Radioimmunotherapy versus autologous hematopoietic stem cell transplantation in relapsed/refractory follicular lymphoma: a Fondazione Italiana Linfomi multicenter, randomized, phase III trial

BACKGROUND

Optimal consolidation for young patilents with relapsed/refractory (R/R) follicular lymphoma (FL) remains uncertain in the rituximab era, with an unclear benefit of autologous stem cell transplantation (ASCT). The multicenter, randomized, phase III FLAZ12 (NCT01827605) trial compared anti-CD20 radioimmunotherapy (RIT) with ASCT as consolidation after chemoimmunotherapy, both followed by rituximab maintenance.

PATIENTS AND METHODS

Patients (age 18-65 years) with R/R FL and without significant comorbidities were enrolled and treated with three courses of conventional, investigator-chosen chemoimmunotherapies. Those experiencing at least a partial response were randomized 1 : 1 to ASCT or RIT before CD34+ collection, and all received postconsolidation rituximab maintenance. Progression-free survival (PFS) was the primary endpoint. The target sample size was 210 (105/group).

RESULTS

Between August 2012 and September 2019, of 164 screened patients, 159 were enrolled [median age 57 (interquartile range 49-62) years, 55% male, 57% stage IV, 20% bulky disease]. The study was closed prematurely because of low accrual. Data were analyzed on 8 June 2023, on an intention-to-treat basis, with a 77-month median follow-up from enrollment. Of the 141 patients (89%), 70 were randomized to ASCT and 71 to RIT. The estimated 3-year PFS in both groups was 62% (hazard ratio 1.11, 95% confidence interval 0.69-1.80, P = 0.6662). The 3-year overall survival also was similar between the two groups. Rates of grade ≥3 hematological toxicity were 94% with ASCT versus 46% with RIT (P < 0.001), and grade ≥3 neutropenia occurred in 94% versus 41%, respectively (P < 0.001). Second cancers occurred in nine patients after ASCT and three after radioimmunotherapy (P = 0.189).

CONCLUSIONS

Even if prematurely discontinued, our study did not demonstrate the superiority of ASCT versus RIT. ASCT was more toxic and demanding for patients and health services. Both strategies yielded similar, favorable long-term outcomes, suggesting that consolidation programs milder than ASCT require further investigation in R/R FL.

Erasmus+sport let’s move Europa: learning units for health promotion among children and adolescents

Background

School years are crucial for acquiring life-lasting healthy habits. However, an increasing rate of children and adolescents fail to maintain a healthy lifestyle. European Union has financed the Erasmus+ Sport Let’s Move Europa project to design an innovative digital tool for promoting healthy lifestyles among those age groups. University of Bologna, partner of the project, has developed 30 Learning Units (LUs) about Physical Activity, Sleep and Nutrition to be integrated in the school program by teachers.

Methods

A group of 17 teachers (15 females and 2 males, mean SD age 49,5 ±11,6) from primary and secondary schools located in Bologna province (Italy) took part in semi-structured focus groups (FGs). The investigation focused on facilitators/barriers of the intervention and possible solutions, identifying time frames and locations, suggestions for engaging the different stakeholders (teachers, students and families). All FGs were recorded, transcribed, anonymized, and analyzed through inductive thematic analysis.

Results

30 LUs were created based on the latest scientific evidence and the FGs output. Each LU addresses a specific topic and is tailored differently for primary and secondary school. The layout includes an investigation on the topic, classroom activities, and a section about “healthy homework” or “challenges” to be accomplished at home, engaging families in the construction of a healthy routine. All the activities were designed to be feasible and sustainable. Each LU includes a discussion phase to understand students’ feedback about proposed homework and learning content.

Conclusions

FGs have proven crucial to tailoring LUs on the needs of different stakeholders and co-designing an effective intervention. “Healthy homework” and “Challenges” encourage students to pursue healthy habits also outside the school setting, involving families. Feedback on the activity provides an insight into the progression and effectiveness of the intervention.

Key messages

• The EUmove project integrates knowledge about sleeping, nutritional and physical activity habits into the school curriculum to promote healthy lifestyles among students and their families.

• Thanks to the FGs, LUs are designed to suit the target audience. LUs integration into school curricula is therefore a feasible intervention, not requiring specialized personnel to be implemented.

