Analysis of cancer registry data from Denmark, Iceland, and Sweden over more than 60 years found that survivors of childhood cancer had a 1.4-fold higher risk of autoimmune disease compared with matched controls.

Results showed significantly increased rates of hospital visits for 11 of 33 autoimmune diseases investigated. The most prominent excesses were for insulin-dependent diabetes mellitus, Addison’s disease, and Hashimoto’s thyroiditis, accounting for more than half the total number of excess autoimmune cases (Ann Rheum Dis 2015 Nov 6. doi: 10.1136/annrheumdis-2015-207659). The investigators could not rule out the influence of surveillance bias, given that hospitalization rate ratios were highest in the first 5 years after cancer diagnosis, potentially a consequence of closer surveillance during that period. For most autoimmune diseases, however, the excess risk persisted through the second and third decades after cancer diagnosis.

The Nordic childhood cancer survivor cohort comprised 25,635 individuals diagnosed with cancer before the age of 20 years, from the 1940s-1950s (start of cancer registries in Denmark, Iceland, and Sweden) to 2008. Expected autoimmune disease rates were based on rates of hospital visits for the comparison cohort, which included 128,023 individuals matched for age, sex, and country of the corresponding survivor. The standardized hospitalization rate ratio is the observed number of autoimmune diseases among survivors divided by the expected rate. Childhood malignancies with the most pronounced risk increases were leukemia (standardized hospitalization rate ratio, 1.6), Hodgkin lymphoma (1.6), renal tumors (1.6), and central nervous system neoplasms (1.4).

“Cure is no longer a sufficient goal in childhood cancer care. As the vast majority of these patients survive, attention must be to paid to their long-term quality of life and health challenges,” wrote Dr. Anna Salifors Holmqvist of the department of clinical sciences, pediatric oncology and hematology, Skane University Hospital, Lund University, Sweden.

Increased risks were noted for a wide range of relatively rare autoimmune diseases after treatment for several types of childhood malignancies, and underlying mechanisms should be addressed in future studies, noted Dr. Holmqvist and her colleagues.

Analysis of cancer registry data from Denmark, Iceland, and Sweden over more than 60 years found that survivors of childhood cancer had a 1.4-fold higher risk of autoimmune disease compared with matched controls.

Results showed significantly increased rates of hospital visits for 11 of 33 autoimmune diseases investigated. The most prominent excesses were for insulin-dependent diabetes mellitus, Addison’s disease, and Hashimoto’s thyroiditis, accounting for more than half the total number of excess autoimmune cases (Ann Rheum Dis 2015 Nov 6. doi: 10.1136/annrheumdis-2015-207659). The investigators could not rule out the influence of surveillance bias, given that hospitalization rate ratios were highest in the first 5 years after cancer diagnosis, potentially a consequence of closer surveillance during that period. For most autoimmune diseases, however, the excess risk persisted through the second and third decades after cancer diagnosis.

The Nordic childhood cancer survivor cohort comprised 25,635 individuals diagnosed with cancer before the age of 20 years, from the 1940s-1950s (start of cancer registries in Denmark, Iceland, and Sweden) to 2008. Expected autoimmune disease rates were based on rates of hospital visits for the comparison cohort, which included 128,023 individuals matched for age, sex, and country of the corresponding survivor. The standardized hospitalization rate ratio is the observed number of autoimmune diseases among survivors divided by the expected rate. Childhood malignancies with the most pronounced risk increases were leukemia (standardized hospitalization rate ratio, 1.6), Hodgkin lymphoma (1.6), renal tumors (1.6), and central nervous system neoplasms (1.4).

“Cure is no longer a sufficient goal in childhood cancer care. As the vast majority of these patients survive, attention must be to paid to their long-term quality of life and health challenges,” wrote Dr. Anna Salifors Holmqvist of the department of clinical sciences, pediatric oncology and hematology, Skane University Hospital, Lund University, Sweden.

Increased risks were noted for a wide range of relatively rare autoimmune diseases after treatment for several types of childhood malignancies, and underlying mechanisms should be addressed in future studies, noted Dr. Holmqvist and her colleagues.

Analysis of cancer registry data from Denmark, Iceland, and Sweden over more than 60 years found that survivors of childhood cancer had a 1.4-fold higher risk of autoimmune disease compared with matched controls.

Results showed significantly increased rates of hospital visits for 11 of 33 autoimmune diseases investigated. The most prominent excesses were for insulin-dependent diabetes mellitus, Addison’s disease, and Hashimoto’s thyroiditis, accounting for more than half the total number of excess autoimmune cases (Ann Rheum Dis 2015 Nov 6. doi: 10.1136/annrheumdis-2015-207659). The investigators could not rule out the influence of surveillance bias, given that hospitalization rate ratios were highest in the first 5 years after cancer diagnosis, potentially a consequence of closer surveillance during that period. For most autoimmune diseases, however, the excess risk persisted through the second and third decades after cancer diagnosis.

The Nordic childhood cancer survivor cohort comprised 25,635 individuals diagnosed with cancer before the age of 20 years, from the 1940s-1950s (start of cancer registries in Denmark, Iceland, and Sweden) to 2008. Expected autoimmune disease rates were based on rates of hospital visits for the comparison cohort, which included 128,023 individuals matched for age, sex, and country of the corresponding survivor. The standardized hospitalization rate ratio is the observed number of autoimmune diseases among survivors divided by the expected rate. Childhood malignancies with the most pronounced risk increases were leukemia (standardized hospitalization rate ratio, 1.6), Hodgkin lymphoma (1.6), renal tumors (1.6), and central nervous system neoplasms (1.4).

“Cure is no longer a sufficient goal in childhood cancer care. As the vast majority of these patients survive, attention must be to paid to their long-term quality of life and health challenges,” wrote Dr. Anna Salifors Holmqvist of the department of clinical sciences, pediatric oncology and hematology, Skane University Hospital, Lund University, Sweden.

Increased risks were noted for a wide range of relatively rare autoimmune diseases after treatment for several types of childhood malignancies, and underlying mechanisms should be addressed in future studies, noted Dr. Holmqvist and her colleagues.

The letter from the insurance company was addressed to my patient. The two pages of information boiled down to one simple sentence: “After a thorough review, our decision to not cover the medication Provigil (modafinil) is unchanged.” The letter went on to explain that there was no further recourse, and that the medication would not be approved because it was not Food and Drug Administration–approved for the condition my patient had: major depression. If she chose to take it, there would be no reimbursement. In many psychiatric conditions, the FDA-approved options are very limited; for some disorders, there simply are no approved medications, despite the fact that research has shown medications to be helpful. For a medication that now has a generic, there is no reason for the pharmaceutical agency to incur the cost of getting a medication approved by the FDA for a specific use.

Psychiatrists are all familiar with the process of medication preauthorization. Insurance companies require the physician to make an extra effort in order to prescribe certain medications. Often, as in the case of modafinil, the medications are expensive, and one might wonder why a generic medication costs $25 a pill. The name-brand medication, Provigil, costs more than $33 for a single dose. Sometimes, however, a preauthorization process is put in place for very inexpensive medications that might cost only a few dollars a month. Preauthorization requirements waste enormous amounts of physician time and don’t necessarily save money for insurers.

What many physicians don’t realize is that there is no national oversight to this process. In some arenas, the insurers can set the hoops as high as they want and in perpetual motion, thereby making the process a long and miserable adventure – all while the patient suffers.

Nothing about my patient’s depression has been easy to treat. We started working together 8 years ago; her suffering at that time was extreme and her presentation was unusual. I arranged for her admission to a specialty unit in a psychiatric hospital, and she remained under their care for several months – an astounding period of time in an era where the average length of stay is 7 to 10 days. She was discharged – very much improved – on an unusual cocktail of medications.

Over time, we tapered some of the medications because of side effects. Five years ago, her insurance changed and after I answered a 13-question prior authorization form, the medication was denied because she did not have narcolepsy or any of the sleep disorders for which the FDA does approve the use of Provigil. An appeal was denied, and I prescribed stimulants instead. It wasn’t until recently, when the patient’s depression returned full-force, and every medication option I could think of had been tried, that I decided to try modafinil again, especially since I have found it helpful in another patient with a treatment-resistant depression.

I wrote a prescription and heard from the pharmacy that Provigil required preauthorization. I prescribed Nuvigil instead, but that too required preauthorization. A 20-minute phone call resulted in directions on how to find a form and fax a request for the medication. It contained many of the same questions from years ago, and the request was denied.

Several more phone calls led me to a reviewer with the pharmacy benefits company in Nevada, who told me I could find a form on the website, send in an appeal to the insurance company in Iowa, and I would hear within 15 business days if my patient could get the medication. When I said that was not acceptable – the patient was suffering and needed the medication now – I was told I would receive a call from a peer reviewer within 48 hours. A week later, a pharmacist called and asked the exact same questions that I had already answered. When I said that no, I had not ordered polysomnography or multiple sleep latency tests because they were not medically indicated, she denied approval of the medication and said she had no leeway to approve its use if the questions were not answered correctly. I found it curious that this step was called a “peer-to-peer” review. By this point, I had spent about an hour in a two-step process where the second step was exactly the same as the first step. It’s okay; the insurance company doesn’t mind the inefficient use of everyone’s time.

I was told that to file an appeal, I would need more forms off the website, and I was given (at my request) directions on where to find those forms. But first, I needed to get the patient to sign a form to authorize to release information on her behalf. The patient lives a 90-minute drive from my office and does not have a fax machine, and this delayed the process. It remained unclear to me why the patient’s permission was needed when it had not been needed for the first two steps of the process. The authorization was to be mailed or faxed to one location, while the appeal letter was to be mailed (fax or electronic submissions were not options) to another address.

In the appeal letter, I discussed her past history of a lengthy hospitalization, a long list of other medications that had been tried, and a study that documented the efficacy of modafinil as an adjunct agent in the treatment of depression.

As the weeks ticked by, I contacted the chief medical officer of the insurance company and complained; I had spent hours on an arbitrary, repetitive, and inefficient process that was yielding no results. I asked how he sleeps at night.

The response was infuriating: “I know that the appeal is being set up in the queue. I am sorry that this process has been drawn out for you and your patient.” In the queue? Had he ever sat with a sobbing, depressed patient who couldn’t get out of bed all day? A family member was taking off work to stay with her, and her life was on hold. The chief medical officer didn’t give any indication as to how long this queue might be. The family was hurting both emotionally and financially.

I tried one of my U.S. senators. His office replied that preauthorization oversight was not a legislative issue. I spoke with the insurance commission in Maryland where I practice, and I filed a formal complaint with the insurance commissioner in Iowa. I was told it could take up to 45 days for a response, but the next day, I heard back: The plan is funded through a family member’s employer and is not under the jurisdiction of the insurance commissioner. Simply put, the insurance company can set up as many hurdles as they like and take as long as they want to respond, regardless of the patient’s need.

