Body mass index (BMI) influence on Cetuximab-induced antibody-dependent cellular cytotoxicity in advanced colon cancer

To date, we do not know if the excess of the body mass index (BMI) improves or worsens the outcomes in colorectal cancer treatment, and the correlation between BMI and prognosis remains unclear. A recent study in vitro showed a significant negative correlation between BMI and Cetuximab-induced antibody-dependent cellular cytotoxicity. On these bases, we tried to analyze the potential correlation between BMI and survival in patients affected by metastatic colorectal cancer (mCRC) and treated with Cetuximab. Retrospective data were collected from 132 patients affected by mCRC treated with Cetuximab in monotherapy or association with chemotherapy between January 2007 and October 2019. The cohort of patients was divided into different groups according to the World Health Organization (WHO) BMI classification: underweight (BMI < 18.59), normal weight (BMI 18.5-24.9,) overweight (BMI 25-29.9), and obese (BMI > 30), and we observed the influence of BMI on survival and treatment response. Patients with BMI ≥ 25 had statistically significantly better survival than patients BMI < 25 (19 vs 10 months, p = 0.025). Dividing the sample into the four WHO BMI categories, the best survival rates were seen in the overweight and obese subgroups (18 and 26 months respectively, p < 0.01). The multivariate analysis confirmed BMI as the only parameter able to influence survival. No correlation between BMI and treatment response was seen between BMI ≥ 25 and BMI ≤ 24 groups (p = 0.14). Our experience suggests that mild obese and overweight patients treated with Cetuximab could experience a better survival. We also observed that among normal weight, overweight, and mild obese patients, there is a better response to immunochemotherapy in comparison with underweight patients, but this difference does not reach a significative statistical value.

Discontinuation of first-line bevacizumab in metastatic colorectal cancer: the BEAWARE Italian Observational Study

AIMS

BEAWARE investigated the pattern of first-line bevacizumab early interruption in the Italian real-world setting of metastatic colorectal cancer.

METHODS

A total of 386 patients were followed for 15 months after first-line chemotherapy + bevacizumab start. The rate of bevacizumab interruption for progression or adverse drug reactions (ADRs) constituted the primary endpoint.

RESULTS

A total of 78.2% of patients interrupted bevacizumab: 56.6% for progression, 7.3% for ADRs, and 36.1% for other reasons. Median treatment duration was 6.7, 2.5, and 4.6 months, respectively. Median progression-free survival was 10.3 months; however, 35.8% of patients were not progressed and were thus censored at the data cutoff of 15 months, while 21.8% were still receiving bevacizumab. Patients discontinuing for progression/ADRs more frequently had metastases in >1 site (p = .0001), and a shorter median progression-free survival (6.9 vs 13.9 months, p < .0001).

CONCLUSIONS

In Italy, first-line bevacizumab is interrupted mainly for progression, only 7.3% due to adverse events, and about one third of cases for other reasons. In clinical practice, the attitude to treat until progression as per guidelines might be implemented. ClinicalTrials.gov Identifier: NCT01609075.

Baseline PET as prognostic index in diffuse large B-cell lymphoma and grade IIIb follicular lymphoma: a retrospective study of a single-center experience

BACKGROUND

International guidelines support performing baseline positron emission tomography (PET) in lymphoma. Metabolic tumor volume (MTV) measurement has been proposed as a good measurement of disease burden. We investigated if MTV at baseline PET can be predictive of complete response (CR) to first line standard chemotherapy in diffuse large B-cell lymphoma (DLBCL) and in follicular lymphoma (FL) grade IIIb.

METHODS

We retrospectively analyzed data on 54 consecutive patients with DLBCL and FL grade IIIb treated in our institution. Dedicated software automatically estimated the SUV<inf>max</inf> of the most active lesion and the MTV of the entire lesion burden using an isocontour threshold method set at 42% (MTV42) and 28% (MTV28) of the SUV<inf>max</inf>. In addition, the ratio value (MTV28/MTV42) was calculated. Every group of lesions was evaluated separately. All patients were treated with R-CHOP-21. We performed a univariate and a multivariate logistic regression analysis to explore any possible association between PET parameters and CR.

