Endocrine toxicity in cancer patients treated with nivolumab or pembrolizumab: results of a large multicentre study

INTRODUCTION

The immune checkpoint inhibitors (ICPIs) agents anti-T lymphocytes-associated antigen 4 (CTLA-4) and anti-programmed cell death protein-1 (PD-1) and its ligands (PD-L1/PD-L2) have opened a new scenario in the treatment of cancer. These agents can induce immuno-related adverse events (irAEs), which may affect the endocrine system.

PURPOSE

The aim of this study was to analyze the occurrence and the course of endocrine irAEs in cancer patients treated with anti-PD-1 immunotherapy.

METHODS

This was a retrospective, multicentre study, involving cancer patients treated with the PD-1 inhibitors nivolumab or pembrolizumab at reference Oncology Centres. One hundred and seventy-nine consecutive patients with different types of cancer (mostly non-small cell lung cancer, melanoma, kidney cancer) were included in the study. Patients had received nivolumab (70.9%) or pembrolizumab (29.1%) for 2-33 months. The study evaluated clinical data records until the established date of July 15, 2018. The primary end point was the assessment of endocrine toxicity and possible predictive factors.

RESULTS

Endocrine toxicity occurred in 54 out of 179 patients (30.2%) and was related to thyroid dysfunction, with the exception of one case of diabetes mellitus. Thyroid toxicity occurred mostly within 2 months from the initiation of immunotherapy (83% of cases). A pre-existing thyroid dysfunction was a significant predictor of disease flare.

CONCLUSIONS

Thyroid alterations are frequently associated with anti PD-1 treatment in cancer patients. Regular thyroid assessment should be performed, particularly in the first months of treatment and in patients with a pre-existing thyroid disease.

Persistent Generalized Lymphadenopathy Syndrome vs «Aids» - Unrelated Malignant Lymphoma: Comparison of Presenting Clinical and Laboratory Findings in 88 Patients

The purpose of this report is to document and compare the presenting clinical and laboratory findings of 38 patients, all intravenous drug abusers, with pathologically documented persistent generalized lymphadenopathy (PGL), and of 50 patients with AIDS-unrelated malignant lymphoma (30 with Hodgkin's disease and 20 with non-Hodgkin's lymphoma). All patients, aged 40 years or less, consecutively seen since May 1984 in a single institution in Italy, have prospectively undergone a similar clinico-pathologic approach. In addition to a history of intravenous drug abuse and HIV serology, the results indicate that a history of infection in the previous year, night sweats, weight loss, generalized lymphadenopathy, β2 microglobuline, transaminase, T4/T8 ratio < 1, and polyclonal hypergamma-globulinemia significantly increased among PGL patients compared with patients with AIDS-unrelated malignant lymphoma. In contrast, patients with malignant lymphoma had a significant increase in mediastinal lymph nodes, sedimentation rate, LDH, fibrinogen and anemia. Therefore, at this time of an AIDS epidemic, after histologic diagnosis of reactive lymphadenopathy has been performed in young patients presenting with generalized lymphadenopathy, a request for a second biopsy and other invasive procedures may be avoided if clinical and laboratory data suggest a PGL syndrome. If not already performed, HIV antibody detection should be carried out in this setting.

Practical Importance of Routine Paraffin-Embedded Bone Marrow Biopsy in Multiple Myeloma

Paraffin-embedded bone marrow biopsy specimens obtained prior to (37) or after (25) therapy from 62 patients with multiple myeloma (MM) were analyzed with particular reference to infiltration pattern, extent of infiltration, and myeloid to myeloma tissue percentage ratio (MMR) to verify their mutual relationships and clinicopathologic relevance. Fifty-nine biopsies were evaluable for infiltration pattern (diffuse in 27, interstitial in 25, and nodular in 7). Diffuse and interstitial patterns were more common (P < 0.025) in stage III and stage I patients, respectively. A higher (P < 0.001) mean serum paraprotein level was found in patients with’ the diffuse pattern than in those with the interstitial pattern. The average extent of infiltration by myeloma cells in the residual myeloid tissue was higher (P < 0.001) and a high extent (75% or more) was more frequently (P < 0.005) seen in diffuse than in interstitial pattern cases. The average MMR value was lower (P < 0.001) and a MMR value less than 1 was more frequently (P < 0.005) seen in the diffuse pattern group than in the interstitial pattern group. All these differences were present also when a separate analysis was performed for treated and untreated patients. It seems that a diffuse histologic pattern, as opposed to interstitial, would significantly predict a bone marrow extent of infiltration of 75% or more, a MMR lower than 1, a higher serum paraprotein level, and a clinical stage III. Bone marrow biopsy appears thus to play a role in providing parameters of prognostic relevance in MM also in the course of the disease. Prospective studies are needed to establish whether histologic pattern has an independent prognostic value.

