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Ibba SV, Luu HH, Boulares AH. Differential effects of poly(ADP ribose) polymerase inhibitor-based metronomic therapy on programmed death-ligand 1 and matrix-associated factors in human myeloid cells. Am J Transl Res 2022; 14:9025-9030. [PMID: 36628210 PMCID: PMC9827284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 11/29/2022] [Indexed: 01/12/2023]
Abstract
We recently showed that while partial poly(ADP-ribose) polymerase (PARP)-1 inhibition with a low metronomic sub-half-maximal inhibitory concentration/dose (IC50) of olaparib provides superior protection against colon cancer in mice compared to complete inhibition by blocking the suppressive function of myeloid-derived suppressor cells (MDSCs) and synergizing with anti-program cell death (PD)-1-based immunotherapy. Here, we examined whether PARP inhibitors (PARPi) exert effects on human myeloid cells that alter T cell function (e.g. PD-ligand (L)1) or metastasis/tumor microenvironment-associated factors (e.g. tissue inhibitor of matrix metalloproteinases (MMPs) (TIMP)-2 and MMPs activity). We show that olaparib-based metronomic therapy induced a marginal increase in PD-L1 expression in MDSCs-enriched cells, decreased its expression in dendritic cells (DCs)-enriched cells, and caused little to no effect on macrophage-enriched cells. Interestingly, MDSCs-enriched cells also expressed low levels of PARP-1 while dendritic cells and macrophages expressed high levels of the protein. Bone marrow progenitors expressed no PD-L1; however, when differentiated into MDSCs, the expression was high displaying higher glycosylation levels compared to those observed in peripheral blood mononuclear cells (PBMCs)-derived cells. Contrary to reported effects on cancer cells, the sub-IC50 or moderate olaparib concentration caused substantial decrease in PD-L1. A sub-IC50 concentration of other clinically used PARPi (rucaparib, niraparib, and talazoparib) as well as the failed PARPi, iniparib, exerted similar effects. Furthermore, PARPi-based metronomic therapy reprogramed myeloid cells with the potential to stabilize intratumoral matrix by increasing secreted-TIMP-2 with a differential reduction in MMP-2/MMP-9 activity. Thus, PARPi-based metronomic therapy may promote functional changes in myeloid cells that provide an additional rationale for combining it with immunotherapy. Our results also provide new opportunities for iniparib in cancer therapy.
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Affiliation(s)
- Salome V Ibba
- The Stanley Scott Cancer Center/Louisiana Cancer Research CenterNew Orleans, LA, USA,Department of Interdisciplinary Oncology, School of Medicine, Louisiana State University Health Sciences CenterNew Orleans, LA, USA
| | - Hanh H Luu
- The Stanley Scott Cancer Center/Louisiana Cancer Research CenterNew Orleans, LA, USA
| | - A Hamid Boulares
- The Stanley Scott Cancer Center/Louisiana Cancer Research CenterNew Orleans, LA, USA,Department of Interdisciplinary Oncology, School of Medicine, Louisiana State University Health Sciences CenterNew Orleans, LA, USA
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2
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Mazánková D, Bárková V, Mazánek P. Metronomic therapy in the treatment of cancer. Ceska Slov Farm 2022; 71:91-97. [PMID: 36058637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Metronomic therapy is a therapeutic method in selected oncological diseases, using long-term administration of low doses of drugs with direct or indirect antitumor effect. In addition, to direct cytotoxic eradication of tumor cells, metronomic therapy can very strongly affect the tumor microenvironment; it also has an immunomodulatory and antiangiogenic effect. Its minimal toxic profile allows for use in patients with severe organ dysfunctions and directly impacts the quality of life and social inclusion of oncological patients.
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3
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Álvarez-León W, Mendieta I, Delgado-González E, Anguiano B, Aceves C. Molecular Iodine/Cyclophosphamide Synergism on Chemoresistant Neuroblastoma Models. Int J Mol Sci 2021; 22:8936. [PMID: 34445656 DOI: 10.3390/ijms22168936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 12/29/2022] Open
Abstract
Neuroblastoma (Nb), the most common extracranial tumor in children, exhibited remarkable phenotypic diversity and heterogeneous clinical behavior. Tumors with MYCN overexpression have a worse prognosis. MYCN promotes tumor progression by inducing cell proliferation, de-differentiation, and dysregulated mitochondrial metabolism. Cyclophosphamide (CFF) at minimum effective oral doses (metronomic therapy) exerts beneficial actions on chemoresistant cancers. Molecular iodine (I2) in coadministration with all-trans retinoic acid synergizes apoptosis and cell differentiation in Nb cells. This work analyzes the impact of I2 and CFF on the viability (culture) and tumor progression (xenografts) of Nb chemoresistant SK-N-BE(2) cells. Results showed that both molecules induce dose-response antiproliferative effects, and I2 increases the sensibility of Nb cells to CFF, triggering PPARγ expression and acting as a mitocan in mitochondrial metabolism. In vivo oral I2/metronomic CFF treatments showed significant inhibition in xenograft growth, decreasing proliferation (Survivin) and activating apoptosis signaling (P53, Bax/Bcl-2). In addition, I2 decreased the expression of master markers of malignancy (MYCN, TrkB), vasculature remodeling, and increased differentiation signaling (PPARγ and TrkA). Furthermore, I2 supplementation prevented loss of body weight and hemorrhagic cystitis secondary to CFF in nude mice. These results allow us to propose the I2 supplement in metronomic CFF treatments to increase the effectiveness of chemotherapy and reduce side effects.