RESULTS

At the univariate logistic regression analysis, patients with a MTV28 lower than the median value (173.1) had an odds ratio (OR) of 4 (95% CI: 0.94-16.9) of obtaining a CR in comparison to patients with a MTV 28 higher than the median value; patients with a MTV42 lower than the median value (i.e. 85.6) had an OR of 3.63 (95% CI: 0.85-15.34) of obtaining a CR in comparison to patients with a MTV 42 equal or higher than the median value. Using MTV28/MTV42 value with median as cut-off instead of MTV28, patients with a MTV28/MTV42 lower than the median value (i.e. 1.81) had an OR of 4.26 (95% CI: 0.72-25.07) and of 7.54 (95% CI: 0.70-80.91) of obtaining a CR in comparison to patients with a MTV28/MTV42 equal or higher than the median value in the two models, respectively.

CONCLUSIONS

The results of our study suggest that MTV could be a useful tool to predict response to R-CHOP in patients affected with DLBCL and FL grade IIIb and that a multi-parameters evaluation should be considered.

Early colorectal cancer: diagnosis, treatment and survivorship care

CRC is the third most commonly diagnosed malignancy and the fourth leading cause of cancer-related death in the world. With advances in treatment, colorectal cancer is being transformed from a deadly disease to an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. They often suffer late/long-term side effects of therapies that may compromise their QoL such as fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. In this review, we discuss what is known about early colorectal diagnosis, staging, treatments and their long-term effects on quality of life and survivorship care.

Primary extranodal diffuse large B-cell lymphomas: Many sites, many entities? Clinico-pathological, immunohistochemical and cytogenetic study of 106 cases

We analyzed the clinicopathological, immunohistochemical and cytogenetic features of 106 extranodal (EN) diffuse large B-cell lymphomas (DLBCLs) from stomach (34 cases), intestine (10), cervico-cephalic region (11), central nervous system (13), testes (21), skin (8), and miscellaneous sites (9). Hans' algorithm and the immunohistochemical double expressor score (DES) for MYC and BCL2 were applied to all cases. A subset of fifty-eight cases were analyzed with fluorescent in situ hybridization (FISH) with specific break apart probes for BCL6, MYC, BCL2, CCND1, BCL10 and MALT1 genes. Clinical records were available for all patients. The immunohistochemical study showed that, in our series of EN-DLBCLs, the Hans' subgroup and the DES differed significantly according to the site of origin. At FISH analysis, BCL6 and BCL2 were the most commonly rearranged genes in non-GC and in GC cases, respectively. Gastrointestinal lymphomas displayed the highest rate of gene rearrangements, often with MYC involvement. One testicular DLBCL showed BCL2/MYC double hit. At survival analysis, cerebral and testicular origin was associated with poor prognosis. In addition, Hans' subgroup and other immunohistochemical markers influenced patients' outcome. In conclusion, our data suggest that immunophenotypic, genetic and survival characteristics of EN-DLBCL are related to the specific primary site of the disease.

Ramucirumab as Second-Line Therapy in Metastatic Gastric Cancer: Real-World Data from the RAMoss Study

BACKGROUND

Ramucirumab-alone or combined with paclitaxel-represents one of the main options for patients failing first-line treatment for advanced gastric cancer.

OBJECTIVE

The RAMoss study aimed to evaluate the safety and efficacy profile of ramucirumab in the "real-life setting".

PATIENTS AND METHODS

Patients from 25 Italian hospitals started therapy consisting of ramucirumab 8 mg/kg i.v. d1,15q28 with or without paclitaxel 80 mg/m2 i.v. d1,8,15q28. The primary endpoint was safety, and secondary endpoints were overall response rate (ORR), progression-free survival (PFS), and overall survival (OS).

RESULTS

One hundred sixty-seven patients with disease progression on first-line therapy received ramucirumab as monotherapy (10%) or combined with paclitaxel (90%). Median treatment duration was 4 months (1-17 months). Global incidence of grade (G) 3-4 toxicity was 9.6%, and for neutropenia 5.4%; treatment was discontinued due to toxicity in 3% of patients. The most frequent adverse events (AE) were G1-2 fatigue (27.5%), G1-2 neuropathy (26.3%), and G1-2 neutropenia (14.9%). ORR was 20.2%. Stable disease was observed in 39.2% of patients, with a disease control rate of 59.4%. With a median follow-up of 11 months, median PFS was 4.3 months (95% confidence interval [CI] 4.1-4.7), whereas median OS was 8.0 months (95% CI: 7.09-8.9). In a multivariate analysis, ECOG performance status <1 or ≥1 (HR 1.13, 95% CI 1.0-1.27, p = 0.04) and the presence versus absence of peritoneal metastases (HR 1.57, 95% CI 1.63-2.39, p = 0.03) were independent poor prognostic factors.

