Salvage Regimen With Autologous Stem Cell Transplantation With Or Without Rituximab Maintenance For Relapsed Diffuse Large B-Cell Lymphoma (Dlbcl): Coral Final Report

Times Cited: 0 References: 0 Citation MapAbstract : Background: Chemotherapy followed by autologous stem cell transplantation (ASCT) is the standard treatment for relapsed DLBCL. No study has compared salvage therapies and evaluated maintenance post ASCT.Methods: DLBCL CD 20+ in first relapse or pts refractory after first therapy were randomized between R ICE (rituximab, ifosfamide, etoposide, carboplatinum) or R DHAP (rituximab dexamethasone cytarabine cisplatinum). Responding patients received BEAM and ASCT then randomized between observation or maintenance with rituximab every 2 m for 1 yr (Gisselbrecht J Clin Oncol; 2010).Results: Analysis was made on 477 pts (R ICE: 243 pts; R DHAP: 234 pts): 255 relapses >12m, 213 refractory/early relapses; 306 pts had prior rituximab; secondary(s) IPI 0-1: 281 pts; s IPI 2-3:181pts. There was no difference in response rate between R ICE 63.6% and R DHAP 64.3%. There was no difference between R ICE and R DHAP at 4 yrs for EFS (26% vs 37% p=0.2) and OS (43% vs 51%, p=0.3). Factors affecting 4 yrs EFS, PFS and OS were: prior treatment with rituximab; early relapse< 12 m; s IPI 2-3. ASCT was performed in 255 pts and 242 randomized for maintenance: 122 pts rituximab (R), 120 pts observation (O). Distribution between R/O arms were respectively: median age 54 /53 yrs, Male 76/83; female 46/37; secondary IPI 0-1: 84/81; sIPI 2-3: 36/36. 89/76 relapses >12m., 33/41 refractory/early relapses. Median follow up was 44 m with 111 events. 4 yrs EFS was 52.8 % (CI 46-59) with 63% (CI 56-69) OS. There was no difference in EFS, PFS and OS between R and O arms. In multivariate analysis, sIPI2-3 significantly affected EFS, PFS, OS (p=0.0004). Women (83pts) had a better 4 yrs EFS 63% than male (159pts) 37% (p=0.01). The difference was only in the R arm (p=0.004). Gender was an independent prognostic factor in the R arm. Toxicity was mild with 12% SAE versus 4% for R /O respectively.Conclusions: There was no difference between R ICE and R DHAP and between post ASCT maintenance with R or O. Women did significantly better after ASCT with rituximab. Early relapses to upfront rituximab-based chemotherapy have a poor prognosis.

Les métastases orbitaires [Orbital metastasis]

PURPOSE: The purpose of this paper is to present our data and to provide some conclusions about the attitude that has to be chosen when metastasis of the orbit is suspected. PATIENTS AND METHODS: Between 1965 and 1994, 571 patients with non-traumatic orbital diseases were controlled in the department of ophthalmology of Lausanne. Thirty-four cases of metastasis of the orbit were selected, that is 24 females and 10 males, aged from 1 to 81 years. Tumors of the breast are the most frequent origin of this metastasis, followed by cutaneous melanomas and pulmonary tumors. Orbital metastasis was the first sign of a malignant process in 7 patients. The histologic diagnosis was confirmed in 15 patients. The type of treatment is presented herein and the follow-up of more than half of the cases is given. RESULTS AND CONCLUSION: Orbital metastasis can develop after a long time in patients who were previously treated for malignant tumors. In several cases, orbital metastasis was the first sign of a malignant process which starts to become general. This diagnosis has to be taken into account when a patient was treated earlier for a malignant tumor, and it is reasonable to propose a biopsy or an excision biopsy in every orbital pathology which was not confirmed by clinical or paraclinical investigations.

Current concepts and management of glioblastoma.

