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Dimitriou F, Namikawa K, Reijers ILM, Buchbinder EI, Soon JA, Zaremba A, Teterycz P, Mooradian MJ, Armstrong E, Nakamura Y, Vitale MG, Tran LE, Bai X, Allayous C, Provent-Roy S, Indini A, Bhave P, Farid M, Kähler KC, Mehmi I, Atkinson V, Klein O, Stonesifer CJ, Zaman F, Haydon A, Carvajal RD, Hamid O, Dummer R, Hauschild A, Carlino MS, Mandala M, Robert C, Lebbe C, Guo J, Johnson DB, Ascierto PA, Shoushtari AN, Sullivan RJ, Cybulska-Stopa B, Rutkowski P, Zimmer L, Sandhu S, Blank CU, Lo SN, Menzies AM, Long GV. Single-agent anti-PD-1 or combined with ipilimumab in patients with mucosal melanoma: an international, retrospective, cohort study. Ann Oncol 2022; 33:968-980. [PMID: 35716907 DOI: 10.1016/j.annonc.2022.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/15/2022] [Accepted: 06/07/2022] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Mucosal melanoma (MM) is a rare melanoma subtype with distinct biology and poor prognosis. Data on the efficacy of immune checkpoint inhibitors (ICIs) is limited. We determined the efficacy of ICIs in MM, analysed by primary site and ethnicity/race. PATIENTS AND METHODS Retrospective cohort study from 25 cancer centres in Australia, Europe, USA and Asia. Patients with histologically confirmed MM were treated with anti-PD1+/-ipilimumab. Primary endpoints were response rate (RR), progression-free survival (PFS), overall survival (OS) by primary site (naso-oral, urogenital, anorectal, other), ethnicity/race (Caucasian, Asian, Other) and treatment. Univariate and multivariate Cox proportional hazard model analyses were conducted. RESULTS In total, 545 patients were included: 331 (63%) Caucasian, 176 (33%) Asian and 20 (4%) Other. Primary sites included 113 (21%) anorectal, 178 (32%) urogenital, 206 (38%) naso-oral and 45 (8%) other. 348 (64%) received anti-PD1 and 197 (36%) anti-PD1/ipilimumab. RR, PFS and OS did not differ by primary site, ethnicity/race or treatment. RR for naso-oral was numerically higher for anti-PD1/ipilimumab (40%, 95% CI 29-54%) compared with anti-PD1 (29%, 95% CI 21-37%). 35% of patients that initially responded progressed. Median duration of response (mDOR) was 26 months (95% CI 18-NR [Not Reached]). Factors associated with short PFS were ECOG PS ≥3 (p<0.01), LDH >ULN (p=0.01), lung metastases (p<0.01) and ≥1 previous treatments (p<0.01). Factors associated with short OS were ECOG PS ≥1 (p<0.01), LDH >ULN (p=0.03), lung metastases (p<0.01) and ≥1 previous treatments (p<0.01). CONCLUSIONS MM has poor prognosis. Treatment efficacy of anti-PD1+/-ipilimumab was similar and did not differ by ethnicity/race. Naso-oral primaries had numerically higher response to anti-PD1/ipilimumab, without difference in survival. The addition of ipilimumab did not show greater benefit over anti-PD1 for other primary sites. In responders, mDOR was short and acquired resistance was common. Other factors, including site and number of metastases were associated with survival.
