Pathological response and tumour bed histopathological features correlate with survival following neoadjuvant immunotherapy in stage III melanoma.

BACKGROUND: Guidelines for pathological evaluation of neoadjuvant specimens and pathological response categories have been developed by the International Neoadjuvant Melanoma Consortium (INMC). As part of the Optimal Neo-adjuvant Combination Scheme of Ipilimumab and Nivolumab (OpACIN-neo) clinical trial of neoadjuvant combination anti-programmed cell death protein 1/anti-cytotoxic T-lymphocyte-associated protein 4 immunotherapy for stage III melanoma, we sought to determine interobserver reproducibility of INMC histopathological assessment principles, identify specific tumour bed histopathological features of immunotherapeutic response that correlated with recurrence and relapse-free survival (RFS) and evaluate proposed INMC pathological response categories for predicting recurrence and RFS. PATIENTS AND METHODS: Clinicopathological characteristics of lymph node dissection specimens of 83 patients enrolled in the OpACIN-neo clinical trial were evaluated. Two methods of assessing histological features of immunotherapeutic response were evaluated: the previously described immune-related pathologic response (irPR) score and our novel immunotherapeutic response score (ITRS). For a subset of cases (n = 29), cellular composition of the tumour bed was analysed by flow cytometry. RESULTS: There was strong interobserver reproducibility in assessment of pathological response (κ = 0.879) and percentage residual viable melanoma (intraclass correlation coefficient = 0.965). The immunotherapeutic response subtype with high fibrosis had the strongest association with lack of recurrence (P = 0.008) and prolonged RFS (P = 0.019). Amongst patients with criteria for pathological non-response (pNR, >50% viable tumour), all who recurred had ≥70% viable melanoma. Higher ITRS and irPR scores correlated with lack of recurrence in the entire cohort (P = 0.002 and P ≤ 0.0001). The number of B lymphocytes was significantly increased in patients with a high fibrosis subtype of treatment response (P = 0.046). CONCLUSIONS: There is strong reproducibility for assessment of pathological response using INMC criteria. Immunotherapeutic response of fibrosis subtype correlated with improved RFS, and may represent a biomarker. Potential B-cell contribution to fibrosis development warrants further study. Reclassification of pNR to a threshold of ≥70% viable melanoma and incorporating additional criteria of <10% fibrosis subtype of response may identify those at highest risk of recurrence, but requires validation.

Surgical removal of the index node marked using magnetic seed localization to assess response to neoadjuvant immunotherapy in patients with stage III melanoma.

This pilot study explored the value of localized index node removal after neoadjuvant immunotherapy in patients with stage III melanoma, for use as a response indicator to guide the extent of completion lymph node dissection. Promising technology.

Validation of whole genome linkage-linkage disequilibrium and association results, and identification of markers to predict genetic merit for twinning.

A previous genome-wide search with a moderate density 10K marker set identified many marker associations with twinning rate, either through single-marker analysis or combined linkage-linkage disequilibrium (LLD; haplotype) analysis. The objective of the current study was to validate putative marker associations using an independent set of phenotypic data. Holstein bulls (n = 921) from 100 paternal half-sib families were genotyped. Twinning rate predicted transmitting abilities were calculated using calving records from 1994 to 1998 (Data I) and 1999 to 2006 (Data II), and the underlying liability scores from threshold model analysis were used as the trait in marker association analyses. The previous analysis used 201 bulls with daughter records in Data I. In the current analysis, this was increased to 434, providing a revised estimate of effect and significance. Bulls with daughter records in Data II totaled 851, and analysis of this data provided the validation of results from analysis of Data I. Single nucleotide polymorphisms (SNPs) were selected to validate previously significant single-marker associations and LLD results. Bulls were genotyped for a total of 306 markers. Nine of 13 LLD regions located on chromosomes 1, 2, 3, 6, 9, 22, 23(2) and 26 were validated, showing significant results for both Data I and II. Association analysis revealed 55 of 174 markers validated, equating to a single-marker validation rate of 31%. Stepwise backward elimination and cross-validation analyses identified 18 SNPs for use in a final reduced marker panel explaining 34% of the genetic variation, and to allow prediction of genetic merit for twinning rate.