Basal expression of RAD51 foci predicts olaparib response in patient-derived ovarian cancer xenografts

BACKGROUND

The search for biomarkers to evaluate ovarian cancer (OC) homologous recombination (HR) function and predict the response to therapy is an urgent clinical need to improve the selection of patients who could benefit from platinum- and olaparib (poly-ADP ribose polymerase inhibitors, PARPi)-based therapies.

METHODS

We used a large collection of OC patient-derived xenografts (PDXs) (n = 47) and evaluated their HR status based on BRCA1/2 mutations, BRCA1 promoter methylation and the HRDetect score. RAD51 foci were quantified in formalin-fixed, paraffin-embedded untreated tumour specimens by immunofluorescence and the messenger RNA expression of 21 DNA repair genes by real-time PCR.

RESULTS

Tumour HR deficiency predicted both platinum and olaparib responses. The basal level of RAD51 foci evaluated in geminin-positive/replicating cells strongly inversely correlated with olaparib response (p = 0.011); in particular, the lower the foci score, the greater the sensitivity to olaparib, while low RAD51 foci score seems to associate with platinum activity.

CONCLUSIONS

The basal RAD51 foci score is a candidate predictive biomarker of olaparib response in OC patients as it can be easily translatable in a clinical setting. Moreover, the findings corroborate the importance of OC-PDXs as a reliable tool to identify and validate biomarkers of response to therapy.

Association between parents’ education level and KIDMED index: a cross-sectional study

Background

Mediterranean diet (MD) is considered a healthy dietary model with several beneficial effects.

A strict adherence to the MD in children, coupled with daily exercise, can prevent obesity and significantly reduce the risk of correlated chronic diseases, such metabolic syndrome. The aim of this study is to evaluate the association between parents' educational level and compliance to the MD in a convenience sample of Italian children.

Methods

We conducted a cross-sectional study among 428 children aged 6-11 recruited in a primary school of Calderara di Reno (Italy) between May and June of 2017. Children's and parents' information were collected at baseline (i.e. age, BMI, occupation, educational level). A weekly food diary was administered to evaluate the participant's dietary habits. The degree of adherence to MD was derived from these diaries using the KIDMED index developed in 2003 by Serra-Majem et al. We used multiple linear regression models, adjusted for age and gender, to investigate how parents' educational level affected children's KIDMED index.

Results

Adherence to the MD was high, medium and poor in, respectively, 4%, 60% and 36% of children. Higher prevalence of overweight and obesity was observed among those with lower adherence to the MD. The linear regression model shows that fathers' educational level is not associated to children's KIDMED index variation. On the other hand, a higher mothers' educational level is linked to an increased weekly KIDMED index (p = 0.012) as well as an increased weekend KIDMED index (p = 0.048).

Conclusions

Mothers' education level is associated with increased adherence to MD, both weekly and weekend. The greater difference has been observed during weekend, when children of highly educated mothers score higher at KIDMED index.

Key messages

Mothers’ educational level plays an important role in children’s eating habits, with higher educational level associated with a better adherence to the MD. It is critical to implement parents' toolkit to promote healthy dietary patterns and adherence to MD in order to correct these social differences.

Production and persistence of specific antibodies in COVID-19 patients with hematologic malignancies: role of rituximab

The ability of patients with hematologic malignancies (HM) to develop an effective humoral immune response after COVID-19 is unknown. A prospective study was performed to monitor the immune response to SARS-CoV-2 of patients with follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), chronic lymphoproliferative disorders (CLD), multiple myeloma (MM), or myelodysplastic/myeloproliferative syndromes (MDS/MPN). Antibody (Ab) levels to the SARS-CoV-2 nucleocapsid (N) and spike (S) protein were measured at +1, +3, +6 months after nasal swabs became PCR-negative. Forty-five patients (9 FL, 8 DLBCL, 8 CLD, 10 MM, 10 MDS/MPS) and 18 controls were studied. Mean anti-N and anti-S-Ab levels were similar between HM patients and controls, and shared the same behavior, with anti-N Ab levels declining at +6 months and anti-S-Ab remaining stable. Seroconversion rates were lower in HM patients than in controls. In lymphoma patients mean Ab levels and seroconversion rates were lower than in other HM patients, primarily because all nine patients who had received rituximab within 6 months before COVID-19 failed to produce anti-N and anti-S-Ab. Only one patient requiring hematological treatment after COVID-19 lost seropositivity after 6 months. No reinfections were observed. These results may inform vaccination policies and clinical management of HM patients.

