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Hübner YR, Spuck N, Berger M, Schlabe S, Rieke GJ, Breitschwerdt S, van Bremen K, Strassburg CP, Gonzalez-Carmona MA, Wasmuth JC, Rockstroh JK, Boesecke C, Monin MB. Antiviral treatment of COVID-19: which role can clinical parameters play in therapy evaluation? Infection 2023; 51:1855-1861. [PMID: 37555885 PMCID: PMC10665228 DOI: 10.1007/s15010-023-02081-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023]
Affiliation(s)
- Yannis R Hübner
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Nikolai Spuck
- Faculty of Medicine, Institute of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Moritz Berger
- Faculty of Medicine, Institute of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Stefan Schlabe
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany
| | - Gereon J Rieke
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany
| | - Sven Breitschwerdt
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany
| | - Kathrin van Bremen
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Maria A Gonzalez-Carmona
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jan-Christian Wasmuth
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany
| | - Jürgen K Rockstroh
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany
| | - Christoph Boesecke
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany
| | - Malte B Monin
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- German Centre for Infection Research (DZIF), partner-site Cologne-Bonn, Bonn, Germany.
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Orth HM, Flasshove C, Berger M, Hattenhauer T, Biederbick KD, Mispelbaum R, Klein U, Stemler J, Fisahn M, Doleschall AD, Baermann BN, Koenigshausen E, Tselikmann O, Killer A, de Angelis C, Gliga S, Stegbauer J, Spuck N, Silling G, Rockstroh JK, Strassburg CP, Brossart P, Panse JP, Jensen BEO, Luedde T, Boesecke C, Heine A, Cornely OA, Monin MB. Early combination therapy of COVID-19 in high-risk patients. Infection 2023:10.1007/s15010-023-02125-5. [PMID: 38017344 DOI: 10.1007/s15010-023-02125-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/24/2023] [Indexed: 11/30/2023]
Abstract
PURPOSE Prolonged shedding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been observed in immunocompromised hosts. Early monotherapy with direct-acting antivirals or monoclonal antibodies, as recommended by the international guidelines, does not prevent this with certainty. Dual therapies may therefore have a synergistic effect. METHODS This retrospective, multicentre study compared treatment strategies for corona virus disease-19 (COVID-19) with combinations of nirmatrelvir/ritonavir, remdesivir, molnupiravir, and/ or mABs during the Omicron surge. Co-primary endpoints were prolonged viral shedding (≥ 106 copies/ml at day 21 after treatment initiation) and days with SARS-CoV-2 viral load ≥ 106 copies/ml. Therapeutic strategies and risk groups were compared using odds ratios and Fisher's tests or Kaplan-Meier analysis and long-rank tests. Multivariable regression analysis was performed. RESULTS 144 patients were included with a median duration of SARS-CoV-2 viral load ≥ 106 copies/ml of 8.0 days (IQR 6.0-15.3). Underlying haematological malignancies (HM) (p = 0.03) and treatment initiation later than five days after diagnosis (p < 0.01) were significantly associated with longer viral shedding. Prolonged viral shedding was observed in 14.6% (n = 21/144), particularly in patients with underlying HM (OR 3.5; 95% CI 1.2-9.9; p = 0.02). Clinical courses of COVID-19 were mild to moderate with only few adverse effects potentially related to combination treatment. CONCLUSION Early combination treatment of COVID-19 effectively prevented prolonged viral shedding in 85.6% of cases. Considering the rapid viral clearance rates and low toxicity, individualized dual therapy approaches may be beneficial in high-risk patients.
