Image-guided Hypofractionated Radiotherapy as an Alternative to Radical Prostatectomy in Localized Prostate Cancer in Elderly Patients with Low Life Expectancy.

INTRODUCTION: Radical prostatectomy is appropriate for any patient whose cancer appears clinically localised to prostate. However because of potential perioperative morbidity, radical prostatectomy is generally reserved for patients whose life expectancy is more than ten years. Moderate hypofractionation for localized prostate cancer is safe and effective. There is a growing body of evidence in support of extreme hypofractionation for localized prostate cancer. Hypofractionation for prostate cancer was originally carried out in the pursuit of efficiency and convenience, but has now attracted greatly renewed interest based upon a hypothesis that prostate cancers have a higher sensitivity to fraction size, reflected in a low α/ß ratio, then do late responding organs at risk such as the rectum or bladder. MATERIAL AND METHODS: From January 2017 to December 2020 we treated 112 patients of localised Prostate Cancer with Image Guided Radiotherapy (IGRT). They were in range of 75-85 years. They were of stage T1-T3, N0 or N1. There were significant comborbidities. ECOG performance status was 0-1. They were given 3 months of Androgen Deprivation Therapy (ADT) before starting IGRT. Patients were immobilised with casts and subject to CT simulation. CBCT was taken daily. Dose was 70 Gy @ 250 cGy per fraction at a frequency of 5 fractions per week. Complete blood counts were done weekly for assessment of haematological toxicity. Androgen Deprivation Therapy was continued post IGRT. RESULTS: All the patients were able to complete the treatment. Evaluation was done at one month, three month and six months post treatment. 104 out of 112 patients achieved complete response. Other 8 had near complete response. There were no acute grade 3-4 toxicities. Grade 1-2 toxicities like skin desquamation, diarrhoea, burning micturition were managed conservatively. Late toxicity was rectal bleeding seen after one year of completion of treatment and was managed with steroid enemas. 23 patients required argon plasma laser therapy. CONCLUSION: Image guided radiotherapy is well tolerated, easy to implement and an effective alternative to radical prostatectomy in elderly patients with comorbidities and low life expectancy.

Résumé Introduction:La prostatectomie radicale est appropriée pour tout patient dont le cancer apparaît cliniquement localisé à la prostate. Cependant, en raison de la morbidité périopératoire potentielle, la prostatectomie radicale est généralement réservée aux patients dont l'espérance de vie est supérieure à dix ans. L'hypofractionnement modéré pour le cancer localisé de la prostate est sûr et efficace. Il existe un ensemble croissant de preuves à l'appui de l'hypofractionnement extrême pour le cancer de la prostate localisé. L'hypofractionnement pour le cancer de la prostate a été initialement menée dans la poursuite de l'efficacité et de la commodité, mais a maintenant suscité un intérêt considérablement renouvelé en fonction d'une hypothèse selon laquelle les cancers de la prostate ont une sensibilité plus élevée à la taille des fraction Les organes répondants à risque tels que le rectum ou la vessie.Matériel et méthodes:De janvier 2017 à décembre 2020, nous avons traité 112 patients d'un cancer de la prostate localisé avec radiothérapie guidée par l'image (IGRT). Ils étaient de 75 à 85 ans. Ils étaient de stade T1-T3, N0 ou N1. Il y avait des comorbidités importantes. Le statut de performance ECOG était de 0-1. Ils ont reçu 3 mois de thérapie de privation des androgènes (ADT) avant de commencer l'IGRT. Les patients ont été immobilisés avec des moulages et soumis à une simulation CT. CBCT a été pris quotidiennement. La dose était de 70 Gy @ 250 cgy par fraction à une fréquence de 5 fractions par semaine. Les numéros sanguins complets ont été effectués chaque semaine pour évaluer la toxicité hématologique. La thérapie de privation des androgènes s'est poursuivie après l'IGRT.Résultats:Tous les patients ont pu terminer le traitement. L'évaluation a été effectuée à un mois, trois mois et six mois après le traitement. 104 sur 112 patients ont obtenu une réponse complète. Les 8 autres avaient une réponse presque complète. Il n'y avait pas de toxicités aiguës de grade 3-4. Toxicités de grade 1-2 comme la desquamation cutanée, la diarrhée, la miction brûlante ont été gérés de manière conservatrice. La toxicité tardive a été des saignements rectaux observés après un an d'achèvement du traitement et a été géré avec des lavements stéroïdes. 23 patients ont besoin d'un traitement au laser plasma d'argon.Conclusion:La radiothérapie guidée par l'image est bien tolérée, facile à mettre en œuvre et une alternative efficace à la prostatectomie radicale chez les patients âgés atteints de comorbidités et une faible espérance de vie.

