Case Report: Circulating Myeloid-Derived Suppressive-Like Cells and Exhausted Immune Cells in Non-Small Cell Lung Cancer Patients Treated With Three Immune Checkpoint Inhibitors

Immune checkpoint inhibition induced a great step forward in the treatment of non-small cell lung cancer patients. In cancer immune microenvironment many checkpoints were studied and their involvement could represent a mechanism of resistance to cancer immunotherapy. For this reason, the inhibition of multiple immune checkpoints is under development. However, myeloid-derived suppressor cells (MDSC) and exhausted immune cells could limit the efficacy of cancer immunotherapy. We analyzed the variation of circulating immune suppressive-like cell subsets and exhausted immune cells in three non-small cell lung cancer patients treated with the combination of anti-CTLA-4 plus anti-PD-1 plus anti-LAG-3 at T0 (baseline), T1 (after 2 months) and T2 (after 4 months). We also describe the clinical and radiological course of the disease during this treatment in all three patients. We observed both clinical differences and changes in the composition of immune suppressive-like cell subsets and exhausted immune cells between the patients receiving the same schedule of treatment with immune checkpoint inhibitors. The study on a wider patient population and experimental model design could help to clarify the kinetics of these cell subpopulations with the perspective to find new targets for treatment or new biomarkers for resistance to cancer immunotherapy.

Aromatase inhibitors and anti-synthetase syndrome

Adjuvant therapy in postmenopausal women with endocrine-responsive breast cancer (BC) is actually centered on the use of anti-aromatase inhibitors (AI). Several reports, however, are emerging in literature associating the use of this drugs to rheumatic disorders. This case report describes the first case of anti-synthetase syndrome diagnosis after treatment with anti-estrogen agents in a patient with pre-existing rheumatoid arthritis.

Adjuvant therapy in resected pancreatic cancer: A systematic review of literature with meta-analysis of randomized clinical trials

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Background: To assess the role of adjuvant treatments (AT), adjuvant chemotherapy (AC) and adjuvant chemo-radiotherapy (ACR) in resected pancreatic adenocarcinoma.

Methods: A systematic review of literature in the MEDLINE and EMBASE data bases from 1966 to 2011 was independently performed by two authors (FD and DT). All the randomized phase III trials investigating the role of AT in radically resected pancreatic cancer were considered eligible and included into the pooled analysis. 5-year-survival rate in patients treated with AT was the primary end point of the trial, 5-year-survival rate of patients treated with AC and ACR, and the 5-year-survival number needed to treat (NNT) of AT, AC and ACR were the secondary ones.

Results: The outcomes of 1402 patients enrolled in 8 trials were compared in the pooled analysis. 816 patients were treated with AT (540 with AC and 276 with ACR), and 586 were enrolled in the control arm (no adjuvant treatment). Significant improve in 5-year-survival rate was observed for AT and AC (odds ratio of 0.636, p<0.05 and 0.422, p<0.01 respectively), but not for ACR (odds ratio=1.139, p=0.489), with a 5-year survival NNT of 20, 10 and 38 respectively for AT, AC and ACR. Low to moderate heterogeneity between the trials was documented both for AT (I2=58%) and AC (I2=31.63%), but not for ACR (I2=0%,).

Conclusions: Our data confirm that adjuvant chemotherapy improves the 5-year survival rate in radically resected cancer patients and gemctabine based regimens seem to be better than FU based regimens.

Perturbation of cytochrome P450, generation of oxidative stress and induction of DNA damage in Cyprinus carpio exposed in situ to potable surface water