CONCLUSIONS

These "real-life" efficacy data on ramucirumab treatment are in line with previous randomized trials. Ramucirumab is well tolerated in daily clinical practice.

Cytomegalovirus Infection of Endocrine System in a Patient with Diffuse Large B-cell Lymphoma. Report of a Case

Cytomegalovirus (CMV) is an opportunistic pathogen causing different diseases in immunocompromised patients and leading to death in a high percentage of cases. CMV infection is also relatively frequent among patients with hematological malignancies, especially when treated with immunosuppressive agents. We describe the clinical history of a patient with stage IV diffuse large B-cell lymphoma (DLBCL) treated with eight courses of R-CHOP every two weeks, who presented clinical remission of the disease at the end of therapy. However, two months later he developed neurological symptoms due to cerebellar involvement and a subcutaneous dorsal lymphomatous infiltration. He had a partial response after chemotherapy and brain radiotherapy, but his clinical course was complicated by fever and hypotension. Although the fever resolved with broad-spectrum antibiotics, he presented progressive endocrine failure and died three weeks later. Autopsy confirmed disseminated multiorgan involvement by DLBCL associated with an unexpected CMV infection of the lungs and several endocrine organs including the pituitary gland, pancreatic islets and adrenals, a clinical association not previously reported in the English literature.

The genetic and genomic background of multiple myeloma patients achieving complete response after induction therapy with bortezomib, thalidomide and dexamethasone (VTD)

The prime focus of the current therapeutic strategy for Multiple Myeloma (MM) is to obtain an early and deep tumour burden reduction, up to the level of complete response (CR). To date, no description of the characteristics of the plasma cells (PC) prone to achieve CR has been reported. This study aimed at the molecular characterization of PC obtained at baseline from MM patients in CR after bortezomib-thalidomide-dexamethasone (VTD) first line therapy.

One hundred and eighteen MM primary tumours obtained from homogeneously treated patients were profiled both for gene expression and for single nucleotide polymorphism genotype. Genomic results were used to obtain a predictor of sensitivity to VTD induction therapy, as well as to describe both the transcription and the genomic profile of PC derived from MM with subsequent optimal response to primary induction therapy.

By analysing the gene profiles of CR patients, we identified a 5-gene signature predicting CR with an overall median accuracy of 75% (range: 72%–85%). In addition, we highlighted the differential expression of a series of genes, whose deregulation might explain patients' sensitivity to VTD therapy. We also showed that a small copy number loss, covering 606Kb on chromosome 1p22.1 was the most significantly associated with CR patients.

[Therapeutic decisions and treatment with sorafenib in hepatocellular carcinoma: final analysis of GIDEON study in Italy]

INTRODUCTION

Sorafenib, an oral multikinase inhibitor, is the only targeted agent approved for the treatment of patients with hepatocellular carcinoma (HCC) after demonstration to increase overall survival compared to placebo in two randomized phase III study. GIDEON (Global Investigation of therapeutic DEcisions in HCC and Of its treatment with sorafeNib) is the largest, global, non-interventional, prospective study of patients with uHCC (n>3200) treated with sorafenib in real-life clinical practice conditions. Here we report the final analysis of safety and efficacy in the Italian cohort of patients.

METHODS

Patients with unresectable HCC who are candidates for systemic therapy, and for whom a decision has been made to treat with sorafenib, are eligible for inclusion. Patients demographics disease characteristics and treatment history were recorded at baseline visit. Sorafenib dose, concomitant medications, performance status, liver function, adverse events and efficacy (survival and response rate) were collected throughout the study.

RESULTS

In the Italian cohort of the GIDEON study 278 patients were included in 36 centers. The global rate of adverse events was 81%. Drug-related events accounted for 67%, mostly of grade 1 and 2, and only 8% were classified as serious. The most common were diarrhea (24%), fatigue (23%), dermatological (14%), rash/exfoliation (10%), hypertension (9%), hemorrage/bleeding of gastrointestinal tract (6%). Overall survival was 14.4 months and time to progression 6.2 months. Objective responses were observed in 14 patients (5%) with 3 complete responses (1%). Stable diseases of at least 6 weeks were observed in 113 patients (41%) with a 30% of disease control rate.

DISCUSSION

The safety profile of sorafenib in terms of rate and type of adverse events is similar to that emerged in the global international GIDEON study as well as in the pivotal registration studies.

