TROG 15.03/ANZUP International Multicenter Phase II Trial of Focal Ablative STereotactic RAdiotherapy for Cancers of the Kidney (FASTRACK II)

PURPOSE/OBJECTIVE(S)

Stereotactic body radiotherapy (SBRT) is an emerging non-invasive alternative for primary renal cell cancer (RCC) in patients unsuitable for surgery. The objective of the FASTRACK II clinical trial was to investigate the efficacy of SBRT for primary RCC.

MATERIALS/METHODS

This non-randomized, intergroup multi-institutional phase II study was activated in 7 Australian centers and 1 Dutch center, through the Trans Tasman Radiation Oncology Group (TROG) and the Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP). Eligible patients had biopsy confirmed diagnosis of primary RCC with a single lesion within a kidney, ECOG performance ≤2 and were medically inoperable, high risk or declined surgery. For tumors ≤4 cm a single fraction of 26 Gy was prescribed, for tumors > 4 cm, 42 Gy in three fractions was prescribed. The primary outcome of the study was to estimate the efficacy of SBRT for primary RCC, defined as local control based on RECIST criteria. The study was powered assuming that 1-year local control would be 90%, with the null hypothesis of ≤80% considered undesirable and not worthy of proceeding to a future randomized controlled trial.

RESULTS

Between July 2016 and February 2020, 70 patients were enrolled with a median follow-up of 42 months. Median age was 77 years. Forty-nine patients were male (70%), median BMI was 32 and median Charlson comorbidity score was 7. The median [IQR] RENAL complexity score was 8 [7-10]. Biopsy confirmation was 100%. Twenty-three patients (33%) had T1a disease. The median (interquartile range [IQR]) tumor size was 4.6cm [3.7-5.5]; it was 3.3cm [3.0-3.6] in those receiving single fraction (n = 23), and 5.3cm [4.6-6.0] in those receiving 3-fraction SBRT (n = 47). During real-time pre-treatment quality assurance review, 10 cases (14.3%) required resubmission for protocol deviation, 2119 variables were assessed at final review, and final protocol compliance was 99.3%. Seven (10%) patients experienced grade 3 treatment-related adverse events, with no grade 4 or 5 events observed. Eleven (16%) patients reported no adverse events. Local control was 100% throughout the lifetime of the trial (p<0.001). Cancer-specific survival was also 100% throughout the lifetime of the trial. Freedom from distant failure (95% CIs) at 1 and 3 years was 99% (90-100%). Overall survival (95% CIs) at 1 and 3 years was 99% (90-100%) and 82% (70-89%), respectively. Baseline mean eGFR (95% CI) was 61.1 mLs/min (56.6; 65.6) and reduced by -10.8 mLs/min (-13.0; -8.6) by 1-year, by -14.6 mLs/min (-17.0; -12.2) by 2-years and plateaued thereafter.

CONCLUSION

In the first multicenter prospective trial of a non-surgical primary RCC cohort, enrolling mostly T1b+ disease, SBRT was an effective treatment strategy with no observed local failures. We observed an acceptable side effect profile and renal function after SBRT. These outcomes support the design of a future randomized clinical trial of SBRT versus surgery for primary RCC. The trial was registered with ID: NCT02613819.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

OP0069 THE ROLE OF POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY (PET/CT) IN DISEASE ACTIVITY ASSESSMENT IN PATIENTS WITH LARGE VESSEL VASCULITIS

Background:

Assessment of disease activity in large vessel vasculitis (LVV) is still an unmet need. PET Vascular Activity Score (PETVAS) is a new composite score aimed at quantifying the overall inflammatory burden by adding together PET qualitative visual scores (0-3, according to Meller) in nine selected arterial regions (1). In two independent cohorts, PETVAS showed to be effective in discriminating between patients with clinically active and inactive vasculitis.

Objectives:

To assess the role of PET/CT and the performance of PETVAS in differentiating between clinically active and inactive vasculitis in a single center cohort of patients with LVV.

Methods:

One-hundred patients with radiographic evidence of LVV were enrolled by the Rheumatology Unit of Reggio Emilia Hospital (Italy) between June 2007 and September 2020. All subjects underwent full clinical, laboratory and imaging evaluation (including PET/CT) at baseline, annually and when a relapse was suspected. Medical records of recruited patients were retrospectively reviewed from baseline visit until 30 September 2020, last follow-up or death.

For each PET/CT test, the nuclear medicine physician’s interpretation of scans (active/inactive vasculitis) was compared with disease activity clinical judgement (active disease/remission). The latter was based on comprehensive signs/symptoms assessment, laboratory and imaging (excluding PET/CT) data and was considered the reference standard.

For each PET/CT scan, PETVAS score was calculated and its performance in discriminating between patients with active and inactive disease was compared to clinical judgement.

Results:

In the study period 100 LVV patients [51 giant cell arteritis (GCA), 49 Takayasu arteritis (TAK)] underwent a total of 474 PET scans. Nuclear medicine physician’s interpretation of PET/CT was able to discriminate between patients in clinically active LVV (n 167) and those in clinical remission (n 307) with a sensitivity of 60% (95% CI, 51 to 69%) and a specificity of 80% (95% CI, 75 to 84%). The following sensitivity and specificity values were found in LVV subgroups: 73% (95% CI, 59 to 84%) and 77% (95% CI, 70 to 83%) for TAK, and 51% (95% CI, 38 to 63%) and 82% (95% CI, 76 to 88%) for GCA, respectively.

