Rituximab Chimeric Anti-CD20 Monoclonal Antibody Therapy for Relapsed Indolent Lymphoma: Half of Patients Respond to a Four-Dose Treatment Program

PURPOSE

The CD20 antigen is expressed on more than 90% of B-cell lymphomas. It is appealing for targeted therapy, because it does not shed or modulate. A chimeric monoclonal antibody more effectively mediates host effector functions and is itself less immunogenic than are murine antibodies.

PATIENTS AND METHODS

This was a multiinstitutional trial of the chimeric anti-CD20 antibody, IDEC-C2B8. Patients with relapsed low grade or follicular lymphoma received an outpatient treatment course of IDEC-C2B8 375 mg/m2 intravenously weekly for four doses.

RESULTS

From 31 centers, 166 patients were entered. Of this intent-to-treat group, 48% responded. With a median follow-up duration of 11.8 months, the projected median time to progression for responders is 13.0 months. Serum antibody levels were sustained longer after the fourth infusion than after the first, and were higher in responders and in patients with lower tumor burden. The majority of adverse events occurred during the first infusion and were grade 1 or 2; fever and chills were the most common events. Only 12% of patients had grade 3 and 3% grade 4 toxicities. A human antichimeric antibody was detected in only one patient.

CONCLUSION

The response rate of 48% with IDEC-C2B8 is comparable to results with single-agent cytotoxic chemotherapy. Toxicity was mild. Attention needs to be paid to the rate of antibody infusion, with titration according to toxicity. Further investigation of this agent is warranted, including its use in conjunction with standard chemotherapy.

The experiences and beliefs of people with severe haemophilia and healthcare professionals on pain management, and their views of using exercise as an aspect of intervention: a qualitative study

PURPOSE

To explore the experiences, views and beliefs of people with severe haemophilia and healthcare professionals (HCPs) on approaches for pain management, as well as their views on exercise being used as an aspect of management.

METHODS

Taking a qualitative inquiry approach using focus groups and semi-structured interviews, participants included people with severe haemophilia living with chronic pain and haemophilia HCPs. Data were analysed using reflexive thematic analysis.

RESULTS

Fourteen men with haemophilia with a median age of 47 (range 23-73) and six haemophilia HCPs agreed to participate. Of the people with haemophilia, 11 attended two focus groups and three were interviewed over telephone. Healthcare professionals were interviewed face-to-face. Two themes were conceptualised from the data: (i) haemophilia management and pain management is discordant (imbalance between good haemophilia care but poor pain management, historical medico-social influences on pain management, the need for trust); (ii) uncertain about exercise but clear on what matters (conflicting views on exercise, the need for proof of safety, personalised care).

CONCLUSIONS

Options for effective pain management remain limited and what is used is heavily influenced by beliefs and experience. Exercise as a treatment option in pain management is conceptually acceptable for people with haemophilia. Effective pain management requires understanding of individual beliefs and fears, and a personalised approach supported by knowledgeable, trusted clinicians.Implications for rehabilitationMusculoskeletal joint pain and its relationship with bleeding in people with haemophilia continues to be a management challenge.Current pain management strategies are of limited effectiveness with little evidence of an approach that reflects the multi-modal pain experience.Whilst exercise and rehabilitation approaches are conceptually possible for people with severe haemophilia, barriers remain regarding perception of overall safety and effectiveness.People with severe haemophilia may consider exercise as part of a pain management strategy if it is individualised, and they are supported to do it by clinicians who understand them and their haemophilia.

How does a lifetime of painful experiences influence sensations and beliefs about pain in adults with severe haemophilia? A qualitative study

PURPOSE

To explore the life experiences of pain in people with severe haemophilia and understand how such experiences influence beliefs and sensation of pain in adulthood.

METHODS

A qualitative inquiry approach using focus groups and semi-structured individual interviews was used. Participants included people with severe haemophilia living with chronic pain. Data were analysed using reflexive thematic analysis.

RESULTS

Fourteen men with a median age of 47 (range 23-73) agreed to take part. Eleven participated in two focus groups and three were interviewed over telephone. Two themes were conceptualised from the data: (i) haemophilia and pain - an evolving life biography (the personal narrative, historical, social, and medical context, continuous adaptation of activity choices, surveillance of pain and its meaning); (ii) "My normal isn't normal" - identity and self-agency (pain as a feature of life and identify with severe haemophilia, loss of enjoyable activities balanced against staying active, barriers to participation).

