglobulinaemia or vasculitis-related PNS involvement in pSS.

Outcome of liver transplantation in a Hispanic population: 100 liver transplants in Puerto Ricans

BACKGROUND

The residents of Puerto Rico (PR) had limited access to liver transplantation (LTx) prior to 1996. LTx remains locally unavailable and success rates for LTx for patients from PR have never been published. The outcome of the first 100 LTx recipients from PR transplanted at our center is analyzed.

METHODS

100 consecutive patients transplanted between 3/1997 and 1/2005 were evaluated.

RESULTS

Hepatitis C was the indication for LTx in 44%. Overall patient survival at 1, 3 and 5 yrs was: 94.0%, 81.4% and 75.7%, respectively, while for hepatitis C, it was 90%, 73% and 73%, respectively. At mean follow up of 44 mo., 80% of patients were alive (66% HCV were alive vs 91% non HCV, p < 0.01).

CONCLUSIONS

Access to LTx in Puerto Rico has dramatically improved since 1996. The government-sponsored fund has provided access to indigent patients. Decreased survival in this minority population was not observed at 1, 3 and 5 years. Long-term survival was most affected by recurrence of HCV.

12-month safety and efficacy of everolimus with reduced exposure cyclosporine in de novo renal transplant recipients

The proliferation signal inhibitor everolimus (Certican), has demonstrated efficacy with full-dose cyclosporine (CsA) (Neoral). Two multicenter randomized controlled studies were performed to compare 12-month efficacy and safety of everolimus 1.5 and 3.0 mg/day with reduced-dose CsA. Study 1 enrolled 237 de novo renal allograft recipients, randomizing 222 nonblack patients to either everolimus 1.5 or 3.0 mg/day, with the Neoral) dose guided by C(2) (monitoring of CsA concentration 2 h after dosing). Study 2 had a similar protocol, with basiliximab included, enrolling 256 recipients and randomizing 243 nonblack patients. In Study 1, there was a lower incidence of acute rejection in nonblack patients on 3 mg/day (16.4%) compared with 1.5 mg/day (25.9%), P = 0.08. In Study 2, the inclusion of basiliximab lowered the overall incidence of acute rejection; 14.3% of nonblack patients (3 mg/day) and 13.6% of nonblack patients (1.5 mg/day) had acute rejection by 12 months (P =0.891). Renal function was preserved throughout the study, with no differences observed between groups within studies. Everolimus was well tolerated with no significant differences between doses. Everolimus, in combination with reduced-dose Neoral), demonstrated efficacy and was well tolerated. Basiliximab allows for utilization of lower doses of everolimus with reduced dosing of Neoral).

Flow around a Complex Building: Experimental and Large-Eddy Simulation Comparisons

A field program to study atmospheric releases around a complex building was performed in the summers of 1999 and 2000. The focus of this paper is to compare field data with a large-eddy simulation (LES) code to assess the ability of the LES approach to yield additional insight into atmospheric release scenarios. In particular, transient aspects of the velocity and concentration signals are studied. The simulation utilized the finite-element method with a high-fidelity representation of the complex building. Trees were represented with a canopy term in the momentum equation. Inflow and outflow conditions were used. The upwind velocity was constructed from a logarithmic law fitted to velocities obtained on two levels from a tower equipped with a 2D sonic anemometer. A number of different kinds of comparisons of the transient velocity and concentration signals are presented—direct signal versus time, spectral, Reynolds stresses, turbulent kinetic energy signals, and autocorrelations. It is concluded that the LES approach does provide additional insight, but the authors argue that the proper use of LES should include consideration of cost and may require an increased connection to field sensors; that is, higher-resolution boundary and initial conditions need to be provided to realize the full potential of LES.

