Decrease of VEGF within malignant ascites during catumaxomab treatment: Results from a pivotal phase II/III study

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Background: Treatment with the trifunctional anti-EpCAM x anti-CD3 antibody catumaxomab efficiently eliminates tumor cells from the peritoneal cavity (Jäger et al., ASCO 2007) and led to clinically relevant prolongation of puncture-free survival (PuFS) in patients with malignant ascites (MA) in a pivotal phase II/III trial (Parsons et al., ASCO 2008). As vascular endothelial growth factor (VEGF) levels are markedly elevated in MA in comparison to cirrhotic ascites the question was addressed whether catumaxomab treatment impacts the expression or accumulation of VEGF within MA. Here we report that in addition to tumor cell depletion, VEGF protein levels in MA significantly decreased upon catumaxomab therapy. We propose that the strongly correlated tumor cell elimination and reduced VEGF protein levels are causative for the prolonged PuFS of patients suffering from MA. Methods: VEGF and total protein levels were measured by ELISA and BCA from MA supernatants before catumaxomab therapy, after the 1st infusion (10μg; day 3) and after the 4th infusion (150μg; day 11). Data were statistically analysed for the ratio of the VEGF protein concentration versus the total protein concentration for the MA treatment groups with ovarian (OC) or nonovarian cancer (NC) as underlying disease and the corresponding control groups that received paracentesis only. Results: One day after the last catumaxomab infusion 46 or 47 patients analysed in the OC or NC treatment group showed a statistically significant decrease in VEGF to total protein ratio when compared to the measurement before catumaxomab therapy (ANOVA p=0.034 for OC and p<0.001 for NC). These results are consistent with the tumor cell elimination previously assessed in these patients. In contrast, the OC control group showed a statistically significant increase of VEGF to total protein ratio (p=0.009), which is accompanied by an increase in tumor cell numbers. In the NC control group VEGF to total protein ratio remained unaffected (p=0.096). Conclusions: Catumaxomab therapy significantly reduced VEGF protein levels correlating with tumor cell elimination in MA, which in turn led to the prevention of fluid accumulation in the peritoneal cavity and finally to prolonged PuFS of patients suffering from MA.

[Table: see text]

Influence of catumaxomab on tumor cells in bone marrow and blood in ovarian cancer

The trifunctional antibody catumaxomab with bispecificity for the epithelial cell adhesion molecule EpCAM and the T-cell antigen CD3, is a new therapeutic strategy for ovarian cancer patients with symptomatic malignant ascites. Whether or not intraperitoneal (i.p.) catumaxomab-therapy has influence on disseminated and circulating tumor cells was investigated by analyzing cytokeratin-positive (CK+) cells in bone marrow (BM) and peripheral blood (PB). Fourteen ovarian cancer patients with symptomatic ascites were treated with catumaxomab (up to 5 i.p.-infusions; increasing dosages (10-200 microg)). CK+-cells were isolated before and after antibody-therapy by density gradient centrifugation and immunocytochemistry (anti-CK antibody A45-B/B3). Catumaxomab-treatment resulted in the sustained reduction of ascites flow and arrested ascites reaccumulation. The mean overall survival was 8 months. CK+-cells in the BM were found in 70% before and 83% after therapy (in the PB 57% and 42%, respectively). A marked reduction of CK+-cells occurred in the BM in 2 and in the PB in 4 patients. Catumaxomab shows a strong intraperitoneal effect and possibly also systemic effects on tumor cells in the BM and PB.

The hematopoietic stem cell in chronic phase CML is characterized by a transcriptional profile resembling normal myeloid progenitor cells and reflecting loss of quiescence

We found that composition of cell subsets within the CD34+ cell population is markedly altered in chronic phase (CP) chronic myeloid leukemia (CML). Specifically, proportions and absolute cell counts of common myeloid progenitors (CMP) and megakaryocyte-erythrocyte progenitors (MEP) are significantly greater in comparison to normal bone marrow whereas absolute numbers of hematopoietic stem cells (HSC) are equal. To understand the basis for this, we performed gene expression profiling (Affymetrix HU-133A 2.0) of the distinct CD34+ cell subsets from six patients with CP CML and five healthy donors. Euclidean distance analysis revealed a remarkable transcriptional similarity between the CML patients' HSC and normal progenitors, especially CMP. CP CML HSC were transcriptionally more similar to their progeny than normal HSC to theirs, suggesting a more mature phenotype. Hence, the greatest differences between CP CML patients and normal donors were apparent in HSC including downregulation of genes encoding adhesion molecules, transcription factors, regulators of stem-cell fate and inhibitors of cell proliferation in CP CML. Impaired adhesive and migratory capacities were functionally corroborated by fibronectin detachment analysis and transwell assays, respectively. Based on our findings we propose a loss of quiescence of the CML HSC on detachment from the niche leading to expansion of myeloid progenitors.

