Neoadjuvant therapy for locally advanced melanoma: new strategies with targeted therapies

Neoadjuvant chemotherapy has been successfully tested in several bulky solid tumors, but it has not been utilized in advanced cutaneous melanoma, primarily because effective medical treatments for this disease have been lacking. However, with the development of new immunotherapies (monoclonal antibodies specific for cytotoxic T lymphocyte-associated antigen 4 [anti-CTLA-4] and programmed death protein-1 [anti-PD1]) and small molecules interfering with intracellular pathways (anti-BRAF and mitogen-activated protein kinase kinase [anti- MEK]) the use of this approach is becoming a viable treatment strategy for locally advanced melanoma. The neoadjuvant setting provides a double opportunity for a better knowledge of these drugs: a short-term evaluation of their intrinsic activity, and a deeper analysis of their action and resistance-induction mechanisms. BRAF inhibitors seem to be ideal candidates for the neoadjuvant setting, because of their prompt, repeatedly confirmed response in V600E BRAF-mutant metastatic melanoma. In this report we summarize studies focused on the neoadjuvant use of traditional medical treatments in advanced melanoma and anecdotal cases of this approach with the use of biologic therapies. Moreover, we discuss our experience with neoadjuvant targeted therapy as a priming for radical surgery in a patient with BRAF V600E mutation-positive advanced melanoma.

Systemic nickel allergy syndrome: epidemiological data from four Italian allergy units

The prevalence of nickel hyper-sensitivity varies widely in different countries, nevertheless it is the leading cause of contact dermatitis. The presence of nickel in the diet (mainly plant foods) in some nickel-sensitive subjects can provoke/aggravate eczema and systemic contact dermatitis as well as cause extra-cutaneous symptoms (respiratory, gastrointestinal, neurological). These symptoms, correlated to the ingestion of nickel-containing foods and beverages, in nickel patch test positive individuals, defines the so called Systemic Nickel Allergy Syndrome (SNAS), a condition successfully treated by oral desensitization. Although numerous studies have investigated the prevalence of contact nickel allergy or addressed the relationship between nickel intake and onset of systemic symptoms, to our knowledge no epidemiological studies have attempted to estimate the prevalence of SNAS. Therefore, we decided to evaluate consecutive patients (1,696), afferent to four allergy units in Sicily, a region of southern Italy, from October 2010 to March 2011. SNAS was confirmed in 98 patients (5.78 percent) of the 1,696 studied, suggesting that this clinical entity may be an emergent allergological condition rather than an occasional finding. The most common symptoms complained of in our population were cutaneous (51 patients), gastrointestinal (87 patients) and other systemic clinical manifestations (37 patients). Furthermore, 16 out of the 98 SNAS patients (16.3 percent) presented IgE-mediated food allergy with a statistically significant association (X2=16.950; P<0.0001), therefore suggesting underlying cross-facilitating pathways. These findings need confirmation on wider populations but may help allergists to suspect, during common clinical practice, that cutaneous and extra-cutaneous symptoms may be referred to nickel intake and deserve specific in-depth investigation.

A randomized, placebo-controlled study on the effects of a nutraceutical combination of red yeast rice, silybum marianum and octasonol on lipid profile, endothelial and inflammatory parameters

