1
|
Lurain K, Yarchoan R, Ramaswami R. Immunotherapy for KSHV-associated diseases. Curr Opin Virol 2022; 55:101249. [PMID: 35803203 PMCID: PMC9464688 DOI: 10.1016/j.coviro.2022.101249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 11/18/2022]
Abstract
Kaposi sarcoma herpesvirus (KSHV)-associated diseases (Kaposi sarcoma, multicentric Castleman disease, primary effusion lymphoma, and KSHV inflammatory cytokine syndrome) are associated with immune suppression and dysregulation and loss of KSHV-specific immunity. These diseases are most frequent in people living with HIV as well as those with primary or iatrogenic immune deficiencies. KSHV itself can modulate the immune system via viral homologs of host cytokines or downregulation of immune-surface markers altering host immune surveillance. These factors make KSHV-associated diseases prime targets for immunotherapy approaches. Several agents have been studied or are under investigation in KSHV-associated diseases, including monoclonal antibodies, immunomodulatory agents, and therapeutic cytokines. Here, we review the role of immunotherapies in KSHV-associated diseases.
Collapse
Affiliation(s)
- Kathryn Lurain
- HIV & AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Robert Yarchoan
- HIV & AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ramya Ramaswami
- HIV & AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
2
|
Reid EG, Shimabukuro K, Moore P, Ambinder RF, Bui JD, Han S, Martínez-Maza O, Dittmer DP, Aboulafia D, Chiao EY, Maurer T, Baiocchi R, Mitsuyasu R, Wachsman W. AMC-070: Lenalidomide Is Safe and Effective in HIV-Associated Kaposi Sarcoma. Clin Cancer Res 2022; 28:2646-2656. [PMID: 35247913 PMCID: PMC9197984 DOI: 10.1158/1078-0432.ccr-21-0645] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 10/23/2021] [Accepted: 02/25/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Kaposi sarcoma (KS), an endothelial cell tumor associated with KS herpesvirus (KSHV), remains among the most common malignancies occurring with HIV infection (HIV-KS). As an oral anti-inflammatory, antiangiogenic, and immunomodulatory agent, lenalidomide is potentially an attractive alternative to standard chemotherapy for KS. EXPERIMENTAL DESIGN The primary objectives of this phase I/II trial were to determine the maximum tolerated dose (MTD) and response rates for lenalidomide in HIV-KS. Secondary objectives included correlating response with natural killer (NK) and T-cell subsets, plasma cytokines, viral copy number, and KSHV gene expression in biopsies. Four dose levels of oral lenalidomide taken 21 consecutive days of 28-day cycles were evaluated in adults with HIV-KS on antiretroviral therapy with controlled viremia. RESULTS Fifteen and 23 participants enrolled in phases I and II, respectively, 76% of whom had received prior KS therapy. The MTD was not reached, declaring 25 mg as the recommended phase II dose (RP2D). The most frequent adverse events were neutropenia, fatigue, leukopenia, and diarrhea. Of the 25 evaluable participants receiving RP2D, 60% responded. Correlative studies performed in a subset of participants demonstrated a significant increase in proportions of blood T cells with T-regulatory phenotype, and plasma cytokines trended toward a less inflammatory pattern. Clinical response was associated with loss of KSHV transcription. CONCLUSIONS Lenalidomide is active in HIV-KS. The most common adverse events were manageable. With 60% of participants receiving RP2D obtaining a partial response and <10% discontinuing due to adverse events, the response and tolerability to lenalidomide support its use in HIV-KS. See related commentary by Henry and Maki, p. 2485.
