Initial versus early switch to targeted therapy during first-line treatment among patients with biomarker-positive advanced or metastatic non-small cell lung cancer in the United States

OBJECTIVES

This study compared outcomes between patients with biomarker-positive advanced/metastatic non-small cell lung cancer (a/mNSCLC) who initiated treatment with targeted therapy versus those who initiated chemotherapy-based treatment and switched to targeted therapy during the first ∼3 cycles (defined as the first 56 days) of first-line treatment.

MATERIALS AND METHODS

This was an observational study of patients with a/mNSCLC who received targeted therapy from a nationwide electronic health record (EHR)-derived de-identified database. Outcomes were compared between those who initiated targeted therapy versus those who switched from chemotherapy to a targeted agent. Time-to-event outcomes were evaluated using Kaplan-Meier method; Cox proportional hazards models (adjusted for baseline covariates) were used to compare outcomes between groups.

RESULTS

Of the 4,244 patients in this study, 3,107 (73.2%) initiated the first line with targeted therapy and 346 (8.2%) switched to targeted therapy. Patients who received initial targeted therapy were significantly more likely to be non-smokers, treated in an academic practice setting, and of slightly older age (all p < 0.05). Patients who received initial targeted therapy also had a significantly longer time to start of first-line treatment (35.8 vs 25.3 days, p < 0.001). No significant differences were observed for clinical outcomes between groups.

CONCLUSION

In both unadjusted and adjusted analyses, there were no differences in the clinical outcomes observed among patients with a/mNSCLC in this study. This study found that initiating chemotherapy with an early switch to targeted therapy (within 56 days) of receiving biomarker positive results may be an acceptable strategy for a patient for whom immediate care is needed.

Clinical outcomes among patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) who received treatment with a covalent BTK and BCL2 inhibitor in the United States: a real-world database study

This retrospective study using the nationwide de-identified Flatiron Health electronic health record-derived database was designed to evaluate clinical outcomes among patients with chronic lymphocytic leukemia (CLL) who previously received both a covalent Bruton's tyrosine kinase inhibitor (cBTKi) and B-cell lymphoma 2 inhibitor (BCL2i) in a real-world setting. Outcomes for the immediate next line of therapy following the latter of the cBTKi or BCL2i treatment included: real-world response rate of 34.4% (using methods most consistent with clinical trials); median duration of real-world response of 13.3 months; and median real-world progression-free survival of 9.2 months. Median overall survival was 25.5 months from the start of the immediate next line of therapy. There remains a need for more effective therapies after cBTKi and BCL2i therapy for patients with CLL.

External control cohorts for the single-arm LIBRETTO-001 trial of selpercatinib in RET+ non-small-cell lung cancer

Background

Data for selpercatinib [a selective REarranged during Transfection (RET) inhibitor] from a single-arm trial (LIBRETTO-001, NCT03157128) in RET-fusion-positive advanced/metastatic non-small-cell lung cancer (NSCLC) were used in combination with external data sources to estimate comparative efficacy [objective response rate (ORR), progression-free survival, and overall survival (OS)] in first- and second-line treatment settings.

Methods

Patient-level data were obtained from a de-identified real-world database. Patients diagnosed with advanced/metastatic NSCLC with no prior exposure to a RET inhibitor and one or more prior line of therapy were eligible. Additionally, individual patient-level data (IPD) were obtained from the pemetrexed + platinum arm of KEYNOTE-189 (NCT03950674, first line) and the docetaxel arm of REVEL (NCT01168973, post-progression). Patients were matched using entropy balancing, doubly robust method, and propensity score approaches. For patients with unknown/negative RET status, adjustment was made using a model fitted to IPD from a real-world database.

Results

In first-line unadjusted analyses of the real-world control, ORR was 87.2% for LIBRETTO-001 versus 66.7% for those with RET-positive NSCLC (P = 0.06). After adjustment for unknown RET status and other patient characteristics, selpercatinib remained significantly superior versus the real-world control for all outcomes (all P < 0.001 except unadjusted RET-fusion-positive cohort). Similarly, outcomes were significantly improved versus clinical trial controls (all P < 0.05).

Conclusions

Findings suggest improvement in outcomes associated with selpercatinib treatment versus the multiple external control cohorts, but should be interpreted with caution. Data were limited by the rarity of RET, lack of mature OS data, and uncertainty from assumptions to create control arms from external data.

•

Single-arm trials are limited by the lack of a comparison arm, and external controls are needed.

•

Multiple methodological approaches with various external control arms evaluated the comparative efficacy of selpercatinib.

•

Findings suggest that selpercatinib is associated with significantly improved clinical outcomes versus standard therapies.

•

Results should be considered exploratory and hypothesis generating due to the limitations of this study.

Cardiac events among patients with sarcoma treated with doxorubicin by method of infusion: A real-world database study

BACKGROUND

Administration of doxorubicin by continuous intravenous (CIV) infusion, versus bolus (BOL) administration, has been proposed to mitigate the risk of cardiac events. This study used real-world data to explore the association between mode of doxorubicin administration and duration of treatment, time-to-treatment failure (TTF), and cardiac events.

METHODS

Occurrence of cardiac events after initiation of BOL versus CIV doxorubicin for sarcoma in the International Business Machines MarketScan claims database were compared. Duration of doxorubicin treatment, TTF, and time-to-first-cardiac event (TCE) were evaluated using Kaplan-Meier method and unadjusted and adjusted Cox regression models.

RESULTS

A total of 196 patients were included in the BOL group and 399 in the CIV group. In unadjusted analyses, there were significant differences between BOL versus CIV for duration of doxorubicin treatment (median 1.4 vs. 2.1 months, p = .002), TTF (median 8.8 vs. 5.6 months, p = .002), and TCE (medians not reached, p = .03). Adjusting for baseline covariates, only TTF remained significant (hazard ratio: 0.71, 95% confidence interval 0.59-0.86, p = .0004), favoring BOL.

CONCLUSIONS

While the risk of cardiac complications was higher with BOL in unadjusted analysis, the risk was no longer present in the adjusted analysis. While we cannot draw causal inferences due to the retrospective, nonrandomized study design, these data suggest that replacing BOL with prolonged CIV administration has not been effective as a strategy to mitigate cardiac events, given community standards of oncologic practice.

POS0522 ASSOCIATED FACTORS WITH PHYSICAL DYSFUNCTION OF ELDERLY-ONSET RHEUMATOID ARTHRITIS TREATED WITH A TREAT-TO-TARGET STRATEGY

Background

Achievement of normal physical function is an important outcome for older patients. Previous studies of younger cohorts showed that aging, comorbidities, and joint damage influenced the physical function of patients with RA who achieved clinical remission or low disease activity (LDA). We previously demonstrated that a treat-to-target (T2T) strategy for methotrexate (MTX)-naïve elderly-onset RA (EORA) was effective with an acceptable safety profile. It showed that 60.9% of 197 patients achieved HAQ Disability Index (HAQ-DI) ≤0.5 at three years by following the T2T strategy targeting LDA (1).

Objectives

We aimed to evaluate associated factors with HAQ-DI in the T2T strategy targeting LDA for patients with EORA during three-year observational period.

Methods

Treatment was adjusted to target LDA with conventional synthetic disease-modifying antirheumatic drugs (DMARDs), followed by biological DMARDs (bDMARDs) in 197 MTX-naïve EORA patients (mean age 74.9 years) with moderate-to-high disease activity. HAQ-DI was evaluated at week 0, 24, 52, 76, 104, 128, and 156. To evaluate associated factors with SDAI and HAQ-DI over the 36-month follow-up, Bayesian hierarchical logistic regression modeling was applied for 1067 periods from the 197 patients.

Results

At baseline, the enrolled 197 patients with EORA who had normal physical function (HAQ-DI ≤0.5) in 29.4%, HAQ-DI >0.5 and <1.5 in 36.5%, and HAQ-DI ≥1.5 in 33.0%, and the mean age (standard deviation [SD]) in each group was 72.7 (5.9), 74.8 (7.3), and 75.6 (6.7), respectively. Baseline SDAI increased in the group with higher HAQ-DI. The proportions of patients with each comorbidity and estimated creatinine clearance at baseline were not significantly different across the 3 groups.

In the multilevel logistic model, the association of MTX, bDMARDs, and GC use with changes in SDAI in each period was evaluated. Age, sex, and comorbidities (chronic lung disease, cardiovascular disease, history of malignancy, osteoporosis, history of serious infections, and osteoarthritis) were included as inter-individual factors. The model indicated that the use of bDMARDs was associated with a reduction of the SDAI (ΔSDAI: -9.75, SD 0.75, p<0.001), while neither MTX (ΔSDAI: -1.25, SD 1.13, p=0.270) nor GCs (ΔSDAI: -0.78, SD 0.88, p=0.372) was associated with changes in SDAI. Chronic lung diseases (ΔSDAI: 4.64, SD 1.44, p=0.001) and osteoporosis (ΔSDAI: 3.78, SD 1.46, p=0.001) at baseline were associated with the increment of SDAI.