Eight weeks after I wrote the prescription, a copy of the denial letter arrived in my mail. A physician in Iowa has determined that the medication is not medically necessary for a patient he or she had never seen in Maryland. I’ve turned to the American Psychiatric Association. With so many psychiatrists complaining about the burdens of preauthorization, this case would be a good example; one of its attorneys has agreed to write a letter to the Department of Labor. Perhaps that will help, but as of this writing, I have not yet seen that letter. All in all, it has been hours of my time, and lots of waiting, all without regard to the person who could possibly find some relief with a medication that is available to some, but not to her.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

The letter from the insurance company was addressed to my patient. The two pages of information boiled down to one simple sentence: “After a thorough review, our decision to not cover the medication Provigil (modafinil) is unchanged.” The letter went on to explain that there was no further recourse, and that the medication would not be approved because it was not Food and Drug Administration–approved for the condition my patient had: major depression. If she chose to take it, there would be no reimbursement. In many psychiatric conditions, the FDA-approved options are very limited; for some disorders, there simply are no approved medications, despite the fact that research has shown medications to be helpful. For a medication that now has a generic, there is no reason for the pharmaceutical agency to incur the cost of getting a medication approved by the FDA for a specific use.

Psychiatrists are all familiar with the process of medication preauthorization. Insurance companies require the physician to make an extra effort in order to prescribe certain medications. Often, as in the case of modafinil, the medications are expensive, and one might wonder why a generic medication costs $25 a pill. The name-brand medication, Provigil, costs more than $33 for a single dose. Sometimes, however, a preauthorization process is put in place for very inexpensive medications that might cost only a few dollars a month. Preauthorization requirements waste enormous amounts of physician time and don’t necessarily save money for insurers.

What many physicians don’t realize is that there is no national oversight to this process. In some arenas, the insurers can set the hoops as high as they want and in perpetual motion, thereby making the process a long and miserable adventure – all while the patient suffers.

Nothing about my patient’s depression has been easy to treat. We started working together 8 years ago; her suffering at that time was extreme and her presentation was unusual. I arranged for her admission to a specialty unit in a psychiatric hospital, and she remained under their care for several months – an astounding period of time in an era where the average length of stay is 7 to 10 days. She was discharged – very much improved – on an unusual cocktail of medications.

Over time, we tapered some of the medications because of side effects. Five years ago, her insurance changed and after I answered a 13-question prior authorization form, the medication was denied because she did not have narcolepsy or any of the sleep disorders for which the FDA does approve the use of Provigil. An appeal was denied, and I prescribed stimulants instead. It wasn’t until recently, when the patient’s depression returned full-force, and every medication option I could think of had been tried, that I decided to try modafinil again, especially since I have found it helpful in another patient with a treatment-resistant depression.

I wrote a prescription and heard from the pharmacy that Provigil required preauthorization. I prescribed Nuvigil instead, but that too required preauthorization. A 20-minute phone call resulted in directions on how to find a form and fax a request for the medication. It contained many of the same questions from years ago, and the request was denied.

Several more phone calls led me to a reviewer with the pharmacy benefits company in Nevada, who told me I could find a form on the website, send in an appeal to the insurance company in Iowa, and I would hear within 15 business days if my patient could get the medication. When I said that was not acceptable – the patient was suffering and needed the medication now – I was told I would receive a call from a peer reviewer within 48 hours. A week later, a pharmacist called and asked the exact same questions that I had already answered. When I said that no, I had not ordered polysomnography or multiple sleep latency tests because they were not medically indicated, she denied approval of the medication and said she had no leeway to approve its use if the questions were not answered correctly. I found it curious that this step was called a “peer-to-peer” review. By this point, I had spent about an hour in a two-step process where the second step was exactly the same as the first step. It’s okay; the insurance company doesn’t mind the inefficient use of everyone’s time.

I was told that to file an appeal, I would need more forms off the website, and I was given (at my request) directions on where to find those forms. But first, I needed to get the patient to sign a form to authorize to release information on her behalf. The patient lives a 90-minute drive from my office and does not have a fax machine, and this delayed the process. It remained unclear to me why the patient’s permission was needed when it had not been needed for the first two steps of the process. The authorization was to be mailed or faxed to one location, while the appeal letter was to be mailed (fax or electronic submissions were not options) to another address.

In the appeal letter, I discussed her past history of a lengthy hospitalization, a long list of other medications that had been tried, and a study that documented the efficacy of modafinil as an adjunct agent in the treatment of depression.

As the weeks ticked by, I contacted the chief medical officer of the insurance company and complained; I had spent hours on an arbitrary, repetitive, and inefficient process that was yielding no results. I asked how he sleeps at night.

The response was infuriating: “I know that the appeal is being set up in the queue. I am sorry that this process has been drawn out for you and your patient.” In the queue? Had he ever sat with a sobbing, depressed patient who couldn’t get out of bed all day? A family member was taking off work to stay with her, and her life was on hold. The chief medical officer didn’t give any indication as to how long this queue might be. The family was hurting both emotionally and financially.

I tried one of my U.S. senators. His office replied that preauthorization oversight was not a legislative issue. I spoke with the insurance commission in Maryland where I practice, and I filed a formal complaint with the insurance commissioner in Iowa. I was told it could take up to 45 days for a response, but the next day, I heard back: The plan is funded through a family member’s employer and is not under the jurisdiction of the insurance commissioner. Simply put, the insurance company can set up as many hurdles as they like and take as long as they want to respond, regardless of the patient’s need.

Eight weeks after I wrote the prescription, a copy of the denial letter arrived in my mail. A physician in Iowa has determined that the medication is not medically necessary for a patient he or she had never seen in Maryland. I’ve turned to the American Psychiatric Association. With so many psychiatrists complaining about the burdens of preauthorization, this case would be a good example; one of its attorneys has agreed to write a letter to the Department of Labor. Perhaps that will help, but as of this writing, I have not yet seen that letter. All in all, it has been hours of my time, and lots of waiting, all without regard to the person who could possibly find some relief with a medication that is available to some, but not to her.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

The letter from the insurance company was addressed to my patient. The two pages of information boiled down to one simple sentence: “After a thorough review, our decision to not cover the medication Provigil (modafinil) is unchanged.” The letter went on to explain that there was no further recourse, and that the medication would not be approved because it was not Food and Drug Administration–approved for the condition my patient had: major depression. If she chose to take it, there would be no reimbursement. In many psychiatric conditions, the FDA-approved options are very limited; for some disorders, there simply are no approved medications, despite the fact that research has shown medications to be helpful. For a medication that now has a generic, there is no reason for the pharmaceutical agency to incur the cost of getting a medication approved by the FDA for a specific use.

Psychiatrists are all familiar with the process of medication preauthorization. Insurance companies require the physician to make an extra effort in order to prescribe certain medications. Often, as in the case of modafinil, the medications are expensive, and one might wonder why a generic medication costs $25 a pill. The name-brand medication, Provigil, costs more than $33 for a single dose. Sometimes, however, a preauthorization process is put in place for very inexpensive medications that might cost only a few dollars a month. Preauthorization requirements waste enormous amounts of physician time and don’t necessarily save money for insurers.

What many physicians don’t realize is that there is no national oversight to this process. In some arenas, the insurers can set the hoops as high as they want and in perpetual motion, thereby making the process a long and miserable adventure – all while the patient suffers.

Nothing about my patient’s depression has been easy to treat. We started working together 8 years ago; her suffering at that time was extreme and her presentation was unusual. I arranged for her admission to a specialty unit in a psychiatric hospital, and she remained under their care for several months – an astounding period of time in an era where the average length of stay is 7 to 10 days. She was discharged – very much improved – on an unusual cocktail of medications.

Over time, we tapered some of the medications because of side effects. Five years ago, her insurance changed and after I answered a 13-question prior authorization form, the medication was denied because she did not have narcolepsy or any of the sleep disorders for which the FDA does approve the use of Provigil. An appeal was denied, and I prescribed stimulants instead. It wasn’t until recently, when the patient’s depression returned full-force, and every medication option I could think of had been tried, that I decided to try modafinil again, especially since I have found it helpful in another patient with a treatment-resistant depression.

I wrote a prescription and heard from the pharmacy that Provigil required preauthorization. I prescribed Nuvigil instead, but that too required preauthorization. A 20-minute phone call resulted in directions on how to find a form and fax a request for the medication. It contained many of the same questions from years ago, and the request was denied.

Several more phone calls led me to a reviewer with the pharmacy benefits company in Nevada, who told me I could find a form on the website, send in an appeal to the insurance company in Iowa, and I would hear within 15 business days if my patient could get the medication. When I said that was not acceptable – the patient was suffering and needed the medication now – I was told I would receive a call from a peer reviewer within 48 hours. A week later, a pharmacist called and asked the exact same questions that I had already answered. When I said that no, I had not ordered polysomnography or multiple sleep latency tests because they were not medically indicated, she denied approval of the medication and said she had no leeway to approve its use if the questions were not answered correctly. I found it curious that this step was called a “peer-to-peer” review. By this point, I had spent about an hour in a two-step process where the second step was exactly the same as the first step. It’s okay; the insurance company doesn’t mind the inefficient use of everyone’s time.

I was told that to file an appeal, I would need more forms off the website, and I was given (at my request) directions on where to find those forms. But first, I needed to get the patient to sign a form to authorize to release information on her behalf. The patient lives a 90-minute drive from my office and does not have a fax machine, and this delayed the process. It remained unclear to me why the patient’s permission was needed when it had not been needed for the first two steps of the process. The authorization was to be mailed or faxed to one location, while the appeal letter was to be mailed (fax or electronic submissions were not options) to another address.

In the appeal letter, I discussed her past history of a lengthy hospitalization, a long list of other medications that had been tried, and a study that documented the efficacy of modafinil as an adjunct agent in the treatment of depression.

As the weeks ticked by, I contacted the chief medical officer of the insurance company and complained; I had spent hours on an arbitrary, repetitive, and inefficient process that was yielding no results. I asked how he sleeps at night.

The response was infuriating: “I know that the appeal is being set up in the queue. I am sorry that this process has been drawn out for you and your patient.” In the queue? Had he ever sat with a sobbing, depressed patient who couldn’t get out of bed all day? A family member was taking off work to stay with her, and her life was on hold. The chief medical officer didn’t give any indication as to how long this queue might be. The family was hurting both emotionally and financially.

I tried one of my U.S. senators. His office replied that preauthorization oversight was not a legislative issue. I spoke with the insurance commission in Maryland where I practice, and I filed a formal complaint with the insurance commissioner in Iowa. I was told it could take up to 45 days for a response, but the next day, I heard back: The plan is funded through a family member’s employer and is not under the jurisdiction of the insurance commissioner. Simply put, the insurance company can set up as many hurdles as they like and take as long as they want to respond, regardless of the patient’s need.

Eight weeks after I wrote the prescription, a copy of the denial letter arrived in my mail. A physician in Iowa has determined that the medication is not medically necessary for a patient he or she had never seen in Maryland. I’ve turned to the American Psychiatric Association. With so many psychiatrists complaining about the burdens of preauthorization, this case would be a good example; one of its attorneys has agreed to write a letter to the Department of Labor. Perhaps that will help, but as of this writing, I have not yet seen that letter. All in all, it has been hours of my time, and lots of waiting, all without regard to the person who could possibly find some relief with a medication that is available to some, but not to her.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

BOSTON – An experimental agent that targets the byproducts of gene fusions has shown surprising clinical activity against notoriously treatment-refractory cancers in early results from a phase I trial.

“I think that’s what remarkable about this is that we have all these different histologies and many different fusions, but all seem to be having some kind of [response] to this molecule,” said lead investigator Dr. David S. Hong, deputy chair and associate professor in the department of investigational cancer therapeutics at the University of Texas MD Anderson Cancer Center, Houston.