CONCLUSIONS

Pain is a constantly evolving, lifetime feature for many adults with haemophilia and it is viewed as part of their identity with their condition. Healthcare professionals working in haemophilia should try to better understand the influence of an individuals lived experience with their haemophilia on beliefs and behaviours of pain.Implications for rehabilitationSevere haemophilia is a rare bleeding disorder that results in musculoskeletal joint disease.Adults with severe haemophilia have experienced multiple episodes of bleeding related musculoskeletal pain since childhood.Pain beliefs and behaviours in adulthood appear to be influenced by a lifetime of painful experiences associated with haemophilia.In order to better support people with haemophilia and chronic pain, healthcare professionals in haemophilia need to better understand how an individuals lived experience of pain helps inform their beliefs about it.

European principles of care for physiotherapy provision for persons with inherited bleeding disorders: Perspectives of physiotherapists and patients

INTRODUCTION

In their Chronic Care Model, the World Health Organisation states that people with chronic disorders and their families should be informed about the expected course, potential complications, and effective strategies to prevent complications and manage symptoms. Physiotherapists are a key professional group involved in the triage, assessment and management of musculoskeletal conditions of persons with a bleeding disorder (PWBD). Nevertheless, recent reports describe access to physiotherapy for those with these conditions is only sometimes available.

AIM

Access to high quality individualised physiotherapy should be ensured for all PWBD, including those with mild and moderate severities, male and female, people with von Willebrand Disease (vWD) and other rare bleeding disorders. Physiotherapy should be viewed as a basic requisite in their multidisciplinary care.

METHODS/ RESULTS

Following a series of meetings with physiotherapists representing the European Association for Haemophilia and Allied Disorders (EAHAD) and PWBD representing the European Haemophilia Consortium (EHC) and a review of publications in the field, eight core principles of physiotherapy care for persons with a bleeding disorder have been co-produced by EAHAD and EHC.

CONCLUSION

These eight principles outline optimum standards of practice in order to advocate personalised patient-centred care for physical health in which both prevention and interventions include shared decision making, and supported self-management.

Recommendations on multidisciplinary management of elective surgery in people with haemophilia

Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.

Study of physical function in adolescents with haemophilia: The SO-FIT study

INTRODUCTION

Contemporary haemophilia care demands Patient-Reported Outcomes. SO-FIT is a UK multi-centre study, assessing self-reported function, health-related quality of life (HRQoL) and joint health in boys with severe haemophilia.

METHODS

Subjective physical function (PedHAL, HEP-Test-Q) and HRQoL (Haemo-QoL Short Form [SF]) were assessed alongside joint health using the objective Haemophilia Joint Health Score (HJHS v2.1). Demographic and clinical data were collected.

RESULTS

Data from 127 boys mean age 12.38 ± 2.5 (range 8-17) treated at 16 sites were analysed. One-hundred-and-thirteen had haemophilia A, 25/9 past/current inhibitor, 124 were treated prophylactically (46.8% primary) and three on-demand. In the preceding 6 months, boys reported median 0 joint bleeds (range 0-8) with a median HJHS score of 1 (range 0-30). Boys reported good physical functioning; HEP-Test-Q (M = 80.32 ± 16.1) showed the highest impairments in the domain "endurance" (72.53 ± 19.1), in PedHAL (M = 85.44 ± 18.9) highest impairments were in the domains "leisure activities & sports" (M = 82.43 ± 23.4) and "lying/sitting/kneeling/standing" (M = 83.22 ± 20.3). Boys reported generally good HRQoL in Haemo-QoL SF SF (M = 22.81 ± 15.0) with highest impairments in the domains "friends" (M = 28.81 ± 30.5) and "sports & school" (M = 26.14 ± 25.1). HJHS revealed low correlations with the Haemo-QoL SF (r = .251, P < .006), the PedHAL (r = -.397, P < .0001) and the HEP-Test-Q (r = -.323, P < .0001). A moderate correlation was seen between HEP-Test-Q and Haemo-QoL SF of r = -.575 (P < .0001) and between PedHAL and Haemo-QoL SFr = -.561 (P < .0001) implying that good perceived physical function is related to good HRQoL.

CONCLUSIONS

The SO-FIT study has demonstrated that children with severe haemophilia in the UK report good HRQoL and have good joint health as reflected in low HJHS scores.

A case-control study assessing bone mineral density in severe haemophilia A in the UK

It has been shown that bone mineral density (BMD) may be lower in patients with haemophilia (PWH). A comparison to control subjects is required to thoroughly assess current BMD in PWH in the UK. The objective of this study was to test the hypothesis that BMD is lower in PWH than in controls, and in patients with more severely affected joints or lower activity levels. In this case-control study, 37 patients with severe haemophilia A were recruited from two haemophilia centres in the UK. A group of 37 age, gender and ethnicity-matched control participants were recruited. All participants had a bone density scan, a musculoskeletal assessment, a blood test for vitamin D and completed a functional activity questionnaire. Of the case group, 5% had osteoporosis and 24% had BMD lower than expected for age. No control participants had osteoporosis, 3% had osteopenia and 14% had BMD lower than expected for age. Ninety one per cent of case participants and 92% of control participants had reduced 25(OH)D levels. Case participants had significantly lower BMD than control participants, and case participants with more severely affected joints, lower activity levels, HIV, history of hepatitis C or lower BMI had significantly lower BMD. Patients with severe haemophilia have a higher risk of low BMD than men without haemophilia. Patients with more severely affected joints and lower activity levels have lower BMD. It remains unclear whether patients with low BMD reached adequate peak bone mass. Low vitamin D may be present in the majority of PWH.