Glioblastoma is the most common malignant primary brain tumor in adults. Its often rapid clinical course, with many medical and psychosocial challenges, requires a multidisciplinary management. Modern multimodality treatment and care improve patients' life expectancy and quality of life. This review covers major aspects of care of glioblastoma patients with a focus on the management of common symptoms and complications. We aim to provide a guide for clinicians confronted with glioblastoma patients in their everyday practice. Ann Neurol 2011;

Mixed medullary-papillary carcinoma of the thyroid: report of a case and review of the literature.

BACKGROUND: Mixed medullary-follicular thyroid carcinoma denotes a rare and heterogeneous group of tumors displaying morphological and immunophenotypical features of both origins within the same lesion. METHOD: We report a case of a 41-year-old woman with a lump in the right side of the neck, increasing in pain and size over several weeks. Serum levels of calcitonine (1140 ng/L) and carcinoembryonic antigen (288 microg/L) were very high. Fine-needle aspiration cytology suggested a diagnosis of medullary thyroid carcinoma. Total thyroidectomy, along with bilateral functional neck and mediastinal lymph-node dissection, were performed. RESULTS: The histopathological examination yielded a diagnosis of medullary carcinoma in the right thyroid lobe, closely intermingled with a nonencapsulated classical papillary carcinoma. One ipsilateral lymph node showed micrometastasis of the medullary counterpart. CONCLUSION: When compared with other cases reported in literature, this particular presentation should be recognized, if required, morphologic and functional criteria are used. The treatment is mostly surgical, driven by the medullary component. The presence of micrometastasis in 1 ipsilateral cervical lymph-node underlines the importance of cervicomediastinal lymph-node dissection and careful searching for metastatic disease.

Cancer mortality in Europe, 2000-2004, and an overview of trends since 1975.

BACKGROUND: To update the pattern of cancer mortality in Europe. Materials and methods: We analysed cancer mortality in 34 European countries during 2000-2004, with an overview of trends in 1975-2004 using data from the World Health Organization. RESULTS: From 1990-1994 to 2000-2004, overall cancer mortality in the European Union declined from 185.2 to 168.0/100 000 (world standard, -9%) in men and from 104.8 to 96.9 (-8%) in women, with larger falls in middle age. Total cancer mortality trends were favourable, though to a variable degree, in all major European countries, including Russia, but not in Romania. The major determinants of these favourable trends were the decline of lung (-16%) and other tobacco-related cancers in men, together with the persistent falls in gastric cancer, and the recent appreciable falls in colorectal cancer. In women, relevant contributions came from the persistent decline in cervical cancer and the recent falls in breast cancer mortality, particularly in northern and western Europe. Favourable trends were also observed for testicular cancer, Hodgkin lymphomas, leukaemias, and other neoplasms amenable to treatment, though the reductions were still appreciably smaller in eastern Europe. CONCLUSION: This updated analysis of cancer mortality in Europe showed a persistent favourable trend over the last years.

BRAF mutation in 'sarcomas': a possible method to detect de-differentiated melanomas

AIMS: BRAF is mutated in 50-60% of melanomas, but BRAF mutation in sarcomas has not been systematically evaluated. Some melanomas are spindled and may show no immunohistochemical evidence of melanocytic differentiation. Similarly, many sarcomas are undifferentiated, i.e. undifferentiated pleomorphic sarcomas (UPS). Diagnosing melanoma versus sarcoma in an undifferentiated spindle cell malignancy can be challenging. Our aim was to evaluate the prevalence of BRAF mutation in sarcomas and the use of BRAF mutational status in the diagnosis of spindle cell malignancies. METHODS AND RESULTS: BRAF mutational analysis was performed on tissue from 104 patients: 90 with sarcoma only (50 UPS) and 14 with sarcoma and melanoma (seven UPS). In the sarcoma-only group, BRAF mutation was absent. In the sarcoma-melanoma group, three sarcomas showed BRAF mutation; all were UPS, occurred after the melanomas and did not stain for melanocytic markers. One melanoma-sarcoma pair showed identical BRAF V600E mutations. CONCLUSIONS: The presence of BRAF mutation in these tumours raises the possibility that poorly differentiated spindle cell malignancies with BRAF mutation may represent melanomas, and BRAF mutational analysis should be considered in a patient with a spindle cell malignancy and a history of melanoma, as a positive result may indicate de-differentiated melanoma.

