Long-term outcome of peripheral T-cell lymphomas: Ten-year follow-up of the International Prospective T-cell Project

Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of haematological cancers with generally poor clinical outcomes. However, a subset of patients experience durable disease control, and little is known regarding long-term outcomes. The International T-cell Lymphoma Project (ITCLP) is the largest prospectively collected cohort of patients with PTCLs, providing insight into clinical outcomes at academic medical centres globally. We performed a long-term outcome analysis on patients from the ITCLP with available 10-year follow-up data (n = 735). The overall response rate to first-line therapy was 68%, while 5- and 10-year overall survival estimates were 49% and 40% respectively. Most deaths occurred prior to 5 years, and for patients alive at 5 years, the chance of surviving to 10 years was 84%. However, lymphoma remained the leading cause of death in the 5- to 10-year period (67%). Low-risk International Prognostic Index and Prognostic Index for T-cell lymphoma scores both identified patients with improved survival, while in multivariate analysis, age >60 years and Eastern Cooperative Oncology Group performance status 2-4 were associated with inferior outcomes. The favourable survival seen in patients achieving durable initial disease control emphasizes the unmet need for optimal front-line therapeutic approaches in PTCLs.

The ECHELON-2 Trial: 5-year results of a randomized, phase 3 study of brentuximab vedotin with chemotherapy for CD30-positive peripheral T-cell lymphoma

Background:

For patients with peripheral T-cell lymphoma (PTCL), outcomes using frontline treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP-like therapy are typically poor. The ECHELON-2 study demonstrated that brentuximab vedotin plus cyclophosphamide, doxorubicin, and prednisone (A+CHP) exhibited statistically superior progression-free survival (PFS) per independent central review and improvements in overall survival versus CHOP for the frontline treatment of patients with systemic anaplastic large cell lymphoma or other CD30-positive PTCL.

Patients and methods:

ECHELON-2 is a double-blind, double-dummy, randomized, placebo-controlled, active-comparator phase III study. We present an exploratory update of the ECHELON-2 study, including an analysis of 5-year PFS per investigator in the intent-to-treat analysis group.

Results:

A total of 452 patients were randomized (1 : 1) to six or eight cycles of A+CHP (N = 226) or CHOP (N = 226). At median follow-up of 47.6 months, 5-year PFS rates were 51.4% [95% confidence interval (CI): 42.8% to 59.4%] with A+CHP versus 43.0% (95% CI: 35.8% to 50.0%) with CHOP (hazard ratio = 0.70; 95% CI: 0.53–0.91), and 5-year overall survival (OS) rates were 70.1% (95% CI: 63.3% to 75.9%) with A+CHP versus 61.0% (95% CI: 54.0% to 67.3%) with CHOP (hazard ratio = 0.72; 95% CI: 0.53–0.99). Both PFS and OS were generally consistent across key subgroups. Peripheral neuropathy was resolved or improved in 72% (84/117) of patients in the A+CHP arm and 78% (97/124) in the CHOP arm. Among patients who relapsed and subsequently received brentuximab vedotin, the objective response rate was 59% with brentuximab vedotin retreatment after A+CHP and 50% with subsequent brentuximab vedotin after CHOP.

Conclusions:

In this 5-year update of ECHELON-2, frontline treatment of patients with PTCL with A+CHP continues to provide clinically meaningful improvement in PFS and OS versus CHOP, with a manageable safety profile, including continued resolution or improvement of peripheral neuropathy.

Survival, disease progression and prognostic factors in elderly patients with mycosis fungoides and Sézary syndrome: a retrospective analysis of 174 patients

BACKGROUND

Advanced age at diagnosis is considered a poor prognostic factor in mycosis fungoides (MF) and Sézary syndrome (SS).

OBJECTIVE

To evaluate the outcomes and prognostic factors in patients diagnosed at an advanced age (≥65 years) with MF/SS.

METHODS

Survival, progression rates and various clinical and histopathological variables were studied in a group of 174 elderly patients diagnosed with MF/SS between 1992 and 2015 at a single referral cancer center in the United States. Kaplan-Meier estimates were used to determine survival and progression and Cox proportional hazards regression univariate and multivariate models were used to identify prognostic factors.