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Affiliation(s)
- F Dimitriou
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Department of Dermatology, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - K Namikawa
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - I L M Reijers
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E I Buchbinder
- Melanoma Disease Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02481, USA
| | - J A Soon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A Zaremba
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - P Teterycz
- Department of Soft Tissue/Bone Sarcoma and Melanoma, 49585Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - M J Mooradian
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - E Armstrong
- Department of Medicine, Melanoma Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Y Nakamura
- Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center, Saitama, Japan
| | - M G Vitale
- Istituto Nazionale Tumori IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - L E Tran
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - X Bai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma and Sarcoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - C Allayous
- APHP Hôpital Saint-Louis, Dermatology Department, DMU ICARE, Paris, France
| | - S Provent-Roy
- Dermatology Service, Department of Medicine, Gustave Roussy and Paris-Saclay University, Villejuif, France
| | - A Indini
- Unit of Medical Oncology, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | - P Bhave
- Westmead and Blacktown Hospitals, Sydney, New South Wales, Australia
| | - M Farid
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - K C Kähler
- Department of Dermatology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - I Mehmi
- Department of Hematology/Oncology, The Angeles Clinic and Research Institute, a Cedars-Sinai Affiliate, 11800 Wilshire Blvd Suite 300, Los Angeles, CA, 90025, USA
| | - V Atkinson
- Princess Alexandra Hospital, Greenslopes Private Hospital, University of Queensland, Queensland, Australia
| | - O Klein
- Department of Medical Oncology, Austin Health, Melbourne, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria
| | - C J Stonesifer
- Columbia University Irving Medical Center, New York City, New York, USA
| | - F Zaman
- Alfred Hospital, Melbourne, Victoria, Australia
| | - A Haydon
- Alfred Hospital, Melbourne, Victoria, Australia
| | - R D Carvajal
- Columbia University Irving Medical Center, New York City, New York, USA
| | - O Hamid
- Department of Hematology/Oncology, The Angeles Clinic and Research Institute, a Cedars-Sinai Affiliate, 11800 Wilshire Blvd Suite 300, Los Angeles, CA, 90025, USA
| | - R Dummer
- Department of Dermatology, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - A Hauschild
- Department of Dermatology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - M S Carlino
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Westmead and Blacktown Hospitals, Sydney, New South Wales, Australia
| | - M Mandala
- Unit of Medical Oncology, University of Perugia, Perugia, Italy
| | - C Robert
- Dermatology Service, Department of Medicine, Gustave Roussy and Paris-Saclay University, Villejuif, France
| | - C Lebbe
- Université de Paris, APHP Hôpital Saint-Louis, Dermatology Department, DMU ICARE, INSERM U-976, Paris, France
| | - J Guo
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma and Sarcoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - D B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - A N Shoushtari
- Department of Medicine, Melanoma Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - R J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - B Cybulska-Stopa
- Department of Clinical Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Cracow Branch, Poland
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, 49585Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - L Zimmer
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - S Sandhu
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - C U Blank
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - A M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - G V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia.
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Abstract
PURPOSE OF REVIEW Patients with advanced or metastatic v-raf murine sarcoma viral oncogene homolog B1 (BRAF)-mutated melanoma can be treated with a BRAF inhibitor in combination with a MAPK/ERK kinase (MEK) inhibitor, achieving high but short-lived response rates. Immune checkpoint inhibitors (ICIs), in contrast, give lower response rates but more durable responses. Preclinical and translational data indicate that combining BRAF and MEK inhibitors with ICI could exceed the limitations of each class and potentially lead to longer lasting responses. RECENT FINDINGS Vemurafenib, dabrafenib and encorafenib are designed to block mutated forms of BRAF, which cause abnormal signalling inside cancer cells leading to tumour growth. Trametinib, binimetinib and cobimetinib are designed to target and inhibit MEK1/2, proteins in a cell signalling pathway that help cell growth and survival. Pembrolizumab, nivolumab, durvalumab and atezolizumab are ICIs which can inhibit the pathway of programmed death-1/ programmed death-ligand-1 proteins, allowing tumours to avoid detection by the immune system. SUMMARY Treating patients with targeted therapy would allow the release of antigens from tumour cells, which could be more easily acknowledged by the immune system. Efficacy can also be increased by combining ICIs with the aim of maintaining a longer response. The possibility to administer three drugs in combination, would allow to induce tumour regression and produce an immune response with a synergistic effect.
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Affiliation(s)
- Claudia Trojaniello
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
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Trojaniello C, Vitale MG, Ascierto PA. Checkpoint inhibitor therapy for skin cancer may be safe in patients with asymptomatic COVID-19. Ann Oncol 2021; 32:674-676. [PMID: 33600920 PMCID: PMC7884251 DOI: 10.1016/j.annonc.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 01/30/2021] [Accepted: 02/07/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- C Trojaniello
- Department Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - M G Vitale
- Department Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - P A Ascierto
- Department Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy.