The effects of repetitive haemarthrosis on postural balance in children with haemophilia

Sensory information from visual, vestibular and proprioceptive systems is necessary to control posture and balance. Impairment in proprioception due to repetitive joints bleeding may lead to a deficit in postural balance which, in turn, leads to high joint stress and risk of bleeding recurrence. Despite the increase in attention in this field during the past few years, the data concerning to how bleeds can affect postural control in children with haemophilia (CWH) remain scarce. This study aimed to evaluate the postural balance in CWH. Twenty CWH Haemophilia Group (HG) and 20 age-matched children Control Group (CG) were recruited to this study. A force plate was used to record centre of pressure (COP) displacement under four different postural conditions during quiet standing: eyes open on firm surface, eyes open on foam surface, eyes closed on firm surface and eyes closed on a foam surface. Variables of COP as sway area and mean velocity and in anterior-posterior (y) medio-lateral (x) direction were processed and for each variable sensory, quotients were calculated and compared between groups. No differences were found in visual and vestibular quotients variables between groups. A higher value was found in sway area variable on proprioception quotient in the HG when compared with CG (P = 0.042). CWH with repetitive joint bleed on lower limbs showed differences in postural balance when compared with non-haemophiliac children. The identification of early balance impairments in CWH can help us understand better the effects of bleeds inside joints on postural control and plan a more effective preventive and rehabilitative treatment.

Effects of abdominal fat distribution parameters on severity of acute pancreatitis

BACKGROUND

Obesity is a well-established risk factor for acute pancreatitis. Increased visceral fat has been shown to exacerbate the pro-inflammatory milieu experienced by patients. This study aimed to investigate the relationship between the severity of acute pancreatitis and abdominal fat distribution parameters measured on computed tomography (CT) scan.

METHODS

Consecutive patients admitted to Cork University Hospital with acute pancreatitis between January 2005 and December 2010 were evaluated for inclusion in the study. An open source image analysis software (Osirix, v 3.9) was used to calculate individual abdominal fat distribution parameters from CT scans by segmentation of abdominal tissues.

RESULTS

A total of 214 patients were admitted with pancreatitis between January 2005 and December 2010. Sixty-two of these patients underwent a CT scan and were thus eligible for inclusion. Visceral fat volume was the volumetric fat parameter that had the most significant association with severe acute pancreatitis (P = 0.003). There was a significant association between visceral fat volume and subsequent development of systemic complications of severe acute pancreatitis (P = 0.003). There was a strong association between mortality and visceral fat volume (P = 0.019). Multivariate regression analysis, adjusted for gender, did not identify any individual abdominal fat distribution index as an independent risk factor for severe acute pancreatitis.

CONCLUSIONS

Overall, estimation of abdominal fat distribution parameters from CT scans performed on patients with acute pancreatitis indicates a strong association between visceral fat, severe acute pancreatitis, and the subsequent development of systemic complications. These data suggest that visceral fat volume should be incorporated into future predictive scoring systems.

Does Courvoisier's sign stand the test of time?

AIM

To investigate the validity of Courvoisier's sign, in the age of cross-sectional imaging and image analysis software by objectively measuring gallbladder volumes at magnetic resonance cholangiopancreatography (MRCP) in patients with and without biliary obstruction and to assess whether gallbladder volume is more significantly increased in patients with gallstone-related rather than non-gallstone-related biliary obstruction.

MATERIALS AND METHODS

All MCRP investigations that were performed at a tertiary hepatobiliary centre over a 2-year period were analysed. The information recorded included the presence or absence of gallbladder stones as well as the presence and type of common bile duct (CBD) disease. Gallbladder volume was calculated from MRCP studies using image analysis software.

RESULTS

Three hundred and ninety-four of 645 examined MRCPs (61.1%) were eligible for analysis. A statistically significant difference in mean gallbladder volume existed between the summated obstructive and non-obstructive groups (p < 0.001). In addition, a significant difference existed in mean gallbladder volume between those with CBD stones and non-gallstone CBD obstruction (p = 0.03).

CONCLUSION

A significant difference was observed in gallbladder volumes in the group with biliary obstruction from choledocholithiasis compared with the group with biliary obstruction from other causes. Thus, objective measurement of gallbladder volume from modern cross-sectional imaging studies appears to validate Courvoisier's sign as a valuable clinical sign, which could be applied to modern imaging studies in distinguishing different causes of biliary obstruction in the jaundiced patient.

