cGAS-STING drives ageing-related inflammation and neurodegeneration

Low-grade inflammation is a hallmark of old age and a central driver of ageing-associated impairment and disease1. Multiple factors can contribute to ageing-associated inflammation2; however, the molecular pathways that transduce aberrant inflammatory signalling and their impact in natural ageing remain unclear. Here we show that the cGAS-STING signalling pathway, which mediates immune sensing of DNA3, is a critical driver of chronic inflammation and functional decline during ageing. Blockade of STING suppresses the inflammatory phenotypes of senescent human cells and tissues, attenuates ageing-related inflammation in multiple peripheral organs and the brain in mice, and leads to an improvement in tissue function. Focusing on the ageing brain, we reveal that activation of STING triggers reactive microglial transcriptional states, neurodegeneration and cognitive decline. Cytosolic DNA released from perturbed mitochondria elicits cGAS activity in old microglia, defining a mechanism by which cGAS-STING signalling is engaged in the ageing brain. Single-nucleus RNA-sequencing analysis of microglia and hippocampi of a cGAS gain-of-function mouse model demonstrates that engagement of cGAS in microglia is sufficient to direct ageing-associated transcriptional microglial states leading to bystander cell inflammation, neurotoxicity and impaired memory capacity. Our findings establish the cGAS-STING pathway as a driver of ageing-related inflammation in peripheral organs and the brain, and reveal blockade of cGAS-STING signalling as a potential strategy to halt neurodegenerative processes during old age.

Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

[Impact of a more stringent organization of intravitreal injection treatment on the number of treatments and examinations in routine practice]

BACKGROUND

Results from recent studies show that less intravitreal injections are often performed in everyday practice than in controlled trials, which subsequently leads to worse treatment success. In this study we analyzed the introduction of a more stringent organization of treatment using workflow optimization and new IT systems and analyzed the effect on treatment continuity.

MATERIAL AND METHODS

In the second quarter of 2019 a new medical practice management software and a software for automated injection planning were implemented. There was also a change of the treatment regimen from pro re nata (PRN) to treat and extend (T&E ). We analyzed the results of the patients regarding the frequency of injections and treatment controls three quarters before (Q3/2018-Q1/2019) and three quarters after the change (Q2/2019-Q4/2019). Treatment-naive and pretreated patients were analyzed.

RESULTS

In group 1 (Q3/2018-Q1/2019) the average number of injections per quarter was 1.74 (SD = 0.4). Eyes of patients from group 2 (Q2/2019-Q4/2019) received on average 2.17 (SD = 0.3) injections. The number of check-ups per quarter was 1.71 (SD = 0.3) before the introduction, and thereafter 2.16 (SD = 0.3). There was a significant increase in the number of OCTs from 1.18 (SD = 0.2) to 1.98 (SD = 0.3). The visual acuity was stable in both groups.

CONCLUSION

We were able to show that the introduction of the medical practice management software and the change of the regimen from PRN to T&E can achieve numbers of injections, check-ups and OCT similar to those in studies. A standardized procedure facilitates efficient treatment planning and enables a better patient management.

[Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic]

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

nab-Paclitaxel plus carboplatin or gemcitabine versus gemcitabine plus carboplatin as first-line treatment of patients with triple-negative metastatic breast cancer: results from the tnAcity trial

Background

Metastatic triple-negative breast cancer (mTNBC) has a poor prognosis and aggressive clinical course. tnAcity evaluated the efficacy and safety of first-line nab-paclitaxel plus carboplatin (nab-P/C), nab-paclitaxel plus gemcitabine (nab-P/G), and gemcitabine plus carboplatin (G/C) in patients with mTNBC.

Patients and methods

Patients with pathologically confirmed mTNBC and no prior chemotherapy for metastatic BC received (1 : 1 : 1) nab-P 125 mg/m2 plus C AUC 2, nab-P 125 mg/m2 plus G 1000 mg/m2, or G 1000 mg/m2 plus C AUC 2, all on days 1, 8 q3w. Phase II primary end point: investigator-assessed progression-free survival (PFS); secondary end points included overall response rate (ORR), overall survival (OS), percentage of patients initiating cycle 6 with doublet therapy, and safety.

Results

In total, 191 patients were enrolled (nab-P/C, n = 64; nab-P/G, n = 61; G/C, n = 66). PFS was significantly longer with nab-P/C versus nab-P/G [median, 8.3 versus 5.5 months; hazard ratio (HR), 0.59 [95% CI, 0.38-0.92]; P = 0.02] or G/C (median, 8.3 versus 6.0 months; HR, 0.58 [95% CI, 0.37-0.90]; P = 0.02). OS was numerically longer with nab-P/C versus nab-P/G (median, 16.8 versus 12.1 months; HR, 0.73 [95% CI, 0.47-1.13]; P = 0.16) or G/C (median, 16.8 versus 12.6 months; HR, 0.80 [95% CI, 0.52-1.22]; P = 0.29). ORR was 73%, 39%, and 44%, respectively. In the nab-P/C, nab-P/G, and G/C groups, 64%, 56%, and 50% of patients initiated cycle 6 with a doublet. Grade ≥3 adverse events were mainly hematologic.

Conclusions

First-line nab-P/C was active in mTNBC and resulted in a significantly longer PFS and improved risk/benefit profile versus nab-P/G or G/C.

Innate immune sensing of cytosolic chromatin fragments through cGAS promotes senescence

Cellular senescence is triggered by various distinct stresses and characterized by a permanent cell cycle arrest. Senescent cells secrete a variety of inflammatory factors, collectively referred to as the senescence-associated secretory phenotype (SASP). The mechanism(s) underlying the regulation of the SASP remains incompletely understood. Here we define a role for innate DNA sensing in the regulation of senescence and the SASP. We find that cyclic GMP-AMP synthase (cGAS) recognizes cytosolic chromatin fragments in senescent cells. The activation of cGAS, in turn, triggers the production of SASP factors via stimulator of interferon genes (STING), thereby promoting paracrine senescence. We demonstrate that diverse stimuli of cellular senescence engage the cGAS-STING pathway in vitro and we show cGAS-dependent regulation of senescence following irradiation and oncogene activation in vivo. Our findings provide insights into the mechanisms underlying cellular senescence by establishing the cGAS-STING pathway as a crucial regulator of senescence and the SASP.