Everolimus with optimized cyclosporine dosing in renal transplant recipients: 6-month safety and efficacy results of two randomized studies

Two prospective, randomized studies evaluated everolimus 1.5 vs. 3 mg/day with steroids and low-exposure cyclosporine (CsA) (C2 monitoring) in de novo renal transplant patients. Everolimus dosing was adjusted to maintain a minimum trough level of 3 ng/mL. Study 1 (A2306; n=237) had no induction therapy; in Study 2 (A2307; n=256) basiliximab was administered (Days 0 and 4). The primary endpoint was renal function at 6 months. CsA C2 target levels, initially 1200 ng/mL in Study 1 and 600 ng/mL in Study 2, were tapered over time post-transplant. Median creatinine levels in Study 1 were 133 and 132 micromol/L at 6 months in the 1.5 and 3 mg/day groups, respectively, and 130 micromol/L in both groups in Study 2. Biopsy-proven acute rejection (BPAR) occurred in 25.0% and 15.2% of patients in the 1.5 and 3 mg/day groups in Study 1, and 13.7% and 15.1% in Study 2. Incidence of BPAR was significantly higher in patients with an everolimus trough <3 ng/mL. There were no significant between-group differences in the composite endpoint of BPAR, graft loss or death, nor any significant between-group differences in adverse events in either study. Concentration-controlled everolimus with low-exposure CsA provided effective protection against rejection with good renal function.

Carotid intima media thickness decreases after pancreas transplantation

BACKGROUND

Pancreas transplantation (PTX) improves diabetic microvascular complications, but it is unknown whether PTX alters macrovascular disease. Carotid intima media thickness (IMT) has been shown to correlate with cardiovascular events, so this study was designed to evaluate changes in carotid IMT after PTX.

METHODS

Four groups were studied: PTX candidates (n=60); successful PTX recipients (n=89; mean time since PTX=4.0+/-0.3 years); patients with type 1 diabetes but without nephropathy (n=20); and normal controls (n=32). Mean IMT and mean of maximum carotid IMT measurements (mean-max IMT), hemoglobin A1C, serum creatinine, body mass index (BMI), blood pressure, smoking status, use of hypolipidemic medications, and fasting lipids were determined in all groups.

RESULTS

Age, gender distribution, and BMI were not different among the groups. Duration of diabetes was also equal between pre- and post-PTX groups. Mean and mean-max IMT were greatest pre-PTX and decreased after PTX (P<0.05) to a value that was not different from controls. Hemoglobin A1C and creatinine decreased, and high density lipoprotein (HDL) increased after PTX (P<0.05), but there were no significant differences in other lipids, BMI, use of lipid lowering agents, blood pressure, or smoking status.

CONCLUSIONS

Carotid IMT is lower after PTX, suggesting a reduction in overall cardiovascular risk independent of changes in use of hypolipidemic agents, smoking, blood pressure, BMI, or lipids, except HDL. Improved carotid IMT after successful PTX predicts a reduction in future vascular disease events and suggests that the macrovascular disease of type 1 diabetes is at least partially reversible with improved glucose control.

Anterior intramuscular transposition with ulnar nerve decompression at the elbow

The effectiveness of decompression and anterior intramuscular transposition of the ulnar nerve for treatment of severe cubital tunnel syndrome was evaluated. A consecutive series of 39 anterior intramuscular transpositions were reviewed. One surgeon performed the transpositions between 1993 and 1997 in 34 patients who presented with clinically severe cubital tunnel syndrome. Clinical outcome and satisfaction with surgery were assessed. The results showed early clinical improvement of 77% of patients (mean followup, 3.34 months). With repeated assessments later, the same group of patients had clinical improvement of 62% (mean followup, 30.9 months). Patients younger than 50 years, individuals who underwent external neurolysis, or patients who had a previously failed subcutaneous transposition had fewer satisfactory results.

Early versus delayed operative management of closed tibial fractures

Fractures of the tibial shaft are the most common long bone fractures. Operative treatment of isolated closed tibial shaft fractures frequently is delayed in favor of treatment of life threatening injuries. A retrospective chart review of 200 tibial fractures was performed. These injuries were managed by two surgeons at a Level 1 trauma center between 1989 and 1996. Strict inclusion criteria identified 54 patients with an isolated closed tibial fracture. Postoperative hospital stay and complication rates were recorded. At a mean followup of 3.6 years, a quality of life questionnaire was administered via telephone calls to these patients. Two patient groups were identified: Group 1, 21 patients (< 12-hour surgical delay); and Group 2, 33 patients (> 12-hour surgical delay). Both groups were similar for baseline characteristics. Group 2 patients remained an extra 4.6 days in the hospital. A Kaplan-Meier analysis revealed that by the eighth postoperative day, all Group 1 patients were discharged from the hospital, whereas 47.8% of Group 2 patients remained in the hospital. Plate fixation was associated with a greater incidence of complications when compared with intramedullary nail internal fixation. Complication rates were significantly greater in the delayed surgical group. A multiple regression analysis revealed that surgical delay and postoperative complications accounted for 35% of the total variance in postoperative hospital stay. Time to surgical treatment was not prognostic of long term quality of life. Surgical delay results in longer postoperative hospital stays, greater complication rates, and increased total cost to the health care system.