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4
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Cortellini A, Vitale MG, De Galitiis F, Di Pietro FR, Berardi R, Torniai M, De Tursi M, Grassadonia A, Di Marino P, Santini D, Zeppola T, Anesi C, Gelibter A, Occhipinti MA, Botticelli A, Marchetti P, Rastelli F, Pergolesi F, Tudini M, Silva RR, Mallardo D, Vanella V, Ficorella C, Porzio G, Ascierto PA. Early fatigue in cancer patients receiving PD-1/PD-L1 checkpoint inhibitors: an insight from clinical practice. J Transl Med 2019; 17:376. [PMID: 31730009 PMCID: PMC6857130 DOI: 10.1186/s12967-019-02132-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/07/2019] [Indexed: 12/12/2022] Open
Abstract
Background Fatigue was reported as the most common any-grade adverse event (18.3%), and the most common grade 3 or higher immune-related adverse event (irAE) (0.89%) in patients receiving PD-1/PD-L1 checkpoint inhibitors in clinical trial. Methods The aim of this retrospective multicenter study was to evaluate the correlations between “early ir-fatigue”, “delayed ir-fatigue”, and clinical outcomes in cancer patients receiving PD-1/PD-L1 inhibitors in clinical practice. Results 517 patients were evaluated. After the 12-weeks landmark selection, 386 (74.7%) patients were eligible for the clinical outcomes analysis. 40.4% were NSCLC, 42.2% were melanoma, 15.3% renal cell carcinoma and 2.1% other malignancies. 76 patients (19.7%) experienced early ir-fatigue (within 1 month from treatment commencement), while 150 patients (38.9%) experienced delayed ir-fatigue. Early ir-fatigue was significantly related to shortened PFS (HR = 2.29 [95% CI 1.62–3.22], p < 0.0001) and OS (HR = 2.32 [95% CI 1.59–3.38], p < 0.0001) at the multivariate analysis. On the other hand, we found a significant association between the occurrence of early ir-fatigue, ECOG-PS ≥ 2 (p < 0.0001), and disease burden (p = 0.0003). Delayed ir-fatigue was not significantly related to PFS nor OS. Conclusions Early ir-fatigue seems to be negative prognostic parameter, but to proper weight its role we must to consider the predominant role of performance status, which was related to early ir-fatigue in the study population.
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Affiliation(s)
- Alessio Cortellini
- Medical Oncology Unit, St. Salvatore Hospital, L'Aquila, Italy. .,Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy.
| | - Maria G Vitale
- Medical Oncology, University Hospital of Modena, Modena, Italy
| | | | - Francesca R Di Pietro
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Rossana Berardi
- Oncology Clinic, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Mariangela Torniai
- Oncology Clinic, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Michele De Tursi
- Department of Medical, Oral & Biotechnological Sciences University G. D'Annunzio, Chieti-Pescara, Chieti, Italy
| | - Antonino Grassadonia
- Department of Medical, Oral & Biotechnological Sciences University G. D'Annunzio, Chieti-Pescara, Chieti, Italy
| | | | | | - Tea Zeppola
- Medical Oncology, Campus Bio-Medico University, Rome, Italy
| | - Cecilia Anesi
- Medical Oncology, Campus Bio-Medico University, Rome, Italy
| | - Alain Gelibter
- Medical Oncology (B), Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | | | - Andrea Botticelli
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy.,Medical Oncology (B), Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Paolo Marchetti
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy.,Medical Oncology (B), Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | | | | | | | | | - Domenico Mallardo
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori-IRCCS Fondazione "G. Pascale", Naples, Italy
| | - Vito Vanella
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori-IRCCS Fondazione "G. Pascale", Naples, Italy
| | - Corrado Ficorella
- Medical Oncology Unit, St. Salvatore Hospital, L'Aquila, Italy.,Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy
| | - Giampiero Porzio
- Medical Oncology Unit, St. Salvatore Hospital, L'Aquila, Italy.,Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy
| | - Paolo A Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori-IRCCS Fondazione "G. Pascale", Naples, Italy
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5
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Simeone E, Grimaldi AM, Festino L, Trojaniello C, Vitale MG, Vanella V, Palla M, Ascierto PA. Immunotherapy in metastatic melanoma: a novel scenario of new toxicities and their management. Melanoma Manag 2019; 6:MMT30. [PMID: 31871619 PMCID: PMC6920742 DOI: 10.2217/mmt-2019-0005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Checkpoint inhibitors can cause an imbalance in immune tolerance that may clinically manifest as immune-related adverse events (irAEs). These events may involve many organs and tissues, including the skin, gastrointestinal (GI) tract, liver, endocrine system, kidneys, central nervous system (CNS), eyes and lungs. The incidence of irAEs appears to be lower with anti-programmed death antigen-1/programmed death antigen-ligand-1 agents than with the anti-cytotoxic T-lymphocyte-associated protein-4 antibody ipilimumab. Combined immunotherapy does not appear to be associated with novel safety signals compared with monotherapy, but more organs may be involved. Increased experience and the use of algorithms for the most common irAEs have resulted in severe toxicity and related deaths being reduced. However, continuous vigilance, especially regarding less common events, is needed to better characterize the wide spectrum of clinical manifestations.