Toxicity profile differences of adjuvant docetaxel/cyclophosphamide (TC) between Asian and Caucasian breast cancer patients

AIM

For early-stage breast cancer, four cycles of docetaxel and cyclophosphamide (TC) was proven superior to doxorubicin plus cyclophosphamide in the US Oncology 9375 trial. Given primary prophylactic antibiotics, 5% febrile neutropenia was recorded in a population comprising 75.5% Caucasians. Smaller trials and retrospective studies reviewing TC use in Asian patients did not produce similar incidence rates. This study aims to discover the variable hematological toxicities with TC use in Caucasian and Asian patients.

METHODS

Breast cancer data was retrospectively reviewed for patients receiving adjuvant docetaxel 60-75 mg/m² plus cyclophosphamide 600 mg/m² from six countries (China, Hong Kong, Japan, Taiwan, Italy, and United States). Similar number of patients with relatively balanced baseline characteristics were chosen for analysis of hematological and nonhematological toxicities and survival data.

RESULTS

From March 2004 to July 2013, data of 227 patients (127 Asians and 100 Caucasian) patients were analyzed for treatment-related toxicities. During the four cycles of TC, Asians had a significantly higher rate of grade ≥2 neutropenia than Caucasians (45.7% vs 6.0%; P <0.001) and significantly more grade ≥3 neutropenia events were documented (respectively 30.7% vs 4.0%, P <0.001). The prophylactic use of G-CSF was similar; 26.0% in Asians and 28.0% in Caucasian (P = 0.764). There were no differences in nonhematological toxicities. No significant difference in disease-free survival was observed between Asians and Caucasians (log-rank P = 0.910).

CONCLUSIONS

Ethnic differences in toxicity profile exist between Asian and Caucasian patients given adjuvant TC. Over 30% Asians but less than 5% Caucasians experienced grade ≥3 neutropenia.

MicroRNAs interfere with DNA methylation in rheumatoid arthritis synovial fibroblasts

Background

The DNA of rheumatoid arthritis synovial fibroblasts (RASF) is globally hypomethylated; this contributes to an aggressive behaviour. In an attempt to remethylate these cells, we supplemented with methyl donors. We investigated the possible interference of microRNAs (miRs).

Material and methods

RASF were treated with L-methionine or betaine. Transcripts of de novo methyltransferases (DNMTs) and miRs were measured by real-time PCR, and a transcription PCR array was performed. Levels of homocysteine, matrix metalloproteinase-1 (MMP-1) and global DNA methylation were determined. Transfection with lipofectamine was performed with specific pre-miRs and anti-miRs, such as miR29 and let7f.

Results

L-methionine was more efficient to increase DNA methylation than betaine. This was associated with a reduced expression of DNMT3A mRNA in betaine-treated RASF. Betaine increases the expression of miR29 in RASF which targets DNMT3A, thereby limiting the remethylation process. Nevertheless, betaine inhibited the expression of multiple transcription factors, decreased the release of MMP-1, biosynthesis of homocysteine and cell migration.

Conclusion

Alterations in cellular miRs profiles, in particular the upregulation of miR29, which targets DNMT3A, may limit the efficiency of betaine if it is used as DNA remethylating agent. However, L-methionine also has similar impact on miR29 expression. On the other hand, betaine has multiple other beneficial effects on the activated phenotype of RASF; it is not excluded that the effect of betaine on DNMT3A is, at least in part, indirect. Clinical trials with betaine could be promising.

Abstract P1-12-01: Clinical impact of internet-based tools to help guide therapeutic decisions for metastatic breast cancer (MBC)

Background: Clinical practice guidelines are an important resource to help guide management of patients with MBC. However, guidelines are sometimes difficult to apply to individual patients, particularly when there are 2 or more treatment options with similar levels of evidence. We sought to determine whether expert recommendations on MBC treatment, delivered via an interactive, online decision support tool, would change or confirm the treatment decisions of community practitioners. We further sought to analyze changes in practice patterns and expert recommendations over time by comparing data from the current tool (2013) with data from a similar tool developed previously (2012).

Methods: Both online decision support tools were developed based on input from a panel of 5 experts. Each expert provided treatment recommendations for more than 400 patient scenarios based on a simplified set of variables: disease phenotype (HR status, HER2 status), previous therapy, visceral crisis (yes/no), and rate of disease progression. Users of the tool are prompted to enter specific patient criteria, and are asked to state their intended management approach for that particular patient case. The tool then shows the recommendations of the 5 MBC experts for the specific patient case that the user entered. Finally, the user is prompted to indicate whether the experts’ recommendation confirmed or changed their intended management approach. An analysis of expert recommendations and user-selected treatments was performed to compare results of the 2013 and 2012 tools.

Results: The 2012 decision support tool was utilized by 697 individuals who entered more than 1000 patient case scenarios. Users indicated that the experts’ recommendations changed their intended management approach for 30% of the cases, confirmed their approach for 36%, and did not impact their intended approach for 34%. Utilization data for the 2013 tool are pending. Expert recommendations in the 2012 vs 2013 tools changed to reflect emerging developments in guidelines, evidence, and clinical practice. For example, in 2012 there was no expert consensus on use of everolimus + hormonal therapy for HR+, HER2- patient cases, whereas in 2013, everolimus-based therapy was recommended by the majority of experts (3 out of 5) for 12 different HR+, HER2- cases. There was no consensus among the experts on the use of pertuzumab + trastuzumab and a taxane for HER2+ MBC in 2012, whereas in 2013 at least 3 out of 5 experts recommended it for a total of 36 HER2+ cases. At least 3 of 5 experts recommended trastuzumab emtansine for 96 different HER2+ cases in 2013 vs 0 in 2012. In both 2012 and 2013, the greatest variability in expert treatment recommendations was observed for HR-, HER2- cases.

Conclusions: An online tool providing expert advice on specific MBC patient scenarios either confirmed or changed the clinical approach for a majority of community practitioners. Decision support tools may increase the number of clinicians who make optimal treatment decisions for patients with MBC, especially when new data, agent indications, and guideline updates must be incorporated. Detailed comparisons of expert and user responses from the 2012 and 2013 decision support tools will be presented.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-12-01.

Abstract P3-13-05: Eribulin mesylate as first-line therapy for locally recurrent or metastatic HER2-negative breast cancer: Results of a phase 2, multicenter, single-arm study

Background: Eribulin mesylate is a novel nontaxane microtubule dynamics inhibitor that is approved for treatment of metastatic breast cancer (MBC) in patients who have previously received at least two chemotherapeutic regimens for MBC. We present final data from a phase 2 study that evaluated the efficacy and safety of eribulin as first-line therapy for HER2-negative (HER2-) MBC.

