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Lowder J, Fallah S, Venditti C, Musa-Veloso K, Kotlov V. An open-label, acute clinical trial in adults to assess ketone levels, gastrointestinal tolerability, and sleepiness following consumption of ( R)-1,3-butanediol (Avela™). Front Physiol 2023; 14:1195702. [PMID: 37457035 PMCID: PMC10338333 DOI: 10.3389/fphys.2023.1195702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction: A study was undertaken to determine the acute effects of a beverage made with Avela™ (R)-1,3-butanediol, on blood beta-hydroxybutyrate (BHB) levels (using the Keto-Mojo monitor), gastrointestinal (GI) tolerability (using the modified visual analogue scale GI Symptoms Tool), and sleepiness (using the Stanford Sleepiness Scale). Methods: Following a 12-h overnight fast, 26 healthy adults consumed one beverage containing 11.5 g of (R)-1,3-butanediol at each of 0, 30, and 60 min, culminating in a total intake of 34.5 g of (R)-1,3-butanediol. Blood BHB levels, GI tolerability, and sleepiness were assessed at baseline (0 min), and at 30, 60, 90, 120, 180, 240, and 300 min. At 240 min, a protein bar was consumed. Results: The mean (±SD) BHB fasting baseline level, maximal concentration, time at maximal concentration, and incremental area under the curve over 300 min were 0.23 ± 0.21 mmol/L, 2.10 ± 0.97 mmol/L, 133.85 ± 57.07 min, and 376.73 ± 156.76 mmol/L*min, respectively. BHB levels at each time point were significantly increased relative to baseline. In females, BHB Tmax was significantly greater (p = 0.046), and BHB iAUC0-300 min nearly significantly greater (p = 0.06) than in males. Discussion: The beverage formulated with Avela™ had no impact on sleepiness and was generally well-tolerated, with no or mild GI symptoms reported in most participants. Mild headaches were reported as an adverse event by five participants and judged possibly related to the study product in two of the participants.
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Affiliation(s)
- James Lowder
- Principal Investigator, Impact Science Alliance, San Diego, CA, United States
| | | | | | | | - Vassili Kotlov
- Study Coordinator, Impact Science Alliance, San Diego, CA, United States
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Lenger S, Bradley M, Thomas D, Bertolet M, Lowder J, Sutcliffe S. 39: D-Mannose vs other agents for recurrent urinary tract infection prevention in adult women: A systematic review and meta-analysis. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.12.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lenger S, Liang B, Lowder J, Strand E, Chu C. 22: Creation of a surgical skills teaching model for anterior and posterior colporrhaphy. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.12.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Di Giacomo AM, Covre A, Finotello F, Rieder D, Danielli R, Sigalotti L, Giannarelli D, Petitprez F, Lacroix L, Valente M, Cutaia O, Fazio C, Amato G, Lazzeri A, Monterisi S, Miracco C, Coral S, Anichini A, Bock C, Nemc A, Oganesian A, Lowder J, Azab M, Fridman WH, Sautès-Fridman C, Trajanoski Z, Maio M. Guadecitabine Plus Ipilimumab in Unresectable Melanoma: The NIBIT-M4 Clinical Trial. Clin Cancer Res 2019; 25:7351-7362. [PMID: 31530631 DOI: 10.1158/1078-0432.ccr-19-1335] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/23/2019] [Accepted: 09/13/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE The immunomodulatory activity of DNA hypomethylating agents (DHAs) suggests they may improve the effectiveness of cancer immunotherapies. The phase Ib NIBIT-M4 trial tested this hypothesis using the next-generation DHA guadecitabine combined with ipilimumab. PATIENTS AND METHODS Patients with unresectable stage III/IV melanoma received escalating doses of guadecitabine 30, 45, or 60 mg/m2/day subcutaneously on days 1 to 5 every 3 weeks, and ipilimumab 3 mg/kg intravenously on day 1 every 3 weeks, starting 1 week after guadecitabine, for four cycles. Primary endpoints were safety, tolerability, and MTD of treatment; secondary were immune-related (ir) disease control rate (DCR) and objective response rate (ORR); and exploratory were changes in methylome, transcriptome, and immune contextures in sequential tumor biopsies, and pharmacokinetics. RESULTS Nineteen patients were treated; 84% had grade 3/4 adverse events, and neither dose-limiting toxicities per protocol nor overlapping toxicities were observed. Ir-DCR and ir-ORR were 42% and 26%, respectively. Median CpG site methylation of tumor samples (n = 8) at week 4 (74.5%) and week 12 (75.5%) was significantly (P < 0.05) lower than at baseline (80.3%), with a median of 2,454 (week 4) and 4,131 (week 12) differentially expressed genes. Among the 136 pathways significantly (P < 0.05; Z score >2 or ←2) modulated by treatment, the most frequently activated were immune-related. Tumor immune contexture analysis (n = 11) demonstrated upregulation of HLA class I on melanoma cells, an increase in CD8+, PD-1+ T cells and in CD20+ B cells in posttreatment tumor cores. CONCLUSIONS Treatment of guadecitabine combined with ipilimumab is safe and tolerable in advanced melanoma and has promising immunomodulatory and antitumor activity.