Phase I/IIa study of cilengitide and temozolomide with concomitant radiotherapy followed by cilengitide and temozolomide maintenance therapy in patients with newly diagnosed glioblastoma.

Purpose: Invasion and migration are key processes of glioblastoma and are tightly linked to tumor recurrence. Integrin inhibition using cilengitide has shown synergy with chemotherapy and radiotherapy in vitro and promising activity in recurrent glioblastoma. This multicenter, phase I/IIa study investigated the efficacy and safety of cilengitide in combination with standard chemoradiotherapy in newly diagnosed glioblastoma. Patients and Methods: Patients (age >= 18 to >= 70 years) were treated with cilengitide (500 mg) administered twice weekly intravenously in addition to standard radiotherapy with concomitant and adjuvant temozolomide. Treatment was continued until disease progression or for up to 35 weeks. The primary end point was progression-free survival (PFS) at 6 months. Results: Fifty-two patients ( median age, 57 years; 62% male) were included. Six- and 12-month PFS rates were 69% (95% CI, 54% to 80%) and 33% ( 95% CI, 21% to 46%). Median PFS was 8 months ( 95% CI, 6.0 to 10.7 months). Twelve- and 24-month overall survival ( OS) rates were 68% ( 95% CI, 53% to 79%) and 35% ( 95% CI, 22% to 48%). Median OS was 16.1 months ( 95% CI, 13.1 to 23.2 months). PFS and OS were longer in patients with tumors with O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation (13.4 and 23.2 months) versus those without MGMT promoter methylation (3.4 and 13.1 months). The combination of cilengitide with temozolomide and radiotherapy was well tolerated, with no additional toxicity. No pharmacokinetic interactions between temozolomide and cilengitide were identified. Conclusion: Compared with historical controls, the addition of concomitant and adjuvant cilengitide to standard chemoradiotherapy demonstrated promising activity in patients with glioblastoma with MGMT promoter methylation. J Clin Oncol 28:2712-2718. (C) 2010 by American Society of Clinical Oncology

Melan-A/MART-1-specific CD8 T cells: from thymus to tumor.

The self-antigen Melan-A/MART-1 is frequently involved in T-cell responses against malignant melanoma. The use of fluorescent tetramers incorporating the immunodominant Melan-A/MART-1 peptide has provided new insights into HLA-A2-restricted T-cell responses against this antigen in cancer patients and in healthy individuals. Direct evidence has been provided that a large Melan-A/MART-1-specific CD8 T-cell pool is generated during thymic selection. Although several other examples of naive self-peptide-specific T-cell repertoires are known, this is the only one directly accessible to analysis in healthy individuals

Clinical utility of g-cimp and idh1 status as dual prognostic markers in glioblastoma

The glioma CpG island methylator phenotype (G-CIMP) has been shown to be highly correlated with prognosis andwas noted to be highly concordant with IDH1mutation in malignant glioma in the limited number of samples analyzed. To better understand the relationship of G-CIMP with IDH1 mutation status and patient outcome, we examined G-CIMP status in detail in a larger retrospective series of glioblastomas as well as tumor samples from the RTOG 0525 clinical trial. Sampleswere tested for 6 CIMPmarkers andwere correlated with patient outcomes. In the retrospective tumor set (n ¼ 301),we found 3 distinct survival groups based on the number of CIMP markers: 0-1 (CIMP-negative), 2-4 (CIMP-intermediate), and 5 or greater (CIMP-positive) with median survivals 13.8, 20.1, and 90.6 months, respectively. This finding was validated in the RTOG 0525 samples (median survivals 15.0, 20.3, and 37.0 months). Among 787 cases with both IDH and CIMP data, 617 were CIMP-negative, 136 were CIMP-intermediate, and 34 were CIMP-positive. Seven hundred forty-four were wild type for IDH1 mutation, and 43 were mutant. CIMP and IDH status were positively correlated but outliers were found. Among the 610 CIMP-negative tumors, there were 7 IDH-mutant tumors, which showed no difference in outcome. Similarly, among the 34 CIMP-positive tumors, there were 21 IDH-mutant cases, which also showed no difference in outcome. However, among the CIMP-intermediate cases, there were 15 IDH-mutant cases with significantly (p ¼ 0.0003) improved outcome (medians not reached vs. 18.5 months, 2 year survival 87% vs. 32%). Multivariate analysis showed that both IDH1 mutation status and CIMP status were independent predictors of outcome. These findings suggest the clinical utility of refining the CIMP status into negative, intermediate, and positive groups and the finding that both IDH1 and CIMPstatus are important molecular markers in GBM.