Is a uniform round-the-clock theophylline blood level necessary for optimal asthma therapy in the adolescent patient?

Twenty-one patients, 12 to 18 years of age, with nocturnal asthma controlled with sustained-release theophylline administered twice daily, were enrolled in a 10-week, double-blind, two-way crossover study that compared Theo-Dur tablets administered twice daily with an equivalent daily dose of Uniphyl tablets administered once daily at bedtime. Seventeen patients completed the study. The mean morning theophylline serum level obtained with Uniphyl tablets was significantly higher than that obtained with Theo-Dur tablets (13.1 versus 9.6 micrograms/ml, p = 0.02). The mean evening serum level was significantly lower with Uniphyl tablets (6.3 versus 10.1 micrograms/ml, p = 0.003). Despite these differences in serum concentrations, morning and evening pulmonary function test values (forced expiratory volume in one second and peak expiratory flow rate) and symptom scores were nearly identical for the two preparations, as was the supplemental use of aerosol bronchodilators. Once-daily dosing with Uniphyl tablets may benefit adolescent patients with nocturnal asthma by increasing compliance and providing better asthma control. In addition, the lower daytime theophylline levels produced by this preparation may also reduce long-term adverse effects on behavior and cognition.

Free running test for exercise-induced bronchospasm.

The free running test has been successfully carried out in patients from 5 to 21 years old. It has the following advantages: (1) it simulates normal exercise pattern; (2) it is readily performed in any health care setting; (3) it is simple to perform and noninvasive in nature; and (4) it reveals a maximum decrease in forced expiratory volume at one second at five minutes after the exercise period. There seems to be a seasonal variation that may alter outcome of tests.

The paradoxical effect of adrenergic and methylxanthine drugs in cystic fibrosis.

This study examined the effect of aerosolized isoproterenol and oral theophylline on pulmonary function in cystic fibrosis (CF) to determine how often these drugs are beneficial and whether there is a correlation between response to isoproterenol and response to oral theophylline. After obtaining baseline pulmonary function tests before and after isoproterenol aerosol, 12 patients with CF were put on a double-blind trial of high-dosage theophylline (10 mg/kg three times per day) or placebo for four weeks and were then switched to the alternate regimen for the next four weeks. Patients had weekly evaluations of pulmonary function and plasma theophylline determinations. Gastrointestinal side effects were common with theophylline. The responses to aerosolized bronchodilators were inconsistent from week to week. After aerosolized bronchodilator, five of 12 patients had an average increase of 10% or more in FEF45%-55% and FEF70%-80%. While taking oral theophylline, five patients had a 10% or more decrease in FEF 45%-55% and six patients had a decrease in FEF70%-80%. We conclude that there was no concordance between response to isoproterenol and theophylline, and that adrenergic and methylxanthine drugs must be used with caution in patients with CF.

The pharmacological assessment of single drugs and drug combinations in exercise-induced asthma.

The relative effectiveness of ephedrine, theophylline, hydroxyzine, and their combinations in relieving cycloergometer exercise-induced asthma were studied in 16 children and adolescents. Ephedrine had no effect on post-exercise asthma, hydroxyzine had weak effect on hastening recovery, while theophylline modified on the post-exercise response significantly. The three drugs together produced an additive effect superior to that of theohylline alone.

The effect of cromolyn sodium on exercise-induced bronchospasm using a free running system.