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Affiliation(s)
| | - Alessia Covre
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Francesca Finotello
- Biocenter, Division of Bioinformatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Rieder
- Biocenter, Division of Bioinformatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Riccardo Danielli
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Luca Sigalotti
- Oncogenetics and Functional Oncogenomics Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Florent Petitprez
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Team Cancer, Immune Control and Escape, Paris, France
- University Paris Descartes Paris 5, Sorbonne Paris Cite, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
- Sorbonne University, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
- Programme Cartes d'Identitié des Tumeurs, Ligue Nationale Contre le Cancer, Paris, France
| | - Laetitia Lacroix
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Team Cancer, Immune Control and Escape, Paris, France
- University Paris Descartes Paris 5, Sorbonne Paris Cite, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
- Sorbonne University, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Monica Valente
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Ornella Cutaia
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Carolina Fazio
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Giovanni Amato
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Andrea Lazzeri
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Santa Monterisi
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Clelia Miracco
- Pathology Unit, Department of Medical, Surgical and Neurological Science, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Sandra Coral
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy
| | - Andrea Anichini
- HumanTumors Immunobiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Christoph Bock
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
- Max Planck Institute for Informatics, Saarbrücken, Germany
| | - Amelie Nemc
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | | | - James Lowder
- Astex Pharmaceuticals Inc., Pleasanton, California
| | | | - Wolf H Fridman
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Team Cancer, Immune Control and Escape, Paris, France
- University Paris Descartes Paris 5, Sorbonne Paris Cite, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
- Sorbonne University, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Catherine Sautès-Fridman
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, Team Cancer, Immune Control and Escape, Paris, France
- University Paris Descartes Paris 5, Sorbonne Paris Cite, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
- Sorbonne University, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Zlatko Trajanoski
- Biocenter, Division of Bioinformatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Michele Maio
- Center for Immuno-Oncology, University Hospital of Siena, Siena, Italy.
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Savona MR, Odenike O, Amrein PC, Steensma DP, DeZern AE, Michaelis LC, Faderl S, Harb W, Kantarjian H, Lowder J, Oganesian A, Azab M, Garcia-Manero G. An oral fixed-dose combination of decitabine and cedazuridine in myelodysplastic syndromes: a multicentre, open-label, dose-escalation, phase 1 study. Lancet Haematol 2019; 6:e194-e203. [PMID: 30926081 DOI: 10.1016/s2352-3026(19)30030-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Decitabine, a DNA methyltransferase 1 inhibitor or DNA hypomethylating compound, is not readily orally bioavailable because of rapid clearance by cytidine deaminase (CDA) in the gut and liver. This dose-escalation study, guided by pharmacokinetic and pharmacodynamic observations, evaluated whether simultaneous oral administration with the novel CDA inhibitor cedazuridine increases decitabine bioavailability for the treatment of myelodysplastic syndromes. METHODS In this phase 1 study, we enrolled patients aged 18 years or older with myelodysplastic syndromes or chronic myelomonocytic leukaemia. Eligible patients were assigned to cohorts to receive escalating oral doses of decitabine and cedazuridine. The starting dose was decitabine 20 mg and cedazuridine 40 mg. Treatment cycles lasted 28 days, with 5 days of drug administration. In cycle 1, each patient received a cohort-defined dose of oral decitabine on day -3, a 1-h intravenous infusion of decitabine 20 mg/m2 on day 1, and cohort-defined doses of oral decitabine plus cedazuridine on days 2-5. In cycles 2 and beyond, the oral decitabine and cedazuridine were given on days 1-5. The dose of cedazuridine was escalated first and decitabine was escalated once CDA inhibition by cedazuridine approached the maximum effect. The drug dose was escalated if mean decitabine area under the curve (AUC) of the oral drug was less than 90% of that for intravenous decitabine in the cohort and if no dose-limiting toxicity was observed. Dose-limiting toxicity was defined as a grade 3 or greater non-haematologic toxicity or grade 4 haematologic toxicity lasting more than 14 days and unrelated to the underlying disease. Once the decitabine AUC target range set as the primary endpoint, and established with intravenous decitabine, was reached at a dose deemed to be safe, the cohort that most closely approximated intravenous decitabine exposure was expanded to 18 evaluable patients. The primary objectives were to assess the safety of decitabine plus cedazuridine, and to determine the dose of each drug needed to achieve a mean AUC for decitabine exposure similar to that for intravenous decitabine exposure. This study is registered with ClinicalTrials.gov, number NCT02103478. FINDINGS Between Oct 28, 2014, and Nov 13, 2015, we enrolled 44 eligible patients (of 75 screened) with previously treated or newly diagnosed myelodysplastic syndromes or chronic myelomonocytic leukaemia; 43 of the enrolled patients were evaluable. Participants were treated in five cohorts: cohorts 1-4 included six evaluable patients each; cohort 5 included 19 patients in a 13-patient expansion. Dose-dependent increases in decitabine AUC and peak plasma concentration occurred with each cohort dose escalation. There was no evident increase in toxicity compared with that reported for intravenous decitabine. Decitabine 30 mg and 40 mg plus cedazuridine 100 mg produced mean day-5 decitabine AUCs (146 ng × h/mL for decitabine 30 mg, and 221 ng × h/mL for decitabine 40 mg) closest to the mean intravenous-decitabine AUC (164 ng × h/mL). The most common grade 3 or more adverse events were thrombocytopenia (18 [41%] of 44 patients), neutropenia (13 [30%]), anaemia (11 [25%]), leukopenia (seven [16%]), febrile neutropenia (seven [16%]), and pneumonia (seven [16%]). Four (9%) patients died because of adverse events, none of which was considered drug related, and three (7%) patients died more than 30 days after discontinuing treatment because of progressive disease (two [5%]) and respiratory failure (one [2%]). INTERPRETATION Oral decitabine plus cedazuridine emulated the pharmacokinetics of intravenous decitabine, with a similar safety profile and dose-dependent demethylation. Clinical responses were similar to intravenous decitabine treatment for 5 days. Further study of decitabine plus cedazuridine as an alternative to parenteral therapy or in combination with other new oral agents for myeloid disorders is warranted. FUNDING Astex Pharmaceuticals, Inc.