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Affiliation(s)
- Hans Martin Orth
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Charlotte Flasshove
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Moritz Berger
- Institute for Medical Biometry, Informatics and Epidemiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tessa Hattenhauer
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Kaja D Biederbick
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Rebekka Mispelbaum
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Uwe Klein
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jannik Stemler
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department I of Internal Medicine, European Diamond Excellence Centre for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine, and University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Kerpener Str. 62, 50937, Cologne, Germany
| | - Matthis Fisahn
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department I of Internal Medicine, European Diamond Excellence Centre for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine, and University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Kerpener Str. 62, 50937, Cologne, Germany
| | - Anna D Doleschall
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ben-Niklas Baermann
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Hematology, Oncology, and Clinical Immunology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Eva Koenigshausen
- Department of Nephrology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Olga Tselikmann
- Department of Nephrology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Alexander Killer
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Clara de Angelis
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Smaranda Gliga
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Johannes Stegbauer
- Department of Nephrology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Nikolai Spuck
- Institute for Medical Biometry, Informatics and Epidemiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Gerda Silling
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jürgen K Rockstroh
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christian P Strassburg
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Peter Brossart
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jens P Panse
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Björn-Erik Ole Jensen
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Tom Luedde
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christoph Boesecke
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Annkristin Heine
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Oliver A Cornely
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department I of Internal Medicine, European Diamond Excellence Centre for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine, and University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Kerpener Str. 62, 50937, Cologne, Germany
| | - Malte B Monin
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany.
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Johanniter-Kliniken Bonn GmbH, Johanniter-Krankenhaus Bonn, Bonn, Germany.
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Hermanussen L, Brehm TT, Wolf T, Boesecke C, Schlabe S, Borgans F, Monin MB, Jensen BEO, Windhaber S, Scholten S, Jordan S, Lütgehetmann M, Wiesch JSZ, Addo MM, Mikolajewska A, Niebank M, Schmiedel S. Tecovirimat for the treatment of severe Mpox in Germany. Infection 2023; 51:1563-1568. [PMID: 37273167 PMCID: PMC10240449 DOI: 10.1007/s15010-023-02049-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/07/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND In May 2022, a multi-national mpox outbreak was reported in several non-endemic countries. The only licensed treatment for mpox in the European Union is the orally available small molecule tecovirimat, which in Orthopox viruses inhibits the function of a major envelope protein required for the production of extracellular virus. METHODS We identified presumably all patients with mpox that were treated with tecovirimat in Germany between the onset of the outbreak in May 2022 and March 2023 and obtained demographic and clinical characteristics by standardized case report forms. RESULTS A total of twelve patients with mpox were treated with tecovirimat in Germany in the study period. All but one patient identified as men who have sex with men (MSM) who were most likely infected with mpox virus (MPXV) through sexual contact. Eight of them were people living with HIV (PLWH), one of whom was newly diagnosed with HIV at the time of mpox, and four had CD4+ counts below 200/µl. Criteria for treatment with tecovirimat included severe immunosuppression, severe generalized and/or protracted symptoms, a high or increasing number of lesions, and the type and location of lesions (e.g., facial or oral soft tissue involvement, imminent epiglottitis, or tonsillar swelling). Patients were treated with tecovirimat for between six and 28 days. Therapy was generally well-tolerated, and all patients showed clinical resolution. CONCLUSIONS In this cohort of twelve patients with severe mpox, treatment with tecovirimat was well tolerated and all individuals showed clinical improvement.