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Gebbia V, Aiello MM, Banna G, Blanco G, Blasi L, Borsellino N, Giuffrida D, Mauro ML, Mancuso G, Piazza D, Savio G, Parra HS, Valerio MR, Verderame F, Vigneri P. Metronomic oral vinorelbine in patients with advanced non-small cell lung cancer progressing after nivolumab immunotherapy: a retrospective analysis. Ecancermedicalscience 2020; 14:1113. [PMID: 33144881 PMCID: PMC7581333 DOI: 10.3332/ecancer.2020.1113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 11/06/2022] Open
Abstract
Purpose: The availability of immune checkpoint inhibitors has deeply changed the therapeutic scenario of patients with advanced non-small cell lung cancer (NSCLC). Up until now, chemotherapy still represents the first-line treatment for patients with advanced NSCLC not harbouring genetic mutations or lacking high expression of programmed death ligand even if the addition of immunotherapy to first-line chemotherapy has recently been shown to improve clinical outcome. We carried out a multi-institutional retrospective analysis on third-line chemotherapy with metronomic oral vinorelbine (VNR) in a series of patients with metastatic NSCLC pre-treated with first-line chemotherapy and second-line immunotherapy. Patients and methods: Thirty patients with metastatic NSCLC with progressive disease after first-line chemotherapy and subsequent immunotherapy were treated with metronomic oral VNR continuously at the fixed dose of 30 mg three times per week. Results: A partial response was achieved in 4 patients (13.3%), while 10 patients (33.3%) displayed disease stabilisation for an overall disease control rate of 46.7%. Median progression-free survival was 3.9 months (range 1–13 months) and median OS reached 8.1 months (range 4.0–24.0+ months) with a 12-month survival rate of 22%. Conclusion: Oral metronomic VNR appears to be active and safe in patients with metastatic NSCLC in progression after first-line chemotherapy and second-line immunotherapy. The results reported, although from a limited sample, may suggest its use for long-term stabilisation of the disease with good patient compliance.
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Affiliation(s)
- Vittorio Gebbia
- Medical Oncology Unit, La Maddalena Clinic for Cancer Medical Oncology, Palermo 90100, Italy.,PROMISE Department, University of Palermo, Palermo 90100, Italy
| | - Marco Maria Aiello
- Policlinico-Vittorio Emanuele, Università di Catania, Catania 95100, Italy
| | - Giuseppe Banna
- Medical Oncology Unit, Ospedale Cannizzaro, Catania 95100, Italy
| | - Giusi Blanco
- Medical Oncology Unit, IOM, Catania 95100, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Civico, Palermo 90100, Italy
| | - Nicolò Borsellino
- Medical Oncology Unit, Ospedale Buccheri La Ferla, Palermo 90100, Italy
| | | | - Mario Lo Mauro
- Medical Oncology Unit, Ospedale Buccheri La Ferla, Palermo 90100, Italy
| | - Gianfranco Mancuso
- Medical Oncology Unit, La Maddalena Clinic for Cancer Medical Oncology, Palermo 90100, Italy
| | | | | | - Hector Soto Parra
- Policlinico-Vittorio Emanuele, Università di Catania, Catania 95100, Italy
| | | | | | - Paolo Vigneri
- Medical Oncology Unit, La Maddalena Clinic for Cancer Medical Oncology, Palermo 90100, Italy
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Marconato L, Sabattini S, Marisi G, Rossi F, Leone VF, Casadei-Gardini A. Sorafenib for the Treatment of Unresectable Hepatocellular Carcinoma: Preliminary Toxicity and Activity Data in Dogs. Cancers (Basel) 2020; 12:cancers12051272. [PMID: 32443457 PMCID: PMC7281367 DOI: 10.3390/cancers12051272] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/20/2022] Open
Abstract
Unresectable nodular and diffuse hepatocellular carcinoma (HCC) have a poor prognosis with limited treatment options. Systemic traditional chemotherapy has been only rarely reported, with unsatisfactory results. The aim of this prospective, non-randomized, non-blinded, single center clinical trial was to investigate safety profile, objective response rate, time to progression and overall survival of sorafenib in comparison with metronomic chemotherapy (MC) consisting of thalidomide, piroxicam and cyclophosphamide in dogs with advanced, unresectable HCC. Between December 2011 and June 2017, 13 dogs were enrolled: seven received sorafenib, and six were treated with MC. Median time to progression was 363 days (95% CI, 191–535) in dogs treated with sorafenib versus 27 days (95% CI, 0–68) in dogs treated with MC (p = 0.044). Median overall survival was 361 days (95% CI, 0–909) in dogs receiving sorafenib, while 32 days (95% CI, 0–235) in those receiving MC (p = 0.079). Sorafenib seems to be a good candidate for the treatment of dogs with advanced HCC, due to a benefit in disease control and an acceptable safety profile, offering a good basis on which new randomized prospective clinical trials should be undertaken to compare the efficacy and drawback of sorafenib versus MC or traditional chemotherapy.
