Randomized controlled trials of treatments for hematologic malignancies: study characteristics and outcomes

BACKGROUND: Although randomized controlled trials (RCTs) require a great deal of time, money, and effort, the majority of them have resulted in failure to verify a priori hypotheses. Therefore, the intention in the current study was to clarify the differential elements of studies with 'positive' and 'negative' outcomes. METHODS: The authors performed a comprehensive search of RCT reports on treatments for hematologic malignancies published between 1995 and 2004, with 264 reports eventually identified. The expected rate and the observed rate for the primary endpoint were compared for 70 studies with all relevant information available. RESULTS: Of all the superiority trials (n = 256), positive studies accounted for 33%. Most of the major study characteristics were not found to be associated with the study outcome except for the primary endpoint. Studies evaluating event-free survival were more likely to report positive results than were those evaluating overall survival (P = .061). For the experimental treatment arm, the mean difference between the expected and observed rates was -10.1% (standard deviation [SD], 10.1%) in the negative studies, which indicates a rate lower than expected, and was 1.3% (SD, 9.2%) in the positive studies (P < .0001). In contrast, no statistical significance was observed for the standard treatment arm because the mean difference was 6.3% (SD, 10.7%) for the negative studies and 3.0% (SD, 9.0%) for the positive studies (P = .1885). The journal impact factor was statistically significantly higher for the positive than for the negative reports (P < .0001). CONCLUSIONS: Giving adequate consideration to the estimated effect of an experimental therapy may be critical when planning an RCT.     

Age disparity between a cancer population and participants in clinical trials submitted as a new drug application of anticancer drugs in Japan

BACKGROUND: Underrepresentation of older patients in cancer clinical trials has been reported previously. METHODS: To evaluate disparities in age between actual cancer patients and those enrolled in clinical trials, the authors examined all the review reports of the Pharmaceuticals and Medical Devices Agency, Tokyo, Japan, and summaries of data submitted by applicants for the approval of new cancer drugs and that of a partial change in approved cancer drugs. RESULTS: Information regarding 68 clinical trials was available on the Internet. The median age of trial participants ranged from 33 years to 73 years and was older than 65 years in 13 trials, whereas the estimated median age of patients with all cancers was 69 years, and 64% of these individuals were age > or =65 years. The median age of trial participants was found to be lower than that of the patient population in 60 trials. The median difference in age between the 2 groups was 7 years (range, -16 to +33). With regard to molecular-targeting agents (16 trials) and hormonal agents (10 trials), trial participants were younger than the patient population in 25 of the 26 trials, with a median difference of 6 years (range, -9.5 to +20). The difference was larger for molecular-targeting agents (median, 9.5 years; range, birth-20 years) compared with hormonal agents (median, 2 years; range, -9.5 to +15). CONCLUSIONS: The results of the current study show that participants in cancer clinical trials are younger than the actual Japanese cancer patient population.     

Pericardio-peritoneal drainage using a subcostal approach

A 56-year-old man admitted to our hospital for cardiac tamponade due to dilated cardiomyopathy did not respond to treatment by usual medical means or surgery. Pericardio-peritoneal drainage was conducted using a subcostal approach. Seven months later, the patient remains well and free of signs of pericardial tamponade. This method has proved to be safe and effective in patients with persistent massive pericardial effusion.     

Diagnostic usefulness of KL-6 measurements in patients with pulmonary complications after administration of amiodarone

Amiodarone-induced pulmonary toxicity is one of the major complications in patients receiving administration of amiodarone. KL-6 is a useful indicator to evaluate the activity of interstitial pneumonitis. We studied the clinical utility of KL-6 as a marker for amiodarone-induced pulmonary toxicity. We investigated 6 patients in whom chest radiography revealed abnormal consolidations after administration of amiodarone from 1997 to 1999. All patients were male aged 56 to 76 years (mean 66 +/- 7 years). The indications for amiodarone included sustained ventricular tachycardia in 5 patients and atrial fibrillation in one patient with refractory heart failure. The mean left ventricular ejection fraction was 31 +/- 12% (22-52%). KL-6 levels were measured by a sandwich type enzyme immunoassay using a murine monoclonal antibody (KL-6 antibody), and the cutoff level was determined at 520 U/ml. Complications occurred from 17 days to 45 months after treatment with amiodarone. The KL-6 levels were abnormally high (2,100 and 3,000 U/ml) in 2 patients with amiodarone-induced pneumonitis but under the cutoff level in the non-pneumonitis patients. In one patient with amiodarone-induced pneumonitis, the KL-6 level increased from 695 to 2,100 U/ml concurrently with worsening interstitial changes shown by high resolution computed tomography. We conclude that KL-6 has practical uses as a marker for the detection and evaluation of amiodarone-induced pulmonary toxicity.     