Collapse
Affiliation(s)
- Erin G. Reid
- University of California, San Diego Moores Cancer Center, La Jolla, CA
| | | | | | | | - Jack D. Bui
- University of California, San Diego, La Jolla, CA
| | - Semi Han
- University of Southern California, Los Angeles, CA
| | - Otoniel Martínez-Maza
- UCLA AIDS Institute and Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Dirk P. Dittmer
- Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill, NC
| | - David Aboulafia
- Floyd and Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA
| | | | - Toby Maurer
- University of California San Francisco, San Francisco, CA, USA
| | - Robert Baiocchi
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Ronald Mitsuyasu
- University of California, Los Angeles, Center for AIDS Research and Education, Los Angeles, CA
| | - William Wachsman
- University of California, San Diego Moores Cancer Center, La Jolla, CA
- Research Service, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | | |
Collapse
|
3
|
Ramaswami R, Lurain K, Yarchoan R. Oncologic Treatment of HIV-Associated Kaposi Sarcoma 40 Years on. J Clin Oncol 2022; 40:294-306. [PMID: 34890242 PMCID: PMC8769148 DOI: 10.1200/jco.21.02040] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The observation in 1981 of the emergence of Kaposi sarcoma (KS) among young men who had sex with men was one of the first harbingers of the HIV epidemic. With advances in HIV care, the incidence of HIV-associated KS (HIV+KS) has decreased over time in the United States. However, it remains a persistent malignancy among some HIV-infected populations and is one of the most common tumors in sub-Saharan Africa. Because of the relapsing and remitting nature of this cancer, patients with HIV+KS can experience significant, long-term, morbidity. Patients with severe HIV+KS may also have concurrent lymphoproliferative syndromes, malignancies, and/or infections that can contribute to mortality. Several chemotherapy agents were explored in clinical trials for HIV+KS during the early stage of the epidemic. As HIV+KS emerges with CD4 lymphopenia and immunodysregulation, T-cell-sparing options are important to consider. Here, we explore the pathogenesis of HIV+KS and the current evidence for immunotherapy and therapies that potentially target KS pathogenesis. This review provides the current landscape of therapies for HIV+KS and highlights management issues for patients with HIV and cancer.
Collapse
Affiliation(s)
- Ramya Ramaswami
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, Bethesda, MD,Ramya Ramaswami, MBBS, MPH, HIV and AIDS Malignancy Branch, Center for Cancer Research, 10 Center Drive, 6N106, Bethesda, MD 20892; e-mail:
| | - Kathryn Lurain
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, Bethesda, MD
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, Bethesda, MD
| |
Collapse
|
4
|
Ramaswami R, Polizzotto MN, Lurain K, Wyvill KM, Widell A, George J, Goncalves P, Steinberg SM, Whitby D, Uldrick TS, Yarchoan R. Safety, activity, and long-term outcomes of pomalidomide in the treatment of Kaposi sarcoma among individuals with or without HIV infection. Clin Cancer Res 2021; 28:840-850. [PMID: 34862247 DOI: 10.1158/1078-0432.ccr-21-3364] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Kaposi sarcoma (KS) is caused by Kaposi sarcoma herpesvirus ((KSHV), also known as human herpesvirus 8 (HHV-8)). KS, which develops most frequently among people with HIV, is generally treated with chemotherapy, but these drugs have acute and cumulative toxicities. We previously described initial results of a trial of pomalidomide, an oral immunomodulatory derivative of thalidomide, in patients with KS. Here, we present results on the full cohort and survival outcomes. EXPERIMENTAL DESIGN Participants with KS with or without HIV were treated with pomalidomide 5mg once daily for 21 days per 28-day cycle with aspirin 81mg daily for thromboprophylaxis. Participants with HIV received antiretroviral therapy. Response was defined by modified version of the AIDS Clinical Trial Group KS criteria. We evaluated tumor responses (including participants who had a second course), adverse events, progression-free survival (PFS), and long-term outcomes. RESULTS Twenty-eight participants were enrolled. Eighteen (64%) were HIV-positive, 21 (75%) had advanced (T1) disease. Overall response rate was 71%: 95% confidence interval (CI) 51-87%. Twelve of 18 HIV-positive (67%; 95% CI: 41-87%) and 8 of 10 HIV-negative participants (80%; 95% CI: 44-97%) had a response. Two of 4 participants who received a second course of pomalidomide had a partial response. The median PFS was 10.2 months (95% CI: 7.6-15.7 months). Grade 3 neutropenia was noted among 50% of participants. In the follow-up period, 3 participants with HIV had other KSHV-associated diseases. CONCLUSIONS Pomalidomide is a safe and active chemotherapy-sparing agent for the treatment of KS among individuals with or without HIV.