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Affiliation(s)
- Michael R Savona
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Olatoyosi Odenike
- Department of Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Philip C Amrein
- Medicine Service, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Laura C Michaelis
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WS, USA
| | - Stefan Faderl
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Wael Harb
- Horizon Oncology Center, Lafayette, IN, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Meister M, Brubaker A, Sutcliffe S, Lowder J. 75: Effectiveness of botulinum toxin injection to the pelvic floor for treatment of pelvic floor myofascial pain in women: a systematic review and meta-analysis. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2019.01.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Albany C, Hashemi NS, Fang F, Lowder J, Einhorn L, Nephew K. Abstract 1386: Safety and tolerability of guadecitabine (SGI-110) plus cisplatin in patients with platinum refractory germ cell tumors (GCT): A phase 1 study. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND: Guadecitabine (SGI-110) is a novel hypomethylating dinucleotide of decitabine and deoxyguanosine resistant to degradation by cytidine deaminase. Germ cell tumor including platinum-resistant embryonal carcinoma cells lines are extremely sensitive to hypomethylating agents and low dose decitabine can restore cisplatin sensitivity in cell lines. We aimed to assess the safety and clinical activity of guadecitabine in combination with cisplatin in patients with platinum-refractory GCT.
METHODS: In this open-label, phase 1 study, patients with GCT refractory to or had relapsed after platinum-based treatment were treated with subcutaneous (SQ) guadecitabine, once-daily for 5 consecutive days, followed by cisplatin on day 8 in a 28-day treatment cycle. A modified toxicity probability interval (mTPI) dose-escalation design was used in which we treated patients with guadecitabine doses of 30-45 mg/m2 plus cisplatin 100 mg/m2 up to 6 cycles until progression or intolerable toxicity. The primary objective was to assess safety and tolerability of guadecitabine in combination with cisplatin, determine the maximum tolerated and identify the recommended phase 2 dose of guadecitabine. Safety analyses included all patients who received at least one dose of guadecitabine. Pharmacodynamic analyses to determine the biologically effective dose included all patients for whom samples were available. This study is registered with ClinicalTrials.gov, number NCT02429466.
FINDINGS: Between 2015 and 2017, we enrolled and treated 10 patients. Grade 3 or 4 adverse events were febrile neutropenia, thrombocytopenia, anemia, and diarrhea. The most common serious adverse events were febrile neutropenia and thrombocytopenia. Guadecitabine 45 mg/m2 was associated with prolonged SAE and felt to be unsafe to continue. The maximum tolerated dose was 30 mg/m2 daily × 5. Two patients achieved a complete response to treatment lasting more than 6 months.
INTERPRETATION: Guadecitabine SQ at 30 mg/m2 daily × 5 is well tolerated and is clinically and biologically active in patients with platinum-refractory GCT. The study is still ongoing.
Citation Format: Costantine Albany, Neda S. Hashemi, Fang Fang, James Lowder, Lawrence Einhorn, Kenneth Nephew. Safety and tolerability of guadecitabine (SGI-110) plus cisplatin in patients with platinum refractory germ cell tumors (GCT): A phase 1 study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1386.