Outcome from severe accidental hypothermia with cardiac arrest resuscitated with extracorporeal cardiopulmonary resuscitation

Purpose

This study aimed to identify factors of neurologic prognosis in severe accidental hypothermic patients with cardiac arrest.

Basic procedures

This retrospective observational study was performed in a tertiary care university hospital in Sapporo, Japan (January 1994 to December 2012). We investigated 26 patients with accidental hypothermic cardiac arrest resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR). We evaluated the neurologic outcome in patients who were resuscitated with ECPR at discharge from hospital.

Main findings

In those 26 patients, their median age was 50.5 years; and 69.2% were male. The cause of hypothermia was exposure to cold air in 46.1%, submersion in 46.1%, and avalanche in 7.8%. Ten (38.5%) of these patients survived to favorable neurological outcome at discharge. Factors associated with favorable neurological outcome were a cardiac rhythm other than asystole (P = .009), nonasphyxial hypothermia (P = .006), higher pH (P = .01), and lower serum lactate (P = .01). In subgroup analyses, the patients with hypothermic cardiac arrest due to submersion or avalanche (asphyxia group) showed no factors associated with good neurological outcome, whereas the nonasphyxia group showed a significantly lower core temperature (P = .02) and a trend towards a lower serum lactate (P = .09).

Principal conclusions

Patients with hypothermic cardiac arrest due to nonasphyxial hypothermia have improved neurologic outcomes when treated with ECPR compared to patients with asphyxial hypothermic cardiac arrest. Further investigation is needed to develop a prediction rule for patients with nonasphyxial hypothermic cardiac arrest to determine which patients would benefit from treatment with ECPR.     

Clinicopathological features of 171 cases of primary thyroid lymphoma: a long-term study involving 24553 patients with Hashimoto's disease

There are few large‐scale reports of primary thyroid lymphoma (PTL). This study clinically and pathologically reviewed 171 patients with PTL and 24 553 patients with Hashimoto’s disease at Ito Hospital between January 1990 and December 2004, to investigate the clinical features and the treatment outcomes of PTL. The median age of the patients with PTL was 67 years (range, 27–90 years). The pathological diagnosis of PTL patients included diffuse large B‐cell lymphoma (DLBCL) (n = 74), DLBCL with mucosa‐associated lymphoid tissue (MALT) lymphoma (n = 13), MALT lymphoma (n = 80) and others (n = 4). Of the 167 patients with B‐cell lymphoma, treatment included combined modality therapy (CMT) (n = 95), radiation therapy (RT) alone (n = 60) and chemotherapy alone (n = 6). Information on treatment was not available in six patients. Information on treatment response was available in 154 patients; 149 patients (97%) responded to treatment. According to the institutional treatment strategy of Ito Hospital, 45 of 54 patients with stage IE disease received RT alone, and 87 of 113 stage IIE patients received CMT. The 5‐year overall survival rate was 85% (95% confidence interval, 79–91%). This study demonstrated that PTL showed good response to radiotherapy and chemotherapy and had a favourable prognosis.     

FFA3 Activation Stimulates Duodenal Bicarbonate Secretion and Prevents NSAID-Induced Enteropathy via the GLP-2 Pathway in Rats

Background

Therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with enteropathy in humans and experimental animals, a cause of considerable morbidity. Unlike foregut NSAID-associated mucosal lesions, most treatments for this condition are of little efficacy. We propose that the endogenously released intestinotrophic hormone glucagon-like peptide-2 (GLP-2) prevents the development of NSAID-induced enteropathy. Since the short-chain fatty acid receptor FFA3 is expressed on enteroendocrine L cells and on enteric nerves in the gastrointestinal tract, we further hypothesized that activation of FFA3 on L cells protects the mucosa from injury via GLP-2 release with enhanced duodenal HCO₃ ^? secretion. We thus investigated the effects of synthetic selective FFA3 agonists with consequent GLP-2 release on NSAID-induced enteropathy.

Methods

We measured duodenal HCO₃ ^? secretion in isoflurane-anesthetized rats in a duodenal loop perfused with the selective FFA3 agonists MQC or AR420626 (AR) while measuring released GLP-2 in the portal vein (PV). Intestinal injury was produced by indomethacin (IND, 10 mg/kg, sc) with or without MQC (1–10 mg/kg, ig) or AR (0.01–0.1 mg/kg, ig or ip) treatment.