Methods: Patients with measureable HER2- locally recurrent or MBC with ≥12 months since prior neoadjuvant or adjuvant chemotherapy received eribulin mesylate 1.4 mg/m2 IV on days 1 and 8 of each 3-week cycle. Endpoints included objective response rate (ORR) (primary), safety, progression-free survival (PFS), time to response (TTR), and duration of response (DOR). Tumor assessments were conducted every 6 weeks for the first 6 cycles and every 6-12 weeks thereafter per RECIST 1.1.

Results: Fifty-six patients enrolled and received eribulin. Patients had a median age of 56 years (range 31-85); 32 (57%) had an ECOG status of 0; 17 (30%) had de novo stage IV; 33 (59%) had prior (neo)adjuvant therapy, including anthracycline and/or taxane (A/T) chemotherapy. Thirty-nine patients (70%) had visceral disease (45% liver, 32% lung); 41(73%) had estrogen receptor-positive (ER+) disease and 12 (21%) had triple negative (TN) disease. Thirty-two patients (57%) completed at least 6 cycles of treatment; among the 24 patients who completed fewer than 6 cycles, reasons for not completing were progressive disease (PD; n = 18), adverse events (AEs; n = 3) and patient choice (n = 3). The median number of cycles delivered was 7 (range 1-39); 6 patients (11%) received treatment for ≥12 months. Overall ORR was 27%, with median TTR of 1.4 months and median DOR of 7.4 months; stable disease (SD) rate was 48% (Table 1). Median PFS was 6.8 months. Thirty-five patients (63%) had grade 3/4 treatment-related AEs (Table 2). Treatment-related serious AEs occurred in 5 (9%) patients: neutropenia (5%), febrile neutropenia (5%), and leukopenia (2%).

Conclusions: The results of this study suggest that first-line eribulin has antitumor activity in ER+/HER2- and TN MBC with safety consistent with the known profile. Further exploration of this treatment as part of earlier lines of breast cancer therapy, including neo/adjuvant, is warranted.

Table 1. Summary of EfficacyEfficacyEribulin-treated patients N = 56ORR, n (%)15 (27)CR0PR15 (27)SD27 (48)PD12 (21)Clinical benefit rate (ORR + ≥6 mo SD)27 (48)Median months (95% CI) TTR1.4 (1.2, 2.7)DOR7.4 (4.7, NE)PFS6.8 (4.4, 7.4)NE, not estimable

Table 2. Treatment-Related AEsAE (N = 56)All events (%)Grade 3/4 (%)Leading to study drug withdrawal1111Leading to dose reduction3427Common AEs (≥25%)  Alopecia820Neutropenia7050Fatigue572Peripheral neuropathy5420Nausea460Anemia364Leukopenia3018Constipation270

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-13-05.

Treatment effect of capecitabine and docetaxel or docetaxel alone by oestrogen receptor status in patients with metastatic breast cancer: results of an exploratory analysis

We investigated treatment effects by oestrogen receptor (ER) status among women with metastatic breast cancer (MBC) receiving capecitabine (C) plus docetaxel (D) or D alone in a randomised phase III trial. Data were retrospectively analysed from patients whose disease had recurred following (neo)adjuvant anthracyclines. ER status was identified in 356/506 patients. In patients with ER-positive tumours, median overall survival from enrolment was 17.7 months with CD versus 12.5 months with D (hazard ratio [HR] 0.65, 95% confidence interval [CI]: 0.47-0.89; P = 0.007) and median time to progression (TTP) was 6.8 and 5.4 months, respectively (HR 0.62, 95% CI: 0.46-0.84; P = 0.002). For patients with ER-negative tumours, significantly longer TTP was seen with CD (5.2 versus 3.5 months; HR 0.73, 95% CI: 0.53-0.98; P = 0.038). Whether there is an additional C to D treatment benefit in ER-positive versus ER-negative MBC requires further evaluation.

Phase 2 study of neoadjuvant treatment with NOV-002 in combination with doxorubicin and cyclophosphamide followed by docetaxel in patients with HER-2 negative clinical stage II-IIIc breast cancer

NOV-002 (a formulation of disodium glutathione disulfide) modulates signaling pathways involved in tumor cell proliferation and metastasis and enhances anti-tumor immune responsiveness in tumor models. The addition of NOV-002 to chemotherapy has been shown to increase anti-tumor efficacy in animal models and some early phase oncology trials. We evaluated the clinical effects of NOV-002 in primary breast cancer, whether adding NOV-002 to standard preoperative chemotherapy increased pathologic complete response rates (pCR) at surgery, and determined whether NOV-002 mitigated hematologic toxicities of chemotherapy and whether levels of myeloid derived suppressor cells (MDSC) were predictive of response. Forty-one women with newly diagnosed stages II-IIIc HER-2 negative breast cancer received doxorubicin-cyclophosphamide followed by docetaxel (AC → T) every 3 weeks and concurrent daily NOV-002 injections. The trial was powered to detect a doubling of pCR rate from 16 to 32% with NOV-002 plus AC → T (α = 0.05, β = 80%). Weekly complete blood counts were obtained as well as circulating MDSC levels on day 1 of each cycle were quantified. Of 39 patients with 40 evaluable tumors, 15 achieved a pCR (38%), meeting the primary endpoint of the trial. Concurrent NOV-002 resulted in pCR rates for AC → T chemotherapy higher than previously reported. Patients with lower levels of circulating MDSCs at baseline and on the last cycle of chemotherapy had significantly higher probability of a pCR (P = 0.02). Further evaluation of NOV-002 in a randomized study is warranted.

The effect of age on overall survival (OS) in patients with metastatic breast cancer (MBC) treated with capecitabine

1097

Background: Both in monotherapy and in combination with a taxane, C has been shown to improve OS in patients with MBC. Since C is often used in older adults because of tolerability and ease of administration (PO vs IV), and lack of alopecia, an exploratory analysis was conducted to see if an association exists between age and OS among patients with MBC treated with C. Methods: Data from the intermittent dose (2510 mg/m2) 2 wks on/1 wk off arms of 5 phase II/III monotherapy or combination therapy with C registration trials involving patients with MBC were analyzed. Intent-to-treat (ITT) was defined as all randomized patients who took at least 1 dose of study medication. Patients were divided into 3 groups by age. A Kaplan-Meier method was used to estimate the age-category specific survival by trial. Next, Cox proportional hazard regression analysis was conducted using pooled data from the 5 trials with stratification by trial and key baseline characteristics. Analyses were conducted at the 95% confidence level. Results: A total of 570 ITT patients were included in the analysis (median age 55.0 years; range, 26–83): 193 (34%) were 18–49 years old; 246 (43%) 50–64 years old; and 131 (23%) ≥65 years old. A baseline Karnofsky score ≥90 was observed in 65.3%, 56.5%, and 50.4% of patients, respectively. The median treatment duration (range) was 93.0 (2–397) days in the 18 to 49-year-old group, 109.5 (2–448) days in the 50 to 64-year-old group, and 80.0 (5–371) days in the ≥65-year-old group. Unadjusted log-rank tests for each of the 5 trials showed no significant differences in OS between age categories. In the pooled analysis, Cox regression did not detect significant differences in survival based on age. Using age ≥65 years as the reference group, the hazard ratios were 1.06 (95% CI 0.81, 1.41) for age 18–49 years and 0.99 (95% CI 0.77, 1.29) for age 50–64 years. The Cox model revealed consistent results after further controlling for the Karnofsky score and number of metastatic sites. Conclusions: No statistically significant effect of age on OS was observed in patients with MBC treated with C. OS outcomes appear comparable across predefined age groups of patients with MBC treated with C.