The association of age, sex, the comorbidities, and MTX, bDMARDs, and GC use with physical function in each period was evaluated by the multilevel logistic model. The model indicated that older age (ΔHAQ-DI: 0.03, SD 0.01, p <0.001), chronic lung diseases (ΔHAQ-DI: 0.15, SD 0.10, p=0.001), and osteoporosis (ΔHAQ-DI: 0.30, SD 0.10, p=0.010) at baseline were associated with the increment of HAQ-DI. When the mean SDAI during the observation period was added to the model as an inter-individual factor, the associations of HAQ-DI with the chronic lung diseases and osteoporosis at baseline were not statistically significant.

Conclusion

These data indicate that bDMARDs had a central role in reducing disease activity in the T2T strategy targeting LDA in EORA patients. Chronic lung diseases and osteoporosis at baseline were associated with increase in disease activity and worsening of physical function. However, disease activity had a greater impact on physical function than the comorbidities at baseline.

References

[1]Sugihara T, et al. Rheumatology (Oxford). 2021;60(9):4252-4261

Disclosure of Interests

takahiko sugihara Speakers bureau: TS has received honoraria from Abbvie Japan Co., Ltd., AsahiKASEI Co., Ltd., Astellas Pharma Inc., Ayumi Pharmaceutical, Bristol Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi-Tanabe Pharma Co., Ono Pharmaceutical, Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and UCB Japan Co. Ltd., Grant/research support from: TS has received research grants from AsahiKASEI Co., Ltd., Daiichi Sankyo., Chugai Pharmaceutical Co., Ltd., and Ono Pharmaceutical., Tatsuro Ishizaki: None declared, Hiroyuki Baba: None declared, Takumi Matsumoto: None declared, Kanae Kubo Speakers bureau: KK has received honoraria from Asahi KASEI, Astellas Pharma, Bristol Myers Squibb, Eisai, AbbVie GK, Boehringer Ingelheim, Daiichi-Sankyo, Chugai Pharmaceutical, Mitsubishi Tanabe Pharma and Nippon Shinyaku., Grant/research support from: KK has received research grants from Asahi KASEI, Mari Kamiya: None declared, Fumio Hirano: None declared, Tadashi Hosoya: None declared, Masayo Kojima Speakers bureau: MK has received speakers bureau from AbbVie, Astellas, Ayumi Pharma, Chugai, Eisai, Eli Lilly, Janssen, Ono Pharmaceutical, Pfizer, Tanabe-Mitsubishi, and Takeda Pharmaceutical Co., Ltd., Nobuyuki Miyasaka: None declared, Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Consultant of: MH is a consultant for AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: MH has received research grants from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd.

POS0794 PREGNANCY AND CHILDBIRTH IN TAKAYASU ARTERITIS IN JAPAN – A NATIONWIDE RETROSPECTIVE STUDY

Background

Takayasu arteritis (TAK), a granulomatous large vessel vasculitis, mainly involves the aorta and its proximal branches and commonly occurs in young females. However, studies of pregnancy in women with TAK are sparse and limited, probably due to the rarity of the disease.

Objectives

The purpose of this study was to understand the status quo of medical treatments of the primary disease and outcomes of pregnancy in patients with TAK, and birth outcomes of the children in Japan.

Methods

Patients with TAK who conceived after the onset of the disease and were managed at medical facilities participating in the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS) were retrospectively enrolled in this study. The following information was collected from patients who had a live-born baby: age at diagnosis of TAK, disease classification, age at delivery, treatments before and during pregnancy, complications during pregnancy, birth outcomes of the children, and changes in disease activity during pregnancy and after delivery.

Results

Fifty-one cases and 69 pregnancies from 19 ethics committee-approved centers were enrolled during the study period 2019–2021. Of these, 49 cases and 66 pregnancies (95.7%) resulted in delivery and live-born babies. The Numano classification of the 49 cases was as follows: type I, 11; type IIa, 15; type IIb,12; type III, 1; type IV, 1; type V, 9; with type IIa being the most common. The age of diagnosis was 22 years (13–37 years, year of diagnosis 1965–2017), the median age of the delivery of 66 pregnancies was 31 years (year of delivery 1969-2021), and the median duration of illness at delivery was nine years. There were 34 planned pregnancies (51.5%, including four pregnancies by artificial insemination/ovulation induction). Preconception therapy included prednisolone (PSL) in 51 pregnancies (77.3%, median dose 7.5 mg (range 4–30 mg)/day), immunosuppressive drugs in 18 pregnancies (27.3%, azathioprine 8, tacrolimus 7, methotrexate 4, cyclosporin A 1, and colchicine 1), biologics in 12 pregnancies (18.1%, infliximab 6, tocilizumab 5, and adalimumab 1), antihypertensive drugs in 5 pregnancies (7.6%). Surgical treatment had been performed before pregnancy in 6 cases (aortic root replacement 2, subclavian artery dilatation 1, subclavian artery bypass 1, subclavian artery stenting 1, and ascending aorta semicircular artery replacement 1). Medications used during the course of pregnancy included PSL in 48 pregnancies (72.7%, median dose 8 mg (range 4–30 mg)/day, increased in 13 pregnancies, decreased in 1 pregnancy), immunosuppressants in 13 pregnancies (19.7%, azathioprine 6, tacrolimus 6, and cyclosporin A 1), biologics 9 pregnancies (13.6%, infliximab 4, tocilizumab 4, and adalimumab 1). Immunosuppressants and biologics were discontinued in five and four pregnancies after conception. Complications during pregnancy were observed in 20 pregnancies (30.3%), with hypertension being the most common. Complications related to TAK or its treatment were severe infections in two pregnancies and aneurysm enlargement due to increased circulating plasma volume in one pregnancy. Aortic arch replacement was performed after delivery for the latter case. Relapse of TAK was observed in 4 pregnancies (6.1%) during pregnancy and in 8 pregnancies (12.1%) after delivery. One pregnancy resulted in restenosis of subclavian artery for which dilatation procedure was performed prior to the pregnancy. There were 13/66 (19.7%) preterm infants and 17/59 (28.8%) low birth weight infants; all but one had a birth weight of more than 2,000 g and no had serious postnatal abnormalities. Forty-three (82.7%) of the 52 confirmed infants were breastfeed fully or mixed.

Conclusion

Most of the pregnancies in patients with TAK were successfully delivered while they had low disease activity at a dose of less than 10 mg/day of PSL. Relapse occurred during pregnancy and after delivery in some cases. The babies tended to have low birth weight, but 82.7% of them were breastfed without serious complications.

Disclosure of Interests

Takako Miyamae: None declared, Yusuke Manabe: None declared, takahiko sugihara Speakers bureau: TS has received honoraria from Abbvie Japan Co., Ltd., AsahiKASEI Co., Ltd., Astellas Pharma Inc., Ayumi Pharmaceutical, Bristol Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi-Tanabe Pharma Co., Ono Pharmaceutical, Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and UCB Japan Co., Grant/research support from: TS has received research grants from AsahiKASEI Co., Ltd., Daiichi Sankyo., Chugai Pharmaceutical Co., Ltd., and Ono Pharmaceutical., Natsuka Umezawa: None declared, Hajime Yoshifuji Speakers bureau: HY has received lecture fees from Janssen and Chugai., Naoto Tamura: None declared, Yoshiyuki Abe: None declared, Shunsuke Furuta Speakers bureau: Chugai Pharmaceutical Co.,Ltd.

DaiichiSankyo Co.,Ltd.

Asahi-Kasei Pharma Corporation, Manami Kato: None declared, Takashi Kumagai: None declared, Kaito Nakamura: None declared, Hiroko Nagafuchi: None declared, Jun Ishizaki: None declared, Naoko Nakano: None declared, Tatsuya Atsumi Speakers bureau: Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Astellas Pharma Inc., Takeda Pharmaceutical Co., Ltd., Pfizer Inc., AbbVie Inc., Eisai Co. Ltd., Daiichi Sankyo Co., Ltd., Bristol-Myers Squibb Co., UCB Japan Co. Ltd., Eli Lilly Japan K.K., Novartis Pharma K.K., Eli Lilly Japan K.K., Kyowa Kirin Co., Ltd.,TAIHO PHARMACEUTICAL CO., LTD., Consultant of: AstraZeneca plc., MEDICAL & BIOLOGICAL LABORATORIES CO., LTD., Pfizer Inc., AbbVie Inc., ONO PHARMACEUTICAL CO. LTD.,

