The Third Italian Consensus Conference for Malignant Pleural Mesothelioma: State of the art and recommendations

Malignant Pleural Mesothelioma (MPM) remains a relevant public health issue, and asbestos exposure is the most relevant risk factor. The incidence has considerably and constantly increased over the past two decades in the industrialized countries and is expected to peak in 2020-2025. In Italy, a standardized-rate incidence in 2011 among men was 3.5 and 1.25 per 100,000 in men and women, respectively, and wide differences are noted among different geographic areas. The disease remains challenging in terms of diagnosis, staging and treatment and an optimal strategy has not yet been clearly defined. The Third Italian Multidisciplinary Consensus Conference on Malignant Pleural Mesothelioma was held in Bari (Italy) in January 30-31, 2015. This Consensus has provided updated recommendations on the MPM management for health institutions, clinicians and patients.

Correlation of tumor response and survival in advanced NSCLC patients treated with paclitaxel plus carboplatin (PC) versus paclitaxel plus carboplatin plus gemcitabine (PCG)

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Background: We showed that PCG significantly increases both response rate (RR) (43.6% vs 20%) and median survival (10.8 mo vs 8.3 mo) over PC and that at Cox analysis, the only independent prognostic factors were PS and treatment (Paccagnella et al, J Clin Oncol 2006;24: 681–687). According to the Prentice criteria (Stat Med 1989;8: 431–440), to directly relate response and survival it is necessarily that responding patients (and non responding) of both arms have a similar survival and that the survival difference between the two arms disappear when the response factor is included in the multivariate analysis. Methods: Out of 324 pts included in the original analysis, 26 pts were not evaluable for response (early death, toxicity, refusal) before the planned response evaluation at two months and were excluded (15 pts from PC arm and 11 pts from PCG arm). The analysis however was also performed considering the non evaluable patients as non responders. Results: Overall, Responder patients had a median Survival that nearly doubled that of no responders: 14.73 mo vs 7.67 mo (HR: 0.49; CI: 0.31–0.54; P=0.000). No responder pts from PC and PCG arms had a similar survival (median 7.53 mo and 8.07 mo respectively; P= 0.96) as well as responder (CR + PR) patients (median 14.13 mo and 15.40 mo respectively; P=0.38). The principal difference between the two arms was that more than the double of patients in PCG arm responded (43.6% vs 20%) and consequently had a survival advantage of clinical relevance in comparison to patients in PC arm. When tumor response was introduced in the Cox model (as a four level variable), the difference in Overall Survival between PCG and PC changed from a significant level (HR=1.28; CI 1.00–1.63; P=0.049) to a not significant level (HR=0.99; CI: 0.76 - 1.28; P=0.97). Conclusions: To our knowledge this is the first report showing a significant direct correlation between response and survival in advanced NSCLC according to Prentice criteria.

No significant financial relationships to disclose.

Cisplatin versus carboplatin in combination with mitomycin and vinblastine in advanced non small cell lung cancer. A multicenter, randomized phase III trial

BACKGROUND

In advanced not selected NSCLC chemotherapy achieved an advantage of approximately 1-2 months on median survival versus best supportive care. Chemotherapy seems to improve symptoms control, even if randomised studies with quality of life as first endpoint are lacking and often chemotherapy toxicity compromises the frail cost/benefit ratio. The aim of the present study is to evaluate the impact on QoL, substituting cisplatin, a pivot drug in NSCLC therapy, with carboplatin, an analogue with an improved toxicity profile. The combination of cisplatin with Mitomycin and Vinblastine was one of the most frequently used in the palliative setting at the time of design of our study.

METHODS

Patients were randomized to receive MVP regimen (Mitomycin-C 8 mg/m2 d1, Vinblastine 4 mg/m2 d 1-8, Cisplatin 100 mg/m2 d1) or MVC regimen (Mitomycin-C 8 mg/m2 d1, Vinblastine 4 mg/m2 d 1-8, Carboplatin 300 mg/m2 d1) every 3 weeks. The QoL was evaluated by the Spitzer QL-Index and by the EORTC QLQ-C30+LC 13 questionnaires before chemotherapy, after one cycle, after three cycles, and then every 6 weeks in the first 6 months and every 3 months thenafter.