Management of muscle haematomas in patients with severe haemophilia in an evidence-poor world

Treatment studies in haemophilia focus on joint bleeds; however, some 10-25% of bleeds occur in muscles. This review addresses management of muscle haematoma in severe haemophilia, defines gaps in the published evidence, and presents a combined clinician and physiotherapist perspective of treatment modalities. The following grade 2C recommendations were synthesized: (i) Sport and activity should be based on individual factor levels, bleeding history and physical characteristics, (ii) Musculoskeletal review aids the management of children and adults, (iii) 'Time to full recovery' should be realistic and based on known timelines from the healthy population, (iv) Diagnosis should be carried out by both a clinician and physiotherapist, (v) Severe muscle bleeds should be treated similarly to surgical patients: a 50% trough for 10-14 days followed by high-level prophylaxis, (vi) Protection, rest, ice, compression and elevation should be implemented in the acute stage, and (vii) Physiotherapy and rehabilitation should be divided into: control of haemorrhage (phase 1); restoration of Range of Movement (ROM) and strength (phase 2); functional rehabilitation and return to normal living (phase 3). Recommendations specifically for inhibitor patients include: (i) Minor to moderate bleeds should be managed by home-treatment within 1 h of bleed onset using either one injection of rFVIIa 270 μg kg(-1), or two to three injections of rFVIIa 90 μg kg(-1) (2-3 h intervals), or FEIBA 50-100 U kg(-1) (repeated at 12-hourly intervals, if necessary) and (ii) Severe muscle bleeds should be supervised by the treatment centre and include bypassing agents until clinical improvement is observed.

Prognostic factors for non-Hodgkin's lymphoma patients treated with chemotherapy may not predict outcome in patients treated with rituximab

Several factors predict outcome for patients with non-Hodgkin's lymphoma (NHL) after chemotherapy. However, predictors of response to rituximab have not been identified. Baseline characteristics for 166 NHL patients (130 follicular) in a phase III trial of rituximab were analysed by univariate and multivariate methods to determine whether any of 27 factors predict response and/or response duration. In a univariate analysis, response to rituximab was associated with follicular histology, no prior fludarabine therapy, prior autologous bone marrow transplantation (ABMT), lack of bone marrow involvement or extranodal disease, positive bcl-2 in blood, and fewer relapses. By univariate analysis, longer median time to progression (TTP) and/or duration of response (DR) after rituximab therapy was associated with International Prognostic Index lower-risk group, multiagent chemotherapy, and low/normal serum lactate dehydrogenase (LDH) or beta2 microglobulin. In the multivariate analysis, response to rituximab correlated with follicular histology, prior ABMT, multiagent chemotherapy, and no bone marrow involvement; longer TTP and/or DR correlated with low/normal serum LDH or beta2 microglobulin, high CD3+ cells, and response to last chemotherapy. The follicular lymphoma international prognostic index (FLIPI) did not correlate consistently with response to rituximab or response duration. Several factors associated with prognosis following chemotherapy did not correlate with response to rituximab or response duration. NHL patients can respond to rituximab despite having factors associated with a poor outcome to chemotherapy.

Lenalidomide and rituximab for untreated indolent non-Hodgkin's lymphoma

8548

Background: Despite advances in therapy and a better understanding of the natural history of indolent non-Hodgkins lymphomas (NHL), the optimal treatment for newly diagnosed patients (pts) has not been determined. While several combination chemotherapy regimens have response rates approaching 90%, toxicity is common with genotoxic drugs and secondary malignancies is a concern. Lenalidomide has been shown to have single agent activity in indolent NHL, and is approved for the treatment of multiple myeloma and myelodysplastic syndrome. Rituximab is effective as a single agent and in combination with chemotherapy for indolent NHL. The aim of this phase II, single arm study is to evaluate the efficacy and safety of lenalidomide and rituximab in pts with untreated, stage III, or IV indolent NHL. Methods: Pts with indolent NHL who were previously untreated, with measurable disease (>1.5 cm), were eligible for enrollment. Pts received 20mg of lenalidomide orally once daily on days 1–21 and rituximab 375mg/m2 intravenously on day 1 of each 28 day cycle. Pts could receive up to 6 cycles of therapy. Response was assessed after 3 cycles and at the end of therapy using the International Working Group Response Criteria. Results: At time of this report 17 pts have been enrolled and 14 are eligible for safety evaluation. The median age was 55 (33–77) years and 53% were male. Therapy was well tolerated with the following grade 3 adverse events (AE) reported; myalgia (1 pt), rash (1 pt), peripheral neuropathy (1pt). There were no grade 4 AEs. There have been no reported grade 3/4 hematologic AEs. There has been no tumor flare observed. In the 5 pts eligible for response assessment, 4 pts (80%) attained a complete response (CR), 1 patient (20%) had stable disease (SD). After 3 cycles, one patient had unconfirmed stable disease who also was previously treated with combination chemotherapy for Hodgkin's lymphoma. Updates for response will be presented. Conclusions: The combination of lenalidomide and rituximab has activity and is well tolerated with minimal toxicity in patients with newly diagnosed indolent lymphoma.