Novartis Pharma K.K., Nippon Boehringer Ingelheim Co., Ltd., Grant/research support from: Astellas Pharma Inc., TAIHO PHARMACEUTICAL CO., LTD.AbbVie Inc., Nippon Boehringer Ingelheim Co., Ltd.,Takeda Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Daiichi Sankyo Co. Ltd., Otsuka Pharmaceutical Co., Ltd. and Pfizer Inc. Alexion Inc., TEIJIN PHARMA LIMITED., Kohei Karino: None declared, Koichi Amano Speakers bureau: AbbVie GK, Asahi-Kasei Pharma, Astellas, Chugai Pharmaceutical Co.Ltd., Eisai, Eli Lilly, GlaxoSmithKlein, Janssen Pharma, Pfizer Japan, Grant/research support from: Asahi-Kasei Pharma,Chugai Pharmaceutical Co.Ltd., Takahiko Kurasawa: None declared, Shuichi Ito: None declared, Ryusuke Yoshimi: None declared, Noriyoshi Ogawa: None declared, Shogo Banno: None declared, Taio Naniwa Speakers bureau: Chugai, Tanabe, Abbbvie, Eisai, Grant/research support from: Chugai, Tanabe, Abbbvie, Eisai, Satoshi Ito Speakers bureau: SI has received speaker’s fees from pharmaceutical companies., Akinori Hara: None declared, Shinya Hirahara: None declared, Haruhito A. Uchida: None declared, Yasuhiro Onishi: None declared, Yohko Murakawa Speakers bureau: Astellas, UCB, Chugai, AbbVie, Grant/research support from: Chugai, AbbVie, Yoshinori Komagata: None declared, Yoshikazu Nakaoka: None declared, Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Janssen Pharmaceutical K.K., Kissei Pharmaceutical Co., Ltd., Novartis Japan, Pfizer Japan Inc., Mitsubishi Tanabe Pharma Co., Teijin Pharma Ltd and UCB Japan., Consultant of: MH is a consultant for AbbVie, Boehringer-Ingelheim, Kissei Pharmaceutical Co., Ltd., and Teijin Pharma.

A real-world US study of recurrence risks using combined clinicopathological features in HR-positive, HER2-negative early breast cancer

Aim: To assess invasive disease-free survival (IDFS) and distant relapse-free survival (DRFS) in hormone receptor-positive, HER2-negative early breast cancer with combined clinicopathological criteria from monarchE, a phase III study of abemaciclib. Methods: US electronic health records were used to compare outcomes between high-risk (≥4 lymph nodes, or 1-3 lymph nodes and grade 3, tumor ≥5 cm, or Ki-67 ≥20%) versus nonhigh-risk groups using Kaplan-Meier methods and Cox regression models. Results: The high-risk group (n = 557) was at higher risk for IDFS and DRFS events than the nonhigh-risk group (n = 3471). IDFS events (hazard ratio: 3.07; 95% CI: 2.45-3.83) and DRFS events (hazard ratio: 3.15; 95% CI: 2.49-3.97) were significantly higher for the high-risk group. Conclusion: Risk of recurrence was three-times greater in the high-risk group, highlighting the need for better therapies.

Study of patient characteristics, treatment patterns, EGFR testing patterns and outcomes in real-world patients with EGFRm+ non-small cell lung cancer

OBJECTIVE

This retrospective, observational study examined patient characteristics, treatment patterns, testing patterns, and outcomes of US patients receiving first-/second- or third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs).

METHODS

This study used an electronic health record-derived de-identified database. Eligible patients had advanced EGFRm⁺ non-small cell lung cancer. Descriptive statistics were used to describe demographic, clinical, and treatment characteristics. Logistic regression models were used to identify patient characteristics that were associated with the use of osimertinib vs. a first-/second-generation EGFR TKI. Kaplan-Meier methods were used for survival analysis.

RESULTS

Of the 782 patients who received first-line (1L) therapy with first-/second-generation EGFR TKIs in cohort A, erlotinib was the most common (58%), and osimertinib was the most widely prescribed second-line (2L) therapy (52%). Of the patients who received 1L therapy with osimertinib, a greater range of treatments were prescribed in 2L. A third of patients treated with first-/second-generation EGFR TKIs underwent EGFR testing near the end of 1L, and 44% of these patients had T790M positive disease. The median time on targeted therapy (TTT) of the cohort was 11.1 months (95% confidence interval [CI] 9.7, 12.3), and the median overall survival from the start of 1L therapy was 23.5 months (95% CI 20.7, 24.8).

CONCLUSIONS

The majority of patients treated with first-/second-generation EGFR TKIs went on to receive osimertinib in the 2L setting, but overall, only a third of patients had received molecular testing at progression. Improved testing frequency is vital to inform treatment decisions.

POS0336 PATTERNS OF LARGE-VESSEL LESIONS AND POOR TREATMENT OUTCOMES IN PATIENTS WITH LARGE-VESSEL GIANT CELL ARTERITIS

Background:

Giant cell arteritis (GCA) is characterized by cranial symptoms and large-vessel lesions (LVL) in the aorta or its branches. We retrospectively analyzed the Japanese patients newly diagnosed as GCA between 2007 and 2014, and subsequently treated with glucocorticoid (GC). The imaging studies revealed that LVLs were observed in approximately half of the GCA patients, and the LVLs were significantly associated with the increased probability of poor treatment outcomes (1).

Objectives:

The objective of this study is to evaluate whether the distribution of LVLs of GCA was associated with poor treatment response.

Methods:

In a retrospective, multi-centric, nationwide registry of GCA patients treated with GCs between 2007 and 2014, 68 newly-diagnosed GCA with LVLs by imaging were detected. All investigators were members of Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS). Poor treatment outcomes (non-achievement of clinical remission by week 24 or relapse during 104 weeks) were primarily evaluated. Cumulative rates and median time to the first event were analyzed by the Kaplan-Meier method and the log-rank test. Associated factors with the outcomes were analyzed by using the Cox proportional hazard model.

Results:

The mean age was 70.5 years, and 70.6% were women. Twenty-seven (39.7%) of the 68 patients were diagnosed as having GCA by both positive temporal artery biopsy and positive imaging, and 41 (60.3%) by positive imaging. Aortic lesions were detected in 72.1% (group 2, n=49) of the 68 GCA patients with LVLs. Patients without aortic lesions were categorized into two phenotypes: large-vessel GCA with subclavian lesions (group 1, n=9) and atypical large-vessel GCA without subclavian lesions (group 3, n=10). Cranial lesions were observed in 66.7%, 55.1%, and 80.0% in the group 1, 2, and 3, respectively. The initial mean dose (SD) of prednisolone was 0.74 (0.26) mg/kg/day, and 20.6 % received methotrexate for remission induction therapy. Baseline dose of GCs and mean time to achievement of low-dose GCs (prednisolone ≤ 5 mg/day) was not significantly different among the three groups.

Overall, 35 (51.5%) of the 68 patients had the event of poor treatment outcomes. Eleven patients were not able to achieve clinical remission by week 24. Relapse after achievement of clinical remission was reported in total of 24 patients; 9 between week 0 and 24, 12 between week 24 and 52, 3 between week 52 and 104. The cumulative rate of events of poor treatment outcomes over the two years was 11.1% in patients with group 1, 55.3% in those with group 2, and 88.0% in those with group 3. Mean time to events was significantly different among the three groups. Multivariable analysis showed the risk of poor treatment outcomes was likely to decrease in the group 1 (hazard ratio 0.14 [95% CI 0.02-1.03], p=0.054), while it increased in the group 3 (hazard ratio 2.22 [95% CI 1.06-4.68], p=0.035).

Conclusion:

The distribution of LVLs were associated with poorer treatment outcomes. A half of the patients with aortic lesions had poor treatment outcomes while subclavian arteritis without aortic lesions had better clinical outcomes. Atypical large vessel-GCA without the aortic and subclavian artery involvement was the worst prognostic phenotype of LV-GCA. Extent of LVLs by imaging should be considered when determining the treatment strategy for GCA.

References:

[1]Sugihara T, et al. Arthritis Res Ther. 2020;22(1):72

Acknowledgements:

The authors would like to acknowledge Mitsuaki Isobe (Sakakibara Heart Institute), Yoshihiro Arimura (Kichijoji Asahi Hospital), and all the investigators in the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS). In addition to the authors, the following investigators and institutions participated in this study: Department of Internal Medicine, Juntendo University Koshigaya Hospital (Shigeto Kobayashi); Niigata Rheumatic Center (Satoshi Ito); Niigata Prefectural Shibata Hospital (Noriyuki Homma).