LVV patients with higher PETVAS scores were more frequently classified as having active disease: age and sex adjusted OR 1.15 (95% CI, 1.11 to 1.19), p<0.0001. Similar results were found in LVV subgroups, [age and sex adjusted OR 1.12 (95% CI, 1.08 to 1.17) for GCA and 1.22 (95% CI, 1.14 to 1.31) for TAK, all p<0.0001].

The area under receiver operating characteristics (ROC) curve (AUC) of PETVAS in differentiating between clinically active and inactive LVV was 0.73 (95% CI, 0.68 to 0.79). Similar results were found in LVV subgroups, [0.70 (95% CI, 0.62 to 0.78) for GCA, and 0.79 (95% CI, 0.71 to 0.87) for TAK]. A PETVAS ≥10 provided 61% sensitivity and 80% specificity in differentiating between clinically active and inactive LVV (52% sensitivity and 82% specificity in GCA subgroup and 73% sensitivity and 78% specificity in TAK subgroup).

Conclusion:

In our cohort PET/CT has shown to be useful in monitoring LVV disease activity.

PETVAS seems to be a reliable tool in helping clinicians to discriminate between LVV patients with active disease and those in remission.

References:

[1]Grayson PC, Alehashemi S, Bagheri AA, Civelek AC, Cupps TR, Kaplan MJ, Malayeri AA, Merkel PA, Novakovich E, Bluemke DA, Ahlman MA. 18 F-Fluorodeoxyglucose-Positron Emission Tomography as an Imaging Biomarker in a Prospective, Longitudinal Cohort of Patients with Large Vessel Vasculitis. Arthritis Rheumatol. 2018 Mar;70(3):439-449. doi: 10.1002/art.40379. Epub 2018 Feb 6. PMID: 29145713; PMCID: PMC5882488.

Disclosure of Interests:

None declared

Correction to: Gr-MDSC-linked asset as a potential immune biomarker in pretreated NSCLC receiving nivolumab as second-line therapy

Acknowledgements section was missing.

Gr-MDSC-linked asset as a potential immune biomarker in pretreated NSCLC receiving nivolumab as second-line therapy

PURPOSE

Immunotherapy is a new standard first-line treatment for non-small cell lung cancers (NSCLC) with high programmed cell death-ligand 1 (PD-L1) expression (≥ 50%) and second-line treatment regardless of PD-L1 status, though not all patients benefit from this approach. Much effort is ongoing to identify robust prognostic and predictive biomarkers of response to immune checkpoint inhibitors, overcoming PD-L1 that appears limited in its ability to discriminate patient candidates to this new class of anticancer agents. The purpose of this research study is to identify potential new biomarkers for immunotherapy in lung cancer.

METHODS

Fifty-three consecutive patients with advanced NSCLC treated with nivolumab were enrolled in the study. All the patients received a blood analysis looking for the relationship between different populations of baseline white blood cells and granulocytic myeloid-derived suppressor cells (Gr-MDSC) detected by flow cytometry, to identify and characterize patients with poor likelihood of benefit from nivolumab in NSCLC second-line setting, regardless of clinical feature and PDL1 expression.

RESULTS

Univariate analysis showed that high baseline levels of Gr-MDSC and low baseline CD8/Gr-MDSC ratio are associated with significantly better (P = 0.02) response to immunotherapy treatment. Log-rank tests suggested a significant improvement in OS and PFS with high baseline levels of Gr-MDSC levels (≥ 6 cell/μl), low absolute neutrophil count (< 5840/μl), high eosinophil count (> 90 /μl), and NLR < 3. The multivariate analysis showed a statistically significant improvement for PFS (P = 0.003) and OS (P = 0.05) in favour of the identified good prognostic Gr-MDSC-linked asset group, compared with the poor prognosis group.

CONCLUSION

The role of Gr-MDSC appears interesting as a potential biomarker in NSCLC patients receiving immune-checkpoint inhibitors. Further analyses are needed to confirmed and study in deep the role of these particular cells and their role in cancer response and progression during ICI therapy.

Urban blue: A global analysis of the factors shaping people's perceptions of the marine environment and ecological engineering in harbours

Marine harbours are the focus of a diverse range of activities and subject to multiple anthropogenically induced pressures. Support for environmental management options aimed at improving degraded harbours depends on understanding the factors which influence people's perceptions of harbour environments. We used an online survey, across 12 harbours, to assess sources of variation people's perceptions of harbour health and ecological engineering. We tested the hypotheses: 1) people living near impacted harbours would consider their environment to be more unhealthy and degraded, be more concerned about the environment and supportive of and willing to pay for ecological engineering relative to those living by less impacted harbours, and 2) people with greater connectedness to the harbour would be more concerned about and have greater perceived knowledge of the environment, and be more supportive of, knowledgeable about and willing to pay for ecological engineering, than those with less connectedness. Across twelve locations, the levels of degradation and modification by artificial structures were lower and the concern and knowledge about the environment and ecological engineering were greater in the six Australasian and American than the six European and Asian harbours surveyed. We found that people's perception of harbours as healthy or degraded, but not their concern for the environment, reflected the degree to which harbours were impacted. There was a positive relationship between the percentage of shoreline modified and the extent of support for and people's willingness to pay indirect costs for ecological engineering. At the individual level, measures of connectedness to the harbour environment were good predictors of concern for and perceived knowledge about the environment but not support for and perceived knowledge about ecological engineering. To make informed decisions, it is important that people are empowered with sufficient knowledge of the environmental issues facing their harbour and ecological engineering options.