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Affiliation(s)
- Ester Simeone
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Antonio M Grimaldi
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Lucia Festino
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Claudia Trojaniello
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Maria G Vitale
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Vito Vanella
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Marco Palla
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Paolo A Ascierto
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
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Cinausero M, Aprile G, Ermacora P, Basile D, Vitale MG, Fanotto V, Parisi G, Calvetti L, Sonis ST. New Frontiers in the Pathobiology and Treatment of Cancer Regimen-Related Mucosal Injury. Front Pharmacol 2017. [PMID: 28642709 PMCID: PMC5462992 DOI: 10.3389/fphar.2017.00354] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mucositis is a common complication of chemotherapy, radiotherapy and targeted agents. It often affects compliance to anticancer therapies as it frequently causes schedule delays, interruptions or discontinuations of treatment. Moreover, the economic impact related to the management of mucositis is topical and several estimations of additional hospital costs due to this clinical condition have been recently reported. The ability to determine risk factors for mucositis, to early detect its onset, to assess correctly the degree of this toxicity and to plan its multidisciplinary management are all key elements to guarantee the quality of life of patients and to avoid useless dose reduction or interruption of treatment. The pathogenesis of mucositis is multifactorial and it is classily subdivided into oral and gastrointestinal mucositis according to its anatomic presentation. Treatment and patients’ related factors might help in predicting the frequency and the potential degree of symptoms onset. Here we discuss about clinical presentation and pathogenesis of mucositis in relation to different kinds of treatments. Moreover, we focus on therapeutic and prevention strategies, describing past and present management according to international guidelines and the most promising new data about agents potentially able to further improve the treatment of mucositis in the next future.
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Affiliation(s)
- Marika Cinausero
- Department of Oncology, University and General HospitalUdine, Italy
| | - Giuseppe Aprile
- Department of Oncology, University and General HospitalUdine, Italy.,Department of Oncology, San Bortolo General HospitalVicenza, Italy
| | - Paola Ermacora
- Department of Oncology, University and General HospitalUdine, Italy
| | - Debora Basile
- Department of Oncology, University and General HospitalUdine, Italy
| | - Maria G Vitale
- Department of Oncology, University and General HospitalUdine, Italy
| | | | - Giuseppe Parisi
- Department of Oncology, University and General HospitalUdine, Italy
| | - Lorenzo Calvetti
- Department of Oncology, San Bortolo General HospitalVicenza, Italy
| | - Stephen T Sonis
- Divisions of Oral Medicine, Brigham and Women's Hospital, BostonMA, United States.,Dana-Farber Cancer InstituteBoston, MA, United States.,Biomodels LLC, WatertownMA, United States
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7
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D'Aniello C, Vitale MG, Farnesi A, Calvetti L, Laterza MM, Cavaliere C, Della Pepa C, Conteduca V, Crispo A, De Vita F, Grillone F, Ricevuto E, De Tursi M, De Vivo R, Di Napoli M, Cecere SC, Iovane G, Amore A, Piscitelli R, Quarto G, Pisconti S, Ciliberto G, Maiolino P, Muto P, Perdonà S, Berretta M, Naglieri E, Galli L, Cartenì G, De Giorgi U, Pignata S, Facchini G, Rossetti S. Axitinib after Sunitinib in Metastatic Renal Cancer: Preliminary Results from Italian "Real-World" SAX Study. Front Pharmacol 2016; 7:331. [PMID: 27733829 PMCID: PMC5039205 DOI: 10.3389/fphar.2016.00331] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/07/2016] [Indexed: 12/20/2022] Open
Abstract
Axitinib is an oral angiogenesis inhibitor, currently approved for treatment of metastatic renal cell carcinoma (mRCC) after failure of prior treatment with Sunitinib or cytokine. The present study is an Italian Multi-Institutional Retrospective Analysis that evaluated the outcomes of Axitinib, in second-line treatment of mRCC. The medical records of 62 patients treated with Axitinib, were retrospectively reviewed. The Progression Free Survival (PFS), the Overall Survival (OS), the Objective Response Rate (ORR), the Disease Control Rate (DCR), and the safety profile of axitinib and sunitinib–axitinib sequence, were the primary endpoint. The mPFS was 5.83 months (95% CI 3.93–7.73 months). When patients was stratified by Heng score, mPFS was 5.73, 5.83, 10.03 months according to poor, intermediate, and favorable risk group, respectively. The mOS from the start of axitinib was 13.3 months (95% CI 8.6–17.9 months); the observed ORR and DCR were 25 and 71%, respectively. When stratified patients by subgroups defined by duration of prior therapy with Sunitinib (≤ vs. >median duration), there was a statistically significant difference in mPFS with 8.9 (95% CI 4.39–13.40 months) vs. 5.46 months (95% CI 4.04–6.88 months) for patients with a median duration of Sunitinib >13.2 months. DCR and ORR to previous Sunitinib treatment was associated with longer statistically mPFS, 7.23 (95% CI 3.95–10.51 months, p = 0.01) and 8.67 (95% CI 4.0–13.33 months, p = 0.008) vs. 2.97 (95% CI 0.65–5.27 months, p = 0.01) and 2.97 months (95% CI 0.66–5.28 months, p = 0.01), respectively. Overall Axitinib at standard schedule of 5 mg bid, was well-tolerated. The most common adverse events of all grades were fatig (25.6%), hypertension (22.6%), gastro-intestinal disorders (25.9%), and hypothyroidism (16.1%). The sequence Sunitinib–Axitinib was well-tolerated without worsening in side effects, with a median OS of 34.7 months (95% CI 18.4–51.0 months). Our results are consistent with the available literature; this retrospective analysis confirms that Axitinib is effective and safe in routine clinical practice.