Disclosure of Interests:

takahiko sugihara Speakers bureau: TS has received honoraria from Abbvie Japan Co., Ltd., AsahiKASEI Co., Ltd., Astellas Pharma Inc., Ayumi Pharmaceutical, Bristol Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi-Tanabe Pharma Co., Ono Pharmaceutical, Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and UCB Japan Co. Ltd., Grant/research support from: TS has received research grants from AsahiKASEI Co., Ltd., Daiichi Sankyo., and Ono Pharmaceutical., Haruhito A. Uchida Grant/research support from: HAU belongs to the Department of Chronic Kidney

Disease and Cardiovascular Disease which is endowed by Chugai Pharmaceutical, MSD, Boehringer Ingelheim, and Kawanishi Holdings., Hajime Yoshifuji Speakers bureau: HY has received lecture fees from Chugai Pharmaceutical Co., Ltd. and Nihon Medi-Physics Co., Ltd., Yasuhiro Maejima Speakers bureau: YM have received honoraria from Chugai Pharmaceutical Co., Ltd.., Taio Naniwa Speakers bureau: TN has received lecture fees from Chugai Pharmaceutical Co., Ltd.., Grant/research support from: TN has received research grants from Chugai Pharmaceutical Co., Ltd.., Yasuhiro Katsumata Speakers bureau: YK has received honoraria from Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., Sanofi K.K., Pfizer Japan Inc., and Asahi Kasei Pharma Corp., Takahiro Okazaki Grant/research support from: TO has received research grants from Chugai Pharmaceutical Co., Ltd., Eisai Pharmaceutical., and Actelion, Jun Ishizaki: None declared, Yohko Murakawa Speakers bureau: YM has received honoraria from Abbvie, Astellas, Ayumi Pharmaceutical, Bristol Myers Squibb, Chugai Pharmaceutical, Eisai Pharmaceutical, Janssen Pharmaceutical, Kissei Pharmaceutical, Nippon Kayaku, Pfizer Pharmaceutical, Takeda Pharmaceutical, UCB Pharmaceutical, Grant/research support from: YM has received research grant support from Asahi Kasei Pharma, AbbVie Japan, Chugai Pharmaceutical, Daiichi Sankyo, Eisai Pharmaceutical, Mitsubishi Tanabe Pharma, Nippon Kayaku, Gilead Sciences Inc, Janssen Pharmaceutical, and Teijin Pharma., Noriyoshi Ogawa: None declared, Hiroaki Dobashi: None declared, Tetsuya Horita: None declared, Yoshiya Tanaka Speakers bureau: YT has received consulting fees, speaking fees, and/or honoraria from Daiichi-Sankyo, Astellas, Pfizer, Mitsubishi-Tanabe, Bristol-Myers, Chugai, YL Biologics, Eli Lilly, Sanofi, Janssen, UCB, Grant/research support from: YT has received research grants from Mitsubishi-Tanabe, Takeda, Bristol-Myers, Chugai, Astellas, Abbvie, MSD, Daiichi-Sankyo, Pfizer, Kyowa- Kirin, Eisai, Ono., Shunsuke Furuta: None declared, Tsutomu Takeuchi Speakers bureau: TT has served on speakers’ fees for AbbVie, Bristol-Myers Squibb, Chugai, Mitsubishi Tanabe, Pfizer, Astellas, Daiichi Sankyo, Eisai, Sanofi, Teijin, Takeda, and Novartis., Consultant of: TT has received consulting fees from Astra Zeneca, Eli Lilly, Novartis, Mitsubishi Tanabe, AbbVie, Nippon Kayaku, Janssen, Astellas, Taiho, Chugai, Taisho Toyama, GlaxoSmithKline, and UCB., Grant/research support from: TT has received research grants from Astellas, Chugai, Daiichi Sankyo, Takeda, AbbVie, Asahi Kasei, Mitsubishi Tanabe, Pfizer, Eisai, AYUMI, Nippon Kayaku, and Novartis., Yoshinori Komagata Speakers bureau: YK has received speakers’ fees from Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Daiichi Sankyo, AbbVie, Nippon Shinyaku, Towa., Consultant of: YK has received consulting fees from Chugai, Kyowa Hakko Kirin, Asahi Kasei, UCB, Yoshikazu Nakaoka Speakers bureau: YN has received lecture fees from Astellas, Takeda, Daiichi Sankyo, Actelion, and Japan Blood Products Organization (JB)., Consultant of: YN has received consulting fees and/or lecture fees from AbbVie and Chugai, Grant/research support from: YN has received research grants from Chugai and Bayer Yakuhin, Ltd, masayoshi harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Consultant of: MH is a consultant for AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: MH has received research grants from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd.

Abstract PS13-38: Cardiotoxicity among patients with breast cancer treated with doxorubicin: A real-world database study

Background While novel targeted agents are increasingly used to care for patients with breast cancer, doxorubicin (DOX) continues to play a role in management of patients, particularly those with aggressive disease. Dose-dependent cardiomyopathy is a challenge in its use. Strategies have been proposed to mitigate this, including administration by continuous intravenous (CIV) infusion as an alternative to bolus (BOL) administration. This study used real world data to explore the impact of DOX administration mode on cardiotoxicity, duration of DOX and time to treatment failure (TTF). Methods IBM MarketScan claims were used to identify patients age ≥ 18 who received at least 2 DOX administrations (excluding liposomal DOX) after cancer diagnosis. Patients with history of cardiac events were excluded. Cardiac events based on a range of International Classification of Disease (ICD) codes were compared for BOL versus CIV overall, by tumor site and by regimen during three follow-up periods, early (within 1 year), middle (&gt;1 to 5 years) and late (&gt;5 years), from DOX initiation using Fisher’s exact test. Duration of DOX and TTF, defined as time from initiation of DOX to subsequent systemic therapy, hospice or death, were evaluated using Kaplan-Meier method and unadjusted Cox proportional hazards models. Results: A total of 38,924 patients with breast cancer met eligibility criteria (13,186 with confirmed metastatic disease). The most common regimen used was DOX plus cyclophosphamide (n=31,815, 81.7%). Most patients had codes for both modes on the same claim date and could not be definitely assigned to BOL or CIV infusion groups; however, 917 and 5,433 patients had exclusive BOL and CIV codes, respectively. Among patients receiving DOX monotherapy (n=687), 361 and 100 had exclusive BOL and CIV codes, respectively. For patients with exclusive infusion type codes, the mean duration of DOX treatment was not significantly different for BOL vs CIV (58.9 vs 56.2 days, p=0.33 overall; 74.4 vs 74.8 days for monotherapy, p=0.97). Overall, cardiac events for BOL vs CIV were 5.1% vs 4.7% (p=0.55) during the early period, 3.1% vs 5.0%, (p=0.01) during the middle period, and 0.4% vs 1.0% (p=0.10) in the late period. There were no differences in cardiac events for BOL vs CIV among those treated with DOX monotherapy (p=0.90, 0.56 and 0.52 for the early, middle, and late period, respectively). TTF was shorter for BOL vs CIV (262.3 vs 366.0 days, p&lt;0.001). However, when evaluating TTF, there was a significant relationship between cardiotoxicities and longer TTF (hazard ratio, HR=0.85, 95% confidence interval, CI: 0.81-0.88, p&lt;0.001). This relationship was statistically significant for the early, middle and late periods, respectively (all p&lt;0.001). Conclusions: These data suggest that cardiac events may occur at a similar rate for BOL and CIV. This study is limited by the retrospective nature of this study and the ability to determine causality; the use of strict coding rules to correctly assign patients to BOL vs CIV groups maintained scientific integrity and a large sample size but did result in the loss of eligible patients. Future research, including adjusted analyses, are needed to further investigate the relationship between mode of infusion and clinical outcomes.

Citation Format: Poorni Manohar, Hannah M Linden, Lisa M Hess, Tomoko Sugihara, Yajun E Zhu, Howard G Muntz, Lee D Cranmer. Cardiotoxicity among patients with breast cancer treated with doxorubicin: A real-world database study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-38.

Impact of bolus versus continuous infusion of doxorubicin (DOX) on cardiotoxicity in patients with breast cancer (BC) and sarcomas: Analysis of real-world data

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Background: Doxorubicin continues to play a central role in management of breast cancer and sarcomas. Dose-dependent cardiomyopathy is a challenge in its use. Strategies have been proposed to mitigate this, including administration by continuous intravenous (CIV) infusion as an alternative to bolus (BOL) administration. This study used real world data to explore the impact of DOX administration mode on cardiotoxicity, duration of DOX and time to treatment failure (TTF). Methods: This study used IBM MarketScan claims to identify patients age ≥ 18 who received at least 2 DOX administrations after cancer diagnosis. Patients with history of cardiac events/toxicities were excluded. Cardiac events were compared for BOL versus CIV overall, by tumor site and by regimen during three follow-up periods, early (within 1 year), middle (>1 to 5 years) and late (>5 years), from DOX initiation using Fisher’s exact test. Duration of DOX and TTF, defined as time from initiation of DOX to subsequent systemic therapy, hospice or death, were evaluated using Kaplan-Meier method and unadjusted Cox proportional hazards models. Results: 62,597 patients were eligible, including 38,961 with BC and 1,772 with sarcoma. Most patients had codes for both modes; 1,941 and 7,094 patients had exclusive BOL and CIV codes, respectively. For these patients, mean duration of DOX was longer for BOL vs. CIV (83.9 vs. 65.4 days, p<0.001). Cardiac events for BOL vs. CIV were 6.5% vs. 5.6% (p=0.098) during the early period, 4% vs. 5.1% (p=0.046) middle period, and 0.5% vs. 0.9% (p=0.068) late period. This pattern was consistent for BC and sarcoma and among those who were pre-treated. There were no differences in cardiac events for BOL vs. CIV for the chemotherapy naïve or DOX monotherapy groups (all periods p>0.10) but statistically different for the breast during the middle period, sarcoma at any time, and pretreated subgroup middle period (all p<0.05). TTF favored CIV over BOL among patients with BC (p<0.0001) but BOL over CIV in sarcoma (p=0.002). TTF was not significantly different between BOL and CIV for BC monotherapy (p=0.067) but was significant for sarcoma monotherapy favoring BOL administration (hazard ratio 0.72, 95% confidence interval 0.54-0.95, p=0.02). Conclusions: These data suggest that cardiac events may occur at a similar rate irrespective of mode of DOX administration. Further analyses are needed to understand how these relationships are impacted by other potential risk covariates (eg, age, gender) and by protective factors (eg, dexrazoxane).

