Type 2 diabetes mellitus and risk of malignancy: is there a strategy to identify a subphenotype of patients with increased susceptibility to endogenous and exogenous hyperinsulinism?

AIMS

To give an overview on the relationship between diabetes mellitus and increased cancer risk.

METHODS

We identified studies evaluating the association between diabetes mellitus, its treatment with insulin and insulin analogues and malignancies, paying special attention to studies on in vitro and in vivo effects of the long-acting analogue insulin glargine.

RESULTS

Even although the pathophysiological mechanisms underlying the relationship between elevated cancer risk and Type 2 diabetes mellitus are not completely understood, hyperinsulinaemia in the presence of insulin resistance appears to be a key factor. Because of the mitogenic actions of insulin at high concentrations, hyperinsulinaemia may favour tumorigenesis. In line with this, an insulin-based therapy is associated with an increased cancer risk, whereas an insulin-sensitizing treatment results in a cancer risk reduction. Furthermore, alterations of the insulin receptor profile on tumour cells may contribute to an enhanced susceptibility towards insulin. Studies on the analogue insulin glargine have been controversial. In vitro data pointed to an elevated mitogenicity of insulin glargine, whereas in vivo data did not confirm cancerogenous effects. Moreover, recently published clinical studies on the association of insulin glargine (Lantus®) and cancer suggest that treatment with insulin glargine is not associated with increased cancer risk.

CONCLUSIONS

The relationship between elevated cancer risk and Type 2 diabetes mellitus has been shown by numerous epidemiological studies, with endogenous and exogenous hyperinsulinaemia in the presence of insulin resistance as potential underlying pathophysiological mechanisms. Recent clinical studies do not support an increased cancer risk in patients treated with insulin glargine.

Eight cycles of BEACOPP escalated compared with 4 cycles of BEACOPP escalated followed by 4 cycles of BEACOPP baseline with or without radiotherapy in patients in advanced stage Hodgkin lymphoma (HL): Final analysis of the HD12 trial of the German Hodgkin Study Group (GHSG)

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Background: The GHSG HD9 trial had established BEACOPP escalated (BE) as new standard of care for advanced-stage HL patients. The successor study, HD12, evaluated a possible reduction in toxicity by comparing 8 cycles of BE with 4 cycles BE followed by 4 cycles BB. The second question in this trial related to the need of additional radiotherapy (RT) to initial bulk and residual disease. Methods: HL patients in stage IIB with large mediastinal mass and/or E-lesions or stage III/IV were randomised according to a 2x2-factorial design between: 8BE + RT, 8BE no RT, 4BE+4BB + RT, 4BE+4BB no RT. Primary endpoint of the trial was FFTF. Between 9/1999 and 1/2003, a total of 1,670 patients aged 16–65 were randomized. For this final analysis at a median follow up of 78 months, 99 patients were excluded for various reasons resulting in 1,571 eligible patients. Results: Patient characteristics in the 4 groups were comparable. Treatment-related toxicity of WHO grade III/IV was observed in 97% of patients. Most prominent differences between pooled chemotherapy arms were anemia (65% 8BE vs 51% 4BE+4BB) and thrombopenia (65% vs 51%). Treatment outcome: complete remission 92.4%; early progression 2.2%; progression/relapse 7.8% (6.6% and 8.5%). A total of 156 (9.9%) deaths (72 vs 84) have been observed (22 vs 32 acute or salvage treatment toxicity; 15 vs 24 HL; 22 vs 13 secondary neoplasia). Most treatment related deaths occurred in the >60 years age group, the first 4 cycles and the IPS> 3 RF groups. Secondary neoplasias were observed in 77 patients (4.9%). At 5 years, OS was 91%, FFTF 85.5% and progression free survival (PFS) 86.2% (Kaplan-Meier estimates). Estimates for the difference at 5 years are 1.8% for OS, 2.3% for FFTF and 2.7% for PFS favoring BE. However, there was no statistical difference between 8x BE and 4BE+4BB in all outcome parameters (p>0.19, log rank test). There is also no significant difference between the RT or no-RT arms in this study. Conclusions: The adoption of 4BE+4BB as a new standard in the future GHSG studies will depend on a refined analysis of the total data set and will be presented.

No significant financial relationships to disclose.

The value of PET/CT with 18F-FLT and 18F-FDG in the management of metastatic germ cell tumors (GCT): A pilot study