A randomized, phase 2 study of cetuximab plus cisplatin with or without paclitaxel for the first-line treatment of patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

B490 (EudraCT# 2011-002564-24) is a randomized, phase 2b, noninferiority study investigating the efficacy and safety of first-line cetuximab plus cisplatin with/without paclitaxel (CetCis versus CetCisPac) in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN).

PATIENTS AND METHODS

Eligible patients had confirmed R/M SCCHN (oral cavity/oropharynx/larynx/hypopharynx/paranasal sinus) and no prior therapy for R/M disease. Cetuximab was administered on day 1 (2-h infusion, 400 mg/m2), then weekly (1-h infusions, 250 mg/m2). Cisplatin was given as a 1-h infusion (CetCis arm: 100 mg/m2; CetCisPac arm: 75 mg/m2) on day 1 of each cycle for a maximum of six cycles. Paclitaxel was administered as a 3-h infusion (175 mg/m2) on day 1 of each cycle. After six cycles, maintenance cetuximab was administered until disease progression or unacceptable toxicity. The primary end point was progression-free survival (PFS). We assumed a noninferiority margin of 1.40 as compatible with efficacy.

RESULTS

A total of 201 patients were randomized 1 : 1 to each regimen; 191 were assessable. PFS with CetCis (median, 6 months) was noninferior to PFS with CetCisPac (median, 7 months) [HR for CetCis versus CetCisPac 0.99; 95% CI: 0.72-1.36, P = 0.906; margin of noninferiority (90% CI of 1.4) not reached]. Median overall survival was 13 versus 11 months (HR = 0.77; 95% CI: 0.53-1.11, P = 0.117). The overall response rates were 41.8% versus 51.7%, respectively (OR = 0.69; 95% CI: 0.38-1.20, P = 0.181). Grade ≥3 adverse event rates were 76% and 73% for CetCis versus CetCisPac, respectively, while grade 4 toxicities were lower in the two-drug versus three-drug arm (14% versus 33%, P = 0.015). No toxic death or sepsis were reported and cardiac events were negligible (1%).

CONCLUSION

The two-drug CetCis regimen proved to be noninferior in PFS to a three-drug combination with CetCisPac. The median OS of both regimens is comparable with that observed in EXTREME, while the life-threatening toxicity rate appeared reduced.

CLINICAL TRIAL NUMBER

EudraCT# 2011-002564-24.

Clinical presentation and outcome of non-AIDS defining cancers, in HIV-infected patients in the ART-era: the Italian Cooperative Group on AIDS and tumors activity

The advent of antiretroviral therapy (ART) has markedly extended the survival rates of patients with human immunodeficiency virus (HIV), leading to suppression even though not eradication of HIV. In HIV infected patients, cancer has become a growing problem, representing the first cause of death. A large number of worldwide studies have shown that HIV infection raises the risk of many non-AIDS defining cancers (NADCs), including squamous cell carcinoma of the anus (SCCA), testis cancer, lung cancer, cancer of the colon and rectum (CRC), skin (basal cell skin carcinoma and melanoma), Hodgkin disease (HD) and hepatocellular carcinoma (HCC). Generally in HIV positive patients NADCs are more aggressive and in advanced stage disease than in the general population. In the ART era, however, the outcome of HIV positive patients is more similar as in the general population. Only about lung cancer the outcome seems different between HIV positive and HIV negative patients. The aim of this article is to provide an up-date on NADCs within the activity of the Italian Cooperative Group on AIDS and Tumors (GICAT) to identify clinical prognostic and predicting factors in patients with HIV infection included in the GICAT.

Head and neck cancer survivors patients and late effects related to oncologic treatment: update of literature

Cancer survivorship represents a new challenge in the third Millennium. In Europe the number of cancer survivors was estimated to be 17,8 million in 2008 and this number is growing. Recent improvements in cancer survival are largely due to earlier diagnosis and advancements in treatment. Despite having favorable effects on cancer survival, radiation therapy, surgery treatment and combination chemotherapy regimens can also cause long-term organ damage and functional disabilities. In this paper we review the most important aspects of long-term toxicities in otolaryngology cancer survivors patients.

Lung cancer in HIV positive patients: the GICAT experience

PURPOSE

AIDS incidence and mortality have decreased since the introduction of highly active antiretroviral therapy (HAART) into clinical practice. HIV-related malignancies, namely Kaposi's sarcoma and Non-Hodgkin's lymphoma, have decreased, whereas non-AIDS defining tumors have been increasing. Our aim was to study the impact of HAART on natural history of lung cancer in HIV-positive patients, comparing patients with HIV-lung cancer treated in the pre-HAART era versus the HAART era.

PATIENTS AND METHODS

We collected 68 patients with HIV-lung cancer diagnosed from 1986 to 2003. Pre-HAART era included 34 patients who did not receive HAART, whereas the HAART era included 34 patients diagnosed after January 1997 who received HAART.