[Table: see text]

Outcomes in patients with pulmonary hypertension undergoing percutaneous atrial septal defect closure

OBJECTIVES

To examine the outcomes in patients with moderate or severe pulmonary arterial hypertension (PAH) undergoing percutaneous atrial septal defect (ASD) closure.

DESIGN

Retrospective study.

SETTING

Teaching hospital-based study.

PATIENTS

Fifty-four patients with moderate (n = 34) or severe PAH (n = 20) who underwent successful device implantation between 1999 and 2004 were included in the study. Clinical and transthoracic echocardiographic data were reviewed. Pulmonary hypertension was classified as moderate (50-59 mm Hg) or severe (>or=60 mm Hg) according with the right ventricular systolic pressure (RVSP) calculated by echocardiography.

RESULTS

At the early follow-up (mean (SD) 2.3 (1.2) months) all patients were alive and the baseline RVSP decreased from 57 (11) mm Hg to 51 (17) mm Hg (p = 0.003). At the late follow-up (n = 39, mean (SD) duration 31 (15) months) two patients had died and the baseline RVSP decreased from 58 (10) mm Hg to 44 (16) mm Hg (p = 0.004). Although the overall mean RVSP decreased at late follow-up, only 43.6% (17/39) of patients had normalisation (<40 mm Hg) of the RVSP and 15.4% (6/39) had persistent severe PAH.

CONCLUSION

Transcatheter closure in patients with secundum ASD and PAH can be successfully performed in selected subjects and is associated with good outcomes. Early improvements in RVSP are seen in patients with moderate or severe PAH undergoing transcatheter ASD closure. Continued improvement in RVSP occurs in late follow-up. Despite decreases in the mean RVSP in late follow-up, many patients do not have complete normalisation of pressures.

Balance and Injury in Elite Australian Footballers

This project measured pre-season balance ability and determined its relationship to knee and ankle ligament injuries during the season for professional Australian footballers. The balance test involved the players stepping onto a foam balance mat on top of a force plate and maintaining single limb balance. Throughout the playing season, injuries were monitored. The results from two hundred and ten players participating in this project were analysed. During the 2003 season, 8 % (17 out of 210) sustained a knee ligament injury and 10 % (21 out of 210) sustained an ankle ligament injury. Multivariate analysis revealed that pre-season balance ability was a significant independent predictor of ankle ligament injury. Players with low balance ability had at least twice as many ankle ligaments injuries as those with average or good balance ability. Balance ability was not a significant predictor of knee ligament injuries. The height of the players was the only significant independent predictor of knee ligament injuries. Low pre-season balance ability was associated with an increased risk of ankle ligament injury. A modifiable injury risk factor has been identified. Research is now required to determine the optimal training regime to enhance balance ability and whether this translates to a reduction in the incidence of ankle injuries.

A phase II study of a novel oral isotype-selective histone deacetylase (HDAC) inhibitor in patients with relapsed or refractory Hodgkin lymphoma

8000

Background: MGCD0103 is a non-hydroxamate, isotype-selective, inhibitor of human HDACs. Abnormal regulation of HDAC activity is associated with malignant disease in humans, and small molecule HDAC inhibitors are a novel drug class with anticancer potential. Their proposed anti-Hodgkin activity is through regulation of aberrant gene expression at the transcriptional level by inhibiting proliferation, inducing apoptosis, and/or initiating differentiation in cancer cells. Methods: A phase II trial of MGCD0103 (110 mg 3x/week in 4- week cycles) is ongoing in patients (pts) with relapsed/refractory Hodgkin Lymphoma (RRHL). The primary endpoint is a composite of objective response and stable disease. Results: As of Dec 15th, 2006, 18 pts out of a planned 12–35 have been enrolled; median age 28 (range: 21–62). All pts were previously treated with autologous and/or allogeneic stem cell transplant. The median number of cycles received to date is 2 (range: 1–4). Seven pts have completed =8 weeks (2 cycles) of therapy and are evaluable for response analysis; 5 of these had tumor reduction ranging between 21% and 70% by CT, which is associated with a significant reduction in FDG-PET activity in 4 pts. Of the 18 pts, 5 have had dose reductions/discontinuations due to: mucositis (n=1); fatigue/nausea/diarrhea (n=1); nausea/vomiting (n=1); fatigue (n=1) and pancreatitis/hypotension (n=1). Significant HDAC inhibition (>20% of total activity), was seen in PBMCs from 7/9 pts with samples. Treatment is ongoing in 14 pts; including those with tumor reduction. Criteria have been met to expand to the second stage of the study (>1 response demonstrated in the first 12 patients). Conclusions: Preliminary results suggest that single-agent MGCD0103 demonstrates significant anti-tumor activity in RRHL and is well tolerated at a Phase II dose of 110mg in this ongoing trial.