Epidemiological evidence suggests a link between consumption of chlorinated drinking water and various cancers. Chlorination of water rich in organic chemicals produces carcinogenic organochlorine by-products (OBPs) such as trihalomethanes and haloacetic acids. Since the discovery of the first OBP in the 1970s, there have been several investigations designed to determine the biological effects of single chemicals or small artificial OBP combinations. However, there is still insufficient information regarding the general biological response to these compounds, and further studies are still needed to evaluate their potential genotoxic effects. In the current study, we evaluated the effect of three drinking water disinfectants on the activity of cytochrome P450 (CYP)-linked metabolizing enzymes and on the generation of oxidative stress in the livers of male and female Cyprinus carpio fish (carp). The fish were exposed in situ for up 20 days to surface water obtained from the Trasmene lake in Italy. The water was treated with 1-2 mg/L of either sodium hypochlorite (NaClO) or chlorine dioxide (ClO2) as traditional disinfectants or with a relatively new disinfectant product, peracetic acid (PAA). Micronucleus (MN) frequencies in circulating erythrocytes from the fish were also analysed as a biomarker of genotoxic effect. In the CYP-linked enzyme assays, a significant induction (up to a 57-fold increase in the deethylation of ethoxyresorufin with PAA treatment) and a notable inactivation (up to almost a 90% loss in hydroxylation of p-nitrophenol with all disinfectants, and of testosterone 2beta-hydroxylation with NaClO) was observed in subcellular liver preparations from exposed fish. Using the electron paramagnetic resonance (EPR) spectroscopy radical-probe technique, we also observed that CYP-modulation was associated with the production of reactive oxygen species (ROS). In addition, we found a significant increase in MN frequency in circulating erythrocytes after 10 days of exposure of fish to water treated with ClO2, while a non-significant six-fold increase in MN frequency was observed with NaClO, but not with PAA. Our data suggest that the use of ClO2 and NaClO to disinfect drinking water could generate harmful OBP mixtures that are able to perturb CYP-mediated reactions, generate oxidative stress and induce genetic damage. These data may provide a mechanistic explanation for epidemiological studies linking consumption of chlorinated drinking water to increased risk of urinary, gastrointestinal and bladder cancers.

Glucoraphanin, the bioprecursor of the widely extolled chemopreventive agent sulforaphane found in broccoli, induces phase-I xenobiotic metabolizing enzymes and increases free radical generation in rat liver

Epidemiological and animal studies linking high fruit and vegetable consumption to lower cancer risk have strengthened the belief that long-term administration of isolated naturally occurring dietary constituents could reduce the risk of cancer. In recent years, metabolites derived from phytoalexins, such as glucoraphanin found in broccoli and other cruciferous vegetables (Brassicaceae), have gained much attention as potential cancer chemopreventive agents. The protective effect of these micronutrients is assumed to be due to the inhibition of Phase-I carcinogen-bioactivating enzymes and/or induction of Phase-II detoxifying enzymes, an assumption that still remains uncertain. The protective effect of glucoraphanin is thought to be due to sulforaphane, an isothiocyanate metabolite produced from glucoraphanin by myrosinase. Here we show, in rat liver, that while glucoraphanin slightly induces Phase-II enzymes, it powerfully boosts Phase-I enzymes, including activators of polycyclic aromatic hydrocarbons (PAHs), nitrosamines and olefins. Induction of the cytochrome P450 (CYP) isoforms CYP1A1/2, CYP3A1/2 and CYP2E1 was confirmed by Western immunoblotting. CYP induction was paralleled by an increase in the corresponding mRNA levels. Concomitant with this Phase-I induction, we also found that glucoraphanin generated large amount of various reactive radical species, as determined by electron paramagnetic resonance (EPR) spectrometry coupled to a radical-probe technique. This suggests that long-term uncontrolled administration of glucoraphanin could actually pose a potential health hazard.

CYP superfamily perturbation by diflubenzuron or acephate in different tissues of CD1 mice

This work aimed to investigate whether the insecticide acephate (125 or 250 mg/kg b.w.) or diflubenzuron (752 or 1075 mg/kg b.w.), two of the most widely used pesticides worldwide, impairs CYP-linked murine metabolism in liver, kidney and lung microsomes after repeated (daily, for three consecutive days) i.p. administration. The regio- and stereo-selective hydroxylation of testosterone was used as multibiomarker of different CYP isoforms. Both gender and tissue specific effects were observed. Lung was the most responsive tissue to induction by lower diflubenzuron dose, as exemplified by the marked increase of testosterone 7alpha-hydroxylation (CYP2A) (up to 13-fold) in males. Higher dose produced a generalized inactivation. At the lower dose acephate induced 6beta- (CYP3A1/2, liver) as well as 2beta- (CYP2B1/2, kidney) hydroxylase activities ( approximately 5 and approximately 4-fold increase, respectively) in males. In females, a marked suppression of the various hydroxylations was observed. At 250 mg/kg of acephate, animals did not survive. Induction of the most affected isoforms was sustained by immunoblotting analysis. Corresponding human CYP modulations might disrupt normal physiological functions related to these enzymes. Furthermore, the co-mutagenic and promoting potential of these pesticides, phenomena linked to CYP upregulation (e.g. increased bioactivation of ubiquitous pollutants and generation of oxygen free radicals) are of concern for a more complete definition of their overall toxicological potential.