[Table: see text]

Safety and efficacy of pegfilgrastim administration on the same day as myelosuppressive chemotherapy (CT) in women with ovarian or primary peritoneal cancer

16009

Background: According to prescribing information, pegfilgrastim should not be administered within 14 days prior to, or within 24 hours after, the administration of cytotoxic CT. However, little data exist to support this recommendation. The purpose of the current study is to determine the safety and efficacy of administering pegfilgrastim on the same day as myelosuppressive CT in patients with ovarian or primary peritoneal carcinoma. Methods: A retrospective review was conducted of all ovarian and primary peritoneal cancer patients that received prophylactic pegfilgrastim on the same day as CT from May 2003 to June 2006. Results: Forty-six patients (mean age: 57, range: 21–82) were treated for the following malignancies: 35 (76%) epithelial ovarian, 6 (13%) primary peritoneal, and 5 (11.0%) ovarian germ cell or stromal cell carcinoma. Twenty-six patients (56%) had primary cancers and 20 (44 %) had recurrent disease. All patients met the ASCO or NCCN recommendations of using colony-stimulating factors for prophylaxis against febrile neutropenia (FN) (Risk of FN > 20%). A total of 269 cycles of CT were administered including 125 cycles (46.5%) docetaxel + carboplatin, 39 cycles (14.5%) gemcitabine + platinum, 30 cycles (11.1%) intravenous paclitaxel + carboplatin, 28 cycles (10.4%) liposomal doxorubicin, 19 cycles (7.1%) paclitaxel + intraperitoneal platinum, 6 cycles (2.2%) docetaxel, 6 cycles (2.2%) liposomal doxorubicin + cisplatin, 5 cycles (2%) bleomycin + etoposide + cisplatin, 4 cycles (1.5%) topotecan, 3 cycles (1.1%) of paclitaxel, 2 cycles (0.7%) vincristine + actinomycin-D + cyclophosphamide, and 2 cycles (0.7%) docetaxel + gemcitabine. All patients received pegfilgrastim within one hour of the completion of CT administration. Grade 1 or 2 neutropenia developed in 10 cycles (3.7%) out of the 269 cycles, mean absolute neutrophil count = 4926 (range, 1293 -24300). No patients had FN episodes, hospitalizations or antibiotic use secondary to neutropenia, or dose-reductions and CT delays due to neutropenia. Conclusions: Administration of pegfilgrastim on the same day as CT in ovarian and primary peritoneal cancer patients is more convenient to the patient and appears safe and effective.

No significant financial relationships to disclose.

Evaluation of sICAM-1, sVCAM-1, and sE-Selectin levels in patients with metastatic breast cancer receiving high-dose chemotherapy

Soluble forms of some cell adhesion molecules (CAM), sICAM-1, sVCAM-1, and sE-selectin, are elevated in the sera and plasma of patients with inflammation, arthritis, diabetes, and cancer. Increased levels of these soluble molecules in patients with cancer have been shown to correlate with disease progression and survival. This suggests that increased expression of the soluble forms of CAMs may play an important role in cancer cell growth and metastasis and may be prognostic and/or predictive of malignant disease. In this retrospective study, we assessed the clinical significance of sICAM-1, sVCAM-1, and sE-selectin in 95 patients with metastatic breast cancer enrolled in clinical trials of high-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT). The significance of soluble HER-2 (sHER-2) and sFAS status, determined in previous studies for this group of patients, was also included in this analysis. Univariate analysis showed that sICAM-1, sVCAM-1, sFas, sHER-2 positive status, and the presence of liver metastases were significant prognostic factors for both progression-free survival (PFS) and overall survival (OS) in the total patient group. In multivariable analysis, HER-2 and sFAS were shown to be independent prognostic factors for PFS and OS. Within the various treatment groups examined, sICAM-1 was a prognostic factor for clinical outcome for patients with metastatic breast cancer enrolled in trials with cyclophosphamide- and carboplatin-based or vinblastine-based HDC, but not in trials with paclitaxeland cyclophosphamide-based HDC.

The role of depletion of dimethyl sulfoxide before autografting: on hematologic recovery, side effects, and toxicity

Cryopreservation of stem cells after collection from peripheral blood or bone marrow for autologous transplantation necessitates protection with dimethyl sulfoxide (DMSO). Unfortunately, DMSO, when infused with the thawed cell suspension, may induce serious complications and side effects. To assess whether depletion of DMSO before autografting affects safety and efficacy, 56 consenting consecutive patients treated with high-dose chemotherapy and autologous blood stem cell transplantation were assigned to obtain either an untreated or DMSO-depleted autograft. On the day of transplantation, the cryopreserved cells were thawed and infused to the patient either immediately or after washing 3 times in normal saline supplemented with 6% anticoagulant citrate dextrose solution. Cell count with viability, clonogenic assay, and phenotyping were performed before and after thawing and after washing. Hematologic recovery, side effects, and complications were recorded. The in vitro and clinical data on 56 patients show that the depletion of DMSO in vitro before autografting does not induce a significant loss of cell number, viability, colony-forming unit-granulocyte-macrophage activity, or number of CD34(+) cells. Furthermore, it leads to a safe and sustained engraftment. The complications and side effects, as recorded by continuous monitoring, were substantially less; however, the procedure takes 3 to 4 hours of laboratory work per patient.

