Patients with cancer and hospital admissions: disease trajectory and strategic choices

OBJECTIVES

Hospital admission (HA) in cancer history is a common, repeated and frequently unplanned event. The emergency departments (EDs) and the oncological outpatient service (OOS) are the ordinary way of entry. We studied the reasons of admission, pathways of access and discharge and prognostic factors in a population of admitted patients with cancer.

METHODS

The health records of the admitted patients in the oncological ward of a referral hospital in a 6-month period were retrieved and analysed. The characteristics of those admitted in the last 3 months of life were compared with the other group.

RESULTS

Among the 147 HA, 79.5% were unplanned, 48.9% passing through the ED and 30.6% through the OOS; 56.5% were due to cancer-related symptoms; 50.3% occurred in the last 3 months of life. Median overall survival was 90 days (95% IC 53.1-126.9). Independent prognostic factors for survival were: being admitted for symptoms, referral through the ED and not being discharged at home.

CONCLUSIONS

Hospital is a turning point in the cancer care pathway. Patients needing HA have a dismal prognosis, half of them being in the last 3 months of life. This group can be identified using universally available variables.

Exploratory analysis of circulating cytokines in patients with metastatic breast cancer treated with eribulin: the TRANSERI-GONO (Gruppo Oncologico del Nord Ovest) study

Background

Anticancer drugs can interact with the tumour microenvironment and their effects could be exploited to favour anticancer immune response. Eribulin contributes to tumour vasculature remodelling and transforming growth factor β (TGF-β) modulation in experimental models and in humans. We performed a prospective, translational, exploratory analysis of the levels of circulating cytokines at different time points in patients with metastatic breast cancer treated with eribulin.

Methods

TGF-β, tumour necrosis factor α, vascular endothelial growth factor, IL-6, IL-8, IL-10, IL-21 and C-C motif chemokine ligand-2 levels were assessed in peripheral blood samples obtained from seven healthy volunteers and 41 patients at baseline (T₀), after four cycles of eribulin (T₁) and at disease progression (T_PD). Baseline values and longitudinal changes in cytokine levels were then related to clinical outcome.

Results

In the 41 patients, high IL-6 and IL-8 (above the median) at T₀ significantly correlated with worse survival. At T₁, IL-21 significantly decreased in patients with T_PD within the fourth course of treatment, compared with patients without progression. TGF-β and IL-8 above the median and IL-21 below the median at T₁ significantly correlates with worse progression free survival (PFS). Patients exhibiting an increase of TGF-β or a decline of IL-21 between T₀ and T₁ showed a significantly worse PFS. Multivariate Cox regression analysis showed that only plasma TGF-β changes at T₁ correlated with survival. At T_PD, TGF-β significantly increased in all patients.

Conclusions

We observed a significant correlation between TGF-β decline during eribulin treatment and outcome in patients with metastatic breast cancer. Altogether, our data suggest that eribulin treatment might interfere with the tumour microenvironment.

Effect of moderate physical exercise on the immune system modulation in patients with breast cancer during preoperative chemotherapy: The NEO-RUNNER study