Induction and suppression of cytochrome P450 isoenzymes and generation of oxygen radicals by procymidone in liver, kidney and lung of CD1 mice

Although chronic administration of procymidone (a widely used dicarboximide fungicide) leads to an increased incidence of liver tumors in mice, short-term genotoxicity studies proved negative. As cytochrome P450 (CYP) induction has been linked to non-genotoxic carcinogenesis, we investigated whether procymidone administration causes induction of CYP-dependent monooxygenases in liver, kidney and lung microsomes of male Swiss Albino CD1 mice after single or repeated (daily for three consecutive days) i.p. treatment with either 400 or 800 (1/10 or 1/20 of the DL(50)) mgkg(-1) b.w. procymidone. CYP content and CYP3A1/2, 1A1, 1A2, 2B1/2, 2E1, 2A, 2D9 and 2C11 supported oxidations were studied using either the regio- and stereo-selective hydroxylation of testosterone as multibiomarker or highly specific substrates as probes of various CYPs. While a single dose was uneffective, multiple procymidone administration lead to marked inductions of various monooxygenases: CYP3A1/2 in liver and lung (as measured by N-demethylation of aminopyrine and testosterone 6 beta-hydroxylase); CYP2E1 in liver (p-nitrophenol hydroxylation); CYP1A1 in liver and kidney (deethylation of ethoxyresorufin). Several hydroxylations were induced in the liver, including the CYP2A-linked 7 alpha (14-fold) as well as 6 alpha (22-fold), 6 beta, 16 beta and 2 beta hydroxylases. The pattern of inductions/suppressions recorded in the three different tissues suggests that procymidone exerts complex effects on the CYP profile. Tissue-specific trends included a large number of inductions in the liver and suppressions in the lung. The main inductions were corroborated by immunoblotting analyses and Northern blotting showed that inductions of CYP3A1/2, CYP2E1 and CYP1A1/2 were paralleled by increased mRNA levels. It was also found that CYP over-expression generates large amounts of reactive oxygen species (ROS), especially in liver. These data may explain why in vitro short-term genotoxicity studies on procymidone were negative, whereas in vivo long-term carcinogenesis studies turned out positive: long-term CYP induction (e.g. oxygen centered free radicals over-production) can have a co-carcinogenic and/or promoting potential.

In vitro induction of benzo(a)pyrene cell-transforming activity by the glucosinolate gluconasturtiin found in cruciferous vegetables

Cytotoxic and cell-transforming activity of gluconasturtiin (GNST), a promising chemopreventive agent commonly found in human diet, was studied in a medium-term bioassay utilizing BALB/c 3T3 cells. We also assessed whether GNST coupled with myrosinase, thus yielding product phenylethyl isothiocyanate (as shown by gas chromatography-mass spectral analysis), can affect the transforming potential of benzo(a)pyrene (B(a)P). Neither cytotoxicity nor cell-transforming activity was recorded. On the contrary, a marked increase (up to sevenfold) of the transforming activity of B(a)P was seen. This cocarcinogenic potential could be ascribed to an imbalance among bioactivation/detoxication during cell growth. These results indicate the need for an overall toxicological characterization of a chemopreventive agent prior to large-scale use.

Cardiac involvement in Churg-Strauss syndrome: a follow-up of three cases

Three cases of Churg-Strauss syndrome with myocardial involvement are reported. Cardiac disease is known to be the major cause of death in Churg-Strauss syndrome. Aggressive therapy (steroids and cyclophosphamide) may cure the myocardial dysfunction associated with the disease.

