`
`
`
`
`
`
`
`
`
`
`
`
`14. Blomsterwall E, Bilting M, Stephensen H, Wikkelso' C. Gait
`
`
`
`
`
`
`
`
`
`
`abnormality is not the only motor disturbance in normal pres-
`
`
`
`
`
`
`sure hydrocephalus. Scand J Rehabil Med 1995;27:205—209.
`
`
`
`
`
`
`
`
`
`15. Lindquist G, Malmgren H. Classification and diagnosis of or-
`
`
`
`
`
`
`ganic mental disorders. Acta Psychiatr Scand 1993;88(suppl
`
`373):5—64.
`
`
`
`
`
`
`
`
`
`
`16. Larsson A, Bergh A-C, Bilting M, Jacobsson L, Stephensen H,
`
`
`
`
`
`
`
`
`Wikkelso C. Regional cerebral blood flow in normal pressure
`
`
`
`
`
`
`hydrocephalus: diagnostic and prognostic aspects. Eur J Nucl
`
`
`Med 1994;21:118—123.
`
`
`
`
`
`
`
`
`
`17. Wikkelso' C, Andersson H, Blomstrand C, Lindquist G, Svendsen
`
`
`
`
`
`
`
`
`P. Normal pressure hydrocephalus: predictive value of the cere-
`
`
`
`
`
`
`
`brospinal fluid tap-test. Acta Neurol Scand 1986;73:556—573.
`
`
`
`
`
`
`
`
`18. Graff-Radford NR, Rezai K, Godersky JC, Eslinger P,
`
`
`
`
`
`
`
`
`
`Damasio H, Kirchner PT. Regional cerebral blood flow in nor-
`
`
`
`
`
`
`mal pressure hydrocephalus. J Neurol Neurosurg Psychiatry
`
`
`
`1987;50:1589—1596.
`
`
`
`
`
`
`
`
`
`
`19. Aurell A, Rosengren LE, Karlsson B, Olsson JE, Zbornikova
`
`
`
`
`
`
`
`
`
`V, Haglid KG. Determination of 8-100 and glial fibrillary
`
`
`
`
`
`
`
`
`acidic protein concentrations in cerebrospinal fluid after brain
`
`
`
`infarction. Stroke 1991;22:1254—1258.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`20. Graff-Radford NR, Godersky JC. Normal pressure hydroceph-
`
`
`
`
`
`
`
`
`alus: onset of gait abnormality before dementia predicts a
`
`
`
`
`
`
`good surgical outcome. Arch Neurol 1986;43:940—942.
`
`
`
`
`
`
`
`
`
`
`21. Jacobs L, Conti D, Kinkel WR, Manning EJ. Normal pressure
`
`
`
`
`
`
`hydrocephalus: relationship of clinical and radiographic find-
`
`
`
`
`
`
`
`ings to improvement following shunt surgery. JAMA 1976;
`
`235:510—512.
`
`
`
`
`
`
`
`
`
`
`22. Petersen RC, Mokri B, Laws ER. Surgical treatment of idio-
`
`
`
`
`
`
`pathic hydrocephalus in elderly patients. Neurology 1985;35:
`
`
`307—311.
`
`
`
`
`
`
`
`
`23. Grafi-Radford NR, Godersky JC, Jones NP. Variables predict-
`
`
`
`
`
`
`
`ing surgical outcome in symptomatic hydrocephalus in the
`
`
`
`elderly. Neurology 1989;39:1601—1604.
`
`
`
`
`
`
`
`
`
`24. Koto A, Rosenburg G, Zingesser LH, Horoupian D, Katzman
`
`
`
`
`
`
`
`R. Syndrome of normal pressure hydrocephalus: possible rela-
`
`
`
`
`
`
`tion to hypertensive and arteriosclerotic vasculopathy. J Neu-
`
`
`
`
`rol Neurosurg Psychiatry 1977;40:73—79.
`
`
`
`
`
`
`
`25. Graff-Radford NR, Godersky JC. Idiopathic normal pressure
`
`
`
`
`
`hydrocephalus and systemic hypertension. Neurology 1987;37:
`
`868—871.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Effect of copolymer-l on serial
`
`
`
`gadolinium-enhanced MRI in relapsing
`
`
`
`remitting multiple sclerosis
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`G.L. Mancardi, MD; F. Sardanelli, MD; R.C. Parodi, MD; E. Melani, MD; E. Capello, MD; M. Inglese, MD;
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`A. Ferrari, PhD; M.P. Sormani, PhD; C. Ottonello, MD; F. Levrero, PhD; A. Uccelli, MD; and P. Bruzzi, MD
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Article abstract—We examined the effect of Copolymer—l (Copl) on magnetic resonance (MR) imaging changes in 10
`
`
`
`
`
`
`
`
`
`
`
`
`
`patients with relapsing-remitting multiple sclerosis (RRMS). Monthly gadolinium (Gd)-enhanced MR imaging was per-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`formed for 9 to 27 months in the pretreatment period followed by 10 to 14 additional months during Copl treatment. MR
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`images were evaluated by two radiologists (PS. and R.C.P.) masked to the scan date. We found a 57% decrease in the
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`frequency of new Gd—enhancing lesions and in the mean area/month of new Gd-enhancing lesions in the Copl treatment
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`period compared with the pretreatment period (0.92 versus 2.20 lesions per month and 22 mm2 versus 43 mm2 area/
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`month; p = 0.1, Wilcoxon signed rank test). Percentage change in lesion load area on T2-weighted images showed a
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`decrease in the accumulation of lesion area during treatment, which was significant for the patient group with a longer
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`pretreatment period (p = 0.05, Friedman test). These results demonstrate a reduction in the number of new Gd-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`enhancing lesions and in the lesion load during Copl treatment compared with the preceding period without therapy and
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`are suggestive of an effect of Copl on MR abnormalities observed in multiple sclerosis.