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Affiliation(s)
- Lennart Hermanussen
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Thomas Theo Brehm
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Infection Research (DZIF), Partner-Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Timo Wolf
- Internal Medicine II, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
| | - Christoph Boesecke
- Department of Medicine I, Bonn University Hospital, Bonn, Germany
- German Center for Infection Research (DZIF), Partner-Site Cologne-Bonn, Bonn, Germany
| | - Stefan Schlabe
- Department of Medicine I, Bonn University Hospital, Bonn, Germany
| | - Frauke Borgans
- Internal Medicine II, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
| | - Malte B Monin
- Department of Medicine I, Bonn University Hospital, Bonn, Germany
| | - Björn-Erik Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Düsseldorf University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Stefan Windhaber
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Düsseldorf University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Stefan Scholten
- Praxis Hohenstaufenring in den RingColonnaden, Cologne, Germany
| | - Sabine Jordan
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marc Lütgehetmann
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Infection Research (DZIF), Partner-Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Marylyn M Addo
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Infection Research (DZIF), Partner-Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
- Institute for Infection Research and Vaccine Development (IIRVD), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Agata Mikolajewska
- Centre for Biological Threats and Special Pathogens (ZBS), Robert Koch Institute, Berlin, Germany
| | - Michaela Niebank
- Centre for Biological Threats and Special Pathogens (ZBS), Robert Koch Institute, Berlin, Germany
| | - Stefan Schmiedel
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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4
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Monin MB, Baier LI, Gorny JG, Berger M, Zhou T, Mahn R, Sadeghlar F, Möhring C, Boesecke C, van Bremen K, Rockstroh JK, Strassburg CP, Eis-Hübinger AM, Schmid M, Gonzalez-Carmona MA. Deficient Immune Response following SARS-CoV-2 Vaccination in Patients with Hepatobiliary Carcinoma: A Forgotten, Vulnerable Group of Patients. Liver Cancer 2023; 12:339-355. [PMID: 37901199 PMCID: PMC10601882 DOI: 10.1159/000529608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/06/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Data on immune response rates following vaccination for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in patients with hepatobiliary carcinoma (HBC) are rare. However, impaired immunogenicity must be expected due to the combination of chronic liver diseases (CLDs) with malignancy and anticancer treatment. Methods In this prospective, longitudinal study, 101 patients were included, of whom 59 were patients with HBC under anticancer treatment. A cohort of patients with a past medical history of gastrointestinal cancer, of whom 28.6% had HBC without detectable active tumor disease having been off therapy for at least 12 months, served as control. Levels of SARS-CoV-2 anti-spike IgG, surrogate neutralization antibodies (sNABs), and cellular immune responses were compared. In uni- and multivariable subgroup analyses, risk factors for impaired immunogenicity were regarded. Data on rates and clinical courses of SARS-CoV-2 infections were documented. Results In patients with HBC under active treatment, levels of SARS-CoV-2 anti-spike IgG were significantly lower (2.55 log10 BAU/mL; 95% CI: 2.33-2.76; p < 0.01) than in patients in follow-up care (3.02 log10 BAU/mL; 95% CI: 2.80-3.25) 4 weeks after two vaccinations. Antibody levels decreased over time, and differences between the groups diminished. However, titers of SARS-CoV-2 sNAB were for a longer time significantly lower in patients with HBC under treatment (64.19%; 95% CI: 55.90-72.48; p < 0.01) than in patients in follow-up care (84.13%; 95% CI: 76.95-91.31). Underlying CLD and/or liver cirrhosis Child-Pugh A or B (less than 8 points) did not seem to further impair immunogenicity. Conversely, chemotherapy and additional immunosuppression were found to significantly reduce antibody levels. After a third booster vaccination for SARS-CoV-2, levels of total and neutralization antibodies were equalized between the groups. Moreover, cellular response rates were balanced. Clinically, infection rates with SARS-CoV-2 were low, and no severe courses were observed. Conclusion Patients with active HBC showed significantly impaired immune response rates to basic vaccinations for SARS-CoV-2, especially under chemotherapy, independent of underlying cirrhotic or non-cirrhotic CLD. Although booster vaccinations balanced differences, waning immunity was observed over time and should be monitored for further recommendations. Our data help clinicians decide on individual additional booster vaccinations and/or passive immunization or antiviral treatment in patients with HBC getting infected with SARS-CoV-2.