RESULTS

At diagnosis Performance Status (PS) was significantly different, patients with PS ≥ 2 were 44% in the pre-HAART era, versus 29% in the post-HAART era, p = 0.02. The 79.4% of patients in the post-HAART era received chemotherapy alone or with radiotherapy versus 47% in the pre-HAART era, p = 0.04. Cancer was the leading cause of death for both groups, with 29 (85.3%) and 21 (61.8%) patients in the pre- and post-HAART settings, respectively. The median overall survival (OS) was 3.8 months for the pre-HAART population vs. 7 months for the post-HAART patients, p = 0.01.

CONCLUSIONS

HIV-lung cancer patients have a longer overall survival in the post-HAART era versus the pre-HAART era, due to a not detrimental effect of chemotherapy and positive effect of HAART. Lung cancer is the leading cause of death, showing that treatment of the cancer is the most important target now to improve their outcome.

Plasma HHV-8 viral load in HHV-8-related lymphoproliferative disorders associated with HIV infection

This is a mono-institutional analysis of the clinical features, immunological and virological findings, and prognostic factors of patients with HIV infection and HHV-8-lymphoproliferative disorders. Patients with Multicentric Castleman Disease and HHV-8-related lymphoma diagnosed and treated from April 1987 to June 2004 were included in the study. HHV-8 and HIV plasma viral load, CD4+ count, hematologic parameters, and general wellbeing (performance status) were assessed at the onset of the diseases and analyzed in order to identify possible prognostic factors. Nine patients with Multicentric Castleman disease, and 16 with HHV-8-related lymphomas (13 primary effusion lymphomas and 3 solid lymphomas), were diagnosed and treated out of 327 HIV-related non-Hodgkin's lymphomas. Four patients with Multicentric Castleman disease received only antiretroviral drugs; 5 HAART plus oral etoposide. Nine patients with primary effusion lymphoma were treated with a CHOP-like regimen (Cyclophosphamide, Prednisone anthracyclines, Vinca alkaloids, Bleomycin, Etoposide) and HAART; 1 with etoposide and HAART, 1 with HAART alone. The patients with solid lymphoma underwent CHOP-like chemotherapy. Patients with Multicentric Castleman disease showed lower median values of HHV-8 viral load and longer overall survival compared with HHV-8-related lymphomas. Patients with viral load of HHV-8, >40,000 cp/ml had a significant shorter overall survival. In the univariate analysis, HHV-8-related lymphoma, HHV-8 viral load >40,000 cp/ml and performance status >2 were associated with an increased risk of death. Multivariate analysis confirmed the diagnosis of lymphoma as an independent predictor of shorter survival.

MUC-1 (CA 15–3 Antigen) as a Highly Reliable Predictor of Response to EGFR Inhibitors in Patients with Bronchioloalveolar Carcinoma: An Experience on 26 Patients

Background

Bronchioloalveolar carcinoma (BAC) is a histological subtype of non-small cell lung cancer (NSCLC), particularly of adenocarcinoma. Given its multifocality and the poor activity of chemotherapy, there is no established treatment for BAC, although promising results have been achieved with inhibitors of the epidermal growth factor receptor (EGFR). No tumor marker has been validated in the diagnosis and follow-up of lung cancer, in particular to predict the outcome of treatment with EGFR inhibitors.

Purpose

As CA 15–3 antigen serum levels are reported to be pathologically abnormal in adenocarcinoma of the lung, we chose this tumor marker to monitor treatment with EGFR inhibitors of patients affected by adenocarcinoma with BAC features or pure BAC.

Patients and methods

We collected data from 26 consecutive Caucasian patients with BAC, mostly women and never smokers, who received EGFR inhibitors.

Results

We noticed that all patients with normal CA 15–3 serum levels at baseline (15/26, 57.7%) showed a response to EGFR inhibitors, whereas all patients with abnormal CA 15–3 serum levels (11/26, 42.3%) did not.

Conclusion

Our data suggest that CA 15–3 levels might be a predictive factor for the response to EGFR inhibitors in patients with BAC.

Lopinavir–Ritonavir Dramatically Affects the Pharmacokinetics of Irinotecan in HIV Patients With Kaposi’s Sarcoma

The coadministration of protease inhibitors with anticancer drugs in the management of human immunodeficiency virus-related malignancies can cause potential drug-drug interactions. The effect of lopinavir/ritonavir (LPV/RTV) on the pharmacokinetics of irinotecan (CPT11) has been investigated in seven patients with Kaposi's sarcoma. Coadministration of LPV/RTV reduces the clearance of CPT11 by 47% (11.3+/-3.5 vs 21.3+/-6.3 l/h/m(2), P=0.0008). This effect was associated with an 81% reduction (P=0.02) of the AUC (area under the curve) of the oxidized metabolite APC (7-ethyl-10-[4-N-(5-aminopentanoic-acid)-1-piperidino]-carbonyloxycamptothecin). The LPV/RTV treatment also inhibited the formation of SN38 glucuronide (SN38G), as shown by the 36% decrease in the SN38G/SN38 AUCs ratio (5.9+/-1.6 vs 9.2+/-2.6, P=0.002) consistent with UGT1A1 inhibition by LPV/RTV. This dual effect resulted in increased availability of CPT11 for SN38 conversion and reduced inactivation on SN38, leading to a 204% increase (P=0.0001) in SN38 AUC in the presence of LPV/RTV. The clinical consequences of these substantial pharmacokinetic changes should be investigated.