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Affiliation(s)
| | | | - Fang Fang
- 2Indiana University, Bloomington, IN
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Robison K, Bevis K, Howe C, Wohlrab K, Sung V, Richter H, Lokich E, McCourt C, Glaser G, Brown A, Wethington S, Carlson M, Rahn D, Lowder J, Occhino J, Dunivan G, Tunitsky E, Chen G, Luis C, Raker C, DiSilvestro P, Clark M. Characteristics of women with endometrial cancer and stress urinary incontinence (SUI) that desire concurrent cancer and SUI surgery: Cancer of the uterus and treatment of incontinence (CUTI) study. Gynecol Oncol 2018. [DOI: 10.1016/j.ygyno.2018.04.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Meister M, Shivakumar N, Lowder J. 86: Evidence-based physical examination techniques for the diagnosis of pelvic floor myofascial pain: A systematic review. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.12.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Maio M, Covre A, Coral S, Amato G, Taverna P, Lowder J, Azab M, Giannarelli D, Natali P, Di Giacomo A. A phase Ib study combining the second-generation DNA hypomethylating agent (DHA) guadecitabine (SGI-110) and ipilimumab in patients with metastatic melanoma: The NIBIT-M4 Study. Ann Oncol 2015. [DOI: 10.1093/annonc/mdv514.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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King C, Donnellan N, Arden D, Hur H, Moawad N, Lowder J. Patient Perceptions of Removal of the Cervix at Time of Hysterectomy. J Minim Invasive Gynecol 2014. [DOI: 10.1016/j.jmig.2013.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Clark J, Flaherty L, Ernstoff M, Koon H, Milhem M, Militello G, Agarwala S, Curti B, Cranmer L, Lao CD, Logan TF, Lutzky J, Rudrapatna V, Daniels G, Taback B, Aung S, Lowder J, Lawson D. A multi-center study of high dose Aldesleukin (Proleukin® (HD IL-2) + Vemurafenib Zelboraf® ) therapy in patients with BRAFV600 mutation positive metastatic melanoma (proclivity 01). J Immunother Cancer 2014. [PMCID: PMC4288741 DOI: 10.1186/2051-1426-2-s3-p77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Patel S, Milhem M, Hallmeyer S, Daniels G, Cranmer L, Taback B, Flaherty L, Aung S, Lowder J, Sharfman W. Open-label, randomized, multi-center study comparing the sequence of high dose Aldesleukin (Proleukin® (HD IL-2) and Ipilimumab Yervoy® ) in patients with metastatic melanoma (proclivity 02). J Immunother Cancer 2014. [PMCID: PMC4288743 DOI: 10.1186/2051-1426-2-s3-p78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kaufman HL, Aung S, Morse M, Wong M, Lowder J, Daniels G, McDermott D. Stable disease after high dose interleukin-2 (HD IL-2) immunotherapy: observations on long term survival and clinical benefit of additional HD IL-2. J Immunother Cancer 2014. [PMCID: PMC4288765 DOI: 10.1186/2051-1426-2-s3-p88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Allison J, Herrinton LJ, Liu L, Yu J, Lowder J. Natural history of severe ulcerative colitis in a community-based health plan. Clin Gastroenterol Hepatol 2008; 6:999-1003. [PMID: 18774533 DOI: 10.1016/j.cgh.2008.05.022] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Revised: 04/23/2008] [Accepted: 05/29/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We sought to evaluate long-term outcomes of patients with severe ulcerative colitis (UC) after their first hospitalization for the disease. METHODS A cohort of 656 patients hospitalized for UC during 1996 to 2004 was followed up for 9 years through 2004. Time-to-event was estimated using actuarial methods, and the proportions of those under follow-up evaluation who experienced outcomes at month 3, year 1, and year 5 were determined. Outcome measures studied were time to subsequent colectomy, rehospitalization for inflammatory bowel disease, and restarting steroid medication. We also used survival analysis to evaluate whether patient characteristics predicted the risk of rehospitalization and colectomy. RESULTS Among 656 patients initially hospitalized for severe UC, 20% (N = 129) underwent colectomy during their initial hospitalization. Of the remaining 527, a total of 95% (N = 498) were discharged on a steroid taper. At 1 year after discharge, 29% of those remaining under observation were rehospitalized for UC, and an additional 10% required colectomy. At 1 and 5 years after discharge, 34% and 26% received at least a 90-day supply of steroid in the preceding 9 months. Risk of rehospitalization and colectomy were unrelated to the patient's age, sex, or race/ethnicity. CONCLUSIONS The risk for colectomy in patients hospitalized for the first time with severe UC is 20%. In the 3 months after hospitalization the risk for colectomy is 6%. After that, risks appear to decrease proportionate to the time since initial hospitalization.
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Affiliation(s)
- James Allison
- Division of Research, Kaiser Permanente Northern California, Oakland, California 94612, USA.