Clinical features associated with early drop-out among outpatients with unipolar and bipolar depression

Drop-out from follow-up visits carries significant burden for people diagnosed with depression. The present study assesses multiple clinical moderators of drop-out among depressed outpatients. We retrospectively followed-up 131 outpatients over 6 months: 78 major depressive disorder (MDD), and 53 bipolar disorder (BD-I = 24; BD-II = 29) patients diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Participants were assessed with standard rating scales administered by experienced psychiatrists. Upon descriptive and Cox regression analyses, 17/53 BDs (32%) dropped-out; the overall survival time until drop-out was 57.94 ± 17.79 days. BD drop-outs were younger, had an earlier age at onset, shorter illness duration, lower rates of lifetime obsessive-compulsive disorder/suicidal behavior, higher rates of substance use disorder (SUD), anxious and mixed features of depression compared to BDs attending up to six months. Among MDD patients, 10/78 cases (13%) dropped-out by month-6 with an average survival of 42.40 ± 16.45 days. Earlier age of onset, younger age, positive family history for mood disorders, lower rates of lifetime generalized anxiety disorder were significantly more frequent among drop-outs than completers, as opposite to SUD, and lifetime recurrent depression. Older age predicted lower drop-out among BDs and MDDs, although with almost null hazard ratio (HR) = 0.928, p < 0.01 vs. HR = 0.941, p < 0.01, respectively. Higher rates of lifetime SUD predicted higher drop-out rates by month-6 among MDDs (HR = 5.477, p = 0.02). Limitations of the study: retrospective design, small sample size, lack of objective measures of treatment-adherence/mood rating during follow-up. Drop-out is common in the real-world setting, warranting specific interventions since the beginning of the treatment.

Early ethanol pre-exposure alters breathing patterns by disruptions in the central respiratory network and serotonergic balance in neonate rats

Early ethanol exposure alters neonatal breathing plasticity. Respiratory EtOH's effects are attributed to central respiratory network disruptions, particularly in the medullary serotonin (5HT) system. In this study we evaluated the effects of neonatal pre-exposure to low/moderate doses upon breathing rates, activation patterns of brainstem's nuclei and expression of 5HT 2A and 2C receptors. At PD9, breathing frequencies, tidal volumes and apneas were examined in pups pre-exposed to vehicle or ethanol (2.0 g/kg) at PDs 3, 5 and 7. This developmental stage is equivalent to the 3^rd human gestational trimester, characterized by increased levels of synaptogenesis. Pups were tested under sobriety or under the state of ethanol intoxication and when subjected to normoxia or hypoxia. Number of c-Fos and 5HT immunolabelled cells and relative mRNA expression of 5HT 2A and 2C receptors were quantified in the brainstem. Under normoxia, ethanol pre-exposed pups exhibited breathing depressions and a high number of apneas. An opposite phenomenon was found in ethanol pre-treated pups tested under hypoxia where an exacerbated hypoxic ventilatory response (HVR) was observed. The breathing depression was associated with an increase in the neural activation levels of the raphe obscurus (ROb) and a high mRNA expression of the 5HT 2A receptor in the brainstem while desactivation of the ROb and high activation levels in the solitary tract nucleus and area postrema were associated to the exacerbated HVR. In summary, early ethanol experience induces respiratory disruptions indicative of sensitization processes. Neuroadaptive changes in central respiratory areas under consideration appear to be strongly associated with changes in their respiratory plasticity.

Predictors of hospitalization length of stay among re-admitted treatment-resistant Bipolar Disorder inpatients

BACKGROUND

Hospitalization accounts for significant health care resource utilization for treatment-resistant Bipolar Disorder (BD), especially among frequent users of acute inpatient psychiatric units. Appraisal of the clinical features and predictive role of selected variables is therefore crucial in such population, representing the aim of the present research.

METHODS

A hundred and nineteen BD inpatients with an established history of pharmacological treatment resistance for either mania or bipolar depression were classified as long hospitalization cases (LOS⁺) and their controls and compared against each other for a number of demographic, clinical, and psychopathological features.

RESULTS

Overall, female sex, current second-generation atypical antipsychotic (SGA)/mood stabilizer other than lithium as well as antidepressant treatment at the admission occurred statistically more frequently among LOS⁺ cases, concordant with higher scores at the Hamilton scales for depression and anxiety. Lithium utilization at the time of hospitalization did not differ between cases and controls (LOS^-, n = 81/119), as predominant affective temperament and other psychopathological rating did not. Overall, the time of admission, use of SGA, anticonvulsant (other than lithium), antidepressant, lifetime alcohol dependence, and BD Type (-I or -II), but not current mood polarity at the time of hospitalization, correctly predicted LOS⁺ grouping 68.2% of the times: Exp(B) = 3.151, p042.