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Background: The link between physical activity (PA) and the immune system (IS) is known. However, it is not yet fully understood the immune mechanisms activated by PA. We investigated the immune effect of moderate PA (MPA), nordic or fit walking, during neoadjuvant chemotherapy (NACT) in patients (pts) with breast cancer. Methods: Pts received sequential epirubicin and cyclophosphamide for 4 cycles followed by paclitaxel for 12 weeks. Blood samples from pts underwent MPA (TR) were collected before starting chemotherapy (CT) at baseline (T0), at day 1 of week 6 of paclitaxel (before starting MPA) (T1), before surgery (S) (T2) and after S (T3). Samples were also collected in a group of pts who declined MPA (UN) at the same time points and in 15 healthy volunteers (HV). MPA consisted of 3 workouts per week, 1 hour each, in the 9 weeks before S. At each time point the level of 17 cytokines (IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, CCL-2, CCL-4, CXCL-10, CCL-22, IFN-γ, TGF-β, TNF-α, VEGF) was measured. The difference among the median value of cytokines was analyzed using non parametric Mann Whitney U test. Principal component analysis (PCA) was computed to compare the best discriminating cytokine, identified by ROC analysis, of pts at T1, T2, T3 and in HV. Each patient was distributed in the PCA. Pts having similar cytokine values were plotted in the near position. Normalized values of 8 cytokines (IL-2, IL-4, IL-5, IL-6, IL-13, IL-15, CCL-2, VEGF) were used in PCA. Results: Data from 27 pts are available: 10 TR and 17 UN. A significant increase of IFN-γ, IL-5, IL-8, CCL-2 and CXCL-10 between T0 and T1 (P = 0.004, P = 0.013, P = 0.032, P = 0.046, P = 0.046, respectively) was found in the whole population. CXCL-10 significantly increased also between T1 and T2 in UN pts (P = 0.033). TR pts showed a significant lower level of IL-6, IL-13, CCL-2 at T2 (P = 0.012, P = 0.038, P = 0.023) and higher IL-15 level at T3 (P = 0.047) compared to UN pts. Moreover, a significant decrease of IL-5 was observed between T2 and T3 (P = 0.031). PCA showed that TR and UN pts were mixed at T1. HV were clustered all together and distinct from pts. At T2 TR pts moved toward HV and mixed with them while UN remained separated. TR pts tended to separate from HV at T3, while UN pts still remained distinct. Conclusions: NACT upregulated median values of IFN-γ, IL-5, IL-8, CCL-2 and CXCL-10; CXCL-10 value continues to increase during CT only in UN pts supporting the inflammatory effect of CT. On the contrary, during MPA the level of IL-6, IL-13, CCL-2 decreases in TR compared to UN pts. All together these data suggest that MPA damps the inflammatory response to NACT. Our results show that the majority of TR pts reach an immune profile similar to that of HV in PCA. However, at T3 the effect of MPA is dampened, suggesting a potential negative effect of S.

Treating patients with cancer amidst the COVID-19 pandemic: experience of a regional hospital in the Piedmont region in northern Italy

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic is posing an unprecedented dilemma to oncologists worldwide, forcing them to decide whether to continue or suspend treatments in order to protect their most vulnerable patients from infection. After the first report from China, the outbreak spread rapidly worldwide. To, date no clear indications on how to treat patients with cancer with COVID-19 infection are available.

METHODS

We report data on 21 patients with cancer referred to a single medical oncology unit of a general hospital from mid-March to April 23, 2020.

RESULTS

Nine patients were on active cancer therapy during the infection and all stopped medical treatments. Overall 8 patients developed pneumonia and 6 patients died of COVID-19.

CONCLUSION

The management of patients with cancer during the pandemic should be carefully balanced and discussed among oncologists and other key professionals involved in the treatment of this vulnerable group of patients, in order to balance the risk of treatment and the risk of infection.

Abstract 4137: Circulating TGFâ and TNFá in metastatic breast cancer patients treated with eribulin. The TRANSERI project

Background: Eribulin (E) is approved for the treatment of metastatic breast cancer (mBC) patients (pts) after failure of antracyclines and taxanes. E interferes with microtubule leading to apoptosis and G2/M cell cycle arrest. In human cancer cell lines and in mice, it reverses epithelial mesenchimal transition (EMT) and reduces metastases in mice. TGFβ, an immunosuppressive cytokine, acts as growth factor for cancer-associated fibroblasts (CAFs) and promotes EMT. TNFα synergizes with TGFβ to promote EMT. The TRANSERI study investigates the modifications of TGFβ and TNFα levels in 40 mBC pts treated with E.

Methods: Plasma levels of TGFβ and TNFα were determined by ELISA assay at baseline, before cycle (C) 3, 5 and at disease progression in mBC pts treated with E at 1.23 mg/m2, d 1-8 every 21 d. Statistical analysis of the changes in the longitudinal samples was performed by GraphPad 5. Clinical outcome was monitored according to standard internal follow up procedure.

Results: We report analyses in pts who completed 5 C or progressed before C 5. So far, we have evaluated TGFβ level in 34 pts and TNFα in 26 pts. The median (M) basal TGFβ value was higher in pts than in 9 healthy volunteers (201.9 pg/ml vs 115.1 respectively). At C 5, 14 pts had a decrease in TGFβ with a M value approaching the one of healthy controls (161.9 pg/ml vs 115.1 pg/ml respectively). 19 pts progressed before C 5. Overall 26/33 pts experienced progression. The M value of TGFβ in pts at progression was 293.4 pg/ml. A significant difference of TGFβ was observed between non progressed vs progressed pts (p=0.021). The M TNFα value at baseline was higher in pts than in healthy volunteers, even if in both groups it was close to the lower sensitivity cut-off of the assay. Altogether 20/26 pts experienced progression, that occurred before C 5 in 14 out of them.Intriguingly, at C 5, the TNFα / TGFβ ratio was significantly lower in pts who did not progressed compared to the value at progression (p=0.048).