`
`
`NEUROLOGY 1998;50:1127—1 133
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Magnetic resonance (MR) imaging is increasingly
`exacerbation rate and occurrence of contrast enhanc-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`ing lesions3 and between disability (Expanded Dis-
`used in monitoring the clinical course of multiple
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`ability Status Scale [EDSSD and frequency of acute
`sclerosis (MS) and assessing the therapeutic effects
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`enhancing lesions.4 Moreover, the total lesion load
`of promising treatments.” Although the relation be-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`tween clinical and MR measures remains weak, a
`detected on T2-weighted images at MR examination
`
`
`
`
`
`
`
`
`
`
`
`
`
`correlation between MR changes and clinical course
`correlates with clinical progression in monosymp-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`has been demonstrated. There is a relation between
`tomatic disease5 and the increase in disability is re-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`From the Department of Neurological Sciences (Drs. Mancardi, Capella, Inglese, and Uccelli) and the Institute of Radiology (Drs. Sardanelli, Parodi, Melani,
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`and Ottonello), University of Genoa; Medical Physics (Drs. Ferrari and Levrero), S. Martino Hospital, Genoa; and the Unit of Clinical Epidemiology and
`
`
`
`
`
`
`
`
`
`
`Trials (Drs. Sormani and Bruzzi), National Cancer Institute, Genoa, Italy.
`
`
`
`
`
`
`
`
`
`
`Supported in part by Teva Pharmaceutical Industries, Petah Tiqva, Israel.
`
`
`
`
`
`
`
`
`
`
`
`
`Mylan v. Biogen
`
`Presented at the annual meeting of the American Neurological Association, Miami, FL, October 1996.
`
`
`
`
`
`
`
`
`
`
`Received March 17, 1997. Accepted in final form September 5, 1997.
`IPR 2018-01403
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Address correspondence and reprint requests to Dr. G.L. Mancardi, Department of Neurological Sciences, University of Genoa, via De Toni 5, 16132 Genoa,
`
`Italy.
`
`Biogen Exhibit 2077
`
`
`
`
`
`
`
`
`Page 1 of 7
`
`
`
`
`
`
`
`
`
`
`Copyright © 1998 by the American Academy of Neurology
`
`1127
`
`
`
`Page 1 of 7
`
`Biogen Exhibit 2077
`Mylan v. Biogen
`IPR 2018-01403
`
`

`

`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`lated to the accumulation of hypointense lesion load
`
`
`
`
`
`on T1-weighted images.“7 Although clinical end-
`
`
`
`
`
`
`points remain the definitive measure of treatment
`
`
`
`
`
`
`
`
`efficacy, an effective therapy should also have a ben-
`
`
`
`
`
`
`
`
`eficial effect on an objective marker of disease activ-
`
`
`
`
`
`ity such as MR imaging.
`
`
`
`
`
`
`
`Three treatments have been proven to reduce the
`
`
`
`
`
`
`
`
`
`relapse rate and, possibly, have an effect on the nat-
`
`
`
`
`
`ural course of relapsing-remitting multiple sclerosis
`
`
`
`
`
`(RRMS): interferon beta 1b,8 Copolymer-l (Copl),9
`
`
`
`
`
`
`
`
`and interferon beta 1a.10 Although the effects of the
`
`
`
`
`
`
`
`interferons on the pathologic process of the disease
`
`
`
`
`
`
`
`are strongly supported by MR imaging data—which
`
`
`
`
`
`
`
`
`
`show a decrease in the number of active brain
`
`
`
`
`
`
`
`
`
`
`lesions”13 and in the accumulation of the MR lesion
`
`
`
`
`
`
`
`
`load‘l—information on the effect of Copl on MR
`
`
`
`changes remains limited.14
`
`
`
`
`
`
`
`
`
`In this study, the effect of Copl was evaluated
`
`
`
`
`
`
`
`
`in 10 patients with RRMS studied with serial
`
`
`
`gadolinium-diethylenetriamine penta-acetic acid
`
`
`
`
`
`
`
`
`(Gd)—enhanced MR imaging for a long period of time,
`
`
`
`
`
`
`
`comparing the monthly frequency of new Gd-
`
`
`
`
`
`
`enhanced lesions on T1-weighted images,
`the
`
`
`
`
`
`
`
`
`monthly enhanced area of the new enhancing le-
`
`
`
`
`
`
`
`
`
`sions, and the rate of accumulation of lesion burden
`
`
`
`
`
`
`
`on T2-weighted scans during the baseline pretreat-
`
`
`
`
`
`
`
`ment period with the subsequent Copl treatment
`
`period.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Materials and methods. Study design. A baseline ver-
`
`
`
`
`
`
`
`
`sus treatment design was used, with patients serving as
`
`
`
`
`
`
`
`
`
`
`their own controls,1 similar to the design used by Stone et
`
`
`
`
`
`
`
`
`
`al.13 to evaluate the effect of interferon beta 1b on contrast-
`
`
`
`
`
`
`
`enhanced MR imaging. Ten patients with clinically con-
`
`
`
`
`
`
`
`
`
`
`firmed RRMS had monthly MR imaging for 9 to 27 months
`
`
`
`
`
`
`
`
`
`in the pretreatment period followed by 10 to 14 additional
`
`
`
`
`
`
`
`months with serial MR imaging during Copl treatment.