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Affiliation(s)
- Laura Marconato
- Department of Veterinary Medical Sciences, University of Bologna, via Tolara di Sopra 50, Ozzano dell’Emilia, 40064 Bologna, Italy;
- Correspondence:
| | - Silvia Sabattini
- Department of Veterinary Medical Sciences, University of Bologna, via Tolara di Sopra 50, Ozzano dell’Emilia, 40064 Bologna, Italy;
| | - Giorgia Marisi
- Biosciences Laboratory, Istituto Scientifico Romagnolo per Lo Studio e La Cura Dei Tumori (IRST) IRCCS, Via Piero Maroncelli 40, Meldola, 47014 Forlì-Cesena, Italy;
| | - Federica Rossi
- Centro Oncologico Veterinario, via San Lorenzo 1-4, Sasso Marconi, 40037 Bologna, Italy; (F.R.); (V.F.L.)
| | - Vito Ferdinando Leone
- Centro Oncologico Veterinario, via San Lorenzo 1-4, Sasso Marconi, 40037 Bologna, Italy; (F.R.); (V.F.L.)
| | - Andrea Casadei-Gardini
- Division of Oncology, Department of Oncology and Hematology, University Hospital Modena, 41124 Modena, Italy;
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Wu S, Calero-Pérez P, Villamañan L, Arias-Ramos N, Pumarola M, Ortega-Martorell S, Julià-Sapé M, Arús C, Candiota AP. Anti-tumour immune response in GL261 glioblastoma generated by Temozolomide Immune-Enhancing Metronomic Schedule monitored with MRSI-based nosological images. NMR Biomed 2020; 33:e4229. [PMID: 31926117 DOI: 10.1002/nbm.4229] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 06/10/2023]
Abstract
Glioblastomas (GB) are brain tumours with poor prognosis even after aggressive therapy. Improvements in both therapeutic and follow-up strategies are urgently needed. In previous work we described an oscillatory pattern of response to Temozolomide (TMZ) using a standard administration protocol, detected through MRSI-based machine learning approaches. In the present work, we have introduced the Immune-Enhancing Metronomic Schedule (IMS) with an every 6-d TMZ administration at 60 mg/kg and investigated the consistence of such oscillatory behaviour. A total of n = 17 GL261 GB tumour-bearing C57BL/6j mice were studied with MRI/MRSI every 2 d, and the oscillatory behaviour (6.2 ± 1.5 d period from the TMZ administration day) was confirmed during response. Furthermore, IMS-TMZ produced significant improvement in mice survival (22.5 ± 3.0 d for controls vs 135.8 ± 78.2 for TMZ-treated), outperforming standard TMZ treatment. Histopathological correlation was investigated in selected tumour samples (n = 6) analyzing control and responding fields. Significant differences were found for CD3+ cells (lymphocytes, 3.3 ± 2.5 vs 4.8 ± 2.9, respectively) and Iba-1 immunostained area (microglia/macrophages, 16.8% ± 9.7% and 21.9% ± 11.4%, respectively). Unexpectedly, during IMS-TMZ treatment, tumours from some mice (n = 6) fully regressed and remained undetectable without further treatment for 1 mo. These animals were considered "cured" and a GL261 re-challenge experiment performed, with no tumour reappearance in five out of six cases. Heterogeneous therapy response outcomes were detected in tumour-bearing mice, and a selected group was investigated (n = 3 non-responders, n = 6 relapsing tumours, n = 3 controls). PD-L1 content was found ca. 3-fold increased in the relapsing group when comparing with control and non-responding groups, suggesting that increased lymphocyte inhibition could be associated to IMS-TMZ failure. Overall, data suggest that host immune response has a relevant role in therapy response/escape in GL261 tumours under IMS-TMZ therapy. This is associated to changes in the metabolomics pattern, oscillating every 6 d, in agreement with immune cycle length, which is being sampled by MRSI-derived nosological images.