RESULTS

Of 174 elderly patients, 76.4% were diagnosed with early-stage (clinical stages IA-IIA) and 23.6% with late-stage MF/SS (IIB-IV). Advanced age was associated with poor overall survival, but not with disease-specific survival (DSS) or progression-free survival (PFS). Gender, increasing clinical stage, T and B classifications, elevated lactate dehydrogenase (LDH) levels and development of large cell transformation (LCT) were significant predictors of poor survival or disease progression. Patients with early-stage MF and <10% total skin involvement (T1 classification) or patch-only disease (T1a/T2a) showed better PFS with no observed disease-specific mortality. Folliculotropic MF was associated with poor DSS in patients with early-stage disease.

CONCLUSIONS

Older age at diagnosis of MF/SS does not predict worse disease-specific outcomes. Elderly patients with early-stage disease, specifically involving less than 10% of the skin surface with patches but without plaques or folliculotropism, have an excellent prognosis. However, the development of LCT is a strong prognostic indicator of poor survival in elderly patients with MF/SS.

Global patterns of care in advanced stage mycosis fungoides/Sezary syndrome: a multicenter retrospective follow-up study from the Cutaneous Lymphoma International Consortium

BACKGROUND

Advanced-stage mycosis fungoides (MF)/Sézary syndrome (SS) patients are weighted by an unfavorable prognosis and share an unmet clinical need of effective treatments. International guidelines are available detailing treatment options for the different stages but without recommending treatments in any particular order due to lack of comparative trials. The aims of this second CLIC study were to retrospectively analyze the pattern of care worldwide for advanced-stage MF/SS patients, the distribution of treatments according to geographical areas (USA versus non-USA), and whether the heterogeneity of approaches has potential impact on survival.

PATIENTS AND METHODS

This study included 853 patients from 21 specialist centers (14 European, 4 USA, 1 each Australian, Brazilian, and Japanese).

RESULTS

Heterogeneity of treatment approaches was found, with up to 24 different modalities or combinations used as first-line and 36% of patients receiving four or more treatments. Stage IIB disease was most frequently treated by total-skin-electron-beam radiotherapy, bexarotene and gemcitabine; erythrodermic and SS patients by extracorporeal photochemotherapy, and stage IVA2 by polychemotherapy. Significant differences were found between USA and non-USA centers, with bexarotene, photopheresis and histone deacetylase inhibitors most frequently prescribed for first-line treatment in USA while phototherapy, interferon, chlorambucil and gemcitabine in non-USA centers. These differences did not significantly impact on survival. However, when considering death and therapy change as competing risk events and the impact of first treatment line on both events, both monochemotherapy (SHR = 2.07) and polychemotherapy (SHR = 1.69) showed elevated relative risks.

CONCLUSION

This large multicenter retrospective study shows that there exist a large treatment heterogeneity in advanced MF/SS and differences between USA and non-USA centers but these were not related to survival, while our data reveal that chemotherapy as first treatment is associated with a higher risk of death and/or change of therapy and thus other therapeutic options should be preferable as first treatment approach.

The emergence of psychological themes in the South African Medical Journal, 1927–1975

The articles published in the South African Medical Journal between 1927 and 1975 were examined for the presence of psychological and psychiatric themes. Two hundred and seventy-seven articles and editorials were identified and analysed. The relative space allocated to issues psychological remained quite stable at low levels in the period under investigation. The following themes are discussed: psychopathology and treatment, psychoneuroses, psychology and physical disease, psychological testing, and psychology as an auxiliary to the medical profession.

Utility of ¹⁸fluoro-deoxyglucose positron emission tomography for prognosis and response assessments in a phase 2 study of romidepsin in patients with relapsed or refractory peripheral T-cell lymphoma

BACKGROUND

For patients with peripheral T-cell lymphoma (PTCL), the value of (18)fluoro-deoxyglucose positron emission tomography (FDG-PET) scans for assessing prognosis and response to treatment remains unclear. The utility of FDG-PET, in addition to conventional radiology, was examined as a planned exploratory end point in the pivotal phase 2 trial of romidepsin for the treatment of relapsed/refractory PTCL.

PATIENTS AND METHODS

Patients received romidepsin at a dose of 14 mg/m(2) on days 1, 8, and 15 of 28-day cycles. The primary end point was the rate of confirmed/unconfirmed complete response (CR/CRu) as assessed by International Workshop Criteria (IWC) using conventional radiology. For the exploratory PET end point, patients with at least baseline FDG-PET scans were assessed by IWC + PET criteria.