`
`
`
`
`
`T2-weighted scans and Gd-enhanced Tl-weighted scans
`
`
`
`
`
`
`
`
`
`
`were obtained at each visit. Six of the 10 patients were
`
`
`
`
`
`
`
`
`
`
`followed for a long pretreatment period of 25 to 27 months
`
`
`
`
`
`
`
`
`
`
`and four patients were followed for 9 to 12 months before
`
`
`
`
`
`
`
`initiating treatment. All these patients were initially in-
`
`
`
`
`
`
`
`
`
`
`cluded in a study of MR imaging changes related to the
`
`
`
`
`
`
`
`
`
`
`
`natural course of the disease. At the end of the study, they
`
`
`
`
`
`
`
`
`were offered the opportunity to begin treatment with Copl.
`
`
`
`
`
`
`
`The MR imaging-derived primary endpoint was the differ-
`
`
`
`
`
`
`
`
`
`ence in the mean number of new Gd-enhancing lesions per
`
`
`
`
`
`
`
`month on T1-weighted images between the treatment and
`
`
`
`
`
`
`pretreatment periods. New enhancing lesions were defined
`
`
`
`
`
`
`
`
`
`as those that did not enhance in the preceding examina—
`
`
`
`
`
`
`
`tion. Therefore, areas of persistent enhancement that en—
`
`
`
`
`
`
`
`
`
`hanced on the preceding scan were not counted as new
`
`lesions.
`
`
`
`
`
`
`
`Secondary study endpoints were the difference in the
`
`
`
`
`
`
`mean enhancing area/month of new Gd-enhancing lesions
`
`
`
`
`
`
`
`between the treatment and pretreatment periods; the dif-
`
`
`
`
`
`
`
`
`
`
`ference in the proportion of months with at least one new
`
`
`
`
`
`
`
`Gd-enhancing lesion in the treatment versus the pretreat-
`
`
`
`
`
`
`
`
`
`
`ment period; or the change in rate of accumulation of le-
`
`
`
`
`
`
`
`
`sion load measured on T2-weighted images in the periods
`
`
`
`
`
`
`
`
`before and during Copl treatment. This protocol was ap-
`
`
`
`
`
`1128 NELRagao2 0f 1pm 1998
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`proved by the Ethics Committee of Genoa University and
`
`
`
`
`
`
`
`informed consent was obtained from each patient.
`
`
`
`
`
`
`
`Patients and treatment. Entry criteria included a defi-
`
`
`
`
`
`
`
`
`
`nite diagnosis of MS of the relapsing remitting type with
`
`
`
`
`
`
`
`
`
`
`at least two clinical relapses in the previous 2 years. The
`
`
`
`
`
`
`
`
`
`
`patients were not selected on the basis of the MR imaging
`
`
`
`
`
`
`
`
`activity. The patient group included four women and six
`
`
`
`
`
`
`
`
`
`
`
`
`men with a mean age of 36.6 i 9.9 years and a mean
`
`
`
`
`
`
`
`
`
`
`disease duration of 12 i 7 years. EDSS at baseline was
`
`
`
`
`
`
`
`
`
`
`3.8 i 1.25 and ambulation index 2.3 i 1.06. EDSS at the
`
`
`
`
`
`
`
`
`
`
`end of pretreatment period was 4.1 i 1.17. During the
`
`
`
`
`
`
`treatment, the patients received daily subcutaneous injec-
`
`
`
`
`
`
`tions of 20 mg Copl (Copaxone).
`
`
`
`
`
`
`
`
`MR protocol. The same 0.5-T imager (Esatom MR
`
`
`
`
`
`
`
`
`
`
`5000; Esaote SpA, Genoa, Italy) was used during the en-
`
`
`
`
`
`
`
`
`
`
`tire trial period. Axial oblique images parallel to the bi-
`
`
`
`
`
`
`
`
`
`commissural plane, with a slice thickness of 5-mm and
`
`
`
`
`
`
`
`
`
`l-mm gap interslice, were acquired (field of view was
`
`
`
`
`
`
`
`
`
`
`
`26.1 X 19.5 cm and matrix 192 X 256); spin-echo (SE)
`
`
`
`
`
`
`
`
`
`slightly T2-weighted images (TR/TE = 2000/30 ms, 1 exci-
`
`
`
`
`
`
`
`
`
`tation) were obtained and followed by SE T1-weighted im—
`
`
`
`
`
`
`
`
`
`
`ages (TR/TE = 660/20 ms, 2 excitations) 5 minutes after
`
`
`
`
`
`
`
`intravenous administration of 0.15 mmol/Kg Gd (Magnev-
`
`
`
`
`
`
`
`
`ist Schering; Berlin, Germany). All images were photo-
`
`
`
`
`
`
`
`
`
`
`
`graphed by a laser imager and stored on a magnetic tape.
`
`
`
`
`
`
`
`
`
`The guidelines stated by Miller et al.15 were carefully
`
`observed.