Conclusions: TGFβ levels changed during treatment with E and correlate with outcome. We are evaluating the role of tumor burden in modulating the TNFα / TGFβ ratio. Definitive data will be presented.

Citation Format: Ornella Garrone, Cristiana Lo Nigro, Andrea Michelotti, Fillippo Montemurro, Anna Maria Vandone, Andrea Abbona, Matteo Paccagnella, Antonella Falletta, Elena Genua, Claudia De Angelis, Federica Tonissi, Paola Vanella. Circulating TGFâ and TNFá in metastatic breast cancer patients treated with eribulin. The TRANSERI project [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4137.

Abstract P5-04-01: The TRANSERI project: Effect of eribulin (E) in patients with metastatic breast cancer (mBC) on circulating TGFβ and TNFα. Relationship with outcome

Background: E is approved for the treatment of mBC patients (pts) after failure of at least 2 previous chemotherapy (CT) regimens containing antracyclines and taxanes. Its mechanism of action interferes with microtubule leading to cell cycle arrest in G2/M phase and cell apoptosis.

An in vitro study in triple negative BC cell lines shows that exposure to E reverses epithelial mesenchimal transition (EMT) phenotype toward an epithelial morphology and induces changes of gene profiling and protein expression. Accordingly in mice E reduces metastatization and can reverse EMT. TGFβ is an immunosuppressive cytokine and a growth factor for cancer-associated fibroblasts (CAFs). In addition it drives EMT. TNFα synergizes with TGFβ to promote EMT.

While CAFs pave the way for metastatization, EMT permits cancer cells trafficking through the blood flow following CAFs and finally developing metastases.

The purpose of the study is to investigate whether E interferes with TGFβ and TNFα levels and if the changes correlate with the outcome and the metastatic spread.

Methods: Pts with mBC, after failure of at least 2 previous CT lines were treated with E delivered at 1.23 mg/m2, d 1–8 every 21 d. Blood levels of TGFβ and TNFα were determined at baseline, before cycle 3, 5 and at disease progression. The changes observed were correlated with the outcome and the metastatic spread.

Results: The study is ongoing. Here we report preliminary data on 16 pts who completed 3 cycles of E. No change of TNFα level was observed during treatment. On the contrary, TGFβ levels changed during treatment.

Basal levels of TGFβ were divided in upper or lower the median (m) value. We did not observe any difference in m PFS between high or low values (137 d vs 141). However the m TGFβ value in pts was much higher than that observed in 3 healthy volunteers (m concentrations: 205 pg/ml [C.I. 115-920] vs 108 pg/ml [C.I. 85-120] respectively).

In 5 pts, TGFβ increased between cycle 1 and cycle 3, while diminished in 11 pts. We observed a numerical difference in PFS between the pts with decreased and increased values (150 d vs 85, p=NS).

We then divided the population in 3 groups: pts with TGFβ increased more than 25% of their basal levels (increased), pts with changes between +25% and -25% compared to their basal levels (stable) and pts with decreased values more than 25% of their basal levels (decreased). Comparing “increased” vs “stable” + “decreased” we observed a trend toward longer PFS favouring the latter group (77 d vs 144 p=0.12).

We collected the third determination in 14 pts. We did not analyse these data yet. However we observed that in 6 pts, TGFβ continues to decline. None of these pts progressed. In these pts the m value of TGFβ approaches healthy controls value (m concentrations: 180 pg/ml [C.I. 200-100] vs 108 pg/ml [C.I. 85-120]).

Conclusions: TNFα does not change during E treatment. On the contrary, TGFβ changes compared to basal levels. In pts with increased TGFβ between cycle 1 and 3 the PFS is lower than that observed in pts with stable or decreased levels (p=0.12). Pts with continue decline of TGFβ at cycle 5, approach the values of the healthy volunteers. None of them progressed. Updated results will be presented.

Citation Format: Garrone O, Tonissi F, Lingua D, Vandone AM, Vivenza D, Denaro N, Lo Nigro C, Merlano MC. The TRANSERI project: Effect of eribulin (E) in patients with metastatic breast cancer (mBC) on circulating TGFβ and TNFα. Relationship with outcome [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-04-01.