The molecule, LOXO-101 is a selective inhibitor of abnormal TRKA, TRKAB, and TRKC kinases that arise from gene fusions. TRK fusions have been implicated in tumor development in preclinical studies, he reported at the AACR–NCI–EORTC International Conference on Molecular Targets and Cancer Therapeutics.

One patient, a 41-year-old woman with undifferentiated soft tissue sarcoma of the groin that had metastasized to her lungs had rapid and “substantial” tumor and lung-nodule regression that radiographically fell just shy of a complete response, Dr. Hong said.

The drug also induced robust partial responses in a 55-year-old man with a gastrointestinal stromal tumor (GIST) for whom five prior targeted agents had failed, and a 33-year-old man with mammary analogue secretory carcinoma of the salivary gland (MASC) that had progressed on chemotherapy with docetaxel, carboplatin, and 5-fluorauracil.

A fourth patient, a man (age unspecified) who had papillary thyroid cancer with palpable lymphadenopathy, had no palpable nodes at 1-month follow-up, and appears to be responding to the drug, Dr. Hong added.

“This is really a dramatic example, I think, of a targeted therapy that is not histology specific, and this is another area in oncology where it’s new, and we’re just feeling our way,” commented Dr. Lee C. Helman, a sarcoma specialist at the National Cancer Institute in Bethesda, Md., who moderated the briefing where Dr. Hong presented the data.

Tumor promoters

The TRK family of proteins consists of separate tyrosine kinases that, when functioning normally, are important for the development of peripheral central nervous system processes such as pain and thermoregulation, Dr. Hong explained.

“The NTRK 1, 2, and 3 genes which encode for the TRK proteins are subject to these gene rearrangements and fusions, and the resulting TRK gene fusions may become erroneously expressed, and the kinase domain constitutively activated,” he said.

Gene fusions resulting in constitutively active TRKA, B, and C kinases can occur in the range of about 2%-25% in a wide variety of tumors, including adenocarcinomas of the lung, gliomas, thyroid tumors, head and neck cancers, sarcomas, and other types. These fusions have also been detected in more than 75% of MASC tumors, secretory breast carcinomas, and infantile (congenital) fibrosarcoma.

LOXO-101 is an orally delivered small molecule that was rationally designed to target the TRK fusions while largely leaving other kinases alone. In preclinical studies, the compound showed potent tumor growth inhibition and regression in mice bearing NTRK fusions.

The phase I trial is a dose-finding study including a total of 24 patients with various treatment-refractory advanced or metastatic solid tumors. Patients were enrolled regardless of fusional status.

Well tolerated

At the selected dose of 100 mg twice daily, patients appeared to tolerate the drug very well, with few off-target adverse events, Dr. Hong said. The most common side effect was mild dizziness. Grade 3 or 4 adverse events occurring at all doses levels include fatigue (one patient), anemia (two), abdominal pain (one), increased alkaline phosphatase (one), increased aspartate aminotransferase, delirium, and syncope (two each).

A total of six of the 24 patients had TRK fusions in their tumors, and three of these patients were available for assessment as of Oct. 20, 2015.

Dr. Hong and colleagues previously reportedon the case of the 41-year old woman with sarcoma. She was found to have a fusion of LMNA (a gene that encodes for nuclear membrane proteins) with NTRK1. She was started on the 100-mg b.i.d. dose of LOX-101 and had rapid resolution of dyspnea and hypoxemia. She had a confirmed partial response, and a CT scan showed that her multiple pulmonary nodules had regressed, with just a single, small disease site remaining at most recent follow-up. This patient continues on treatment and has been followed for more than 8 months.

The man with GIST had experienced disease progression while on therapy with imatinib, sunitinib, sorafenib, nilotinib, and regorafenib. He was treated in the 150-mg b.i.d. dose cohort, had a confirmed partial response, and remains on study after 4-plus months.

The third patient, the 33-year-old man with MASC, was assigned to the 100-mg b.i.d. dose. He too had a partial response, with radiologic evidence of substantial tumor shrinkage, and a persistent, tumor-related cough that disappeared after about 10 days of treatment, and remains on study after more than 3 months of follow-up.

The investigators have begun accruing patients for a phase II “basket” trial in adult patients with advanced or metastatic solid tumors displaying TRK fusions, including non–small cell lung cancers, thyroid tumors, sarcomas, colorectal cancer, salivary gland cancers, primary central nervous system cancers, and all other solid tumors.

Dr. Hong said that the results indicate the importance of tumor profiling for the majority of patients, especially those whose disease is refractory to standard therapies.

The study was funded by Loxo Oncology. Dr. Hong disclosed receiving travel expenses from the company. Three coauthors are employees and shareholders of the company.

BOSTON – An experimental agent that targets the byproducts of gene fusions has shown surprising clinical activity against notoriously treatment-refractory cancers in early results from a phase I trial.

“I think that’s what remarkable about this is that we have all these different histologies and many different fusions, but all seem to be having some kind of [response] to this molecule,” said lead investigator Dr. David S. Hong, deputy chair and associate professor in the department of investigational cancer therapeutics at the University of Texas MD Anderson Cancer Center, Houston.

The molecule, LOXO-101 is a selective inhibitor of abnormal TRKA, TRKAB, and TRKC kinases that arise from gene fusions. TRK fusions have been implicated in tumor development in preclinical studies, he reported at the AACR–NCI–EORTC International Conference on Molecular Targets and Cancer Therapeutics.

One patient, a 41-year-old woman with undifferentiated soft tissue sarcoma of the groin that had metastasized to her lungs had rapid and “substantial” tumor and lung-nodule regression that radiographically fell just shy of a complete response, Dr. Hong said.

The drug also induced robust partial responses in a 55-year-old man with a gastrointestinal stromal tumor (GIST) for whom five prior targeted agents had failed, and a 33-year-old man with mammary analogue secretory carcinoma of the salivary gland (MASC) that had progressed on chemotherapy with docetaxel, carboplatin, and 5-fluorauracil.

A fourth patient, a man (age unspecified) who had papillary thyroid cancer with palpable lymphadenopathy, had no palpable nodes at 1-month follow-up, and appears to be responding to the drug, Dr. Hong added.

“This is really a dramatic example, I think, of a targeted therapy that is not histology specific, and this is another area in oncology where it’s new, and we’re just feeling our way,” commented Dr. Lee C. Helman, a sarcoma specialist at the National Cancer Institute in Bethesda, Md., who moderated the briefing where Dr. Hong presented the data.

Tumor promoters

The TRK family of proteins consists of separate tyrosine kinases that, when functioning normally, are important for the development of peripheral central nervous system processes such as pain and thermoregulation, Dr. Hong explained.

“The NTRK 1, 2, and 3 genes which encode for the TRK proteins are subject to these gene rearrangements and fusions, and the resulting TRK gene fusions may become erroneously expressed, and the kinase domain constitutively activated,” he said.

Gene fusions resulting in constitutively active TRKA, B, and C kinases can occur in the range of about 2%-25% in a wide variety of tumors, including adenocarcinomas of the lung, gliomas, thyroid tumors, head and neck cancers, sarcomas, and other types. These fusions have also been detected in more than 75% of MASC tumors, secretory breast carcinomas, and infantile (congenital) fibrosarcoma.

LOXO-101 is an orally delivered small molecule that was rationally designed to target the TRK fusions while largely leaving other kinases alone. In preclinical studies, the compound showed potent tumor growth inhibition and regression in mice bearing NTRK fusions.

The phase I trial is a dose-finding study including a total of 24 patients with various treatment-refractory advanced or metastatic solid tumors. Patients were enrolled regardless of fusional status.

Well tolerated

At the selected dose of 100 mg twice daily, patients appeared to tolerate the drug very well, with few off-target adverse events, Dr. Hong said. The most common side effect was mild dizziness. Grade 3 or 4 adverse events occurring at all doses levels include fatigue (one patient), anemia (two), abdominal pain (one), increased alkaline phosphatase (one), increased aspartate aminotransferase, delirium, and syncope (two each).

A total of six of the 24 patients had TRK fusions in their tumors, and three of these patients were available for assessment as of Oct. 20, 2015.

Dr. Hong and colleagues previously reportedon the case of the 41-year old woman with sarcoma. She was found to have a fusion of LMNA (a gene that encodes for nuclear membrane proteins) with NTRK1. She was started on the 100-mg b.i.d. dose of LOX-101 and had rapid resolution of dyspnea and hypoxemia. She had a confirmed partial response, and a CT scan showed that her multiple pulmonary nodules had regressed, with just a single, small disease site remaining at most recent follow-up. This patient continues on treatment and has been followed for more than 8 months.

The man with GIST had experienced disease progression while on therapy with imatinib, sunitinib, sorafenib, nilotinib, and regorafenib. He was treated in the 150-mg b.i.d. dose cohort, had a confirmed partial response, and remains on study after 4-plus months.

The third patient, the 33-year-old man with MASC, was assigned to the 100-mg b.i.d. dose. He too had a partial response, with radiologic evidence of substantial tumor shrinkage, and a persistent, tumor-related cough that disappeared after about 10 days of treatment, and remains on study after more than 3 months of follow-up.

The investigators have begun accruing patients for a phase II “basket” trial in adult patients with advanced or metastatic solid tumors displaying TRK fusions, including non–small cell lung cancers, thyroid tumors, sarcomas, colorectal cancer, salivary gland cancers, primary central nervous system cancers, and all other solid tumors.

Dr. Hong said that the results indicate the importance of tumor profiling for the majority of patients, especially those whose disease is refractory to standard therapies.

The study was funded by Loxo Oncology. Dr. Hong disclosed receiving travel expenses from the company. Three coauthors are employees and shareholders of the company.

BOSTON – An experimental agent that targets the byproducts of gene fusions has shown surprising clinical activity against notoriously treatment-refractory cancers in early results from a phase I trial.

“I think that’s what remarkable about this is that we have all these different histologies and many different fusions, but all seem to be having some kind of [response] to this molecule,” said lead investigator Dr. David S. Hong, deputy chair and associate professor in the department of investigational cancer therapeutics at the University of Texas MD Anderson Cancer Center, Houston.

The molecule, LOXO-101 is a selective inhibitor of abnormal TRKA, TRKAB, and TRKC kinases that arise from gene fusions. TRK fusions have been implicated in tumor development in preclinical studies, he reported at the AACR–NCI–EORTC International Conference on Molecular Targets and Cancer Therapeutics.

One patient, a 41-year-old woman with undifferentiated soft tissue sarcoma of the groin that had metastasized to her lungs had rapid and “substantial” tumor and lung-nodule regression that radiographically fell just shy of a complete response, Dr. Hong said.

The drug also induced robust partial responses in a 55-year-old man with a gastrointestinal stromal tumor (GIST) for whom five prior targeted agents had failed, and a 33-year-old man with mammary analogue secretory carcinoma of the salivary gland (MASC) that had progressed on chemotherapy with docetaxel, carboplatin, and 5-fluorauracil.

A fourth patient, a man (age unspecified) who had papillary thyroid cancer with palpable lymphadenopathy, had no palpable nodes at 1-month follow-up, and appears to be responding to the drug, Dr. Hong added.