RESULTS

From September 1994 to July 1997, 153 consecutive patients were randomized to MVP (75 patients) or MVC arm (78 patients). Despite difficulties in carrying out and analysing QoL items in such patients, the global QoL evaluated by the Spitzer's questionnaire suggested an advantage for MVC regimen (P=0.05) and a significant difference was observed in global health subdomain (P=0.04). The disease-related symptoms improved with time, and the benefits lasted for the entire treatment period. When evaluated with the EORTC questionnaire there was significantly less nausea and vomiting (P=0.0001), appetite loss (P=0.01), insomnia (P=0.03), constipation (P=0.01) and peripheral neuropathy (P=0.01) in favour of MVC, and a trend for less hair loss (P=0.05). The advantage lasted for all the duration of chemotherapy. No differences were observed in global quality of life subdomain (P=0.40) between the two regimen. QoL was the first endpoint and the statistical power was inadequate to assess other parameters. However, we reported a response rate of 43.1 and 38.6%, respectively, in MVP and MVC arm (P=0.59) and a median survival of 10.2 and 7.2 months, respectively, for cisplatin and carboplatin arm (P=0.39).

CONCLUSIONS

The carboplatin containing regimen (MVC) has a significant better toxicity profile than the cisplatin containing (MVP) regimen as proven both by the EORTC questionnaires and by the WHO toxicity data reported by physicians. No significant differences in terms of response rate, time to progression and overall survival were observed between the two regimen. The two chemotherapy regimen showed a similar effectiveness in symptom palliation when evaluated with C30 addendum of EORTC QOL questionnaire. With the Spitzer's questionnaires a trend towards an improved quality of life index was observed during treatment with the carboplatin combination in comparison to the cisplatin combination. This difference, however, was not observed when the global quality of life was evaluated with the EORTC patients compiled questionnaires. A carboplatin containing regimen with better toxicity profile and a similar potentiality for symptoms control offers an option in comparison to similar cisplatin containing combinations in the palliative treatment of advanced NSCLC.

[Treatment of malignant pleural mesothelioma]

BACKGROUND

In this study all patients observed between January 1993 and October 1997 with malignant pleural mesothelioma (MPM) have been analyzed in order to describe the impact of treatment modality on survival.

METHODS

Medical records of 56 patients with MPM (44 male, 12 female, median age = 59 yrs) were reviewed. In 34 cases the histotype was epithelial, in 4 sarcomatoid, in 4 mixed, in 3 desmoplastic, and in 11 not specified. Four treatment modalities were identified: 1) Surgery (subtotal pleurectomy) = 20 patients; 2) Chemotherapy = 19 patients; 3) Surgery+Chemo-therapy = 8 patients; 4) Supportive care = 9 patients.

RESULTS

The median survival was: 1) Surgery = 12.4 months; 2) Chemotherapy = 7.5 months; 3) Surgery+Chemotherapy = 12 months; 4) Supportive care = 11.4 months. Using univariate analysis, 8 prognostic factors were studied (age, sex, asbestos exposure, side, histotype, performance status, stage, treatment). Among these, only the stage and the performance status had shown a prognostic value on survival (p<0.05), while the treatment modality had not significantly influenced the prognosis. Using multivariate analysis only performance status showed to be significatively associated with survival (p=0.01 and odds ratio = 1.9, I.C. 1.2-3.2).

CONCLUSIONS

Despite the limits of a retrospective study, personal experience confirms the ineffectiveness of current therapeutical approaches to MPM. A better understanding of MPM is required to develop new therapeutical approaches and alter the dismal prognosis of this disease.

Primary cardiac sarcoma in pregnancy: a case report and review of the literature

Primary cardiac sarcoma (PCS) is a rare disease with a poor prognosis, because of diagnostic delay, therapeutic difficulties, and high metastatic potential. Surgery is the standard treatment. A case of PCS in pregnancy is reported, with a review of published surgical series of PCSs, focusing on the role of surgery and adjuvant therapy. Prompt surgery improved cardiac function and patients' outcome in comparison with untreated cases. The role of adjuvant treatment was analyzed only in a few series, mainly without distinction between postoperative chemotherapy and radiotherapy; adjuvant therapy improved survival in the larger series of resected PCSs. Only three other cases of PCS in pregnancy were reported. In the present case, resection was performed with no major complication for the mother and the infant. Even if the patient's survival was short, cardiac surgery allowed prolonging of pregnancy until an acceptable possibility of fetal survival was reached. Although resection is not curative in most cases, surgery remains the treatment of choice for PCS and has a definite palliative significance. The role of postoperative chemotherapy and radiotherapy is difficult to ascertain; however, adjuvant chemotherapy seems advisable in high-grade tumors.