Comprehensive geriatric assessment (CGA)-adapted chemotherapy (CT) in 100 elderly patients (pts) (>70 years) with diffuse large B-cell non-Hodgkin’s lymphoma (DLBCL)

19515

Rituximab+CHOP (R-CHOP) is the standard CT regimen for elderly pts with CD20+ DLBCL. However, many pts ≥70 yrs are often unable to received R-CHOP and are excluded from clinical trials. Moreover, CGA has been demonstrated a useful instrument to predict the clinical outcome of elderly cancer pts even if it has never been tested prospectively. Within the GOL (Onco-hematological Lymphoma Group) from June 2000 to March 2006 we started a phase II prospective study to evaluate the feasibility and activity of a CGA-driven CT for elderly pts with DLBCL. Rituximab was used in all pts after February 2002. Pts with no comorbidity received CHOP or R-CHOP; in pts with mild cardiopathy epirubicin was used instead of doxorubicin (CEOP or R-CEOP); in pts with moderate or severe cardiopathy the use of antracyclines was omitted (CVP or R-CVP). CT dosage was decided according to CGA: pts with a good CGA score (ADL=6, IADL>6) received full doses of CT; pts with an intermediate score (ADL=5, IADL>4) received 75% of the planned dose; pts with a poor score (ADL<5, IADL<5) received 50% dose. All pts received prophylactic filgrastim; 100 pts (41 males and 59 females) have been treated and no pt was excluded from this approach. Median age was 75 yrs (range 70–89) and 51% were stages III-IV. Sixty-one per cent of pts received full doses of CT, 86% received antracycline (doxorubicin in 56% and epirubicin in 30%) and 54% received rituximab plus CT. The following regimens were used: R-CHOP 22%, CHOP 16%, 75%-R-CHOP 10%, 75%-CHOP 8%, CEOP 11%, R-CEOP 4%, 75%-R-CEOP 9%, 75%-CEOP 6%. The remaining pts received CVP in 5% of cases and reduced R-CVP in 9% of cases. The toxicity was quite acceptable, however 4 toxic deaths occurred (2 septic shock, 1 acute respiratory failure and 1 acute myocardial infarction). Overall, 76% achieved CR and with a median follow-up of 24 months (range 1–71 months) only 16% relapsed. Seventy-three pts are alive and 63% in CR. Our results demonstrated that a CGA-driven approach is feasible and highly active in elderly pts with DLBCL. Moreover this strategy allows a potentially curative approach to all pts with aggressive NHL avoiding both to under-treat elderly pts with a curable disease and to over-treat elderly pts with comorbidities.

No significant financial relationships to disclose.

Factors influencing tymic function in 55 patients with lymphomas: Candidates to autologous stem cell transplantation (ASCT)

18512

Background: Signal joint T cell receptor excision circles (sjTRECs) have been reported to be a clinical marker to evaluate the tymic reservoir after immunosuppression treatments. Methods: We studied the sjTRECs levels in a mono-institutional series of a cohort of 26 HIV-positive and 29 HIV-negative pts with relapsed or refractory lymphomas, candidates to ASCT, considering important biological and clinical characteristics, virological parameters and immunological settings including age, type of lymphoma, number of first line CT cycles, time from the end of first line chemotherapy to the enrolment (TECT), HIV infection and T subpopulations. Results: The overall study subjects, showed lower sjTRECs levels than healthy donors (p<0.01), but no differences in the sjTRECs content were seen between HIV-negative and HIV-positive pts (536 vs. 401 TRECs/106 PBMCs, respectively) as well as in the T cell naive count. We found a significant correlation between the sjTRECs decay and the increase of age (r=-0.32, p=0.02), CD4 and CD8 naive cell count and the sjTRECs level; on the contrary we did not observe any significant correlation between CT cycles number TECT, lymphoma type in both subgroups. HIV-positive viremic pts showed significant lower level of sjTRECs level than averimic pts. Conclusions: Our analyses suggest that de novo T cell generation is partially maintained in lymphoma pts’ candidates to ASCT and could contribute to restore the immune function after transplantation. Chemotherapeutic treatments seem to induce a similar influence on thymic output despite their intensity and, surprisingly, HIV infection is not a detrimental factor on thymic reservoir at the time of lymphoma relapse, and a good control of HIV replication seems to preserve thymic reservoir.