LIMITATIONS

Post-hoc, cross-sectional study, relatively small sample size, recall and selection bias on some diagnoses.

CONCLUSIONS

Overall, LOS⁺ treatment-resistant BD inpatients characterize for higher severity and greater pharmaco-utilization use, which warrants replication studies to include additional predictors to shed further light on the matter.

High-dose melphalan with autologous stem cell support in refractory Hodgkin lymphoma patients as a bridge to second transplant

Persistence of disease after salvage therapy among relapsed or refractory Hodgkin lymphoma (HL) patients predicts poor outcome. Here, we report on 41 HL patients with active disease after salvage therapy and who received high-dose melphalan (HD-PAM) and auto-SCT as a bridge to a second autologous or an allogeneic transplantation between 2002 and 2013 at our center. Disease response was based on 18-fluoro-deoxyglucose-positron emission tomography results in all patients. Overall response rate after HD-PAM was 78% and it did not differ among PR or stable/progressive disease patients (P=1.00). Response was associated with better OS: hazard ratio=0.32 (95% confidence interval: 0.13-0.77, P=0.01) irrespective of disease status before HD-PAM. Thirty-three patients (80%) were able to complete the planned treatment, intended as tandem autologous or auto-allo transplant. Hematological and extrahematological toxicity of HD-PAM was manageable, without any treatment-related death. In conclusion, HD-PAM is a valuable therapeutic option in relapsed/refractory HL patients with active disease after salvage therapy, with an impressive 78% overall response rate and 80% rate of proceeding to further transplantation. The present data may be integrated with the growing literature on new drugs in the field of relapsed/refractory HL.

Dissociative symptoms in female patients with mood and anxiety disorders: a psychopathological and temperamental investigation

OBJECTIVE

Dissociative symptoms are frequent among psychiatric patients and may considerably affect patients' psychopathological condition and treatment outcomes. The objectives of the study are to assess the presence of dissociative symptoms in female patients with mood and anxiety disorders, to investigate their correlation with the clinical severity of the disorders and to investigate those personality traits that are more frequent in patients with high levels of dissociation.

PATIENTS AND METHODS

50 Caucasian females were enrolled in the study. Patients were assessed through the Self-Report Symptom Check-List, the Dissociative Experiences Scale (DES) and rating scales for Depression and Anxiety.

RESULTS

The mean DES score in the overall sample was 16.6. 32% of patients had a DES score > 20. Depressive symptoms positively correlated with the DES total scores. Dissociator patients presented some significantly different temperamental characteristics in comparison with non dissociator patients.

CONCLUSIONS

Dissociative symptoms are highly present in patients with mood and anxiety disorders and correlate with the severity of depressive symptoms. Specific personality traits more frequently observed in dissociator people may represent predisposing factors; their early identification could be clinically relevant.

A phase II randomized study comparing pegfilgrastim (PEG) versus filgrastim (FIL) after high-dose chemotherapy (HDC) and autologous peripheral blood stem cell support (PBSC)

7038

Background: The aim of this study was to demonstrate the non-inferiority of one fixed dose of PEG compared to daily FIL, in patients (pts) receiving HDC and PBSC. Methods: Criteria for elegibility were: HDC for haematological or solid tumors; at least 3 x10^6/kg CD34+ reinfused; age >18 years; normal cardiac, renal, liver and pulmonary function; signed written informed consent. Pts were randomized to receive on day+1 subcutaneously(sc) PEG (6mg) or 5 mcg/kg/d sc of FIL until ANC >1.0 x 10^9/L. Primary end points were: absolute neutrophil count (ANC) < 0.5 x 10^9/L and the number (no.) of days to achieve an ANC > 0.5 x 10^9/L from day +1. Secondary end points were: no. of days to achieve an ANC > 1.0 x 10^9/L; no. of days with fever > 38 °C; duration of antibiotic therapy; and no. of documented infections. Results: 80 pts were enrolled (40 pts for group). The duration of ANC < 0.5 x 10^9/L, the time to reach an ANC > 0.5 x 10^9/L and the time to reach an ANC > 1.0 x 10^9/L were superimposable in the two groups (mean days 6, 11, 12 respectively ). No. significant differences between FIL versus PEG group were observed in incidence of fever (24 vs 22), no. of documented infections (12 vs 10), no. of days with fever (1.7 vs 0.97 days), duration of antibiotic therapy (5.7 vs 3.5 days). No. differences in terms of extra-hematological toxicities and time to discharge between the two groups (16 vs 14). Time to reach a platelets count > 20 x 10^9/L was significantly shorter in PEG group compared to FIL group (15 vs 11 days, p value 0.05). Conclusions: This study shows that PEG was not inferior to FIL in terms of hematological reconstitution. Additionally PEG significantly shortened duration of thrombocytopenia <20 x 10^9/L. Consequently, PEG could be safely used after PBSC infusion.