Swelling of Doubly Magic ^{48}Ca Core in Ca Isotopes beyond N=28

Interaction cross sections for ^{42-51}Ca on a carbon target at 280  MeV/nucleon have been measured for the first time. The neutron number dependence of derived root-mean-square matter radii shows a significant increase beyond the neutron magic number N=28. Furthermore, this enhancement of matter radii is much larger than that of the previously measured charge radii, indicating a novel growth in neutron skin thickness. A simple examination based on the Fermi-type distribution, and mean field calculations point out that this anomalous enhancement of the nuclear size beyond N=28 results from an enlargement of the core by a sudden increase in the surface diffuseness of the neutron density distribution, which implies the swelling of the bare ^{48}Ca core in Ca isotopes beyond N=28.

Real-World Outcomes and Factors Associated With the Second-Line Treatment of Patients With Gastric, Gastroesophageal Junction, or Esophageal Adenocarcinoma

This retrospective observational study was designed to evaluate overall survival in a real-world patient population and to identify predictive factors associated with receipt of second-line therapy. A retrospective analysis of electronic medical records (Flatiron Health, New York) was conducted among patients initiating first-line therapy from January 1, 2013, through April 30, 2018. Eligible patients were diagnosed with advanced gastric, gastroesophageal junction, or esophageal adenocarcinoma and ≥18 years of age at the time of treatment initiation. Patients alive 45 days after discontinuation of first-line therapy were considered potentially eligible for continued therapy and were categorized into those who received and those who did not receive second-line therapy. Survival analyses were conducted using Kaplan-Meier method and log-rank test without adjusting for any baseline covariates. Factors associated with further treatment were evaluated using logistic regression. A total of 3850 patients met eligibility criteria. Among the 2516 patients available to receive second-line therapy, 1515 (60.2%) received second-line therapy and 1001 (39.8%) did not receive further therapy. Among those potentially eligible to receive second-line therapy, median survival was 15.4 months (95% confidence interval [CI]: 14.6-16.0) from initiation of first-line therapy for those who received second-line therapy and 10.0 months (95% CI: 9.3-10.7) for those who did not. Longer duration of first-line therapy (≥169 vs ≤84 days), HER2-positive tumors, initially diagnosed with stage IV disease, less weight loss during first-line therapy, and younger age were associated with receipt of second-line therapy (all P < .001). Longer survival was associated with multiple lines of therapy; however, these results should be interpreted with caution, and no causal relationship can be inferred.

Challenges of Using ICD-9-CM and ICD-10-CM Codes for Soft-Tissue Sarcoma in Databases for Health Services Research

OBJECTIVES

Soft-tissue sarcoma (STS) is a heterogeneous group of rare solid tumors that arise from various soft tissues in the body, such as muscle, fat, nerves, and blood vessels. Current International Classification of Diseases (ICD) coding systems include a set of nonspecific codes for malignancies of connective and soft tissue (ICD-9-CM code 171 and ICD-10-CM code C49). The goal of this study was to evaluate the use of these codes for health services research involving patients with a diagnosis of this rare malignancy.

METHODS

Two databases were utilized to explore ICD coding for STS: claims data from Truven MarketScan and electronic medical records (EMRs) from Flatiron Health. Eligible patients from claims data were those with at least two ICD-9-CM codes of 171.x on two different days between July 1, 2004, and March 30, 2014. The treatment patterns of these cases were evaluated for consistency with known therapeutic approaches for STS. Eligible patients from the Flatiron EMR system were those who received olaratumab (a drug indicated only for use in patients diagnosed with STS) after its US Food and Drug Administration approval in October 2016 through the end of the data set (November 2017). ICD-10-CM codes were evaluated for this known STS cohort.

RESULTS

In claims data, 4,159 patients were eligible for inclusion. Although national treatment guidelines include only a limited number of drugs used to treat STS, 98 unique anticancer drugs were identified as being used to treat patients in a claims data cohort. Only 7.7 percent of patients had claims for doxorubicin-based therapy and 3.8 percent had claims for ifosfamide-based therapy as initial treatment for STS, despite these being a standard of care. In the EMR data, 350 patients were eligible; only 170 patients (48.6 percent) had any evidence in the database of a connective or soft-tissue ICD-10-CM malignancy code within 60 days before or after initiation of olaratumab.

CONCLUSIONS

ICD coding for STS using the "Malignant neoplasm of connective and soft tissue" code is not reliable as a method to identify patients diagnosed with STS. Although codes reflecting the primary site of disease may have clinical relevance, lack of consistency in ICD coding for the diagnosis and treatment of this disease is a limiting factor in the ability to conduct real-world observational research of this rare disease. In the absence of consistent use of this code, an algorithm needs to be developed and validated to accurately identify patients with STS in these databases.

Fracture risk and healthcare resource utilization and costs among osteoporosis patients with type 2 diabetes mellitus and without diabetes mellitus in Japan: retrospective analysis of a hospital claims database

Background

Osteoporosis, osteoporosis-related fractures, and diabetes are considerable health burdens in Japan. Diabetes in patients with osteoporosis has been reported to be associated with increased fracture risk. This retrospective analysis of a Japanese hospital claims database investigated the real-world effect of type 2 diabetes mellitus (T2DM) on the incidence of clinical fractures, costs, and healthcare resource utilization in patients with osteoporosis and a subgroup of patients prescribed raloxifene.

Methods

Women aged ≥50 years diagnosed with osteoporosis who had a first prescription claim for osteoporosis treatment with a pre-index period ≥12 months and a post-index period of 30 months were selected from a database extract (April 2008-July 2013). Patients prescribed raloxifene were classed as a subgroup. Patients diagnosed with T2DM constituted the T2DM group; all other patients (excluding patients with type 1 diabetes mellitus) constituted the non-diabetes mellitus (non-DM) group. Groups were matched by exact matching, using selected baseline characteristics. Patient demographic and clinical characteristics were compared using chi-squared tests, t-tests, or Wilcoxon rank sum tests. Time to first fracture was examined using Kaplan-Meier survival analysis.

Results

Overall, the T2DM and non-DM groups had 7580 and 7979 patients, respectively; following matching, there were 3273 patients per group. In the raloxifene subgroup, the T2DM and non-DM groups had 668 and 699 patients, respectively; following matching, there were 239 patients per group. At baseline, the T2DM group (overall and raloxifene subgroup) had significantly higher healthcare resource utilization and comorbidities. During the post-index period, a similar pattern was observed in the overall group, even after matching; the T2DM group also had a higher incidence of fracture. In the raloxifene subgroup, after matching, there were no significant differences in fracture incidence or costs and fewer differences in healthcare resource utilization between the T2DM and non-DM groups.

Conclusions

These findings suggest that comorbid T2DM increases fracture incidence in patients with osteoporosis, compared with patients without DM. Increases in fracture incidence were accompanied by greater costs and healthcare resource utilization, which are important considerations for clinical practice in Japan. Further research investigating the use of raloxifene for treatment of osteoporosis with comorbid T2DM may also be warranted.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1344-9) contains supplementary material, which is available to authorized users.

Real-world clinical and economic outcomes for daily teriparatide patients in Japan

A large medical and pharmacy claims database was used to evaluate outcomes in daily teriparatide (D-TPD) patients in Japan. 445 patients were identified (April 2008-July 2013) with 6+ months' pre- and 18+ months' post-index observation. D-TPD 20 µg subcutaneous injection is indicated for individuals at high risk of fracture. Descriptive analyses were conducted on clinical fractures, health care utilization, and costs. Adherence was measured by medication possession ratio (MPR) (High MPR > 0.8; 0.5 ≤ Medium MPR ≤ 0.8, Low MPR < 0.5). Adjusted analyses of Lower (Low + Medium) MPR vs. High MPR for fracture incidence and hospital admissions were performed using logistic and Poisson regression models; adjusted cost analyses used propensity bin bootstrapping methods. Baseline characteristics were: mean 74.7 years (standard deviation = 8.9); 90 % female; 20 % 1+ fracture. Post-index, 249 and 196 patients had High and Lower MPR, respectively. Mean incident fractures/1000 patient-years for Lower and High MPR patients were 77.4 and 57.7, respectively. Adjusted fracture risk was greater in Lower MPR patients [logistic odds ratio (OR) = 1.67, 95 % confidence interval 0.791-3.541; Poisson incidence rate ratio (IRR) = 1.505, 0.764-2.966]. Hospital admission risk was significantly greater in Lower than High MPR patients (OR = 1.85, 1.169-2.921; IRR = 1.47, 1.137-1.904). High MPR patients had numerically lower inpatient and total unadjusted costs than Lower MPR patients. Adjusted inpatient costs were significantly less in High MPR patients; outpatient and pharmacy costs were greater. Better adherence to D-TPD revealed a trend towards lower fracture risk, and significant reductions in hospital admissions and costs. The small sample size limited the robustness of these results.