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Affiliation(s)
- Carmine D'Aniello
- Oncology Unit, A.O.R.N. dei COLLI "Ospedali Monaldi-Cotugno-CTO," Naples, Italy
| | | | | | | | - Maria M Laterza
- Division of Medical Oncology, Department of Internal and Experimental Medicine "F. Magrassi," Second University of Naples - School of Medicine Naples, Italy
| | - Carla Cavaliere
- Department of Onco-Hematology Medical Oncology, S.G. Moscati Hospital of Taranto Taranto, Italy
| | - Chiara Della Pepa
- Department of Uro-Gynaecological Oncology, Division of Medical Oncology, Istituto Nazional Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Vincenza Conteduca
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS Meldola, Italy
| | - Anna Crispo
- Unit of Epidemiology, Struttura Complessa di Statistica Medica, Biometria e Bioinformatica, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Ferdinando De Vita
- Division of Medical Oncology, Department of Internal and Experimental Medicine "F. Magrassi," Second University of Naples - School of Medicine Naples, Italy
| | - Francesco Grillone
- Medical Oncology Unit, Azienda Ospedaliera "Mater Domini," Catanzaro, Italy
| | - Enrico Ricevuto
- Oncology Network ASL1 Abruzzo, Oncology Territorial Care Unit, Division of Medical Oncology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila L'Aquila, Italy
| | - Michele De Tursi
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio," Chieti, Italy
| | | | - Marilena Di Napoli
- Department of Uro-Gynaecological Oncology, Division of Medical Oncology, Istituto Nazional Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Sabrina C Cecere
- Department of Uro-Gynaecological Oncology, Division of Medical Oncology, Istituto Nazional Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Gelsomina Iovane
- Department of Uro-Gynaecological Oncology, Division of Medical Oncology, Istituto Nazional Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Alfonso Amore
- Hepatobiliary Unit, Division of Abdominal Surgical Oncology, National Cancer Institute "G. Pascale Foundation," IRCCS Naples, Italy
| | - Raffaele Piscitelli
- Pharmacy Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Giuseppe Quarto
- Division of Urology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Salvatore Pisconti
- Department of Onco-Hematology Medical Oncology, S.G. Moscati Hospital of Taranto Taranto, Italy
| | - Gennaro Ciliberto
- Scientific Direction, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Piera Maiolino
- Pharmacy Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Paolo Muto
- Division of Radiation Oncology, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Sisto Perdonà
- Division of Urology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | | | - Emanuele Naglieri
- Division of Medical Oncology, Istituto Oncologico Giovanni Paolo II Bari, Italy
| | - Luca Galli
- Oncology Unit 2, University Hospital of Pisa Pisa, Italy
| | | | - Ugo De Giorgi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS Meldola, Italy
| | - Sandro Pignata
- Department of Uro-Gynaecological Oncology, Division of Medical Oncology, Istituto Nazional Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Gaetano Facchini
- Department of Uro-Gynaecological Oncology, Division of Medical Oncology, Istituto Nazional Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
| | - Sabrina Rossetti
- Department of Uro-Gynaecological Oncology, Division of Medical Oncology, Istituto Nazional Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
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8
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Riccardi F, Mocerino C, Barbato C, Ambrosio F, Festino L, Vitale MG, Carrillo G, Trunfio M, Minelli S, Carteni G. First-line chemotherapy with liposomal doxorubicin plus cyclofosfamide in metastatic breast cancer: a case report of early and prolonged response. Int J Immunopathol Pharmacol 2013; 26:773-8. [PMID: 24067476 DOI: 10.1177/039463201302600323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The treatment choice for metastatic breast cancer should consider the appropriate balance between efficacy and toxicity of the therapy. We discuss a clinical case with an early response and prolonged to liposomal anthracyclines-based chemotherapy, without cardiotoxicity, enhancing the evidence of safety of liposomal formulation to prevent heart damage. Moreover, the case seems to be of interest for the role of 18F-FDG-PET in clinical response assessment: an early decrease of the standardized uptake value value, even before conventional imaging evaluation, is highly predictive for prolonged clinical response.