[Integration of computerized tomography imaging with single photon emission in a commercial system for developing radiotherapy fields: application to conformational irradiation for lung carcinoma]

PURPOSE

Single photon emission computed tomography (SPECT) of lung perfusion permits to map functioning lung parenchyma with higher sensitivity than CT. Delivering higher radiation doses is used to increase local control in lung carcinoma; this strategy is based on radiobiological and clinical studies. Lung parenchyma is a dose-limiting tissue in patients irradiated for lung cancer. Functional mapping based on SPECT and CT findings permits to design radiation beams such as to minimize irradiation of functioning lung.

MATERIAL AND METHODS

CT and SPECT were used to examine a patient with non small cell lung carcinoma (stage IIIB, T4N0, left lung) candidate to conformal irradiation. Images were spatially correlated based on lung contours and using CT findings as reference. SPECT images were normalized to mean right lung value and expressed as perfusion (functional) contours. CT images and perfusion contours were transferred to the treatment planning system (Cadplan V 2.79, Varian-Dosetek Oy): in this way both functional (SPECT) and anatomical (CT) data were available for planning. A comparison was made between two irradiation techniques defined at TPS with (technique B) or without (technique A) SPECT contour information. The prescribed dose was 70.2 Gy. Rival plans were compared using dose volume histograms of target and risk organs. Both functional and anatomical regions were considered in the lung, together with single lung(s) and lung parenchyma. A second perfusion SPECT was obtained 5 months after irradiation and correlated with pretreatment CT images.

RESULTS

SPECT lung scans showed marked heterogeneity in the left lung, which was found neither at CT nor at classic lung function tests. The lung volume with perfusion exceeding 80% of average corresponds to about 70% of the anatomical volume. Mean doses to anatomical and to functional lung parenchyma were 24 Gy and 19 Gy, respectively, with technique A and 23 Gy and 18 Gy, respectively, with technique B. Thirty-five percent and 20%, respectively of anatomical and functional lung parenchyma received > or = 25 Gy (V25) with technique B. The figure for functional lung parenchyma was reduced by 5% with technique B. Optimal design of irradiation field geometry decreased the area of functional parenchyma given high doses, which sparing was greater with smaller irradiation volumes.

CONCLUSIONS

We have integrated the functional data provided by SPECT lung perfusion into a commercial irradiation planning system. Lung function mapping permits to design irradiation portals sparing larger areas of functional lung parenchyma.

Use of dose-volume histograms and biophysical models to compare 2D and 3D irradiation techniques for non-small cell lung cancer

For non-small cell lung cancer (NSCLC), unsatisfactory local control (LC) still remains an important cause of failure. It has been suggested that improved LC can be achieved with both higher radiation dosage and adequate target coverage. Modern three-dimensional treatment planning systems (3D-TPSs) offer many tools for planning optimization. Biophysical models, which estimate the normal tissue complication probability (NTCP), are gaining in importance in comparing plans. This study compares conventional two-dimensional (2D) with 3D irradiation techniques using parameters related to volumetric dose distribution and two different biophysical models predicting normal tissue tolerance to radiotherapy (RT). Nine patients with inoperable locally advanced NSCLC were treated with a beam's eye view-based 3D technique. For the same patients, a conventional treatment was simulated; the irradiation geometry and beam contour were fully defined at the simulator and then transferred to the 3D-TPS to calculate the dose distribution. Both techniques gave the same prescribed dose at the reference point. Dose-volume histograms (DVHs) and dose statistics of organs at risk (OARs) (heart, lung(s), parenchyma lung, spinal cord and oesophagus) were analysed. The probability of side effects was estimated using two different biophysical models: the integrated normal ("empirical") model and the relative seriality model. Apart from contralateral lung, the 3D irradiation technique significantly reduced the average mean doses to all OARs. The current analysis suggests that in the treatment of locally advanced NSCLC, the use of 3D irradiation techniques allows a large sparing of OARs; this advantage is confirmed by both dose statistics analysis and NTCP values.