`
`
`
`
`
`
`
`Image analysis. MR images were segmented, patient
`
`
`
`
`
`
`
`
`by patient, using a semiautomated “growing region” soft-
`
`
`
`
`
`
`
`
`
`ware package by two radiologists (F.S., R.C.P.) masked to
`
`
`
`
`
`
`
`
`
`the scan date. The first radiologist segmented the Gd—Tl-
`
`
`
`
`
`
`
`
`weighted images, counting the number of enhancing areas
`
`
`
`
`
`
`
`
`
`and determining the area of enhancement; the second ra-
`
`
`
`
`
`
`
`diologist examined the T2—weighted scans, obtaining the
`
`
`
`
`
`
`
`
`
`
`lesion load. The procedure of analysis was as follows: a
`
`
`
`
`
`
`
`T2-weighted or a Gd-Tl-weighted image was randomly
`
`
`
`
`
`
`
`
`
`
`
`
`presented on the screen to the user, who did not know if
`
`
`
`
`
`
`
`
`
`the image belonged to the pretreatment or treatment pe—
`
`
`
`
`
`
`
`
`riod. The evaluation was therefore performed in a manner
`
`
`
`
`
`
`
`
`
`
`
`
`
`masked to the date of the scan. If one or more lesions were
`
`
`
`
`
`
`
`
`
`
`
`present, the user chose a top and bottom line and the
`
`
`
`
`
`
`
`
`
`
`median longitudinal axis of the cranial image. If this longi-
`
`
`
`
`
`
`
`
`
`
`tudinal axis was not perfectly vertical, the image was ro-
`
`
`
`
`
`
`
`
`
`tated moving the axis in vertical position before starting
`
`
`
`
`
`
`
`
`the segmentation. Examining image by image, the radiolo-
`
`
`
`
`
`
`
`
`
`gist could identify and count each enhancing lesion by
`
`
`
`
`
`
`
`
`
`
`“clicking” a point inside the lesion with the mouse. The site
`
`
`
`
`
`
`
`
`
`
`
`of the lesion was defined by the software using two Carte-
`
`
`
`
`
`
`
`
`
`sian coordinates. Lesion area of enhancement on T1- or
`
`
`
`
`
`
`
`
`lesion area on T2-weighted images was determined using a
`
`
`
`
`
`
`
`
`segmentation method based on a growing region, begin-
`
`
`
`
`
`
`
`
`
`
`ning from the seed identified by the operator clicking a
`
`
`
`
`
`
`
`
`
`point inside the lesion. The region then grows, including
`
`
`
`
`
`
`
`
`pixels spatially connected with signal levels between two
`
`
`
`
`
`
`
`
`
`thresholds that were calculated from the analysis of the
`
`
`
`
`
`
`
`
`
`
`signal level histograms of the lesion region of interest. The
`
`
`
`
`
`
`
`
`
`
`operator can change the thresholds to obtain the best cov-
`
`
`
`
`
`
`
`
`
`
`
`
`ering of the lesion. This method was verified on a subset of
`
`
`
`
`
`
`
`
`
`
`the data obtained in this trial: 22 Gd-enhancing lesions on
`
`
`
`
`
`
`
`
`
`T1- and 42 lesions on T2-weighted images were selected
`
`
`
`
`
`
`
`
`and randomly presented to three radiologists who repeated
`
`
`
`
`
`
`
`the growing region segmentation three times. Moreover,
`
`
`
`
`
`
`
`
`
`measurements were carried out of 47 lesions on Gd-
`
`Page 2 of 7
`
`

`

`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`enhancing T1- and 40 lesions on T2-weighted images with
`
`
`
`
`
`
`
`
`both the growing region and standard manual contouring
`
`
`
`
`
`
`
`
`methods. All these data were evaluated with two-way
`
`
`
`
`
`
`
`
`analysis of variance (“fixed effect” model). The intraob-
`
`
`
`
`
`
`
`
`server variability was 3.8 pixels on T1-weighted images
`
`
`
`
`
`
`
`
`
`
`(3.7% of the total variability) and 5.9 pixels on T2-
`
`
`
`
`
`
`
`
`weighted images (2.1% of the total variability). The inter-
`
`
`
`
`
`
`
`
`rater variability was significant (p = 0.02) but appraised
`
`
`
`
`
`
`
`
`
`
`about 1 pixel for T1-weighted images, and was not signifi-
`
`
`
`
`
`
`
`
`cant for T2-weighted images. Data analysis showed that
`
`
`
`
`
`
`
`
`the growing region segmentation was affected by a reduced
`
`
`
`
`
`
`
`
`variance both for T1- and T2-weighted images (p < 0.01).16
`
`
`
`
`
`
`
`Therefore, the segmentation method used in this study
`
`
`
`
`
`
`
`was reproducible and less user-dependent than the stan-
`
`
`
`
`dard manual contouring method.
`
`
`
`
`
`
`
`
`Site, number of enhancing lesions, and area of enhance-
`
`
`
`
`
`
`
`
`ment of each lesion were recorded for each Gd—enhanced
`
`
`
`
`
`
`
`
`
`T1—weighted image; site and area of each lesion were re-
`
`
`
`
`
`
`
`corded for each T2-weighted image. Number of enhancing
`
`
`
`
`
`
`lesions, enhancing area (mmz) on Gd-enhanced T1-
`
`
`
`
`
`
`
`
`weighted images, and total
`lesion area (mmz) on T2-
`
`
`
`
`
`
`
`weighted images were calculated per monthly scan.