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Plevy S, Salzberg B, Van Assche G, Regueiro M, Hommes D, Sandborn W, Hanauer S, Targan S, Mayer L, Mahadevan U, Frankel M, Lowder J. A phase I study of visilizumab, a humanized anti-CD3 monoclonal antibody, in severe steroid-refractory ulcerative colitis. Gastroenterology 2007; 133:1414-22. [PMID: 17920064 DOI: 10.1053/j.gastro.2007.08.035] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 08/02/2007] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS To evaluate the safety and biological activity of visilizumab (a humanized anti-CD3 monoclonal antibody) and to determine a maximum tolerated dose in patients with severe ulcerative colitis that had not responded to 5 days of treatment with intravenous corticosteroids. METHODS In this open-label phase 1 study, 32 subjects received visilizumab at a dose of 10 or 15 microg/kg, administered intravenously on 2 consecutive days. Clinical response was defined as a Modified Truelove and Witts Severity Index <10 with a minimum decrease of 3 points; remission was <4 points. Endoscopic remission was a Mayo endoscopic subscore of 0 or 1. RESULTS Eight patients received 15 microg/kg visilizumab. Because of dose-limiting toxicities (T-cell recovery >30 days in 2 of 8 patients), the dose was reduced to 10 microg/kg in 24 patients. On day 30, 84% of patients demonstrated a clinical response, 41% achieved clinical remission, and 44% achieved endoscopic remission. Forty-five percent of patients did not require salvage therapies or colectomy during the first year postdose. Mild to moderate symptoms of cytokine release occurred in 100% and 83% of patients in the 15- and 10-microg/kg dose groups, respectively. All patients exhibited a rapid decrease in circulating CD4(+) T-cell counts, which returned to baseline values by day 30 in 26 of 30 evaluable patients (86%). There were no serious infections. CONCLUSIONS Visilizumab had an acceptable safety profile at the 10-microg/kg dose level and may be clinically beneficial in patients with severe intravenous corticosteroid-refractory ulcerative colitis.
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Affiliation(s)
- Scott Plevy
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.
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Carpenter PA, Lowder J, Johnston L, Frangoul H, Khoury H, Parker P, Jerome KR, McCune JS, Storer B, Martin P, Appelbaum F, Abonour R, Westervelt P, Anasetti C. A phase II multicenter study of visilizumab, humanized anti-CD3 antibody, to treat steroid-refractory acute graft-versus-host disease. Biol Blood Marrow Transplant 2005; 11:465-71. [PMID: 15931635 DOI: 10.1016/j.bbmt.2005.03.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Results of a previous phase I study suggested that a single 3 mg/m2 dose of the humanized non-FcR-binding anti-CD3 monoclonal antibody visilizumab (Nuvion) was well tolerated and had efficacy for the treatment of steroid-refractory acute graft-versus-host disease (GVHD). We now report results of a multicenter phase II study in which visilizumab was given to 44 participants with steroid-refractory acute GVHD. Eighty-two percent of the participants had visceral involvement, and 86% had overall grade III or IV acute GVHD at study entry. The respective complete and overall response rates were 14% and 32% at 42 days. Plasma Epstein-Barr virus DNA increased to more than 1000 copies per milliliter in 19 subjects. Seventeen received rituximab, and no fatal lymphoproliferative disorders were observed. Survival at 180 days was 32% (95% confidence interval, 18%-46%). The administration of visilizumab as used in this study seems to be sufficiently safe and effective to warrant further assessment for treatment or prevention of GVHD.
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Affiliation(s)
- Paul A Carpenter
- Fred Hutchinson Cancer Research Center, Clinical Research Division, 1100 Fairview Ave. N., Mailstop D5-290, Seattle, WA 98109, USA.
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18
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Vigh AG, Lowder J, Deantonio HJ. Does acute volume overloading in the setting of left ventricular dysfunction and pulmonary hypertension affect the defibrillation threshold? Pacing Clin Electrophysiol 1999; 22:759-64. [PMID: 10353135 DOI: 10.1111/j.1540-8159.1999.tb00540.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The impact of acute volume overload hemodynamics on the DFT with concurrent moderate left ventricular systolic dysfunction is unknown. Ten mongrel dogs (17.2 kg), using a crossover study design, each had baseline (study 1) hemodynamic, echocardiographic, and DFT measurements. These measurements were repeated after left ventricular dysfunction was induced using a norepinephrine (5 micrograms/kg per min) infusion (study 2). Hemodynamic and DFT parameters were obtained simulating acute heart failure by volume overload with an 0.9% normal saline infusion to an associated mean pulmonary capillary wedge pressure of > 19 mmHg (study 3). Numerous significant echocardiographic and hemodynamic parameters were noted when the animals from studies 1 and 2, 2 and 3, and 1 and 3 were compared. A significant difference in the DFT was observed only when study animals 1 and 3 were compared (P < 0.02). None of the dogs were hypoxemic at the time of the acute heart failure DFT. The mechanism of this finding remains unknown. This data would suggest that acute volume overload with associated left ventricular dysfunction does adversely affect the DFT in a canine model.