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Affiliation(s)
- Shuang Wu
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Pilar Calero-Pérez
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 08193 Cerdanyola del Vallés, Spain
| | - Lucia Villamañan
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Nuria Arias-Ramos
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 08193 Cerdanyola del Vallés, Spain
| | - Martí Pumarola
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 08193 Cerdanyola del Vallés, Spain
- Unit of Murine and Comparative Pathology, Department of Animal Medicine and Animal Surgery, Veterinary Faculty, UAB, Cerdanyola del Vallès, Spain
| | | | - Margarida Julià-Sapé
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 08193 Cerdanyola del Vallés, Spain
- Institut de Biotecnologia i de Biomedicina (IBB), Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Carles Arús
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 08193 Cerdanyola del Vallés, Spain
- Institut de Biotecnologia i de Biomedicina (IBB), Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Ana Paula Candiota
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 08193 Cerdanyola del Vallés, Spain
- Institut de Biotecnologia i de Biomedicina (IBB), Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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Nakano Y, Gatell SP, Schultz KAP, Carrillo TM, Fujisaki H, Okada K, Horiike M, Nakamura T, Watanabe Y, Matsusaka Y, Sakamoto H, Fukushima H, Inoue T, Williams GM, Hill DA, Hara J. Successful treatment of metastatic cerebral recurrence of pleuropulmonary blastoma. Pediatr Blood Cancer 2019; 66:e27628. [PMID: 30677214 DOI: 10.1002/pbc.27628] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 11/06/2018] [Accepted: 11/30/2018] [Indexed: 01/06/2023]
Abstract
Pleuropulmonary blastoma (PPB) is a rare pediatric tumor. The central nervous system (CNS) is the most common site of extrathoracic metastasis. The prognosis of PPB patients with CNS metastases is dismal: most patients die within one year after recurrence. Here, we describe two patients diagnosed with PPB who developed intracranial recurrences shortly after the end of their initial treatment and were successfully treated by gross total resection, radiotherapy, and chemotherapy. Both patients are in complete remission four and three years after recurrence. Although an optimal regimen remains to be determined, these cases demonstrate that PPB with CNS metastases is potentially curable.
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Affiliation(s)
- Yoshiko Nakano
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
| | - Sandra Pisa Gatell
- Department of Pediatric Hematology and Oncology, Hospital Universitari de Sabadell Parc Taulí, Sabadell, Barcelona, Spain
| | - Kris Ann P Schultz
- Cancer and Blood Disorders, International Pleuropulmonary Blastoma/DICER1 Registry, Children's Minnesota, Minneapolis, Minnesota
| | - Thais Murciano Carrillo
- Department of Pediatric Hematology and Oncology, Hospital Universitari de Sabadell Parc Taulí, Sabadell, Barcelona, Spain
| | - Hiroyuki Fujisaki
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
| | - Keiko Okada
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
| | - Masaki Horiike
- Department of Pediatric Surgery, Osaka City General Hospital, Osaka, Japan
| | - Tetsuro Nakamura
- Department of Pediatric Surgery, Osaka City General Hospital, Osaka, Japan
| | - Yusuke Watanabe
- Department of Pediatric Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Yasuhiro Matsusaka
- Department of Pediatric Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Hiroaki Sakamoto
- Department of Pediatric Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Hiroko Fukushima
- Department of Pathology, Osaka City General Hospital, Osaka, Japan
| | - Takeshi Inoue
- Department of Pathology, Osaka City General Hospital, Osaka, Japan
| | - Gretchen M Williams
- Cancer and Blood Disorders, International Pleuropulmonary Blastoma/DICER1 Registry, Children's Minnesota, Minneapolis, Minnesota
| | - D Ashley Hill
- Department of Pathology, Children's National Medical Center, Washington, District of Columbia
| | - Junichi Hara
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
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8
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Dalgleish AG, Stern PL. The failure of radical treatments to cure cancer: can less deliver more? Ther Adv Vaccines Immunother 2018; 6:69-76. [PMID: 30623172 PMCID: PMC6304701 DOI: 10.1177/2515135518815393] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 11/05/2018] [Indexed: 12/31/2022] Open
Abstract
All too often attempts to deliver improved cancer cure rates by increasing the dose of a particular treatment are not successful enough to justify the accompanying increase in toxicity and reduction in quality of life suffered by a significant number of patients. In part, this drive for using higher levels of treatment derives from the nature of the process for testing and incorporation of new protocols. Indeed, new treatment regimens must now consider the key role of immunity in cancer control, a component that has been largely ignored until very recently. The recognition that some drugs developed for cytotoxicity at higher doses can display alternative anticancer activities at lower doses including through modulation of immune responses is prompting a significant re-evaluation of treatment protocol development. Given that tumours are remarkably heterogeneous and with inherent genetic instability it is probably only the adaptive immune response with its flexibility and extensive repertoire that can rise to the challenge of effecting significant control and ultimately elimination of a patient's cancer. This article discusses some of the elements that have limited higher levels of treatment outcomes and where too much proved less effective. We explore observations that less can often be as effective, if not more effective especially with some chemotherapy regimens, and discuss how this can be exploited in combination with immunotherapies to deliver nontoxic improved tumour responses.