Eribulin in advanced breast cancer: safety, efficacy and new perspectives

Eribulin is a synthetic analog of halichondrin B belonging to microtubule-targeted agents with a distinct mechanism of inhibition of microtubule dynamics. This molecule has multiple nonmitotic effects on tumor biology, exhibiting effects on epithelial-mesenchimal transition and tumor vasculature. We review here preclinical and clinical studies on eribulin. The mitotic and nonmitotic effects together with its favorable safety profile make eribulin a unique drug with high potential in the treatment of metastatic breast cancer. The new emphasis of eribulin mechanism of action on vascular remodeling, microenvironment modifications and reversal of epithelial-mesenchimal transition paves the way to rethinking the use of the drug in an immunological perspective.

Metronomic chemotherapy (mCHT) in HER2-ve advanced breast cancer (ABC) patients (pts): What has changed over the time? Preliminary results of the VICTOR-6 study

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Background: mCHT is the minimum biologically effective dose of a chemotherapeutic agent, given at regular dosing regimen with no prolonged drug free interval, that leads to anti-tumor activity. Old regimens included Cyclophosphamide-Methotrexate (CM), whereas in the last years new regimens, such as Vinorelbine (VRL) and Capecitabine (CAPE)-based have been developed. Aim of this observational retrospective ongoing study is to describe the use of mCHT in ABC pts across 5 years and the clinical characteristics of the pts together with efficacy of old (CM-like) vs new (VRL/CAPE-based) metronomic regimens in terms of response and disease control. Methods: We retrospectively identified from clinical records those HER2-ve ABC pts who have received any kind of mCHT in the years 2011-2015, alone, or in combination with a non-metronomic drug. Standard statistical approaches were used for describing the sample characteristics. Logistic and non proportional hazard analysis were used to identify factors associated with response, and time to treatment failure and survival, respectively. This preliminary analysis focuses on Response Rate (RR) and Disease Control Rate (DCR). Results: From June 2011 to December 2015, 267 pts have been identified till now and 233 are fully evaluable. Median age at mCHT start was 67 years. 81% was HR+ and 33% had non-visceral metastatic disease. 22% of the pts received CM, 55% VRL-based and 23% mCAPE-based regimens. mCHT use increased over the time from 15.0% (2011) to 30% (2015). As 1st-line treatment, CM was administered in 27% of compared with more than 48% of patients receiving CAPE/VRL-based regimens. Overall Response Rate (ORR) was 28% and Disease Control Rate (DCR) was 79%. Median duration of mCHT was 6.2 months. New generation metronomic regimens produced higher ORR in comparison to old ones (32% vs 13.5%), with similar duration of treatment (6.4 vs 5.4 months, respectively). Conclusions: The use of mCHT in the treatment of HER2-ve ABC pts has deeply changed across the last 5 years, being new generation regimens used in earlier lines of treatment, producing interesting results in terms of objective response and disease control.

From the CLEOPATRA study to real life: An observational study from 11 Italian Centres; Preliminary report from the G.O.N.O. SUPER trial

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Background: Approximately 20% of breast cancers (BC) are HER-2+. Trastuzumab (T) has substantially improved the outcome, both in early and in advanced settings, in HER-2+BC. Pertuzumab (P), combined with T and taxanes, ameliorated progression free survival (PFS) and overall survival (OS) in the phase III CLEOPATRA study. In order to verify the results of the trial in unselected patients (pts), we performed a multicenter, retrospective-prospective, observational study, in HER-2+ metastatic BC (MBC) pts. Methods: We analyze the outcome of all HER-2+ MBC pts treated with P+T and taxanes, as first line therapy since the availability of P in Italy, at 11 general and university hospitals. Results: Up to February 1stdata from 103 HER-2+ MBC pts were recorded. Main pts’ characteristics were: median (M) age 52 y (28-78), m ECOG PS 0 (0-2), ER/PgR positive 68 pts (66%). Most common metastatic sites: liver 51 pts (49.5%), bone 64 pts (62.1%), lung 26 pts (25.2%). Thirty pts (29.1%) had bone and soft tissue disease only; 78 pts (75.7%) had metastatic disease on presentation. m number of metastatic sites was 3 (1-7); 25 pts (24.3%) received neo/adjuvant chemotherapy (CT) + T and 36 pts (34.9%) adjuvant endocrine therapy; 71 pts (69%) and 32 pts (31%) received docetaxel (D) and paclitaxel (P) respectively. m number of CT cycles was 6 for both drugs (D range 3-12; P range 1-18).At the time of the present analysis 12 pts are still on CT and 78 on maintenance; response is available for 91 pts and ORR is 80.2% (22 pts and 51 pts obtained CR and PR respectively), 6 pts experienced PD during CT. Median PFS is 13.9 months (1.5+ - 33.8+).Among hematological toxicities leucopenia (any grade) was recorded in 29 pts (28.1%), g 3 febrile neutropenia in 6 pts (5.8%). No change of left ventricular ejection fraction (LVEF) was recorded during CT; 4 pts interrupted maintenance P due to drop in LVEF and 1 due to rash. Onicopathy, nausea, alopecia, rash and arthro-myalgia were the most common non-hematological toxicities. Conclusions: Our preliminary results highlight the activity and the safety of the combination of CT plus P and T in unselected HER2+ MBC patients. The study is ongoing and updated results will be presented.

