Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this second of 5 sections of the guidelines of care for psoriasis, we give an overview of psoriatic arthritis including its cardinal clinical features, pathogenesis, prognosis, classification, assessment tools used to evaluate psoriatic arthritis, and the approach to treatment. Although patients with mild to moderate psoriatic arthritis may be treated with nonsteroidal anti-inflammatory drugs and/or intra-articular steroid injections, the use of disease-modifying antirheumatic drugs, particularly methotrexate, along with the biologic agents, are considered the standard of care in patients with more significant psoriatic arthritis. We will discuss the use of disease-modifying antirheumatic drugs and the biologic therapies in the treatment of patients with moderate to severe psoriatic arthritis.

https://www.jaad.org/article/S0190-9622(09)00012-7/pdf

Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: Overview and guidelines of care for treatment with an emphasis on the biologics

When cancer is diagnosed in a pregnant woman, life-saving chemotherapy for the mother poses life-threatening concerns for the developing fetus. Depending on the type of cancer and the stage at diagnosis, chemotherapy cannot necessarily be delayed until after delivery. Women diagnosed with acute lymphoblastic leukaemia who decline both termination and chemotherapy often die with the previable fetus in utero. Safe use of chemotherapy, especially during the second and third trimester, have been reported, and pregnant women with cancer can accept therapy without definite neonatal harm. Here, we review the use of chemotherapy in pregnancy by trimester of exposure and summarise neonatal outcomes, including malformations, perinatal complications, and oldest age of neonatal follow-up. We will also discuss the modes of action of the drugs used and look at the multiagent regimens recommended for use during pregnancy.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(04)01466-4.pdf

Use of chemotherapy during human pregnancy

Background: We conducted a systematic review and meta-analysis to clarify the risk of early and late cardiotoxicity of anthracycline agents in patients treated for breast or ovarian cancer, lymphoma, myeloma or sarcoma. Methods: Randomized controlled trials were sought using comprehensive searches of electronic databases in June 2008. Reference lists of retrieved articles were also scanned for additional articles. Outcomes investigated were early or late clinical and sub-clinical cardiotoxicity. Trial quality was assessed, and data were pooled through meta-analysis where appropriate. Results: Fifty-five published RCTs were included; the majority were on women with advanced breast cancer. A significantly greater risk of clinical cardiotoxicity was found with anthracycline compared with non-anthracycline regimens (OR 5.43 95% confidence interval: 2.34, 12.62), anthracycline versus mitoxantrone (OR 2.88 95% confidence interval: 1.29, 6.44), and bolus versus continuous anthracycline infusions (OR 4.13 95% confidence interval: 1.75, 9.72). Risk of clinical cardiotoxicity was significantly lower with epirubicin versus doxorubicin (OR 0.39 95% confidence interval: 0.20, 0.78), liposomal versus non-liposomal doxorubicin (OR 0.18 95% confidence interval: 0.08, 0.38) and with a concomitant cardioprotective agent (OR 0.21 95% confidence interval: 0.13, 0.33). No statistical heterogeneity was found for these pooled analyses. A similar pattern of results were found for subclinical cardiotoxicity; with risk significantly greater with anthracycline containing regimens and bolus administration; and significantly lower risk with epirubicin, liposomal doxorubicin versus doxorubicin but not epirubicin, and with concomitant use of a cardioprotective agent. Low to moderate statistical heterogeneity was found for two of the five pooled analyses, perhaps due to the different criteria used for reduction in Left Ventricular Ejection Fraction. Meta-analyses of any cardiotoxicity (clinical and subclinical) showed moderate to high statistical heterogeneity for four of five pooled analyses; criteria for any cardiotoxic event differed between studies. Nonetheless the pattern of results was similar to those for clinical or subclinical cardiotoxicity described above.

/pdf/cardiotoxicity-of-anthracycline-agents-for-the-treatment-of-50et202bx4.pdf

Cardiotoxicity of anthracycline agents for the treatment of cancer: systematic review and meta-analysis of randomised controlled trials

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this fourth of 6 sections of the guidelines of care for psoriasis, we discuss the use of traditional systemic medications for the treatment of patients with psoriasis. Treatment should be tailored to meet individual patients' needs. We will discuss in detail the efficacy and safety, and offer recommendations for the use of the 3 most commonly used, and approved, traditional systemic agents: methotrexate, cyclosporine, and acitretin. We will also briefly discuss the available data for the use of azathioprine, fumaric acid esters, hydroxyurea, leflunomide, mycophenolate mofetil, sulfasalazine, tacrolimus, and 6-thioguanine in psoriasis.

https://piel-l.org/blog/wp-content/uploads/2010/05/Guidelines-of-care-for-the-management.pdf

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents.

Rheumatic diseases in women of childbearing years may necessitate drug treatment during a pregnancy, to control maternal disease activity and to ensure a successful pregnancy outcome. This survey is based on a consensus workshop of international experts discussing effects of anti-inflammatory, immunosuppressive and biological drugs during pregnancy and lactation. In addition, effects of these drugs on male and female fertility and possible long-term effects on infants exposed to drugs antenatally are discussed where data were available. Recommendations for drug treatment during pregnancy and lactation are given.

/pdf/anti-inflammatory-and-immunosuppressive-drugs-and-3enlo6fxtc.pdf

Anti-inflammatory and immunosuppressive drugs and reproduction.