No significant financial relationships to disclose.

Meta-analyses of the association between Chlamydia psittaci and ocular adnexal lymphoma and the response of ocular adnexal lymphoma to antibiotics

8090

Background: There are conflicting reports regarding the association between Chlamydia psittaci (Cps) and ocular adnexal lymphoma (OAL) and the efficacy of antibiotics for OAL. We sought to clarify the association between Cps and OAL and the efficacy of antibiotics for OAL. Methods: We conducted 2 meta-analyses. One focused on Cps association with OAL across geographic regions and among different studies. The other was a meta-analysis of responses to antibiotic treatment. Results: We identified 10 studies of Cps prevalence which included 430 cases of OAL from 10 different countries. We found 4 studies on the efficacy of oral antibiotics to treat OAL. Ninety-six (22%) of the 430 OAL specimens and 78 (26%) of the 305 MALT lymphoma specimens were positive for Cps. Ninety-four (98%) of the 96 Cps-positive OAL specimens came from 3 of the 10 studies. There was wide variation between geographic regions and even between studies from the same geographic region in the rate of Cps positivity. The 4 studies on the efficacy of antibiotics for OAL were from Italy, Austria, Taiwan, and the United States and included 24 patients. Eleven patients (46%) had some response (complete response in 4, partial response in 3, minimal response in 4). Twelve patients had stable disease, and 1 patient progressed during antibiotic therapy. Objective documentation of response (radiographs or clinical slit-lamp photographs) was available for only 2 out of 24 patients. Conclusions: Our findings suggest a striking variability in the association of Cps and OAL across geographic regions and even between studies from the same geographic regions. The overall rate of Cps positivity in our meta- analysis (22%) was much lower than that reported in the original report by Ferrari et al. Our findings also suggest that antibiotics have low efficacy against OAL. Future prospective trials with standard objective response criteria and a longer follow-up time would be necessary to further evaluate the role of antibiotics in the treatment of OAL.

No significant financial relationships to disclose.

Revalidation of FLIPI in patients with follicular lymphoma (FL) registered in the F2 study and treated upfront with immunochemotherapy

8008

Background: The Follicular Lymphoma International Prognostic Index (FLIPI) has become a widely accepted tool for risk assessement of FL. However, the recent shift to upfront immuno-chemotherapy (ICHT) requires confirmation studies of FLIPI discriminant power to ensure that the advent of Anti-CD20 MoAb did not modify its predictive value. Methods: We looked for the role of rituximab and its impact on the predictive value of FLIPI in the group of 1,093 patients diagnosed with FL between January 2003 and May 2005 and registered by 69 European and American Institutions in the F2-study. We identified 827 patients = 18 years of age and treated with systemic therapy. For the purposes of the present examination the prognosis was investigated in terms of progression-free survival (PFS) and the impact of rituximab explored by Cox analysis. Results: Patients characteristics are as follows: median age 57 yrs (21–93), male 50.1%, advanced stage 77.2%, elevated LDH 22.3%. To date central pathology review has been performed in 406 cases and the diagnosis of FL was confirmed in 98.3%. Patients at low risk (LR), intermediate risk (IR) and high risk (HR) on the basis of FLIPI were 40.3%, 32.6% and 27.1% respectively. Five-hundred sixty patients (67.7%) received ICHT, and 267 (32.3%) were treated with CHT only. After a median follow-up of 26 months the 3-yr PFS is 63.0%. Overall, the FLIPI remains highly predictive, being the 3-yr PFS of 77.8%, 60.5% and 49.1% for patients at LR, IR and HR respectively. Moreover, the 3-yr PFS predicted from Cox analysis is 81%, 62%, and 50% for patients at LR, IR and HR treated with ICHT (p<0.001), and 76%, 56%, 43% in those treated with CHT only (p<0.001). Finally, the relative risk for progression adjusted by the use of Anti-CD20 MoAb confirmed the efficacy of rituximab in all risk groups. The relative risk of progression for patients at IR was 2.01 as compared to patients at LR (p<0.001), and that for patients at HR was 1.47 as compared to patients at IR (p=0.021). Conclusions: Our study demonstrates that the FLIPI remains a useful tool to predict outcome even in the era of ICHT. Moreover, rituximab added to upfront chemotherapy improves the outcome of patients with FL in any risk group and in association with any chemotherapy regimen.