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Affiliation(s)
- Angus G Dalgleish
- Infection and Immunity Centre, St George's, University of London, Cranmer Terrace, London, UK
| | - Peter L Stern
- Division of Molecular and Clinical Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Cancer Research Centre, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
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9
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Ueno T, Masuda N, Kamigaki S, Morimoto T, Akiyama F, Kurosumi M, Tsuda H, Mikami Y, Tanaka S, Morita S, Toi M. A multicenter phase II trial of neoadjuvant letrozole plus low-dose cyclophosphamide in postmenopausal patients with estrogen receptor-positive breast cancer (JBCRG-07): therapeutic efficacy and clinical implications of circulating endothelial cells. Cancer Med 2018; 7:2442-2451. [PMID: 29733541 PMCID: PMC6010720 DOI: 10.1002/cam4.1516] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/27/2018] [Accepted: 04/02/2018] [Indexed: 12/12/2022] Open
Abstract
Neoadjuvant endocrine therapy has been reported to decrease tumor size, which leads to increased breast conservation rates. To improve the clinical response, metronomic chemotherapy with endocrine therapy is a promising strategy. A multicenter phase II single‐arm neoadjuvant trial with letrozole and cyclophosphamide was conducted. Eligibility criteria included postmenopausal status, T2–4 N0–1, and estrogen receptor‐positive breast carcinoma. Letrozole (2.5 mg) plus cyclophosphamide (50 mg) was given orally once a day for 24 weeks. The primary endpoint was the clinical response rate (CRR). To investigate anti‐angiogenic effects, circulating endothelial cells (CECs) were quantified using the CellSearch system. From October 2007 to March 2010, 41 patients were enrolled. The CRR was 67.5% (52.0–80.0%), which was above the prespecified threshold (65%). The conversion rate from total mastectomy to breast‐conserving surgery was 64% (18/28). Grade 3 or greater nonhematological toxicity was not reported. Clinical response was associated with improved disease‐free survival (DFS) (P = 0.020). The increase in CEC counts at 8 weeks was observed in nonresponders (P = 0.004) but not in responders. Patients with higher CEC counts at baseline or post‐treatment showed worse DFS than those with lower counts (P < 0.001 at baseline and = 0.014 post‐treatment). Multivariate analysis showed that post‐treatment CEC counts but not pretreatment counts were independently correlated with DFS (P = 0.046). In conclusion, neoadjuvant letrozole plus cyclophosphamide showed a good clinical response for postmenopausal patients with estrogen receptor‐positive breast cancer. CEC quantification is a promising tool for treatment monitoring and prognostic stratification for metronomic therapy following validation of our results in larger studies. Clinical trial registration number: UMIN000001331 Phase II study of neoadjuvant letrozole combined with low‐dose metronomic cyclophosphamide for postmenopausal women with endocrine‐responsive breast cancer (JBCRG‐07)
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Affiliation(s)
- Takayuki Ueno
- Breast Surgical Oncology, Breast Oncology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Breast Surgery, School of Medicine, Kyorin University, Tokyo, Japan
| | - Norikazu Masuda
- National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | | | | | - Futoshi Akiyama
- Department of Pathology, The Cancer Institute of Japanese Foundation for Cancer Research, Tokyo, Japan
| | | | - Hitoshi Tsuda
- Department of Basic Pathology, National Defense Medical College, Saitama, Japan
| | - Yoshiki Mikami
- Department of Diagnostic Pathology, Kumamoto University Hospital, Kumamoto, Japan
| | - Sunao Tanaka
- Department of Breast Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Masakazu Toi
- Department of Breast Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
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10
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de Boo LW, Vulink AJE, Bos MEMM. Metronomic cyclophosphamide-induced long-term remission after recurrent high-grade serous ovarian cancer: A case study. Mol Clin Oncol 2017; 7:1130-1134. [PMID: 29285388 DOI: 10.3892/mco.2017.1457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/28/2017] [Indexed: 11/06/2022] Open
Abstract
Metronomic oral cyclophosphamide has gained increasing interest in recent years as a promising maintenance therapy in advanced, platinum-sensitive, high-grade serous ovarian cancer (HGSOC). Metronomic treatment with cyclophosphamide refers to the frequent, usually daily, administration of a low (oral) dose of cyclophosphamide with no prolonged drug-free breaks. Main advantages of this treatment are the effective reduction of tumour activity, oral administration in an outpatient setting, low cost and the low toxicity profile. Metronomic oral cyclophosphamide can benefit patients suffering from types of cancer known to be sensitive to alkylating agents, such as platinum-sensitive HGSOC. In recent years, several publications have underlined the advantage of this regimen and possible explanations were explored. We here present a patient with multiple recurrences of metastasized HGSOC, platinum-sensitive, with an on-going complete response to monotherapy with oral cyclophosphamide. This observation supports that patients with relapsing HGSOC who responded to platinum-based chemotherapy and cannot continue platinum-based chemotherapy because of toxicity, can be offered a course of metronomic cyclophosphamide. This case may serve as a reminder that old drugs can be used successfully even in the age of new upcoming therapy such as anti-angiogenic agents (VEGF inhibitors) and poly-ADP-ribose polymerase (PARP) inhibitors.