Results

Luminal perfusion with MQC or AR (0.1–10 µM) dose-dependently augmented duodenal HCO₃ ^? secretion accompanied by increased GLP-2 concentrations in the PV. The effect of FFA3 agonists was inhibited by co-perfusion of the selective FFA3 antagonist CF3-MQC (30 µM). AR-induced augmented HCO₃ ^? secretion was reduced by iv injection of the GLP-2 receptor antagonist GLP-2(3-33) (3 nmol/kg), or by pretreatment with the cystic fibrosis transmembrane conductance regulator (CFTR) inhibitor CFTR_inh-172 (1 mg/kg, ip). IND-induced small intestinal ulcers were dose-dependently inhibited by intragastric administration of MQC or AR. GLP-2(3-33) (1 mg/kg, ip) or CF3-MQC (1 mg/kg, ig) reversed AR-associated reduction in IND-induced enteropathy. In contrast, ip injection of AR had no effect on enteropathy.

Conclusion

These results suggest that luminal FFA3 activation enhances mucosal defenses and prevents NSAID-induced enteropathy via the GLP-2 pathway. The selective FFA3 agonist may be a potential therapeutic candidate for NSAID-induced enteropathy.

     

Probing the binding specificities of human Siglecs by cell-based glycan arrays

Siglecs are a family of sialic acid–binding receptors expressed by cells of the immune system and a few other cell types capable of modulating immune cell functions upon recognition of sialoglycan ligands. While human Siglecs primarily bind to sialic acid residues on diverse types of glycoproteins and glycolipids that constitute the sialome, their fine binding specificities for elaborated complex glycan structures and the contribution of the glycoconjugate and protein context for recognition of sialoglycans at the cell surface are not fully elucidated. Here, we generated a library of isogenic human HEK293 cells with combinatorial loss/gain of individual sialyltransferase genes and the introduction of sulfotransferases for display of the human sialome and to dissect Siglec interactions in the natural context of glycoconjugates at the cell surface. We found that Siglec-4/7/15 all have distinct binding preferences for sialylated GalNAc-type O-glycans but exhibit selectivity for patterns of O-glycans as presented on distinct protein sequences. We discovered that the sulfotransferase CHST1 drives sialoglycan binding of Siglec-3/8/7/15 and that sulfation can impact the preferences for binding to O-glycan patterns. In particular, the branched Neu5Acα2–3(6-O-sulfo)Galβ1–4GlcNAc (6′-Su-SLacNAc) epitope was discovered as the binding epitope for Siglec-3 (CD33) implicated in late-onset Alzheimer’s disease. The cell-based display of the human sialome provides a versatile discovery platform that enables dissection of the genetic and biosynthetic basis for the Siglec glycan interactome and other sialic acid–binding proteins.