Micrometastases in apheresis products predict shorter progression-free and overall survival in patients with breast cancer undergoing high-dose chemotherapy (HDCT) and autologous blood stem cell transplantation (ABSCT)

The presence of cancer cells in autografts of breast cancer patients has been described to have prognostic value or directly lead to relapse. Previously, we demonstrated that apheresis products (APs) collected after induction chemotherapy have a significantly lower likelihood of tumor cell contamination. Here, we examine the prognostic value of micrometastases in autografts. Data from 83 patients with breast cancer treated with autologous blood stem cell transplantation were analyzed. Pan-cytokeratin-FITC conjugated antibodies were used to detect contaminating breast cancer cells in the APs. Progression and survival data analyzed on the basis of three or fewer cancer cells showed no significant differences in outcomes. Of the 83 patients, 11 had more than three cancer cells detectable in their APs. In total, 72 patients were shown to have less than three cells detectable. When patients with more than three cells were compared to patients with 0-3, we found statistically significant differences in progression-free survival. We also found a significant difference in overall survival (OS) between the two groups. No difference was observed in OS since the time of diagnosis. We conclude that patients with more than three contaminating cells in their APs have micrometastases and represent a poor prognosis group.

[Sentinel lymph node biopsy in breast cancer patients--results and experience after 500 sentinel lymph node biopsies]

INTRODUCTION

Sentinel lymph node biopsy (SLNB) is a widely used technique for axillary staging in breast cancer patients. The principle to evaluate the axillary status of a breast cancer patient with a less invasive surgery than axillary lymph node dissection (ALND) meets the new minimally invasive concept in breast cancer surgery. Some breast cancer centers proceed to SLNB without ALND in SLN-negative patients.

PATIENTS AND METHODS

Between March 1998 and March 2002, 500 SLNBs were performed. After a learning period with SLNB and ALND in 75 patients with a sensitivity of 96.2% and a false-negative rate of 3.8%, SLNB alone without further ALND was performed in a group of patients. In addition, the feasibility of SLNBin patients with locally advanced breast cancer, in patients after neoadjuvant chemotherapy and in patients with multicentricity was evaluated. The combined method with blue dye and technetium-99m-labeled human albumin for identification of SLNs was applied.

RESULTS

500 SLNBs were performed. The identification rate was 86.2%. After exclusion of patients with neoadjuvant chemotherapy and patients with multicentricity, the identification rate was 94.5%. SLNs were positive in 41.3% of patients and negative in 58.7% of patients.

DISCUSSION

SLNB is an excellent method for axillary stag-ing and an alternative for ALND in a certain group of breast cancer patients.

High-dose thiotepa, busulfan, cyclophosphamide and ASCT without whole-brain radiotherapy for poor prognosis primary CNS lymphoma

Treatment of primary central nervous system lymphoma (PCNSL) with combined high-dose methotrexate (HD-MTX)-based chemotherapy and whole-brain radiotherapy (WBRT) is associated with severe neurotoxicity, but high relapse rates are associated with the use of either modality alone. In an attempt to improve upon these dismal results, we treated seven PCNSL patients with HD-MTX-based induction therapy followed by thiotepa, busulfan, cyclophosphamide (TBC), and autologous stem cell transplant (ASCT), without WBRT. Six of these patients had at least one of the following poor prognostic features: Karnofsky performance status (KPS) <or=50%, age >60 years, or relapsed disease. All but one patient tolerated the treatment well and experienced improvements in neurological function and overall performance status post-transplant. No treatment-induced neurotoxicity (dementia, ataxia, and incontinence) was observed although the follow-up is short. One early treatment-related death occurred in a patient with multiple comorbid medical conditions. The other six patients achieved a complete response (CR) after TBC and ASCT. Five patients are currently alive and relapse-free at 5, 8, 24, 36, and 42 months from diagnosis. One additional patient relapsed and died 33 months after diagnosis. Two of the seven patients received TBC/ASCT as the only treatment after disease progression following their initial chemotherapy and both remain relapse-free at the time of this report, 22 and 31 months post-TBC/ASCT. In conclusion, prolonged CR can be attained after chemotherapy-only treatment of poor prognosis PCNSL. Furthermore, this small series suggests that high-dose chemotherapy for PCNSL should include drugs that penetrate the CNS such as busulfan and thiotepa rather than standard lymphoma regimens such as BEAM.

Storage of blood for in vitro generation of dendritic cells

BACKGROUND

Since the development of techniques to cultivate DC from peripheral blood, there has been a great deal of interest in the use of these cells in immunotherapeutic strategies. In a clinical setting, delays often occur between when blood is drawn and when it is processed. We therefore investigated the effect of overnight storage on the yield, morphology and phenotype of DC cultured from the peripheral blood of healthy volunteers.

METHOD

Blood was processed either immediately, or after storage for 24 h in the fridge (4 degrees C) or at room temperature (RT, 20 degrees C). Samples were compared for starting cell number, DC yield and characteristics (morphology and phenotype).

RESULTS

The number of PBMC that could be obtained was significantly lower from the refrigerated samples compared with both the freshly processed sample and that stored at RT. Samples processed after overnight storage at RT yielded cells morphologically identical to DC cultured from freshly processed samples. Only when samples were both stored and processed cold did the cultured cells not have typical DC morphology. DC cultured from the refrigerated samples showed a significant reduction in MHC II expression compared with samples processed fresh or stored at RT. This expression increased slightly when the sample was first warmed. Total DC yield and the percentage yield of cultured DC was not significantly different for any of the groups.

DISCUSSION

We conclude that, if immediate processing of blood for in vitro generation of DC is not possible, samples should be stored at room temperature (approximately 20 degrees C).

Unrelated donor BMT recipients given pretransplant low-dose antithymocyte globulin have outcomes equivalent to matched sibling BMT: a matched pair analysis

Fifty-seven patients receiving unrelated donor (UD) BMT were matched for disease and stage with 57 recipients of genotypically matched related donor (MRD) BMT. All UD recipients were matched serologically for A and B and by high resolution for DR and DQ antigens. All patients received CsA and 'short course' methotrexate with folinic acid. Unrelated donor BMT patients also received thymoglobulin 4.5 mg/kg (6 mg/kg if <30 kg) in divided doses over 3 days pretransplant. For UD and RD BMT, respectively, incidence of acute GVHD grade II-IV was 19 +/- 6% vs 36 +/- 8%, grade III-IV 10 +/- 6% vs 18 +/- 7%, chronic GVHD 44 +/- 8% vs 51 +/- 8%, non-relapse mortality 15 +/- 5% vs 8 +/- 4% at 100 days, 28 +/- 8% vs 36 +/- 7% at 3 years. At 3 years, relapse was 45 +/- 7% vs 42 +/- 7%, and disease-free survival 39 +/- 7% vs 37 +/- 7%. None of these differences are significant. Three-year overall survival was identical at 42 +/- 7%. For 29 patients with low/intermediate risk leukemia, disease-free survival was 68 +/- 10% after UD BMT vs 59 +/- 9% for RD BMT recipients (P = NS). Corresponding figures for high risk patients were 14 +/- 7% and 21 +/- 8%, respectively. We conclude that UD BMT recipients matched as above and given pretransplant ATG have similar outcomes to recipients of MRD BMT using conventional drug prophylaxis. Unrelated donor BMT should be considered in any circumstance where MRD BMT is routine.