The aim of this study was to evaluate the effects of a combination of red yeast rice, Silybum marianum and octasonol compared to placebo on lipid profile, endothelial, and inflammatory parameters in low risk dislipidemic patients. One hundred and thirty-four dislipidemic patients were randomised to take placebo or a patented nutraceutical association in tablet form (Zeta ColestRT), 1 tablet /day (immediately after the dinner), for three months in a double-blind, placebo-controlled trial. At baseline and after 3 months the following were evaluated: body weight, body mass index (BMI), fasting plasma glucose (FPG), lipid profile, soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble E-selectin (sE-selectin), metalloprotineases-2 and -9 (MMP-2 and MMP-9), high sensitivity C-reactive protein (Hs-CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha). The nutraceutical combination decreased total cholesterol and low density lipoprotein cholesterol compared to baseline (p = 0.042, and p = 0.041, respectively) and to placebo (p = 0.039, and p = 0.037, respectively). Triglycerides were reduced by the active treatment (p = 0.039), but not by placebo, even if, in group to group comparison, no differences were recorded (p = 0.061). All adipocytokines were reduced by the nutraceutical combination, in particular p = 0.044 for sICAM-1, p = 0.045 for sVCAM-1, p = 0.040 for sE-selectin, p = 0.035 for MMP-2, p = 0.039 for MMP-9, p = 0.038 for Hs-CRP, p = 0.036 for TNF-α, and p = 0.036 for IL-6 compared to baseline, and p = 0.042 for sICAM-1, p = 0.043 for sVCAM-1, p = 0.042 for sE-selectin, p = 0.031 for MMP-2, p = 0.038 for MMP-9, p =0.038 for Hs-CRP, and p = 0.043 for TNF-alpha, espectively, compared to placebo. We can conclude that a combination of red yeast rice, Silybum marianum and octasonol was effective in improving lipid profile, endothelial, and inflammatory parameters in low risk dislipidemic patients.

Clinical outcomes of patients (pts) age 60 or younger treated with docetaxel (DOC) for castration-resistant prostate cancer (CRPC): Results of an Italian multicenter retrospective study (CYCLOP study)

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Background: Since prostate cancer is usually diagnosed in patients (pts) over age 60, castration-resistant prostate cancer (CRPC) is rarely observed in pts age 60 or younger. Despite the clinical outcomes of these pts are not clearly defined, there is a common feeling of a worse prognosis for pts with CRPC age 60 or younger. The present study is aimed to assess the clinical outcomes of this specific population. Methods: In this multicentric retrospective study, after Ethical Committee approval, we have reviewed the clinical records of all pts younger than 60 with CRPC from participating institutions, treated with docetaxel (DOC), both in clinical trials and in clinical practice. We recorded the pre- and post-DOC clinical history, the DOC treatment details and outcomes. Results: To date we have collected a consecutive series of 128 pts from 24 Italian hospitals. The median age was 57 (range 41 to 60). The median baseline prostate-specific antigen (PSA) was 85 ng/ml (range 1 to 3,020); 87% of the pts had bone metastases while 47%, 10%, and 13% showed nodal, liver and lung metastases, respectively. All but 12 pts received DOC with a 3 week standard schedule, the remaining being treated with a weekly schedule. A PSA reduction greater than 50% was observed in 61% of the pts; among the 86 pts with measurable disease who underwent a radiological re-evaluation at the treatment end, four and 13 pts achieved complete and partial response, respectively (response rate 20%). The main grade 3-4 toxicities were anemia (five pts), neutropenia (18 pts), febrile neutropenia (one pt), fatigue (five pts), peripheral neuropathy (three pts). The median progression-free survival (PFS) and overall survival (OS) were 7 months and 21 months, while the 1 year PFS and OS rates were 17.6% and 74.9%, respectively. Conclusions: Our data seems to not confirm that younger pts with CRPC have a worse prognosis compared to the older pts since their survival outcomes and response rate are similar to those observed in general population of pts wiht CRPC.