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Affiliation(s)
- Malte B. Monin
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Leona I. Baier
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Jens G. Gorny
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Moritz Berger
- Institute of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Taotao Zhou
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Robert Mahn
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Farsaneh Sadeghlar
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Christian Möhring
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Christoph Boesecke
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Kathrin van Bremen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Jürgen K. Rockstroh
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | | | | | - Matthias Schmid
- Institute of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
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5
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Möhring C, Mańczak A, Timotheou A, Sadeghlar F, Zhou T, Mahn R, Monin MB, Toma M, Feldmann G, Brossart P, Köksal M, Sarria GR, Sommer N, Lingohr P, Jafari A, Kalff JC, Strassburg CP, Gonzalez-Carmona MA. Perioperative Therapy with Flot4 Significantly Increases Survival in Patients with Gastroesophageal and Gastric Cancer in A Large Real-World Cohort. Int J Cancer 2023. [PMID: 36919950 DOI: 10.1002/ijc.34511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/16/2023]
Abstract
In 2019, the FLOT4 protocol was established as the new standard for perioperative therapy in patients with locally advanced gastroesophageal and gastric cancer. Whether this protocol is beneficial in a real-world setting remains a question with limited answers to date. In this study, a large cohort of unselected patients treated with FLOT4 was analyzed and compared to protocols based on 5-FU/platinum derivative. This retrospective analysis included patients with locally advanced gastroesophageal and gastric cancer treated with perioperative FLOT or 5-FU/platinum derivative at University Hospital, Bonn between 2010 and 2022 in a curative setting (n=99). Overall survival, disease-free survival, therapy response and therapy complications were analyzed. Patients treated with FLOT showed a statistically significant longer median overall survival of 57.8 vs. 28.9 months (HR: 0.554, 95% CI: 0.317 - 0.969, p=0.036). Moreover, pathological tumor regression (pTR) was significantly higher in the FLOT group compared to the 5-FU/platinum group (p=0.001). Subgroup analysis showed a favorable survival benefit for the FLOT vs. 5-FU/platinum derivate in patients with AEG and non-signet cell carcinoma. Overall, FLOT was tolerated well but CTCAE ≥3 grade neutropenia and diarrhea occurred more often within the FLOT group. Similar to the prospective phase II/III trials, FLOT4 was the best protocol for patients with locally advanced gastroesophageal and gastric cancer as perioperative therapy in terms of overall survival and pathological response rate compared to 5-FU/platinum derivative protocols. Interestingly, patients with gastroesophageal cancer benefitted more from this therapy. In contrast, patients with signet ring cells appear not to benefit from addition of docetaxel.
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Affiliation(s)
- Christian Möhring
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Adrianna Mańczak
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Aliki Timotheou
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Farsaneh Sadeghlar
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Taotao Zhou
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Robert Mahn
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Malte B Monin
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Marieta Toma
- Department of Pathology, University Hospital of Bonn, Bonn, Germany
| | - Georg Feldmann
- Department of Internal Medicine III, University Hospital of Bonn, Bonn, Germany
| | - Peter Brossart
- Department of Internal Medicine III, University Hospital of Bonn, Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital of Bonn, Bonn, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital of Bonn, Bonn, Germany
| | - Nils Sommer
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
| | - Philipp Lingohr
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
| | - Azin Jafari
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
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6