`
`
`
`
`
`
`
`
`To obtain the number of new Gd-enhancing lesions, 3
`
`
`
`
`
`
`specific algorithm was elaborated.l7 To decide whether two
`
`
`
`
`
`
`
`
`
`lesions present on the same slice in two subsequent exam-
`
`
`
`
`
`
`
`
`inations are the same, the automated procedure uses an
`
`
`
`
`
`
`algorithm including Cartesian coordinates of the lesions,
`
`
`
`
`
`
`
`
`their area (schematized as circle), and a constant. The
`
`
`
`
`
`
`
`
`
`
`used algorithm is (xi — xk)2 + (yi — yk)2 < (C(ail/2 +
`
`
`
`
`
`
`
`
`
`akl’2)2)/Tr, where x,, yi, and ai are, respectively, the abscissa
`
`
`
`
`
`
`
`
`
`
`
`and the ordinate of the seed and the area of the lesion
`
`
`
`
`
`
`
`
`
`under analysis; xk, yk, and ak are the same measurements
`
`
`
`
`
`
`
`
`
`
`calculated on the k-th lesion of the preceding MR scan; c is
`
`
`
`
`
`
`
`
`
`
`a constant to be calculated (0 < c < 1). When the inequal-
`
`
`
`
`
`
`
`
`
`
`ity holds, the two lesions are considered as the same. The
`
`
`
`
`
`
`automatic determination of the new Gd—enhancing lesions
`
`
`
`
`
`
`
`
`
`
`was compared with the visual analysis of a subset of se-
`
`
`
`
`
`
`
`
`quential scans; the c value was determined evaluating 27
`
`
`
`
`
`
`
`
`enhancing lesions on Gd T1-weighted images. With 0.4 <
`
`
`
`
`
`
`
`
`
`
`
`c < 0.5, all the lesions considered new in our study using
`
`
`
`
`
`
`
`the automatic method would have been considered new
`
`
`
`
`with a visual analysis.17
`
`
`
`
`
`
`
`
`
`Percentage change from baseline in lesion area was cal-
`
`
`
`
`
`
`
`
`
`culated on T2-weighted images: for the six patients with
`
`
`
`
`
`
`
`
`
`
`the longest follow-up, the mean total lesion area was deter-
`
`
`
`
`
`
`
`
`
`mined 2 years before treatment, 1 year before treatment,
`
`
`
`
`
`
`
`
`
`immediately before beginning treatment, and at the end of
`
`
`
`
`
`
`
`
`
`
`the treatment period. The same was calculated for all 10
`
`
`
`
`
`
`
`patients, but without the -2 years measure.
`
`
`
`
`
`
`
`Statistical analysis. The standard approach to evalu-
`
`
`
`
`
`
`
`
`
`ate the difference in the occurrence of lesions between
`
`
`
`
`
`
`
`
`pretreatment and treatment periods in studies with a
`
`
`
`
`
`
`
`
`
`baseline versus treatment design is, according to Nauta et
`
`
`
`
`
`
`
`
`
`
`
`al.18 and Mc Farland et al.,1 the Wilcoxon signed rank test,
`
`
`
`
`
`
`
`
`
`
`contrasting the mean number of lesions per month in the
`
`
`
`
`
`
`
`
`
`two periods in each patient. However, this approach has
`
`
`
`
`
`
`
`
`
`low statistical power as all observations in each patient
`
`
`
`
`
`
`
`
`
`are collapsed into a single figure, with a substantial loss of
`
`
`
`
`
`
`
`
`information. Therefore, to overcome this problem, we also
`
`
`
`
`
`
`
`
`
`
`analyzed the results in a secondary analysis as a series of
`
`
`
`
`
`
`
`
`
`single patient trials using the Mantel’s extension of the
`
`
`
`
`
`
`
`
`
`
`Mantel-Haenszel test”; that is, a test for trend in propor-
`
`
`
`
`
`
`
`
`
`tions. For each patient, each observation (i.e., month) was
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Page 3 0f 7
`
`
`
`
`
`
`
`
`
`weighted according to the number of new Gd-enhancing
`
`
`
`
`
`
`
`
`
`
`lesions. This approach is identical to that used in meta-
`
`
`
`
`
`
`
`
`analyses, as within-patient (each one considered as an
`
`
`
`
`
`
`independent
`trial) differences between observed and
`
`
`
`
`
`
`
`
`
`
`expected events are pooled into a summary test of signifi-
`
`
`
`
`
`
`
`
`
`
`
`
`
`cance, and is similar to that used by Moreau et 31.20 in a
`
`
`
`
`
`
`
`
`preliminary study evaluating the effect of the humanized
`
`
`
`
`
`
`monoclonal antibody CAMPATH-lH by monthly Gd-
`
`
`
`
`
`
`
`
`
`enhanced MR images. Using a similar approach, the pro-
`
`
`
`
`
`
`
`
`
`
`portion of scans with new Gd-enhancing lesions in the two
`
`
`
`
`
`
`
`
`
`periods was computed for each patient,
`to estimate the
`
`
`
`
`
`
`
`
`
`relative odds (odds ratio and 95% confidence limits) of
`
`
`
`
`
`
`
`
`
`
`having at least one new Gd-enhancing lesion at any month
`
`
`
`
`
`
`
`
`during the pretreatment period compared to the treatment
`
`
`
`
`
`
`
`
`
`period. A pooled estimate of the summary odds ratio
`
`
`
`
`
`
`
`
`
`
`among all patients was obtained by means of the Mantel-
`
`
`
`
`
`
`
`
`Haenszel procedure.21 All analyses were conducted in pa-
`
`
`
`
`
`
`
`
`tients using the entire pretreatment period and replicated
`
`
`
`
`
`
`
`
`
`focusing on the 12 months before initiating the treatment.