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Ferrer-Font L, Arias-Ramos N, Lope-Piedrafita S, Julià-Sapé M, Pumarola M, Arús C, Candiota AP. Metronomic treatment in immunocompetent preclinical GL261 glioblastoma: effects of cyclophosphamide and temozolomide. NMR Biomed 2017; 30:e3748. [PMID: 28570014 DOI: 10.1002/nbm.3748] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/27/2017] [Accepted: 04/13/2017] [Indexed: 06/07/2023]
Abstract
Glioblastoma (GBM) causes poor survival in patients even when applying aggressive treatment. Temozolomide (TMZ) is the standard chemotherapeutic choice for GBM treatment, but resistance always ensues. In previous years, efforts have focused on new therapeutic regimens with conventional drugs to activate immune responses that may enhance tumor regression and prevent regrowth, for example the "metronomic" approaches. In metronomic scheduling studies, cyclophosphamide (CPA) in GL261 GBM growing subcutaneously in C57BL/6 mice was shown not only to activate antitumor CD8+ T-cell response, but also to induce long-term specific T-cell tumor memory. Accordingly, we have evaluated whether metronomic CPA or TMZ administration could increase survival in orthotopic GL261 in C57BL/6 mice, an immunocompetent model. Longitudinal in vivo studies with CPA (140 mg/kg) or TMZ (range 140-240 mg/kg) metronomic administration (every 6 days) were performed in tumor-bearing mice. Tumor evolution was monitored at 7 T with MRI (T2 -weighted, diffusion-weighted imaging) and MRSI-based nosological images of response to therapy. Obtained results demonstrated that both treatments resulted in increased survival (38.6 ± 21.0 days, n = 30) compared with control (19.4 ± 2.4 days, n = 18). Best results were obtained with 140 mg/kg TMZ (treated, 44.9 ± 29.0 days, n = 12, versus control, 19.3 ± 2.3 days, n = 12), achieving a longer survival rate than previous group work using three cycles of TMZ therapy at 60 mg/kg (33.9 ± 11.7 days, n = 38). Additional interesting findings were, first, clear edema appearance during chemotherapeutic treatment, second, the ability to apply the semi-supervised source analysis previously developed in our group for non-invasive TMZ therapy response monitoring to detect CPA-induced response, and third, the necropsy findings in mice cured from GBM after high TMZ cumulative dosage (980-1400 mg/kg), which demonstrated lymphoma incidence. In summary, every 6 day administration schedule of TMZ or CPA improves survival in orthotopic GL261 GBM with respect to controls or non-metronomic therapy, in partial agreement with previous work on subcutaneous GL261.
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Affiliation(s)
- Laura Ferrer-Font
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Spain
- Institut de Biotecnologia i de Biomedicina (IBB), Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Nuria Arias-Ramos
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Spain
| | - Silvia Lope-Piedrafita
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Spain
- Servei de Ressonància Magnètica Nuclear, Edifici C, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Margarida Julià-Sapé
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Spain
- Institut de Biotecnologia i de Biomedicina (IBB), Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Martí Pumarola
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Spain
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Edifici V, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Carles Arús
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Spain
- Institut de Biotecnologia i de Biomedicina (IBB), Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Ana Paula Candiota
- Departament de Bioquímica i Biologia Molecular, Unitat de Bioquímica de Biociències, Edifici Cs, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Spain
- Institut de Biotecnologia i de Biomedicina (IBB), Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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Mencoboni M, Filiberti RA, Taveggia P, Del Corso L, Del Conte A, Covesnon MG, Puccetti C, Donati S, Auriati L, Amoroso D, Camerini A. Safety of First-line Chemotherapy with Metronomic Single-agent Oral Vinorelbine in Elderly Patients with NSCLC. Anticancer Res 2017; 37:3189-3194. [PMID: 28551663 DOI: 10.21873/anticanres.11679] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The optimal therapeutic use of metronomic vinorelbine has not yet been defined. We aimed to assess the safety of metronomic oral vinorelbine in first-line treatment of elderly patients with advanced lung cancer who were unfit for polychemotherapy. Progression-free survival, response rate and overall survival were secondary end-points. PATIENTS AND METHODS Seventy-six patients received 50 mg of oral vinorelbine three times per week, until disease progression, patient refusal or unacceptable toxicity. Patients were evaluated for response and toxicity after one cycle of chemotherapy. The treatment was considered feasible with a grade 3/4 toxicity rate lower than 20%. RESULTS Clinical benefit was observed in 50% of patients. Median overall survival was 8.0 months. Grade 1/2 toxicity was observed in 53 patients (69.7%), grade 3 toxicity in eight patients (10.5%). One patient had grade 4 diarrhea. CONCLUSION Metronomic oral vinorelbine is safe in elderly patients, allowing for long-term disease stabilization with optimal patient compliance.