Metabolism of [5-(3)H]kynurenine in the developing rat brain in vivo: effect of intrastriatal ibotenate injections

Two metabolites of the kynurenine pathway of tryptophan degradation, the neurotoxin quinolinic acid (QUIN) and the neuroprotectant kynurenic acid (KYNA), may play a role in the initiation or propagation of brain diseases. In order to study their disposition during the acute and chronic stages of neurodegeneration, effects of an excitotoxic insult on the de novo synthesis of several kynurenine pathway metabolites were examined in vivo. Neuronal injury and lesions were produced in 7-day (PND 7), 14-day (PND 14) and young adult rats by an intrastriatal injection of the excitotoxin ibotenic acid. At 2 h, 2, 7 and 28 days later, the formation of tritiated KYNA, 3-hydroxykynurenine (3HK), xanthurenic acid and QUIN was assessed after an acute intrastriatal injection of their common bioprecursor, [5-(3)H]kynurenine. In all three age groups, the acute insult resulted in a shift towards enhanced KYNA formation, as indicated by 2-4 fold decreases in the 3HK/KYNA and QUIN/KYNA ratios in ibotenate-treated striata. At later post-lesion intervals, age-specific several-fold changes were observed in the flux through both the KYNA and QUIN branches of the kynurenine pathway. With aging, kynurenine conversion to QUIN and especially to 3HK, became increasingly more prominent, though KYNA synthesis was substantially activated as well. The acute toxin-induced changes in kynurenine metabolism, the propensity of the lesioned immature striatum to increase KYNA production preferentially, and the pronounced lesion-induced long-term increases in cerebral KYNA, 3HK and QUIN formation may participate in the modulation of NMDA receptor function following injury. In particular, changes in the production of these kynurenine pathway metabolites may play a role in mechanisms involved in endogenous neuroprotection, delayed neurodegeneration and regenerative processes.

Excitotoxic lesions of the rat striatum: different responses of kynurenine pathway enzymes during ontogeny

Excitotoxic lesions of the adult rat striatum result in reactive gliosis and an associated increase in the activities of the astrocytic enzymes 3-hydroxyanthranilic acid oxygenase (3HAO) and kynurenine aminotransferase (KAT), which are responsible for the biosynthesis of the neurotoxin quinolinic acid and the neuroprotectant kynurenic acid, respectively. Unilateral ibotenate injections were made in the striatum of 7-, 14-, 21- and 28-day- and 2.5-month-old rats to study the reaction of 3HAO and KAT when injury is inflicted during ontogeny. By one week, all lesioned striata showed a > 50 percent decrease in the activity of the neuronal marker enzyme glutamic acid decarboxylase. At this timepoint, lesion-induced elevations in 3HA0 activity increased progressively from 130 to 206, 280, 385 and 456 percent of the contralateral striatum in the five age groups studied. In contrast, in the same animals the respective increases in striatal KAT activity were 601, 350, 312, 259 and 159 percent (n = 6-13 per group). In all age groups, statistically significant lesion-induced increases in 3HA0 and KAT were seen up to 4 weeks after the ibotenate injection. Rats receiving an intrastriatal injection of ibotenate on postnatal day 7 also showed an increase in the striatal tissue level of kynurenic acid 1 week after the lesion. These data demonstrate that substantial qualitative differences exist between the immature and adult rat in the reaction of two glial enzymes to striatal injury. Moreover, the ability of the immature brain to mobilize kynurenic acid production preferentially may play a role in the brain's response to perinatal injury.

Alterations of adenylyl cyclase-coupled growth hormone-releasing hormone (GHRH) pituitary receptors in different conditions of GHRH deprivation