Successful treatment of post-transplant lymphoproliferative disorder in autologous blood stem cell transplant recipients

We report three cases of post-transplant lymphoproliferative disorder (PTLD) in the context of autologous stem cell transplantation (ASCT) for multiple myeloma (MM) and non-Hodgkin's lymphoma. The first two cases received ASCT for MM, one with a CD34-selected autograft and the other with an unmanipulated autograft. Both these cases of PTLD achieved a complete response following treatment with IVIG, gancyclovir, solumedrol and interferon (IFN). The third case received ASCT with an unmanipulated autograft for relapsed angioimmunoblastic lymphoma. He also achieved a complete response but only after rituximab was added to IVIG, gancyclovir, solumedrol and IFN. None of these patients experienced a relapse of their PTLD with follow-up ranging from 1.5 to 5 years. These cases highlight the importance of considering PTLD in the differential diagnosis of lymphadenopathy and fever post ASCT. They also demonstrate the possibility of durable complete remission of post-ASCT PTLD following antiviral and immune modulating therapy.

The worldwide perspective in the adjuvant treatment of primary lymph node positive breast cancer

Adjuvant treatment of early breast cancer has experienced major changes in the last 25 years. Since the mid 1970s when cyclophosphamide, methotrexate and 5-fluorouracil (CMF) resulted in statistically significant and clinically meaningful improvements in disease-free and overall survival, the use of adjuvant chemotherapy has become common practice worldwide. Anthracyclines have long been considered to be among the most active available agents to treat breast cancer and they have become a core component of adjuvant regimens. Anthracycline-containing polychemotherapy regimens provide a significant benefit over CMF. Regimens containing epirubicin are associated with a significant prolongation in relapse-free and overall survival rates compared with standard therapies including CMF. Epirubicin-taxane combinations are highly active in treating metastatic breast cancer and do not appear to be associated with any pharmacokinetic interactions. Epirubicin is a unique anthracycline whose introduction to the US market represents a significant advance in breast cancer treatment. Ongoing research efforts are focusing on combining anthracyclines with taxanes in an effort to continue to improve outcomes following adjuvant therapy.

Soluble Fas (CD95) is a prognostic factor in patients with metastatic breast cancer undergoing high-dose chemotherapy and autologous stem cell transplantation

The Fas/Fas ligand (FasL) system plays an important role in cellular apoptosis and is involved in cancer cell death induced by the immune system and anticancer drugs. Increased serum levels of soluble Fas (sFas) are associated with a number of different disease states and with tumor progression and metastasis in patients. In this study, we examined the plasma levels of sFas in 94 women with metastatic breast cancer undergoing high-dose chemotherapy (HDCT) treatment with autologous stem cell transplantation (ASCT) using a quantitative enzyme-linked immunosorbent assay (ELISA) method. Thirty-one patients (31/94, 33%) had plasma sFas levels greater than the optimum cut point of 1.90 ng/ml (median 2.47, range 1.98-13.54 ng/ml) and were designated as sFas positive. Sixty-three patients (63/94, 67%) had sFas levels below 1.90 ng/ml (median 1.14, range 0.47-1.89 ng/ml). In univariate analysis, patients with sFas-positive status, HER-2 overexpression, and the presence of liver metastases had a significantly shorter time to disease progression (PFS) and significantly decreased overall survival (OS). Multivariable analysis (Cox proportional hazards model) for PFS determined that sFas status significantly predicted disease progression (p = 0.004) with an adjusted hazard ratio (HR) of 2.0 (95% CI, 1.3-3.3). HER-2 status and liver metastases were also significant independent predictors of disease progression (p < 0.001) for both. sFas level was also an independent prognostic factor for OS with an adjusted HR of 2.0 (p = 0.006; 95% CI, 1.2-3.4). HER-2 status and liver metastases also remained highly significant independent prognostic factors for OS (HER-2: p < 0.001, HR 2.3, and liver metastases: p = 0.001, HR 2.7). In conclusion, these results suggest that plasma levels of sFas may be a valuable clinical prognostic factor in predicting outcome (PFS and OS) for patients with metastatic breast cancer undergoing HDCT with ASCT.

Generation of dendritic cells ex vivo: differences in steady state versus mobilized blood from patients with breast cancer, with lymphoma, and from normal donors

Dendritic cells (DC) are potent antigen-presenting cells that are integral to the initiation of T cell immunity. The ability to culture these cells in vitro has allowed DC immunotherapy to be investigated as a mechanism of enhancing immune responses against various malignancies. We examined the optimal time for generating DC and compared DC generated from normal donors for allogeneic blood stem cell transplantation, or patient's with non-Hodgkin's lymphoma or breast cancer undergoing high-dose chemotherapy and autologous stem cell transplantation. Experiments were conducted to compare DC cultured prior to and post mobilization chemotherapy. Blood was obtained from consenting patients prior to granulocyte colony-stimulating factor (G-CSF) administration with (non-Hodgkin lymphoma and breast cancer) or without (normal donors) chemotherapy. A sample of apheresis product (AP) was obtained at the time of apheresis. DC were generated from peripheral blood mononuclear cells by culturing the adherent cells in the presence of interleukin-4 and granulocyte-macrophage colony-stimulating factor. Resultant DC were harvested and examined for yield, morphology, phenotype, and function. All cell populations yielded highly pure DC, as assessed by light microscopy and flow cytometry. The average cellular yield was significantly greater from AP than steady-state blood in paired and unpaired samples. Yield did not correlate with the percentage of CD14(+) cells, and it negatively correlated with CD34 counts. DC from breast cancer patients functioned significantly better than DC from lymphoma patients in a mixed lymphocyte reaction. These data suggest that the optimal timing of culturing DC is after mobilization, and that differences may exist in the functional capabilities of DC derived from different patient populations.

Dendritic cell-based therapy: a review focusing on antigenic selection

Recently, technologies have developed that allow for the culturing of antigen-presenting cells (APC), such as dendritic cells (DC). The normal function of these cells is to present antigens to T cells, which then specifically recognize and ultimately eliminate the antigen source. Over the past number of years, these cells have been used in a variety of different immunotherapeutic strategies. Paramount in the success of such endeavors is the generation of desired T cell responses through the selection of appropriate antigens. This paper will serve to discuss the development and current status of dendritic cell-based therapy focusing on antigen selection for cancer.