Immune cells are equipped with an array of glycan-binding proteins (GPBs) capable of interpreting the biological information encoded by glycans. Endogenous GBPs recognize host-derived “self” and foreign-derived “nonself” glycans and produce cues that are integrated into the signaling network of immune cells and contribute to immune homeostasis and the immune response (1). Siglecs (sialic acid–binding immunoglobulin-like lectins) serve in self-recognition and transmit immune inhibitory signals upon binding to a select repertoire of sialoglycans expressed by host cells raising the threshold for immune activation (2, 3). The human Siglec family consists of 14 functionally expressed members, and these are composed of an N-terminal V-set immunoglobulin (Ig)-like domain that mediates sialoglycan binding followed by varying numbers of C2-set Ig-like domains. Intracellularly, most Siglecs have immunoreceptor tyrosine-based inhibition motifs, and Siglec-14/15/16 carry immunoreceptor tyrosine-based activation motifs (3–7). Siglecs are broadly expressed throughout the immune system, and several Siglecs are also found outside of the immune system, such as Siglec-4 (MAG), which is expressed by oligodendrocytes and Schwann cells in the nervous system (8). Although the diverse biological functions within and outside of the immune system of Siglecs are not fully understood, Siglecs generally contribute to immune homeostasis by dampening immune activation upon recognition of sialoglycans. For example, Siglec-2 (CD22) can suppress B cell receptor activation (9), and Siglec-9 can dampen neutrophil activation (10). Cancer cells with aberrant sialoglycans and pathogens that express sialic acids can exploit Siglec signaling to modulate immune responses (11, 12). Moreover, Siglec-3 (CD33) is strongly associated with risk for Alzheimer’s disease and expressed on microglia cells (13, 14). Given the potent immune modulatory functions of Siglecs and their wide involvement in autoimmunity, infection, cancer, and neurodegeneration, Siglecs are promising therapeutic targets (7, 15). However, many of the natural ligands of Siglecs have not been fully identified, and endogenous ligands for several Siglecs including Siglec-3/CD33 remain elusive.Human cells can produce a large diversity of glycans capped with sialic acids (Sia), a family of chemically diverse sugars with N-acetylneuraminic acid (Neu5Ac) being the predominant type in humans. Sialic acids are generally found at the termini of mammalian glycans, and most types of glycoconjugates including N-glycoproteins, multiple types of O-glycoproteins, and glycolipids carry oligosaccharides capped by sialic acids (16, 17). Sialylation is one of the most complex regulated steps in glycosylation with 20 distinct Golgi-located sialyltransferase isoenzymes dedicated to catalyze transfer of sialic acids to galactose (ST3GAL1-6, ST6GAL1 and 2), N-Acetylgalactosamine (Gal-NAc) (ST6GALNAC1-6), or sialic acid (ST8SIA1-6) via α2-3, α2-6, or α2-8 linkages, respectively and with different preferences for the underlying glycan structures and types of glycoconjugate (18–20). The resulting plethora of sialic acid-containing glycans constituting the sialome of cells provides a vast catalog of ligands for Siglecs and potential for distinct instructive cues for the immune response (16). The current insight into the interactome of Siglecs is largely derived from studies with libraries of synthetic and natural glycans printed on glass arrays (21, 22). These glycan arrays have demonstrated distinct structural glycan features that drive selective binding of individual Siglecs, including the linkage type of sialic acids, the core disaccharide carrying sialic acids, and glycan modifications such as sulfation or acetylation (23–27). However, printed glycan arrays may not present glycans in the natural context of the overall glycoconjugate structure and the cell surface with spatial organization and competition dynamics limiting insight into the fine binding specificities of Siglecs and their interactions with the host cell sialome.Here, we took advantage of our recently developed cell-based glycan array strategy (28–30) and generated an expanded sialome sublibrary with the human embryonic kidney (HEK) 293 for dissection of Siglec binding properties. First, combinatorial gene knockout (KO) was used to delete distinct subsets of sialyltransferase isoenzymes or all endogenous sialylation capacity. Second, using targeted gene knock-in (KI), individual sialyltransferase isoenzymes were introduced in the absence of other isoenzymes. Finally, we introduced selected sulfotransferase isoenzymes to explore cross-talk between sialylation and sulfation. To specifically address the influence of clustered O-glycan presentation for Siglec binding, we introduced a large panel of reporter constructs designed to display human O-glycodomains derived from mucins and mucin-like O-glycoproteins with different densities and patterns of O-glycans. The cell-based sialome array reproduced previous results for binding specificities for Siglec-2 (CD22) and Siglec-9 and led to insight into the binding specificities of Siglec-4/7/15 for distinct GalNAc-type O-glycans and their presentation on O-mucin–like glycoproteins. Finally, we demonstrate that Siglec-3/7/8/15 have preferential binding to sulfated sialoglycans yet have different specificities for underlying glycoconjugate structures. We further discovered the 6′-Su-SLacNAc (Neu5Acα2-3[6-O-sulfo]Galβ1-4GlcNAc) epitope on N-glycans and glycolipids as the ligand for Siglec-3/CD33 as well as Siglec-8. In summary, the cell-based display of the human sialome enables dissection of the Siglec interactome in the natural context of a human cell and provides the biosynthetic and genetic basis for the identified ligands.     

Conditioning regimen of melphalan, fludarabine and total body irradiation in unmanipulated HLA haploidentical stem cell transplantation based on feto-maternal tolerance

Unmanipulated hematopoietic stem cell transplantation from haploidentical family donors is frequently associated with graft failure and severe graft-versus-host disease (GVHD). We employed a myeloablative conditioning regimen consisting of 125 mg/m2 of fludarabine, 140 mg/m2 of melphalan and TBI of 10 to 12 Gy for three patients. The donor in each case was a haploidentical two-loci HLA mismatch mother or son. Engraftment failure was observed in one patient. In the other two patients, engraftment was confirmed within 15 days after transplantation. Acute and chronic GVHD was observed, but was controllable in both cases. HLA mismatched transplantation based on feto-maternal tolerance may provide an alternative option for patients who do not have HLA-matched donors.     

Immunohistological studies on the identification of T cells and T cell subsets infiltrating in human stomach cancer tissues

T cells and T cell subsets in human gastric cancer tissues were identified using the immunoperoxidase technique with anti-T cell monoclonal antibodies (Leu-1, Leu-2, Leu-3 and Leu-4), anti-HLA-DR(Ia) monocronal antibody, and anti-Ig sera. The majority of lymphocytes infiltrating into gastric cancer tissues were Leu-1 and Leu-4 positive T cells; they consisted of a Leu-2 positive T cell subset (Tc/s) and a Leu-3 positive T cell subset (Th/i). Leu-2 positive T cells infiltrated the gastric cancer tissues of 6 patients with a moderate or marked degree of lymphocyte infiltration; Leu-3 positive T cells infiltrated these tissues of 11 patients. These results show that the degree of T cell and T cell subset infiltration may effect the host-tumor relationship.