Collapse
Affiliation(s)
- Ramya Ramaswami
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Mark N Polizzotto
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Kathryn Lurain
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Kathleen M Wyvill
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Anaida Widell
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Jomy George
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Priscila Goncalves
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Thomas S Uldrick
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| |
Collapse
|
5
|
Tsai YC, Tsai TF. Oral disease-modifying antirheumatic drugs and immunosuppressants with antiviral potential, including SARS-CoV-2 infection: a review. Ther Adv Musculoskelet Dis 2020; 12:1759720X20947296. [PMID: 32952617 PMCID: PMC7476354 DOI: 10.1177/1759720x20947296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/02/2020] [Indexed: 12/23/2022] Open
Abstract
There have been several episodes of viral infection evolving into epidemics in recent decades, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the latest example. Its high infectivity and moderate mortality have resulted in an urgent need to find an effective treatment modality. Although the category of immunosuppressive drugs usually poses a risk of infection due to interference of the immune system, some of them have been found to exert antiviral properties and are already used in daily practice. Recently, hydroxychloroquine and baricitinib have been proposed as potential drugs for SARS-CoV-2. In fact, there are other immunosuppressants known with antiviral activities, including cyclosporine A, hydroxyurea, minocycline, mycophenolic acid, mycophenolate mofetil, leflunomide, tofacitinib, and thalidomide. The inherent antiviral activity could be a treatment choice for patients with coexisting rheumatological disorders and infections. Clinical evidence, their possible mode of actions and spectrum of antiviral activities are included in this review article. LAY SUMMARY Immunosuppressants often raise the concern of infection risks, especially for patients with underlying immune disorders. However, some disease-modifying antirheumatic drugs (DMARDs) with inherent antiviral activity would be a reasonable choice in the situation of concomitant viral infections and flare up of autoimmune diseases. This review covers DMARDs of treatment potential for SARS-CoV-2 in part I, and antiviral mechanisms plus trial evidence for viruses other than SARS-CoV-2 in part II.
Collapse
Affiliation(s)
- Y. C. Tsai
- Department of Dermatology, Far Eastern Memorial Hospital, New Taipei city, Taiwan
| | - T. F. Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Zhongshan S. Rd, Zhongzheng District, Taipei City 100, Taiwan
| |
Collapse
|
6
|
Reid E, Suneja G, Ambinder RF, Ard K, Baiocchi R, Barta SK, Carchman E, Cohen A, Crysler OV, Gupta N, Gustafson C, Hall A, Johung KL, Klopp A, LaCasce AS, Lin C, Mehta A, Menon MP, Morgan D, Nathwani N, Noy A, Ratner L, Rizza S, Rudek MA, Sanchez J, Taylor J, Tomlinson B, Wang CCJ, Yendamuri S, Dwyer MA, Freedman-Cass DA. AIDS-Related Kaposi Sarcoma, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 17:171-189. [PMID: 30787130 DOI: 10.6004/jnccn.2019.0008] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As treatment of HIV has improved, people living with HIV (PLWH) have experienced a decreased risk of AIDS and AIDS-defining cancers (non-Hodgkin's lymphoma, Kaposi sarcoma, and cervical cancer), but the risk of Kaposi sarcoma in PLWH is still elevated about 500-fold compared with the general population in the United States. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for AIDS-Related Kaposi Sarcoma provide diagnosis, treatment, and surveillance recommendations for PLWH who develop limited cutaneous Kaposi sarcoma and for those with advanced cutaneous, oral, visceral, or nodal disease.