Clinical outcomes of patients (pts) age 80 or older treated with docetaxel (DOC) as first-line chemotherapy for castration-resistant prostate cancer (CRPC): Results of an Italian multicenter retrospective study (DELPHI study)

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Background: Docetaxel (DOC) represents the treatment of choice in the first line treatment for patients (pts) with castration-resistant prostate cancer (CRPC). However, when CRPC is diagnosed in pts age 80 or older, the fear of high toxicity degree usually limits chemotherapy use due to both pts frailty and several comorbidities occurrence. The present retrospective study is aimed to assess the clinical outcomes in this very elderly CRPC population. Methods: In this multicentric retrospective study, after Ethical Committee approval, we have reviewed the clinical records of all pts age 80 and older CRPC pts from participating institutions, treated with DOC in clinical practice, recording the pre- and post-DOC clinical history, the DOC treatment details and outcomes. Results: To date we collected a consecutive series of 115 pts from 28 Italian hospitals. The median age was 82 (range 80 to 90). The median baseline prostate-specific antigen (PSA) was 92 ng/ml (range 3 to 2,981); 83% of the pts had bone metastases, while nodal, lung and liver metastases were observed in 39%, 9%, and 8% of the pts, respectively. Median Cumulative Illness Rating Scale score was 3 (range 0 to 11), median Activity Daily Living index score was 0 (range 0 to 5), median Instrumental Activities of Daily Living score was 0 (range 0 to 5). The DOC was administered on 3 week or weekly schedule basis (43%/57%). A PSA reduction greater than 50% was observed in 55% of the pts; an objective response was observed in 15% of the 60 pts who underwent a radiological re-evaluation at the treatment end. Grade 3-4 toxicities were: anemia (2%), neutropenia (10%) , thrombocytopenia (2%), fatigue (10%), diarrhea (4%), nausea (2%), renal (2%), and febrile neutropenia (2%). The median progression-free survival (PFS) and overall survival (OS )were 7 months and 20 months, while the 1 year PFS and OS rates were 21.2% and 71.5%, respectively. Conclusions: This data suggests that selected very older (age 80 and older) CRPC pts may received DOC with a good toxicity profile. In this pts population the treatment, both on 3 week or weekly schedule, is able to produce survival outcomes comparable to pivotal trials (18 months).

Safety and clinical outcome of a cohort of patients (pts) with castration resistant prostate cancer (CRPC) treated with abiraterone acetate (AA) in a named patient program (NPP): Updated results of a retrospective study from an Italian cooperative group

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Background: Abiraterone acetate (AA) provided a survival advantage compared to placebo in patients (pts) with castration resistant prostate cancer (CRPC) who had received docetaxel (de Bono JS et al, NEJM 2011). The present retrospective study is aimed to assess safety and clinical outcome in an unselected CRPC population which received AA in a named patient program (NPP). Methods: We retrospectively reviewed the clinical records of all pts treated with AA for CRPC by NPP in our institutions. All pts have been previously treated with a docetaxel-based first-line chemotherapy and received the standard AA dose of 1,000 mg daily plus prednisone 10 mg daily. For each pt we recorded the pre- and post-AA clinical history, the AA treatment details toxicities and clinical outcomes. Results: To date we have collected a consecutive series of 245 pts from 18 Italian hospitals. The median age was 73 (range 45 to 91). The median baseline prostate-specific antigen (PSA) level was 100 ng/ml (range 0.33->100.000); 79% of the pts had bone metastases, while nodal, lung and liver metastases were observed in 52%, 9%, and 7% of the pts, respectively. The median duration of AA treatment was 5 months (range, 1 to 26). Grade 3 to 4 toxicities were anemia (11 pts), fatigue (nine pts), bone pain (four pts), constipation (two pts), thrombocytopenia (two pts), nausea (one pt), diarrhea (one pt), dyspnea (one pt), edema (one pt), hypertension (one pt), hyperbilirubinemia (one pt), and hypokaliemia (one pt). A PSA reduction of more than 50% was observed in 50.9% of the pts. The median progression-free survival (PFS) and overall survival (OS) were 6 months and 15 months, respectively; the 1 year PFS and OS rates were 24.3% and 56.9%, respectively. Conclusions: Our results have confirmed the safety and efficacy of AA in an unselected population of pts with pre-treated CRPC outside clinical trials and provided further support concerning the good safety profile of the drug.