Effects of symptom reduction and psychotropic medication on cognitive impairment in depression

BACKGROUND

Depression is related to cognitive performance. This follow-up study examines the influence of depression symptoms and psychopharmacological treatment on change in the cognitive performance of patients with depressive episodes over a 2-year period.

SAMPLING AND METHODS

Sixty-two in- and outpatients with depression of varying severity (ICD-10: F31-F33) were examined in an open prospective naturalistic observational study with 3 points of measurement and tested by use of 3 computerized cognitive performance tests [Visual Attentiveness Test (VAT), Continuous Attention Test (CAT), Word Recognition Test (WRT)], while the psychotropic medication was classified by subclass and dosage. Statistical analysis was performed by random-effects regression models.

RESULTS

The raw values of VAT speed, CAT speed and WRT quality improved over time. However, the positive time trend disappeared after the patients' clinical and personal characteristics were controlled for. The processing speed of the VAT was found to be negatively influenced by depressive symptoms. That of the CAT developed favorably with increasing level of education. The performance qualities of the VAT, WRT and CAT were positively related to the participants' educational level. The patients who received antipsychotic treatment performed worse on WRT quality than those who were not treated with antipsychotics.

CONCLUSIONS

The cognitive performance was relatively stable during the treatment process and not affected by clinical characteristics or type of medication. Cognitive deficits in patients with depression could be a trait rather than a state marker.

Standardized remission criteria in schizophrenia: descriptive validity and comparability with previously used outcome measures

INTRODUCTION

Standardized consensus criteria for remission in schizophrenia were recently proposed. As yet, the validity of these criteria and their comparability with previously used outcome measures are unclear.

METHODS

The symptom-severity component of the proposed remission criteria was applied to 288 inpatients who fulfilled the ICD-10 criteria for schizophrenia. Global functioning and psychopathological symptoms were assessed using GAF, PANSS, SANS, HAM-D and CDSS.

RESULTS

When patients with symptom remission at discharge from hospitalization (n=158, 54.9%) were compared to those without symptom remission, significant differences were found with respect to the global functioning (GAF) and all observed psychopathological symptom dimensions. The percentage agreement with previously used outcome measures ranged between 52.6 and 80.0%, the kappa values between 0.120 and 0.594. A moderate accordance (kappa value: 0.495) was found with a Clinical Global Impression (CGI) severity score of three or less.

DISCUSSION

The results indicate a high descriptive validity of the symptom-severity component of the proposed remission definition. However, the new criteria differ partially from previously used outcome measures. This aspect should be considered in the interpretation of clinical trials.

[Anxiety and anorexia as symptoms of pulmonary disease]

Symptoms of anxiety can occur in several mental and somatic diseases. Therefore, a sound diagnostic classification of symptoms is necessary. A 47-year-old woman was admitted to a psychiatric ward because of anxiety symptoms and anorexia. The symptoms were attributed to chronic obstructive pulmonary disease with pulmonary cachexia. This case indicates that one should consider the possibility of pulmonary disease in patients with anxiety symptoms. The case also points out the necessity of interdisciplinary collaboration.

Applicability of cord blood-derived unrestricted somatic stem cells in tissue engineering concepts

OBJECTIVES

Cell-based tissue engineering concepts are becoming an important therapeutic alternative in the treatment of traumatic or chronic skeletal diseases. Here, we have evaluated cord blood-derived unrestricted somatic stem cells (USSCs) for use in bone and cartilage repair strategies.

METHODS AND RESULTS

This type of somatic stem cell can be generated from cord blood with a current rate of 29% and we have documented excellent proliferation potential to high passage numbers. The cells have an initial population doubling time of 39 h, which slightly decreased with increasing passage number, but cells maintained their proliferation abilities up to passage 23. Cells clearly differentiated towards chondrogenic, adipogenic and osteogenic lineage as shown by reverse transcription-polymerase chain reaction as well as by histological, biochemical and immunohistochemical stains. Differentiation potential of USSCs was observed at passage 6, passage 15 and passage 21. In addition, USSCs showed increased secretion of vascular endothelial growth factor (VEGF) during osteogenic differentiation, as well as expression of key markers of angiogenesis such as vascular endothelial growth factor receptor-2 and platelet/endothelial cell adhesion molecule.

CONCLUSIONS

USSCs when transplanted into a bone defect might support the repair process not only by pure remineralization but also by installation of angiogenic environment.

Primary total hip replacement in childhood, adolescence and young patients: quality and outcome of clinical studies

OBJECTIVE

The present meta-analysis illustrates relevant information about hip replacement in young patients that has been published during the past 3 decades.

MATERIAL AND METHODS

Based on a MedLine literature review a total of 95 studies were evaluated. Parameters for evaluation of study quality and outcome were implant survival rates (ISR),number of patients, indications, follow-up, surgical approaches and number of surgeons.

RESULTS

Most studies consider patient numbers <50. In 33 studies one implant system was applied compared to 65 studies in which more than one system was used. Most studies include different surgical approaches. 20% of all studies contained neither the number of surgeons,nor the type of surgical approach. The overall ISR could be evaluated in 67 studies. Sufficient data about the ISR of stem and/or sockets were available in 50 papers.