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Affiliation(s)
- A G Vigh
- Division of Cardiology/Section Electrophysiology, East Carolina University School of Medicine, Greenville, North Carolina, USA
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19
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Vowells S, Cadden M, Lowder J, Versiegen H, Ketele L, Miller D, Jordan S. P17-16 Leuco CountTM: kit de numération de leucocytes résiduels. Étude pour évaluer la linéarité. Transfus Clin Biol 1998. [DOI: 10.1016/s1246-7820(98)80270-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Abstract
An approach to perform lymphocyte subset analysis on frozen-thawed whole blood (F/T WB) is described. WB from 24 human immunodeficiency virus type 1 (HIV-1) seropositive individuals and 21 controls was analyzed fresh and after frozen storage (with or without dimethyl sulfoxide) at -80 degrees C, in liquid nitrogen (LN2), and at -20 degrees C. Analysis of F/T WB utilized 3-color flow cytometry with CD45 and right angle light scatter gating. Absolute cell counts were obtained for 30 samples by using staining tubes containing internal bead standards [TruCount, Becton Dickinson Immunocytometry Systems (BDIS), San Jose, CA]. The mean difference between CD3+4+ percentages for F/T (-80 degrees C storage for up to 1 year) and fresh WB was less than -0.2% (95% limits +/-3%, P = 0.5) with 39 of 45 (87%) results falling within 2% of the fresh values (P = 0.74). Absolute CD3+4+ cell counts for F/T WB were generally lower than corresponding results for fresh aliquots (median difference was 33 cells/microl, P < 0.0001), but the results were highly correlated (r2 = 0.975, P < 0.0001). Results were more variable, although still highly correlated, for CD3+8+ cells, and with other freezing and storage conditions. It is concluded that lymphocyte subset analysis using F/T WB yields comparable results to fresh samples, which should prove useful for a number of practical applications.
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Affiliation(s)
- E W Fiebig
- Irwin Memorial Blood Centers, San Francisco, California 94118, USA
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21
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Lowder J, Ingram B, Buser M. Innovations in quality. Calif Hosp 1993; 7:6-13. [PMID: 10127683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
To strengthen their operations many hospitals have embraced total quality management (TQM) strategies used by companies throughout the world. California Hospitals examines how some of these hospitals have used TQM to improve clinical outcomes, cut costs, boost staff morale and increase patient satisfaction.
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Affiliation(s)
- J Lowder
- United Western Medical Centers, Santa Ana, CA
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22
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Abstract
Using two colour immunofluorescence with fluorescein isothiocyanate and phycoerythrin labelled monoclonal antibodies, multi-parameter flow cytometry was used to examine the antigenic characteristics of peripheral blood lymphocytes in whole blood of patients with ulcerative colitis and Crohn's disease who were not taking immunosuppressive drugs. The numbers of CD4+ and CD8+ lymphocytes in patients with ulcerative colitis and Crohn's disease remained unchanged so that the CD4/CD8 ratio was the same as that of normal control subjects. In Crohn's disease there were many activated T cells (CD3+, CD25+). Although natural killer cells in active Crohn's disease were lower than in normal control subjects, cytotoxic T lymphocytes, as defined by CD3+, CD16+, did not differ in patients with inflammatory bowel disease compared with normal control subjects. For B cell subsets, there were differences in Leu-1+ B cells, Leu-8+ B cells, Fc epsilon R+B cells (Leu-16+, Leu-20+), and activated B cells (Leu-12+, Leu-21+) between patients with inflammatory bowel disease and normal control subjects. These differences are compatible with local activation of B cells in the inflamed colon.
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Affiliation(s)
- M Senju
- Gastroenterology Unit, Radcliffe Infirmary, Oxford, UK
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23
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Kontiainen S, Toomath R, Lowder J, Feldmann M. Selective activation of T cells in newly diagnosed insulin-dependent diabetic patients: evidence for heterogeneity of T cell receptor usage. Clin Exp Immunol 1991; 83:347-51. [PMID: 1825939 PMCID: PMC1535309 DOI: 10.1111/j.1365-2249.1991.tb05641.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Cell surface phenotyping of 58 newly diagnosed diabetic children and 25 controls confirmed the presence of activated T cells, expressing HLA class II antigens or receptors for interleukin-2 (IL-2R, CD25) in the majority of the patients. Some of these cells putatively include those involved in islet cell destruction, as reported previously. Monoclonal antibodies recognizing three families of the variable regions of the beta chain (V beta) of the T cell receptor were used to determine the percentage of peripheral blood cells expressing those specific gene segment products. The number of the activated T cells from each V beta family was compared with that of the resting T cells of the same family in the patients and the controls. In 18 out of 58 (31%) of these patients there was evidence of oligoclonal proliferation of activated T cells as judged by marked increases in cells expressing a V beta family in the IL-2R+ T cell pool, compared with the total T cell pool. However, different V beta families were augmented in individual patients, indicating considerable heterogeneity of T cell activation in different patients. These results are in contrast to murine models of autoimmunity, where virtually monoclonal T cell activation, restricted to a single V beta family has been reported.