A comparison between sitagliptin or glibenclamide in addition to metformin + pioglitazone on glycaemic control and β-cell function: the triple oral therapy

AIMS

To evaluate which triple oral therapy between metformin + pioglitazone + sitagliptin and metformin + pioglitazone + glibenclamide can be more useful in improving glycaemic control and should be preferred in clinical practice.

METHODS

During the 2-year run-in period, patients were instructed to take metformin monotherapy for the first year, then a combination of metformin and pioglitazone for the second year, then patients were randomized to add glibenclamide or sitagliptin to the dual combination of metformin and pioglitazone for another year.

RESULTS

Body weight reached with sitagliptin at 36 months was lower than that reached with glibenclamide. Fasting plasma insulin and homeostasis model assessment of insulin resistance were significantly increased by triple therapy with glibenclamide and decreased by that with sitagliptin. While sitagliptin did not change homeostasis model assessment of β-cell function, this value was significantly increased by glibenclamide. Fasting plasma proinsulin was not influenced by triple oral therapy including glibenclamide, while it was decreased by the therapy including sitagliptin compared to glibenclamide. Triple oral therapy with sitagliptin better improved β-cell function measures compared with the glibenclamide therapy.

CONCLUSIONS

Sitagliptin should be preferred to glibenclamide as an addition to the metformin + pioglitazone combination for its better protection of β-cell secretion and its neutral effect on body weight.

Hard two-body photodisintegration of 3He

We have measured cross sections for the γ(3)He → pd reaction at photon energies of 0.4-1.4 GeV and a center-of-mass angle of 90°. We observe dimensional scaling above 0.7 GeV at this center-of-mass angle. This is the first observation of dimensional scaling in the photodisintegration of a nucleus heavier than the deuteron.

Clinical outcome (CO) and predictive factors (PRE) evaluation of a cohort of castration resistant prostate cancer (CRPC) patients (pts) treated with abiraterone acetate (AA) in a named patient program (NPP): Preliminary results from a retrospective study

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Background: AA provided a survival advantage compared to placebo, in pts who had received docetaxel for CRPC. Before the regulatory authority approval, AA was made available in Italy through a NPP supervised by the local ethic committees. The present retrospective study is aimed to assess PRE and CO in an unselected CRPC population which received AA by NPP. Methods: We retrospectively reviewed the clinical records of all pts treated with AA by NPP in our Institutions. For each pt we have recorded the pre and post-AA clinical history, the treatment details and outcomes. We have assessed the ability of a series of selected 22 clinical factors to predict AA response through a logistic regression analysis. Continuous variables were categorized by quartiles and chosen for the initial model after a univariate chi-square analysis. Results: To date we have collected a consecutive series of 136 pts from 13 Italian hospitals. The median age was 72 yrs (range 52-87). The median baseline PSA was 154 ng/ml (range 0.33->100.000); 80% and 16.7% of the pts showed bone and measurable lesions respectively. The median duration of AA treatment was 15 wks (range 1-73); 59 treatments are ongoing. Grade 3-4 toxicities were anemia (5 pts), nausea (1 pt), fatigue (4 pts), bone pain (3 pts), and hypokaliemia (1 pt). A PSA reduction > 50% was observed in 37.5% of the pts. Having a performance status (PS) 0-1 [(exp(beta) 4.541; p= 0.018], a previous ormonotherapy lasting >40 months [(exp(beta) 3.299; p= 0.020], baseline hemoglobin >12 g/dl [(exp(beta) 2.595; p= 0.074], no visceral organ involvement [(exp(beta) 1.929; p= 0.097] resulted to be independently predictive of a PSA reduction > 50%. The median PFS and OS were 5 mos and 14 mos, respectively; the 1-year PFS and OS rates were 25.7% and 53%, respectively. Conclusions: Our preliminary results have confirmed the efficacy of AA in second line CRPC outside clinical trials. Pts with good PS, with good hemoglobin levels, with long-lasting hormosensitivity, and without visceral organ involvement have higher probability to achieve a biochemical response to AA.