Eribulin in pretreated metastatic breast cancer patients: results of the TROTTER trial-a multicenter retrospective study of eribulin in real life

This retrospective multicenter analysis was aimed to evaluate clinical activity and tolerability of eribulin in pretreated metastatic breast cancer patients in clinical practice. Patients treated with eribulin from January 2012 to July 2013 were enrolled in the observational study from 10 italian hospitals. Tumor and toxicity evaluation were performed according to Agenzia Italiana Farmaco. One-hundred and thirteen patients were included in the study. Median age 62 years old. 71.7 % of the patients had visceral involvement and the majority had a burden of disease involving two or more organs with a median number of 2 (1-6). The median number of previous chemotherapy regimens for advanced disease was 3 (1-10). Median number of eribulin cycles was 4 (1-27). Overall response rate was 24 % (95 % CI 16.0-31.8). Clinical benefit rate, was 35.4 % (95 % CI 26.6-44.2). At a median follow-up of 29.6 months (8.3-41.9) the median progression free survival was 3.3 months (0.6-26.7; 95 % CI 2.4-4.2), and the median overall survival 11.6 months (0.6-33.3; 95 % CI 8.7-14.5). No correlation was recorded between subtypes in terms of ORR and CBR. Toxicity was manageable. Main common grade 3-4 toxicities were neutropenia (19.4 %), febrile neutropenia (0.9 %), asthenia (3.5 %), abnormal liver function test (1.8 %), stomatitis (0.9 %). Our results confirm that treatment with eribulin is feasible and safe in real-world patients.

A simple and reproducible prognostic index in luminal ER-positive breast cancers

BACKGROUND

The group of estrogen receptor (ER)-positive breast cancers (both luminal-A and -B) behaves differently from the ER-negative group. At least in early follow-up, ER expression influences positively patients' prognosis. This low aggressive biology flattens out the differences of clinical management. Thus we aimed to produce a prognostic index specific for ER-positive (ERPI) cancers that could be of aid for clinical decision.

PATIENTS AND METHODS

The test set comprised 495 consecutive ER-positive breast cancers. Tumor size, number of metastatic lymph nodes and androgen receptor expression were the only independent variables related to disease-specific survival. These variables were used to create the ERPI, which was applied to the entire test set and to selected subpopulations (grade 2 (G2)-tumors, luminal-A and -B breast cancers). A series of 581 ER-positive breast cancers, collected from another hospital, was used to validate ERPI.

RESULTS

In the test population, 96.9% of patients classified as ERPI-good showed a good prognosis compared with 79.6% classified as ERPI-poor (P < 0.001). ERPI effectively discriminated outcome in luminal-A and luminal-B and in G2-tumors. In the validation series, the ERPI maintained its value.

CONCLUSION

ERPI is a practical tool in refining the prediction of outcome of patients with ER-positive breast cancer.

Exposing human epithelial cells to zoledronic acid can mediate osteonecrosis of jaw: an in vitro model

BACKGROUND

Osteonecrosis of the jaw (ONJ) is a chronic complication of bisphosphonate therapy, mainly when intravenous, in cancer patients with bone metastases and myeloma. Its pathophysiology is not yet fully elucidated; in particular, the molecular/cellular events triggering ONJ remain unclear. This complication could result from the effect of bisphosphonates released from bone into the soft-tissues, or from osteolysis induced by soft-tissues directly exposed to bisphosphonates. This research investigated the possibility that ONJ may be evocated by changes induced in osteoblast activity by factors released by soft-tissue cells exposed to zoledronic acid.