Cytotoxic evaluation of pure and doped iron oxide nanoparticles on cancer cells: a magnetic fluid hyperthermia perspective.

The need of the hour with respect to cancer treatment is a targeted approach with minimal or nil ramifications. Apropos, magnetic fluid hyperthermia (MFH) is emerging as a potential therapeutic strategy with anticipated reduced side effects for solid tumors. MFH causes cytotoxicity due to the heat generated owing to Hysteresis, Neel, and Brownian relaxation losses once magnetic nanoparticles (MNPs) carrying cancer cells are placed under an alternating magnetic field. With respect to MFH, iron oxide-based MNPs have been most extensively studied to date compared to other metal oxides with magnetic properties. The effectiveness of MFH relies on the composition, coating, size, physical and biocompatible properties of the MNPs. Pure iron oxide and doped iron oxide MNPs have been utilized to study their effects on cancer cell killing through MFH. This review evaluates the biocompatibility of pure and doped iron oxide MNPs and their subsequent hyperthermic effect for effectively killing cancer cells in vitro and in vivo.

Characteristics of Bilateral Adrenal Lesions: Experience from an Indian Tertiary Care Centre.

Introduction: The aetiologies in unilateral and bilateral adrenal lesions can be different with different clinical implications and management guidelines, the latter having aetiologies like hyperplasia, infections, infiltrative lesions and neoplasia. Bilateral tumours are more likely to have hereditary/syndromic associations. There is limited data on the clinical and pathological profile of bilateral adrenal lesions. Methods: This was a retrospective study where patients with bilateral adrenal lesions were selected from a total of 266 patients with adrenal lesions who presented to our institute between January 2016 and August 2022. The demographic, laboratory and imaging data were retrieved from the Hospital Information System and patient case files. Results: The study included 51 patients; the mean age at presentation was 51.15 years (range 14 to 82 years). Forty-eight patients (94.1%) were symptomatic at presentation with an average duration of symptoms being 10.68 months (range 10 days to 1 year). The most common presentation was adrenal insufficiency in 18 cases (38%), followed by fever in 17 cases (36%). The commonest aetiology, as revealed on histopathology, was histoplasmosis (n = 22, 43%), followed by pheochromocytoma (n = 11, 21.5%), metastases (n = 6, 11.7%), adrenal hyperplasia (n = 5, 9.8%), adrenocortical adenoma (n = 1, 1.9%), lymphoma (n = 3, 5.8%), neuroblastoma (n = 1, 1.9%), myelolipoma (n = 1, 1.9%) and tuberculosis (n = 1, 1.9%). Histoplasmosis and metastatic lesions were commonly seen in older people, and pheochromocytoma was associated with young age. 6/11 patients with a diagnosis of bilateral pheochromocytoma were associated with family history, genetic mutation and extra-adrenal involvement. Conclusion: The approach to bilateral adrenal lesions differs from that of unilateral lesions due to differences in aetiologies and the more significant role of genetics in some bilateral tumours. The age at presentation, presenting symptoms, lesion size and biochemical features help delineate varied underlying aetiologies.

Potential and Pitfalls of Postoperative Volumetric Assessment of Extent of Resection in High-Grade Glioma in Resource-Constrained Settings.