Molecular insights for optimizing T cell receptor specificity against cancer.

Cytotoxic CD8 T cells mediate immunity to pathogens and they are able to eliminate malignant cells. Immunity to viruses and bacteria primarily involves CD8 T cells bearing high affinity T cell receptors (TCRs), which are specific to pathogen-derived (non-self) antigens. Given the thorough elimination of high affinity self/tumor-antigen reactive T cells by central and peripheral tolerance mechanisms, anti-cancer immunity mostly depends on TCRs with intermediate-to-low affinity for self-antigens. Because of this, a promising novel therapeutic approach to increase the efficacy of tumor-reactive T cells is to engineer their TCRs, with the aim to enhance their binding kinetics to pMHC complexes, or to directly manipulate the TCR-signaling cascades. Such manipulations require a detailed knowledge on how pMHC-TCR and co-receptors binding kinetics impact the T cell response. In this review, we present the current knowledge in this field. We discuss future challenges in identifying and targeting the molecular mechanisms to enhance the function of natural or TCR-affinity optimized T cells, and we provide perspectives for the development of protective anti-tumor T cell responses.

Autologous stem cell transplantation for enteropathy-associated T-cell lymphoma: a retrospective study by the EBMT.

Enteropathy-associated T-cell lymphoma (EATL) is a rare subtype of peripheral T-cell lymphomas with a poor prognosis. Autologous stem cell transplantation (ASCT) was retrospectively evaluated as a consolidation or salvage strategy for EATL. The analysis included 44 patients who received ASCT for EATL between 2000 and 2010. Thirty-one patients (70%) were in first complete or partial remission at the time of the ASCT. With a median follow-up of 46 months, relapse incidence, progression-free survival, and overall survival were 39%, 54%, and 59% at 4 years, respectively, with only one relapse occurring beyond 18 months posttransplant. There was a trend for better survival in patients transplanted in first complete or partial remission at 4 years (66% vs 36%; P = .062). ASCT is feasible in selected patients with EATL and can yield durable disease control in a significant proportion of the patients.

Abaisser la pression arterielle: urgent ou pas urgent? [How urgent is it to decrease high blood pressure?]

Severe hypertension represents a frequent problem for the general practitioner. One has to decide if the blood pressure needs to be decreased immediately (hypertensive emergency), or if the blood pressure maybe progressively decreased in a few hours and normalized in a few days (hypertensive crisis). Thus it is crucial to identify on the basis of the clinical history and a careful physical examination, the patients for whom the arterial blood pressure elevation represents an acute danger for organ damage or a vital threat in the absence of immediate blood pressure control. In the case of hypertensive crisis, oral medication is usually sufficient (slow release or GITS nifedipine, nitroglycerin, labetalol, captopril). The hypertensive emergency sometimes requires an oral medication before the admission to the emergency room, then followed by intravenous drug administration (sodium nitroprussiate, nitroglycerin, labetalol).