[Renal manifestations of Kimura disease. Apropos of a case]

A nephrotic syndrome with focal sclerosis associated with Kimura's disease is reported in a young asiatic man. The nephrotic syndrome started three years prior to the usual skin tumors and lymph nodes involvement. Epidemiological, clinical and nosological characteristics of Kimura's disease are discussed. Renal manifestations are the only visceral localisations of the disease. Thirteen Kimura's disease associated with documented nephrotic syndromes have been reported in german-english literature. They display a wide variety of histologic patterns. Their clinical course do not differ from the primary form of nephrotic syndrome with identical histology.

Effect of chlorambucil on bone mineral density in the course of chronic lymphoid leukemia

The purpose of this work was to study the effects of chronic lymphoid leukemia (CLL) and its treatments on bone mineral density (BMD). Lumbar and femoral BMD was measured by X-ray absorptiometry in 50 (32 M, 18 F, median age 65, range age: 47-87 yr) CLL patients. In order to gauge the respective effects of CLL and corticoids on bone mass, 31 CLL patients under treatment were compared with 31 controls on cortisone. Nineteen untreated patients with CLL were compared with controls devoid of osteopenia risk factor. There was no significant difference regarding lumbar and femoral BMD between the untreated patients with CLL and the healthy controls. An increase in lumbar and femoral BMD was noted in the treated CLL group compared with the controls on cortisone (lum BMD: 1.018 vs. 0.861 g/cm2, p=6.10(-4); fem BMD: 0.773 vs. 0.699 g/cm2, p=0.037). This increase was observed only in patients who had received chlorambucil (lum BMD: 1.066 vs. 0.861 g/cm2, p=0.10(-4); fem BMD: 0.806 vs. 0.699 g/cm2, p=4.10(-3)), whereas there was no difference between the CLL patients treated without chlorambucil and the controls on cortisone. Multiple linear regression analysis confirmed the marked effect of chlorambucil (r=0.3715, p<10(-3)) on BMD increase in the course of CLL.

The double-tuck model: a new animal model of arterial thrombosis

PURPOSE

To develop an animal model of a fibrin- and platelet-rich intraluminal arterial thrombus with abnormal mural substrate to simulate in situ thrombosis of human atherosclerotic arteries.

MATERIALS AND METHODS

Parallel studies of the crush-thrombin model (CT) and double-tuck model (DT) were performed and evaluated with use of angiography and histologic analysis. Ten Yorkshire swine (1-6 months; 20-30 kg; 10 females) underwent right femoral and carotid cutdowns performed after administration of general anesthesia (4 mL intravenous thiopental sodium, isoflurane 2% in 1 L of oxygen). After angiography, the CT model was created in the left carotid artery and the DT model was performed in the right carotid artery. Angiograms were obtained at 20 minutes (n = 1), at 1 hour (n = 3), at 2 hours (n = 4), and at 3 hours (n = 2) before sacrifice. After sacrifice, histologic specimens were stained with hematoxylin-eosin (H-E stain) and phosphotungstic acid hematoxylin for fibrin. The specimens were examined for endothelial irregularity and adhesion, platelet aggregation, fibrin layering, vessel wall injury, and adventitial hemorrhage. The findings were quantified as 0 = absent, 1+ = slight, 2+ = moderate, and 3+ = severe.

RESULTS

Angiographic results were similar. However, histologic analysis of the CT model showed severe damage to the arterial wall with dissection in nine of 10 animals. In the DT model, no dissection was found (n = 10). Endothelial irregularity was found in six of 10 arteries treated with the CT method, as compared with nine of 10 arteries prepared with the DT model; endothelial adhesion was found in five DT arteries and in four CT arteries. Platelet aggregation was present equally in both methods. A fibrin- and platelet-rich thrombus was created in five of 10 examined arteries by both methods.