BACKGROUND: While literature suggests the need for routine postoperative volumetric estimation of the EOR and residual tumour volume (RTV) in all cases of gliomas, the utility and feasibility of this protocol in resource-constrained centers remain underinvestigated. OBJECTIVES: Our objective was to study the feasibility of volumetric EOR in routine neurosurgical practice and determine correlation with surgeons' intraoperative estimation of EOR. The secondary objective was to determine the survival impact of EOR and RTV on survival. METHODS AND MATERIALS: A prospective study of pathologically proven high-grade gliomas (WHO grades 3 and 4) in adults was conducted at a tertiary care center. Pre- and postoperative magnetic resonance imaging (MRI) was obtained for volumetric analysis using OsiriX software and manual segmentation. Overall survival and predictors were studied using Kaplan-Meier and Cox regression analysis. RESULTS: Postoperative volumetry was feasible in 31% patients (n = 25) of study eligible patients (n = 84). The median EOR, CE-PTV, and CE-RTV were 79.1%, 69.8 cm3, and 8.7 cm3, respectively. There was a poor correlation of surgeons' intraoperative impression and volumetric data (P = 0.359). Interestingly, the EOR was not significantly associated with the survival time (P = 0.920), while tumor grade, molecular profile, Ki 67 score, and postoperative functional status showed statistically significant impact. CONCLUSION: Logistic difficulties impede routine implementation of this protocol in developing countries. MRI volumetry is clearly more accurate than surgeons' intraoperative estimation of EOR. Notwithstanding the role of EOR in survival, our study reveals a perhaps bigger impact of tumor biology and postoperative functional status in this equation.

Tuberculosis is the predominant infection in systemic sclerosis: thirty-year retrospective study of serious infections from a single centre.

To look for the spectrum of infections and the factors predisposing to infection in patients with systemic sclerosis (SSc). In this retrospective study, demographic, clinical features, details of infections, immunosuppressive therapy, and outcomes of patients with SSc attending clinics at department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India from 1990 to 2022 were captured. Multivariable-adjusted logistic regression was applied to identify independent predictors of infection. Data of 880 patients, mean age 35.5 ± 12 years, and female: male ratio 7.7:1, were analyzed. One hundred and fifty-three patients had at least 1 infection with a total of 233 infectious episodes. Infections were most common in lung followed by skin and soft tissue. Tuberculosis was diagnosed in 45 patients (29.4%). Klebsiella was the commonest non-tubercular organism in lung and Escherichia coli in urinary tract infections. In comparison to matched control group, patients with infection had a greater number of admissions due to active disease, odds ratio (OR) 6.27 (CI 3.23-12.18), were receiving immunosuppressive medication OR, 5.05 (CI 2.55-10.00), and had more digital ulcers OR, 2.53 (CI 1.17-5.45). Patients who had infection had more likelihood for death OR, 13.63 (CI 4.75 -39.18). Tuberculosis is the commonest infection and lung remains the major site of infection in patients with SSc. Number of hospital admissions, digital ulcers and immunosuppressive therapy are predictors of serious infection in patients with SSc. Patients with infections had more likelihood of death.

Targeting CERS6-AS1/FGFR1 axis as synthetic vulnerability to constrain stromal cells supported proliferation in Mantle cell lymphoma.

The interaction between stromal and tumor cells in tumor microenvironment is a crucial factor in Mantle cell lymphoma (MCL) progression and therapy resistance. We have identified a long non-coding RNA, CERS6-AS1, upregulated in MCL and associated with poor overall survival. CERS6-AS1 expression was elevated in primary MCL within stromal microenvironment and in a subset of MCL cells adhered to stromal layer. These stromal-adhered MCL-subsets exhibited cancer stem cell signatures than suspension counterparts. Mechanistically, we found that downregulating CERS6-AS1 in MCL reduced Fibroblast Growth Factor Receptor-1 (FGFR1), expression attributed to loss of its interaction with RNA-binding protein nucleolin. In addition, using in-silico approach, we have discovered a direct interaction between nucleolin and 5'UTR of FGFR1, thereby regulating FGFR1 transcript stability. We discovered a positive association of CERS6-AS1 with cancer stem cell signatures, and Wnt signaling. Building on these, we explored potential therapeutic strategies where combining nucleolin-targeting agent with FGFR1 inhibition significantly contributed to reversing cancer stem cell signatures and abrogated primary MCL cell growth on stromal layer. These findings provide mechanistic insights into regulatory network involving CERS6-AS1, nucleolin, and FGFR1 axis-associated crosstalk between tumor cells and stromal cell interaction and highlights therapeutic potential of targeting a non-coding RNA in MCL.

MRI Evaluation of Microstructural and Perfusion Changes in Patients with Hemsensory Neurological Syndromes.