“This is really a dramatic example, I think, of a targeted therapy that is not histology specific, and this is another area in oncology where it’s new, and we’re just feeling our way,” commented Dr. Lee C. Helman, a sarcoma specialist at the National Cancer Institute in Bethesda, Md., who moderated the briefing where Dr. Hong presented the data.

Tumor promoters

The TRK family of proteins consists of separate tyrosine kinases that, when functioning normally, are important for the development of peripheral central nervous system processes such as pain and thermoregulation, Dr. Hong explained.

“The NTRK 1, 2, and 3 genes which encode for the TRK proteins are subject to these gene rearrangements and fusions, and the resulting TRK gene fusions may become erroneously expressed, and the kinase domain constitutively activated,” he said.

Gene fusions resulting in constitutively active TRKA, B, and C kinases can occur in the range of about 2%-25% in a wide variety of tumors, including adenocarcinomas of the lung, gliomas, thyroid tumors, head and neck cancers, sarcomas, and other types. These fusions have also been detected in more than 75% of MASC tumors, secretory breast carcinomas, and infantile (congenital) fibrosarcoma.

LOXO-101 is an orally delivered small molecule that was rationally designed to target the TRK fusions while largely leaving other kinases alone. In preclinical studies, the compound showed potent tumor growth inhibition and regression in mice bearing NTRK fusions.

The phase I trial is a dose-finding study including a total of 24 patients with various treatment-refractory advanced or metastatic solid tumors. Patients were enrolled regardless of fusional status.

Well tolerated

At the selected dose of 100 mg twice daily, patients appeared to tolerate the drug very well, with few off-target adverse events, Dr. Hong said. The most common side effect was mild dizziness. Grade 3 or 4 adverse events occurring at all doses levels include fatigue (one patient), anemia (two), abdominal pain (one), increased alkaline phosphatase (one), increased aspartate aminotransferase, delirium, and syncope (two each).

A total of six of the 24 patients had TRK fusions in their tumors, and three of these patients were available for assessment as of Oct. 20, 2015.

Dr. Hong and colleagues previously reportedon the case of the 41-year old woman with sarcoma. She was found to have a fusion of LMNA (a gene that encodes for nuclear membrane proteins) with NTRK1. She was started on the 100-mg b.i.d. dose of LOX-101 and had rapid resolution of dyspnea and hypoxemia. She had a confirmed partial response, and a CT scan showed that her multiple pulmonary nodules had regressed, with just a single, small disease site remaining at most recent follow-up. This patient continues on treatment and has been followed for more than 8 months.

The man with GIST had experienced disease progression while on therapy with imatinib, sunitinib, sorafenib, nilotinib, and regorafenib. He was treated in the 150-mg b.i.d. dose cohort, had a confirmed partial response, and remains on study after 4-plus months.

The third patient, the 33-year-old man with MASC, was assigned to the 100-mg b.i.d. dose. He too had a partial response, with radiologic evidence of substantial tumor shrinkage, and a persistent, tumor-related cough that disappeared after about 10 days of treatment, and remains on study after more than 3 months of follow-up.

The investigators have begun accruing patients for a phase II “basket” trial in adult patients with advanced or metastatic solid tumors displaying TRK fusions, including non–small cell lung cancers, thyroid tumors, sarcomas, colorectal cancer, salivary gland cancers, primary central nervous system cancers, and all other solid tumors.

Dr. Hong said that the results indicate the importance of tumor profiling for the majority of patients, especially those whose disease is refractory to standard therapies.

The study was funded by Loxo Oncology. Dr. Hong disclosed receiving travel expenses from the company. Three coauthors are employees and shareholders of the company.

LAKE BUENA VISTA, FLA. – Levothyroxine therapy during pregnancy in women with subclinical hypothyroidism was associated with a decrease in low birth weight and low Apgar scores but not with a significant decrease in pregnancy loss in a large retrospective cohort study.

In 79 pregnant women with subclinical hypothyroidism (SCH) who received therapy with levothyroxine (LT4), and 285 with SCH who did not receive LT4 therapy, the frequency of low birth weight (less than 2,500 g) was 1.3% vs. 10%, respectively, and the frequency of Apgar scores of 7 or less at 5 minutes was 0% vs. 6.9%, Dr. S. Maraka reported at the International Thyroid Congress.

The rate of pregnancy loss was clinically, but not significantly, lower in the treated group (5.1% vs. 8.8%), and there was no difference between the groups with respect to 11 other maternal and neonatal outcomes, Dr. Maraka of the Mayo Clinic, Rochester, Minn., said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Study subjects were women evaluated at the Mayo Clinic, Rochester, between January 2011 and December 2013, who had SCH during pregnancy. SCH was defined as thyroid stimulating hormone levels greater than 2.5 mIU/L during the first trimester, or greater than 3 mIU/L but no more than 10 mIU/L during the second and third trimesters. Those with a twin pregnancy or who used medications that might affect thyroid function were excluded.

The treated and untreated groups were similar with regard to age, history of pregnancy loss, and smoking status, but the treated group had higher body mass index and higher TSH levels, Dr. Maraka noted.

The findings that LT4 may improve pregnancy outcome in women with SCH are important because SCH has been associated with an increased risk of adverse pregnancy outcomes in some studies and it has been unclear whether LT4 therapy improves outcomes.

However, the association seen in the current study, which involves the largest cohort reporting pregnancy outcomes of women with SCH treated vs. untreated with LT4 therapy, requires confirmation in randomized trials before widespread use of LT4 therapy for SCH can be recommended, she concluded.

Dr. Maraka reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Levothyroxine therapy during pregnancy in women with subclinical hypothyroidism was associated with a decrease in low birth weight and low Apgar scores but not with a significant decrease in pregnancy loss in a large retrospective cohort study.

In 79 pregnant women with subclinical hypothyroidism (SCH) who received therapy with levothyroxine (LT4), and 285 with SCH who did not receive LT4 therapy, the frequency of low birth weight (less than 2,500 g) was 1.3% vs. 10%, respectively, and the frequency of Apgar scores of 7 or less at 5 minutes was 0% vs. 6.9%, Dr. S. Maraka reported at the International Thyroid Congress.

The rate of pregnancy loss was clinically, but not significantly, lower in the treated group (5.1% vs. 8.8%), and there was no difference between the groups with respect to 11 other maternal and neonatal outcomes, Dr. Maraka of the Mayo Clinic, Rochester, Minn., said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Study subjects were women evaluated at the Mayo Clinic, Rochester, between January 2011 and December 2013, who had SCH during pregnancy. SCH was defined as thyroid stimulating hormone levels greater than 2.5 mIU/L during the first trimester, or greater than 3 mIU/L but no more than 10 mIU/L during the second and third trimesters. Those with a twin pregnancy or who used medications that might affect thyroid function were excluded.

The treated and untreated groups were similar with regard to age, history of pregnancy loss, and smoking status, but the treated group had higher body mass index and higher TSH levels, Dr. Maraka noted.

The findings that LT4 may improve pregnancy outcome in women with SCH are important because SCH has been associated with an increased risk of adverse pregnancy outcomes in some studies and it has been unclear whether LT4 therapy improves outcomes.

However, the association seen in the current study, which involves the largest cohort reporting pregnancy outcomes of women with SCH treated vs. untreated with LT4 therapy, requires confirmation in randomized trials before widespread use of LT4 therapy for SCH can be recommended, she concluded.

Dr. Maraka reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Levothyroxine therapy during pregnancy in women with subclinical hypothyroidism was associated with a decrease in low birth weight and low Apgar scores but not with a significant decrease in pregnancy loss in a large retrospective cohort study.

In 79 pregnant women with subclinical hypothyroidism (SCH) who received therapy with levothyroxine (LT4), and 285 with SCH who did not receive LT4 therapy, the frequency of low birth weight (less than 2,500 g) was 1.3% vs. 10%, respectively, and the frequency of Apgar scores of 7 or less at 5 minutes was 0% vs. 6.9%, Dr. S. Maraka reported at the International Thyroid Congress.

The rate of pregnancy loss was clinically, but not significantly, lower in the treated group (5.1% vs. 8.8%), and there was no difference between the groups with respect to 11 other maternal and neonatal outcomes, Dr. Maraka of the Mayo Clinic, Rochester, Minn., said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Study subjects were women evaluated at the Mayo Clinic, Rochester, between January 2011 and December 2013, who had SCH during pregnancy. SCH was defined as thyroid stimulating hormone levels greater than 2.5 mIU/L during the first trimester, or greater than 3 mIU/L but no more than 10 mIU/L during the second and third trimesters. Those with a twin pregnancy or who used medications that might affect thyroid function were excluded.

The treated and untreated groups were similar with regard to age, history of pregnancy loss, and smoking status, but the treated group had higher body mass index and higher TSH levels, Dr. Maraka noted.

The findings that LT4 may improve pregnancy outcome in women with SCH are important because SCH has been associated with an increased risk of adverse pregnancy outcomes in some studies and it has been unclear whether LT4 therapy improves outcomes.

However, the association seen in the current study, which involves the largest cohort reporting pregnancy outcomes of women with SCH treated vs. untreated with LT4 therapy, requires confirmation in randomized trials before widespread use of LT4 therapy for SCH can be recommended, she concluded.

Dr. Maraka reported having no disclosures.

[email protected]

A 49-year-old woman presents to dermatology with a lesion on her back. It’s been there for at least 20 years, slowly growing to its present size; it is now so prominent that it shows through her clothes and is subject to traumatization. The visibility of the lesion, particularly when the patient wears a swimsuit, is a source of considerable embarrassment.

Notable medical history includes polycystic ovarian syndrome and related diabetes and dyslipidemia. Family history reveals that the patient’s mother died of heart disease in her 40s.

EXAMINATION
The lesion, which measures 3 cm x 3 cm, is an impressive, pedunculated, doughy, rubbery, skin-colored mass protruding from her left mid back. No redness or edema is seen on or around the lesion. On palpation, the lesion is found to be uniformly soft and rubbery.

The patient is quite obese and has numerous skin tags in skin folds, under the arms, and around the neck.

What is the diagnosis?

DISCUSSION
The lesion was excised with deep margins and submitted to pathology. The report showed benign histology, consistent with a fibroepitheliomatous polyp.

In one sense, it’s hard to believe this huge lesion was a “skin tag,” and there are other things it might have been. But the microscopic examination of the tissue proved it was simply a large version of the same skin tags we see around necks and in axillae. These lesions are known by various names, including fibroepitheliomatous polyps (FEP) and acrochordons. A more typical FEP would be the size of a grain of rice, but they can take on various forms and sizes.

There is a differential for lesions that look like FEPs; it includes seborrheic  keratoses, warts, molluscum contagiosum, neurofibromas, and fibrolipomas. Even melanoma and squamous cell carcinoma can assume a tag-like morphology. So it pays to take a close look at these lesions, checking to see if they’re soft and pliable, as well as skin colored. With any odd feature, including increased size, they need to be removed and sent for pathologic examination.

Heredity appears to play a role in the development of FEPs, as do age and obesity. There are studies showing an association between FEPs and insulin resistance and others identifying FEPs as a marker for increased risk for atherosclerotic vessel disease. In any case, 59% of the population has them by age 70, with men and women affected equally. Of the general population, 46% has some sort of skin tag somewhere.