No significant financial relationships to disclose.

Complete response (CR) to ifosfamide, gemcitabine, and vinorelbine (IGEV) and outcome in relapsed/refractory Hodgkin's lymphoma (HL) patients

8568

Background: High dose chemotherapy with autologous stem cells transplant (ASCT) is the gold standard in patients with relapsed/refractory HL. Response to induction chemotherapy (chemosensitive patients) plays a major role in prognosis, however the role of CR status after induction therapy has not been established. Methods: One hundred twenty one patients with relapsed/refractory HL received 4 courses of IGEV followed by single (N=59) or tandem (N=19) ASCT (Santoro et al., Haematologica 92, 2007). Response to IGEV was evaluated by Cheson criteria (1999).The aim of this study was to evaluate the role of CR versus no-CR to IGEV induction therapy on the outcome in terms of progression free survival (PSF) and overall survival (OS). Statistical analysis was performed by using the Kaplan-Meier method and Cox proportional hazard model. Results: IGEV induced an overall response rate of 75% with 46% of CR. In the univariate analysis favourable factors for outcome were CR vs no-CR to IGEV (PFS: p <0.001, OS: p 0.002), A vs B symptoms (PFS: p 0.003; OS: p 0.05), limited vs advanced stage (PFS: p 0.03; OS: p 0.03), and 1 vs≥2 previous chemotherapy lines (PFS: p 0.03, OS: p 0.02); response to last therapy (relapsed vs refractory) influenced PFS (p 0.03) but not OS (p 0.70). The multivariate analysis confirmed the favourable prognostic role of CR to IGEV (PFS HR: 2.5, CI 95%:1.3; 4.6 - OS HR 2.3, CI 95%:1.1;4.8) and of the number of previous chemotherapy lines (PFS HR:1.8, CI 95%:1.0;3.2 - OS HR 2.1, CI 95%:1.1;3.9). Conclusions: According to our data, we conclude that: 1. CR to IGEV is the strongest indicator of outcome in relapsed/refractory HL. 2. Achievement of CR to IGEV overcomes the role of initial disease status. 3. Efforts are warranted to increase the CR rate by induction therapy.

No significant financial relationships to disclose.

Carnitine deficiency in patients with coeliac disease and idiopathic dilated cardiomyopathy

BACKGROUND AND AIMS

Idiopathic dilated cardiomyopathy (IDCM) and coeliac disease (CD) are two pathological conditions which may lead, by different mechanisms, to malabsorption of various micronutrients, including carnitine, active in cardiac metabolism. The aim of the present investigation was primarily to evaluate differences in serum concentrations of total carnitine between IDCM patients and patients with IDCM associated with CD and then also to evaluate, in the latter, the effect of a gluten-free diet on serum concentrations of total carnitine.

METHOD AND RESULTS

Serum carnitine was determined by enzymatic spectrophotometric assay in three groups of individuals: group A, 10 patients (5 males, 5 females), mean age 46.5+/-10.8 years, presenting isolated IDCM; group B, 3 patients (2 males, 1 female), mean age 34+/-8 years, with IDCM+CD; and group C, 10 healthy subjects (5 males, 5 females), mean age 38.6+/-11.1 years. All patients with IDCM belonged to class NYHA I-II. Mean concentrations of total serum carnitine in the group of patients with isolated IDCM (group A) were found to be lower than in the controls (group C). The concentrations in patients with IDCM associated with CD (group B) were lower than in the control group and also lower than in the isolated IDCM (group A). After 2 years on a gluten-free diet, patients presenting IDCM associated with CD showed a progressive increase in mean serum carnitine levels compared to values observed prior to the diet.

CONCLUSIONS

Patients presenting IDCM associated with CD show a greater decrease in serum total carnitine levels than patients presenting the isolated form of IDCM. A gluten-free diet, in these patients, leads to a progressive increase in serum levels of this substance.