RESULTS

Of 130 patients, 110 had baseline FDG-PET scans, and 105 were PET positive at baseline. The use of IWC + PET criteria increased the objective response rate to 30% compared with 26% by conventional radiology. Durations of response were well differentiated by both conventional radiology response criteria [CR/CRu versus partial response (PR), P = 0.0001] and PET status (negative versus positive, P < 0.0001). Patients who achieved CR/CRu had prolonged progression-free survival (PFS, median 25.9 months) compared with other response groups (P = 0.0007). Patients who achieved PR or stable disease (SD) had similar PFS (median 7.2 and 6.3 months, respectively, P = 0.6427). When grouping PR and SD patients by PET status, patients with PET-negative versus PET-positive disease had a median PFS of 18.2 versus 7.1 months (P = 0.0923).

CONCLUSIONS

Routine use of FDG-PET does not obviate conventional staging, but may aid in determining prognosis and refine response assessments for patients with PTCL, particularly for those who do not achieve CR/CRu by conventional staging. The optimal way to incorporate FDG-PET scans for patients with PTCL remains to be determined.

TRIAL REGISTRATION

NCT00426764.

Topical treatment of hyperpigmentation disorders

Hyperpigmentation has traditionally been a relatively difficult condition to treat, especially in darker racial ethnic groups. Multiple topical agents available act upon different steps of the pigmentation pathway. We review these topical agents, their mechanisms of action, and their effectiveness as monotherapy and in combination with other compounds. Ultimately, combination therapy is the most efficacious when considering overall depigmentation as well as treatment time required to achieve clinical improvement.

PROPEL: Results of the pivotal, multicenter, phase II study of pralatrexate in patients with relapsed or refractory peripheral T-cell lymphoma (PTCL)

8561

Background: Pralatrexate is a novel targeted antifolate designed to accumulate preferentially in cancer cells. PROPEL, a pivotal phase 2, non-randomized, open-label, international study, is the largest prospective study in patients (pts) with relapsed or refractory PTCL. Methods: Pts received 30 mg/m2 of pralatrexate intravenously weekly for 6 of 7 weeks, supplemented with B12 and folic acid. Primary endpoint = objective response rate (ORR); secondary endpoints = response duration, progression-free survival, and overall survival. Eligibility criteria: histologically confirmed PTCL, disease progression after ≥ 1 prior treatment, and ECOG performance status ≤ 2. Pathology was confirmed by independent central review, response to therapy was assessed by independent central review using International Workshop Criteria (IWC). Results: 115 pts were enrolled, 109 were evaluable for efficacy. 111 treated pts included 76 males (68%) and 35 females (32%). Pts had failed a median of 3 prior regimens and thus were heavily pre-treated. 78 pts (70%) failed CHOP, 18 (16%) had previous autologous stem cell transplant. 25% of pts never responded to any prior therapy; 53% did not respond to last prior therapy. The majority (59 pts, 53%) had PTCL not-otherwise specified. The ORR by central review was 27% (n = 29). 11 pts (10% overall, 38% of responders) had a complete response (CR), 18 pts (17%) had a partial response (PR), and 23 (21%) had stable disease. ORR by investigators assessment was 39% (n = 42). The median duration of response cannot be accurately estimated at this time, though responses of > 1 year have been observed. 69% of responses were after just 1 cycle. 5 responding pts went on to transplant. The most frequent Grade (Gr) 3–4 adverse events were mucosal inflammation (Gr 3 = 17%, Gr 4 = 4%) and thrombocytopenia (Gr 3 = 14%, Gr 4 = 19%). Conclusions: The results of PROPEL show that pralatrexate exhibits substantial activity in pts with relapsed or refractory PTCL, as assessed by a rigorous central review, with durable CRs /PRs, irrespective of the amount of prior therapy.

[Table: see text]

Phase I/II trial of Arginine Butyrate and ganciclovir in Epstein-Barr virus-associated lymphoid malignancies