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Background: The purpose is to assess the ability of [F-18]-3’-Fluoro-3’-deoxythymidin (FLT), a cell proliferation marker, for early response monitoring and prediction of histology of residual tumor masses in patients (pts) with metastatic GCT in comparison to the standard tracer F-18-FDG, CT-scans and tumor markers. Methods: 11 male pts, age 23–48 yrs, with metastatic GCT were evaluated with both FDG- and FLT-PET/CT prior to chemotherapy (CTh), after the first cycle (early response) and 3 weeks after completion of induction CTh. PET was analyzed visually and quantitatively. The results were validated by histopathology of resected residual masses after CTh in 7 pts or by clinical follow-up for at least 6 mos in 4 pts. Presence of necrosis was judged as responder, as well as CR/PRm- within a minimum progression-free interval (PFI) of 6 mos. In case of multiple resections, the worse histology was taken into account. Regarding early tumor response EORTC criterias were used. Results: 8 out of 11 pts had a PFI > 6 mos (range, 206–1337 days). Examination of resected masses revealed necrosis in 3/7, teratoma in 2/7 as well as 2/7 pts with viable tumors. Prior to CTh the reference lesions showed increased FDG uptake (SUVrange/mean, 2.9–15.0/8.8) in all pts but moderate FLT uptake (SUVrange/mean, 1.7–9.7/3.7) in 10 out of 11 pts. SUVavg decrease in early response FDG monitoring was 64% in responders and 60% in non-responders (p = 0.8), as well as 57% vs. 48% for FLT (p = 0.5), respectively, and 85% vs. 72% (FDG, p = 0.1) and 67% vs. 65% (FLT, p = 0.8) in the final monitoring. Results of early and final response were inconsistent in 6/11 pts in FDG and in 4/10 pts in FLT-PET. In 2 pts with teratoma false negative results in both FDG- and FLT-PET have been seen. The sensitivities, specificities, positive and negative predictive values (%) of FDG and FLT-PET for early and final response monitoring were 60/33/43/50, 60/80/75/67, 20/100/100/60, and 0/100/0/50, respectively. Conclusions: PET negative residual masses after CTh of metastatic GCT still require resection, since the low negative predictive value of FDG-PET cannot be improved by application of the proliferation marker FLT.

No significant financial relationships to disclose.

Clinical impact and follow-up of taste disturbances following myeloablative or nonmyeloablative chemotherapy and stem cell transplantation

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Background: Stem cell transplantation (SCT) after myeloablative (MA) or non-myeloablative (NMA) chemotherapy is a successful treatment option for a variety of diseases. Although alterations of taste and smell are frequently encountered after these modalities, no systematic evaluation is available so far. Methods: A questionaire was developed covering aspects of the dietary pattern and changes in the perception of taste and smell. Clinical data were gathered from the charts. The study was approved by the institutional review board. Data of the first 100 of 200 planned patients’ (pts) are presented. Results: pts were surveyed after a median of 22 months from SCT (range 1–292), their age ranged from 20–76 years. Indications for SCT included acute leukemia (n=38), myeloproliferative disease (n=20), lymphoma (n=13), and others (n=29). Pts received an allogeneic graft after MA (n=48) or NMA (n=32) conditioning, 20 pts received an autologous one. 75% of pts reported moderate to severe changes in taste perception on a semiquantitative visual analogue scale during the acute phase of SCT with no differences between the three groups (73%, 79%, 75%). 28% of the pts reported a complete regression at the time of survey, 25% still suffered from moderate to severe changes. This finding was more prevalent after allogeneic SCT (30% after MA conditioning, 28% after NMA) compared to pts with autologous grafts (10%). Whereas pts without persisting changes in taste perception lost a median of 3 kg of body weight, pts suffering from severe changes lost 15 kg. Conclusions: Taste disturbances are a common after SCT. Symptoms are persistant in one third of the pts. In the allogeneic setting, no differences exist between MA and NMA conditioning. The lower incidence of persiting changes in taste perception after autologous SCT might be attributed to the absence of graft versus host disease or the dispensability of immunosuppression. Changes in taste perception correlate with weight loss.

No significant financial relationships to disclose.

[Current value of stem-cell transplantation in autoimmune diseases]

Transplantations of autologous or allogeneic stem cells from bone marrow or peripheral blood are preformed for the treatment of resistant autoimmune diseases. Data have been systematically collected since 1996. We describe the historical development of this procedure for autoimmune diseases, the possible mechanisms of action, the options for stem cell collection, purging and conditioning (high-dose chemotherapy, combination with monoclonal anti-T- or B-cell antibodies, total body irradiation), as well as the reported outcomes in the literature.

Hyperattenuating bone marrow abnormalities in myeloma patients using whole-body non-enhanced low-dose MDCT: correlation with haematological parameters

We aimed to establish the role of hyperattenuating medullary abnormalities detected by whole-body non-enhanced low-dose multidetector CT (WBLD-MDCT) in multiple myeloma (MM) patients referred for primary evaluation. 50 consecutive patients with untreated Stage I (n(I) = 11), Stage II (n(II) = 10) and Stage III (n(III) = 29) MM underwent WBLD-MDCT for staging. The number and size of osteolysis, as well as haematologic parameters including paraprotein and beta2-microglobulin levels, were assessed and related to the number, size and density of medullary abnormalities assumed to represent myeloma involvement. Bone marrow abnormalities were found in 2/11 (18%) Stage I, 6/10 (60%) Stage II and 20/29 (69%) Stage III myeloma patients, and did not parallel the incidence of osteolysis. Patients with medullary lesions had higher levels of immunoglobulin A (median, 4730 mg dl(-1) vs 1520 mg dl(-1)), light-chain proteinuria (median, 690 mg dl(-1) vs 214 mg dl(-1)) and IgG paraprotein (median, 3270 mg dl(-1) vs 2610 mg dl(-1)) compared with patients without medullary lesions. In patients with medullary abnormalities, levels of serum beta2-microglobulin were significantly higher than in patients without detectable marrow infiltrates (median, 4.3 mg dl(-1) vs 2.4 mg dl(-1); p = 0.0015). In conclusion, medullary abnormalities visualized by WBLD-MDCT are encountered in all stages of myeloma, including cases without osteolysis. They are associated with significantly elevated serum levels of paraprotein (reflecting tumour mass) and beta2-microglobulin, a prospective prognostic marker for myeloma. The nature and possible prognostic significance of medullary abnormalities detected by WBLD-MDCT therefore warrants further investigation.