Tumor vaccines in 2010: need for integration

Induction of tumor-specific immunity is an attractive approach to cancer therapy, however to date every major pivotal trial has resulted in failure. While the phenomena of tumor-mediated immune suppression has been known for decades, only recently have specific molecular pathways been elucidated, and for the first time, rationale means of intervening and observing results of intervention have been developed. In this review we describe major advances in our understanding of tumor escape from immunological pressure and provide some possible therapeutic scenarios for enhancement of efficacy in future cancer vaccine trials.

Lasers, stem cells, and COPD

The medical use of low level laser (LLL) irradiation has been occurring for decades, primarily in the area of tissue healing and inflammatory conditions. Despite little mechanistic knowledge, the concept of a non-invasive, non-thermal intervention that has the potential to modulate regenerative processes is worthy of attention when searching for novel methods of augmenting stem cell-based therapies. Here we discuss the use of LLL irradiation as a "photoceutical" for enhancing production of stem cell growth/chemoattractant factors, stimulation of angiogenesis, and directly augmenting proliferation of stem cells. The combination of LLL together with allogeneic and autologous stem cells, as well as post-mobilization directing of stem cells will be discussed.

Mesenchymal stem cells as anti-inflammatories: implications for treatment of Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a lethal X-linked musculodegenerative condition consisting of an underlying genetic defect whose manifestation is augmented by inflammatory mechanisms. Previous treatment approaches using gene replacement, exon-skipping or allogeneic cell therapy have been relatively unsuccessful. The only intervention to mediate improvement in survival, albeit minor, is glucocorticoid treatment. Given this modality appears to function via suppression of underlying inflammation; we focus this review on the inflammatory response as a target for mesenchymal stem cell (MSC) therapy. In contrast to other cell based therapies attempted in DMD, MSC have the advantages of (a) ability to fuse with and genetically complement dystrophic muscle; (b) possess anti-inflammatory activities; and (c) produce trophic factors that may augment activity of endogenous repair cells. We conclude by describing one practical scenario of stem cell therapy for DMD.

Acute scurvy during treatment with interleukin-2

The association of vitamin C deficiency with nutritional factors is commonly recognized. However, an acute form of scurvy can occur in patients with an acute systemic inflammatory response, which is produced by sepsis, medications, cancer or acute inflammation. The frequency of acute hypovitaminosis C in hospitalized patients is higher than previously recognized. We report the occurrence of acute signs and symptoms of scurvy (perifollicular petechiae, erythema, gingivitis and bleeding) in a patient hospitalized for treatment of metastatic renal-cell carcinoma with high-dose interleukin-2. Concomitantly, serum vitamin C levels decreased to below normal. Better diets and longer lifespan may result a lower frequency of acute scurvy and a higher frequency of scurvy associated with systemic inflammatory responses. Therefore, increased awareness of this condition can lead to early recognition of the cutaneous signs of acute scurvy in hospitalized patients with acute illnesses or in receipt of biological agents, and prevent subsequent morbidity such as bleeding, anaemia, impaired immune defences, oedema or neurological symptoms.

Circulating endothelial progenitor cells: a new approach to anti-aging medicine?

Endothelial dysfunction is associated with major causes of morbidity and mortality, as well as numerous age-related conditions. The possibility of preserving or even rejuvenating endothelial function offers a potent means of preventing/treating some of the most fearful aspects of aging such as loss of mental, cardiovascular, and sexual function.

Endothelial precursor cells (EPC) provide a continual source of replenishment for damaged or senescent blood vessels. In this review we discuss the biological relevance of circulating EPC in a variety of pathologies in order to build the case that these cells act as an endogenous mechanism of regeneration. Factors controlling EPC mobilization, migration, and function, as well as therapeutic interventions based on mobilization of EPC will be reviewed. We conclude by discussing several clinically-relevant approaches to EPC mobilization and provide preliminary data on a food supplement, Stem-Kine, which enhanced EPC mobilization in human subjects.

Prophylactic antivirals may be helpful in prevention of varicella-zoster virus reactivation in myeloma, but are they safe?

PURPOSE

Retrospective analysis of two recent multiple myeloma (MM) clinical trials suggested that the use of bortezomib may be associated with an increased incidence of herpes zoster infections. Therefore, prophylactic use of antivirals has been advocated by some authors. This article explores the potential risks and pitfalls linked to routine acyclovir prophylaxis in bortezomib-treated MM.

SUMMARY

use of antivirals can be associated with important nephro- and neurotoxicity. The nephrotoxicity induced by MM itself and its supportive therapies, superimposed to aging and inherent immunosuppression in myeloma, makes the development of renal impairment even more likely. On the other hand, sensory neuropathy is known to occur both during myeloma progression and in the setting of bortezomib therapy. Furthermore, preexisting nephropathy in MM patients can contribute to the occurrence of serious neurologic toxicity with acyclovir.