No significant financial relationships to disclose.

Predictive value for survival of a risk model of two serological markers, beta-2-microglobulin (B2M) and lactic dehydrogenase (LDH), in diffuse large cell lymphoma (DLCL)

10599

Background: The International Prognostic Index (IPI), the standard tumor risk model in patients (pts) with diffuse large cell lymphoma (DLCL), has 5 factors (age, LDH, performance status, extra nodal sites, and stage). We previously proposed a simpler two-factor model, based on LDH and B2M (JCO10;1989). B2M is a component of HLA class I antigens, expressed in lymphocytes, and a known prognostic indicator in some lymphoid malignancies. The benefits of this model are: objective measures; lab method widely available; simplicity; biologic marker. Methods: We applied the model to a large cohort of DLCL patients with prospective baseline B2M, and treated with doxorubicin-based (chemo) regimens, with and without rituximab. 718 pts with DLCL were sequentially treated at MDACC by IRB approved chemo protocols from 1988–2000. In 2001, rituximab plus chemo (RCHOP) became standard. 311 DLCL pts were sequentially treated with RCHOP from 2001–2005. Cox regression analyses for univariate and multivariate models of IPI factors and B2M were done. Kaplan-Meier survival projections were in three risk categories: low (normal [nl] LDH and B2M); intermediate (either LDH or B2M > nl); or high (LDH and B2M > nl). Results: In both treatment groups, IPI factors and B2M were significant as univariate factors. In the RCHOP group, however, the IPI multivariate model showed age, stage, and extra-nodal sites were not significant risk factors, while B2M and LDH remained highly significant (p<0.01). The 5 year survival projections by risk category were: (*) combines intermediate low and intermediate-high categories Conclusions: This simple two-factor model predicts risk for patients with DLCL, treated with or without rituximab, comparably to the IPI. B2M should be considered an important prognostic indicator in DLCL, particularly in rituximab treated patients. Exploratory analyses to revise the IPI model are indicated.

[Table: see text]

No significant financial relationships to disclose.

R-HCVAD/R-MTX-ARAC is an effective regimen for untreated diffuse large B-cell lymphoma (DLBCL) with aggressive features: M. D. Anderson experience in 40 patients

8058

Background: R-HCVAD (rituximab-cyclphosphamide, vincristine, dexamethasone, doxorubicin) alternating with R-MTX-ARAC (rituximab, methotrexate-cytarabine) is a chemoimmunotherapy regimen with activity in ALL, mantle cell, and Burkitt’s lymphomas (BL). Histological differentiation between BL, atypical BL, and DLBCL with high-grade features can be difficult. We thus have treated patients with DLBCL with high-grade histological features and/or poor-risk IPI with R-HCVAD. Methods: Forty consecutive patients with information collected prospectively in the NCCN database, treated between 7/2002 and 10/05 at M.D Anderson Cancer Center, and who received at least one cycle are included in this cohort analysis. Characteristics: 18 (45%) male; 18 (45%) HI and High IPI; 25 (62.5%) ↑LDH; 26 (65%) with Stage III/IV; 2 (5%) with PS>1; 8 (20%) with >60 years; 25 (62%) a Ki-67 >90%. Four patients received less than 4 cycles of treatment. Results: ORR was of 100%, with 95% CR/CRu. With a median follow-up of 26 months, 6 patients failed: 1 died in CR of pulmonary embolism while on treatment; 1 patient who achieved CR, had PD before the end of treatment; 1 achieved a PR and was transplanted (is alive in remission); 1 achieved a PR and progressed died of disease; and 2 relapsed (one is in remission after an ASCT). Four patients have died: 3 of disease, 1 of pulmonary embolism. The 3-year OS is 88% (95% CI 77%-99%); 3-year FFS is 71% (95% CI 47%-95%). The 3-year FFS for patients with L/LI risk (3-failures of 22 pts) was 78% (95% CI 52%-100%); and for patients with HI/H IPI (3 failures of 18 pts) 65% (95% CI 27%-100%). Conclusions: R-HCVAD/R-MTC-ARAC is a very active regimen for DLBCL of high grade. Toxicity was mostly hematological. We are currently doing a prospective randomized phase II study comparing this regimen to standard R-CHOP in patients with poor-risk IPI scores.

No significant financial relationships to disclose.