To evaluate the potential teratogenicity of modern cancer treatment, 43 children born to mothers with hematological malignancies (18 with non-Hodgkin lymphoma, 14 Hodgkin disease, seven acute leukemia, and four with chronic granulocytic leukemia) who received chemotherapy during some portion of their pregnancy, including 19 of these 43 who received chemotherapy during the first trimester, were examined for physical health, growth, and development. Immunological, hematological, and cytogenetic status also were evaluated. The children's ages ranged from 3 to 19 years. The children had a careful history and physical examination to detect any abnormal symptoms or signs and the mother's previous chemotherapy was carefully documented. In all of the children studied, physical, neurological, psychological, hematological, immune function, and cytogenetics were normal. These results suggest that chemotherapy can be administered during pregnancy, even during the first trimester, because it is not hazardous to the fetus; nevertheless, this study is inadequate in size to exclude the possibility of teratogenesis, and more reports are necessary to define the best treatment from cancer during pregnancy.

Growth and development of children of mothers treated with chemotherapy during pregnancy: current status of 43 children.

Solitary bone plasmacytoma (SBP) is a rare presentation of plasma cell dyscrasias. Radiotherapy has been considered the treatment of choice, however, most patients will develop multiple myeloma, 3 to 10 years after initial diagnosis and treatment. No innovations have been introduced in the treatment of SBP in the last 30 years. We began a prospective clinical trial to assess the efficacy and toxicity of adjuvant chemotherapy with low doses of melphalan and prednisone administered to patients with SBP after radiation therapy in an attempt to improve the disease-free survival and overall survival. Between 1982 and 1989, 53 patients with SBP were randomly assigned to be treated with either local radiotherapy with doses ranged from 4000 to 5000 cGy to achieve local control of disease (28 patients) or the same radiotherapy schedule followed by melphalan and prednisone given every 6 weeks for 3 years (25 patients). After a median follow-up of 8.9 years, disease-free survival and overall survival were improved in patients who were treated with combined therapy, 22 patients remain alive and free of disease in the combined treatment group compared to only 13 patients in the radiotherapy group (p < 0.01). Treatment was well tolerated; planned doses were administered in all cases; no delays in treatment or acute side-effects were observed during treatment. Long-term secondary toxicities including secondary neoplasms and acute leukaemia, have not been observed. We felt that the use of adjuvant chemotherapy after adequate doses of radiotherapy in patients with SBP improved duration of remission and survival without severe side-effects. However, as with other studies in SBP, the group was too small to draw definitive conclusions and more controlled clinical trials are necessary to define the role of this therapeutic approach in patients with SBP.

Improved outcome in solitary bone plasmacytomata with combined therapy.

A study was carried out to investigate the efficacy and toxicity of granulocyte colony-stimulating factor (G-CSF) in the treatment of infection in 119 severely granulocytopenic patients with hematological malignancies after intensive chemotherapy. Patients were assigned randomly to receive either antibiotics alone (ceftazidime, 2 g, i.v., every 8 h + amikacin 7.5 mg/kg, i.v., every 12 h) or the same antimicrobial regimen plus G-CSF (5 micrograms/kg/day, s.c.). Measurements were clinical improvement, eradication of infection and toxicity. Patients who received antibiotics plus G-CSF had more clinical responses (82 versus 60%), less superinfections (6 versus 20%), less mortality (5 versus 15 patients), less days in hospital (median 10 versus 27) and reduced antibiotic usage compared to patients who received only antibiotics. Hematological recovery (granulocytes > 1.0 x 10(9)/l) was also shorter in these patients (12 versus 23 days). Fungal infections occurred only in the group treated with antibiotics alone. Toxicity secondary to G-CSF was absent. We conclude that the addition of G-CSF to broad spectrum antibiotics is useful in selected patients with severe granulocyctopenia after intensive chemotherapy and infection, because if may prove the outcome in these patients.

Results of a randomized trial of granulocyte colony-stimulating factor in patients with infection and severe granulocytopenia.

Sixty-five cases of malignant lymphoma of the nose, paranasal sinuses and hard palate were retrospectively analysed to identify the presence or absence of angiocentric lesions. We observed that the 23 patients with angiocentric lesions had a worse prognosis with a shorter duration of response and also a shorter duration of survival, compared with 42 cases of malignant lymphoma of the same anatomical region but without angiocentric lesions. Patients with angiocentric lymphoma were associated with other bad prognostic factors such as elevated levels of lactic dehydrogenase and beta 2 microglobulin, local bone destruction and lymphopenia. Immunophenotyping studies showed that most patients with angiocentric lesions had T cell lymphomas (18 of 23, 78 per cent). We believe that patients with angiocentric T cell lymphomas of the nose, paranasal sinuses and hard palate represent a distinctive clinico-pathological entity with different clinical presentation and outcome. Patients with angiocentric T cell lymphomas had frequent relapse at extranodal sites and combined therapy should be considered as the initial therapeutic approach.

Angiocentric T-cell lymphoma of the nose, paranasal sinuses and hard palate.

Fifty-two patients with primary gastric lymphoma were randomly assigned to two different surgical approaches. Twenty-eight cases were diagnosed by endoscopy and treated with chemotherapy CHOP-Bleo (cyclophosphamide, adriamycin, vincristine, prednisone and bleomycin) alternating with CMED (cyclophosphamide, metothexate, etoposide and dexamethasone). Twenty four cases underwent debulking surgery (partial or total gastrectomy) followed by the same chemotherapy. No differences were observed in relapse free disease or survival in resected or unresected patients. Complications were more frequent and severe in patients who underwent surgery. We believe that surgery is not necessary in the treatment of patients with primary gastric lymphoma.

José C. Díaz-Maqueo

Papers

Growth and development of children of mothers treated with chemotherapy during pregnancy: current status of 43 children.

Improved outcome in solitary bone plasmacytomata with combined therapy.

Results of a randomized trial of granulocyte colony-stimulating factor in patients with infection and severe granulocytopenia.

Angiocentric T-cell lymphoma of the nose, paranasal sinuses and hard palate.

Is Surgery Necessary in the Treatment of Primary Gastric Non-Hodgkin Lymphoma?