Multimodal treatment of gastric cancer

Gastric cancer is the second leading cause of death from malignant disease worldwide. Although complete surgical resection remains the only curative modality for early stage gastric cancer, surgery alone only provides long-term survival in 20% of patients with advanced-stage disease. To improve current results, it is necessary to consider multimodality treatment, including chemotherapy, radiotherapy and surgery. Recent clinical trials have shown survival benefit of combining different neoadjuvant or adjuvant protocols compared with surgery with curative intent. Furthermore, the implementation of chemotherapy with novel targeted agents could play an important role in the multimodal management of advanced gastric cancer. In this paper, we focus on a multidisciplinary approach in the treatment of gastric cancer and discuss future strategies to improve the outcome for these patients.

Salvage chemoimmunotherapy with rituximab, ifosfamide and etoposide (R-IE regimen) in patients with primary CNS lymphoma relapsed or refractory to high-dose methotrexate-based chemotherapy

Despite a high proportion of patients with primary CNS lymphoma (PCNSL) experiences failure after/during first-line treatment, a few studies focused on salvage therapy are available, often with disappointing results. Herein, we report feasibility and activity of a combination of rituximab, ifosfamide and etoposide (R-IE regimen) in a multicentre series of patients with PCNSL relapsed or refractory to high-dose methotrexate-based chemotherapy. We considered consecutive HIV-negative patients ≤75 years old with failed PCNSL treated with R-IE regimen (rituximab 375 mg/m(2) , day 0; ifosfamide 2 g/m(2) /day, days1-3; etoposide 250 mg/m(2) , day 1; four courses). Twenty-two patients (median age 60 years; range 39-72; male/female ratio: 1:4) received R-IE as second-line (n = 18) or third-line (n = 4) treatment. Eleven patients had refractory PCNSL, and 11 had relapsing disease. Twelve patients had been previously irradiated. Sixty (68%) of the 88 planned courses were actually delivered; only one patient interrupted R-IE because of toxicity. Grade 4 hematological toxicity was manageable; a single case of grade 4 non-hematological toxicity (transient hepatotoxicity) was recorded. Response was complete in six patients and partial in three (overall response rate = 41%; 95%CI: 21-61%). Seven patients were successfully referred to autologous peripheral blood stem cell collection; four responders were consolidated with high-dose chemotherapy supported by autologous stem cell transplant. At a median follow-up of 24 months, eight responders did not experience relapse, two of them died of neurological impairment while in remission. Six patients are alive, with a 2-year survival after relapse of 25 ± 9%. We concluded that R-IE is a feasible and active combination for patients with relapsed/refractory PCNSL. This regimen allows stem cell collection and successful consolidation with high-dose chemotherapy and autologous transplant.

Partial trisomy of chromosome 13 as a single cytogenetic abnormality in an Italian case of nasal NK/T lymphoma

Extranodal NK/T lymphoma, nasal type, is an uncommon neoplasm that occurs with a higher prevalence among Asian populations and Native American populations of Central and Southern America. In Western countries, this tumor is extremely rare, accounting for less than 1.5% of all non-Hodgkin lymphomas. Cytogenetic analyses have been performed only in a limited number of cases, mainly because of technical problems related to extensive necrosis and the scarcity of clinical samples, and these have shown complex karyotypes with no specific chromosomal translocations. Here, we report the cytogenetic characterization of a clinically aggressive nasal NK/T-cell lymphoma occurring in a 40-year-old Italian male patient, in which the sole chromosome abnormality was a partial trisomy of chromosome 13.

MGMT methylation in diffuse large B-cell lymphoma: validation of quantitative methylation-specific PCR and comparison with MGMT protein expression

AIMS

(1) To validate a quantitative real time methylation specific PCR assay (MethyLight) for the detection of O6-methylguanine-DNA methyltransferase (MGMT) gene methylation status (MS) in diffuse large B-cell lymphoma (DLBCL). (2) To determine the immunohistochemical (IHC) expression of the MGMT protein and correlate it with MS. Both IHC and MethyLight results were compared with patient's outcome.

METHODS

71 patients with primary nodal DLBCL were studied. MGMT immunoreactivity was detected using a specific monoclonal antibody. The MS of MGMT gene was analysed in 52/71 DLBCL using MethyLight. A selected subset of 40 DLBCL was also analysed using qualitative methylation-specific PCR (MSP). Statistical analysis of overall survival (OS), lymphoma-specific survival (LSS) and progression free survival (PFS) was performed according to IHC and MS results.