This study was designed to assess the effectiveness of comolyn sodium in modifying exercise-induced bronchospasm (EIB). Twenty children and adolescents with EIB were given either cromolyn or placebo in a prerandomized double-blind fashion. They then performed a free running maneuver. Pulmonary function tests were obtained before and after this exercise. Patients returned one week later to repeat the same precedure. This time subjects took placebo if they had previously taken cromolyn and vice versa. Significant beneficial effects of cromolyn were noted in forced vital capacity and forced expiratory volume in one second measurements but not in forced expiratory fhis suggests that larger airway disease is preferentially helped by cromolyn when subjects are stressed maximally as with a free running system. Subjects who received placebo on study day 1 and cromolyn on study day 2 showed the most striking benefit from cromolyn. This may be related to the better baseline status of subjects on day 2 as well as to familiarity with the procedure and medication.

Modification of cycloergometer-induced bronchospasm with cromolyn sodium.

Cycloergometer exercise-induced bronchospasm was significantly diminished by pretreatment with sodium cromolyn. This effect was most pronounced in the large airways as manifested by changes in forced expiratory volume in one second.

Immunologic defects in patients with refractory sinusitis.

Sixty-one patients with chronic sinusitis who were referred for an allergy evaluation were evaluated for immunologic competence including assessment of quantitative serum immunoglobulin levels, IgG subclass levels, and response to pneumococcal and Haemophilus influenzae vaccines. In addition to chronic sinus disease, recurrent otitis media and asthma exacerbation were common problems in this group. Five patients had an elevated age-adjusted IgE level and 22 patients had positive prick tests to one or more environmental inhalants; these findings suggest an allergic component in this subgroup. Twelve additional patients had highly reactive intradermal tests to common environmental allergens, which also may be clinically significant for underlying atopy. Eleven patients had low immunoglobulin levels, 6 had low immunoglobulin levels and vaccine hyporesponsiveness, and 17 had poor vaccine response only. Thus, 34 of 61 patients with refractory sinusitis had abnormal results on immune studies, with depressed IgG3 levels and poor response to pneumococcal antigen 7 being most common. In addition to allergy, immunologic incompetence may be an important etiologic factor in patients with chronic, refractory sinusitis.

Double-blind evaluation of methylprednisolone versus placebo for acute asthma episodes.

Twenty-eight children with persistent bronchospasm after outpatient therapy were treated for eight days with methylprednisolone or placebo in a prerandomized double-blind manner, in addition to treatment with optimal oral bronchodilators. At follow-up visits 1, 7, and 14 days after onset of therapy, a history was taken and physical examination and pulmonary function tests were performed. Initially and on the 14th day, patients underwent cosyntropin tests of adrenal function. Patients kept daily peak flow charts. Both groups improved with time. However, by 24 hours after starting methylprednisolone therapy, the placebo group continued to show reversibility after isoproterenol inhalation whereas the methylprednisolone group did not. By day 7 there were significantly more patients with normal 1-second forced expiratory volume (FEV1) and forced expiratory flow in the middle half of the forced vital capacity (FEF25-75%) in the methylprednisolone group and mean FEF25-75% was significantly higher for this group (P less than .02). By day 14, six days after finishing treatment with the study drugs, more patients in the placebo group had residual wheezing, but pulmonary function tests were now similar for the two groups. Although both groups showed a decline in cosyntropin responsiveness on day 14 compared with day 1, there was no difference between the steroid- and placebo-treated patients. This study proves that short-term corticosteroid therapy will accelerate resolution of moderately severe and severe-acute attacks of asthma without significant suppression of adrenal function.

Efficacy of dyphylline (dihydroxypropyltheophylline) in exercise-induced bronchospasm.

The efficacy of dyphlline in prevention of exercise-induced bronchospasm (EIB) was studied in seven subjects. A single 15 mg/kg dose of dyphylline 40 minutes prior to exercise prevented EIB as documented by a significantly smaller mean greatest percent decrease in forced expiratory volume in one second when compared to placebo. Mean serum dyphylline concentrations 40 minutes after a dose of 15 mg/kg were probably in the lower portion of the therapeutic range.

