Soluble CTLA-4 as a favorable predictive biomarker in metastatic melanoma patients treated with ipilimumab: an Italian melanoma intergroup study

CTLA-4 blockade by means of ipilimumab (IPI) potentiates the immune response and improves overall survival (OS) in a minority of metastatic melanoma (MM) patients. We investigated the role of soluble CTLA-4 (sCTLA-4) as a possible biomarker for identifying this subset of patients. sCTLA-4 levels were analyzed at baseline in sera from 113 IPI-treated MM patients by ELISA, and the median value (200 pg/ml) was used to create two equally sized subgroups. Associations of sCTLA-4 with best overall response (BOR) to IPI and immune-related adverse events (irAEs) were evaluated through logistic regression. Kaplan-Meier and Cox regression methods were used to analyze OS. A remarkable association between sCTLA-4 levels and BOR was found. Specifically, the proportion of patients with sCTLA-4 > 200 pg/ml in irSD or irPD (immune-related stable or progressive disease) was, respectively, 80% (OR = 0.23; 95%CL = 0.03-1.88) and 89% (OR = 0.11; 95%CL = 0.02-0.71) and was lower than that observed among patients in irCR/irPR (immune-related complete/partial response). sCTLA-4 levels increased during IPI treatment, since the proportion of patients showing sCTLA > 200 pg/ml after 3 cycles was 4 times higher (OR = 4.41, 95%CL = 1.02-19.1) than that after 1 cycle. Moreover, a significantly lower death rate was estimated for patients with sCTLA-4 > 200 pg/ml (HR = 0.61, 95%CL = 0.39-0.98). Higher baseline sCTLA-4 levels were also associated with the onset of any irAE (p value = 0.029), in particular irAEs of the digestive tract (p value = 0.041). In conclusion, our results suggest that high sCTLA-4 serum levels might predict favorable clinical outcome and higher risk of irAEs in IPI-treated MM patients.

Current status and perspectives in immunotherapy for metastatic melanoma

Metastatic melanoma was the first malignancy in which immune checkpoint inhibitors demonstrated their successful efficacy. Currently, the knowledge on the interaction between the immune system and malignant disease is steadily increasing and new drugs and therapeutic strategies are overlooking in the clinical scenario. To provide a comprehensive overview of immune modulating drugs currently available in the treatment of melanoma as well as to discuss of possible future strategies in the metastatic melanoma setting, the present review aims at analyzing controversial aspects about the optimal immunomodulating treatment sequences, the search for biomarkers of efficacy of immunocheckpoint inhibitors, and innovative combinations of drugs currently under investigation.

Analysis of the Expression and Single-Nucleotide Variant Frequencies of the Butyrophilin-like 2 Gene in Patients With Uveal Melanoma

Importance

Chromosome 6p amplification is associated with more benign behavior for uveal melanomas (UMs) with an otherwise high risk of metastasis conferred by chromosome 3 monosomy. Chromosome 6p contains several members of the B7 family of immune regulator genes, including butyrophilin-like 2 (BTNL2; OMIM, 606000), which is associated with prostate cancer risk and autoimmune diseases.

Objective

To investigate the expression and variant allele frequencies of BTNL2, a candidate gene for chromosome 6 amplification, in patients with UM.

Design, Setting, and Participants

In this case-control study, we analyzed the expression of BTNL2 in UM cell lines and human macrophages in patients with UM. Variants of BTNL2 were analyzed using probes for polymerase chain reaction and high-resolution melting. The association of missense variants rs28362679 and rs41441651 with tumor risk was analyzed in 209 patients with UM and 116 matched control patients as well as 12 UM and 64 other tumor cell lines. Genes that were differentially expressed in M1- and M2-polarized macrophages were identified by microarray analysis of 111 patients with UM, and the association of the expression of these genes with disease-free survival was analyzed by Cox regression analysis. Data were collected from September 2013 to November 2015.

Main Outcomes and Measures

Butyrophilin-like 2 single-nucleotide variants were associated with UM risk; M1 and M2 macrophage-specific gene expression was associated with disease-free survival.

Results

We genotyped a total of 325 patients. Of the 209 patients with UM, 124 (59.3%) were male, 114 (54.5%) were Italian, and 95 (45.5%) were German; the mean (range) age was 65 (27-94) years. Of the 116 Italian control patients, 67 (57.8%) were female, and the mean (range) age was 39 (21-88) years. Butyrophilin-like 2 is expressed in patients with UM and macrophages. The frequency of the rs28362679 variant was higher in patients with UM (16 of 209 [7.7%]; 95% CI, 4.7-12.2) than frequencies from European Variation Archive and Exome Aggregation Consortium data (2134 of 118 564 [1.8%]; 95% CI, 1.7-1.9) and Exome Sequencing Project data (100 of 4540 [2.2%]; 95% CI, 1.8-2.7) but were not higher compared with Italian control patients (10 of 116 [8.6%]; 95% CI, 4.6-15.4). The rs41441651 variant was present in 5 patients with UM (2.4%; 95% CI, 0.9-5.7), 2 Italian control patients (1.7%; 95% CI, 0.1-6.5), 2846 patients from European Variation Archive and Exome Aggregation Consortium data (2.4%; 95% CI, 2.3-2.5), and 23 patients from Exome Sequencing Project data (0.5%; 95% CI, 0.3-0.8). Human UM cells express M1 and M2 macrophage-specific genes, whose expression is associated with disease-free survival.