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MESH Headings
- Adolescent
- Antigens, CD/physiology
- Antigens, Differentiation, T-Lymphocyte/analysis
- Antigens, Differentiation, T-Lymphocyte/physiology
- CD3 Complex
- Child
- Child, Preschool
- Diabetes Mellitus, Type 1/immunology
- Female
- Humans
- Infant
- Lymphocyte Activation
- Lymphocyte Subsets/immunology
- Male
- Receptors, Antigen, T-Cell/analysis
- Receptors, Antigen, T-Cell/physiology
- Receptors, Antigen, T-Cell, alpha-beta
- Receptors, Interleukin-2/physiology
- T-Lymphocytes/immunology
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Affiliation(s)
- S Kontiainen
- Charing Cross Sunley Research Centre, London, England
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24
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Wolff SN, Herzig RH, Fay JW, LeMaistre CF, Frei-Lahr D, Lowder J, Bolwell B, Giannone L, Herzig GP. High-dose thiotepa with autologous bone marrow transplantation for metastatic malignant melanoma: results of phase I and II studies of the North American Bone Marrow Transplantation Group. J Clin Oncol 1989; 7:245-9. [PMID: 2492594 DOI: 10.1200/jco.1989.7.2.245] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
We evaluated thiotepa in escalating dose in a broad phase I and II study using cryopreserved autologous bone marrow transplantation to assure hematopoietic recovery. Thiotepa was administered intravenously (IV) over two hours daily for three consecutive days followed in three to four days by marrow transplantation. The daily dose ranged from 60 to 525 mg/m2 (total dose, 180 to 1,575 mg/m2). A total of 71 patients with malignant melanoma were treated. Forty-three patients (61%) had received prior cytotoxic therapy and 28 were untreated. Sixty-two patients (87%) had melanoma disseminated to at least one visceral site, nine patients had skin and/or lymphatic metastases only. As of January 1, 1988 one patient was too early to be evaluated, 15 patients were inevaluable for tumor response, four patients had a complete response (CR), and 25 patients had a partial response (PR) to treatment. The response rates (95% confidence interval) for the 55 evaluable patients and for all 71 treated patients were 53% (40% to 65%) and 41% (30% to 53%), respectively. The median duration of response was 3 months, with a range of 1 to 31 + months. Three patients were alive and well without evidence of tumor more than 1 year after treatment. Analysis of patient subsets indicated that neither total dose, previous cytotoxic therapy, or sites of metastases influenced response rate. In this study, high-dose thiotepa has demonstrated a high response rate in patients with metastatic malignant melanoma with both PRs and CRs noted. Although most of the responses were not durable, 10% of the responses lasted more than 1 year. Future studies will evaluate additional methods for increasing the response rate and improving the duration of response.
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Affiliation(s)
- S N Wolff
- Vanderbilt University, Nashville, TN 37232
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25
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Garcia CF, Weiss LM, Lowder J, Komoroske C, Link MP, Levy R, Warnke RA. Quantitation and estimation of lymphocyte subsets in tissue sections. Comparison with flow cytometry. Am J Clin Pathol 1987; 87:470-7. [PMID: 3103419 DOI: 10.1093/ajcp/87.4.470] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A quantitation method for lymphocyte subsets in immunoperoxidase-stained frozen tissue sections was compared with flow cytometry in 23 cases of non-Hodgkin's lymphoma. Close correlations were obtained, demonstrating the accuracy of the technic. Weak intensity of fluorescence and fragility of the tumor cells during the fluorescence-activated cell sorter (FACS) analyses were the most likely explanations for a number of the discrepancies observed. The tissue quantitation method was precise, particularly at low values, where it was better than the FACS. A simpler and faster estimation method employing categories within 10 percentage units was also tested in this study; this method correlated as well with the FACS as the quantitation method and gave the best interobserver correlations.
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26
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Garcia CF, Lowder J, Meeker TC, Bindl J, Levy R, Warnke RA. Differences in "host infiltrates" among lymphoma patients treated with anti-idiotype antibodies: correlation with treatment response. J Immunol 1985; 135:4252-60. [PMID: 2933460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
To correlate treatment responses with numbers and types of "host cell infiltrates," lymphoid tissues from 10 patients with low-grade B cell malignancies were stained before, during, and after anti-idiotype therapy with a panel of monoclonal antibodies applied to frozen sections. Tissue penetration by the anti-idiotype antibodies was confirmed in five patients by these immunoperoxidase methods. Large numbers of phenotypic T helper cells were the main component of the "host infiltrate" in most patients. Two patients showed a complete and a near-complete clinical remission, four others had partial responses, and four did not respond to therapy. The two patients that developed clinical remission demonstrated the largest number of T cells, T helper cells, TAC+ cells, Leu-7+ cells, and in general the smallest number of proliferating cells as measured by the Ki-67 antibody. Other major differences in host cells were not evident among the patients. These preliminary data suggest that the type and amount of "host infiltrate" in low-grade B cell lymphomas may predict which patients will respond to anti-idiotype therapy.