Osteoporotic fractures and associated hospitalizations among patients treated with teriparatide compared to a matched cohort of patients not treated with teriparatide

OBJECTIVE

To compare fractures and fracture-related resource utilization (RU) among patients with a recent fracture and treated with teriparatide (TPTD) to a matched cohort of patients not treated with TPTD (non-TPTD).

RESEARCH DESIGN AND METHODS

Women aged 50 years or older initiating TPTD (N = 5314; index date between 1 January 2007 and 31 December 2012) were identified in an insurance claims database. Patients with fragility fracture (hip, pelvis, clavicle, humerus, wrist, leg or spine) during the 12 months prior to the index date (N = 1164) were selected to control for unmeasured confounding due to absence of bone mineral density test levels. TPTD patients were matched to the non-TPTD cohort using propensity score and exact matching (N = 912). Relative risk (RR) of fracture and fracture-related RU were estimated by Cox proportional hazard modeling, adjusted for potential fracture risk factors.

RESULTS

Fractures were observed in 4.6%, 8.6%, 10.3%, and 11.3% of TPTD patients and in 9.2%, 15.2%, 19.2% and 21.7% of non-TPTD patients over 6, 12, 18, and 24 months, respectively. The adjusted RR reduction in TPTD was 36% (RR = 0.64, 95% CI: 0.44-0.94) during 6 months, 27% (RR = 0.73, 95% CI: 0.54-0.97) during 12 months, 28% (RR = 0.72, 95% CI: 0.55-0.93) during 18 months, and 28% (RR = 0.72, 95% CI: 0.56-0.92) during 24 months versus matched non-TPTD patients. Fracture-related RU followed a similar trend to that observed for fracture risk.

CONCLUSIONS

This real-world study found TPTD to be more effective in reducing risk of fragility fractures as early as 6 months with continuous treatment benefit up to 24 months compared to a matched non-TPTD cohort. TPTD patients experienced lower rates of fracture-related RU than non-TPTD patients. Key study limitations include the inability to confirm reported diagnostic and procedural codes and the absence of uninsured and individually insured patients in the claims database.

Construct validity of 2 measures to assess reasons for antipsychotic discontinuation and continuation from patients' and clinicians' perspectives in a clinical trial

BACKGROUND

Little is known about the specific reasons for antipsychotic discontinuation or continuation from patients' or clinicians' perspectives. This study aimed to assess the construct validity of 2 new measures of the Reasons for Antipsychotic Discontinuation/Continuation (RAD): RAD-I (a structured interview assessing the patient's perspective) and RAD-Q (a questionnaire assessing the clinician's perspective).

METHODS

Data were used from a 12-week antipsychotic trial of schizophrenia patients in which the RAD was administered at study entry and at study completion (or discontinuation). Construct validity was assessed through comparisons of RAD responses, clinicians' responses to a standard patient disposition form identifying reasons for patient's study discontinuation, and several standard psychiatric measures. Percent agreement quantified the correspondence between patient and clinician scores.

RESULTS

Patients indicating lack of improvement/worsening of positive symptoms as a 'somewhat' to 'primary' reason for medication discontinuation had statistically significantly less improvement in Positive and Negative Syndrome Scale positive score than patients not reporting these as a reason (concurrent validity). Similar results were observed for the RAD negative symptom, functional, social support, and adherence items, whereas the mood and cognitive items were not significantly associated with change scores on standard psychiatric measures. Responses to the RAD were also weakly associated with variables that theoretically should not be related to them (divergent validity). Level of agreement between the clinician- and patient-rated RAD scores was high (60%-100%).

CONCLUSIONS

Initial validation of the RAD suggests that the instruments are valid tools for gathering detailed information regarding reasons for antipsychotic discontinuation and continuation from patients' and clinicians' perspectives.

Role of bone graft in reconstruction of skull base defect: is a bone graft necessary

Ten patients underwent reconstruction of skull base defects between 1989 and 1992. In this series, the maximum size of the skull base defect was 6 x 5 cm. Three patients underwent bone grafts to reinforce the skull base. The postoperative course of seven patients without bone grafts was uneventful. There was no cerebrospinal fluid leakage, meningitis, extradural abscess, on brain herniation. On the other hand, two of the three patients with bone grafts developed extradural abseesses requiring the bone grafts to be removed. Although the number of patients in this series is not large, this study demonstrates that the use of bone grafts in reconstruction of skull base detects could be one of the factors in increasing the chances of infectious complications. We think that a bone graft is not necessary to reconstruct moderate-sized skull base defects.

Experience with 24 cases of reconstructive anterior skull base surgery: classification and evaluation of postoperative facial appearance

This article details our experience with 24 cases of anterior skull base reconstruction after tumor resection. They were classified into four types according to the resected region. In 11 cases of type I resection, the orbital part of frontal bone and/or cribriform plate of ethmoid bone were resected. In two cases of type II resection, the orbital contents and partial orbital bone were resected with the addition of type I. In five cases of type III resection, the maxillary bone was resected with the addition of type II. In six cases of type IV resection, the zygomatic bone and/or facial skin were resected with the addition of type III. The tumor originating from intracranial region was 25% of this series and all of them belonged to type I. The tumor originating from extracranial region tumor was 75% and its resected region was more extensive. In type I and II resections, the cranial flap, radial forearm free flap, or a combination of the two was used for reconstruction. The rectus abdominis myocutaneous/muscle free flap was used for reconstruction of massive defects in type III and IV defects. Total incidence of postoperative complications was 16.7%. Donor site deformity of the cranial flap at the frontal and temporal region in types I and II resections and facial contour deformity in zygomatic region and defect of upper and/or lower palpebra in type IV resection were major problems with postoperative facial appearance. Although use of the rectus abdominis myocutaneous free flap combined with costal cartilages improved the midfacial contour, palpebral reconstruction remained an unsolved problem in reconstructive skull base surgery. The reconstructive goals in skull base surgery are not only to obtain safe and reliable skull base reconstruction but also to restore the facial appearance postoperatively.

Assessment of ablative margin by MRI with ferucarbotran in radiofrequency ablation for liver cancer: comparison with enhanced CT

OBJECTIVES

Our aim was to determine whether ablated liver parenchyma surrounding a tumour can be assessed by MRI with ferucarbotran administered prior to radiofrequency ablation (RFA) compared with enhanced CT.

METHODS

55 hepatocellular carcinomas (HCCs) in 42 patients and 5 metastatic liver cancers in 3 patients were treated by RFA after ferucarbotran administration. We then performed T(2)* weighted MRI after 1 week and enhanced CT after 1 month. T(2)* weighted MRI demonstrated the ablated parenchyma as a low-intensity rim around the high intensity of the ablated tumour in these cases. The assessment was allocated to one of three grades: margin (+), high-intensity area with continuous low-intensity rim; margin zero, high-intensity area with discontinuous low-intensity rim; and margin (-), high-intensity area extending beyond the low-intensity rim.

RESULTS

Margin (+), margin zero and margin (-) were found in 17, 35 and 5 nodules, respectively. All 17 nodules with margin (+) and 13 of those with margin zero were assessed as having sufficient ablative margins on CT. The remaining 22 nodules with margin zero had insufficient margins on CT. The overall agreement between MRI and CT for the diagnosis of the ablative margin was moderate (κ = 0.507, p < 0.001). No local recurrence was found in 15 HCC nodules with margin (+), whereas local recurrence was found in 4 (11.8%) out of 34 HCC nodules with margin zero.

CONCLUSION

Administration of ferucarbotran before RFA enables the ablative margin to be visualised as a low-intensity rim, and also enables the evaluation of the ablative margin to be made earlier and more easily than with enhanced CT.

Healthcare resource utilization and costs assessment of type 2 diabetes patients initiating exenatide BID or glargine: a retrospective database analysis

OBJECTIVE

To examine resource utilization and healthcare costs associated with the use of exenatide versus glargine in type 2 diabetes (T2D) patients.

METHODS

A retrospective analysis comprised of patients with T2D initiating exenatide (n = 7,255) or glargine (n = 2,819) between 04/01/2005 and 06/30/2007. Propensity score matching was used (2,506 matched pairs) to control for baseline demographic, clinical, resource use, and cost variables to balance treatment groups. Mean medical costs and other cost components were estimated using nonparametric bootstrapping.