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5

BACKGROUND

The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival.

METHODS

This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach.

RESULTS

The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers.

CONCLUSIONS

The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

Optimized glycaemic control achieved with add-on basal insulin therapy improves indexes of endothelial damage and regeneration in type 2 diabetic patients with macroangiopathy: a randomized crossover trial comparing detemir versus glargine

AIMS

In diabetes, endothelial damage promotes macroangiopathy and endothelial regeneration is impaired, owing to reduced endothelial progenitor cells (EPCs). Given that insulin influences endothelial biology, we compared the effects of add-on basal insulin analogues on endothelial damage and regeneration in type 2 diabetes (T2D).

METHODS

This was a 6-month randomized crossover trial comparing add-on insulin detemir versus glargine in poorly controlled T2D with macroangiopathy. At baseline, crossover (3 months) and study end (6 months), we measured HbA1c, EPCs, circulating endothelial cells (CECs), VCAM-1, ICAM-1 and E-selectin. Body weight and hypoglycaemic episodes were also recorded.

RESULTS

Forty-two patients completed the study, randomly assigned to the glargine-detemir (n = 21) or the detemir-glargine (n = 21) schedule. At crossover, EPC levels did not change compared with baseline, but significantly increased at study end. CECs decreased over time and were significantly reduced at study end. ICAM-1, VCAM-1 and E-selectin were significantly reduced at crossover and further decreased at study end. No differences were seen in these effects between detemir and glargine. HbA1c showed a carryover effect and its reduction was similar with detemir and glargine in the first arm. Incidence of hypoglycaemia and weight gain was lower with detemir than with glargine in both arms.

CONCLUSION

Optimized glycaemic control by add-on basal insulin improved indexes of endothelial damage and regeneration. Compared to glargine, detemir achieved similar endothelial protection with lower weight gain and less hypoglycaemia. These results might have implications for therapy of aging T2D patients with cardiovascular disease.

Abstract P6-12-06: Oral Vinorelbine and Capecitabine Plus Bevacizumab in Recurrent Inflammatory Breast Cancer: Gene Profiling and Response to Treatment

Background: Therapies that target vasculolymphatic processes - angiogenesis, lymphangiogenesis, and vasculogenesis — have shown potential in the treatment of inflammatory breast cancer.

Methods: We randomly assigned 46 patients to receive oral vinorelbine 55 mg per square meter of body surface on days 1 and 3 and capecitabine 2000 mg per square meter on days 1 to 14 every 3 weeks either concurrent or sequential to bevacizumab 15 mg per kilogram of body weight on days 1 and 21 (BEVIX). The primary end point was progression-free survival;

the response rate and overall survival were a secondary end point. For correlative studies we collected baseline tissue and blood samples of all patients. Gene expression profiling was performed using Affymetrix HG-U133 Plus 2.0 arrays. Data were analyzed using Partek Genomic Suite 6.4 and GeneSpring 7.0. Tissue from normal breast was used as control.

Results: From July 2007 through January 2010, a total of 46 patients were enrolled. Concurrent oral vinorelbine and capecitabine plus bevacizumab significantly increased the objective response rate as compared to the sequential treatment (11.1% vs. 46.4%, p=0.025). No difference in progression-free survival was observed between the two arms (median time to progression 4.3 vs. 4.7 months, p=0.69; Hazard Ratio: 0.86, 95% CI: 0.41-1.80). The median overall survival was 9.1 months in concurrent arm and 15.8 months in sequential arm, (p=0.43). Global gene expression was analyzed in tumor samples from 18 pts bearing a triple negative phenotype. This cohort displayed a specific gene expression profile, including high expression levels of several cytokeratins, Aurora kinase A, Cyclin E and others, similar to the basal-like subtype. This profile did not include genes previously reported as differentially expressed in inflammatory breast cancers. We identified a set of 75 genes whose expression correlates with response to bevacizumab base therapy.

Conclusions: BEVIX is an active treatment for patients with recurrent inflammatory breast cancer. These tumors showed a gene expression pattern similar to that of basal-like type. We identified a set of 75 genes whose expression levels predict the response to BEVIX. The validity of this expression signature is currently being assessed. Supported by Roche and Associazione Italiana per la Ricerca sul Cancro (AIRC) grants. Data partially submitted to 2010 ASCO Meeting

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-12-06.

Is there a role for 'modified VAD' in the treatment of multiple myeloma?