Conclusions and Relevance

Butyrophilin-like 2, expressed at various levels by UM cells and macrophages, might interfere with the immune control of the tumor. Butyrophilin-like 2 variants showed highly variable frequencies among ethnically related cohorts. There was no enrichment of BTNL2 variants in patients with UM compared with control patients.

Potential Role of Soluble c-Met as a New Candidate Biomarker of Metastatic Uveal Melanoma

IMPORTANCE

Conventional melanoma serum biomarkers (S100 and lactate dehydrogenase [LDH]) perform poorly in patients with uveal melanoma, and the search for new biomarkers is needed. A high expression of the oncoprotein c-Met in primary uveal melanoma is associated with metastatic progression, and c-Met is released as a soluble ectodomain through ADAM10- and ADAM17-mediated cleavage, suggesting a possible role as biomarker.

OBJECTIVE

To determine the potential role of soluble c-Met (sc-Met) as a biomarker of uveal melanoma progression in comparison with S100 and LDH.

DESIGN, SETTING, AND PARTICIPANTS

Soluble c-Met was studied in the conditioned medium of 9 uveal melanoma cell lines and in the blood serum samples of 24 mice with uveal melanoma xenografts, 57 patients with uveal melanoma (17 patients whose tumors metastasized and 40 patients whose tumors did not metastasize), and 37 healthy donors. We collected blood samples for as long as 5 years after treatment of the primary tumor. The concentration of sc-Met was measured using enzyme-linked immunosorbent assays, and the receiver operating characteristic curve was used to evaluate sensitivity and specificity in the identification of metastatic uveal melanoma. The study began on May 2, 2011, and the last samples were collected in January 2015.

MAIN OUTCOMES AND MEASURES

Levels of sc-Met in uveal melanoma cell cultures and in the blood serum samples of xenotransplanted mice, of healthy donors, and of patients with uveal melanoma during follow-up.

RESULTS

The conditioned medium of uveal melanoma cell lines and the blood serum samples of mice with uveal melanoma xenografts contained significant levels of sc-Met. Patients with metastatic disease had significantly higher serum levels of sc-Met (median level, 590 ng/mL [range, 246-12,856 ng/mL]) than did patients without metastatic disease (median level, 296 ng/mL [range, 201-469 ng/mL]) (P < .001) and healthy donors (median level, 285 ng/mL [range, 65-463 ng/mL]) (P < .001). Analysis of receiver operating characteristic curves for sc-Met levels in patients with nonmetastatic uveal melanoma vs patients with metastatic uveal melanoma yielded an area under the curve of 0.82 (95% CI, 0.68-0.95) (P < .001), which was superior to the areas under the curve achieved with S100 or LDH markers. Patients with progressive metastatic disease showed further increases in sc-Met level, whereas stable patients did not.

CONCLUSIONS AND RELEVANCE

The present pilot study suggests that sc-Met should be further exploited as a biomarker for monitoring of uveal melanoma.

Differences in X-ray absorption due to cadmium treatment inSaponaria officinalis leaves

A method for detecting cadmium uptake in leaves of Saponaria officinalis doped with a solution of cadmium acetate is described. The technique based on the exposure of dried leaves to X-rays of a wavelength close to that of the metal K-edge could be useful for phytoremediation studies as it could reveal the bioaccumulation in plants due to the treatment either in vivo or in vitro with heavy metals. X-ray microradiography measurements are in agreement with those from peroxidase enzyme assay utilized to follow the oxidative damage induced by heavy metals. At present, as we will see in this report, microradiography has still poorer sensitivity in comparison with enzyme assay, but it has the advantage of being faster, not destructive, and usable even at very high doping levels, where the enzyme assay technique results are fully saturated. Further analysis of the optical density values could lead to a quantitative measurement of the heavy metal in the sample. Thus, the technology developed in this article could be useful for tracing the intake in phytoremediation studies.

A simple method for the purification of type 1 RIPs

We describe a straightforward and simple method for obtaining pure and active preparations of type 1 ribosome inactivating proteins (RIPs). The very high isoelectric point values, characteristic of these proteins, allow this purification in a single chromatographic step.