No significant financial relationships to disclose.

Ca-15.3 antigen as predictor of response to EGFR inhibitors in patients with bronchiolo-alveolar carcinoma

18151

Background: Bronchiolo-alveolar carcinoma (BAC) is a subtype of non-small cell lung cancer (NSCLC). Incidence of pure BAC ranges between 2% and 5% of NSCLC although a BAC histotype may be present in up to 20%. There is no established treatment for BAC, although promising results have been achieved from the use of inhibitors of the Epidermal Growth Factor Receptor (EGFR). It has been demonstrated that there is a very close relationship between responsiveness to EGFR inhibitors Erlotinib and Gefitinib and some factors, including female gender; adenocarcinoma histotype, with BAC features; Asian origin; and never having smoked. No tumor marker has been validated in the diagnosis and follow-up of lung cancer. Ca 15–3 antigen serum levels are reported to be pathologically abnormal in adenocarcinoma of the lung, although it does not seem to be related to the EGFR pathway. We studied this tumor marker in relation with the treatment with EGFR inhibitors in patients affected by BAC. Methods: We collected data from 16 caucasian, female and never smoker pts with BAC. All pts received EGFR inhibitors as first-line therapy. In compliance with the EAP, dosage of Gefitinib and Erlotinib was 250 mg/day and 150 mg/day, respectively. Results: One (6%) pt had a complete response and 6 (38%) showed a partial response to EGFR inhibitors, 1 (6%) pt remained stable for 4 months, while 8 (50%) pts progressed. All 7 pts with normal Ca 15–3 levels before treatment with EGFR inhibitors’ achieved a partial or complete response, but the 8 pts with abnormal Ca 15–3 levels did not (p=0.0001). Among the responders we noticed an increase of Ca 15–3 serum levels at progression. In particular, 5 pts had an increase of Ca 15–3 serum levels up to normal value when their disease progressed; 2 pts have not progressed yet and Ca 15–3 serum levels remain normal. Conclusions: We suggest that Ca 15–3 levels may be a prognostic factor to predict the response to EGFR inhibitors in pts with BAC. We are studying its role in a larger population with BAC and in other NSCLC subtypes as well.

No significant financial relationships to disclose.

Evaluation of angiogenis activation during interleukin-2 infusion in patients with renal cell cancer (RCC)

14640

It is well known that during IL-2 administration a complex activation of the cytokine network is on going, but few data are available about the effect of this activation on angiogenesis. In our Institution all patients with metastatic RCC undergo to the following schedule of IL-2 infusion: IL-2 10 MIU continuous infusion (ci) 5/7 days, one week off followed by IL-2 10 MIU ci 5/7 days, 4 week off (1 cycle); for a total number of 2 cycles. We evaluated the activation of angiogenesis measuring the plasma level of VEGF MMP2 and MMP9 before, during and after the 5 days IL-2 ci. In 13 patients analysed, before IL-2 ci, we have the following median level of plasma VEGF (773+ 378 pg/ml), MMP2 (55.9 + 19.9 ng/ml) and MMP9 (1146+498 ng/ml). The baseline median values of VEGF MMP-9 showed a trend to correlate with the number of metastasis before therapy. During 3 days of IL-2 ci we did not observed any significant increase of VEGF MMP2 and MMP9 as well as after 24 hours from the end of the 5 days ci. On the contrary, at the same time-points, during and after IL-2 ci, we observed the activation of pro-inflammatory cytokines network, measured by the statistically significant increased levels of neopterin IFN-γ and TNF-α and sIcam.This preliminary observation demonstrated that IL-2 ci, even if it highly activates the release of pro-inflammatory factors, does not affect the release of angiogenic surrogate markers such as VEGF MMP2 and MMP9. On the basis of our experience we can suggest that the most suitable time to test angiogenesis inhibitors during IL-2 therapy appear to be the intervals between IL-2 administration and not during IL-2 infusion when the most severe side effects occur and it is not observed a significant increase of angiogenic factor release.

No significant financial relationships to disclose.

Effect of Lopinavir/ritonavir protease inhibitor on the pharmacokinetics of Irinotecan in HIV-infected patients with advanced Kaposi’s sarcoma