Treatment may entail cryotherapy, excision, or electrodessication. With lesions as large as the case patient’s, excision is the only reasonable option. Deep margins are required, since a “shave” would leave a gaping, open wound. For the case patient, there was no postoperative sequelae aside from some scarring.

TAKE-HOME LEARNING POINTS
• Skin tags, also known as fibroepitheliomas, fibroepitheliomatous polyps, or acrochordons, are typically the size of a grain of rice, and tend to appear in skin folds (eg, axillae, neck, groin).

• Studies have shown that there may be an association between having skin tags and developing CAD or insulin resistance.

• Obesity, age, and heredity also appear to be factors in developing skin tags.

• Large or odd tags need to be captured and sent for pathologic examination.

• Skin tags are extremely common, affecting 59% of the population older than 70. 

A 49-year-old woman presents to dermatology with a lesion on her back. It’s been there for at least 20 years, slowly growing to its present size; it is now so prominent that it shows through her clothes and is subject to traumatization. The visibility of the lesion, particularly when the patient wears a swimsuit, is a source of considerable embarrassment.

Notable medical history includes polycystic ovarian syndrome and related diabetes and dyslipidemia. Family history reveals that the patient’s mother died of heart disease in her 40s.

EXAMINATION
The lesion, which measures 3 cm x 3 cm, is an impressive, pedunculated, doughy, rubbery, skin-colored mass protruding from her left mid back. No redness or edema is seen on or around the lesion. On palpation, the lesion is found to be uniformly soft and rubbery.

The patient is quite obese and has numerous skin tags in skin folds, under the arms, and around the neck.

What is the diagnosis?

DISCUSSION
The lesion was excised with deep margins and submitted to pathology. The report showed benign histology, consistent with a fibroepitheliomatous polyp.

In one sense, it’s hard to believe this huge lesion was a “skin tag,” and there are other things it might have been. But the microscopic examination of the tissue proved it was simply a large version of the same skin tags we see around necks and in axillae. These lesions are known by various names, including fibroepitheliomatous polyps (FEP) and acrochordons. A more typical FEP would be the size of a grain of rice, but they can take on various forms and sizes.

There is a differential for lesions that look like FEPs; it includes seborrheic  keratoses, warts, molluscum contagiosum, neurofibromas, and fibrolipomas. Even melanoma and squamous cell carcinoma can assume a tag-like morphology. So it pays to take a close look at these lesions, checking to see if they’re soft and pliable, as well as skin colored. With any odd feature, including increased size, they need to be removed and sent for pathologic examination.

Heredity appears to play a role in the development of FEPs, as do age and obesity. There are studies showing an association between FEPs and insulin resistance and others identifying FEPs as a marker for increased risk for atherosclerotic vessel disease. In any case, 59% of the population has them by age 70, with men and women affected equally. Of the general population, 46% has some sort of skin tag somewhere.

Treatment may entail cryotherapy, excision, or electrodessication. With lesions as large as the case patient’s, excision is the only reasonable option. Deep margins are required, since a “shave” would leave a gaping, open wound. For the case patient, there was no postoperative sequelae aside from some scarring.

TAKE-HOME LEARNING POINTS
• Skin tags, also known as fibroepitheliomas, fibroepitheliomatous polyps, or acrochordons, are typically the size of a grain of rice, and tend to appear in skin folds (eg, axillae, neck, groin).

• Studies have shown that there may be an association between having skin tags and developing CAD or insulin resistance.

• Obesity, age, and heredity also appear to be factors in developing skin tags.

• Large or odd tags need to be captured and sent for pathologic examination.

• Skin tags are extremely common, affecting 59% of the population older than 70. 

A 49-year-old woman presents to dermatology with a lesion on her back. It’s been there for at least 20 years, slowly growing to its present size; it is now so prominent that it shows through her clothes and is subject to traumatization. The visibility of the lesion, particularly when the patient wears a swimsuit, is a source of considerable embarrassment.

Notable medical history includes polycystic ovarian syndrome and related diabetes and dyslipidemia. Family history reveals that the patient’s mother died of heart disease in her 40s.

EXAMINATION
The lesion, which measures 3 cm x 3 cm, is an impressive, pedunculated, doughy, rubbery, skin-colored mass protruding from her left mid back. No redness or edema is seen on or around the lesion. On palpation, the lesion is found to be uniformly soft and rubbery.

The patient is quite obese and has numerous skin tags in skin folds, under the arms, and around the neck.

What is the diagnosis?

DISCUSSION
The lesion was excised with deep margins and submitted to pathology. The report showed benign histology, consistent with a fibroepitheliomatous polyp.

In one sense, it’s hard to believe this huge lesion was a “skin tag,” and there are other things it might have been. But the microscopic examination of the tissue proved it was simply a large version of the same skin tags we see around necks and in axillae. These lesions are known by various names, including fibroepitheliomatous polyps (FEP) and acrochordons. A more typical FEP would be the size of a grain of rice, but they can take on various forms and sizes.

There is a differential for lesions that look like FEPs; it includes seborrheic  keratoses, warts, molluscum contagiosum, neurofibromas, and fibrolipomas. Even melanoma and squamous cell carcinoma can assume a tag-like morphology. So it pays to take a close look at these lesions, checking to see if they’re soft and pliable, as well as skin colored. With any odd feature, including increased size, they need to be removed and sent for pathologic examination.

Heredity appears to play a role in the development of FEPs, as do age and obesity. There are studies showing an association between FEPs and insulin resistance and others identifying FEPs as a marker for increased risk for atherosclerotic vessel disease. In any case, 59% of the population has them by age 70, with men and women affected equally. Of the general population, 46% has some sort of skin tag somewhere.

Treatment may entail cryotherapy, excision, or electrodessication. With lesions as large as the case patient’s, excision is the only reasonable option. Deep margins are required, since a “shave” would leave a gaping, open wound. For the case patient, there was no postoperative sequelae aside from some scarring.

TAKE-HOME LEARNING POINTS
• Skin tags, also known as fibroepitheliomas, fibroepitheliomatous polyps, or acrochordons, are typically the size of a grain of rice, and tend to appear in skin folds (eg, axillae, neck, groin).

• Studies have shown that there may be an association between having skin tags and developing CAD or insulin resistance.

• Obesity, age, and heredity also appear to be factors in developing skin tags.

• Large or odd tags need to be captured and sent for pathologic examination.

• Skin tags are extremely common, affecting 59% of the population older than 70. 

SAN DIEGO – Empagliflozin used in conjunction with standard of care significantly improved renal outcomes in adults with type 2 diabetes, results from a large randomized trial showed.

“These benefits were consistent among patients with and without chronic kidney disease at baseline,” Dr. Christoph Wanner said at the annual meeting of the American Society of Nephrology.

Previous studies have demonstrated that in patients with type 2 diabetes, empagliflozin, an inhibitor of the sodium glucose cotransporter 2 in the kidney, leads to significant reductions in hemoglobin A_1c, weight loss, and reductions in blood pressure without increases in heart rate. Developed by Boehringer Ingelheim and Eli Lilly, the drug was approved in 2014 for the treatment of type 2 diabetes in adults. At the meeting Dr. Wanner presented new finding results from the EMPA-REG OUTCOME trial, which was published in September 2015. That study found that patients with type 2 diabetes at high risk for cardiovascular events who received empagliflozin, compared with placebo, had a lower rate of the primary composite cardiovascular outcome and death from any cause when the study drug was added to standard care.

For the current analysis, the researchers evaluated renal outcomes in the study participants, which consisted of new-onset or worsening nephropathy, including new onset of macroalbuminuria (defined as a urine albumin to creatinine ratio (UACR) of greater than 300 mg/g); doubling of serum creatinine accompanied by an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73m² or less; initiation of renal replacement therapy; or death due to renal disease. There was also a composite outcome of doubling of serum creatinine, initiation of renal replacement therapy, or death due to renal disease.

The EMPA-REG OUTCOME trial included 2,333 patients in the placebo group and 4,687 in the empagliflozin group who were followed for a median observation time of 3.1 years. The mean age of the study participants was 63 years and 71% were male. Compared with patients in the placebo group, those in the empagliflozin group demonstrated a 39% reduction in new-onset or worsening of nephropathy (hazard ratio, 0.61; P less than .0001). The reduction “started very early,” said Dr. Wanner, who is professor of medicine and head of nephrology at University Hospital of Wurzburg, Germany. “After 3 months you see the curves [between the placebo and treatment groups] separating.”

The impact on empagliflozin on the composite outcome of doubling of serum creatinine, initiation of renal replacement therapy, or death due to renal disease was even more profound. Compared with patients in the placebo group, those in the empagliflozin demonstrated a 46% reduced risk in the composite outcome (HR, 0.54; P = .0002).

Dr. Wanner went on to present cardiovascular outcomes in patients with chronic kidney disease (CKD). Among those with an eGFR of less than 60 mL/min/1.73m² at baseline, the primary outcome of three-point major adverse cardiac events occurred in 176 of 1,212 patients in the empagliflozin group (15%), compared with 99 of 607 patients in the placebo group (16%; HR, 0.88). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, the primary outcome of three-point major adverse cardiac events occurred in 314 of 3,473 patients in the empagliflozin group (9%), compared with 183 of 1,726 (11%) patients in the placebo group (HR, 0.84). At the same time, the outcome of cardiovascular death occurred in 75 of 1,212 patients in the empagliflozin group (6%), compared with 48 of 607 patients in the placebo group (8%; HR, 0.78). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, cardiovascular death occurred in 97 of 3,473 patients in the empagliflozin group (3%), compared with 89 of 1,726 patients in the placebo group (5%; HR, 0.53). However, there was no detectable benefit for the study medication in reducing the myocardial infarction or stroke in patients with CKD.

Among those with an eGFR of less than 60 mL/min/1.73m² at baseline, hospitalization for heart failure occurred in 51 of 1,212 patients in the empagliflozin group (4%), compared with 43 of 607 patients in the placebo group (7%; HR, 0.59). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, hospitalization for heart failure occurred in 75 of 3,473 patients in the empagliflozin group (2%), compared with 52 of 1,726 patients in the placebo group (3%; HR, 0.70). At the same time, all-cause mortality occurred in 115 of 1,212 patients in the empagliflozin group (9%), compared with 72 of 607 patients in the placebo group (12%; HR, 0.80). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, hospitalization for heart failure occurred in 154 of 3,473 patients in the empagliflozin group (4%), compared with 122 of 1,726 patients in the placebo group (7%; HR, 0.62).

The most common adverse events in patients with CKD related to the study drug were urinary tract infections and genital infections, but there were no detectable signals on acute kidney failure, hyperkalemia, or bone fracture.

“Empagliflozin reduces cardiovascular death, all-cause mortality, and hospitalization for heart failure in patients with type 2 diabetes at high cardiovascular risk,” Dr. Wanner concluded. “Safety and tolerability of empagliflozin in patients with CKD at baseline were similar to the overall trial population and consistent with previous clinical trials.”

The study was supported by Boehringer Ingelheim and Eli Lilly. Dr. Wanner disclosed numerous financial ties to industry.

[email protected]

SAN DIEGO – Empagliflozin used in conjunction with standard of care significantly improved renal outcomes in adults with type 2 diabetes, results from a large randomized trial showed.

“These benefits were consistent among patients with and without chronic kidney disease at baseline,” Dr. Christoph Wanner said at the annual meeting of the American Society of Nephrology.