BACKGROUND: Hemisensory syndrome is characterized by a nondermatomal sensory deficit involving one half of the body. With the conventional imaging techniques, researches find low diagnostic yield in this condition; however, with the advancements in MRI imaging, there is hope to find the pathophysiological basis of hemisensory symptoms. OBJECTIVE: To evaluate microstructural and perfusion changes in brain parenchyma in patients with hemisensory syndrome on MRI with diffusion tensor imaging (DTI) and arterial spin labeling (ASL). MATERIAL AND METHODS: A total of 20 patients with hemisensory symptoms and 10 age-matched controls were enrolled and divided in two study groups - a) case vs. control and b) affected vs. nonaffected cerebral hemisphere in cases. Quantification of absolute cerebral blood flow (aCBF), fractional anisotropy (FA), and mean diffusivity (MD) was done in both groups. RESULTS: On ASL, there was significantly increased aCBF in thalamus on the contralateral-affected side. DTI revealed significantly decreased FA in the thalamus and increased FA in corona radiata of the affected side. There was a significant difference for MD of corona radiata between affected and nonaffected hemisphere. The mean value of MD in corona radiata is decreased on the affected side. CONCLUSION: Changes in advanced neuroimaging techniques like ASL and DTI along the pain processing pathway suggest an alteration in neuronal density and activity at the microstructural level. These findings may provide an insight into the etiopathogenesis of pain syndromes.

Clinicopathological analysis of patients with dual malignancies: A retrospective study.

BACKGROUND: This study aims to report the increasing incidence of second primary malignancies to better understand the association of multiple primary cancers and the duration of their occurrence. Keeping in view the current trends in dual malignancies and to further emphasize the importance of screening and follow-up diagnosis, we reviewed the records of patients who were diagnosed with dual malignancies. MATERIAL AND METHODS: This is a retrospective observational study. We collected data from the hospital database, of patients presenting with either histologically proven synchronous or metachronous double primaries between January 1, 2017, and December 31, 2021. The time interval to differentiate between synchronous and metachronous has been taken as 6 months. RESULTS: During the period of five years, twenty-three patients presented with dual malignancy. Out of 23 cases, seven were synchronous (30.43%), and 16 were metachronous (69.56%). In the synchronous malignancy group, the most common site of first and second primary malignancy was breast [5 cases (71.4%) and 3 cases (42.8%), respectively]. In the metachronous malignancy group, the most common site of the first primary was breast (7 cases; 43.75%), followed by the head and neck (4 cases; 25%), and the most common site of the second primary was also the breast (6 cases; 37.5%), followed by the lung (5 cases; 31.25%). CONCLUSION: Second primary malignancies are not rare and can occur at any age. Regular follow-up and screening procedures by the treating oncologist can play a major role in early detection followed by appropriate treatment of second primary tumors.

Safety and Efficacy of Golimumab in Indian Patients with Active Spondyloarthritis of Ankylosing Spondylitis or Psoriatic Arthritis: A Multicenter, Noncomparative, Open-Label, Real-World Study.

BACKGROUND: The safety and efficacy of tumor necrosis factor-α (TNF-α) inhibitor therapy for most common rheumatological diseases, ankylosing spondylitis (AS), and psoriatic arthritis (PsA) in controlled clinical trials is well-studied. This study evaluated subcutaneous (SC) golimumab in Indian patients with active spondyloarthritis (SpA) of AS or PsA in a real-world setting. MATERIALS AND METHODS: This phase 4, multicenter, prospective, non-comparative, interventional, 24-week study was performed in patients (age ≥18 years) with active SpA of AS or PsA (NCT03733925). Golimumab 50 mg was given subcutaneously to the patients every 4 weeks. Safety was assessed. The proportion of patients with AS and PsA achieving ≥20% improvement in the Assessment of SpA International Society 20 (ASAS20) criteria and American College of Rheumatology 20 (ACR20) responses, respectively, at weeks 14 and 24 were efficacy endpoints. RESULTS: Of the 100 patients enrolled (men: 78 [78.0%]; mean age: 36.7 [12.02] years), 94 (94.0%) patients completed the study. Treatment-emergent adverse events with golimumab were observed in 29/100 (29.0%) patients, and nasopharyngitis and upper respiratory tract infection (5.0% each) were the most common (≥5%). Deaths were not reported. At week 14, 74.5% (95% confidence interval [CI]: 59.7; 86.1%) of patients with AS and 84.6% (95% CI: 69.5; 94.1%) of patients with PsA achieved ASAS20 and ACR20 responses, which were sustained at week 24 (ASAS20: 66.0% [95% CI: 50.7, 79.1%]; ACR20: 93.2% [95% CI: 81.3, 98.6%]), respectively. CONCLUSION: Golimumab (50 mg) administered subcutaneously was safe and effective in Indian patients with active SpA of AS or PsA during the 24-week study period with no new safety signals.