RESULTS

19/71 DLBCLs (27%) were MGMT-negative at IHC; all were analysed, together with 33/52 MGMT-positive DLBCLs. MethyLight showed a better performance than MSP. There was a good correlation between the presence of MGMT expression and the unmethylated status; the absence of IHC expression was poorly correlated with the presence of methylation. Better OS, LSS and PFS was found in DLBCLs with MGMT gene methylation. DLBCLs not expressing MGMT at IHC showed a longer PFS.

CONCLUSIONS

The quantitative real-time methylation-specific PCR assay for the detection of MGMT gene hypermethylation has been validated for the first time in DLBCL. Immunohistochemistry seems to represent an useful preliminary test to identify unmethylated cases; MS analysis may be performed in non-immunoreactive cases to identify truly methylated DLBCLs, which bear a better prognosis.

Long-term outcome following Helicobacter pylori eradication in a retrospective study of 105 patients with localized gastric marginal zone B-cell lymphoma of MALT type

BACKGROUND

Treatment aimed at eradicating Helicobacter pylori infection results in lymphoma remission in most localized gastric mucosa-associated lymphoid tissue (MALT) lymphomas. The aim of this survey is to investigate the long-term effect of this therapeutic approach in a large series of patients.

METHODS

One hundred and five patients with localized gastric MALT lymphoma were initially treated only with H. pylori eradication regimens. Lymphoma responses were graded using the Wotherspoon score.

RESULTS

Helicobacter pylori, detected by histology in 81% of cases, was eradicated in all positive patients. Histological regression of the lymphoma was achieved in 78 of 102 assessable patients [76%, 95% confidence interval (CI): 67% to 84%] with complete remission (score 0-2) in 66 and partial remission (score 3) in 12. At a median follow-up time of 6.3 years, histological remission was consistently confirmed in 33 of 74 assessable patients, while 25 had score fluctuations (from 0 to 4) and 13 presented a lymphoma relapse (score 5). Only one patient had a distant progression. Transformation to a large-cell lymphoma was seen in two cases. The 5- and 10-year overall survival is 92% (95% CI: 84% to 96%) and 83% (95% CI: 70% to 91%), respectively. Only one patient died of lymphoma after transformation to a high-grade lymphoma.

CONCLUSIONS

Helicobacter pylori eradication resulted in complete lymphoma remission in the majority of cases. Long-term clinical disease control was achieved in most patients. A watch and wait policy appears to be safe in patients with minimal residual disease or histological-only local relapse.

Very long term outcome of patients with gastric marginal zone B cell lymphoma of mucosa associated tissue (MALT) following Helicobacter pylori (Hp) eradication therapy

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Background: Hp infection plays a decisive role in the pathogenesis of low-grade gastric MALT lymphoma and eradication therapy has become a widely accepted initial treatment of stage I disease. The aim of this study was to evaluate the long term outcome of patients (pts) with localized gastric MALT lymphoma exclusively treated with Hp eradication therapy. Methods: a prospective series of 62 newly diagnosed IE gastric MALT lymphoma pts (29M/33F) with median age of 63 years (range 27–87), referred to our department from June 1991 to January 2004 were evaluable for the study. Diagnosis was histologically proved and Hp status was evaluated. Staging was performed according to the modified Ann Arbor system. All pts received the triple eradicating therapy (OMC: omeprazole 20 mg bid, metronidazole 400 mg bid and clarithromycin 500 mg bid or OAC: omeprazole 20 mg bid, amoxycillin 1,000 mg bid and clarithromycin 500 mg bid) for one week. Response, evaluated every 6 months with multiple biopsies, was graded according to the Wotherspoon’s histologic scoring system. Results: Hp was eradicated in all patients, but 8 pts required a second line antibiotic therapy; symptoms disappeared or markedly diminished and endoscopic features improved in all pts. Histological remission (score 0–2) was observed in 57 pts (91.9%) after a median time of 6 months (range 2–72); 5 pts (8.1%) who failed to respond were referred to other treatments. With a median follow-up time of 76 months (range 12–162) the histological remission persists in 27/57 pts (47,4%); 21/57 pts (36.8%) have a continuous histological score fluctuation (from 0 to 4); 8/57 (14%) pts had an histological relapse (score 5) after a median time of 12 months (range 6–48) without Hp reinfection and 6 of them had a second spontaneous histological remission. The OS at 76 months is 93%. Only one patient died for an high grade gastric MALT lymphoma transformation. Conclusion: the majority of pts with gastric MALT lymphoma have a favourable long term outcome, independently of the pathological remission; eradication therapy may offer a real chance of cure. Watch and wait policy in agreement pts who failed to respond could be considered an option outside of clinical trial.

No significant financial relationships to disclose.