CONCLUSIONS

long-term acyclovir prophylaxis in MM patients treated with bortezomib may cause severe renal and neurological toxicity. Prevention of these complications can be achieved through either withholding of the antivirals or a very close monitoring of both neurologic status and renal function in this patient population. This highlights the importance of both clinician's and pharmacist's involvement in optimization of myeloma patient care.

Mitoxantrone, vinblastine and CCNU: long-term follow-up of patients treated for advanced and poor-prognosis Hodgkin's disease

Advanced-stage or relapsed/refractory Hodgkin's disease (HD) has a poor prognosis despite aggressive chemotherapy regimens and the use of high-dose therapy with autologous stem cell support. Mitoxantrone, vinblastine and CCNU (lomustine) (MVC) combines the most effective chemotherapeutic agents of previous regimens for poor prognosis HD, and eliminates marginally active agents with unnecessary toxicities, such as bleomycin and dacarbazine. Sixty-eight patients with HD (23 newly diagnosed and 45 with relapsed/refractory disease, one patient treated both de novo and years later in relapse) were treated with the MVC regimen (mitoxantrone 8 mg/m(2)/day i.v. days 1 - 3; vinblastine 8 m/m(2)/day days 1 and 22; and CCNU (lomustine) 100 mg/m(2) on day 1, repeated at 6 - 8 weeks) in a single-arm Phase II study. All patients responded to treatment in the newly diagnosed group (overall response = 100%). The median response duration was not reached, but was in the range 7.6 - 180 + months, and median survival was 94 months. Eleven complete responses are ongoing at 39 - 180 + months. In the previously-treated patients, 41 responded to MVC (OR = 91%). The median response duration for this group was 11 months, and the median survival was 34 months after initiating MVC. Four secondary myeloid leukemias occurred, three in de novo, and one in the relapsed/refractory group, at a median follow-up of 14 years. MVC regimen for HD is highly active, for both de novo and relapsed/refractory disease, with high response rates and survival that compare favourably with the results obtained by high-dose therapy with stem-cell transplantation. Although significant, the toxicities associated with this regimen were manageable.

Carboplatin—gemcitabine in the therapy of advanced ovarian cancer: dose reduction consideration

Carboplatin—gemcitabine doublet is an important therapeutic option for patients with both previously treated and untreated ovarian cancer (OC). At the currently recommended dosing, its main toxicity is hematological, consisting of thrombocytopenia, neutropenia, including febrile neutropenia, and/or anemia. The use of platelet transfusions, G-CSF and/ or packed red blood cells is often necessary, in order to avoid treatment delays or omission of doses. We report here on the high efficacy of lower doses of gemcitabine at 750 mg/m2 on days 1 and 8 in combination with carboplatin AUC = 4 on day 1, repeated in 21-day cycles, in a small series of patients with advanced/metastatic OC. Using the above dose regimen, durable complete remissions were achieved in all patients in our cohort within 9—12 weeks, with no growth factor support, and no transfusions of blood components being necessary. We believe that lowering the doses of both carboplatin and gemcitabine from the start of therapy would ensure their timely delivery and steady-state plasma drug levels. In conclusion, administration of carboplatin AUC = 4 and gemcitabine 750 mg/m2 appears to be a safe and effective combination for the therapy of advanced/metastatic OC, with clinically tolerable hematological toxicity.

Sea urchin granuloma secondary to Strongylocentrotus purpuratus and Strongylocentrotus franciscanus

Sea urchin injuries have been associated with a variety of cutaneous lesions, ranging from acute, transient reactions, to more chronic inflammatory conditions that result in the formation of granulomas. Although diverse species of sea urchins have been reported to produce chronic cutaneous granulomas, the two most prevalent organisms found on the US West Coast, purple and red sea urchins (Strongylocentrotus purpuratus and Strongylocentrotus franciscanus), have not yet been reported to induce persistent granulomatosis in humans. We describe one case of a 35-year-old marine biologist with chronic cutaneous lesions produced after repeated exposures. The lesions were similar to the ones produced by other urchin species, consisting of small, firm, erythematous nodules on his palms, dorsum of the hands, elbows, and knees. Increased awareness of this condition, including its association with the two prevalent organisms on the West Coast, should lead to a more rapid diagnosis for those affected. This article reviews the types of injuries, clinical cutaneoous lesions, histopathological features, and pathogenesis of the chronic inflammatory process induced by sea urchins.