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Monin MB, Ingiliz P, Lutz T, Scholten S, Cordes C, Martínez-Rebollar M, Spinner CD, Nelson M, Rausch M, Bhagani S, Peters L, Reiberger T, Mauss S, Rockstroh JK, Boesecke C. Low Spontaneous Clearance Rates of Recently Acquired Hepatitis C Virus in Human Immunodeficiency Virus-Positive Men Who Have Sex With Men (PROBE-C Study). Clin Infect Dis 2023; 76:e607-e612. [PMID: 36004410 DOI: 10.1093/cid/ciac680] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/10/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Using direct-acting antivirals (DAAs) for recently acquired hepatitis C virus (RAHCV) infections, particularly in human immunodeficiency virus (HIV)-positive men who have sex with men (MSM), dramatically reduced the incidence of hepatitis C. However, implementation into clinical practice is challenging. The aim of this study was to analyze spontaneous clearance (SC) rates of RAHCV and to identify predictors of SC. METHODS The PROBE-C study is an observational European cohort on RAHCV infections in HIV-positive MSM. Between 2007 and 2017, RAHCV infections were documented with ≥12 months of follow-up. Fisher exact, χ2, and Mann-Whitney U tests were used for statistical analysis. RESULTS A total of 464 RAHCV infections were documented; 457 of 464 patients (98%) were male, and the median age (interquartile range [IQR]) was 41 (38-46) years. The main risk group for hepatitis C virus (HCV) transmission was MSM (98.9%). Most participants were infected with HCV genotype 1 (78.3%). The median baseline HCV RNA level (IQR) was 230 000 (135 000-474 432) IU/mL, and the median CD4+ T-cell count was 574/µL (547-604/µL. Of all cases, 92% received combination antiretroviral therapy, with 91% showing suppressed HIV RNA levels (<200 copies/mL). The median maximum alanine aminotransferase level (IQR) was 445 (402-522) U/L. SC of RAHCV infection occurred in 55 of 464 cases (11.9%). A >2-log decline in HCV RNA levels 4 weeks after diagnosis of RAHCV infection was the strongest predictor of SC (P < .001; sensitivity, 96.4%; specificity, 97.5%; positive predictive value, 84.1%; negative predictive value, 99.5%). CONCLUSIONS SC of RAHCV in HIV-positive MSM is found in only 11.9% of cases and a <2-log drop in HCV RNA level at week 4 after diagnosis should prompt early DAA-based treatment. However, immediate DAA treatment for RAHCV infection may also be favored in patients with ongoing transmission risk behavior.
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Affiliation(s)
- Malte B Monin
- University Hospital Bonn, Bonn, Germany.,German Centre for Infection Research (DZIF), Partner Site Cologne-Bonn, Bonn, Germany
| | - Patrick Ingiliz
- University Hospital Henri-Mondor, Inserm U955-Virus, Hepatology, Cancer, Paris, France
| | | | | | | | - Maria Martínez-Rebollar
- HIV Unit, Infectious Diseases Service, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Christoph D Spinner
- Department of Internal Medicine II, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Mark Nelson
- Chelsea and Westminster Hospital, London, United Kingdom
| | | | | | - Lars Peters
- CHIP, Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Jürgen K Rockstroh
- University Hospital Bonn, Bonn, Germany.,German Centre for Infection Research (DZIF), Partner Site Cologne-Bonn, Bonn, Germany.,European AIDS Treatment Network Infectious Disease (NEAT ID) Foundation, London, United Kingdom
| | - Christoph Boesecke
- University Hospital Bonn, Bonn, Germany.,German Centre for Infection Research (DZIF), Partner Site Cologne-Bonn, Bonn, Germany.,European AIDS Treatment Network Infectious Disease (NEAT ID) Foundation, London, United Kingdom
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7
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Boesecke C, Monin MB, van Bremen K, Schlabe S, Hoffmann C. Severe monkeypox-virus infection in undiagnosed advanced HIV infection. Infection 2022; 50:1633-1634. [PMID: 35969365 PMCID: PMC9705473 DOI: 10.1007/s15010-022-01901-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Christoph Boesecke
- Department of Medicine I, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany.
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Cologne, Germany.
| | - Malte B Monin
- Department of Medicine I, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Cologne, Germany
| | - Kathrin van Bremen
- Department of Medicine I, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Cologne, Germany
| | - Stefan Schlabe
- Department of Medicine I, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Cologne, Germany
| | - Christian Hoffmann
- Infektionsmedizinisches Zentrum Hamburg, Hamburg, Germany
- University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
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8
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Monin MB, Marx B, Meffert L, Boesecke C, Rockstroh JK, Strassburg CP, Brossart P, Heine A. SARS-CoV-2 PrEP complicates antibody testing after vaccination: a call for awareness. Ann Hematol 2022; 101:2089-2090. [PMID: 35608678 PMCID: PMC9127812 DOI: 10.1007/s00277-022-04859-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Malte B Monin
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1 53127, Bonn, Germany. .,German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany.