Previous studies have demonstrated that in patients with type 2 diabetes, empagliflozin, an inhibitor of the sodium glucose cotransporter 2 in the kidney, leads to significant reductions in hemoglobin A_1c, weight loss, and reductions in blood pressure without increases in heart rate. Developed by Boehringer Ingelheim and Eli Lilly, the drug was approved in 2014 for the treatment of type 2 diabetes in adults. At the meeting Dr. Wanner presented new finding results from the EMPA-REG OUTCOME trial, which was published in September 2015. That study found that patients with type 2 diabetes at high risk for cardiovascular events who received empagliflozin, compared with placebo, had a lower rate of the primary composite cardiovascular outcome and death from any cause when the study drug was added to standard care.

For the current analysis, the researchers evaluated renal outcomes in the study participants, which consisted of new-onset or worsening nephropathy, including new onset of macroalbuminuria (defined as a urine albumin to creatinine ratio (UACR) of greater than 300 mg/g); doubling of serum creatinine accompanied by an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73m² or less; initiation of renal replacement therapy; or death due to renal disease. There was also a composite outcome of doubling of serum creatinine, initiation of renal replacement therapy, or death due to renal disease.

The EMPA-REG OUTCOME trial included 2,333 patients in the placebo group and 4,687 in the empagliflozin group who were followed for a median observation time of 3.1 years. The mean age of the study participants was 63 years and 71% were male. Compared with patients in the placebo group, those in the empagliflozin group demonstrated a 39% reduction in new-onset or worsening of nephropathy (hazard ratio, 0.61; P less than .0001). The reduction “started very early,” said Dr. Wanner, who is professor of medicine and head of nephrology at University Hospital of Wurzburg, Germany. “After 3 months you see the curves [between the placebo and treatment groups] separating.”

The impact on empagliflozin on the composite outcome of doubling of serum creatinine, initiation of renal replacement therapy, or death due to renal disease was even more profound. Compared with patients in the placebo group, those in the empagliflozin demonstrated a 46% reduced risk in the composite outcome (HR, 0.54; P = .0002).

Dr. Wanner went on to present cardiovascular outcomes in patients with chronic kidney disease (CKD). Among those with an eGFR of less than 60 mL/min/1.73m² at baseline, the primary outcome of three-point major adverse cardiac events occurred in 176 of 1,212 patients in the empagliflozin group (15%), compared with 99 of 607 patients in the placebo group (16%; HR, 0.88). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, the primary outcome of three-point major adverse cardiac events occurred in 314 of 3,473 patients in the empagliflozin group (9%), compared with 183 of 1,726 (11%) patients in the placebo group (HR, 0.84). At the same time, the outcome of cardiovascular death occurred in 75 of 1,212 patients in the empagliflozin group (6%), compared with 48 of 607 patients in the placebo group (8%; HR, 0.78). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, cardiovascular death occurred in 97 of 3,473 patients in the empagliflozin group (3%), compared with 89 of 1,726 patients in the placebo group (5%; HR, 0.53). However, there was no detectable benefit for the study medication in reducing the myocardial infarction or stroke in patients with CKD.

Among those with an eGFR of less than 60 mL/min/1.73m² at baseline, hospitalization for heart failure occurred in 51 of 1,212 patients in the empagliflozin group (4%), compared with 43 of 607 patients in the placebo group (7%; HR, 0.59). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, hospitalization for heart failure occurred in 75 of 3,473 patients in the empagliflozin group (2%), compared with 52 of 1,726 patients in the placebo group (3%; HR, 0.70). At the same time, all-cause mortality occurred in 115 of 1,212 patients in the empagliflozin group (9%), compared with 72 of 607 patients in the placebo group (12%; HR, 0.80). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, hospitalization for heart failure occurred in 154 of 3,473 patients in the empagliflozin group (4%), compared with 122 of 1,726 patients in the placebo group (7%; HR, 0.62).

The most common adverse events in patients with CKD related to the study drug were urinary tract infections and genital infections, but there were no detectable signals on acute kidney failure, hyperkalemia, or bone fracture.

“Empagliflozin reduces cardiovascular death, all-cause mortality, and hospitalization for heart failure in patients with type 2 diabetes at high cardiovascular risk,” Dr. Wanner concluded. “Safety and tolerability of empagliflozin in patients with CKD at baseline were similar to the overall trial population and consistent with previous clinical trials.”

The study was supported by Boehringer Ingelheim and Eli Lilly. Dr. Wanner disclosed numerous financial ties to industry.

[email protected]

SAN DIEGO – Empagliflozin used in conjunction with standard of care significantly improved renal outcomes in adults with type 2 diabetes, results from a large randomized trial showed.

“These benefits were consistent among patients with and without chronic kidney disease at baseline,” Dr. Christoph Wanner said at the annual meeting of the American Society of Nephrology.

Previous studies have demonstrated that in patients with type 2 diabetes, empagliflozin, an inhibitor of the sodium glucose cotransporter 2 in the kidney, leads to significant reductions in hemoglobin A_1c, weight loss, and reductions in blood pressure without increases in heart rate. Developed by Boehringer Ingelheim and Eli Lilly, the drug was approved in 2014 for the treatment of type 2 diabetes in adults. At the meeting Dr. Wanner presented new finding results from the EMPA-REG OUTCOME trial, which was published in September 2015. That study found that patients with type 2 diabetes at high risk for cardiovascular events who received empagliflozin, compared with placebo, had a lower rate of the primary composite cardiovascular outcome and death from any cause when the study drug was added to standard care.

For the current analysis, the researchers evaluated renal outcomes in the study participants, which consisted of new-onset or worsening nephropathy, including new onset of macroalbuminuria (defined as a urine albumin to creatinine ratio (UACR) of greater than 300 mg/g); doubling of serum creatinine accompanied by an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73m² or less; initiation of renal replacement therapy; or death due to renal disease. There was also a composite outcome of doubling of serum creatinine, initiation of renal replacement therapy, or death due to renal disease.

The EMPA-REG OUTCOME trial included 2,333 patients in the placebo group and 4,687 in the empagliflozin group who were followed for a median observation time of 3.1 years. The mean age of the study participants was 63 years and 71% were male. Compared with patients in the placebo group, those in the empagliflozin group demonstrated a 39% reduction in new-onset or worsening of nephropathy (hazard ratio, 0.61; P less than .0001). The reduction “started very early,” said Dr. Wanner, who is professor of medicine and head of nephrology at University Hospital of Wurzburg, Germany. “After 3 months you see the curves [between the placebo and treatment groups] separating.”

The impact on empagliflozin on the composite outcome of doubling of serum creatinine, initiation of renal replacement therapy, or death due to renal disease was even more profound. Compared with patients in the placebo group, those in the empagliflozin demonstrated a 46% reduced risk in the composite outcome (HR, 0.54; P = .0002).

Dr. Wanner went on to present cardiovascular outcomes in patients with chronic kidney disease (CKD). Among those with an eGFR of less than 60 mL/min/1.73m² at baseline, the primary outcome of three-point major adverse cardiac events occurred in 176 of 1,212 patients in the empagliflozin group (15%), compared with 99 of 607 patients in the placebo group (16%; HR, 0.88). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, the primary outcome of three-point major adverse cardiac events occurred in 314 of 3,473 patients in the empagliflozin group (9%), compared with 183 of 1,726 (11%) patients in the placebo group (HR, 0.84). At the same time, the outcome of cardiovascular death occurred in 75 of 1,212 patients in the empagliflozin group (6%), compared with 48 of 607 patients in the placebo group (8%; HR, 0.78). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, cardiovascular death occurred in 97 of 3,473 patients in the empagliflozin group (3%), compared with 89 of 1,726 patients in the placebo group (5%; HR, 0.53). However, there was no detectable benefit for the study medication in reducing the myocardial infarction or stroke in patients with CKD.

Among those with an eGFR of less than 60 mL/min/1.73m² at baseline, hospitalization for heart failure occurred in 51 of 1,212 patients in the empagliflozin group (4%), compared with 43 of 607 patients in the placebo group (7%; HR, 0.59). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, hospitalization for heart failure occurred in 75 of 3,473 patients in the empagliflozin group (2%), compared with 52 of 1,726 patients in the placebo group (3%; HR, 0.70). At the same time, all-cause mortality occurred in 115 of 1,212 patients in the empagliflozin group (9%), compared with 72 of 607 patients in the placebo group (12%; HR, 0.80). Among those with an eGFR of 60 mL/min/1.73m² or greater at baseline, hospitalization for heart failure occurred in 154 of 3,473 patients in the empagliflozin group (4%), compared with 122 of 1,726 patients in the placebo group (7%; HR, 0.62).

The most common adverse events in patients with CKD related to the study drug were urinary tract infections and genital infections, but there were no detectable signals on acute kidney failure, hyperkalemia, or bone fracture.

“Empagliflozin reduces cardiovascular death, all-cause mortality, and hospitalization for heart failure in patients with type 2 diabetes at high cardiovascular risk,” Dr. Wanner concluded. “Safety and tolerability of empagliflozin in patients with CKD at baseline were similar to the overall trial population and consistent with previous clinical trials.”

The study was supported by Boehringer Ingelheim and Eli Lilly. Dr. Wanner disclosed numerous financial ties to industry.

[email protected]

NEW YORK - Initiation of antipsychotic or antidepressant drug treatment is linked to a reduction in hospitalizations for patients with schizophrenia, according to a new study.

"Use of sulpiride, mirtazapine, venlafaxine, and clozapine-aripiprazole and clozapine amisulpride combinations were associated with fewer subsequent admission-days in patients with schizophrenia," Dr. Rudolf N. Cardinal of the Behavioral and Clinical Neuroscience Institute, University of Cambridge, UK, said by email.

"These studies are correlative and do not prove causation," he cautioned.

Dr. Cardinal and colleagues analyzed eight years' of admission records at a secondary mental health care institution in Cambridgeshire. The analysis included nearly 1,500 patients with a diagnosis of schizophrenia and a median follow-up of five years.

In mirror-image analysis covering two years before and after therapy initiation, the researchers found treatment with amisulpride, aripiprazole, clozapine, fluoxetine, mirtazapine, olanzapine, quetiapine, and sulpiride was associated with fewer subsequent admissions in one year.

The association persisted in a "more stringent" two-year analysis for aripiprazole, clozapine, and sulpiride.

Using regression analysis, the researchers found a continued reduction in admissions with sulpiride and mirtazapine (estimated mean change, -20.4 and -11.6 days/year, respectively).

Treatment with clozapine-aripiprazole and clozapine-amisulpride combinations as well as venlafaxine was associated with significantly fewer hospitalized days (-17.7, -13.8, and -12.3 days/year, respectively).

Overall, the mean admission rate was 26.8 days/year.

"This analysis focused on patients with more severe disease, in that they had at least one hospital admission in the pre-drug period," the researchers note in the article online October 21 in NPJ Schizophrenia.

"Larger correlative studies are required to corroborate these effects, followed by randomized controlled trials if appropriate," Dr. Cardinal said. "We are all very keen that these are not misrepresented as causal-grade findings."

The authors reported no funding. One coauthor reported receiving research funding from Genus Pharmaceuticals and consulting fees from Roche/Genentech.