Electrophysiological evaluation of the sinus node in patients with atrioventricular and/or intraventricular conduction defects

The authors evaluated retrospectively sinoatrial conduction time (SACT), sinus node recovery time (SNRT), and corrected sinus node recovery time (CSNRT) in 272 patients with atrioventricular and/or intraventricular conduction defects without evidence of overt sinus node dysfunction. The study was designed to determine the prevalence of electrophysiologic sinus node abnormalities in patients with overt atrioventricular and/or intraventricular conduction defects. One or more sinus node electrophysiological abnormalities were observed in 133 cases (48.9%). There was a significant prevalence of electrophysiologic sinus node abnormalities only in patients older than 71 years of age. The data suggest that the involvement of the specialized conduction system is much more diffuse than one might expect simply observing the single recorded ECG defect and that the prevalence of associated defects of the conduction system increases with increasing age of patients.

Phrenic nerve paralysis following pediatric cardiac surgery. Role of diaphragmatic plication

Eighteen children sustained unilateral phrenic nerve paralysis (PNP) after cardiac surgical procedures. Ten (Group I), under 7 months (mean: 2.9 +/- 2.2), required long-term ventilatory assistance (mean: 23.9 +/- 13.0 days); they failed to be weaned from the ventilator. All underwent diaphragmatic plication (DP). DP was performed late in 7 cases (Group Ia) with a mean time of 30.8 days between surgery and DP, and early in 3 others (Group Ib) with a mean time of 10.2 days. Eight children (Group II), older than 1 year, tolerated PNP better and could be extubated early without diaphragmatic plication. In Group Ia severe lung infections were recorded in 5 before or/and after DP, and two died at 3 and 30 days after plication. Five children from Group Ia and all 3 from Group Ib were late survivors. They could be weaned from ventilatory support in a mean time of 3 days after DP, although those with severe lung infection (Group Ia) took the longest time. All from Group II were late survivors. We conclude: PNP is well tolerated without plication in children older than 1 year. However early DP offers excellent and immediate results in infants with PNP. Early DP in these children avoids or reduces severe lung infections and death.

Pre-operative sinus node function in adult patients with atrial septal defect (ostium secundum type)

The authors studied, pre-operatively, the sinus node function in adult patients with secundum atrial septal defect and large left-right shunts, using Holter ECG and electrophysiological tests. Sinus node electrophysiological tests were found abnormal in 17 out of 26 patients; on the contrary, Holter monitoring was always within normal limits. The authors believe that concealed sinus node dysfunction existing before surgical correction may be a cause of early, acute, and reversible, post-operative sick sinus syndrome.

Value of purinic compounds in assessing sinus node dysfunction in man: a new diagnostic method

The purpose of this paper is to investigate whether the inhibitory action of purinic compounds (striadyne: STR) on the sinus node is quantitatively different on a pathological sinus node in comparison to a normal one and thus whether it is possible, as suggested by other authors, to use STR as a pharmacological test in the diagnosis of sick sinus syndrome (SSS). With this aim we investigated 55 patients, divided into 3 groups according to ECG and sinus function evaluation tests: 1--normal; 2--SSS (2a: flagrant SSS; 2b: latent SSS); 3--excess vagotonia and/or abnormal response to vagal stimulation. In all patients after a prophylactic insertion of a temporary pacemaker, 30 mg of STR were rapidly injected i.v. and the surface and intracavitary ECG continuously recorded until the basal state was regained; the following parameters were evaluated: average baseline sinus cycle (SC), minimum and maximum SC after the drug. In all patients STR caused first a slowing, then an acceleration of the sinus rate. SC lengthening was moderate in groups 1 and 3 [max SC was respectively 740-1820 ms (1198 +/- 290.9 ms) and 720-1440 ms (1157.5 +/- 223.3 ms)], but it was severe in patients with SSS [max SC in group 2a 2500-11880 ms (5398.3 +/- 2687.4 ms) in group 2b 1620-11140 ms. (4470.7 +/- 3660.6 ms)]. The difference between the max post STR SC of SSS patients, and the control group was highly significant P less than 0.001). Assuming as upper limit of the normal a value of 2071 ms. (corresponding to the mean + 3 standard deviations of the response of the control group) we recorded abnormal responses in 100% in group 2a and in 85.7% in group 2b, whereas there were no abnormal responses in group 3. In addition, nodal atrioventricular block occurred frequently. The authors believe this test could be useful in the diagnosis of SSS, but it is essential to insert a ventricular pacing catheter prophylactically if this test is used.