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Affiliation(s)
| | - Rosa Angela Filiberti
- Clinical Epidemiology, IRCCS AOU San Martino-IST-National Cancer Research Institute, Genoa, Italy
| | | | | | | | | | - Cheti Puccetti
- Medical Oncology, Versilia Hospital, Lido di Camaiore, Italy
| | - Sara Donati
- Medical Oncology, Versilia Hospital, Lido di Camaiore, Italy
| | | | | | - Andrea Camerini
- Medical Oncology, Versilia Hospital, Lido di Camaiore, Italy
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Berthold F, Hömberg M, Proleskovskaya I, Mazanek P, Belogurova M, Ernst A, Sterba J. Metronomic therapy has low toxicity and is as effective as current standard treatment for recurrent high-risk neuroblastoma. Pediatr Hematol Oncol 2017; 34:308-319. [PMID: 29148865 DOI: 10.1080/08880018.2017.1373314] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The metronomic therapy concept uses low doses of continuously applied chemotherapeutic, anti-angiogenetic, and immunomodulating drugs. Twenty patients with recurrent and 3 with refractory high-risk neuroblastoma were treated by the metronomic concept using celecoxib, cyclophosphamide, vinblastine, and etoposide for up to 24 months. The outcome was compared to 274 matched patients with a first recurrence from stage 4 neuroblastoma using the variables time from diagnosis to first recurrence, number of organs involved, and MYCN amplification. All were treated with dose-intensive conventional chemotherapy. The study patients experienced 1-3 recurrences and had 1-3 sites involved (osteomedullary, primary tumor, central nervous system, lymph nodes, liver, lungs) before the metronomic therapy started. Two patients in complete remission and three with active refractory disease following recurrence treatment were excluded from the outcome analysis. The curves for secondary event-free and overall survival demonstrated no significant differences. The toxicity was minimal except for ≥3 grade thrombocytopenia and leukopenia (all heavily pretreated). The treatment was realized in an outpatient setting. The metronomic approach is similarly effective as standard treatment in recurrent high-risk neuroblastoma, has low toxicity, and is applicable in an outpatient setting. A prospective study including propranolol as a fifth drug is underway.
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Affiliation(s)
- Frank Berthold
- a Department of Pediatric Oncology and Hematology , University of Cologne , Germany
| | - Marc Hömberg
- a Department of Pediatric Oncology and Hematology , University of Cologne , Germany
| | - Inna Proleskovskaya
- b Department of Pediatric Oncology and Hematology , University of Minsk , Belarus
| | - Pavel Mazanek
- c Department of Pediatric Oncology and Hematology , University of Brno , Czech Republic
| | - Margarita Belogurova
- d Department of Pediatric Oncology and Hematology , University of Cologne , St. Petersburg , Russia
| | - Angela Ernst
- e Institute of Medical Statistics, Informatics, and Epidemiology , University of Cologne , Germany
| | - Jaroslav Sterba
- c Department of Pediatric Oncology and Hematology , University of Brno , Czech Republic
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Ferrer-Font L, Villamañan L, Arias-Ramos N, Vilardell J, Plana M, Ruzzene M, Pinna LA, Itarte E, Arús C, Candiota AP. Targeting Protein Kinase CK2: Evaluating CX-4945 Potential for GL261 Glioblastoma Therapy in Immunocompetent Mice. Pharmaceuticals (Basel) 2017; 10:E24. [PMID: 28208677 DOI: 10.3390/ph10010024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/01/2017] [Accepted: 02/06/2017] [Indexed: 02/07/2023] Open
Abstract
Glioblastoma (GBM) causes poor survival in patients even with aggressive treatment. Temozolomide (TMZ) is the standard chemotherapeutic choice for GBM treatment but resistance always ensues. Protein kinase CK2 (CK2) contributes to tumour development and proliferation in cancer, and it is overexpressed in human GBM. Accordingly, targeting CK2 in GBM may benefit patients. Our goal has been to evaluate whether CK2 inhibitors (iCK2s) could increase survival in an immunocompetent preclinical GBM model. Cultured GL261 cells were treated with different iCK2s including CX-4945, and target effects evaluated in vitro. CX-4945 was found to decrease CK2 activity and Akt(S129) phosphorylation in GL261 cells. Longitudinal in vivo studies with CX-4945 alone or in combination with TMZ were performed in tumour-bearing mice. Increase in survival (p < 0.05) was found with combined CX-4945 and TMZ metronomic treatment (54.7 ± 11.9 days, n = 6) when compared to individual metronomic treatments (CX-4945: 24.5 ± 2.0 and TMZ: 38.7 ± 2.7, n = 6) and controls (22.5 ± 1.2, n = 6). Despite this, CX-4945 did not improve mice outcome when administered on every/alternate days, either alone or in combination with 3-cycle TMZ. The highest survival rate was obtained with the metronomic combined TMZ+CX-4945 every 6 days, pointing to the participation of the immune system or other ancillary mechanism in therapy response.