`
`
`
`
`
`
`
`
`
`
`As the results of the analyses closely resemble one an-
`
`
`
`
`
`
`other, only the former are presented.
`
`
`
`
`
`
`
`
`Percentage changes in lesion area from baseline on T2-
`
`
`
`
`
`
`weighted images during the pretreatment and treatment
`
`
`
`
`
`
`
`
`periods were analyzed using the Friedman test. SPSS and
`
`
`
`
`
`
`
`
`SAS software were used for the statistical analyses.
`
`
`
`
`
`
`Results. New Gd-enhanced lesions. During the pre-
`
`
`
`
`
`
`
`
`treatment period, 477 areas of Gd enhancement were de-
`
`
`
`
`
`
`
`
`
`tected in all 10 patients, and 139 areas during treatment
`
`
`
`
`
`
`
`
`with Copl. Of these areas, 397 during pretreatment and
`
`
`
`
`
`
`
`115 during treatment were classified as new Gd—enhancing
`
`lesions.
`
`
`
`
`
`
`
`
`
`Table 1 shows the mean rate of new Gd-enhancing le-
`
`
`
`
`
`
`
`
`sions per scan before and during treatment with Copl.
`
`
`
`
`
`
`
`
`
`
`
`Seven of the 10 patients had a 29% to 80% reduction in the
`
`
`
`
`
`
`
`
`
`number of lesions per scan. One patient had no lesions
`
`
`
`
`
`
`
`
`during the pretreatment period and 0.25 lesions per scan
`
`
`
`
`
`
`
`
`during treatment. One patient had no change (2/27 versus
`
`
`
`
`
`
`
`
`
`1/13 lesions/scan) and one patient had an increase of 157%.
`
`
`
`
`
`
`
`
`
`The mean number of new Gd-enhanced lesions per scan in
`
`
`
`
`
`
`
`
`the pretreatment period was 2.20 compared to 0.92 during
`
`
`
`
`
`
`
`the Copl treatment period, indicating an average total
`
`
`
`
`
`
`
`reduction of 57% in lesions/scan (p = 0.10, Wilcoxon
`
`
`
`signed rank test).
`
`
`
`
`
`
`
`
`
`To take advantage of the large number of scans per-
`
`
`
`
`
`
`
`formed and to obtain further information with a secondary
`
`
`
`
`
`
`
`
`
`
`analysis of a possible effect of Copl, the number of new
`
`
`
`
`
`
`
`Gd-enhancing lesions observed in each scan were com—
`
`
`
`
`
`
`
`
`pared for each patient in the pretreatment and treatment
`
`
`
`
`
`
`
`
`periods. The results, pooled by means of the Mantel-
`
`
`
`
`
`
`
`Haenszel test, showed a significant reduction in the occur-
`
`
`
`
`
`
`
`rence of new Gd-enhancing lesions during treatment (table
`
`
`
`
`
`
`
`
`
`
`
`
`2; x2 = 8.77; df = 1; p = 0.003). The reduction in the
`
`
`
`
`
`
`
`proportion of scans with new Gd-enhancing lesions during
`
`
`
`
`
`
`
`
`the period of treatment with Copl was also statistically
`
`
`
`
`
`
`
`significant. During the pretreatment period, 44% of scans
`
`
`
`
`
`
`
`
`showed at least one new Gd-enhancing lesion as compared
`
`
`
`
`
`
`
`
`
`to 29% of scans during the treatment period (x2 = 11.091;
`
`
`
`
`
`
`
`
`
`p = 0.001); the odds ratio, computed as a weighted average
`
`
`
`
`
`
`
`
`
`
`
`of the patient specific odds ratio, was 0.40 (95% CI = 0.23
`
`
`to 0.68).
`
`
`
`
`
`
`Area of Gd-enhanced lesions. The mean enhancing
`
`
`
`
`
`
`
`
`
`
`area of a single lesion was very similar before and after
`
`
`
`
`
`
`
`
`
`
`treatment (13 i 2.4 versus 14 i 2.1 mm2). As a conse-
`
`
`
`April 1998 NEUROLOGY 50
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`1129
`
`Page 3 of 7
`
`

`

`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Table 1 Mean rate of new gadolinium (Gd)-enhancing lesions during the pretreatment and treatment period
`
`
`
`New Gd-enhancing lesions
`
`
`
`
`
`
`Treatment period
`Full pretreatment period
`
` Patient Lesions Months Rate Lesions Months Rate % Difference
`
`
`
`
`
`
`
`
`
`
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`16
`
`18
`
`98
`
`0
`
`181
`
`55
`
`25
`
`10
`
`27
`
`27
`
`10
`
`9
`
`27
`
`25
`
`0.64
`
`0.90
`
`0.07
`
`0.67
`
`9.80
`
`0.00
`
`6.70
`
`2.20
`
`2
`
`2
`
`1
`
`2
`
`56
`
`3
`
`25
`
`6
`
`13
`
`13
`
`13
`
`13
`
`13
`
`12
`
`13
`
`14
`
`0.15
`
`0.15
`
`0.08
`
`0.15
`
`4.31
`
`0.25
`
`1.92
`
`0.43
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`#2909
`1
`11
`26
`0.42
`3
`10
`0.30
`
`
`
`
`
`
`
`
`—75.96
`
`
`
`
`
`
`
`
`-82.91
`
`
`
`
`
`
`
`
`+3.85
`
`
`
`
`
`
`
`
`—76.92
`
`
`
`
`
`
`
`
`—56.04
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`—
`
`
`—71.31
`
`—80.52
`
`
`10
`
`
`
`7
`
`12
`
`0.58
`
`15
`
`10
`
`1.50
`
`+157.14
`
`—57.00
`0.92
`2.20
`Mean
`
`
`
`
`
`
`
`
`(-80.52 + +3.85)
`(0.15 + 1.92)
`(0.07 + 6.70)
`95% CI*
`
`
`
`
`
`0.66 0.28Median —63.68
`
`
`
`
`
`
`
`* Rank-based confidence intervals for the median.