| | - Benjamin Marx
- Institute of Virology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Lisa Meffert
- Department of Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - Christoph Boesecke
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1 53127, Bonn, Germany.,German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Jürgen K Rockstroh
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1 53127, Bonn, Germany.,German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1 53127, Bonn, Germany
| | - Peter Brossart
- Department of Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - Annkristin Heine
- Department of Internal Medicine III, University Hospital Bonn, Bonn, Germany
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9
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Rieke GJ, van Bremen K, Bischoff J, To Vinh M, Monin MB, Schlabe S, Raabe J, Kaiser KM, Finnemann C, Odainic A, Kudaliyanage A, Latz E, Strassburg CP, Boesecke C, Schmidt SV, Krämer B, Rockstroh JK, Nattermann J. OUP accepted manuscript. J Infect Dis 2022; 225:1688-1693. [PMID: 35323975 PMCID: PMC8992321 DOI: 10.1093/infdis/jiac060] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/15/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Gereon J Rieke
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Kathrin van Bremen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Jenny Bischoff
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Michael To Vinh
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Malte B Monin
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Stefan Schlabe
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Jan Raabe
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Kim M Kaiser
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Claudia Finnemann
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Alexandru Odainic
- Institute of Innate Immunity, Medical Faculty, University of Bonn, Bonn, Germany
- Department of Microbiology and Immunology at the Doherty Institute for Infection and Immunity, The University of Melbourne, Victoria, Australia
| | - Anushka Kudaliyanage
- Institute of Innate Immunity, Medical Faculty, University of Bonn, Bonn, Germany
| | - Eicke Latz
- Institute of Innate Immunity, Medical Faculty, University of Bonn, Bonn, Germany
| | | | - Christoph Boesecke
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Susanne V Schmidt
- Institute of Innate Immunity, Medical Faculty, University of Bonn, Bonn, Germany
| | - Benjamin Krämer
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Jürgen K Rockstroh
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-site Cologne-Bonn, Bonn, Germany
| | - Jacob Nattermann
- Corresponding author: Jacob Nattermann, MD; Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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10
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Rieke GJ, Monin MB, Breitschwerdt S, Boesecke C, Schlabe S. Confirmed SARS-CoV-2 Reinfection After 1 Year in a Patient with X-linked Agammaglobulinaemia. Infect Dis (Lond) 2022. [DOI: 10.17925/id.2022.1.1.35] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Though a comprehensive analysis of the immunity following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been performed, little is known about the duration of this protection and the risk of reinfection. This lack of knowledge is of particular interest for patients with impaired immune function. In this report, we describe the course of infection of a 30-year-old male patient with X-linked agammaglobulinaemia, who was reinfected with SARS-CoV-2 after a primary infection 12 months earlier. The initial course of infection took place in April 2020 with the typical symptoms of an upper respiratory tract infection accompanied by compatible changes in laboratory values and computed tomography. With no anti-viral treatment options at that time of the pandemic, only symptomatic therapy could be offered. Twelve months later (April 2021), the patient presented with a short course of fever and headache. Laboratory testing showed elevated C-reactive protein levels, while leukocytes, lymphocytes and lactate dehydrogenase levels were within range. The patient was admitted, and antibiotic treatment was started partially because procalcitonin levels were slightly elevated as well. The SARS-CoV-2 polymerase chain reaction was positive, and therapy with the monoclonal SARS-CoV-2 antibodies casirivimab/imdevimab (1,200 mg/1,200 mg, respectively) were initiated. The course of infection was mild, but low-flow oxygen had to be administered. It was not possible to distinguish between the contribution of the administered antibodies and the role of cytotoxic T-cells in the course of infection. Variant screenings confirmed the Wuhan strain of the virus for the first episode and the alpha variant for the second episode, thus confirming reinfection and ruling out long-term shedding. Neutralizing antibodies seem to play a crucial role in viral clearance and infection prevention, assuming patients with agammaglobulinaemia are at higher risk for a severe course of coronavirus disease 2019. Still, the specific role of neutralizing antibodies and cytotoxic T-cells is not fully understood. Reinfection among this patient population has only been described occasionally. Our case described a reinfection, which was confirmed by variant-testing. In addition, it gave insight into the rapid progression of testing and into specific anti-viral therapy over 1 year of the pandemic.