The CD3- 16+ 56+ NK cell count independently predicts autologous blood stem cell mobilization

Better predictive factors for autologous blood stem cell mobilization (BSCM) are needed. The purpose of this study was to determine if an independent association exists between lymphocyte or NK cell counts and BSCM. Data were analyzed on 141 consecutive patients aged 19-69 years (median 45) who received combined chemotherapy plus G-CSF for BSCM, and who had measurements of immune cells prior to BSCM. Of the 141 patients, 41% had breast cancer, 14% Hodgkin's disease, 34% non-Hodgkin's lymphoma, and 11% other diagnoses. BSCM involved dose-intensive cyclophosphamide, etoposide, cisplatin (DICEP) plus G-CSF 300 microg (<70 kg) or 480 microg (>70 kg) for 45% of patients, while the remaining 55% received other chemotherapy plus similar doses of G-CSF. Only a single apheresis was performed for 94% of patients. The following factors were analyzed for predictors of BSCM: age, gender, prior chemotherapy, prior radiotherapy, diagnosis, disease status, marrow involvement, mobilization regimen, Hb, WBC, platelet count, B cell, T cell, and NK cell counts. The peripheral blood CD34+ counts on the first day of apheresis (PBCD34) were 6-1783 x 10(6)/l (median 150). The PBCD34 count correlated strongly with the number of CD34+ cells collected/l blood apheresed and with the number of CD34+ cells collected/kg. By multivariate analysis using continuous variables, relapsed status (P = 0.0003), not using DICEP mobilization (P = 0.0001), female gender (P = 0.0057), low platelet count (P = 0.051), and low CD3- 16+ 56+ count (P = 0.0158) were associated with low PBCD34 counts. Using categorical variables, the only factors that independently predicted a PBCD34 count <150 x 10(6)/l were: >1 prior chemotherapy regimen (odds ratio = 5.12, P = 0.0003), not using DICEP mobilization (odds ratio = 4.94, P = 0.0001), and CD3- 16+ 56+ count <125 x 10(6)/l (odds ratio= 2.58, P = 0.0157). In conclusion, the CD3- 16+ 56+ count may be a useful additional predictor of BSCM and warrants further study.

Longitudinal effects of high-dose chemotherapy and autologous stem cell transplantation on quality of life in the treatment of metastatic breast cancer

This study determined the effects of high-dose chemotherapy (HDCT) with autologous blood stem cell transplantation (ASCT) on quality of life (QL) in women with metastatic breast cancer prior to, and during treatment, and up to 1-year post-ASCT. Thirty-three women diagnosed with metastatic breast cancer participated in a phase 1 clinical trial of a new combination of cyclophosphamide (CTX) and mitoxantrone (MXT), with dose escalation of paclitaxel. Longitudinal QL data were collected using the functional living index-cancer (FLIC) and symptom scales at seven time periods: pre-induction chemotherapy (CT), post-induction CT, post-high dose CT (HDCT), and at 3, 6, 9 and 12 months post-ASCT. FLIC scores indicated that the worst problems for patients were feelings of hardship on themselves and their families, followed by psychological functioning and physical functioning problems. The time around diagnosis of the metastatic disease and following HDCT were the worst times for all levels of quality of life, but anxiety and depression symptoms continued to increase in severity across the entire follow-up period. The symptoms that were most problematic were worry about the future, loss of sexual interest, anxiety about the treatment, general worrying, and joint pain. These data highlight the problems that women with metastatic breast cancer encounter at different stages of the disease and treatment process, and can be used to tailor psychosocial interventions appropriate for treating the relevant issues at different points in time.

HER-2 expression is a prognostic factor in patients with metastatic breast cancer treated with a combination of high-dose cyclophosphamide, mitoxantrone, paclitaxel and autologous blood stem cell support

The expression levels of a circulating extracellular domain of HER-2 can be detected in the plasma and serum of patients with metastatic breast cancer using an enzyme immunoassay (ELISA) method. In this study, we evaluated the clinical significance of high and low levels of HER-2 in the plasma of 46 patients with metastatic breast cancer enrolled in a clinical trial of high-dose chemotherapy (HDCT) using cyclophosphamide, mitoxantrone, and paclitaxel with autologous stem cell transplantation (ASCT). Using 2500 U/ml as the cut-point, 20 patients (46%) had elevated HER-2 levels (HER-2 positive). Our results suggest that patients with metastatic breast cancer and high soluble plasma HER-2 have a significantly poorer overall (OS) and progression-free survival (PFS) following high-dose chemotherapy with paclitaxel and ASCT. The median OS of patients with low levels of HER-2 was significantly longer (P < 0.01) than the median OS of patients with high levels of HER-2 (29.8 months vs 15.9 months). PFS was also significantly longer (P < 0.01) for patients who were HER-2-negative, than for patients who were HER-2-positive (13.0 vs 8.6 months). Univariate analysis showed that patients with liver or lung metastases had significantly reduced OS and PFS. Patients with metastases to two or more sites also had a significantly reduced time to disease progression, but not OS. In multivariable analysis, lung metastases contributed along with HER-2-positive status to determine a group of patients with significantly poorer OS. However, HER-2-positive status remained the only independent predictor of PFS.

Generation of dendritic cells: role of cytokines and potential clinical applications

Over the last decade there has been great interest in generating populations of antigen presenting cells (APC), which can be exploited to improve immune responses to a variety of diseases including malignancies. Dendritic cells (DC) are an APC population that are easily generated ex vivo using a variety of cytokines. Cytokines can also be used to further manipulate these cells in maturation and function. The following discussion will provide an overview of dendritic cell isolation and generation with a focus on the role cytokines play in this process.

Effects of cytokines on the culture and differentiation of dendritic cells in vitro

The ability to culture dendritic cells (DC) in vitro has been integral to the dramatic increase in research in the area of immunotherapy. Over time, a number of methods for generating these cells have been developed. This article will provide an overview of the isolation and generation of DC and will give a detailed description of the role specific cytokines play in this process from the mobilization of precursors to the final maturation of DC.