RESULTS

Exenatide-treated patients had 19% lower likelihood of all-cause hospitalizations (odds ratio [OR]: 0.81, p = 0.009) compared to glargine-treated patients. Exenatide-treated patients had significantly lower total medical costs of $2,597 (p = 0.008). Exenatide-treated patients had significantly lower inpatient costs of $1,968 (p = 0.004) and outpatient costs of $1,324 (p = 0.011), but higher prescription costs of $706 (p < 0.001). Exenatide-treated patients further incurred lower hospitalization costs of $1,910 (p = 0.005) and physician office visit costs of $608 (p = 0.008).

KEY LIMITATIONS

Lack of availability of clinical measures including duration of diabetes, severity of T2D and lack of control for unmeasured confounding.

CONCLUSIONS

Patients initiating exenatide treatment had significantly lower healthcare resource utilization and total medical costs. Cost offsets were observed in inpatient and outpatient costs despite higher prescription costs.

Assessment of hepatocellular carcinoma by contrast-enhanced ultrasound with perfluorobutane microbubbles: comparison with dynamic CT

OBJECTIVE

The aim of this study was to evaluate tumour vascularity and Kupffer cell imaging in hepatocellular carcinoma (HCC) using contrast-enhanced ultrasonography (CEUS) with Sonazoid (perfluorobutane) and to compare performance with dynamic CT.

METHODS

We studied 118 nodules in 88 patients with HCC. HCC was diagnosed as a hyperenhancement lesion in the arterial phase with washout in the portal phase on dynamic CT or by percutaneous biopsy. We observed tumour vascularity at the early vascular phase (10-30 s after contrast injection) and Kupffer imaging at the post-vascular phase (after 10 min).

RESULTS

Detection of vascularity at the early vascular phase was 88% in nodules that were found to be hypervascular on dynamic CT and 28% in hypo-/isovascular nodules; the detection of local recurrence nodules was 92%. The detection of vascularity was significantly lower in nodules >9 cm deep than in those ≤9 cm deep, but was not affected by tumour size. The detection of tumours at the post-vascular phase on CEUS was 83% in nodules with low density in the portal phase on dynamic CT and 82% in nodules with isodensity. The rate did not depend on the severity of underlying liver disease; rates decreased in nodules deeper than 9 cm, those smaller than 2 cm in diameter and in iso-enhancing nodules at the early vascular phase of CEUS.

CONCLUSION

CEUS with Sonazoid is a useful tool for assessing the vascularity of HCC and is equal to that of dynamic CT; however, the detectability of HCC vascularity is affected by location.

The increased mucosal mRNA expressions of complement C3 and interleukin-17 in inflammatory bowel disease

Recent studies have demonstrated that the complement system participates in the regulation of T cell functions. To address the local biosynthesis of complement components in inflammatory bowel disease (IBD) mucosa, we investigated C3 and interleukin (IL)-17 mRNA expression in mucosal samples obtained from patients with IBD. The molecular mechanisms underlying C3 induction were investigated in human colonic subepithelial myofibroblasts (SEMFs). IL-17 and C3 mRNA expressions in the IBD mucosa were evaluated by real-time polymerase chain reaction. The C3 levels in the supernatant were determined by enzyme-linked immunosorbent assay. IL-17 and C3 mRNA expressions were elevated significantly in the active lesions from ulcerative colitis (UC) and Crohn's disease (CD) patients. There was a significant positive correlation between IL-17 and C3 mRNA expression in the IBD mucosa. IL-17 stimulated a dose- and time-dependent increase in C3 mRNA expression and C3 secretion in colonic SEMFs. The C3 molecules secreted by colonic SEMFs were a 115-kDa alpha-chain linked to a 70-kDa beta-chain by disulphide bonds, which was identical to serum C3. The IL-17-induced C3 mRNA expression was blocked by p42/44 mitogen-activated protein kinase (MAPK) inhibitors (PD98059 and U0216) and a p38 MAPK inhibitor (SB203580). Furthermore, IL-17-induced C3 mRNA expression was inhibited by an adenovirus containing a stable mutant form of I kappaB alpha. C3 and IL-17 mRNA expressions are enhanced, with a strong correlation, in the inflamed mucosa of IBD patients. Part of these clinical findings was considered to be mediated by the colonic SEMF response to IL-17.

A case of polyarteritis nodosa with periurethralaseptic abscesses and testicular lesions

We describe a 54-year-old man presenting with cutaneous ulcerations, livedo reticularis, numbness of the legs, and skin histological findings compatible with the diagnosis of polyarteritis nodosa (PAN). Initial treatment with 50 mg/day of prednisolone (PSL) was effective. However, the symptoms and signs recurred, and the patient developed multiple periurethral aseptic abscesses, urethra-cutaneous fistula, and testicular lesions after tapering of PSL therapy. The condition improved with PSL and cyclophosphamide administration. Since penile and testicular vasculitis could be associated with PAN, although rarely, we should carefully distinguish such an involvement from infection and malignancy.

Positron emission tomography with 18F-FDG in osteoarthritic knee

OBJECTIVES

To evaluate osteoarthritis (OA) of the knee using positron emission tomography (PET) with 2-(18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG) as a tracer.

MATERIALS AND METHODS

Fifteen patients with medial-type knee OA and three healthy subjects were enrolled in the study. After clinical examination and conventional radiography, (18)F-FDG PET and magnetic resonance imaging (MRI) were performed. (18)F-FDG uptake was quantified as a standardized uptake value (SUV) and the localization of (18)F-FDG uptake was identified using fusion images created with MRI scans.

RESULTS

(18)F-FDG generally accumulated in periarticular lesions and was absent in the articular cartilage. SUVs of the whole knee were higher in OA than in controls, and those in the medial condyle were higher than in the lateral condyle in OA. Prominent (18)F-FDG uptake was found in the intercondylar notch in OA and extended along the posterior cruciate ligament (PCL) in some cases. Periosteophytic accumulation was found in one-half of cases with definite osteophytes. Accumulation was also found in subchondral lesions and bone marrow, which corresponded with bone edema diagnosed by MRI. No significant correlation was found between SUV and clinical manifestations.

CONCLUSIONS

(18)F-FDG uptake was upregulated in OA and generally accumulated in periarticular lesions. Increased uptake was found in the intercondylar notch extending along the PCL, periosteophytic lesions, and bone marrow. These results provide in vivo pathognomonic insights into OA.

Change in the cross-sectional area of a patellar tendon graft after anterior cruciate ligament reconstruction

The purpose of this study was to clarify the change in the cross-sectional area (CSA) of a patellar tendon graft after anterior cruciate ligament (ACL) reconstruction, and its relationship with postoperative knee laxity. Forty patients (25 men and 15 women) were included in this study. Intraoperative CSA measurements were performed with an instrumented areamicrometer, while a magnetic resonance imaging (MRI) evaluation was utilized for the assessment postoperatively. For intraoperative measurement, the average CSA of a 10-mm wide patellar tendon graft was 32.3 +/- 7.0 mm2, while the average CSA measured at follow-up (mean: 14.8 months) was 48.8 mm2, showing a significant mean increase ratio of 49.4%. This value corresponded to 115% of the native ACL. The average CSA measured in 30 patients at 6 months was 49.7 mm2, almost equal to the value at the final follow-up (49.8 mm2) in the same patient group. Among potentially influential factors, postoperative notch width (available space for the ACL graft) had significant correlation with the CSA of the graft at follow-up. Finally, both intra- and postoperative CSA values did not correlate with postoperative knee laxity, indicating that a bigger graft does not guarantee a better laxity.

Radioactivity thresholds for sentinel node biopsy in breast cancer

AIMS

The aim of the present study is to clarify the level of radioactive lymph node should be biopsied after the most radioactive SN is removed.

METHODS

SNB using radionuclide was performed in our hospital for 1179 primary breast cancers between April 2000 and October 2005; most (1177/1179) were performed successfully. Our criterion for harvesting SNs is to remove tissue until no radioactive site is present. The level of radioactivity and the order of removal of each lymph node were compared with pathologic results.

RESULTS

More than 2 (overall average 1.9) radioactive SNs were biopsied in 686 of 1177 breasts. Cancer positive results were recorded for 142 breasts with multiple SNs. In 142 breasts, 64 showed metastasis to the most radioactive node only, 39 showed metastasis other than the most radioactive node only, and 39 showed the most radioactive node and other radioactive nodes. Moreover, if several other criteria were applied, false-positive cases were increased significantly.

CONCLUSIONS

It is necessary to harvest radioactive lymph nodes other than the most radioactive. Moreover, efforts to remove every radioactive lymph node will minimize false-negative results.