Ictal kissing: Review of literature and report of 5 cases.

Ictal kissing (IK) is a rare type of automatism observed during epileptic seizures. Despite its uncommon occurrence, understanding the underlying mechanisms, the role of emotions, and the level of consciousness during seizures with IK is essential in providing a comprehensive understanding of epilepsy. We describe five cases (.13%) of IK after performing a retrospective analysis of 3794 long-term, ictal video-EEGs from an epilepsy monitoring unit in Mumbai, India. Our patients with drug-resistant epilepsy showed IK had a wide epileptogenic zone. We discuss the current hypotheses on the mechanisms behind IK, the involvement of temporal lobe structures, and the implications of awareness during seizures. The review concludes by suggesting future directions for research to elucidate the complex phenomenon of IK further.

Prevalence, Predictors, and Prognosis of Serious Infections in Takayasu Arteritis: A Cohort Study.

OBJECTIVE: To describe the incidence, risk factors, and outcomes associated with serious infections in patients with Takayasu arteritis (TA). METHODS: Serious infections, defined as infections resulting in hospitalization or death or unusual infections like tuberculosis, were identified from a cohort of patients with TA. Corticosteroid and disease-modifying antirheumatic drug (DMARD) use at the time of serious infection was noted. Demographic characteristics, clinical presentation, angiography, and disease activity at presentation, and the use of DMARDs during follow-up were compared between patients with TA with or without serious infections. Mortality in patients with TA who developed serious infections was compared to those who did not using hazard ratios (HR; with 95% CI). RESULTS: Of 238 patients with TA, 38 (16%) had developed serious infections (50 episodes, multiple episodes in 8; 3 episodes resulted in death). Among the 38 initial episodes, 11/38 occurred in those not on corticosteroids and 14/38 in those not on DMARDs. Pneumonia (n = 19) was the most common infection, followed by tuberculosis (n = 12). Patients with TA who developed serious infections vs those who did not had higher disease activity at presentation (active disease 97.4% vs 69.5%, mean Indian Takayasu Arteritis Activity Score 2010 12.7 (SD 7.3) vs 10.2 (SD 7.0), mean Disease Extent Index in Takayasu Arteritis 11.2 (SD 6.1) vs 8.8 (SD 6.1) and were more frequently initiated on corticosteroids or DMARDs. HRs calculated using exponential parametric regression survival-time model revealed increased mortality rate in patients with TA who developed serious infections (HR 5.52, 95% CI 1.75-17.39). CONCLUSION: Serious infections, which occurred in the absence of immunosuppressive treatment in approximately one-fifth of patients with TA, were associated with increased mortality in patients with TA.

Dostarlimab: Review on success story and clinical trials.

The PD-1/PD-L1 pathway plays a significant role in inhibiting, escaping from immune response, and promoting self-tolerance of the tumour. Dostarlimab is a selective humanized monoclonal antibody designed to target PD-1 and block its activity with PD-L1, which further prevents the escape of tumour cells from immune surveillance. It got accelerated approval from the FDA for treating adults with mismatch repair deficient, recurrent, or advanced endometrial cancer, and studies confirmed its beneficial effects. A recently published clinical trial reported 100 % remission of advanced rectal cancer without significant side effects in the participants. This clinical trial is still going on and enrolling patients with different types of cancer, including ovarian cancer, melanoma, head and neck cancer, and breast cancer therapy. The clinical trial result gave hope and proof to the medical fraternity and patients for better treatment. The focus of this review is to summarise pre-clinical and clinical studies of Dostarlimab.

Dosimetric comparison between carotid-sparing IMRT and 3DCRT in early glottic cancer patients treated with definitive radiation therapy.