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Affiliation(s)
- F Riccardi
- UOSC Oncologia, Cardarelli Hospital, Naples, Italy
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9
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Abstract
Developmental dysplasia of the hip (DDH) denotes a wide spectrum of pathologic conditions, ranging from subtle acetabular dysplasia to irreducible hip dislocation. When DDH is recognized in the first 6 months of life, treatment with a Pavlik harness frequently results in an excellent outcome. In children older than 6 months, achieving a concentrically reduced hip while minimizing complications is more challenging. Bracing, traction, closed reduction, open reduction, and femoral or pelvic osteotomies are frequently used treatment modalities for children aged 6 months to 4 years. In the past, treatment recommendations have often been based on the patient's age. However, recent practice has placed more emphasis on addressing the specific disorder and avoiding iatrogenic osteonecrosis. The incidence of osteonecrosis of the femoral head has been reduced by avoiding immobilization of the hip in extreme abduction and by using femur-shortening osteotomies when appropriate. Pelvic osteotomy continues to gain favor for the treatment of selected patients over 18 months of age.
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Affiliation(s)
- M G Vitale
- Orthopaedic Surgery, Children's Hospital of New York, New York-Presbyterian Medical Center, New York, NY, USA
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10
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Vitale MG, Levy DE, Moskowitz AJ, Gelijns AC, Spellmann M, Verdisco L, Roye DP. Capturing quality of life in pediatric orthopaedics: two recent measures compared. J Pediatr Orthop 2001; 21:629-35. [PMID: 11521032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There is a clear need for standardized measures to assess health status that are valid and appropriate to the needs of children with orthopaedic problems. The Child Health Questionnaire and the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument, two new pediatric health status measures, were assessed for their ability to detect differences in health states in a pediatric orthopaedic population. The instruments have a range of scales designed to measure various aspects of physical and psychosocial health. Two hundred forty-two patients with wide-ranging diagnoses were enrolled in this cross-sectional study. The instruments exhibited ceiling effects in some domains but generally performed as they were intended in this large cohort. Using secondary factor analysis, it was shown that the domains of the instruments appropriately distinguish physical and psychosocial health. Several domains from each instrument discriminated between diagnosis groups and patients with varying numbers of comorbidities. Both of these measures show significant promise and have an important role in helping define the outcomes of children with orthopaedic problems.
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Affiliation(s)
- M G Vitale
- International Center for Health Outcomes and Innovation Research, College of Physicians and Surgeons and The Joseph L. Mailman School of Public Health, Columbia University and New York Presbyterian Hospital, New York, USA.
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11
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Vitale MG, Levy DE, Johnson MG, Gelijns AC, Moskowitz AJ, Roye BP, Verdisco L, Roye DP. Assessment of quality of life in adolescent patients with orthopaedic problems: are adult measures appropriate? J Pediatr Orthop 2001; 21:622-8. [PMID: 11521031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
New pressures of accountability brought on by a rapidly evolving system of health care financing have underscored the need for standardized, valid measures of patient outcome that reflect the effect of clinical intervention on all aspects of quality of life. In response, there has been a burgeoning interest in the area of outcomes assessment and measurement of quality of life after orthopaedic intervention in adults, but less attention has been focused on the assessment of broadly defined outcomes in children. In an effort to borrow from the broader adult experience in this area, the authors sought to examine whether the Medical Outcomes Study Short Form 36 (SF-36) or the EuroQol questionnaire, widely accepted adult health status measures, would be valid in this setting. These two measures were administered to 196 adolescent patients (10-18 years old) seeking orthopaedic evaluation. Tests of scale properties and construct validity show that these properties are maintained in this population, but neither instrument reflected known differences in health status among this cohort. Most importantly, both the SF-36 and the EuroQol exhibited serious ceiling effects (most respondents scored at the top of their scales), despite evidence indicating those patients often had suboptimal health status. Thus, neither the SF-36 nor the EuroQol is valid for use in this population. The assessment of pediatric health status demands outcomes measures specifically designed to reflect the unique needs of this population.
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Affiliation(s)
- M G Vitale
- International Center for Health Outcomes and Innovation Research, College of Physicians and Surgeons and The Joseph L. Mailman School of Public Health, Columbia University and New York Presbyterian Hospital, New York, USA.