Relationship between static and dynamic balance tests among elite Australian Footballers

Research assessing the direct relationship between static and dynamic balance ability of athletes is sparse. The aim of this project was to determine the relationship between a static balance task on a firm surface with a stepping balance task on an unstable surface. Thirty-seven Australian male professional footballers participated in the study. The static test involved maintaining single limb stance on a force platform. The other balance test involved stepping on to a balance mat on top of the force platform and maintaining single limb stance. The centre of pressure was monitored and the maximum excursion in the medial-lateral direction was recorded and used as the balance value. It was found that the magnitude of the maximum centre of pressure excursion was significantly greater (53%) for the stepping balance task. There were significant but low correlations for the centre of pressure excursion values between the two balance tests for the right limb and average of both limbs. There was no significant correlation between the test values for the left limb. Only a small proportion of the variance could be explained by each test: 16% for right limb values, 7% for left limb values and 11% for the average of both limbs. Given the overall weak associations between the two balance test values, it was concluded that performance in the static balance test was not reflective of performance in the dynamic balance test. Attempting to infer dynamic balance ability based on static balance ability should be avoided.

A phase II study of HCVIDDOXIL alternated with methotrexate-cytarabine in patients with newly diagnosed T-cell lymphoma

7597

Background: T cell lymphomas (TCL) generally are more aggressive and have a poorer prognosis than the corresponding B cell lymphomas. A chemotherapeutic regimen that is effective in aggressive lymphoid malignancies is HCVAD alternating with methotrexate (MTX) and cytarabine (Ara-C). Pegylated liposomal doxorubicin (DOXIL) is associated with greater tumor penetration and less toxicity. We initiated a phase II study to evaluate the efficacy of the regimen HCVIDDOXIL, using DOXIL as a substitute for doxorubicin in the HCVAD regimen, alternated with MTX-Ara-C . Methods: Previously untreated patients (pts) with Zubrod performance status ≤3, age > 18 years, and adequate organ function were eligible. Pts with skin involvement alone, CD30+, ALK +, T-anaplastic large cell lymphoma (ALCL), HIV-1 positive serology, and evidence of CNS involvement were excluded. Pts received HCVIDDOXIL ( cyclophosphamide 300 mg/m2 iv Q 12 h × 6 doses d 1–3, mesna 600 mg/m2 iv daily over 24 hours by continuous infusion d 1–3, DOXIL 25 mg/m2/day iv on d 2, vincristine 1.4 mg/m2 (max. 2 mg) iv days 4 and 11, dexamethasone 40 mg iv or po daily × 4 d 1–4 and 11–14) alternated with MTX/Ara-C ( MTX 200 mg/m2 iv over 2 hours on d 1, then 800 mg/m2 iv over 22 hours on d1, Ara-C 3 g/m2 iv Q 12 hours × 4 doses on d 3–4) every 3 weeks for a maximum of 8 cycles. Endpoints were progression-free survival and response rate. Results: Between October 2003 and November 2005, 23 pts were enrolled. Median age 53 years (range, 23–68). Twelve pts had stage IV, 6 stage III, 3 stage I, and 2 stage II disease. Fourteen (60%) pts had extranodal disease, and 8 (36%) pts had an elevated LDH. In 21 evaluable pts, the ORR was 90% [CR n=12 (57%); PR n= 7 pts (33%)]. Common Grade 3–4 adverse events were thrombocytopenia in 17 pts (77%), neutropenia in 6 (27%), anemia in 5 (23%), and febrile neutropenia in 7 (32%). With a median follow-up of 13 months, the median progression-free survival is 8.3 months (95% CI: 6.5 to 14.2 months). Conclusions: In this high-risk population the regimen HCVIDDOXIL alternated with MTX-Ara-C induced a high response rate. As expected, the most common toxicity was myelosuppression. The efficacy of this regimen should be confirmed in a larger cohort of patients. Enrollment in this study continues.

No significant financial relationships to disclose.

Transcatheter device closure of atrial septal defects in the elderly: Technical considerations and short-term outcomes

BACKGROUND

Device closure of an atrial septal defect (ASD) results in symptom-reduction, right heart remodelling and lower pulmonary artery pressures. However it is unclear if there is a chronological limit to these benefits and whether device closure is safe in elderly subjects. The aim of this study was, therefore, to assess the safety and efficacy of device closure in patients >60 years.

METHODS

Retrospective study of Amplatzer Septal Occluder device closures from a single institution (May 1999-August 2002).

RESULTS

Fifty subjects aged >60 years (range 60-85 years) had ASD device closure (27% of the total cohort). Defect size and shunt size were similar for both younger and older groups (2.2:1 in both groups, p=0.9) as were procedural duration, fluoroscopy time and device size deployed. Baseline right ventricular (RV) systolic pressure ((younger vs. older) 39 vs. 49 mmHg, p<0.001) and right ventricular size (45 vs. 51 mm, p<0.001) were greater in the older group. Following closure RV systolic pressure (49 vs. 45 mmHg, p<0.01) and RV size (51 vs. 44 mm, p=0.01) decreased in the older group.

CONCLUSION

Device closure of an ASD can be performed safely in older patients. The right heart shows signs of remodelling even in elderly subjects.