Effectiveness of cascade filtration plasmapheresis in two patients affected by familial hypercholesterolemia

Hypercholesterolemia has been recognised as a primary risk factor for coronary heart disease. Reduction of plasma levels of total and LDL cholesterol has been shown to decrease coronary atherosclerosis. Plasmapheresis represents an useful non-pharmacological tool to treat severe hypercholesterolemias. We have evaluated the effectiveness of a system of plasmapheresis using a cascade filtration method in two young male subjects (aged 16 and 26 years) with homozygous familial hypercholesterolemia. Both showed severe coronary atherosclerosis as determined by angiography. Procedures were performed at intervals of 7 days in each case. We observed a mean reduction of plasma levels of total cholesterol of 59.5% (range 31.0-75.5%); LDL-cholesterol, 61.6% (range 32.6-77.1%); triglycerides, 48.1%; HDL-cholesterol, 31.1%; apo A-I, 30.8%; and apo B, 57.6%. We also noted a reduction of other parameters, such as fibrinogen (49.9%) and Lp(a) (59.9%). At the end of each procedure about 8 g of cholesterol was removed from the total body pool. A decrease of total proteins (26.9%) and albumin (19.6%) was also observed, but this was completely restored before the next apheresis (1 week). These data show the effectiveness of the removal of LDL in a cascade filtration system, which obtains results not very different from other more selective methods. The lack of selectivity is not much of a problem, since it also reduces other risk factors such as Lp(a) and fibrinogen.

Apo-lipoprotein profile in subjects with extracranial carotid atherosclerosis

Relationships between plasma lipoproteins and cerebrovascular atherosclerosis are not completely clear. In a group of asymptomatic nondiabetic normolipidemic subjects, plasma lipid and apolipoprotein profiles have been related to extracranial carotid atherosclerotic lesions, as assessed by B-mode ultrasonography and independent relations between lipid and clinical parameters and carotid atherosclerosis have been evaluated. We have found that subjects with atherosclerotic lesions (both intimal thickening or plaque) had TG levels and CHO/HDL-C and LDL-C/HDL-C ratios significantly higher and HDL-C and apo A-I levels significantly lower in comparison with subjects with normal arteries. When patients were divided according to the lesions of carotid arteries subjects with atherosclerotic plaque presented HDL-C and apo A-I levels significantly reduced and TG and apo B levels and CHO/HDL-C and LDL-C/HDL-C ratios significantly increased in comparison with subjects with normal arteries, and HDL-C levels reduced and CHO/HDL-C and LDL-C/HDL-C ratios increased in comparison with subjects with intimal thickening. Patients with intimal thickening and normal subjects differed for HDL-C and TG levels and CHO/HDL-C and LDL-C/HDL-C ratios. At multivariate analysis HDL-C levels (negatively), age, hypertension and cigarette smoking (positively) resulted independently associated with cerebrovascular atherosclerosis. Our data seem to show that, although several lipid and apoprotein abnormalities are able to initiate the atherosclerotic process in extracranial carotid district, probably the presence of low HDL-cholesterol levels is an important condition to determine the further worsening of the lesions.

Deeper diagnosis. Multiple determinants of an illness experience

This paper identifies the multiple determinants of a complex illness experience and describes the difficult process of diagnosis and management. The crucial coordination and integration role of the family physician is explained. The perspectives of the family physician, the consulting psychologist, and the patient are elucidated. Interventions by physicians from various specialties are identified and explored. Psychological determinants, including those rooted in the patient's history, are revealed in parallel with the physiological manifestations.

Intraoperative high-flow antegrade irrigation. A new bowel-cleansing system

A new intraoperative method, employing a specially designed apparatus, is described by which the colon can be cleansed to a degree not obtainable by other methods. The method enables continuous antegrade irrigation with large volumes of irrigant at high rates of flow, prior to enterotomy. It has been tested in an experimental canine model and found to be safe and effective.

Identification of T-DNA in the root-inducing plasmid of the agropine type Agrobacterium rhizogenes 1855

The region of the virulence plasmid of the agropine type Agrobacterium rhizogenes 1855 (pRi-1855) which is transferred to plant cells upon infection (T-DNA) has been identified by means of Southern blot hybridizations with the T-DNA of the mannopine type A. rhizogenes 8196. The presence in the plant genome of the pRi-1855 sequences thus identified is demonstrated in carrot roots derived from infection with strain 1855. The T-DNA of pRi-1855 has been mapped by means of cloned Eco RI partial digests. Although strongly homologous with each other, the cores of the T-regions of the mannopine and agropine Ri plasmids are not colinear since the latter contains a central segment of DNA which is absent from the T-region of pRi-8196. Unexpected homologies between the T-region of pRi-1855 and normal carrot DNA have been observed and are discussed here.

Dyspareunia: a symptom of female sexual dysfunction

Dyspareunia is one of the most common sexual symptoms that carries wide-ranging potential foor emotional and physical pain. Informed therapeutic intervention can be useful in helping a person with sexual problems. Organic causes underlying dyspareunia are usually temporary and easily correctable. They are rare as a cause of a continuing problem, compared to issues of intrapersonal and interpersonal conflict. One of the keys to achieving a satisfying relationship on an adult-to-adult basis requires that each partner assume responsibility for his/her own sexual pleasure. The woman who withdraws into the assumption that she has an organic problem in the absence of abnormal findings, or that her partner or therapist must find a solution, abdicates responsibility for her own sexual pleasure. Although few of us will be therapists in the sense that the role is generally understood, indentifying and responding to sexual concerns of patients is part of the professional's commitment. Ultimately, our goal is the same for any problem of human development-- to facilitate the realization of the potentialities of the person.