Effective esophageal balloon dilation for esophageal stenosis in recessive dystrophic epidermolysis bullosa

Recessive dystrophic epidermolysis bullosa (RDEB) is an inherited disorder of squamous epithelium that results in dystrophic scarring of the skin after minor trauma. RDEB is classified into two subtypes: Hallopeau-Siemens (HS) and non-Hallopeau-Siemens (nHS). Although severe scarring of the skin is the most common and obvious complication of the disease, esophageal scarring with formation of long strictures may also develop. Treatment options for esophageal stenosis in patients with RDEB include steroids, hyperalimentation, esophageal dilation and replacement. This report describes a child who was dilated immediately after diagnosis of severe esophageal stenosis subsequent to nHS-RDEB and managed successfully. Endoscopic esophageal balloon dilation under fluoroscopic control was very useful for detecting the region of stenosis and bougienage. The literature on such injuries is reviewed here, and the problems associated with the treatment of children with esophageal stenosis associated with RDEB are discussed.

Variation of microvascular blood flow augmentation--supercharge in esophageal and pharyngeal reconstruction

AIM OF THE STUDY

A gastric tube is commonly used in thoracic esophageal reconstruction. When a gastric tube is not available, pedicled jejunum transfer and colonic interposition are alternative methods. Oral end of the reconstructed esophagus occasionally has poor blood flow and may result in partial necrosis of the oral segment. We performed additional microvascular blood flow augmentation, the "supercharge" technique, to improve a blood flow circulation in the oral segment of the reconstructed esophagus.

METHODS

A series of 86 esophageal reconstructions with microvascular blood flow augmentation using the "supercharge" technique were performed. Reconstructive methods included a gastric tube in five patients, a gastric tube combined with a free jejunual graft in one, an elongated gastric tube in eight, a pedicled colonic interposition in 22, and a pedicled jejunum in 50. Recipient vessels were used in neck or chest region.

RESULTS

The color and blood flow of the transferred intestine appeared greatly improved after microvascular blood flow augmentation. Thrombosis was noticed in three patients during the surgery, and all thrombosies were salvaged by re-anastomosis. There were only three patients with partial graft necrosis of oral segment, two patients with anastomotic leakage, one anastomotic stricture.

CONCLUSIONS

Augmentation of microvascular blood flow by this "supercharge" technique can be expected to reduce the risk of leakage and partial necrosis of the transferred intestine. This technique contributes to the successful reconstruction of esophageal defect.

Evaluation of covered metallic stents in malignant biliary stenosis--prominent effectiveness in gallbladder carcinoma

BACKGROUND/AIMS

The survival time of patients with unresectable malignant biliary stenosis and the patent period of metallic biliary stents are different in each disease. The efficacy of the covered metallic stent was analyzed according to the primary disease.

METHODOLOGY

Seventy-three patients with bile duct carcinoma (12 cases), gallbladder carcinoma (22 cases), and pancreas carcinoma (39 cases) were retrospectively enrolled. Covered metallic stents were used in 42 patients and uncovered metallic stents in 31 patients. The patency of covered stents was compared with that of uncovered stents for each disease.

RESULTS

The patent rate at 6 months after insertion was 80.6% (95% CI [72.6%, 88.6%]) for the covered stent, and 49.5% (95% CI [37.6%, 61.4%]) for the uncovered stent. The mean patent periods of the covered stent and the uncovered stent were 14.6 and 27.6 months for bile duct carcinoma (p=0.424), 12.7 and 3.0 months for gallbladder carcinoma (p=0.003), and 11.9 and 9.6 months for pancreas carcinoma (p=0.919), respectively.

CONCLUSIONS

The covered metallic stent was the most effective in patients with gallbladder carcinoma.

Molecular analysis of non-syndromic preaxial polydactyly: preaxial polydactyly type-IV and preaxial polydactyly type-I

Human GLI3 gene mutations have been identified in several phenotypes of digital abnormality such as Greig cephalopolysyndactyly syndrome, Pallister-Hall syndrome, preaxial polydactyly type-IV (PPD-IV) and postaxial polydactyly. However, the different phenotypes resulting from GLI3 mutations have not yet been properly defined. We have experienced two types of digital abnormality without other complicating developmental defects; a family with foot PPD-IV with syndactyly of the third and fourth fingers, and four sporadic cases with biphalangeal thumb polydactyly (PPD-I). The genes responsible for syndactyly of the third and fourth fingers (syndactyly type-I) and PPD-I have not yet been identified; we therefore examined the involvement of the GLI3 gene in these subtypes of digital abnormality. We found a non-sense mutation in the GLI3 gene in the family with foot PPD-IV accompanied with hand syndactyly of the third and fourth fingers, but no mutations were detected in the GLI3 gene in the four other cases with PPD-I alone. Thus, the phenotype of foot PPD-IV accompanied with hand syndactyly of the third and fourth fingers may result from a GLI3 mutation, whereas the PPD-I phenotype alone is not caused by GLI3 gene defect. These results will help to define the phenotypic spectrum of GLI3 morphopathies, which have been recently proposed.

Expression of protein gene product 9.5 (PGP9.5)/ubiquitin-C-terminal hydrolase 1 (UCHL-1) in human myeloma cells

The neuron cytoplasmic protein gene product 9.5 (PGP9.5)/ubiquitin-C-terminal hydrolase 1 (UCHL-1) protein is a thiol protease that recognizes and hydrolyzes a peptide bond at the C-terminal of ubiquitin, and is involved in the processing of ubiquitin precursors and ubiquinated proteins. Although this molecule is known as a specific tissue marker for the neuroendocrine system, many reports have indicated that PGP9.5 is a marker for certain tumour types, such as cancer of the lung, colon, and pancreas. The expression of PGP9.5 in myeloma cells was examined. PGP9.5 seemed to be expressed specifically in myeloma cells as compared with other haematological malignant cells. In addition, in myeloma cells subjected to growth-factor starvation, the upregulation of PGP9.5 was observed in association with that of p27(Kip1), a cyclin-dependent-kinase inhibitor, although the upregulation caused by irradiation was milder. In contrast, the hypoxic culture of myeloma cells induced down-regulation of PGP9.5. These results suggested that PGP9.5 may be a good marker for myeloma among haematological malignancies. In addition, it may indicate certain cellular features of myeloma cells, such as sensitivity to proteasome inhibitors.

A new technique of microvascular suturing: the chopstick rest technique

With the conventional techniques of tying knots during microvascular anastomosis or neural suturing, time may be lost due to various reasons. The loose end of the suture often falls down into the operative field and gets stuck to the surrounding tissues. In the process of retrieving the suture, the surrounding tissues can be picked up together with the suture. When the posterior wall technique [Br J Plast Surg 34 (1981) 47, Plast Reconstr Surg 69 (1982) 139, Microsurgery 8 (1987) 22, J Reconstr Microsurg 15 (1999) 321] is used, the loose end of the suture may be stuck to the backside of the vessel and may be hard to grab. In order to avoid those problems, a new way of tying a microsuture was developed. By avoiding contact of the loose end of the suture to the surrounding tissue at any point during tying, the microvascular anastomosis can be performed quicker and more efficiently.

The ARF-p53 senescence pathway in mouse and human cells

Mouse and human cells have most frequently been used for studies that have led to the elucidation of various molecular pathways involved in senescence. The ARF-p53 pathway has been assigned as one of the major protagonists in these phenomena. ARF is an alternative reading frame protein encoded along with p16INK4A by the INK4a locus on human chromosome 9p21 and the corresponding locus on mouse chromosome 4. Whereas the mouse ARF (p19ARF) consists of 169 amino acids, the human ARF (p14ARF) consists of 132 amino acids, truncated at the C-terminus. Molecular studies on the regulation of ARF activity by its binding partners have revealed that mouse ARF protein, but not human ARF protein, interacts with a cytoplasmic protein, Pex19p. This interaction of mouse ARF with Pex19p results in its milder p53 activation function in mouse cells as compared to human cells and thus accounts, at least in part, for the weaker tumor surveillance and frequent immortalization of mouse cells.

Identification of a novel gelsolin truncate in the vertical and metastatic phase malignant melanomas

Examination of 38 human melanoma samples by Western blotting analysis with anti-gelsolin antibodies showed that a new 85 kDa truncated gelsolin (GSNp85), co-expressed with wild-type gelsolin, was frequently expressed in vertical growth phase melanomas (Clark level II-IV) and metastatic growth phase melanomas. The GSNp85 truncate was not expressed in radial growth phase melanomas (Clark level I), acquired naevi, other skin cancers or normal skin tissues. Peptide-sequencing analysis revealed that GSNp85 lacks the C-terminal domain of wild-type gelsolin at the region containing the caspase-8 recognition site IETD. Caspase-8 processing was detected in GSNp85-positive but not GSNp85-negative melanomas. These data suggest that GSNp85 is a cleavage product of caspase-8 and may be useful as a new marker for the vertical or metastatic growth phase of malignant melanoma.

Manifestation of a nontrivial vacuum in discrete light-cone quantization

We study a (1+1)-dimensional lambda phi(4) model with a light-cone zero mode and constant external source to describe spontaneous symmetry breaking. In the broken phase, we find degenerate vacua and discuss their stability based on effective-potential analysis. The vacuum triviality is spurious in the broken phase because these states have lower energy than Fock vacuum. Our results are based on the variational principle.