NEW YORK - Initiation of antipsychotic or antidepressant drug treatment is linked to a reduction in hospitalizations for patients with schizophrenia, according to a new study.

"Use of sulpiride, mirtazapine, venlafaxine, and clozapine-aripiprazole and clozapine amisulpride combinations were associated with fewer subsequent admission-days in patients with schizophrenia," Dr. Rudolf N. Cardinal of the Behavioral and Clinical Neuroscience Institute, University of Cambridge, UK, said by email.

"These studies are correlative and do not prove causation," he cautioned.

Dr. Cardinal and colleagues analyzed eight years' of admission records at a secondary mental health care institution in Cambridgeshire. The analysis included nearly 1,500 patients with a diagnosis of schizophrenia and a median follow-up of five years.

In mirror-image analysis covering two years before and after therapy initiation, the researchers found treatment with amisulpride, aripiprazole, clozapine, fluoxetine, mirtazapine, olanzapine, quetiapine, and sulpiride was associated with fewer subsequent admissions in one year.

The association persisted in a "more stringent" two-year analysis for aripiprazole, clozapine, and sulpiride.

Using regression analysis, the researchers found a continued reduction in admissions with sulpiride and mirtazapine (estimated mean change, -20.4 and -11.6 days/year, respectively).

Treatment with clozapine-aripiprazole and clozapine-amisulpride combinations as well as venlafaxine was associated with significantly fewer hospitalized days (-17.7, -13.8, and -12.3 days/year, respectively).

Overall, the mean admission rate was 26.8 days/year.

"This analysis focused on patients with more severe disease, in that they had at least one hospital admission in the pre-drug period," the researchers note in the article online October 21 in NPJ Schizophrenia.

"Larger correlative studies are required to corroborate these effects, followed by randomized controlled trials if appropriate," Dr. Cardinal said. "We are all very keen that these are not misrepresented as causal-grade findings."

The authors reported no funding. One coauthor reported receiving research funding from Genus Pharmaceuticals and consulting fees from Roche/Genentech.

NEW YORK - Initiation of antipsychotic or antidepressant drug treatment is linked to a reduction in hospitalizations for patients with schizophrenia, according to a new study.

"Use of sulpiride, mirtazapine, venlafaxine, and clozapine-aripiprazole and clozapine amisulpride combinations were associated with fewer subsequent admission-days in patients with schizophrenia," Dr. Rudolf N. Cardinal of the Behavioral and Clinical Neuroscience Institute, University of Cambridge, UK, said by email.

"These studies are correlative and do not prove causation," he cautioned.

Dr. Cardinal and colleagues analyzed eight years' of admission records at a secondary mental health care institution in Cambridgeshire. The analysis included nearly 1,500 patients with a diagnosis of schizophrenia and a median follow-up of five years.

In mirror-image analysis covering two years before and after therapy initiation, the researchers found treatment with amisulpride, aripiprazole, clozapine, fluoxetine, mirtazapine, olanzapine, quetiapine, and sulpiride was associated with fewer subsequent admissions in one year.

The association persisted in a "more stringent" two-year analysis for aripiprazole, clozapine, and sulpiride.

Using regression analysis, the researchers found a continued reduction in admissions with sulpiride and mirtazapine (estimated mean change, -20.4 and -11.6 days/year, respectively).

Treatment with clozapine-aripiprazole and clozapine-amisulpride combinations as well as venlafaxine was associated with significantly fewer hospitalized days (-17.7, -13.8, and -12.3 days/year, respectively).

Overall, the mean admission rate was 26.8 days/year.

"This analysis focused on patients with more severe disease, in that they had at least one hospital admission in the pre-drug period," the researchers note in the article online October 21 in NPJ Schizophrenia.

"Larger correlative studies are required to corroborate these effects, followed by randomized controlled trials if appropriate," Dr. Cardinal said. "We are all very keen that these are not misrepresented as causal-grade findings."

The authors reported no funding. One coauthor reported receiving research funding from Genus Pharmaceuticals and consulting fees from Roche/Genentech.

LAKE BUENA VISTA, FLA. – Rapidly enlarging thyroid masses with compressive symptoms may signal thyroid lymphoma, according to findings from a review of cases at the Mayo Clinic.

Radiologically, these masses tend to present as large, unilateral, thyroid-centered masses that are hypoechoic on ultrasound and that expand into adjacent soft tissue, Dr. Anu Sharma reported at the International Thyroid Congress.

The findings are based on a review of 75 patients with biopsy-proven thyroid lymphoma – a relatively rare disease, accounting for between 1% and 5% of all thyroid malignancies, and less than 1% of all lymphomas – who presented to the Mayo Clinic between 2000 and 2014.

“Thyroid lymphoma can sometimes present very similar to anaplastic carcinoma, and we wanted to see if there are any unique identification factors that you can use to increase your suspicion of thyroid lymphoma,” Dr. Sharma of the Mayo Clinic, Rochester, Minn., said.

Indeed, rapid enlargement and compressive symptoms are also common presenting features of anaplastic carcinoma, she said.

Of the 75 cases included in the review – compromising all cases presenting during the study period – 70.7% involved primary thyroid lymphoma. A neck mass was present in 88% of cases, dysphagia in 45%, and hoarseness in 37%.

The typical presentation included a solid, hypoechoic mass with mildly increased vascularity, no internal calcifications, and edge characteristics that ranged from well-defined (80%) to ill-defined (20%). Median tumor volume was 64 cm³, Dr. Sharma said.

This differs from anaplastic carcinoma in that most patients with anaplastic carcinoma have ill-defined edges, she noted.

Another difference between thyroid lymphoma and anaplastic carcinoma as noted in this study involves necrosis; none of the patients in the current study had areas of necrosis, whereas 78% of anaplastic carcinoma patients in another study had areas of necrosis, she explained.

The patients in the current study had a median age of 67 years, although the ages varied widely. About half (50.7%) were men, and 54.7% had a history of Hashimoto’s thyroiditis. Fifty-seven of the patients had an ultrasound before treatment.

The first diagnostic procedure performed was fine needle aspiration (FNA) in 65 subjects, and the FNA biopsies were abnormal in 69% of those, with 42% suggesting a specific lymphoma subtype. The subtype diagnosis was accurate, based on final tissue analysis, in 89% of those.

“While this is quite impressive, all patients who had FNA ended up having further tissue biopsy for subtype confirmation and for treatment, and this is important, because the subtype of the lymphoma is important in determining the type of treatment uses as well as determining prognosis,” she said.

The diagnosis was confirmed by core biopsy in 46.7% of cases, by incisional biopsy in 9.3%, by partial or total thyroidectomy in 25.3%, and by lymph node biopsy in 13.3%; percentages total 94.6% due to downward rounding. Histologic subtypes included diffuse large B-cell lymphoma (DLBCL) in 73.3% of cases, follicular lymphoma in 5.3%, mucosa-associated lymphoid tissue (MALT) in 10.7%, MALT/DLBCL in 2.6%, T-cell lymphoma in 2.6%, and Hodgkin’s lymphoma in 1.3%; percentages total 95.8% rather than 100% due to downward rounding.

In addition to rapid enlargement of a neck mass with compressive symptoms, findings that should raise suspicion of thyroid lymphoma include a history of Hashimoto’s thyroiditis and the ultrasound findings characterized by this study, Dr. Sharma said.

“Once you have that increased suspicion, you should move toward going to core biopsy rather than FNA to save the patient from having two diagnostic steps rather than one,” she concluded.

Dr. Sharma reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Rapidly enlarging thyroid masses with compressive symptoms may signal thyroid lymphoma, according to findings from a review of cases at the Mayo Clinic.

Radiologically, these masses tend to present as large, unilateral, thyroid-centered masses that are hypoechoic on ultrasound and that expand into adjacent soft tissue, Dr. Anu Sharma reported at the International Thyroid Congress.

The findings are based on a review of 75 patients with biopsy-proven thyroid lymphoma – a relatively rare disease, accounting for between 1% and 5% of all thyroid malignancies, and less than 1% of all lymphomas – who presented to the Mayo Clinic between 2000 and 2014.

“Thyroid lymphoma can sometimes present very similar to anaplastic carcinoma, and we wanted to see if there are any unique identification factors that you can use to increase your suspicion of thyroid lymphoma,” Dr. Sharma of the Mayo Clinic, Rochester, Minn., said.

Indeed, rapid enlargement and compressive symptoms are also common presenting features of anaplastic carcinoma, she said.

Of the 75 cases included in the review – compromising all cases presenting during the study period – 70.7% involved primary thyroid lymphoma. A neck mass was present in 88% of cases, dysphagia in 45%, and hoarseness in 37%.

The typical presentation included a solid, hypoechoic mass with mildly increased vascularity, no internal calcifications, and edge characteristics that ranged from well-defined (80%) to ill-defined (20%). Median tumor volume was 64 cm³, Dr. Sharma said.

This differs from anaplastic carcinoma in that most patients with anaplastic carcinoma have ill-defined edges, she noted.

Another difference between thyroid lymphoma and anaplastic carcinoma as noted in this study involves necrosis; none of the patients in the current study had areas of necrosis, whereas 78% of anaplastic carcinoma patients in another study had areas of necrosis, she explained.

The patients in the current study had a median age of 67 years, although the ages varied widely. About half (50.7%) were men, and 54.7% had a history of Hashimoto’s thyroiditis. Fifty-seven of the patients had an ultrasound before treatment.

The first diagnostic procedure performed was fine needle aspiration (FNA) in 65 subjects, and the FNA biopsies were abnormal in 69% of those, with 42% suggesting a specific lymphoma subtype. The subtype diagnosis was accurate, based on final tissue analysis, in 89% of those.

“While this is quite impressive, all patients who had FNA ended up having further tissue biopsy for subtype confirmation and for treatment, and this is important, because the subtype of the lymphoma is important in determining the type of treatment uses as well as determining prognosis,” she said.

The diagnosis was confirmed by core biopsy in 46.7% of cases, by incisional biopsy in 9.3%, by partial or total thyroidectomy in 25.3%, and by lymph node biopsy in 13.3%; percentages total 94.6% due to downward rounding. Histologic subtypes included diffuse large B-cell lymphoma (DLBCL) in 73.3% of cases, follicular lymphoma in 5.3%, mucosa-associated lymphoid tissue (MALT) in 10.7%, MALT/DLBCL in 2.6%, T-cell lymphoma in 2.6%, and Hodgkin’s lymphoma in 1.3%; percentages total 95.8% rather than 100% due to downward rounding.

In addition to rapid enlargement of a neck mass with compressive symptoms, findings that should raise suspicion of thyroid lymphoma include a history of Hashimoto’s thyroiditis and the ultrasound findings characterized by this study, Dr. Sharma said.

“Once you have that increased suspicion, you should move toward going to core biopsy rather than FNA to save the patient from having two diagnostic steps rather than one,” she concluded.

Dr. Sharma reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Rapidly enlarging thyroid masses with compressive symptoms may signal thyroid lymphoma, according to findings from a review of cases at the Mayo Clinic.

Radiologically, these masses tend to present as large, unilateral, thyroid-centered masses that are hypoechoic on ultrasound and that expand into adjacent soft tissue, Dr. Anu Sharma reported at the International Thyroid Congress.

The findings are based on a review of 75 patients with biopsy-proven thyroid lymphoma – a relatively rare disease, accounting for between 1% and 5% of all thyroid malignancies, and less than 1% of all lymphomas – who presented to the Mayo Clinic between 2000 and 2014.