CONCLUSIONS

The DT model creates endothelial irregularity leading to formation of a platelet- and fibrin-rich thrombus, adherent to the vessel wall without damage to the media. This contrasts with the CT method, which created medial dissection in nine of 10 arteries. One hour is the minimum time required to produce a good quality thrombus; 2 hours is the optimum time. The DT model is proposed as a useful tool in the development of new devices, drugs, and biotechnologic advances.

MR imaging of osteomyelitis and neuropathic osteoarthropathy in the feet of diabetics

Distinguishing between osteomyelitis and neuropathic osteoarthropathy of the foot frequently presents a clinical and radiologic challenge in patients with diabetes. Magnetic resonance (MR) imaging was performed in 26 diabetic patients to observe changes in signal intensity in the complicated diabetic foot. In every patient with osteomyelitis (n = 13), signal intensity abnormalities were seen within the bone marrow (low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in 12 cases). Most of these patients had cortical lesions (n = 9) or associated soft-tissue infection (n = 12). Normal bone marrow signal intensity was observed in three of the four patients without osteomyelitis. Characteristic MR imaging findings (decreased signal intensity in bone marrow regardless of pulse sequence) were seen in patients with chronic neuropathic osteoarthropathy (n = 7), who were easily distinguished from patients with osteomyelitis. Conversely, in patients with acutely evolving neuropathic osteoarthropathy (n = 2), signal intensity changes within the bone marrow were similar to those observed in osteomyelitis, leading to potential diagnostic pitfalls. Familiarity with MR imaging findings observed in osteomyelitis and neuropathic osteoarthropathy can help identify these two entities, allowing early diagnosis and appropriate therapy.

Avascular necrosis of the femoral head as a complication of chronic myelogenous leukaemia

A 17-year-old male patient complaining of intense pain in his right hip was found to be suffering from chronic myelogenous leukaemia. Preliminary X-rays and bone scintigraphy did not suggest avascular necrosis of the femoral head. Magnetic resonance imaging (MRI) did, however, reveal leukaemic infiltration of the femoral neck and generalised ischeamia in the femoral head. Further, MRI carried out 4 months later disclosed typical signs of osteonecrosis, despite previous indications of an improvement under chemotherapy. Flattening of the head of the femur appeared in radiographs taken in the 9th month. In the 12th month, recurrence of pain made it necessary to perform a total hip arthroplasty. Anatomo-pathological investigation confirmed both the necrosis and the leukaemic invasion.

Independence of metastatic ability and extravasation: metastatic ras-transformed and control fibroblasts extravasate equally well

Escape of cancer cells from the circulation (extravasation) is thought to be a major rate-limiting step in metastasis, with few cells being able to extravasate. Furthermore, highly metastatic cells are believed to extravasate more readily than poorly metastatic cells. We assessed in vivo the extravasation ability of highly metastatic ras-transformed NIH 3T3 cells (PAP2) versus control nontumorigenic nontransformed NIH 3T3 cells and primary mouse embryo fibroblasts. Fluorescently labeled cells were injected intravenously into chicken embryo chorioallantoic membrane and analyzed by intravital videomicroscopy. The chorioallantoic membrane is an appropriate model for studying extravasation, since, at the embryonic stage used, the microvasculature exhibits a continuous basement membrane and adult permeability properties. The kinetics of extravasation were assessed by determining whether individual cells (n = 1481) were intravascular, extravascular, or in the process of extravasation, at 3, 6, and 24 h after injection. Contrary to expectations, our results showed that all three cell types extravasated with the same kinetics. By 24 h after injection > 89% of observed cells had completed extravasation from the capillary plexus. After extravasation, individual fibroblasts of all cell types demonstrated preferential migration within the mesenchymal layer toward arterioles, not to venules or lymphatics. Thus in this model and for these cells, extravasation is independent of metastatic ability. This suggests that the ability to extravasate in vivo is not necessarily predictive of subsequent metastasis formation, and that postextravasation events may be key determinants in metastasis.