BACKGROUND: The purpose of this study was to evaluate the dosimetric benefits of carotid-sparing IMRT (intensity-modulated radiation therapy) over 3DCRT (three-dimensional conformal radiation therapy) in early glottic cancer patients. MATERIAL AND METHODS: Ten patients with histologically proven early-stage squamous cell cancer of glottis (T1N0), treated with definitive radiotherapy, were selected retrospectively for the dosimetric analysis. Patients were originally treated with 3DCRT technique. For comparison purpose, IMRT plans were generated for each patient. Dosimetric comparison was done between two techniques (IMRT and 3DCRT) in terms of PTV (planning target volume) coverage, HI (homogeneity index), CI (conformity index), and doses to right carotid artery, left carotid artery, and spinal cord. RESULTS: V95% for the PTV was higher in IMRT plans (98.26%) as compared to 3DCRT plans (95.12%) (P-value <0.001), whereas V105% for PTV was significantly higher in 3DCRT plans (16.77%) as compared to IMRT plans (0.32%) (P-value 0.11). In terms of both HI and CI, IMRT plans showed better conformity as compared to 3DCRT plans, with statistically significant difference. Both right and left carotid arteries' average mean and maximum doses were significantly lower in IMRT plans as compared to 3DCRT plans (P-value <0.001). IMRT plans resulted in significant carotid-sparing as compared to 3DCRT plans in terms of V35 and V50 (P-value <0.001). CONCLUSION: Carotid-sparing IMRT resulted in better PTV coverage and lower carotid artery dose as compared to 3DCRT in early glottic cancer patients.

Racemose neurocysticercosis: a case series.

Neurocysticercosis (NCC) is a common parasitic condition of the central nervous system in certain parts of the world. The racemose variety of NCC is distinct from the commonly seen parenchymal form. It frequently infiltrates the basal cisterns and Sylvian fissures. Imaging plays a vital role in the diagnosis; however, as their signal intensity is similar to cerebrospinal fluid and due to the absence of enhancement in most cases, imaging diagnosis is often difficult on the conventional MRI sequences. Here, we present five cases of racemose NCC to emphasize the importance of a heavily T2-weighted sequence (Fast Imaging Employing Steady-state Acquisition) sequence in the diagnosing this entity.

Comparative Analysis of VMAT and IMRT Techniques: Evaluation of Dose Constraints and Bone Marrow Sparing in Cervical Cancer Patients Undergoing Chemoradiotherapy.

BACKGROUND: Carcinoma of the cervix is a globally significant cause of morbidity and mortality among women. Concurrent chemoradiotherapy, a standard approach for locally advanced cervical cancer, invariably involves pelvic irradiation. Although this strategy is effective, it inevitably affects the pelvic bone marrow, a crucial hematopoietic site, and leads to hematological toxicity The potential of IMRT to spare bone marrow in pelvic irradiation settings has been an area of significant interest, with the aim to mitigate the hematological toxicity associated with pelvic radiotherapy. Radiotherapy techniques have evolved in terms of conformity and normal tissue sparing. Our study intends to explore the use of BM sparing techniques among patients of carcinoma cervix. PATIENTS AND METHODS: Twenty patients of carcinoma cervix FIGO Stage IIIB treated with concurrent chemoradiotherapy were selected for this study. The external contour of bones was delineated on planning CT as a surrogate for BM. We generated three plans on a single patient:1. without BM as the dose constraint, namely N-IMRT plan; 2. with BM constraint, namely BMS-IMRT plan; 3. VMAT plan in which BM constraint was given. The dose volume histogram (DVH) for planning target volume (PTV) and organs at risk (OAR) were analyzed. BM parameters: V10, V20, V30, V40, mean, maximum and minimum dose were compared.  Results: PTV coverage was comparable in all techniques. VMAT plans resulted in superior BM sparing compared with N-IMRT plan (P-<0.001) and BMS-IMRT plan (P-<0.001, 0.021 and 0.001 respectively for V20, V30 and V40). VMAT plans had better CI compared with BMS-IMRT (P-0.002) and N-IMRT (P-0.001) plans. CONCLUSION: Our study adds to the growing evidence that VMAT might be the preferred technique for patients with carcinoma of the cervix undergoing concurrent chemoradiotherapy, as it provides comparable target coverage and better sparing of bone marrow compared to IMRT.