Previous studies have clearly shown that the progressive decrease of growth hormone (GH) secretion occurring during ageing is coupled with a reduced responsiveness of pituitary GHRH receptors both in terms of GH secretion and activation of the adenylyl cyclase (AC), in the presence of increased basal values of the enzyme. The mechanism(s) subserving the age-associated alterations of GHRH-sensitive AC is likely related to the progressive decrease of hypothalamic GHRH function occurring with ageing. In this context, in old male rats, short-term administration of GHRH decreased the high basal AC activity and enhanced the GHRH-stimulated AC activity. Along this line, we decided to investigate whether experimentally induced abrogation of GHRH function in adult rats would induce the same alterations of AC-coupled GHRH receptors present in aged rats. Passive immunization of male young-adult rats with supra-maximal doses of GHRH antiserum (Ab-GHRH) significantly reduced the AC responsiveness to GHRH, an effect already evident 5 days post-injection and still present at 10 days. At this time interval, the treatment also evoked a significant increase of basal AC levels and of Gs alpha protein in the pituitary and completely blocked the GH-releasing effect of a bolus injection of GHRH. Furthermore, mechanical disruption of brain-pituitary links by complete stereotaxical ablation of the mediobasal hypothalamus induced a significant increase of basal AC levels and Gs alpha protein in the pituitary and a strikingly lower AC responsiveness to GHRH.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-related changes of growth hormone secretory mechanisms in the rat pituitary gland

The mechanisms underlying the age-related decrease and increase in somatotroph responsiveness to growth hormone-releasing factor (GHRF) and somatostatin respectively were studied in rat pituitary membranes in vitro. Basal adenylate cyclase (AC) activity was similar in pituitary membranes from rats of 8 days (either sex) and male rats of 3 months, but it was almost threefold higher in membranes from male rats of 21-23 months. GHRF induced a lower percentage stimulation of AC activity in membranes from infant and old than adult rats. Somatostatin inhibited stimulation of AC induced by forskolin more effectively in membranes from adult than infant and old rats. In parallel experiments, since the tissue we used is formed by a mixed population of pituitary cells, we evaluated, for comparison, the effect on AC of neurohormones, i.e. vasoactive intestinal polypeptide (VIP) and dopamine which act primarily on lactotrophs. VIP induced a lower fold-stimulation of AC activity in membranes from infant and old than adult rats. Dopamine inhibited forskolin-induced stimulation of AC in the following rank order of magnitude: old, adult and infant rats, and was also more effective in inhibiting basal AC activity in old than in adult rats. The stimulatory and inhibitory G proteins (Gs and Gi) coupled to AC were measured indirectly by evaluating stimulatory and inhibitory effects of different concentrations of GTP on AC. GTP, at stimulatory concentrations, increased AC activity in membranes from infant and adult rats similarly whereas its effect was significantly greater in membranes from old rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of opiates in striatal D-1 dopamine receptor supersensitivity induced by chronic L-dopa treatment

Repeated administration of L-dihydroxyphenylalanine (L-dopa) to rats lesioned with monolateral intranigral injections of 6-hydroxydopamine counteracted the increased density of striatal [3H]spiroperidol binding sites induced by the lesion. On the contrary, the treatment with L-DOPA further enhanced the hypersensitivity of adenylate cyclase to dopamine stimulation that follows striatal denervation. In addition, the apomorphine-induced rotations were strongly potentiated. The latter effect was antagonized by morphine given acutely shortly before the dopamine agonist. On the other hand, the efficacy of [D-Ala2]-methionine enkephalinamide to inhibit striatal adenylate cyclase was decreased in 6-hydroxydopamine-lesioned rats chronically treated with L-dopa. Moreover, in these animals, when naltrexone was given chronically together with L-dopa, the supersensitivity of the enzyme to dopamine stimulation did not develop. Finally, in 6-hydroxydopamine-lesioned rats, chronic morphine, similarly to L-dopa, further enhanced the responses of adenylate cyclase to dopamine stimulation. These data suggest that prolonged indirect activation of striatal opiate receptors and their consequent desensitization could be among the causes of the hyperactivity of D-1 dopamine receptors that follows chronic L-dopa treatment.

Cross-talk between different intracellular signalling pathways in the rat hippocampus

The activation of alpha 1-adrenergic receptors in rat hippocampal slices enhances polyphosphoinositide (PPI) breakdown and cyclicAMP (cAMP) accumulation. The latter effect is antagonized by different protein kinase C (PKC) inhibitors and mimicked by a diacylglycerol (DAG) analogue, 1,2-diolein, which activates PKC, suggesting that cAMP synthesis is indirectly affected by alpha 1-adrenoceptors through the stimulated generation of DAG upon PPI hydrolysis. Furthermore the elevation of hippocampal cAMP decreases the ability of alpha 1-receptor agonists to enhance PPI breakdown. It is proposed that the observed effects are part of a complex cross-talk between PPI and AC signalling pathways operating in hippocampal neurons.