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12
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Abstract
OBJECTIVE To compare the availability of timely orthopedic care to a child with a fractured arm insured by Medi-Cal (California state Medicaid) and by private insurance. STUDY DESIGN Fifty randomly chosen offices of orthopedic surgeons were telephoned with the following scenario: "My 10-year-old son broke his arm last week during a vacation" followed by a request for an appointment that week. Each office was called twice with an identical script except for insurance status: once with Medi-Cal and once with private insurance. RESULTS All 50 offices offered an appointment to see the child with private insurance within 7 days. Only 1 of the same 50 offices offered an appointment to see the child with Medi-Cal within 7 days. Of the offices that would not see a child with Medi-Cal, 87% were unable to recommend an orthopedic office that accepted Medi-Cal. CONCLUSIONS Timely access to orthopedic care was available in 100% of offices polled to a child with private insurance versus in 2% of offices to a child with Medi-Cal. This is a significant difference. Lack of timely orthopedic care may result in poor outcome, ie, if a fracture is not properly aligned in the first few weeks, a permanent deformity may result. Although causation cannot be established from this study, we suspect that Medi-Cal reimbursement rates below the cost of office overhead may be of significance. Although federal guidelines require that payments must be sufficient to enlist enough providers so that services to Medi-Cal recipients are available to the same extent as those available to the general population, this study finds that that children with Medi-Cal insurance have significantly less access to timely orthopedic care.
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Affiliation(s)
- D L Skaggs
- Childrens Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, California, USA.
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13
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Abstract
Despite decades of experience in the area of clubfoot repair, considerable uncertainty remains regarding indications, surgical technique, and long-term results of treatment. Much of this uncertainty is due to the lack of a standardized and valid method for assessing postoperative outcomes of clubfoot repair. The current study used various end points to compare traditional and patient-based outcome measures and to develop a disease-specific instrument that is both meaningful to the patient and statistically valid. A cohort of 46 patients was identified, and several types of outcomes data were collected, including traditional end points of outcome (range of motion and radiographic criteria, qualitative patient-based data) and a previously validated instrument measuring pediatric functional status (FSIIr). At an average follow-up of 45 months, radiographic measures and range of motion were comparable to values published in previous studies. Postoperative functional status, as measured by the FSIIr, did not differ from that of age-matched controls. Psychometric analysis of these data allowed us to generate a 10-item disease-specific instrument (DSI), which conveyed patient-based attitudes toward outcome.
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Affiliation(s)
- B D Roye
- New York Orthopaedic Hospital, Columbia University and the New York Presbyterian Medical Center, USA
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14
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Vitale MG, Higgs GB, Liebling MS, Roth N, Roye DP. Superior mesenteric artery syndrome after segmental instrumentation: a biomechanical analysis. Am J Orthop (Belle Mead NJ) 1999; 28:461-7. [PMID: 10470672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Superior mesenteric artery (SMA) syndrome is a rare complication that occurs after correction of scoliosis. A review of the literature suggests that the incidence of this syndrome may be decreasing, as methods for the correction of scoliosis have improved. We present the first report of SMA syndrome that occurred after segmental 'derotational' instrumentation. Computerized axial tomography was helpful in suggesting the diagnosis of this condition. The risk factors and pathophysiology of SMA syndrome are reviewed with respect to the biomechanical effects of casting and Harrington and segmental instrumentation systems on the spine. Attention to the three-dimensional nature of the scoliotic deformity, particularly in the sagittal plane, may help to predict those at risk for the development of this potentially fatal syndrome.
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Affiliation(s)
- M G Vitale
- Department of Orthopedic Surgery, Columbia Presbyterian Medical Center, New York, New York, USA
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15
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Vitale MG, Krant JJ, Gelijns AC, Heitjan DF, Arons RR, Bigliani LU, Flatow EL. Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair. J Bone Joint Surg Am 1999; 81:763-72. [PMID: 10391541 DOI: 10.2106/00004623-199906000-00003] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although geographic variations in the rates of orthopaedic procedures have been well documented, considerable controversy remains regarding the factors that drive these variations, particularly the role of the availability of orthopaedic surgeons. Moreover, little attention has been specifically focused on variations in the rates of commonly performed shoulder procedures. METHODS The current study documents state-to-state variations in the rates of total shoulder replacement, humeral head replacement, and rotator cuff repair and examines factors that might account for these variations. The regional incidences of these three procedures were analyzed with use of the Health Care Financing Administration Medicare database (MEDPAR, 1992). The rates were age-adjusted, and variations were measured with use of high:low ratios, variation coefficients, and systematic components of variation. Potential causes of variation were analyzed with use of Spearman and partial correlations as well as with Poisson regression. RESULTS Rates for the three procedures that were studied varied from one state to another by as much as tenfold. Humeral head replacement had the lowest rate of variation according to all three measures. All three procedures were performed less often in states that were more densely populated. With the numbers available for study, no consistent, significant relationship was found between the density of orthopaedists and shoulder surgeons and the rates of any procedure. CONCLUSIONS The striking variations that were noted for these commonly performed procedures showed that there is a clear need for well designed clinical research to further define the factors that account for the variations and to examine the effectiveness and appropriate indications for the procedures.