“Thyroid lymphoma can sometimes present very similar to anaplastic carcinoma, and we wanted to see if there are any unique identification factors that you can use to increase your suspicion of thyroid lymphoma,” Dr. Sharma of the Mayo Clinic, Rochester, Minn., said.

Indeed, rapid enlargement and compressive symptoms are also common presenting features of anaplastic carcinoma, she said.

Of the 75 cases included in the review – compromising all cases presenting during the study period – 70.7% involved primary thyroid lymphoma. A neck mass was present in 88% of cases, dysphagia in 45%, and hoarseness in 37%.

The typical presentation included a solid, hypoechoic mass with mildly increased vascularity, no internal calcifications, and edge characteristics that ranged from well-defined (80%) to ill-defined (20%). Median tumor volume was 64 cm³, Dr. Sharma said.

This differs from anaplastic carcinoma in that most patients with anaplastic carcinoma have ill-defined edges, she noted.

Another difference between thyroid lymphoma and anaplastic carcinoma as noted in this study involves necrosis; none of the patients in the current study had areas of necrosis, whereas 78% of anaplastic carcinoma patients in another study had areas of necrosis, she explained.

The patients in the current study had a median age of 67 years, although the ages varied widely. About half (50.7%) were men, and 54.7% had a history of Hashimoto’s thyroiditis. Fifty-seven of the patients had an ultrasound before treatment.

The first diagnostic procedure performed was fine needle aspiration (FNA) in 65 subjects, and the FNA biopsies were abnormal in 69% of those, with 42% suggesting a specific lymphoma subtype. The subtype diagnosis was accurate, based on final tissue analysis, in 89% of those.

“While this is quite impressive, all patients who had FNA ended up having further tissue biopsy for subtype confirmation and for treatment, and this is important, because the subtype of the lymphoma is important in determining the type of treatment uses as well as determining prognosis,” she said.

The diagnosis was confirmed by core biopsy in 46.7% of cases, by incisional biopsy in 9.3%, by partial or total thyroidectomy in 25.3%, and by lymph node biopsy in 13.3%; percentages total 94.6% due to downward rounding. Histologic subtypes included diffuse large B-cell lymphoma (DLBCL) in 73.3% of cases, follicular lymphoma in 5.3%, mucosa-associated lymphoid tissue (MALT) in 10.7%, MALT/DLBCL in 2.6%, T-cell lymphoma in 2.6%, and Hodgkin’s lymphoma in 1.3%; percentages total 95.8% rather than 100% due to downward rounding.

In addition to rapid enlargement of a neck mass with compressive symptoms, findings that should raise suspicion of thyroid lymphoma include a history of Hashimoto’s thyroiditis and the ultrasound findings characterized by this study, Dr. Sharma said.

“Once you have that increased suspicion, you should move toward going to core biopsy rather than FNA to save the patient from having two diagnostic steps rather than one,” she concluded.

Dr. Sharma reported having no disclosures.

[email protected]

SAN FRANCISCO – Patients with symptomatic knee osteoarthritis who received pharmaceutical-grade chondroitin sulfate for 2 years lost about 20% less cartilage volume than did patients treated with celecoxib, according to a randomized, double-blind trial.

Improvements were limited to the medial tibiofemoral compartment, but even such modest structural effects can significantly decrease rates of total knee replacement over time, said lead investigator Dr. Jean-Pierre Pelletier, who presented the findings at the annual meeting of the American College of Rheumatology.

The 194 participants in the study received chondroitin sulfate, 1,200 mg a day, or celecoxib, 200 mg daily. Joint effusion and pain and function improved markedly in both groups, and they had similar rates of adverse events, said Dr. Pelletier, who is a rheumatologist at Institut de recherche en rhumatologie de Montréal. He discussed the findings and plans for future research in an exclusive video interview.

Bioibérica sponsored the study and makes the chondroitin sulfate that participants received. Dr. Pelletier and his associates had no other disclosures.

SAN FRANCISCO – Patients with symptomatic knee osteoarthritis who received pharmaceutical-grade chondroitin sulfate for 2 years lost about 20% less cartilage volume than did patients treated with celecoxib, according to a randomized, double-blind trial.

Improvements were limited to the medial tibiofemoral compartment, but even such modest structural effects can significantly decrease rates of total knee replacement over time, said lead investigator Dr. Jean-Pierre Pelletier, who presented the findings at the annual meeting of the American College of Rheumatology.

The 194 participants in the study received chondroitin sulfate, 1,200 mg a day, or celecoxib, 200 mg daily. Joint effusion and pain and function improved markedly in both groups, and they had similar rates of adverse events, said Dr. Pelletier, who is a rheumatologist at Institut de recherche en rhumatologie de Montréal. He discussed the findings and plans for future research in an exclusive video interview.

Bioibérica sponsored the study and makes the chondroitin sulfate that participants received. Dr. Pelletier and his associates had no other disclosures.

SAN FRANCISCO – Patients with symptomatic knee osteoarthritis who received pharmaceutical-grade chondroitin sulfate for 2 years lost about 20% less cartilage volume than did patients treated with celecoxib, according to a randomized, double-blind trial.

Improvements were limited to the medial tibiofemoral compartment, but even such modest structural effects can significantly decrease rates of total knee replacement over time, said lead investigator Dr. Jean-Pierre Pelletier, who presented the findings at the annual meeting of the American College of Rheumatology.

The 194 participants in the study received chondroitin sulfate, 1,200 mg a day, or celecoxib, 200 mg daily. Joint effusion and pain and function improved markedly in both groups, and they had similar rates of adverse events, said Dr. Pelletier, who is a rheumatologist at Institut de recherche en rhumatologie de Montréal. He discussed the findings and plans for future research in an exclusive video interview.

Bioibérica sponsored the study and makes the chondroitin sulfate that participants received. Dr. Pelletier and his associates had no other disclosures.

DNA repair

Image by Tom Ellenberger

Researchers say they have discovered a more efficient way to edit the genomes of hematopoietic stem and progenitor cells (HSPCs).

The approach involves adeno-associated virus (AAV) serotype 6 and zinc finger nuclease (ZFN) messenger RNA (mRNA).

Combining these delivery techniques allowed the team to “achieve high levels of precise genome editing” in HSPCs, including the most primitive cell population.

Paula Cannon, PhD, of the University of Southern California in Los Angeles, and her colleagues described this work in Nature Biotechnology.

The researchers have been using ZFNs to cut a cell’s DNA at a precise location or sequence. The cell normally uses a copy of the cut DNA sequence as a template to repair the DNA break.

During this process, there is the opportunity to introduce new DNA sequences or to repair mutations, effectively fooling the cell into making a genetic edit.

To provide the cell with both the targeted nuclease and the new DNA template, researchers can use a variety of delivery vehicles or vectors, including viruses and mRNA.

With this study, Dr Cannon and her colleagues found they could deliver the DNA repair template using AAV6, which can naturally enter HSPCs.

At the same time, they found that delivering the ZFNs as short-lived mRNA molecules allowed the DNA cutting and repair process to occur without disrupting the HSPCs.

By combining these delivery methods, the researchers were able to insert a gene at a precise site in even the most primitive human HSPCs, with efficiency rates ranging from 17% to 43%.

The team then transplanted these edited HSPCs into immune-deficient mice and found the cells thrived and differentiated into many different blood cell types, all of which retained the edits to their DNA.

“Our results provide a strategy for broadening the application of genome editing technologies in HSPCs,” said study author Michael C. Holmes, PhD, vice president of research at Sangamo BioSciences in Richmond, California.

“This significantly advances our progress towards applying genome editing to the treatment of human diseases of the blood and immune systems.”

DNA repair

Image by Tom Ellenberger

Researchers say they have discovered a more efficient way to edit the genomes of hematopoietic stem and progenitor cells (HSPCs).

The approach involves adeno-associated virus (AAV) serotype 6 and zinc finger nuclease (ZFN) messenger RNA (mRNA).

Combining these delivery techniques allowed the team to “achieve high levels of precise genome editing” in HSPCs, including the most primitive cell population.

Paula Cannon, PhD, of the University of Southern California in Los Angeles, and her colleagues described this work in Nature Biotechnology.

The researchers have been using ZFNs to cut a cell’s DNA at a precise location or sequence. The cell normally uses a copy of the cut DNA sequence as a template to repair the DNA break.

During this process, there is the opportunity to introduce new DNA sequences or to repair mutations, effectively fooling the cell into making a genetic edit.

To provide the cell with both the targeted nuclease and the new DNA template, researchers can use a variety of delivery vehicles or vectors, including viruses and mRNA.

With this study, Dr Cannon and her colleagues found they could deliver the DNA repair template using AAV6, which can naturally enter HSPCs.

At the same time, they found that delivering the ZFNs as short-lived mRNA molecules allowed the DNA cutting and repair process to occur without disrupting the HSPCs.

By combining these delivery methods, the researchers were able to insert a gene at a precise site in even the most primitive human HSPCs, with efficiency rates ranging from 17% to 43%.

The team then transplanted these edited HSPCs into immune-deficient mice and found the cells thrived and differentiated into many different blood cell types, all of which retained the edits to their DNA.

“Our results provide a strategy for broadening the application of genome editing technologies in HSPCs,” said study author Michael C. Holmes, PhD, vice president of research at Sangamo BioSciences in Richmond, California.

“This significantly advances our progress towards applying genome editing to the treatment of human diseases of the blood and immune systems.”

DNA repair

Image by Tom Ellenberger

Researchers say they have discovered a more efficient way to edit the genomes of hematopoietic stem and progenitor cells (HSPCs).

The approach involves adeno-associated virus (AAV) serotype 6 and zinc finger nuclease (ZFN) messenger RNA (mRNA).

Combining these delivery techniques allowed the team to “achieve high levels of precise genome editing” in HSPCs, including the most primitive cell population.

Paula Cannon, PhD, of the University of Southern California in Los Angeles, and her colleagues described this work in Nature Biotechnology.

The researchers have been using ZFNs to cut a cell’s DNA at a precise location or sequence. The cell normally uses a copy of the cut DNA sequence as a template to repair the DNA break.

During this process, there is the opportunity to introduce new DNA sequences or to repair mutations, effectively fooling the cell into making a genetic edit.

To provide the cell with both the targeted nuclease and the new DNA template, researchers can use a variety of delivery vehicles or vectors, including viruses and mRNA.

With this study, Dr Cannon and her colleagues found they could deliver the DNA repair template using AAV6, which can naturally enter HSPCs.

At the same time, they found that delivering the ZFNs as short-lived mRNA molecules allowed the DNA cutting and repair process to occur without disrupting the HSPCs.

By combining these delivery methods, the researchers were able to insert a gene at a precise site in even the most primitive human HSPCs, with efficiency rates ranging from 17% to 43%.

The team then transplanted these edited HSPCs into immune-deficient mice and found the cells thrived and differentiated into many different blood cell types, all of which retained the edits to their DNA.

“Our results provide a strategy for broadening the application of genome editing technologies in HSPCs,” said study author Michael C. Holmes, PhD, vice president of research at Sangamo BioSciences in Richmond, California.

“This significantly advances our progress towards applying genome editing to the treatment of human diseases of the blood and immune systems.”