9558

Background: Irinotecan (CPT11) in combination with HAART has been found active in patients with advanced AIDS-related Kaposi’s sarcoma [Vaccher E et al. AIDS 2005]. Dose-limiting toxicity consisted of persistent leukopenia, suggesting the potential for pharmacokinetic interactions between CPT11 and lopinavir boostered with ritonavir, the protease inhibitor component of HAART. Methods: Six HIV-infected patients with advanced Kaposi’s sarcoma were prospectively treated with CPT11 at a dose of 150 mg/m2, given as a 90-min infusion on days 1 and 10, in absence and in combination with 400mg/100mg LPV/rtv. Pharmacokinetic parameters of the CPT11, the active metabolite (SN38), its glucoronide derivative (SN-38G), and the APC metabolite were investigated over a 50 h time interval at the first day of chemotherapy cycle. A 2-day LPV/rtv washout was allowed before the evaluation of pharmacokinetics of CPT11 alone. The pharmacokinetics of CPT11 in combination with LPV/rtv was determined at day-10 (paired cross over). Results: The mean (± SD) clearance of CPT11 was found significantly lower when CPT11 was administered in combination with LPV/rtv (13.39±3.39 l/h/m2 vs 23.55±7.16 l/h/m2, p<0.05 for CPT11+ LPV/rtv and CPT11 alone respectively). This was associated with a 94.3% reduction of AUC APC oxidized metabolite and with 2.9 and 1.8-fold increase of SN38 and SN38G AUC, respectively. During the CPT11+ LPV/rtv, the ratio SN38/CPT11 AUC was higher (0.031±0.008 vs 0.019±0.006, p<0.05) while the glucoronidation ratio (the AUC ratio of SN38G and SN38) was found significantly lower (5.50±1.43 vs 9.03±2.49, p<0.05) as compared to the administration of CPT11 alone. Conclusions: This preliminary investigation indicates that CPT11 pharmacokinetics can be strongly influenced by the co-administration of LPV/rtv. This leads to a significant increase of AUC SN38 active metabolite, likely associated to an increase of CPT11 activation and in a reduction of SN38 glucoronidation paths, which may have profound effects on pharmacodynamic of CPT11 when used in combination with LPV/rtv -based HAART.

No significant financial relationships to disclose.

Cytokines modulation and activity in non-small cell lung cancer (NSCLC) by chemotherapy and indinavir

17094

Background: Our aim was to evaluate the activity of chemotherapy (CT) and indinavir, a protease inhibitor affecting matrix metalloproteases (mmps) of tumors, according to in-vitro studies (Sgadari, Nat Med 2002), in NSCLC patients (pts). Methods: All consecutive pts with NSCLC, IIIB and IV, underwent a platin-gemcitabine treatment. All pts with stable disease or partial remission after 3 courses were given 3 more courses plus indinavir 800 mg tid p.o, till progression. For each pt serum samples were collected before CT and every month till end of the study. Results: We enrolled 24 pts, with the same prognostic factors (age <70 years; PS 0 and IV stage disease). Clinical data are available for 18 pts. Up to now we did not find any clinical benefit with indinavir as maintenance therapy: median time to treatment failure (TTF) is 2.75 mos (±1.0) and median overall survival (OS) is 16 mos (±4.5), not significantly different from literature data. For 11 pts, biological data are available. Using a paired T-test to compare differences at different times, we did not find any variation in VEGF, TNF-α, ICAM, neopterine, γ-IFN, mmps by CT. VEGF decreases in comparison with basal time, but not significantly, mean value 326 pg/mL (±79). Indinavir induces an increase of mmp2, before Indinavir 68.8 pg/mL (±9.18), after 97.09 (±10.21), p = 0,04. Analyzing by response, all pts with a RP at CT had a progressive decrease of serological VEGF; pts with SD or PD had an increase of VEGF. Pts with longer OS had a decrease of TNF-α, even at the time of progression. Conclusion: In our pts TNF-α and VEGF seem to have different pathways. TNF-α is related with OS, while VEGF is related with response to treatment. VEGF is a good marker to follow the clinical response and TNF-α is a better prognostical marker for OS. All our pts showed mean serum VEGF values lower than the previously reported values as cut-off level for prognostic value (Laack E. Lung Cancer 2005); in fact we selected pts in SD or RP after the third course of CT. In our pts VEGF is related with tumor response to therapy (i.e. tumor volume) while TNF-α drives their outcome. Modulation of TNF-α and his pathway may improve pts outcome.

No significant financial relationships to disclose.

Stanford V regimen in 59 patients (pts) with HD and HIV Infection (HD-HIV): A very effective approach in the long-term analysis

7583

Background: The introduction of HAART has significantly improved the outcome of pts with HD-HIV. However there are no data on the long-term follow-up of HD-HIV pts treated with conventional chemotherapy (CT) regimens and concomitant HAART. In 2002, we reported the results of a prospective phase II study with the intensive 12-week CT with adjuvant radiotherapy (Stanford V) and concomitant HAART in 59 pts with HD-HIV, a well-known unfavorable subgroup of HD (Spina et al. Blood 2002; 100:1984–1988). Methods: To analyze the long-term outcome of patients included in the Stanford V and HAART protocol. Results: The median follow-up is 53 months (range 3–104 months The overall survival (OS) is 59%, the freedom from progression (FFP) is 62% and the disease free survival (DFS) is 72%. The 5-year probability of OS was significantly different in pts with an international prognostic score (IPS) <3 in comparison to that of pts with an IPS >2 (84% vs 36%, p = 0.001). Similarly, the percentages of FFP at 5 years in these groups were 72% and 45% (p = 0.03). No significant side effects have been observed so far. Conclusions: After a median follow-up of 4.5 years, 72% of pts with this unfavorable subgroup and IPS <3 is free from progression, superimposable to that observed in the general population with comparable adverse prognostic factors. Therefore, Stanford V is a very effective regimen in pts with HD-HIV in the long-term analysis. Supported by AIRC and ISS grants.