METHODS

An 'in vitro' model was used, in which human osteoblast-like MG-63 cells were grown in medium conditioned by human keratinocytes NCTC 2544, exposed or not to zoledronic acid (5 or 50 μM); 5 μM zoledronic acid was also directly administered to MG-63 cells.

RESULTS

In NCTC 2544 cells, zoledronic acid decreased proliferation via decreased hydroxy-3-methyl-glutaryl-CoA reductase, suggesting that a decrease in healing capability can occur in case of injury. An increased pro-inflammatory potential was also observed. Osteoblasts grown in medium conditioned in the presence of zoledronic acid showed decreased proliferation and osteogenic properties, and increased ability to induce osteoclast differentiation and inflammatory process. Zoledronic acid directly administered to MG-63 modulated only some parameters and in a lesser extent.

CONCLUSIONS

The research evidenced, for the first time, the direct involvement of epithelial cells in zoledronic acid-triggered molecular mechanisms leading to osteonecrosis of the jaw, by modulating both osteoblast and osteoclast properties.

Impact of dental care in the prevention of bisphosphonate-associated osteonecrosis of the jaw: a single-center clinical experience

BACKGROUND

Osteonecrosis of the jaw (ONJ) is associated with bisphosphonate (BP) therapy and invasive dental care. An Interdisciplinary Care Group (ICG) was created to evaluate dental risk factors and the efficacy of a preventive restorative dental care in the reduction of ONJ risk.

PATIENTS AND METHODS

This prospective single-center study included patients with bone metastases from solid tumors. Patients who received at least one BP infusion between October 2005 and 31 August 2009 underwent one or more ICG evaluation and regular dental examinations. We also retrospectively evaluated patients with bone metastases from solid tumors who did not undergo dental preventive measures.

RESULTS

Of 269 patients, 211 had received at least one infusion of BP therapy: 62% were BP naive and 38% had previous BP exposure. Of these 211 patients followed for 47 months, 6 patients developed ONJ (2.8%). Of 200 patients included in the retrospective analysis, 11 patients developed ONJ (5.5%).

CONCLUSIONS

In comparison with published ONJ rates and those extrapolated from the retrospective analysis, the observed ONJ rate in the prospective group was lower, suggesting that implementation of a preventive dental program may reduce the risk of ONJ in metastatic patients treated with i.v. BP therapy.

Vascular endothelial growth factor genetic polymorphisms and haplotypes in female patients with bisphosphonate-related osteonecrosis of the jaws

OBJECTIVE

To investigate the polymorphisms of the vascular endothelial growth factor (VEGF) gene in relation to female patients who developed bisphosphonate-related osteonecrosis of the jaws (BRONJ).

METHODS

Test subjects were 30 Italian female patients with BRONJ (Group A). Control subjects were 30 female patients with a history of intravenous bisphosphonate use without any evidence of osteonecrosis (Group B) and 125 unrelated healthy volunteers (Group C). Three single-nucleotide polymorphisms were investigated: -634 G>C, occurring in 5' untranslated region (UTR); +936 C>T, occurring in 3' UTR; and -2578 C>A of the promoter region.

RESULTS

The frequency of the VEGF CAC (+936/-2578/-634) haplotype was increased in patients with BRONJ, compared with female disease-negative controls [odds ratio (OR) = 2.76, 95% CI = 1.09-4.94, P = 0.039; corrected P value: P(c) = 0.117], and was also increased compared with female healthy controls (OR = 2.11, 95% CI = 1.14-3.89, P = 0.024; corrected P value: P(c) = 0.072). The CC homozygotes of -634G>C of VEGF gene and AA homozygotes of -2578C>A have also been significantly correlated in female patients who developed BRONJ compared with healthy controls (OR = 2.04, 95% CI = 1.12-3.70, P = 0.008; corrected P value: P(c) = 0.024).

CONCLUSIONS

These results suggest a possible haplotype effect of VEGF polymorphisms expression in BRONJ Italian female patients. Studies with different and larger populations possibly using TagSNP to represent all haplotypes within the VEGF gene are needed to further delineate the genetic contribution of this gene to BRONJ.