Urinary tract infections in sows in Italy: accuracy of urinalysis and urine culture against histological findings

In order to investigate the prevalence of urinary tract infections (UTI) in sow, lower urinary tract (LUT), kidney and urine samples were collected at slaughterhouse from 65 multiparous culled sows. Histopathology was performed on urethra, urinary bladder and -kidney sections. Urine collected by cystocentesis was analysed for physical and biochemical parameters, in addition to microscopic examination of the sediment and quantitative culture ( > 10(5) CFU/ml urine). The diagnostic accuracy of urinalysis and urine culture was calculated for the parameters that correlated with histological diagnosis: bilateral chronic lesions were found in 54 per cent of kidney samples and diffuse/multifocal lymphoplasmacytic infiltration of the submucosa in 53 per cent of the bladder and 68 per cent of the urethra samples. In 49 per cent of cases, the co-occurrence of bladder and urethra lesions was statistically significant (P < 0.009). Turbid urine (80 per cent sensitivity, 50 per cent specificity), > 5 white blood cells per high-power field (34 per cent sensitivity, 90 per cent specificity), intracellular or free bacteria (43 per cent sensitivity, 90 per cent specificity), and urine culture (49 per cent sensitivity, 97 per cent specificity) correlated with a finding of histopathological changes in the bladder. UTI appears to be common in culled sows in northern Italy. Compared with histopathology, urinalysis and urine culture showed low sensitivity but high specificity in detecting UTI.

Off-pump coronary surgery in a patient with multiple sclerosis

Surgery in patients with multiple sclerosis, the most common autoimmune demyelinating disorder of the central nervous system, represents a challenge for surgeons and anesthesiologists because of the reported risk of relapse of the neurologic symptoms in the perioperative period. In this report, we describe the management of a patient with relapsing-remitting multiple sclerosis and critical coronary artery disease, who underwent an uneventful off-pump coronary artery revascularization. The issues pertaining to the performance of coronary surgery revascularization on patients with multiple sclerosis are discussed.

Astrocytoma in a chamois

Astrocytomas represent the most common cerebral tumors in humans and in animals, and the fibrillary cytological subtype is the most frequently observed. In this report and for the first time, a thalamic astrocytoma is described in a chamois showing depressed mentation, pleurothotonus and circling to the right side.

Sepsis and bacterial suppurative meningitis-meningoencephalitis in critically ill neonatal Piedmontese calves: clinical approach and laboratory findings

Sepsis (S) and bacterial suppurative meningitis-meningoencephalitis (M-ME) are common causes of death in bovine neonates. The aim of this prospective study was to evaluate the prevalence of S and M-ME in critically ill neonatal Piedmontese calves. Critically ill animals up to 15 days old referred by practitioners were registered according to their status and subsequently assigned to clinical standardized score. Calves with a clinical score > = 5 were further assessed under a clinical and clinical-pathological protocol to strengthen the suspicion of S and M-ME. Critically ill neonatal calves sent for necropsy were included in the study as well. Fifty-nine calves were investigated, 26 of which referred alive and 33 dead. Ten out of the 26 clinically evaluated calves were classified as suspicious of S on the basis of the clinical and clinical-pathological protocols. S was confirmed by positive bacteriologic culture in 7 cases and in 3 cases on the basis of necroptic lesions. Concomitant suppurative M-ME suspected in 6 of these 10 calves was subsequently confirmed by CSF analysis or histological findings. Of the 33 calves examined only post-mortem, 20 showed pathognomonic findings of S and 14 signs of M-ME. The prevalence of S and M-ME was 46 and 36 %, respectively. Clinical signs of S were confirmed to be vague and overlapping with other diseases. The developed protocol was highly accurate in predicting S in these neonatal calves.