No significant financial relationships to disclose.

KSHV/HHV-8 associated lymph node based lymphomas in HIV seronegative subjects. Report of two cases with anaplastic large cell morphology and plasmablastic immunophenotype

BACKGROUND

Kaposi sarcoma associated herpesvirus (KSHV)/human herpesvirus 8 (HHV-8) associated lymphomas, which often develop in human immunodeficiency virus (HIV) infected patients with advanced AIDS, present predominantly as primary effusion lymphoma (PEL) or, less frequently, as "solid" extracavitary based lymphomas, associated with serous effusions. These last lymphomas, also called "solid PEL", have been reported before the development of an effusion lymphoma and after resolution of PEL. Interestingly, KSHV/HHV-8 associated lymphomas that present as solid or extracavitary based lesions in HIV seropositive patients without serous effusions have been reported recently.

METHODS/RESULTS

This paper provides evidence for the existence of a previously undescribed KSHV/HHV-8 associated lymphoma in HIV seronegative patients without serous effusions. These lymphomas exhibit a predilection for the lymph nodes and display anaplastic large cell morphology. These tumours were completely devoid of common cell type specific antigens, including epithelial and melanocytic cell markers. B and T cell associated antigens and other commonly used lymphoid markers were absent or weakly demonstrable in a fraction of the tumour cells. Conversely, immunohistochemical studies showed strong immunostaining with plasma cell reactive antibodies.

CONCLUSIONS

Analysis of viral infection and immunohistological studies are of primary importance to define this lymph node based KSHV/HHV-8 associated lymphoma with anaplastic large cell morphology and plasmablastic immunophenotype occurring in HIV seronegative patients without serous effusions.

Effect of highly active antiretroviral therapy (HAART) on pharmacokinetics and pharmacodynamics of doxorubicin in patients with HIV-associated non-Hodgkin's lymphoma

BACKGROUND

We demonstrated that highly active antiretroviral therapy (HAART) increases the toxic effect of cyclophosphamide, vincristine, doxorubicin (DOX) and prednisone (CHOP) in HIV-patients with non-Hodgkin's lymphoma (NHL). To ascertain the cause of increased toxicity, we investigated the pharmacokinetics of DOX in HIV-patients with NHL treated with CHOP with and without HAART.

METHODS

Complete pharmacokinetics and pharmacodynamic analysis was determined in 19 patients during 38 cycles of chemotherapy: 19 cycles with CHOP and 19 CHOP + HAART in a crossover-designed study. HAART included protease inhibitors indinavir (IDV) in nine patients, saquinavir (SQV) hard gel in six patients and nelfinavir (NFV) in four patients.

RESULTS

No significant effects of HAART on pharmacokinetics parameters of DOX were observed. Similarly, no differential effect on DOX pharmacokinetics among IDV, SQV, and NFV was evidenced. Significant associations (P=0.012) were observed between DOX AUC0-infinity (area under the concentration curve) and G3-G4 WHO haematologic toxicity, in patients treated with CHOP alone, but not in those treated with CHOP + HAART (P = not significant).

CONCLUSION

We demonstrated that HAART therapy has no significant effect on DOX pharmacokinetics. DOX AUC appears to be a predictor of toxicity only in patients treated with CHOP alone. Other factors beside DOX plasma levels are detrimental for toxicity after CHOP + HAART. Therefore, pharmacodynamic interactions between HAART and DOX should be considered.

Mitoxantrone, vinorelbine and prednisone (MVD) in the treatment of metastatic hormonoresistant prostate cancer — a phase II trial

A total of 28 patients were treated with mitoxantrone, vinorelbine and prednisone every 3 weeks. In all, 11 patients (46%) had a significant prostate-specific antigen decline for a median duration of 11.4 months. Eight patients (33%) achieved a partial response on pain, while seven (29%) obtained a stabilisation of the symptom. Median duration of the response was 9.5 months. A confirmed partial response was obtained in three out of seven patients who had bidimensionally measurable disease. Toxicity was manageable. Our study provides further support to the concept of combined antimicrotubule therapy for metastatic harmonoresistant prostate cancer, promoting the exploration of new regimens containing antimicrotubule agents in addition to mitoxantrone-prednisone.