VAD, (Vincristine, Doxorubicin and Dexamethasone) was initially proposed as a salvage therapy for myeloma patients in whom prior alkylating agent therapy failed, although in recent years VAD has been surpassed by novel combination therapies with new biological agents such as thalidomide (and its derivative, lenalidomide) and bortezomib. After the excellent results obtained by the novel agents, VAD can no longer be proposed in preparation to autologous transplantation, although there are still indications that VAD remains useful and clinically relevant in the initial treatment of symptomatic multiple myeloma.

Endothelial precursors and mature endothelial cells are increased in the peripheral blood of myelodysplastic syndromes

Increased angiogenesis has been demonstrated to be a significant prognostic factor in many solid tumors. In the oncohematological setting, it has been associated with myelodysplastic syndromes (MDS), chronic myeloid leukemia, acute lymphoid, and myeloid leukemias. Recently, increased circulating endothelial cells (CECs) have been associated with breast cancer and non-Hodgkin lymphoma (NHL). Based on these premises we analysed total and activated CECs, and endothelial precursors (CEPs) in 50 MDS patients and 20 healthy donors. CECs and CEPs were quantified by flow cytometry. CEC levels were compared with bone marrow (BM) microvessel density (MVD). In addition, some angiogenic factors, namely vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and soluble VEGF-Receptor2 (VEGFR2), were tested in the sera from 25 MDS patients. Total, activated CECs and CEPs were significantly increased in MDS when compared to control group (p<0.0001); whereas in the MDS cases no association was found with French--American--British (FAB), International Prognostic Scoring System (IPSS) subtypes or survival. Patients with higher CECs also showed higher MVD. Among the cytokines analysed, sVEGFR2 was significantly higher in the lower IPSS risk classes, while the levels of bFGF directly correlated with total and activated CECs. Taken together these data strengthen the hypothesis of a possible role of angiogenesis in MDS pathogenesis.

Evaluation of ALK-1 expression in circulating endothelial cells (CECs) as an exploratory biomarker for PF-03446962 undergoing phase I trial in cancer patients

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Background: ALK-1 is a member of the TβRI family & a novel target for antiangiogenic therapy (Rx). PF- 03446962 (PF) is a fully human mAB (IgG2, κ) generated against ALK-1 with dose-dependent preclinical antiangiogenic activities (Hu-Lowe et al, Proc AACR, 2009). This study's objectives were to determine whether: 1) CECs in cancer patients express ALK-1; and 2) whether therapy with PF against ALK-1 will modulate ALK-1 expression or CEC function in an ongoing Ph I trial. Methods: The human mAb was conjugated with alexa fluor 647. ALK-1 expression was assayed by a standardized multicolor flow cytometry assay (Mancuso et al, CCR 2009). Results: ALK-1 expression was characterized on human vascular (HUVEC) & lymphatic (HDLC) endothelial cells; HUVEC & HDLC cells highly express ALK-1 (>99% of these cells are ALK- 1+). ALK-1 expression was assessed in healthy controls (n=17) & cancer patients after normalizing for CEC viability. Patients with advanced malignancies had increased numbers of ALK-1+ CECs: Patients with breast ca (n=12), melanoma (n=8), NSCLC (n=11), & CRC (n=4) had 16±12, 39±23, 50±30, & 62±25 ALK-1+ CECs/mL, respectively, vs 7±6 ALK-1+ CECs/mL in controls. In contrast, ALK-1 expression was minimally or not expressed in pts with hematologic malignancies; ALK-1 was absent in CD117+ or CD34+ bone marrow cells. In the Ph I trial, preliminary evidence suggests that PF may alter CEC function; ALK-1+ CECs were markedly reduced in the 1st two pts studied at EIO after 22 days on Rx. Conclusions: ALK-1 is expressed in CECs. Flow cytometry enables rapid assay of ALK-1 expression in cancer patient blood. ALK-1 is expressed in an increased number of CECs/mL in cancer pts with solid malignancies vs controls. ALK-1 expression in CECs in pts with NSCLC & CRC may correspond to high ALK-1 expression observed in corresponding nonmatched tumor microarrays in addition to other malignancies such as sarcoma, SCLC & neuroendrocine pancreatic ca (Fiedler, Proc ASCO, 2009). Additional preliminary Ph I results will be reported as part of assessing whether CECs may have any role as biomarkers to potentially detect patients with ALK-1+ solid malignancies or monitor anti-ALK-1 therapy.

[Table: see text]

Bevacizumab and oral chemotherapy for patients with lymphangitic breast cancer: A phase II randomized study of bevacizumab with sequential versus concurrent oral vinorelbine plus capecitabine