CONCLUSIONS

Most published studies analyzed inhomogeneous study populations; study variables vary as do the implants used for treatment.

[Acute and transient psychotic disorders (ICD-10: F23). Empirical data and implications for therapy]

The defining clinical features of acute and transient psychotic disorders (ICD-10: F23) are an acute onset and a duration of psychotic symptoms not exceeding 1-3 months. Previous empirical investigations show that patients with this diagnosis have a favourable prognosis, but also a high risk of relapses (58-77%). The diagnostic stability in the further course of illness seems to be low (34-73%) with a frequent diagnostic change to schizophrenia and affective disorders being observed. As yet, data from controlled clinical trials regarding therapy do not exist. The implications for the treatment of acute and transient psychotic disorders are discussed with this background.

[Axes of the legs in childhood. What is pathologic?]

At birth the lower extremity is characterized by a varus axis in the lower leg and the knee joint in the frontal plane (bowleg) and an increased femoral antetorsion and a neutral or increased medial torsion of the lower leg in the transverse plane. By the time growth is complete a normal valgus axis of 5-9 degrees has developed in the lower limb and the femoral antetorsion has decreased to about 15 degrees. The lower leg will show a normal external rotation of 15 degrees on average. The evolution of the axis values in the lower extremity is influenced by changing compressive and propelling forces acting on the growth plates as the child adopts an upright posture. There is a wide range of normal values, but pathologic development of the leg axes is rare and mostly idiopathic. Secondary deviations of the axis from normal can occur. Careful clinical examinations are necessary to differentiate between pathologic and physiological variations. Further apparative diagnostic procedures help to elucidate the etiology and are essential for surgical planning. Nonoperative treatment alone is rarely sufficient to influence the deformity.

[Radiological diagnosis of lumbar prolaps with quantitative and morphological criteria]

PURPOSE

The present study examines the differences of radiological diagnosis of lumbar prolaps with quantitative and morphological criteria. Advantages and disadvantages of both methods were analysed.

METHOD

Concerning the "Deutsche Wirbelsäulenstudie" (DWS) 286 male and 278 female patients between 25 and 70 years of age undergoing clinical or ambulant therapy for radicular symptoms and the diagnosis of a lumbar prolaps in CT and/or MRT were integrated into our study. Actual MRT and CT pictures of the patients' lumbar spine were analysed by an independent radiologist (primary radiologist). Radiological diagnosis was concerned with quantitative and morphological criteria. Radiological images of 100 selected patients were reexamined by another radiologist (secondary radiologist). On the basis of these results, the interobserver reliability (kappa) was calculated.

RESULTS

In 95.2% of all segments a prolaps was seen with quantitative and morphological criteria, in 4.5% a prolaps was analysed with quantitative and in 0.3% a prolaps was seen with morphological criteria. The radiological diagnosis of prolaps by quantitative criteria was confirmed by the operative findings. Many prolapses with lateral localisation were seen in these cases. Therefore radiological diagnosis on the basis of morphological criteria could be difficult. For both radiological methods similar interobserver reliabilities were calculated. To sum up both radiological methods are even equivalent. It is also possible to graduate the diagnosis with quantitative criteria. Detrimental effects of quantitative criteria could be difficulties in measurement with non-digital images.

CONCLUSION

Besides several recommendations in the international literature on the radiological analysis of prolaps with morphological criteria, diagnosis with quantitative criteria is also an effective method.

Characterisation of the new EpCAM-specific antibody HO-3: implications for trifunctional antibody immunotherapy of cancer

Epithelial cell adhesion molecule EpCAM is a transmembrane glycoprotein that is frequently overexpressed in a variety of carcinomas. This pan-carcinoma antigen has served as the target for a plethora of immunotherapies. Innovative therapeutic approaches include the use of trifunctional antibodies (trAbs) that recruit and activate different types of immune effector cells at the tumour site. The trAb catumaxomab has dual specificity for EpCAM and CD3. In patients with malignant ascites, catumaxomab significantly increased the paracentesis-free interval, corroborating the high efficacy of this therapeutic antibody. Here, we characterised the monoclonal antibody (mAb) HO-3, that is, the EpCAM-binding arm of catumaxomab. Peptide mapping indicated that HO-3 recognises a discontinuous epitope, having three binding sites in the extracellular region of EpCAM. Studies with glycosylation-deficient mutants showed that mAb HO-3 recognised EpCAM independently of its glycosylation status. High-affinity binding was not only detected for mAb HO-3, but also for the monovalent EpCAM-binding arm of catumaxomab with an excellent K_D of 5.6 × 10⁻¹⁰ M. Furthermore, trAb catumaxomab was at least a 1000-fold more effective in eliciting the eradication of tumour cells by effector peripheral blood mononuclear cells compared with mAb HO-3. These findings suggest the great therapeutic potential of trAbs and clearly speak in favour of EpCAM-directed cancer immunotherapies.