Collapse
Affiliation(s)
| | | | | | - Kevin Ard
- 4Massachusetts General Hospital Cancer Center
| | - Robert Baiocchi
- 5The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Adam Cohen
- 8Huntsman Cancer Institute at the University of Utah
| | | | | | - Chelsea Gustafson
- 11Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Ann Klopp
- 13The University of Texas MD Anderson Cancer Center
| | | | - Chi Lin
- 15Fred & Pamela Buffett Cancer Center
| | - Amitkumar Mehta
- 16University of Alabama at Birmingham Comprehensive Cancer Center
| | - Manoj P Menon
- 17Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Ariela Noy
- 20Memorial Sloan Kettering Cancer Center
| | - Lee Ratner
- 21Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Jeff Taylor
- 24HIV + Aging Research Project - Palm Springs
| | - Benjamin Tomlinson
- 25Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | -
- 28National Comprehensive Cancer Network
| | | |
Collapse
|
7
|
Pourcher V, Desnoyer A, Assoumou L, Lebbe C, Curjol A, Marcelin AG, Cardon F, Gibowski S, Salmon D, Chennebault JM, Poizot-Martin I, Peytavin G, Boué F, Costagliola D. Phase II Trial of Lenalidomide in HIV-Infected Patients with Previously Treated Kaposi's Sarcoma: Results of the ANRS 154 Lenakap Trial. AIDS Res Hum Retroviruses 2017; 33:1-10. [PMID: 27405442 DOI: 10.1089/aid.2016.0069] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Lenalidomide, an oral immunomodulating agent, has shown promising activity in HIV-infected individuals with Kaposi's sarcoma (KS). This single-arm, multicenter, open-label, Gehan's two-stage phase II trial evaluated the efficacy and safety of lenalidomide in HIV-infected patients with progressive KS despite previous chemotherapy (NCT01282047, ANRS 154 Lenakap trial). The primary endpoint was the rate of partial response (PR) or complete response (CR) at week 24, evaluated by both the study investigators and the patients using the Physical Global Assessment (PGA). AIDS Clinical Trials Group (ACTG) criteria for KS treatment evaluation were used as a secondary endpoint. The data and safety monitoring board recommended that enrollments be halted on April 24, 2013, because of lack of responses. We enrolled 12 antiretroviral-treated HIV-infected men with progressive KS despite previous chemotherapy. Their HIV plasma viral load was <50 copies/ml and their median CD4 cell count 444/mm3. One patient stopped taking lenalidomide because of hives at week 1 and a second patient died at week 7. The remaining 10 patients were assessable at week 24, when none had PGA-defined CR or PR and one had ACTG-defined PR. There were no additional PGA responses at week 48, but an additional three patients had ACTG responses, for a total of four patients with ACTG PR at week 48 (40%; 95% confidence interval: 12.2-73.8). Fourteen grade 3-4 adverse events were considered at least possibly related to lenalidomide during a total of 101 cycles. Lenalidomide was well tolerated in antiretroviral experienced patients with progressive KS previously treated with chemotherapy. The ACTG-defined response rate at week 48 was 40%, while it was 0% using PGA criteria.