`
`
`
`
`
`
`
`p = 0.1 (Wilcoxon signed rank test).
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`quence, the decline in mean total area of Gd-enhanced
`
`
`
`
`
`
`
`
`
`lesions/month paralleled to the decrease in the number of
`
`
`
`
`
`
`
`
`
`enhancing lesions. The mean total area of new Gd-
`
`
`
`
`
`
`enhancing lesions/month during the pretreatment period
`
`
`
`
`
`
`
`
`
`
`
`
`
`was 43 i 22 mm2 compared to 22 i 11 mm2 during the
`
`
`
`
`
`
`
`
`
`Copl period (p = 0.09, Wilcoxon signed rank test). Exam-
`
`
`
`
`
`
`
`
`
`
`ples of the number and area of new Gd-enhancing lesions
`
`
`
`
`
`
`
`
`
`
`on monthly MR images of four patients with the most
`
`
`
`
`
`
`
`
`
`
`active scans in the pretreatment period are shown in the
`
`figure.
`
`
`
`
`
`
`
`Lesion load on T2—weighted images. The mean total
`
`
`
`
`
`
`
`
`lesion load on T2-weighted images was determined at dif-
`
`
`
`
`
`
`
`
`
`ferent times: in the six patients with a longer pretreat-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`ment follow-up, there was an increase of lesion load of 24%
`
`
`
`
`
`
`
`
`
`between —2 years and —1 year and 8% between -1 year
`
`
`
`
`
`
`
`
`
`and treatment initiation; and a decrease of 4% between the
`
`
`
`
`
`
`
`
`
`
`
`beginning and end of treatment (Friedman x2 = 7.0, df =
`
`
`
`
`
`
`
`
`
`
`
`
`2, p = 0.05). For all 10 patients, there was an increase of
`
`
`
`
`
`
`
`
`
`
`
`
`14% in the mean total lesion load from —1 year to treat-
`
`
`
`
`
`
`
`
`
`ment initiation, and a very small increase (+2%) from the
`
`
`
`
`
`
`
`
`
`beginning to the end of treatment (p = 0.14, Wilcoxon
`
`
`
`signed rank test).
`
`
`
`
`
`
`
`Clinical data. All patients were examined every 3
`
`
`
`
`
`
`
`
`
`months and within 3 days from a clinical relapse during
`
`
`
`
`
`
`
`both the pretreatment and treatment periods. During the
`
`
`
`
`
`
`pretreatment period, 42 confirmed relapses occurred com-
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Table 2 Number of scans with gadolinium (Gd)-enhancing lesions
`
`Patient 5
`Patient 6
`Patient 7
`Patient 8
`Patient 9
`Patient 10
`Patient 1
`Patient 2
`Patient 3
`Patient 4
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Pre-
`Pre-
`Pre-
`Pre-
`Pre-
`Pre-
`Pre-
`Pre—
`Pte—
`Number Pre-
`
`
`
`
`
`
`
`
`
`
`
`treat Treat
`treat Treat
`treat Treat
`treat Treat
`treat Treat
`treat Treat
`treat Treat
`treat Treat
`treat Treat
`treat Treat
`lesions
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`0
`18
`7
`1 7
`1 1
`6
`12
`25
`12
`17
`1 1
`0
`3
`9
`9
`2
`7
`10
`10
`7
`6
`
`
`
`
`2
`
`0
`
`0
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`1
`
`0
`
`0
`
`5
`
`3
`
`1
`
`2
`
`O
`
`0
`
`1
`
`0
`
`1
`
`1
`
`3
`
`1
`
`0
`
`0
`
`0
`
`l
`
`0
`
`0
`
`6
`
`5
`
`3
`
`l
`
`1
`
`0
`
`5
`
`2
`
`0
`
`2
`
`2
`
`0
`
`4
`
`0
`
`1
`
`1
`
`O
`
`1
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`1
`
`
`
`2
`
`
`
`7
`
`0
`
`3
`
`0
`
`5
`
`1
`
`2
`
`0
`
`O
`
`2
`
`0
`
`1
`
`0
`
`1
`
`0
`
`3
`
`4
`
`5
`
`6
`
`
`
`
`
`
`
`
`0
`
`1
`
`0
`
`0
`
`0
`
`O
`
`0
`
`0
`
`1
`
`0
`
`0
`
`1
`
`0
`
`0
`
`0
`
`1
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`1
`
`0
`
`0
`
`0
`
`0
`
`O
`
`0
`
`1
`
`2
`
`0
`
`1
`
`2
`
`0
`
`1
`
`0
`
`0
`
`0
`
`O
`
`0
`
`0
`
`0
`
`0
`
`0
`
`1
`
`1
`
`0
`
`0
`
`0
`
`2
`
`2
`
`0
`
`4
`
`1
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`O
`
`0
`
`1
`
`1
`
`O
`
`
`
`
`
`
`
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`O
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`2
`
`1
`
`0
`
`0
`
`1
`
`1
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`7
`
`
`
`8
`
`9
`
`0
`
`4
`
`2
`
`0
`
`0
`
`6
`
`0
`
`1
`
`0
`
`0
`
`
`
`
`
`
`
`
`
`
`
`0 E
`
`
`
`10+
`
`
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`n lesions were observed in the two periods for each patient (see text for
`ach column reports the number of months in which 0, 1, .