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Abstract
Objective: The objective of this study is to assess the postmarketing status: Efficacy and safety drugs and biologics related with cancer approved under expedited review. Methods: This observational, analytical study was carried between January and April 2016 by the Department of Pharmacology and Medical Oncology, Saveetha Medical College. Drugs approved under expedited review, fast-track status and its association with anti-cancer effects, postmarketing efficacy and safety, propensity to induce the second tumor was noted. Drug approval status and average time of review process were obtained from the United States-Food and Drug Administration (FDA), Center for Drugs and Biologics Center (Center for Drug Evaluation and Research and Center for Biologics Evaluation and Research). Postmarketing adverse events and safety issues were collected FDA adverse effects reporting system. Further, evidence efficacy and safety of drugs were taken from various meta-analysis, reports on BioMed journals, and Cochrane systematic reviews. Results: In the last 5 years, 166 products were approved by expedited review. Out of 166, 48 (28.9%) drugs/biologics are anticancer drugs and drugs used in precancerous conditions. The average time of review varies from19 months to 8.2 months. Out of these 48 molecules, 37 (77%) molecules received serious adverse event alert. Positive correlation is seen between average time of review and number of adverse events reported. Seven (14.5%) drugs were proven to induce second tumor among receivers. Conclusion: Although expedited review facilitates faster approval of drugs; selection and assessment criteria should be stringent to prevent clinical failure, serious adverse effects of such drugs exposed to many individuals. Focus should be given developing chemosensitizing molecule and evaluation of metronomic regimen which is being more optimistic in current cancer therapeutics.
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Affiliation(s)
| | - Anita Ramesh
- Department of Medical Oncology, Saveetha Medical College, Chennai, Tamil Nadu, India
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Li L, Patel M, Nguyen HS, Doan N, Sharma A, Maiman D. Primary atypical teratoid/rhabdoid tumor of the spine in an adult patient. Surg Neurol Int 2016; 7:27. [PMID: 27069744 PMCID: PMC4802991 DOI: 10.4103/2152-7806.178523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 01/20/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Atypical teratoid/rhabdoid tumor (AT/RT) is an aggressive neoplasm of the central nervous system that generally arises intracranially in patients under 2 years of age. Primary spinal AT/RT in an adult is rare. CASE DESCRIPTION A 23-year-old female presented with left lower extremity sciatica attributed to a magnetic resonance imaging (MRI)-documented intradural mass between L2 and L4. The lesion was biopsied (was unresectable) and treated with high-dose chemotherapy (methotrexate, vincristine, cyclophosphamide, etoposide, and cisplatin) with autologous hematopoietic stem cells rescue, followed by 2 months of radiation therapy (36 Gy to craniospinal axis, 20 Gy to lumbar region) with concurrent temozolomide; the latter was discontinued after 3 weeks due to myelosuppression. Tumor relapsed 1 year later at C7-T1 level. She was started on oral metronomic therapy, and bevacizumab was added 2 months later. Three months later, a cervical MRI showed progression of the tumor, along with new lesions in the thoracic/lumbar spine plus intracranial punctate nodular tumors. Following resection of the C7/T1 lesion, she was started on palliative alisertib; a month later, a cranial computed tomography showed progression of her disease with hydrocephalus. Treatment was discontinued, and she expired 12 months after initial diagnosis. CONCLUSION Primary spinal AT/RT in the adult patient is rare. The pathology is associated with early recurrence and a poor prognosis. Although potential benefits of metronomic chemotherapy and alisertib have been reported, the patient in this study did not favorably respond to these modalities.
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Affiliation(s)
- Luyuan Li
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Mohit Patel
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ha Son Nguyen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ninh Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Abhishiek Sharma
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Dennis Maiman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Ugocsai P, Wolff D, Menhart K, Hellwig D, Holler E, Herr W, Reichle A. Biomodulatory metronomic therapy induces PET-negative remission in chemo- and brentuximab-refractory Hodgkin lymphoma. Br J Haematol 2015; 172:290-3. [PMID: 25944562 DOI: 10.1111/bjh.13480] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Peter Ugocsai
- Department of Internal Medicine III, Haematology & Oncology, University Hospital of Regensburg, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, Haematology & Oncology, University Hospital of Regensburg, Regensburg, Germany
| | - Karin Menhart
- Department of nuclear Medicine, University Hospital of Regensburg, Regensburg, Germany
| | - Dirk Hellwig
- Department of nuclear Medicine, University Hospital of Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, Haematology & Oncology, University Hospital of Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, Haematology & Oncology, University Hospital of Regensburg, Regensburg, Germany
| | - Albrecht Reichle
- Department of Internal Medicine III, Haematology & Oncology, University Hospital of Regensburg, Regensburg, Germany.
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