Collapse
Affiliation(s)
- Valérie Pourcher
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Service de Maladies Infectieuses et Tropicales, Paris, France
- Sorbonne Universités, UPMC Paris Univ 06, Paris, France
- INSERM UMR-S996, Clamart, France
| | - Aude Desnoyer
- INSERM UMR-S996, Clamart, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Département de Pharmaco-Toxicologie Clinique, Paris, France
| | - Lambert Assoumou
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMR 1136), Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - Céleste Lebbe
- Assistance Publique Hôpitaux de Paris, Hôpital Saint Louis, Service de Dermatologie, Paris, France
- INSERM U976, CIC et Dermatologie, Univ Paris Diderot, Paris, France
| | - Angélique Curjol
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMR 1136), Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - Anne-Geneviève Marcelin
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMR 1136), Sorbonne Universités, UPMC Univ Paris 06, Paris, France
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Laboratoire de Virologie, Paris, France
| | - Fanny Cardon
- ANRS (France REcherche Nord&Sud Sida-hiv Hépatites), Clinical and Therapeutic Research on HIV/AIDS Office, Paris, France
| | - Séverine Gibowski
- ANRS (France REcherche Nord&Sud Sida-hiv Hépatites), Clinical Research Safety Office, Paris, France
| | - Dominique Salmon
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Cochin, Service des Maladies Infectieuses, Paris, France
| | | | - Isabelle Poizot-Martin
- APHM Sainte-Marguerite, Service d'Immunohématologie Clinique, Marseille, France
- INSERM U912 (SESSTIM), Université Aix Marseille, Marseille, France
| | - Gilles Peytavin
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Département de Pharmaco-Toxicologie Clinique, Paris, France
- INSERM, IAME UMR 1137, Université Paris Diderot, Paris, France
| | - François Boué
- INSERM UMR-S996, Clamart, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Service de Médecine Interne et Immunologie Clinique, Clamart, France
| | - Dominique Costagliola
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMR 1136), Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | | |
Collapse
|
8
|
Abstract
The use of thalidomide in relation to dermatology is well- known and enough data is available in the literature about various aspects of thalidomide. Despite being an interesting and useful drug for many dermatoses, it is associated with many health hazards including the birth defects, phocomelia. We hereby present a comprehensive review about thalidomide and its application in dermatology.
Collapse
Affiliation(s)
- Iffat Hassan
- Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Konchok Dorjay
- Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Parvaiz Anwar
- Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
| |
Collapse
|
9
|
Bhutani M, Polizzotto MN, Uldrick TS, Yarchoan R. Kaposi sarcoma-associated herpesvirus-associated malignancies: epidemiology, pathogenesis, and advances in treatment. Semin Oncol 2014; 42:223-46. [PMID: 25843728 DOI: 10.1053/j.seminoncol.2014.12.027] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Kaposi sarcoma associated herpesvirus (KSHV), a γ2-herpesvirus, also known as human herpesvirus-8, is the etiologic agent of three virally associated tumors: Kaposi sarcoma, a plasmablastic form of multicentric Castleman disease (KSHV-MCD), and primary effusion lymphoma. These malignancies are predominantly seen in people with acquired immunodeficiencies, including acquired immunodeficiency syndrome and iatrogenic immunosuppression in the setting of organ transplantation, but can also develop in the elderly. Kaposi sarcoma (KS) is most frequent in regions with high KSHV seroprevalence, such as sub-Saharan Africa and some Mediterranean countries. In the era of combination antiviral therapy, inflammatory manifestations associated with KSHV-infection, including KSHV-MCD, a recently described KSHV-associated inflammatory cytokine syndrome and KS immune reconstitution syndrome also are increasingly appreciated. Our understanding of viral and immune mechanisms of oncogenesis continues to expand and lead to improved molecular diagnostics, as well as novel therapeutic strategies that employ immune modulatory agents, manipulations of the tumor microenvironment, virus-activated cytotoxic therapy, or agents that target interactions between specific virus-host cell signaling pathways. This review focuses on the epidemiology and advances in molecular and clinical research that reflects the current understanding of viral oncogenesis, clinical manifestations, and therapeutics for KSHV-associated tumors.
