Asif A. Chaudhry

Aromatase Inhibitor-Related Musculoskeletal Symptoms: Is Preventing Osteoporosis the Key to Eliminating These Symptoms?

BACKGROUND Aromatase inhibitors (AIs) are an effective treatment for postmenopausal women with hormone receptor-positive breast cancer. However, patients receiving AIs report a higher incidence of musculoskeletal symptoms and bone fractures; the mechanism and risk factors for this correlation are not well studied. The aim of this study was to correlate these musculoskeletal symptoms and bone fractures in patients receiving AIs with bone mineral density (BMD), previous tamoxifen use, and administration of calcium/bisphosphonate (Ca/Bis). PATIENTS AND METHODS We reviewed charts of 856 patients with hormone receptor-positive nonmetastatic breast cancer seen at our institution between January 1999 and October 2007. A total of 316 patients met the inclusion criteria of treatment with one of the AIs for > or = 3 months and availability of a dualenergy X-ray absorptiometry (DEXA) during this treatment. Arthralgia, generalized bone pain and/or myalgia, bone fracture after beginning AIs, any tamoxifen treatment, and Ca/Bis therapy were recorded. RESULTS Our study demonstrates a significant association between symptoms and DEXA-BMD results (P < .001). Similarly, the group receiving tamoxifen before AIs had fewer patients with arthralgia or generalized bone pain/myalgia or bone fracture (P < .001). Furthermore, the group receiving AIs plus Ca/Bis had more patients without musculoskeletal symptoms and had fewer fractures. Finally, the group receiving steroidal AIs compared with nonsteroidal AIs had more patients with arthralgia or generalized bone pain and/or myalgia, and bone fractures (P < .001). CONCLUSION Patients on AIs who develop osteoporosis are at increased risk of musculoskeletal symptoms and bone fracture. Comedication with Ca/Bis reduces the likelihood for osteoporosis and musculoskeletal symptoms. Patients who received tamoxifen before AIs were less likely to develop AI-related musculoskeletal symptoms. We recommend that patients on AIs should be offered Ca/Bis to reduce the incidence of musculoskeletal symptoms and fracture, especially if patients are receiving steroidal AI and/or did not receive tamoxifen before AIs.

The utility of 18-F-fluorodeoxyglucose positron emission tomography in evaluation of bone marrow involvement by non-Hodgkin lymphoma.

Purpose:In non-Hodgkin lymphomas (NHLs), the bone marrow (BM) involvement is a sign of extensive disease and the iliac crest BM biopsy (BMB) is the established method for the detection of BM infiltration. However, iliac crest BMB is associated with a high rate of false negative results. We assess the ability of 18-F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scan to ascertain the presence of BM involvement in NHL. Methods:After reviewing charts of histologically proven NHLs, 97 patients were eligible for our study. All patients were examined by whole-body 18F-FDG PET scan for initial staging, and all had unilateral posterior iliac crest BMB. BM involvement was established after the result of unilateral posterior iliac crest BMB and image-guided BMB after positive 18F-FDG PET scan in selected patients. Results:Our data demonstrate an overall sensitivity of 79% for the 18F-FDG PET scan detecting BM involvement in all patients and specificity of 91%. Further analysis revealed no significant difference in the ability of the 18F-FDG PET scan to detect BM involvement between the indolent-NHL and the aggressive/highly aggressive-NHL groups (sensitivity P = 0.23, specificity P = 0.64). Conclusion:18F-FDG PET scan shows potential to detect BM involvement in NHL. In particular, image-guided repeat BMB should be considered in patients with negative initial iliac crest BMB, whose 18F-FDG PET scan demonstrates BM involvement in a different site.

Venous thromboembolism in lymphoma: How effectively are we treating patients?

Introduction:Patients with solid tumors and venous thromboembolic episodes (VTE) have a high risk of recurrence and bleeding during oral anticoagulant treatment. However, we are unaware of studies expressly evaluating such risks in patients with lymphoma. Therefore, we conducted a retrospective study to determine the frequency of such complications during treatment of lymphoma patients who develop VTE. Methods:Charts of patients with histologically proven non-Hodgkin lymphoma and Hodgkin lymphoma were retrospectively reviewed and patients with their first acute symptomatic VTE episode were identified (49 non-Hodgkin lymphoma, 8 Hodgkin lymphoma). Recurrence of VTE episodes and major and minor bleeding during treatment with warfarin or low molecular weight heparin (LMWH) were recorded. Results:All 57 patients were initially treated with high-dose-adjusted intravenous heparin or body-weight-adjusted LMWH. Forty-six patients were started on oral warfarin and 11 patients continued LMWH. Recurrent VTE episodes occurred in 14 of 46 patients on warfarin therapy, whereas major bleeding was documented in 6 of 46 patients, and minor bleeding in 9 of 46 patients. Recurrent VTE episodes occurred in 1 of 11 patients treated with LMWH, whereas major bleeding occurred in 0 of 11 and minor bleeding in 3 of 11 patients. Conclusions:Lymphoma patients treated with warfarin experienced a 30.4% rate of recurrent thrombosis and 13% major bleeding. During this treatment most (65%), but not all, bleeding and thrombotic complications occurred with an international normalized ratio within the therapeutic range. The percentage of serious complications (recurrent VTE and major bleeding) during warfarin use was 44.5%, and the death rate was 6.5%, compared with 9% and 0%, respectively, during use of LMWH.