Anti-tumour effect of monoclonal antibodies against selected antigens expressed by B-cells in Chronic Lymphocytic Leukaemia : strategies to enhance the efficacy of immunotherapy

Résumé : Les anticorps monoclonaux ont une place de plus en plus prépondérante dans le traitement des lymphomes et leucémies. Dans cette étude, trois anticorps monoclonaux murins, dirigés contre les antigènes CDS, CD71 et HLA-DR exprimés à la surface des cellules de leucémies lymphoïdes chroniques (LLC), ont été évalués. In vitro, les anticorps radiomarqués ont montrés des bonnes liaisons spécifiques sur les différentes cellules cibles. L'anti-CD71 inhibait la prolifération de la plupart des lignées cellulaires testées avec une accumulation des cellules en phase S précoce du cycle cellulaire. L'anti-HLA-DR inhibait aussi la prolifération des lignées leucémique JOK1-5.3 et lymphoïde Daudi. Cette inhibition était associée à une agrégation des cellules. Aucune induction d'apoptose n'a pu être clairement observée avec ces anticorps. L'anti-CD5 n'a montré aucun effet d'inhibition de croissance in vitro. In vivo, l'injection des anticorps individuellement augmentait significativement la survie médiane de souris SCID greffées avec des cellules JOK1-5.3 en i.p. De plus, l'anticorps antiCD5 combiné à l'anti-HLA-DR ou l'anti-CD71, sous certaines conditions, inhibait complètement le développement tumoral dans la quasi totalité des souris traitées avec une augmentation significative de l'efficacité comparée aux anticorps seuls. L'augmentation de l'efficacité thérapeutique des anticorps monoclonaux par les cytokines, dont l'IL-2, a déjà été montrée dans la littérature. Au regard du meilleur comportement de l'IL-2 sous la forme complexée à un anticorps anti-IL-2, nous avons évalué l'efficacité de l'IL-2/anti-IL-2 seul ou combinés au rituximab chez différents modèles tumoraux s.c. (BL60.2, Daudi, Ramos) ou i.p. (JOK15.3) de souris SCID. Le complexe IL-2/anti-IL-2 a montré un effet anti-tumoral dans les souris greffées avec BL60.2 et Daudi. Le traitement IL-2/anti-IL-2 combiné au rituximab a montré une efficacité accrue chez des souris avec BL60.2 par rapport au rituximab seul. En revanche, nous n'avons pas observé de différence avec IL-2/anti-IL-2 seul.Aussi, nous avons évalué l'utilisation de l'agent couplant tri-fonctionnel TMEA pour produire des anticorps bispecifiques. Les expériences préliminaires avec les anticorps rituximab et herceptine, ont mis en évidence sur gel SDS-Page la formation de dimers (~100kDa) et de trimers (~150kDa). Les anticorps bispecifiques sont composés d'un fragment Fab' d'une spécificité et de un ou deux fragments Fab' de l'autre spécificité permettant de moduler la capacité de liaison. Nous avons enfin montré qu'une construction anti-CD5/anti-CD20 était capable de se lier indépendamment ou simultanément à ses antigènes cibles. En conclusion, ce travail a montré l'efficacité thérapeutique des trois anticorps monoclonaux étudiés dans un model de LLC in vivo, et plus particulièrement l'intérêt de certaines combinaisons. D'autre part, nous avons montré l'efficacité anti-tumorale du complexe IL-2/anti-IL-2 in vivo. Des études futures devront permettre de définir un régime favorable pour augmenter l'efficacité de la thérapie avec les anticorps monoclonaux. Enfin, nous avons montré la faisabilité d'utiliser l'agent couplant TMEA pour produire des anticorps bispécifiques fonctionnels.Abstract : Monoclonal antibody (mAb) therapy has become an integral part in different treatments of lymphomas and leukaemias. In this study, we describe three murine mAbs directed against the CD5, CD71 and HLA-DR antigens expressed on chronic lymphocytic leukaemia cells (CLL). In vitro, radiolabeled purified mAbs showed good specific binding on live target cells. Anti-CD71 mAb inhibited proliferation of most cell lines with an accumulation of responding cells in early S-phase of the cell cycle, but without induction of apoptosis. Anti-HLA-DR mAb showed proliferation inhibition of leukaemia JOK1-5.3 and lymphoid Daudi cells, associated with cell aggregation, but again no specific sign of apoptosis was observed. Anti-CD5 mAb did not show any growth inhibitory effect in vitro. In vivo, in a model of SCID mice grafted i.p. with JOK1-5.3 cells, injection of individual mAbs induced significant prolongation of median survival, up to complete inhibition of tumour growth in some mice. Antibody combination of anti-CD5 with anti-HLA-DR or anti-CD71, evaluated in an early treatment, completely inhibited tumour growth in most mice, with a significant efficacy enhancement as compared to mAb used as single agents. Previous reports described the improved efficacy of mAb therapy when combined with cytokines such as IL-2. Relying further on the improved efficacy of IL-2 when administered as an immune complex with anti-IL-2 mAb, we evaluated the anti-tumour effect of the IL-2/anti-IL-2 complex alone or combined with rituximab in subcutaneous (BL60.2, Daudi, Ramos) or i.p. (JOK1-5.3) tumour models in SCID mice. The IL-2/anti-IL-2 complex demonstrated an anti-tumour effect in BL60.2 and Daudi grafted SCID mice. Combination of IL-2/anti-IL-2 treatment with rituximab showed increased efficacy as compared to rituximab alone in BL60.2 grafted mice. However, no difference was observed with IL-2/anti-IL-2 complex alone in these experiments. Finally, we evaluated the feasibility of producing bispecific antibodies (bsAbs) using a trifunctional coupling agent, called TMEA. In preliminary experiments coupling rituximab with herceptine Fab' fragments we obtained the formation of dimers (~100kDa) and trimers (~150kDa) as observed on SDS-Page gel. This method allowed us to produce bsAb with one Fab' fragments of one specificity and one or two Fab' fragments of the second specificity. An anti-CD5/anti-CD20 bsAb was shown to bind targeted antigen either independently or simultaneously. In conclusion, these data show that the three mAbs were all able to induce significant growth inhibition of the JOK1-5.3 cell line in vivo, and efficacy was enhanced when used in combination. IL2/anti-IL-2 complex displayed anti-tumour efficacy in vivo. Further evaluation is necessary to define the most favourable combination to improve mAb therapy. BsAb were produced using the tri-functional agent allowing antibody fragments with relatively good binding. The poor yield obtained with such chemical couplings limited the use of these constructs in preclinical experiments.