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Background: Antiangiogenic agents are most likely to be effective in patients (pts) with an extensive cutaneous neo-angiogenic trait of disease. There is a compelling need to monitor the biological activity of such agents and identify markers of efficacy. Methods: We evaluated the activity and biological effects of bevacizumab (B) (15 mg/kg, iv q 3 weeks) in a phase II randomized trial in pts with locally advanced breast cancer (BC) with lymphangitic spread to the chest wall. Primary aim was to assess activity and toxicity of B administered alone followed by sequential oral vinorelbine (V) plus capecitabine (C) (arm A) or with concurrent V plus C (arm B). Secondary aim was to evaluate predictive role of circulating progenitor cells (CECs) and progenitor endothelial cells (CEPs) as surrogate markers of antiangiogenic activity. We collected blood samples of all pts at baseline, at day 12, 42, and at progression. Results: Planned accrual was of 43 pts of whom 23 were enrolled (9 pts in arm A; 14 pts in arm B). Median age was 51 years (range 35–68). Most of the pts had a “triple negative” phenotype [19/23 (82%)]. 10/23 pts (43%) received ≥ 2 previous lines of chemotherapy. 19 pts (82 %) are evaluable for response and all 23 pts are evaluable for toxicity. We observed 5 PR (45%) and 6 SD (55%) in arm B. In arm A, while on B alone, 6 (75%) of the pts had PD and 2 (25%) had a short term SD. Adding VC to B 2 PR (25%), 3 SD (37.5%), and 3 PD (37.5%) were observed. Toxicity profile was typical for use of B (hypertension). The absolute mean number of CECs was 158/ml (range 45–461) (n = 23) at baseline, 116/ml at +12 (range 47–275), and 194/ml at +42 (range 36–891). Mean absolute value of CEPs was 270 (range 28–1060) at baseline, 245/ml at D+12 (range 14–981), and 143/ml (range 5–610) at D+42. The fraction of apoptotic/necrotic CECs was 54±19% at baseline, 64±21 at+12, and 52±18 at+42. Conclusions: Preliminary data showed that B alone is not an effective treatment in pts with lymphangitic spread of BC to the chest wall. Additional data on CECs and CEPs are needed to clarify their potential usefulness as a surrogate markers of antiangiogenic activity of B-based regimen.

No significant financial relationships to disclose.

Preoperative bevacizumab combined with letrozole and chemotherapy in locally advanced ER- and/or PgR-positive breast cancer: clinical and biological activity

The antiangiogenic agent bevacizumab showed synergistic effects when combined with chemotherapy in advanced breast cancer. We presently investigated the activity of bevacizumab in combination with chemotherapy, including capecitabine and vinorelbine, and endocrine therapy, including letrozole (+triptorelin in premenopausal women), as primary therapy for patients with ER and/or PgR ⩾10% T2–T4a-c, N0–N2, M0 breast cancer. Biological end point included the proliferative activity (Ki67), whereas clinical end points were clinical response rate, pathological complete response (pCR) and tolerability. Circulating endothelial cells (CECs) and their progenitors, as surrogate markers of antiangiogenic activity, were measured at baseline and at surgery.Thirty-six women are evaluable. A clinical response rate of 86% (95% CI, 70–95) and no pCR were observed; Ki67 was significantly decreased by 71% (interquartile range, −82%, −62%). Toxicity was manageable: two grade 3 hypertension, four grade 3 deep venous thrombosis and no grade >2 proteinuria were observed. Treatment significantly decreased the percentage of viable CECs and prevented the chemotherapy-induced mobilisation of circulating progenitors. Basal circulating progenitors were positively associated with clinical response. In conclusion, bevacizumab is feasible and active in association with primary chemoendocrine therapy for ER-positive tumours in terms of proliferation inhibition, clinical response and antiangiogenic activity.

Leukotrienes: mediators that have been typecast as villains

As befalls many mediators that act upon the human stage, leukotrienes have become identified with their most powerful roles as villains of the immune system. They are well known for their leading roles in allergic diseases, including asthma. They also have gained recognition for their dramatic role as promoters of inflammation. As new roles for these lipid messengers are sought, it is becoming apparent that the leukotrienes have been typecast as bad guys of the immune system. As examples, their more recent roles have been in atherosclerosis, pulmonary fibrosis and cancer. However, upon further evaluation, we can begin to see their versatility. Thus, leukotrienes stimulate innate immunity against pathogens. In addition, they promote the expression of mediators, receptors and other molecules that are important for immune defense. In these lesser known roles, they lead the fight against bacterial, fungal and viral infection. This review is intended to shed light on the leukotrienes, where they come from and what we really know about them.

Leptin improves pulmonary bacterial clearance and survival in ob/ob mice during pneumococcal pneumonia

The adipocyte-derived hormone leptin is an important regulator of appetite and energy expenditure and is now appreciated for its ability to control innate and adaptive immune responses. We have reported previously that the leptin-deficient ob/ob mouse exhibited increased susceptibility to the Gram-negative bacterium Klebsiella pneumoniae. In this report we assessed the impact of chronic leptin deficiency, using ob/ob mice, on pneumococcal pneumonia and examined whether restoring circulating leptin to physiological levels in vivo could improve host defences against this pathogen. We observed that ob/ob mice, compared with wild-type (WT) animals, exhibited enhanced lethality and reduced pulmonary bacterial clearance following Streptococcus pneumoniae challenge. These impairments in host defence in ob/ob mice were associated with elevated levels of lung tumour necrosis factor (TNF)-alpha, macrophage inflammatory peptide (MIP)-2 [correction added after online publication 28 September 2007: definition of MIP corrected], prostaglandin E(2) (PGE(2)), lung neutrophil polymorphonuclear leukocyte (PMN) counts, defective alveolar macrophage (AM) phagocytosis and PMN killing of S. pneumoniae in vitro. Exogenous leptin administration to ob/ob mice in vivo improved survival and greatly improved pulmonary bacterial clearance, reduced bacteraemia, reconstituted AM phagocytosis and PMN H(2)O(2) production and killing of S. pneumoniae in vitro. Our results demonstrate, for the first time, that leptin improves pulmonary bacterial clearance and survival in ob/ob mice during pneumococcal pneumonia. Further investigations are warranted to determine whether there is a potential therapeutic role for this adipokine in immunocompromised patients.