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11
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Monin MB, Krause P, Stelling R, Bocuk D, Niebert S, Klemm F, Pukrop T, Koenig S. The anthelmintic niclosamide inhibits colorectal cancer cell lines via modulation of the canonical and noncanonical Wnt signaling pathway. J Surg Res 2016; 203:193-205. [PMID: 27338550 DOI: 10.1016/j.jss.2016.03.051] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 03/09/2016] [Accepted: 03/22/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Wnt/β-catenin signaling is known to play an important role in colorectal cancer (CRC). Niclosamide, a salicylamide derivative used in the treatment of tapeworm infections, targets the Wnt/β-catenin pathway. The objective of this study was to investigate niclosamide as a therapeutic agent against CRC. METHODS The antiproliferative effects of 1, 3, 10, and 50 μM concentrations of niclosamide on human (SW480 and SW620) and rodent (CC531) CRC cell lines were determined by MTS assay and direct cell count. The lymphoid enhancer-binding factor 1/transcription factor (LEF/TCF) reporter assay monitored the activity of Wnt signaling. Immunofluorescence staining demonstrated the expression pattern of active β-catenin. Gene expression of canonical and noncanonical Wnt signaling components was analyzed using qRT-PCR. Western blot analysis was performed with antibodies detecting nuclear localization of β-catenin and c-jun. RESULTS Cell proliferation in CRC cell lines was blocked dose dependently after 12 and 24 h of incubation. The Wnt promoter activity of LEF/TCF significantly decreased with niclosamide concentrations of 10 and 50 μM after 12 h of incubation. Active β-catenin did not shift from the nuclear to the cytosolic pool. However, canonical target genes (met, MMP7, and cyclin D1) as well as the coactivating factor Bcl9 were downregulated, whereas the noncanonical key player c-jun was clearly activated. CONCLUSIONS Niclosamide treatment is associated with an inhibitory effect on CRC development and reduced Wnt activity. It may exert its effect by interfering with the nuclear β-catenin-Bcl9-LEF/TCF triple-complex and by upregulation of c-jun representing noncanonical Wnt/JNK signaling. Thus, our findings warrant further research into this substance as a treatment option for patients with advanced CRC.
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Affiliation(s)
- Malte B Monin
- Department of General, Visceral and Paediatric Surgery, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany
| | - Petra Krause
- Department of General, Visceral and Paediatric Surgery, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany
| | - Robin Stelling
- Department of General, Visceral and Paediatric Surgery, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany
| | - Derya Bocuk
- Department of General, Visceral and Paediatric Surgery, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany
| | - Sabine Niebert
- Department of General, Visceral and Paediatric Surgery, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany
| | - Florian Klemm
- Department of Haematology and Oncology, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany
| | - Tobias Pukrop
- Department of Haematology and Oncology, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany; Department for Internal Medicine III, Hematology/Oncology, University Clinic Regensburg, Regensburg, Germany
| | - Sarah Koenig
- Department of General, Visceral and Paediatric Surgery, University Medical Centre, Georg-August-University Goettingen, Göttingen, Germany; University Hospital Wuerzburg, Julius-Maximilians-University Wuerzburg, Chair of Medical Teaching and Medical Education Research, Josef-Schneider-Str. 2/D6, D-97080 Wuerzburg, Germany.
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