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Affiliation(s)
- M G Vitale
- New York Orthopaedic Hospital and International Center for Health Outcomes and Innovation Research, Columbia-Presbyterian Medical Center, New York City 10032, USA
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16
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Vitale MG, Stazzone EJ, Gelijns AC, Moskowitz AJ, Roye DP. The effectiveness of preoperative erythropoietin in averting allogenic blood transfusion among children undergoing scoliosis surgery. J Pediatr Orthop B 1998; 7:203-9. [PMID: 9702670 DOI: 10.1097/01202412-199807000-00005] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Concerns about the transmission of the human immunodeficiency virus (HIV) have driven the evolution of surgical transfusion practices including the use of preoperative erythropoietin (rhEPO). Although there is significant experience documenting the efficacy of preoperative rhEPO in reducing transfusion requirements for adult patients, there is little experience in the pediatric population. With 178 pediatric patients who underwent surgery for spinal deformity, a retrospective cohort study was performed using patient charts, administrative records, and blood bank computer data. Of these patients, 44% received erythropoietin and 55% did not. From the entire population, 17.5% were in the rhEPO treatment group that received homologous blood transfusion compared with 30.6% in the untreated group (p < 0.05). Among the children with idiopathic scoliosis, this effect was more pronounced, with 3.9% of rhEPO patients receiving blood transfusion compared with 23.5% of nontreated patients (p = 0.006). Additionally, rhEPO treatment was associated with a significantly decreased length of stay only for patients in the idiopathic group (9.3 vs. 6.7, p = 0.02). Use of preoperative erythropoietin in pediatric patients undergoing scoliosis surgery resulted in higher preoperative hematocrit levels. Significantly lower rates of transfusion were noted only in the idiopathic group, however. Although there is a possibility of erythropoietin "resistance" in the neuromuscular and congenital patients, alternative explanations for the lack of effect on transfusion rates may include underdosing and biases existent in this nonrandomized retrospective study.
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Affiliation(s)
- M G Vitale
- New York Orthopaedic Hospital, New York, USA
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17
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Mondello P, Patti S, Vitale MG, D'Accardo AM, Spanó C. Anti-HCV antibodies in household contacts of patients with cirrhosis of the liver — Preliminary results. Infection 1992; 20:51-2. [PMID: 1373409 DOI: 10.1007/bf01704900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Cangelosi C, Giardina RA, Pecoraro G, Marcianò R, Vitale MG, Gullotti A, Caronia F, Spanò C. [HIV infection and T-lymphocyte behavior: results of a study in Palermo]. Ann Ig 1989; 1:45-50. [PMID: 2483080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The acquired immunodeficiency syndrome (AIDS) is caused by the HIV infection in people with an already impaired immunological system. The seroprevalence follow-up of different markers of HIV should seem to suggest to predict the course of the disease as well as the T4/T8 ratio did. We examined 111 at risk anti-HIV positive people according to these parameters in comparison with their clinical situation. Serum samples from these subjects were examined by means of the ELISA method for anti-ENV/CORE antibodies and HIV antigen, followed by a Western Blot confirmation. The T4/T8 ratio was controlled and measured by means of monoclonal immunofluorescent antibody test. Sixty six out of eighty three (79.5%) symptomatic patients showed a less than 1.0 T4/T8 ratio in comparison with 15/28 (53.6%) asymptomatic people (p less than 0.01) while no difference was seen in the same patients according to the presence or not of anti-core antibodies. In some patients it was possible to observe a positive trend in the T4/T8 ratio.
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Rolfini G, Palma E, Giudiceandrea LM, Isotton LA, Tibollo FG, Vitale MG, Araco P. [Pregnancy and labor in patients under 17 years of age. Clinico-statistical considerations]. Clin Ter 1987; 122:441-4. [PMID: 2972457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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20
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Rolfini G, Palma E, Tibollo FG, Giudiceandrea LM, Isotton LA, Vitale MG. [Incidence of cesarean section in elderly pregnant women]. Clin Ter 1987; 122:351-5. [PMID: 2972452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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21
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Rolfini G, Palma E, Isotton LA, Araco P, Vitale MG, Giudiceandrea LM, Tibollo FG. [Childbirth in the older woman. Clinico-statistical assessment]. Clin Ter 1987; 122:113-20. [PMID: 2973900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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