Measurement of exclusive π(0) electroproduction structure functions and their relationship to transverse generalized parton distributions

Exclusive π(0) electroproduction at a beam energy of 5.75 GeV has been measured with the Jefferson Lab CLAS spectrometer. Differential cross sections were measured at more than 1800 kinematic values in Q(2), x(B), t, and ϕ(π), in the Q(2) range from 1.0 to 4.6  GeV(2), -t up to 2  GeV(2), and x(B) from 0.1 to 0.58. Structure functions σ(T)+ϵσ(L), σ(TT), and σ(LT) were extracted as functions of t for each of 17 combinations of Q(2) and x(B). The data were compared directly with two handbag-based calculations including both longitudinal and transversity generalized parton distributions (GPDs). Inclusion of only longitudinal GPDs very strongly underestimates σ(T)+ϵσ(L) and fails to account for σ(TT) and σ(LT), while inclusion of transversity GPDs brings the calculations into substantially better agreement with the data. There is very strong sensitivity to the relative contributions of nucleon helicity-flip and helicity nonflip processes. The results confirm that exclusive π(0) electroproduction offers direct experimental access to the transversity GPDs.

Evaluation of emerging biomarkers in cardiovascular risk stratification of hypertensive patients: a 2-year study

OBJECTIVE

To evaluate if there is a correlation between some new emerging biomarkers, such as lipoprotein(a) (Lp[a]), apo(a) isoform phenotyping, soluble advanced glycation end products (sRAGE), soluble CD40 ligand (sCD40L), serum myeloperoxidase (MPO), and cardiovascular risk stratification.

RESEARCH DESIGN AND METHODS

Three hundred patients were enrolled in this open-label, case-control design trial: 156 hypertensive patients and 144 healthy subjects as control group. Hypertensive patients were treated according to the latest ESH/ESC guidelines, until the desirable goal of systolic blood pressure (SBP)<140 mmHg, and diastolic blood pressure (DBP)<90 mmHg was reached. We evaluated at baseline and after 6, 12, 18, and 24 months: SBP, DBP, lipid profile, Lp(a), apo(a) isoform phenotyping, sRAGE, sCD40L, and MPO.

RESULTS

Hypertensive patients presented higher levels of blood pressure, Lp(a), sCD40L, and MPO and lower levels of sRAGE compared with controls. We observed a decrease of blood pressure, Lp(a), sCD40L, and MPO and an increase of sRAGE after anti-hypertensive treatment. Moreover we observed moderate, but statistically significant, correlations between blood pressure decrease and Lp(a), MPO, and sCD40L decrease and between blood pressure decrease and sRAGE increase. There was also a modest, positive correlation between low molecular weight apo(a) isoforms and hypertension. A limitation of this study is that we cannot exclude a role for lifestyle measures. Furthermore the studied markers seem to improve with blood pressure lowering treatment, but we do not have enough statistical power to definitely state which drug used has a specific action on the various variables measured.

CONCLUSION

Lp(a), sRAGE, MPO, sCD40L, and low molecular weight apo(a) isoforms are associated with hypertension and may represent an increased cardiovascular risk. Longer studies are needed to see if these parameters can be also used to predict specific complications linked to hypertension.

Measurement of the neutron F2 structure function via spectator tagging with CLAS

We report on the first measurement of the F(2) structure function of the neutron from the semi-inclusive scattering of electrons from deuterium, with low-momentum protons detected in the backward hemisphere. Restricting the momentum of the spectator protons to ≲100 MeV/c and their angles to ≳100° relative to the momentum transfer allows an interpretation of the process in terms of scattering from nearly on-shell neutrons. The F(2)(n) data collected cover the nucleon-resonance and deep-inelastic regions over a wide range of Bjorken x for 0.65<Q(2)<4.52 GeV(2), with uncertainties from nuclear corrections estimated to be less than a few percent. These measurements provide the first determination of the neutron to proton structure function ratio F(2)(n)/F(2)(p) at 0.2≲x≲0.8 with little uncertainty due to nuclear effects.