Nasopharyngeal cancer WHO type II-III: monoinstitutional retrospective analysis with standard and accelerated hyperfractionated radiation therapy

The aim of this study is to assess the impact of prognostic factors in patients with locoregionally advanced nasopharyngeal cancer (NPC), WHO type II-III, treated with two different radiation therapy (RT) schedules: standard radiation therapy (SRT), and accelerated hyperfractionated radiation therapy (HART), with or without sequential chemotherapy. Between January 1986 and December 1999, 78 consecutive NPC patients were treated either with SRT (until August 1993) or with HART (from September 1993). Of the 78 patients, 60 were males and 18 females, the median age was 56 years (range 14-83). Nine patients had a non-keratinizing carcinoma (WHO type II) and 69 an undifferentiated carcinoma (WHO type III). Five-year overall survival rate (OS) was 62%. Two months after RT, 73 patients were in complete remission. Disease-free survival (DFS) rates at 5 years were: 85% for the HART and 59% for the SRT group, respectively. A multivariate analysis, age (hazard ratio, HR=4.17 for > or = 60 vs. <50 years) and N-stage (HR=3.56 for N3a-N3b vs. N0-N1) were significant for survival, whereas N-stage (HR=8.23 for N3a-N3b vs. N0-N1) and RT schedule (HR=0.30 for HART vs. SRT) were significant for DFS. In our experience, HART achieved higher DFS rates than SRT; however, HART did not favourably affect OS. Toxicity was comparable in the two RT schedules.

[Systemic HIV-non-Hodgkin lymphoma in the era of HAART. Natural history]

In the era of highly active antiretroviral therapy (HAART), systemic non-Hodgkin lymphoma (NHL) represented the most frequent cancer associated to HIV infection. In contrast to Kaposi's sarcoma and primary central nervous system lymphoma (PCNSL) which incidence have been declining after introduction of HAART, systemic NHL-HIV has relatively stable remained. Systemic HIV related NHL are markedly heterogeneous both histologically and clinically and this clinicophatological heterogenity reflects variability in the molecular lesions associated to these lymphomas and immunological status of these patients. The introduction of HAART has substantially modified the approach to HIV related lymphomas. The results of recent monoinstitutional study of Aviano Cancer's Institute on 235 patients have suggested that HAART would otherwise allow a long life expectancy with longer disease free survival and overall survival. In fact the reduced of morbidity of AIDS patients bought by HAART justified the use of aggressive antineoplastic therapies.

The EORTC quality of life questionnaire-head and neck 35 in Italian laryngectomized patients. European organization for research and treatment of cancer

The aim of this study was to test the validity and reliability of the European organization for research and treatment of cancer (EORTC) quality of life questionnaire (QLQ)-head and neck (H&N) 35 in Italian laryngeal cancer patients. The original questionnaire was developed by the EORTC quality of life (QoL) study group and tested in H&N cancer patients from Norway, Sweden, and the Netherlands. The Italian translation of the questionnaire used in this study was made by a team of the CRO, National Cancer Institute, using a double-back translation method between independent translators. The translated EORTC QLQ-H&N35 was given to 99 patients with H&N cancer who had undergone total laryngectomy 1-26 years before and had been then treated with radiotherapy and, in some cases, chemotherapy. The questionnaire was re-administrated to 33 patients after 1 month to test its stability over time. It was structurally made up of seven scales (pain, swallowing, sense, speech, social eating, social contact, and sexuality) and 11 single items that considered the most important clinical aspects characterizing the QoL in H&N cancer patients. The statistical analysis of the indexes of validity and reliability confirmed the results obtained with other linguistic versions of the questionnaire. Our Italian version of the EORTC QLQ-H&N35 proved to be a statistically valid instrument to assess QoL in laryngectomized patients.

Human immunodeficiency virus-related non-Hodgkin lymphoma: activity of infusional cyclophosphamide, doxorubicin, and etoposide as second-line chemotherapy in 40 patients

BACKGROUND

The prognosis of patients with human immunodeficiency virus (HIV)-related non-Hodgkin lymphoma (NHL) is poor. In fact, despite a high complete response (CR) rate, approximately 50% of these patients die from progressive lymphoma.

METHODS

From November 1994 to April 2000, the authors treated 40 patients with resistant or recurrent HIV-related NHL with a 96-hour continuous intravenous infusion of cyclophosphamide (187.5 mg/m(2) per day), doxorubicin (12.5 mg/m(2) per day), and etoposide (60 mg/m(2) per day).

RESULTS

The median number of cycles administered was two (range, one to six cycles). A CR was documented in 4 of 40 patients (10%), and a partial remission (PR) was documented in 7 of 40 patients (18%). The CR median duration was 6 months (range, 4--30+ months), whereas PRs lasted for 5 months (range, 2--8 months). The overall median survival was 4 months (range, < 1--33 months), and the median survival for responding patients was 10 months.

CONCLUSIONS

The current data confirm that infusional cyclophosphamide, doxorubicin, and etoposide is active in patients with refractory or recurrent HIV-related NHL. However, the median survival of these patients remains poor, and the other innovative approaches should be used.