Thalidomide in patients with advanced hepatocellular carcinoma: A clinical/biological study

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Background: thalidomide has been reported to have anti-angiogenic properties and therefore has been studied in several hypervascularized cancers. We evaluated the effect of thalidomide on progression-free survival (PFS) and several surrogate markers of angiogenesis in patients (pts) with advanced hepatocellular carcinoma (HCC). Methods: from June 2005 to November 2006, 19 out of the foreseen 24 HCC pts were treated with oral thalidomide 200 mg/day continuously. All of them had cytological/histological diagnosis of HCC, with no indication for curative treatment. Prior treatment was allowed. Six-month PFS was the main clinical endpoint. Perfusion parameters (Blood Flow -BF-, Blood Volume -BV-, Permeability Surface -PS-, and Mean Transit Time -MTT-) were measured with perfusion Computed Tomography (CTp). Circulating endothelial cells (CEC), progenitor cells (CEP), and apoptotic CECs, were measured by flow cytometry. Results: Eleven pts were HCV-positive and 4 HBV-positive. Eighteen had cirrhosis (80% Child-Pugh A). Five pts had extra-hepatic metastases. The maximum CLIP value was 3, in 5 pts. Six-month PFS was 41%. Constipation and somnolence were the most common G2–3 toxicities, occurring in 50% and 18% of pts, respectively. Three pts stopped treatment because of toxicity (one oedema, one neurotoxicity, and one suspect intratumoral bleeding). Baseline BF and BV of HCC were significantly higher (p<.05) for the background liver in 18 evaluable pts. BF and BV remained quite stable at six months in the 7 pts free of progression, whereas they increased at the time of progression in the 9 pts with progression within 6 months. The baseline BV in the 7 pts free of progression at 6 months was significantly lower compared with that of pts progressive within 6 months (p=0.03). Seven out of 9 pts who underwent both perfusional and circulating evaluations are currently evaluable at 2 months (2 too early). BF and BV showed an inverse trend with respect to CECs in the 4 pts with PD. Pharmacokinetics and QoL evaluation is ongoing. Conclusions: thalidomide may prolong PFS in pts with advanced HCC, with manageable toxicity. CTp and CECs detection could be used to assess the antiangiogenic drug activity, but it requires further studies to be confirmed. The BV grade could be studied as a predictive factor

No significant financial relationships to disclose.

The prevalence and clinical implications of c-kit expression in plasma cell myeloma

AIM

To evaluate the clinical implications of c-kit (CD117) expression in plasma cell myeloma (PCM).

METHODS AND RESULTS

We first evaluated the reliability of immunohistochemistry in assessing c-kit expression by comparing the results with those obtained by flow cytometry and gene expression arrays in 22 PCM and in 10 PCM cell lines. Immunohistochemical results showed a perfect concordance with those of flow cytometry; likewise, immunohistochemical and gene expression data were also concordant in all but one PCM and cell lines analysed. Then, we investigated the clinical implications of c-kit immunoreactivity in bone marrow biopsies of 85 PCM patients with a mean follow-up of 41 months. C-kit immunoreactivity was detected in 24 (28.2%) of the 85 cases and it was significantly associated with a high microvessel density, but not with traditional clinicopathological characteristics or with survival.

CONCLUSIONS

Our findings suggest that immunohistochemistry is a reliable indicator of c-kit gene expression and reinforce the notion that approximately one-third of PCM express high levels of c-kit. The lack of association with traditional clinicopathological parameters and patient survival suggests that c-kit expression may not be an adjunct in predicting the clinical course of the disease.

Spinal epidural hematoma following coronary thrombolysis. A case report

A case of cervicothoracic spontaneous spinal epidural hematoma (SSEH) following coronary thrombolysis with r-TPA and intravenous heparin is reported. The clinical picture is discussed, as well as the importance of rapid neuroradiological diagnosis (with spinal MRI being the method of choice) and surgical treatment. Anyway, in these patients, thorough cardiac function evaluation and rapid correction of any clotting disorder is necessary prior to surgery. With the increasing use of fibrinolytic therapy this complication would be more frequent. This underlines the importance of prompt recognition and adequate treatment.

Idarubicin containing regimen in multiple myeloma: preliminary results of a pilot study using a modified "TANDEM" transplant program

Tandem autologous transplant actually represents a challenge in multiple myeloma treatment, but the best conditioning regimen is still under investigation. With the aim of evaluating the feasibility of a modified tandem transplant strategy, we treated 10 multiple myeloma patients after conventional first line chemotherapy with a two step conditioning regimen consisting of high-dose melphalan (200 mg/m2) followed by high-dose melphalan (180 mg/m2) together with indarubicin (15 mg/sqm2 c.i. x 3 days) both with peripheral stem cell support. At first transplant, the median age wasyears, performance status was good and disease status was CR in 2 patients and PR in the rest. At the end of the first transplant, 70% of patients achieved CR and only mild toxicity was observed. After the second transplant further improvement of the response rate was obtained with 90% CR. However, we observed three toxic early infection-related deaths from CMV and legionella pneumonia at day + 17, +26, +54 after transplantation. Although this schedule seems to be effective in terms of response rate, the 30% TRM imposes an anthracycline dose-reduction with careful patient selection. This approach could reduce the toxic effects and maintain the efficacy of therapy at the same time.

