Effetti clinici e biologici della terapia epigenetica nelle sindromi mielodisplastiche a basso rischio

Background: Nucleoside 5-Azacitidine (5-Aza) in high risk MDS patients (pts) at a dose of 75mg/mq/day subcutaneously for 7 days, every 28 days, induces high hematologic response rates (hematologic improvement (HI) 50-60%, complete remission (CR) 10-30%) and prolongation of survival (at 2 years 50,8%). Aim: The role of 5-Aza in low-risk MDS patients is not well defined but its use in the earlier phases of disease could be more effective and useful to control the expansion of MDS clone and disease progression. In our phase II, prospective, multicentric trial a low-dose schedule of 5-Aza (75 mg/mq daily for 5 consecutive days every 28 days) was given to low-risk MDS pts in order to evaluate its efficacy and tolerability and to identify biological markers to predict the response. Methods: From September 2008 to February 2010, 34 patients were enrolled into the study. Fifteen patients had refractory anemia (RA), 5 patients refractory anemia with ringed sideroblasts (RARS), 7 patients refractory cytopenia with multilineage dysplasia (RCMD) and 7 patients refractory anemia with excess blasts-1 (RAEB-1). All patients failed previously EPO therapy and were in chronic red blood cell (RBC) supportive care with a median transfusions requirement of 4 units/monthly. The response treatment criteria was according to IWG 2006. Results: At present time 31 out of 34 pts are evaluable: 12/31 pts (39%) completed the treatment plan (8 courses), 7/31 pts (22%) performed the first 4 courses, 8/31 (26%) made 1 to 3 courses and 4/31 (13%) died during the treatment period. Out of 12 pts who completed the 8 courses of therapy 10 (83%) obtained an HI, 2/12 (17%) maintained a stable disease. Out of 10 pts who obtained HI, 4 pts (40%) achieved a CR. Generally the drug was very well tolerated. The most commonly reported hematologic toxicities were neutropenia (55%) and thrombocytopenia (19%) but they were transitory and usually no delay of treatment was necessary. 2/4 pts died early after the 1th cycle for septic shock and gastrointestinal hemorrage respectively whereas 2/4 pts died in a condition of stable disease after the 4th cycle for pneumonia and respiratory distress. Samples for biologic studies have been collected from the pts before starting the therapy and at the end of 4th and 8th course. Preliminary data on the lipid signalling pathways suggested a direct correlation between PI-PLC-β1 gene expression and 5-Aza responsiveness. Conclusion: Interim analysis of our study based on the small number of cases who completed the treatment program, shows that 83% of pts obtain an HI and 40% obtain a CR. 4 patients died during the treatment and even if the causes were reported as no related to the therapy it has been considered that caution has to be reserved in given 5-Aza in these pts who are elderly and frail. Preliminary data of PI-PLC-β1 gene expression suggest that this and probably other biological markers could help us to know a priori who are the patients who have more chances to respond.

Histone deacetylase inhibitors in adult patients with diffuse large b-cell lymphoma relapsed/refractory: a phase II study with Panobinostat

Backgrounds:Treatment of patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) not eligible to high dose therapy represents an unmet medical need. Panobinostat showed encouraging therapeutic activity in studies conducted in lymphoma cell lines and in vivo in patients with advanced hematologic malignancies.Purpose:FIL-PanAL10 (NCT01523834) is a phase II, prospective multicenter trial of the Fondazione Italiana Linfomi (FIL) to evaluate safety and efficacy of single agent Panobinostat as salvage therapy for R/R DLBCL patients and to evaluate a possible relationships between response and any biological features. Patients and Methods:Patients with R/R DLBCL were included. The treatment plan included 6 induction courses with Panobinostat monotherapy followed by other 6 courses of consolidation. The primary objective was to evaluate Panobinostat activity in terms of overall response (OR); secondary objectives were: CR rate, time to response (TTR), progression-free survival (PFS), safety and feasibility of Panobinostat. We included evaluation of the impact of pharmacogenetics, immunohistochemical patterns and patient’s specific gene expression and mutations as potential predictors of response to Panobinostat as explorative objectives. To this aim a pre-enrollment new tissue biopsy was mandatory. ResultsThirty-five patients, 21 males (60%), were enrolled between June 2011 and March 2014. At the end of induction phase, 7 responses (20%) were observed, including 4 CR (11%), while 28 patients (80%) discontinued treatment due to progressive disease (PD) in 21 (60%) or adverse events in 7 (20%). Median TTR in 9 responders was 2.6 months (range 1.8-12). With a median follow up of 6 months (range 1-34), the estimated 12 months PFS and OS were 27% and 30.5%, respectively. Grade 3-4 thrombocytopenia and neutropenia were the most common toxicities (in 29 (83%) and 12 (34%) patients, respectively. Conclusions The results of this study indicate that Panobinostat might be remarkably active in some patients with R/R DLBCL, showing durable CR

Malattie immunomediate del cane e del gatto: aspetti diagnostici e terapeutici

La presente tesi di dottorato affronta alcune delle più comuni malattie immunomediate del cane e del gatto. Il manoscritto è incentrato sugli aspetti diagnostici e terapeutici in corso di: anemia emolitica immunomediata (Immune-mediated hemolytic anemia, IMHA), trombocitopenia immunomediata (Immune-mediated thrombocytopenia, ITP) e poliartrite immunomediata (Immune-mediated polyarthritis, IMP). Il capitolo 1 costituisce un’introduzione all’argomento delle malattie immunologiche; vengono sottolineati alcuni aspetti patogenetici delle singole malattie immunomediate e riassunte le difficoltà diagnostiche e terapeutiche. Il capitolo 2 riporta uno studio riguardante una popolazione di gatti con diagnosi, o sospetto diagnostico, di IMHA che evidenziava una discrepanza tra i test diagnostici per il virus della leucemia felina (Feline Leukemia Virus, FeLV). La positività FeLV al test point of care, non confermata dalla PCR del DNA provirale, lascia spazio a diverse interpretazioni. Il capitolo 3 mostra i dati relativi al confronto tra tre diversi protocolli immunosoppressivi (glucocorticoidi, glucocorticoidi+ciclosporina, glucocorticoidi+micofenolato mofetile) in una popolazione di cani con IMHA non associativa. Il confronto verteva, principalmente, sulla risposta ematologica dei pazienti, che non si è dimostrata differente tra i tre gruppi terapeutici. Il capitolo 4 riporta una revisione della letteratura riguardante l’ITP del cane e del gatto. Si tratta di una malattia eterogenea in cui le manifestazioni cliniche appaiono variabili: alcuni pazienti sono asintomatici, altri presentano dei sanguinamenti spontanei. La mancanza di criteri diagnostici standardizzati, porta il clinico a considerare l’ITP una diagnosi “ad esclusione”. Le strategie terapeutiche non si basano purtroppo su linee guida condivise, pertanto il target della terapia rimane, ad oggi, sconosciuto. Nel capitolo 5 viene posta l’attenzione su alcuni interrogativi diagnostici e terapeutici che riguardano l’IMP del cane e del gatto. La sintomatologia clinica, caratterizzata da zoppia, febbre e riluttanza al movimento, talvolta può essere subdola. Anche in questa malattia, non vi sono evidenze scientifiche circa il regime immunosoppressivo più corretto ed indicato.