Superior vena cava syndrome caused by invasive epidermoid carcinoma.

Lung cancer is the most frequent cause of superior vena cava (SVC) syndrome. Malignant SVC syndrome is generally considered a contraindication to curative resection, although palliative bypasses are done for symptoms that do not respond to medical therapy. However, a majority of patients with such advanced disease die of complications caused by the primary tumor rather than distant metastasis. We present the case of one patient with lung cancer invading the mediastinal structures. Combined resection and replacement of the SVC with a segment of Dacron vascular graft was performed. Postoperative survival time was 24 months.

Complex roles of inflammasomes in carcinogenesis.

The central role of chronic inflammation in the promotion of tumor growth is supported by a broad range of experimental and clinical evidence. However, the molecular mechanisms converting transient inflammatory tissue reactions into a tumor-promoting microenvironment remain largely elusive. Because inflammasomes have been shown to regulate the proinflammatory cytokines interleukin 1β (IL-1β) and IL-18, they have been implicated in the relationship between tumor genesis/progression and inflammation. For instance, many cancers have been directly linked to inflammasome-mediated sterile inflammation, where a blockade of IL-1β and IL-18 has been shown to inhibit tumor growth. On the other hand, inflammasome activation also has potent antitumorigenic effects, where malignant precursor cells are eliminated through pyroptotic cell death. Indeed, inflammasome activity can even increase the efficacy of certain chemotherapies. Here, we review the current understanding on the complex and sometimes contradictory role of inflammasomes in carcinogenesis.