Macrophage inflammatory protein 1alpha/CCL3 is required for clearance of an acute Klebsiella pneumoniae pulmonary infection

The objective of these studies was to determine the role of macrophage inflammatory protein 1alpha/CCL3 in pulmonary host defense during Klebsiella pneumoniae infection. Following intratracheal inoculation, 7-day survival of CCL3(-/-) mice was less than 10%, compared to 60% for CCL3(+/+) mice. Survival of CCR5(-/-) mice was equivalent to that of controls, indicating that the enhanced susceptibility of CCL3(-/-) mice to K. pneumoniae is mediated via another CCL3 receptor, presumably CCR1. At day 3, CFU burden in the lungs of CCL3(-/-) mice was 800-fold higher than in CCL3(+/+) mice, demonstrating that CCL3 is critical for control of bacterial growth in the lung. Surprisingly, CCL3(-/-) mice had no differences in the recruitment of monocytes/macrophages and even showed enhanced neutrophil recruitment at days 1, 2, and 3 postinfection, compared to CCL3(+/+) mice. Therefore, the defect in clearance was not due to insufficient recruitment of leukocytes. No significant differences in cytokine levels of monocyte chemoattractant protein 1 (MCP-1), interleukin 12, gamma interferon, or tumor necrosis factor alpha in lung lavages were found between CCL3(+/+) and CCL3(-/-) mice. CCL3(-/-) alveolar macrophages were found to have significantly lower phagocytic activity toward K. pneumoniae than CCL3(+/+) alveolar macrophages. These findings demonstrate that CCL3 production is critical for activation of alveolar macrophages to control the pulmonary growth of the gram-negative bacterium K. pneumoniae.

Evaluation of phagocytosis and arachidonate metabolism by alveolar macrophages and recruited neutrophils from F344xBN rats of different ages

The incidence of infectious respiratory diseases increases with aging. Resident alveolar macrophages (AMs) and recruited leukocytes (PMNL) mediate cellular defense against bacterial infections in the lung, and phagocytosis and lipid mediator synthesis are important components of their antimicrobial capacity. The objective of this study was to determine if either phagocytic capacity or lipid mediator generation declines with normal aging, in either AMs or PMNL recruited to a site of inflammation. The F344xBN rat hybrid has a lower incidence of pathologies associated with aging, particularly up to 20 months; animals aged 6,12 and 18 months were chosen to evaluate changes associated with normal aging. As previously reported for peripheral blood leukocytes, phagocytosis by recruited PMNL declined with aging: recruited PMNL from 18 months rats showed a significantly decreased capacity to phagocytose live Klebsiella pneumoniae bacteria, compared to PMNL from 6 months rats. Surprisingly, however, the phagocytic capacity of AMs increased with aging: the phagocytic index of AMs from 18 months rats was more than three times that of AMs from 6 months rats. The capacity of AMs and recruited PMNL to release arachidonic acid or synthesize leukotrienes or prostaglandins did not change with aging. This study demonstrates that, although phagocytosis by recruited PMNL declines with aging, other aspects of immune function do not decline, and may actually increase, with normal aging. These results suggest that impaired phagocytosis by recruited PMNL may be an important component of the increased susceptibility to infectious respiratory diseases during normal aging.

Selective inhibition of COX-2 improves early survival in murine endotoxemia but not in bacterial peritonitis

Prostaglandins of the E series are believed to act as important mediators of several pathophysiological events that occur in sepsis. Studies were performed to evaluate the effect of cyclooxygenase (COX)-2-specific inhibition on the outcome in murine endotoxemia and cecal ligation and puncture (CLP). We observed a significant time-dependent upregulation of PGE(2) production in both blood and lung homogenates of mice administered lipopolysaccharide intraperitoneally, which was nearly completely suppressed by the administration of the COX-2 inhibitor NS-398. Treatment with NS-398 significantly improved early but not late survival in lipopolysaccharide-challenged mice. On the contrary, elevated PGE(2) levels were found in bronchoalveolar lavage fluid but not in plasma of mice subjected to CLP (21 gauge). Pretreatment with NS-398 failed to significantly improve survival in CLP mice. No significant differences were noted in plasma or lung homogenate proinflammatory cytokine levels or lung neutrophil sequestration between the NS-398-treated and control groups. These results demonstrate that selective COX-2 inhibition confers early but not long-term benefits without affecting the expression of proinflammatory cytokines or the development of lung inflammation.

Thalidomide in multiple myeloma, myelodysplastic syndromes and histiocytosis. Analysis of clinical results and of surrogate angiogenesis markers

BACKGROUND

Thalidomide, as a single agent, has been recently found to induce a clinical response in one third of refractory or relapsed myeloma patients. Although it has been reported that thalidomide significantly inhibits angiogenesis. it is still unclear whether its clinical effect is mediated, at least in part, by its anti-angiogenic properties.