`.
`.
`
`
`
`
`
`
`
`details and for the secondary statistical analysis).
`
`
`
`
`
`1130 NEBIflEQG‘YQJ 7April 1993
`
`Page 4 of 7
`
`

`

`
`
`
`
`
`
`
`
`
`pared to three relapses during the Copl treatment period.
`
`
`
`
`
`
`
`
`
`The yearly relapse rate was 2.5 during the pretreatment
`
`
`
`
`
`
`
`
`period and 0.3 during the treatment period. Corticosteroid
`
`
`
`
`
`
`
`
`
`
`therapy was given to treat 27 relapses during the pretreat-
`
`
`
`
`
`
`
`
`ment period and three relapses occurring during Copl
`
`
`
`
`
`
`
`treatment. The usual steroid therapy was intravenous
`
`
`
`
`
`
`
`
`
`
`methylprednisolone (1 g/day for 3 days; 0.5 g/day for 3
`
`
`
`
`
`
`
`
`days; 0.25 g/day for 3 days). Occasionally, dexamethasone
`
`
`
`
`
`
`
`
`
`
`
`(8 mg intramuscularly for 2 weeks) or ACTH (50 U intra-
`
`
`
`
`
`
`
`
`
`muscularly for 2 weeks) were also used. Considering the
`
`
`
`
`
`
`
`
`
`possible effect of steroid therapy on Gd enhancement, we
`
`
`
`
`
`
`
`
`
`repeated statistical analysis of the number of new Gd-
`
`
`
`
`
`
`
`
`
`enhancing lesions excluding the first month after each ste-
`
`
`
`
`
`
`
`
`roid treatment. The results were comparable to those
`
`
`
`
`
`
`
`
`
`obtained in the previous analysis (data not shown). The
`
`
`
`
`
`
`
`
`
`mean EDSS score was 3.8 at pretreatment baseline and
`
`
`
`
`
`
`
`
`
`
`
`4.1 at the end of the pretreatment period. The mean EDSS
`
`
`
`
`
`
`
`
`
`
`
`
`score did not change at the final visit following 1 year of
`
`therapy.
`
`
`
`
`
`
`
`
`Treatment with Copl was safe and well tolerated and
`
`
`
`
`
`
`
`
`adverse events were similar to those reported in previous
`
`
`
`
`
`
`
`
`trials of Copl,9 consisting of mild erythema and induration
`
`
`
`
`
`
`
`at the injection site and transient self-limited postinjection
`
`
`
`
`
`
`
`reaction, observed in three cases. This reaction occurred
`
`
`
`
`
`
`
`
`
`
`once in two patients and twice in the third, resolving spon-
`
`
`
`
`
`
`
`taneously after a few minutes without sequelae.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Discussion.
`In this study, we examined the effect
`
`
`
`
`
`
`
`
`
`
`of Copl on MR changes in 10 patients with RRMS.
`
`
`
`
`
`
`
`
`
`Six patients had a very long pretreatment period of
`
`
`
`
`
`
`
`
`
`
`25 to 27 months, four patients had a shorter pre-
`
`
`
`
`
`
`
`
`
`
`treatment period of 9 to 12 months. All patients were
`
`
`
`
`
`
`
`
`
`subsequently treated with Copl for 10 to 14 months.
`
`
`
`
`
`
`Monthly Gd-enhanced MR imaging was performed
`
`
`
`
`
`
`
`
`both before and during treatment. The mean number
`
`
`
`
`
`
`
`
`of new Gd-enhancing lesions per month on T1-
`
`
`
`
`
`
`
`weighted images, the mean enhancing area/month of
`
`
`
`
`
`
`
`new Gd-enhancing lesions, the proportion of months
`
`
`
`
`
`
`
`
`
`with at least one new Gd-enhancing lesion, and the
`
`
`
`
`
`
`
`
`change in the accumulation of lesion load measured
`
`
`
`
`
`
`
`
`on T2-weighted images were determined in the peri-
`
`
`
`
`
`
`
`
`
`ods before and during Copl treatment. A 57% de-
`
`
`
`
`
`
`
`
`crease in the frequency of new Gd-enhancing lesions
`
`
`
`
`
`
`
`was obtained during treatment with Copl (mean,
`
`
`
`
`
`
`
`
`
`
`0.92 per month; range, 0.08 to 4.31) as compared to
`
`
`
`
`
`
`
`the pretreatment period (mean, 2.20 per month;
`
`
`
`
`
`
`
`
`range, 0 to 9.80). Analysis of individual patients
`
`
`
`
`
`
`
`
`
`
`showed a reduction in 7 of 10 patients,
`two being
`
`
`
`
`
`
`
`
`
`inactive in both periods and one showing a