Renal artery involvement is associated with increased morbidity but not mortality in Takayasu arteritis: a matched cohort study of 215 patients.

BACKGROUND: We analyzed differences in presentation and survival of Takayasu arteritis (TAK) with or without renal artery involvement (RAI) from a large monocentric cohort of patients with TAK. METHODS: Clinical and angiographic features were compared between TAK with versus without RAI, with bilateral versus unilateral RAI, and with bilateral RAI versus without RAI using multivariable-adjusted logistic regression. Inter-group differences in survival were analyzed [hazard ratios (HR) with 95% confidence intervals (95%CI)] adjusted for gender, age at disease onset, diagnostic delay, baseline disease activity, and significant clinical/angiographic inter-group differences after multivariable-adjustment/propensity score matching (PSM). RESULTS: Of 215 TAK, 117(54.42%) had RAI [66(56.41%) bilateral]. TAK with RAI or with bilateral RAI had earlier disease onset than without RAI (p < 0.001). Chronic renal failure (CRF) was exclusively seen in TAK with RAI. TAK with RAI (vs without RAI) had more frequent hypertension (p = 0.001), heart failure (p = 0.047), abdominal aorta (p = 0.001) or superior mesenteric artery involvement (p = 0.018). TAK with bilateral RAI (vs unilateral RAI) more often had hypertension (p = 0.011) and blurring of vision (p = 0.049). TAK with bilateral RAI (vs without RAI) more frequently had hypertension (p = 0.002), heart failure (p = 0.036), abdominal aorta (p < 0.001), superior mesenteric artery (p = 0.002), or left subclavian artery involvement (p = 0.041). Despite higher morbidity (hypertension, CRF), mortality risk was not increased with RAI vs without RAI (HR 2.32, 95%CI 0.61-8.78), with bilateral RAI vs unilateral RAI (HR 2.65, 95%CI 0.52-13.42) or without RAI (HR 3.16, 95%CI 0.79-12.70) even after multivariable adjustment or PSM. CONCLUSION: RAI is associated with increased morbidity (CRF, hypertension, heart failure) but does not adversely affect survival in TAK. Key Points •Renal artery involvement in TAK is associated with chronic renal failure. •TAK with renal artery involvement more often have heart failure and hypertension. •Bilateral renal artery involvement (compared with unilateral) is more often associated with hypertension and visual symptoms. •Renal artery involvement is not associated with an increased risk of mortality in TAK.

Increased mortality rate in Takayasu arteritis is largely driven by cardiovascular disease-a cohort study.

OBJECTIVES: To analyze the risk, causes, and predictors of mortality in Takayasu arteritis (TAK). METHODS: Survival was assessed in a cohort of patients with TAK using Kaplan-Meier curves. Age- and sex-standardized mortality ratio (SMR = observed: expected deaths) for TAK were calculated by applying age- and sex-specific mortality rates for the local population to calculate expected deaths. Hazard ratios (HR with 95%CI) for predictors of mortality based on demographic characteristics, presenting features, baseline angiographic involvement, disease activity, number of immunosuppressive medications used, procedures related to TAK, and any serious infection were calculated using Cox regression or exponential parametric regression models. RESULTS: Among 224 patients with TAK (159 females, mean follow-up duration 44.36 months), survival at 1, 2, 5, and 10 years was 97.34%, 96.05%, 93.93%, and 89.23%, respectively. Twelve deaths were observed, most of which were due to cardiovascular disease (heart failure, myocardial infarction, stroke). Mortality risk was significantly higher with TAK (SMR 17.29, 95%CI 8.95-30.11) than the general population. Earlier age at disease onset (HR 0.90, 95%CI 0.83-0.98; or pediatric-onset vs adult-onset disease, HR 5.51, 95%CI 1.57-19.32), higher disease activity scores (ITAS2010: HR 1.15, 95%CI 1.05-1.25, DEI.TAK: HR 1.18, 95%CI 1.08-1.29), any serious infections (HR 5.43, 95%CI 1.72-17.12), heart failure (HR 7.83, 95%CI 2.17-28.16), or coeliac trunk involvement at baseline (HR 4.01, 95%CI 1.26-12.75) were associated with elevated mortality risk. CONCLUSION: Patients with TAK had an elevated risk of mortality as compared with the general population. Cardiovascular disease was the leading cause of death in TAK.