7542

Background: Malignancies associated with latent Epstein-Barr virus (EBV) are resistant to nucleoside-type anti-viral agents because the viral enzyme target of these drugs, thymidine kinase (TK), is not expressed. Short-chain fatty acids, such as butyrate, induce EBV-TK expression in latently-infected B cells. In preclinical studies, we have shown that butyrate sensitizes EBV(+) lymphoblastoid cells, tumor lines and primary lymphoma cultures to apoptosis induced by ganciclovir. Methods: We conducted a Phase I/II trial of Arginine Butyrate in combination with ganciclovir in patients with refractory EBV(+) lymphoid malignancies to evaluate toxicity, pharmacokinetic parameters, and clinical responses. Fifteen patients with heavily-pretreated, refractory EBV(+) lymphoid malignancies, consisting of monoclonal refractory lymphoproliferative disease (PTLD), B cell non-Hodgkin’s lymphomas (NHL) (including one HIV-associated anaplastic B cell lymphoma), T cell NHL (including one cutaneous lymphoma), T/NK cell lymphomas, and Hodgkin disease were studied. Ganciclovir was administered twice daily and Arginine Butyrate was administered in an intra-patient dose-escalation. Arginine Butyrate was instituted at 500 mg/kg/day by continuous infusion, and escalated to 2000 mg/kg/day, as tolerated. Results: The MTD for Arginine Butyrate was established as 1000 mg/kg/day. Overall the combination was well-tolerated, with the most common toxicities being nausea and headache. Complications from rapid tumor lysis occurred in three patients, including acute hepatic necrosis in one patient. Reversible grade 3–4 somnolence or stupor occurred in three patients at Arginine Butyrate doses of greater than 1000 mg/kg/day. Ten of fifteen patients showed significant anti-tumor responses, with 5 CR and 5 PR. In certain patients who demonstrated a clinical CR, subsequent pathological analysis showed elimination of all tumor cells. Conclusions: The combination of Arginine Butyrate and ganciclovir was reasonably well-tolerated and appears to have significant biological activity in vitro and in vivo against refractory EBV(+) lymphoid malignancies.

No significant financial relationships to disclose.

Resistance to Taxol in lung cancer cells associated with increased microtubule dynamics

Microtubule dynamics are crucial for mitotic spindle assembly and chromosome movement. Suppression of dynamics by Taxol appears responsible for the drug's potent ability to inhibit mitosis and cell proliferation. Although Taxol is an important chemotherapeutic agent, development of resistance limits its efficacy. To examine the role of microtubule dynamics in Taxol resistance, we measured the dynamic instability of individual rhodamine-labeled microtubules in Taxol-sensitive and -resistant living human cancer cells. Taxol-resistant A549-T12 and -T24 cell lines were selected from a human lung carcinoma cell line, A549. They are, respectively, 9- and 17-fold resistant to Taxol and require low concentrations of Taxol for proliferation. We found that microtubule dynamic instability was significantly increased in the Taxol-resistant cells. For example, with A549-T12 cells in the absence of added Taxol, microtubule dynamicity increased 57% as compared with A549 cells. The length and rate of shortening excursions increased 75 and 59%, respectively. These parameters were further increased in A549-T24 cells, with overall dynamicity increasing by 167% compared with parental cells. Thus, the decreased Taxol-sensitivity of these cells can be explained by their increased microtubule dynamics. When grown without Taxol, A549-T12 cells were blocked at the metaphase/anaphase transition and displayed abnormal mitotic spindles with uncongressed chromosomes. In the presence of 2-12 nM Taxol, the cells grew normally, suggesting that mitotic block resulted from excessive microtubule dynamics. These results indicate that microtubule dynamics play an important role in Taxol resistance, and that both excessively rapid dynamics and suppressed dynamics impair mitotic spindle function and inhibit proliferation.

Coverage and overlaps in bibliographic databases relevant to forensic medicine: a comparative analysis of MEDLINE

This study was designed to make a comparative evaluation of the performance of MEDLINE in covering serial literature. Forensic medicine was chosen because it is an interdisciplinary subject area that would test MEDLARS at the periphery of the system. The evaluation of database coverage was based upon articles included in the bibliographies of scholars in the field of forensic medicine. This method was considered appropriate for characterizing work used by researchers in this field. The results of comparing MEDLINE to other databases evoked some concerns about the selective indexing policy of MEDLINE in serving the interests of those working in forensic medicine.

Interprocedural slicing using dependence graphs

A slice of a program with respect to a program point p and variable x consists of all statements of the program that might affect the value of x at point p . This paper concerns the problem of interprocedural slicing — generating a slice of an entire program, where the slice crosses the boundaries of procedure calls. To solve this problem, we introduce a new kind of graph to represent programs, called a system dependence graph , which extends previous dependence representations to incorporate collections of procedures (with procedure calls) rather than just monolithic programs. Our main result is an algorithm for interprocedural slicing that uses the new representation.

The chief difficulty in interprocedural slicing is correctly accounting for the calling context of a called procedure. To handle this problem, system dependence graphs include some data-dependence edges that represent transitive dependencies due to the effects of procedure calls, in addition to the conventional direct-dependence edges. These edges are constructed with the aid of an auxiliary structure that represents calling and parameter-linkage relationships. This structure takes the form of an attribute grammar. The step of computing the required transitive-dependence edges is reduced to the construction of the subordinate characteristic graphs for the grammar's nonterminals.