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MESH Headings
- Animals
- Antibodies, Monoclonal/therapeutic use
- Antigens, Differentiation, T-Lymphocyte
- Antigens, Surface/immunology
- Cell Movement
- Histocytochemistry
- Humans
- Immunoglobulin Idiotypes/analysis
- Immunoglobulin Idiotypes/immunology
- Lymphoma/immunology
- Lymphoma/pathology
- Lymphoma/therapy
- Mice
- Receptors, Immunologic/analysis
- Receptors, Interleukin-2
- T-Lymphocytes, Cytotoxic/pathology
- T-Lymphocytes, Cytotoxic/physiology
- T-Lymphocytes, Helper-Inducer/pathology
- T-Lymphocytes, Helper-Inducer/physiology
- T-Lymphocytes, Regulatory/pathology
- T-Lymphocytes, Regulatory/physiology
- Tissue Distribution
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27
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Garcia CF, Lowder J, Meeker TC, Bindl J, Levy R, Warnke RA. Differences in "host infiltrates" among lymphoma patients treated with anti-idiotype antibodies: correlation with treatment response. The Journal of Immunology 1985. [DOI: 10.4049/jimmunol.135.6.4252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
To correlate treatment responses with numbers and types of "host cell infiltrates," lymphoid tissues from 10 patients with low-grade B cell malignancies were stained before, during, and after anti-idiotype therapy with a panel of monoclonal antibodies applied to frozen sections. Tissue penetration by the anti-idiotype antibodies was confirmed in five patients by these immunoperoxidase methods. Large numbers of phenotypic T helper cells were the main component of the "host infiltrate" in most patients. Two patients showed a complete and a near-complete clinical remission, four others had partial responses, and four did not respond to therapy. The two patients that developed clinical remission demonstrated the largest number of T cells, T helper cells, TAC+ cells, Leu-7+ cells, and in general the smallest number of proliferating cells as measured by the Ki-67 antibody. Other major differences in host cells were not evident among the patients. These preliminary data suggest that the type and amount of "host infiltrate" in low-grade B cell lymphomas may predict which patients will respond to anti-idiotype therapy.
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28
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Abstract
As an alternative to morphological identification of circulating neoplastic lymphocytes in the blood of patients with non-Hodgkin's lymphoma, DNA of peripheral blood lymphocytes was analysed for clonal immunoglobulin gene rearrangements in 29 patients with low-grade B-cell lymphomas. 76% of the patients showed clonal rearrangements of immunoglobulin genes in their blood, including 58% of those with no other evidence of disease. In seven patients from whom paired samples were available the rearranged bands found in the blood and in lymph-node biopsy specimens containing histologically confirmed lymphoma were identical. Detection of circulating lymphoma cells by use of tumour-specific anti-idiotype antibodies and cytofluorimetry showed complete agreement with the results of DNA analysis.
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29
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Meeker T, Lowder J, Cleary ML, Stewart S, Warnke R, Sklar J, Levy R. Emergence of idiotype variants during treatment of B-cell lymphoma with anti-idiotype antibodies. N Engl J Med 1985; 312:1658-65. [PMID: 3923352 DOI: 10.1056/nejm198506273122602] [Citation(s) in RCA: 192] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We studied two patients with malignant B-cell lymphoma that manifested resistance to the therapeutic effects of anti-idiotype antibody because of the emergence of subclones with changes in their immunoglobulin idiotypes. In both patients, tumor-cell populations arose that were unreactive with anti-idiotype antibody but that retained surface immunoglobulin. One of the patients had an additional subpopulation of tumor cells that had switched from mu to gamma heavy-chain expression. Study of the immunoglobulin genes in the tumors confirmed that the subpopulations were derived from the same original clone of neoplastic B cells in each patient. The available data suggest that the idiotypic variation observed was the result of somatic mutation in the variable region of the active immunoglobulin genes. The fact that such mutations became evident over a short time and in the context of a partial tumor response suggests that the antibody therapy exerted a strong selective force against tumor cells that expressed the idiotype determinant. Multiple anti-idiotype antibodies may therefore be needed to identify all cells of a malignant clone, and some patients may require treatment with more than one monoclonal antibody.
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30
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Meeker TC, Lowder J, Maloney DG, Miller RA, Thielemans K, Warnke R, Levy R. A clinical trial of anti-idiotype therapy for B cell malignancy. Blood 1985; 65:1349-63. [PMID: 3888313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Eleven patients with B lymphocytic malignancy were treated with mouse monoclonal anti-idiotype antibodies. All but one of the patients in this study had received extensive prior treatment with conventional lymphoma therapy. All antibodies were prepared against, and uniquely reactive with, the patient's own tumor. Ten patients were treated with a single antibody, but one patient received three antibodies concurrently. The treatment protocol initially used an escalating dose schedule that was intended to evaluate toxicity, pharmacokinetics and, eventually, to achieve appreciable levels of free mouse antibody in the circulation. The last two patients received substantial initial doses. Tumor sampling was performed before and during therapy to evaluate tissue penetration by antibody. None of the patients had serum paraproteins by routine clinical testing, but six had idiotype protein detectable by a sensitive immunoassay at levels greater than 1 microgram/mL, two of which were greater than 200 micrograms/mL. Plasmapheresis was capable of reducing these levels temporarily. However, the presence of serum idiotype increased the requirement for mouse antibody to achieve tumor penetration. Another obstacle to treatment was immune response to mouse Ig, which occurred in five of the 11 patients. Once an immune response had begun, further infusions of antibody were not capable of reaching the tumor or inducing tumor regression and were associated with toxicity. Our initial patient remains in an unmaintained complete remission 42 months after receiving antibody. Five of ten additional patients have had objective remissions that were also clinically significant. However, these remissions were not complete and were of relatively short duration. This therapy shows promise as an alternative modality for the treatment of B cell malignancy. Further study will be needed to determine the mechanisms of the antitumor effect and to improve the clinical results.
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