Acute and chronic theophylline therapy in exercise-induced bronchospasm.

This study examined the effectiveness of theophylline therapy in modifying exercise-induced bronchospasm (EIB) in children with perennial asthma and evaluated whether tolerance to theophylline developed with prolonged use. Twenty-one children between 7 and 16 years of age were studied by a standardized treadmill exercise test carried out before administration of theophylline, 90 minutes after administration of theophylline, and again after three weeks of round-the-clock theophylline treatment. Changes in forced expiratory volume at one second, forced expiratory flow between 25% and 75% of vital capacity, and peak expiratory flow rate were measured before and after each exercise test. Theophylline inhibited EIB in 20 of 21 subjects. There was considerable intersubject variation in the response to theophylline, however, ranging from complete inhibition in five subjects to no inhibition at all in one subject, even though theophylline controlled perennial asthma in all subjects, and all but one had theophylline levels between 10 and 22 microgram/ml when tested. On repeated testing after three weeks of therapy, no tolerance developed to theophylline. These findings suggest that EIB and perennial asthma may result from different causes and tha theophylline's ability to control asthma will not predict its effect on EIB. Subjects who have severe EIB should be retested after theophylline pretreatment of evaluate the effectiveness of therapy.

Altered theophylline clearance during an influenza B outbreak.

During the 1980 influenza B outbreak in King County, Washington, 11 children whose asthma had previously been controlled with a stable theophylline dose, developed theophylline toxicity on this same dose. Two had seizures, eight had nausea and vomiting, and three had headaches. All had clinical evidence of a febrile viral illness. The toxicity appeared to be related to decreased theophylline clearance, which gradually returned to preillness levels over a period of one to three months. Six of ten children had serologic evidence of influenza B, which is presumed to be the cause of the altered clearance. In children receiving chronic theophylline therapy, symptoms of vomiting, headaches, or seizures during a viral illness may be due to theophylline toxicity rather than the virus. Such patients should have an immediate serum theophylline determination, even if previous levels have been in the therapeutic range.

Cloprednol therapy in steroid-dependent asthma.

Cloprednol is a new oral corticosteroid with a short half-life that is presently under investigation for use in asthma. Seventeen steroid-dependent children and adolescents were switched from daily treatment with prednisone to cloprednol for a one-year study. Patients showed a statistically significant improvement in symptoms while receiving cloprednol therapy. Two patients had extraordinarily good responses. Growth trends, bone age, and chest roentgenograms were not remarkably changed by cloprednol. Pulmonary function was stable. There was a significant improvement in fasting morning cortisol levels and ability to respond to metyrapone and adrenocorticotropic hormone (ACTH) challenge. Cloprednol appears to be a promising drug for steroid-dependent patients who require oral corticosteroid therapy.

Facial characteristics of children who breathe through the mouth.

There are many claims that abnormal breathing patterns alter facial growth; however, there are limited controlled data to confirm these claims. Thirty children with allergy, aged 6 to 12 years, who had moderate-to-severe nasal mucosal edema on physical examination and who appeared to breathe predominantly through the mouth and 15 children without allergy who had normal findings from nasal examination and who appeared to breathe predominantly through the nose were evaluated. All subjects received an intraoral clinical examination and cephalometric radiograph analysis. In comparison with children who breathed through the nose, children who breathed through the mouth had longer faces with narrower maxillae and retruded jaws. This supports the hypothesis that children with nasal obstruction and who appear to breathe through the mouth have distinctive facial characteristics.

Individualization of theophylline dosage using a single serum sample following a test dose.