[Echocardiographic diagnosis of atrial thrombosis]

Seventy patients with rheumatic mitral disease were studied by M-Mode and 2D echocardiography in order to detect left atrial thrombosis before surgery. Thrombosis were suspected by the observation of abnormal echoes in the left atrium. During surgery 17 (24%) patients had atrial thrombosis. It had been suspected by echocardiography in 12 (sensitivity 70%). In 53 patients thrombosis were not found during surgery; in 46 the echo had been also negative (specificity 86%). There was a false positive detection of thrombosis by echo in 7 patients (14%) and false negativity in 5 (30%). Patients with atrial thrombosis had atrial fibrilation in 91% of cases; and the most frequent valvular disease was mitral stenosis. There was not a direct relationship among existence of left atrial thrombosis and the anteroposterior diameter of the left atrium as measured by echo. We conclude that echocardiography has good specificity to rule out atrial thrombosis and moderate sensitivity to detect it in rheumatic mitral disease.

[Echocardiographic abnormalities of the mitral valve in interatrial communication of the ostium secundum type]

Thirty one patients with atrial septal defect were studied by M-mode echocardiography. In sixteen patients (control group) there only findings suggesting right ventricular volume overload. The remaining fifteen patients, were divided into three groups. Group 1 consisted of five patients with mitral valve abnormalities related to the left ventricular pattern. The macroscopic aspect of the mitral valve in this group was reported by the surgeon to be rheumatic or myxomatous degeneration. In four patients (group II), there was prolapse of an atrioventricular valve, three mitral and one tricuspid. Group III consisted of six patients with an abnormal movement of the posterior mitral leaflet, related to a deformed left ventricle. The QP/QS ratio as well as the interatrial shunt was larger in groups I and III. These data suggest that there are abnormal mitral flow patterns and changes in the left ventricular geometry, related to right ventricular volume overload that cause altered mitral valve movement that can be detected by echocardiography.

[Time of ventricular extrasystole and its relation to ventricular tachycardia in patients with myocardial infarct]

The coupling time of ventricular extrasystoles (VE) leading to 41 episodes of ventricular tachycardia (VT) in 35 patients with acute myocardial infarction (AMI) was studied regarding the measurement of the precocity index (R-R/QT) and vulnerability index (R-R x QT/R-R') described by other authors. A comparative group was studied in 50 VE of other patients with AMI but without VT. The majority of episodes (83%) of VT were originated by VE with a prematurity index of more than 1 (VE with coupling intervals longer than the QT duration of the previous cardiac cycle, R-R' > QT). The vulnerability index, with reported "dangerous" values of 1.1 to 1.4, was less than 1 in 92.6% of cases of VT and in 100% of VE without VT. A new index, delta QT, for the study of the abnormality of the QT interval respect to normal values (+/-.04") and its relation to the coupling time of the VE was also measured but did not show any difference among groups. In conclusion, none of the indexes were useful as predictor of ectopic beats that can produce VT in patients with AMI. We suggest that VE ocurring in patients with AMI should be suppressed disregarding the prematurity of diming of their appearance.

Takayasu's arteritis. Clinical study of 107 cases

The clinical experience derived from the retrospective study of 107 cases of TA over a 19 year period is presented. The disease predominated in females (8.5:1), with age of onset usually less than 20 years. In half of the cases an acute inflammatory phase was observed, characterized mainly by systemic and cardiovascular symptoms. Subsequently the natural course of TA was toward chronicity with gradual deterioration. The most frequent variety of TA (65 per cent of the patients) was Type III, in which the supra-aortic trunks and the abdominal aorta were involved. The predominant clinical features were reduction of amplitude of peripheral arterial pulses (96 per cent), vascular bruits (94 per cent), and raised blood pressure (72 per cent), mainly resulting from renal arterial involvement (62 per cent). Heart failure (28 per cent) is rarely the result of direct coronary arteritis. TA is most often confused with aortic coarctation, but usually the aortogram distinguishes these. The etiology of TA is discussed. The high incidence of previous and present active tuberculous (48 per cent) in the present series and previous experimental work suggest that tuberculosis may play an important role in the etiology of TA. Treatment for antihypertension and heart failure should be employed when indicated. Treatment with corticosteroids requires further evaluation. Treatment for tuberculosis is not justified in all cases until the exact role of tuberculosis is well established.