PATIENTS AND METHODS

We evaluated thalidomide as a single agent in myeloma, myelodysplastic syndromes (MDS) and histiocytosis, i.e. hematological diseases characterized by increased angiogenesis, and measured prospectively a number of surrogate angiogenesis markers.

RESULTS

Clinical responses were observed in 7 of 17 myeloma and 2 of 5 MDS patients. The histiocytosis patient had a partial response. At the time of the best clinical response, plasma levels of angiogenic growth factors, vascular endothelial growth factor (VEGF) and basic-fibroblast growth factor (b-FGF), were significantly decreased, and flow cytometry indicated a decrease of activated endothelial cells in the bone marrow of responding MDS patients.

CONCLUSIONS

These observations confirm thalidomide efficacy in myeloma, suggest a possible use in MDS and histiocytosis and may contribute to the prediction of clinical response and to understanding the mechanism of thalidomide's action.

Resting and activated endothelial cells are increased in the peripheral blood of cancer patients

Circulating endothelial cells (CECs) were enumerated in 20 healthy controls and 76 newly diagnosed cancer patients by means of 4-color flow cytometry. In breast cancer (n = 46) and lymphoma (n = 30) patients, both resting and activated CECs were increased by 5-fold (P <.0008 vs control). CECs significantly correlated with plasma levels of vascular cell adhesion molecule-1 and vascular endothelial growth factor. Resting and activated CECs were similar to healthy controls in 7 lymphoma patients achieving complete remission after chemotherapy, and activated CECs were found to decrease in 13 breast cancer patients evaluated before and 24 hours after quadrantectomy. (Blood. 2001;97:3658-3661)

Kinetics and viability of circulating endothelial cells as surrogate angiogenesis marker in an animal model of human lymphoma

Circulating endothelial cells (CECs) were evaluated by flow cytometry in immunodeficient mice bearing human lymphoma. A trend toward higher CEC values was observed on days 7 and 14 after transplant, and differences versus controls were highly significant on day 21 (P = 0.0061). A strong correlation was found between CEC and tumor volume (r, 0.942; P = 0.004) and between CEC and tumor-generated VEGF (r, 0.669; P = 0.02). In mice given cyclophosphamide, most of the circulating apoptotic cells were hematopoietic and not endothelial. Conversely, in mice given endostatin, all of the increase in apoptotic cells was in the endothelial cell compartment. CEC evaluation is promising as a noninvasive, surrogate angiogenesis marker.

Leukotriene B4 augments neutrophil phagocytosis of Klebsiella pneumoniae

Neutrophils play a critical role in the clearance of bacteria from the lung and other organs by their capacity for phagocytosis and killing. Previously, we identified an important role for the leukotrienes in rat alveolar macrophage phagocytosis of Klebsiella pneumoniae. In this report, we explored the possibility that the leukotrienes play an important role in phagocytosis by neutrophils as well. Inhibition of endogenous leukotriene synthesis by 5-lipoxygenase knockout in mice or by pharmacologic means in human peripheral blood neutrophils attenuated phagocytosis of opsonized K. pneumoniae. Reduced phagocytosis was also observed in human neutrophils pretreated with a leukotriene B4 receptor but not a cysteinyl-leukotriene receptor antagonist. While leukotriene B4 reconstituted defective phagocytosis in leukotriene-deficient neutrophils and enhanced phagocytosis in neutrophils capable of leukotriene synthesis, leukotriene C4, leukotriene D4, 5-hydroperoxyeicosatetraenoic acid, and 5-oxo-eicosatetraenoic acid were ineffective. To determine the opsonin dependence of the leukotriene B4 augmentation of phagocytosis, we assessed the ability of leukotriene B4 to modulate neutrophil phagocytosis and the adherence of sheep erythrocytes opsonized with immunoglobulin G or the complement fragment C3bi. While leukotriene B4 augmented both Fc receptor- and complement receptor-mediated phagocytosis, increased adherence to leukotriene B4-treated neutrophils was limited to complement opsonized targets. In conclusion, we have identified a novel role for leukotriene B4 in the augmentation of neutrophil phagocytosis mediated by either the Fc or complement receptor.

Intramural leiomyoma during pregnancy becoming pedunculated postpartally. A case report

BACKGROUND

The natural history of uterine leiomyomas during pregnancy has been reported.

CASE

A 39-year-old primigravida presented with vaginal spotting in the 10th week of pregnancy. Ultrasonic evaluation revealed a large intramural leiomyoma. Unsuccessful tocolysis at 25 weeks' gestation resulted in a cesarean section for breech presentation. At hysterotomy a 10-cm intramural leiomyoma was found in the right fundus and was left in situ. Six months later, at open laparotomy for myomectomy, the 10-cm leiomyoma was pedunculated, on a 4-cm stalk.

CONCLUSION

Large intramural leiomyomas found at cesarean section may become pedunculated postpartally, thus making myomectomy easier and safer at a postpartum intervention than at the time of cesarean section. Also, prior knowledge of the possibility of myoma transformation from intramural to pedunculated postpartally may help in planning a later myomectomy. Myomectomy prior to pregnancy should be considered when it has caused a prior pregnancy complication.