Predictive factors for long-term engraftment of autologous blood stem cells

Data from 170 consecutive patients aged 19-66 years (median age 46 years) who underwent unmanipulated autologous blood stem cell transplant (ASCT) were analyzed to determine if total CD34+ cells/kg infused, CD34+ subsets (CD34+41+, CD34+90+, CD34+33-, CD34+38-, CD34+38-DR-), peripheral blood CD34+ cell (PBCD34+) count on first apheresis day, or various clinical factors were associated with low blood counts 6 months post ASCT. Thirty-four patients were excluded from analysis either because of death (n = 17) or re-induction chemotherapy prior to 6 months post ASCT (n = 13), or because of lack of follow-up data (n = 4). Of the remaining 136 patients, 46% had low WBC ( < 4 x 10(9)/l), 41% low platelets (<150 x 10(9)/l), and 34% low hemoglobin ( < 120 g/l) at a median of 6 months following ASCT. By Spearman's rank correlation, both the total CD34+ cell dose/kg and the PBCD34+ count correlated with 6 month blood counts better than any subset of CD34+ cells or any clinical factor. The PBCD34+ count was overall a stronger predictor of 6 month blood counts than was the total CD34+ cells/kg infused. Both factors retained their significance in multivariate analysis, controlling for clinical factors. In conclusion, subsets of CD34+ cells and clinical factors are inferior to the total CD34+ cell dose/kg and PBCD34+ count in predicting 6 month blood counts following ASCT.

Current status of high dose chemotherapy in breast cancer

To date, no definite answers are available to the initial question, whether or not HDCT and ASCT can improve quantity or quality of life. Completing the available prospective, randomized phase III studies; using HDCT earlier in the course of treatment; applying drugs that are active breast cancer; comparing the experimental treatment to standard therapy; and using appropriate sample size to detect clinically meaningful and statistically significant differences are all paramount requirements to answer the question successfully. Within the next few years, a number of European [13] and two Canadian Studies [6, 14] that are currently accruing patients, will contribute versus important information regarding the role of HDCT and ABMT for breast cancer.

Double high-dose therapy for Hodgkin's disease with dose-intensive cyclophosphamide, etoposide, and cisplatin (DICEP) prior to high-dose melphalan and autologous stem cell transplantation

We previously reported a 50% (95% CI = 33-76%) 5 year event-free survival (EFS) rate for 23 patients with Hodgkin's disease (HD) who received salvage therapy with single agent high-dose melphalan (HDM) and autologous stem cell transplantation (ASCT). Predictors of poor outcome included bulky disease and initial remission <1 year. Since 1995, similar poor prognosis patients have been treated with double high-dose therapy consisting of dose-intensive cyclophosphamide 5.25 g/m2, etoposide 1.05 g/m2, cisplatin 105 mg/m2 (DICEP) for tumor cytoreduction and stem cell mobilization followed by HDM/ASCT. The purpose of the present study is to determine if the use of DICEP is associated with improved event-free (EFS) and overall survival (OAS) for patients treated with HDM/ASCT. From February 1981 to June 1999, 46 consecutive patients received HDM/ASCT for relapsed (n = 35) or refractory (n = 11) HD. DICEP re-induction and blood stem cell mobilization was used for 21 patients. Factors considered for univariate and multivariate analyses included age at transplant, number of failed chemotherapy regimens, prior radiotherapy, length of initial remission, relapsed or refractory disease status, extranodal relapse, B symptoms at relapse, bulk, post-ASCT radiotherapy, and DICEP re-induction therapy. Cox proportional hazards models were constructed for both event and death. DICEP and HDM were well tolerated with no early treatment-related mortality or toxicity requiring life-sustaining measures. For all 46 patients, the projected 5 year EFS was 52% (95% CI = 38-72%) and OAS was 57% (95% CI = 40-82). Factors independently associated with relapse in multivariate analysis included bulk >5 cm (RR = 6.38, P = 0.002), prior radiotherapy (RR = 3.59, P = 0.027), and not using DICEP (RR = 5.29, P = 0.005). Factors independently associated with death included bulk >5 cm (RR = 5.13, P = 0.009), > or =3 prior chemotherapy regimens (RR = 4.72, P = 0.019), and not using DICEP (RR = 7.49, P = 0.015). This study demonstrates that DICEP re-induction prior to HDM/ASCT is feasible. The preliminary data are sufficiently encouraging to warrant a multicenter phase II or a phase III trial evaluating DICEP followed by HDM/ASCT as salvage therapy for HD.

Bacterial decontamination of blood stem cell apheresis products

High-dose chemotherapy using autologous bone marrow or mobilized blood as the source of stem cells for haematologic rescue, is being widely used for a variety of haematological malignancies and solid tumours. To collect sufficient numbers of haematopoietic stem cells for successful engraftment, standard apheresis procedures are performed. Newer techniques and refinements of the procedure allow using only 1 to 2 apheresis products (AP) for autografting. Bacterial contamination of the AP, although very rare, sometimes occurs and may lead to generalized infection in the recipient. The apheresis must be repeated, sometimes even including time-consuming and costly mobilization. At our institution, the patients' blood stem cells are usually mobilized with chemotherapy followed by daily s.c. haematopoietic growth factor injections or with growth factor alone. An apheresis machine is used for collection through a central venous line and the AP is routinely checked for bacterial contamination. Results are only available after the product has been processed and cryopreserved. In the last 5 years, we observed bacterial contamination in four of our AP. Therefore, we investigated the possibility of in vitro antibiotic decontamination. Using standard antibiograms, we determined the sensitivities of the contaminating bacteria. By incubating the products with the specific antibiotics at bactericidal concentrations, we were able to sterilize the probes from the contaminating bacteria. In the concurrently performed controls without the active substance, bacteria were still detectable. We conclude that in selected cases, in vitro decontamination using pretested antibiotics, may be a feasible, cost-effective, and easy alternative to performing additional apheresis procedures.

High-dose therapy in breast cancer: out of favor but not out of promise

The evidence for use of high-dose chemotherapy and autologous stem cell transplantation for breast cancer still remains inconclusive at best. A number of prospective randomized phase III studies have been either published or presented recently or are underway in North America and Europe. It will be crucial to complete the available prospective randomized phase III study and obtain the data when all studies reach a mature status. Only then will level I evidence become available to determine the efficacy and effectiveness of high-dose chemotherapy and autologous stem cell transplantation in breast cancer. Bone Marrow Transplantation (2000).

What's happening? Current status of high dose chemotherapy in breast cancer

To date, no definite answers are available to the initial question, as to whether or not HDCT and ASCT can improve the quantity or quality of life. Completing the available prospective, randomized phase III studies; using HDCT earlier in the course of treatment, applying drugs that are active against breast cancer, comparing the experimental treatment to standard therapy, and using appropriate sample size to detect clinically meaningful and statistically significant differences are all paramount requirements to answer the question successfully. Within the next few years, a number of European [13] and two Canadian studies [6,14] that are currently accruing patients, will contribute important information regarding the role of HDCT and ABMT for breast cancer.