Persistent hair growth during treatment with the EGFR inhibitor erlotinib

Medications belonging to the group of epidermal growth factor (EGFR) inhibitors are currently in widespread use for the treatment of epithelial malignancies. Many cutaneous side effects are known to develop as a result of the use of these agents. Trichomegaly is a newly described side effect, consisting of premature maturation (terminal differentiation) of the hair of the eyelashes and the scalp, which is characterized by a hairy phenotype. Although occurrence of the acneiform skin rash is clearly associated with favorable tumor responses and improvement in patient survival during the use of EGFR inhibitors for the treatment of cancer, the significance of trichomegaly is less clear. A review of all published cases is provided, leading to the observation that trichomegaly also developed in patients whose tumors had a positive response to anti-EGFR therapy. The apparent lack of the development of tolerance to this medication effect and, therefore, the continued clinical sign of trichomegaly is in contrast to the time-limited nature of other cutaneous side effects of EGFR inhibitors, such as the classical papulo-pustular rash. The persistence of trichomegaly in some patients brings into question the precise mechanism of this phenomenon and suggests the possibility of using EGFR inhibition therapeutically to stimulate hair growth.

The cutaneous epidermal growth factor network: Can it be translated clinically to stimulate hair growth?

The influences exerted by the epidermal growth factor receptor (EGFR) on the skin act at multiple levels, which involve compartments that normally express EGFR. These include the basal and suprabasal layers of the epidermis, sebaceous glands, and the outer root sheath of the hair follicles. The physiological roles of EGFR ensure epidermal renewal and integrity, along with a gatekeeping and function and hair growth stimulation functions. Important cellular functions that are altered during EGF receptor blocking therapy consist of epidermal differentiation, proliferation, apoptosis, and migration, with an overall dominating effect of inducing growth arrest and terminal differentiation of the keratinocytes in the basal layers. The effects of EGFR blockage on the hair cycle include terminal differentiation of the hair follicle, which in certain cases may be associated with trichomegaly. Trichomegaly of the eyelashes may occur as an isolated occurrence or, frequently, as part of a generalized phenomenon that may be associated with the use of the EGFR inhibitors. Molecular changes associated with EGFR blockage are discussed, relevant to their association with hair growth. Modulation of Akt, AP2alpha, CDK4, Notch-1, p27KIP1, and Hedgehog expression are involved in the initiation of the hair cycle and inducement of the anagen phase, followed by proliferation and differentiation of the hair follicles. Epidermal growth factor receptor inhibitors have been developed as therapeutic molecules directed against cancer; in these regimens the knowledge of EGF receptor signaling functions has been translated into significant clinical results. However, among their various collateral effects on the skin, hair growth is observed to occur in certain patients. A particular "wavy" hair phenotype is observed during the pharmacological EGFR receptor blockade, just as in murine transgenic models that carry loss of function of TGF-alpha or EGFR genes. A better characterization of the individual roles pertaining to the EGF family ligands and receptors, has the potential provide new strategies for the management of hair loss.

Malignant melanoma in African-Americans

Although relatively uncommon, malignant melanoma in African-Americans and other minority ethnic populations represents an aggressive disease highly associated with invasive lesions and a more advanced stage of disease at diagnosis, and consequently with a decreased survival compared with Caucasians. Data on biology of melanoma in African-Americans is very limited, which complicates the analysis of epidemiological information, as well as identification of accurate prognostic variables. This review article explores critical features of melanoma in African-Americans that distinguish it from disease seen in Caucasians, including the clinical presentation, histological patterns, prognostic indicators, and etiology. Emerging data from biologic and genetic studies will also be discussed, raising the possibility that melanoma in pigmented skin may represent molecular distinct cancers that are inherently more aggressive. Improved understanding of the unique manifestations of melanoma in African-Americans, and its underlying tumor biology, will help improve clinical detection, optimize preventative measures through public health education, and potentially lead to the development of novel targeted therapeutic approaches.

A case of severe aplastic anemia secondary to treatment with lenalidomide for multiple myeloma

Lenalidomide is an important contemporary treatment option for patients with multiple myeloma (MM). Rare instances of autoimmune conditions have been observed in association with its use. Although moderate myelosuppression is not uncommonly seen in patients treated with lenalidomide, aplastic anemia has not previously been reported to be associated with this agent. We describe a case of severe aplastic anemia (AA) that was probably induced by lenalidomide. A 64-year-old male patient developed progressive pancytopenia three weeks into therapy with lenalidomide for his relapsed MM. A bone marrow aspirate and biopsy confirmed the diagnosis of AA and suggested the existence of an immunological reaction at the level of marrow. A gradual spontaneous recovery of normal hematopoiesis followed after the lenalidomide discontinuation.

Acute retinal pigment epithelial detachment secondary to pamidronate administration

Bisphosphonates are associated with an important number of inflammatory ocular side-effects including but not limited to conjunctivitis, episcleritis, scleritis, uveitis, and optic neuritis. The intravenous bisphosphonates appear to be linked with more severe ocular inflammation than the orally administered ones. These eye complications tend to resolve with the bisphosphonate discontinuation and can re-occur with its re-challenge. We present here the first case of an acute retinal pigment epithelial detachment associated with pamidronate infusion in a 59-year-old patient with metastatic prostate cancer.