Because formulas for theophylline requirement based on weight alone carry the risk of overdosing and toxicity, this study was designed to test a clearance nomogram for determining daily theophylline requirement after a known initial dose of theophylline. Twenty asthmatic children who had not taken theophylline for at least 36 hours fasted and were given one dose of anhydrous theophylline (5 mg/kg). Six hours later the serum level was measured and the appropriate dosage of sustained-release theophylline to achieve a serum level of 10 micrograms/ml was selected from the clearance nomogram. Three to seven days later a six-hour theophylline level was obtained. Of 20 patients, therapeutic levels of 10 to 30 micrograms/ml were achieved in 15, and the remaining five patients had levels close to this (range 6.2 to 16.0 micrograms/ml). The dosage requirement per 24 hours ranged from 10 to 32 mg/kg/24 hr. This method of determining theophylline requirements for children required measurement of the serum theophylline level only once for the determination of a safe and effective daily dose. It is especially valuable when follow-up is difficult and is a safe way to avoid serious overdosing while being certain of effective dosing.

Effectiveness of terbutaline and theophylline alone and in combination in exercise-induced bronchospasm.

Theophylline and terbutaline, alone and in combination, were evaluated for effectiveness in treating exercise-induced bronchospasm (EIB) when used at doses that should be tolerated by adolescents taking them intermittently: theophylline, 250 mg (fast release) and terbutaline, 2.5 mg. Twenty-one subjects, 12 to 19 years of age, with EIB performed standardized exercise tests on four separate days and received either theophylline, terbutaline, the combination, or placebo in a prerandomized double-blind manner prior to exercise. Exercise tests were performed two and five hours after each study drug administration. Blood samples were drawn before and again two and five hours after drug administration for theophylline level. Pulmonary function [forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and forced expiratory flow rate (FEF 25% to 75%)] was recorded before and after exercise. All of the active treatments were better than placebo in diminishing EIB. The combination was statistically better than terbutaline or theophylline alone. The effect of theophylline was not significantly different from that of terbutaline. The combination induced significantly more tremor than either agent individually. Either drug alone or the two in combination is effective for diminishing EIB. Although the combination may have additive properties for some patients, the increased incidence of tremor may diminish its appeal. Either drug alone or in combination is effective in decreasing EIB for at least five hours, which makes them practical choices for treatment of school-aged children.

A double-blind study comparing the effectiveness of cromolyn sodium and sustained-release theophylline in childhood asthma.

The effectiveness of cromolyn sodium and theophylline on asthma in children was compared during a 3-month trial. Forty-six children (aged 5 to 15 years) with asthma were assigned at random to cromolyn or theophylline (Theo-Dur) treatment groups. Each subject received theophylline placebo or cromolyn placebo in addition to the active drugs. A methacholine challenge test was done at the start of the study to document asthma and was repeated during the third month. The theophylline dosage was regulated to obtain serum levels of 10 to 15 micrograms/mL by a physician not involved directly with patient care. Forty patients completed the study. Both theophylline and cromolyn treatment groups showed improvement from base-line status in terms of symptom scores, pulmonary function, and decreased use of inhaled albuterol. Patients treated with theophylline had more side effects and required more frequent office visits than those treated with cromolyn. Both groups had decreased sensitivity to methacholine, and for one statistical test patients treated with cromolyn improved significantly. These results indicate that cromolyn is as effective as theophylline in treating mild to moderate asthma in children; additional benefits were fewer side effects and a possible decrease in bronchial hyperactivity.

Therapeutic monitoring of theophylline. Rationale and current status.

Theophylline has been demonstrated to be a useful agent in the therapy of chronic asthma. Its use must be tempered with knowledge of its adverse effects and that these effects are related primarily to serum concentration. Accordingly, it is mandatory to monitor serum theophylline concentrations on a regular basis with any patient receiving maintenance therapy with theophylline. It is also necessary to recognise the potential side effects of theophylline therapy, and when such a patient displays symptoms of vomiting, headache or seizures, serum theophylline concentration must be checked even if a recent concentration was within the therapeutic range. The means for monitoring theophylline concentrations are now available even to the average physician who does not have immediate access to a laboratory that can provide timely serum theophylline determinations.