Collapse
Affiliation(s)
- Manisha Bhutani
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, Bethesda, MD
| | - Mark N Polizzotto
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, Bethesda, MD
| | - Thomas S Uldrick
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, Bethesda, MD
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, Center for Cancer Research, NCI, Bethesda, MD.
| |
Collapse
|
10
|
Molyneux E, Davidson A, Orem J, Hesseling P, Balagadde-Kambugu J, Githanga J, Israels T. The management of children with Kaposi sarcoma in resource limited settings. Pediatr Blood Cancer 2013; 60:538-42. [PMID: 23255282 DOI: 10.1002/pbc.24408] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 11/01/2012] [Indexed: 11/08/2022]
Abstract
Kaposi sarcoma (KS) is common where HIV infection is endemic. Antiretroviral therapy (ART) has reduced the incidence in well-resourced settings but in some parts of the world access to ART is delayed. These recommendations are for use where only minimal requirements for treatment are available. Consensus was sought for the management of childhood HIV-associated KS in this setting. There are no randomised controlled studies of chemotherapy for KS in children and these recommendations have drawn on consensus of a group of experts and published reports from studies in adults.
Collapse
Affiliation(s)
- Elizabeth Molyneux
- Paediatric Department, College of Medicine, University of Malawi, Blantyre, Malawi.
| | | | | | | | | | | | | |
Collapse
|
11
|
Patel AM, Chou EL, Findeiss L, Kelly KM. The horizon for treating cutaneous vascular lesions. ACTA ACUST UNITED AC 2013; 31:98-104. [PMID: 22640429 DOI: 10.1016/j.sder.2012.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 12/28/2022]
Abstract
Dermatologists encounter a wide range of cutaneous vascular lesions, including infantile hemangiomas, port-wine stain birthmarks, arteriovenous malformations, venous malformations, Kaposi sarcomas, angiosarcomas, and angiofibromas. Current treatment modalities to reduce these lesions include topical and/or intralesional steroids, laser therapy, surgical resection, and endovascular therapy. However, each method has limitations owing to recurrence, comorbidities, toxicity, or lesion location. Photodynamic therapy, antiangiogenic therapy, and evolving methods of sclerotherapy are promising areas of development that may mitigate limitations of current treatments and offer exciting options for patients and their physicians.
Collapse
Affiliation(s)
- Amit M Patel
- Department of Dermatology, University of California, Irvine, CA 92612, USA
| | | | | | | |
Collapse
|
12
|
Abstract
Thalidomide is a drug that, since its development, has made history in the world of medicine--having been withdrawn and now has returned with a boom as an anticancer and immunomodulatory drug. However, its mode of action in various diseases (i.e. different types of hematologic malignancies, solid tumors) as well as in various infections (i.e. pneumonia, tuberculosis, HIV infection etc.) and related inflammatory conditions is not well understood. As the immune system plays an important role in the pathogenesis of both infection-related as well as noninfectious (i.e. cancer) inflammatory diseases, much research has been done in the past few years to discover and design better immunomodulatory agents. Such immunomodulatory agents should be able to target the immune system in such a way that host suffers minimum damage and normal function of the immune system remains intact. In the present review an attempt is made to highlight the immunomodulatory action of thalidomide in various pathologic conditions.
Collapse
Affiliation(s)
- V Kumar
- Department of Cancer Biology and Genetics, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada.
| | | |
Collapse
|
13
|
Dai L, Bratoeva M, Toole BP, Qin Z, Parsons C. KSHV activation of VEGF secretion and invasion for endothelial cells is mediated through viral upregulation of emmprin-induced signal transduction. Int J Cancer 2011; 131:834-43. [PMID: 21918972 DOI: 10.1002/ijc.26428] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 08/29/2011] [Indexed: 11/08/2022]
Abstract
Kaposi's sarcoma-associated herpesvirus (KSHV) is the etiologic agent of Kaposi's sarcoma (KS)-one of the most common tumors arising in the setting of immune suppression. Hallmarks of KS lesions include KSHV-infected cells of endothelial lineage and neoangiogenesis. Promigratory factors secreted in the tumor microenvironment by KSHV-infected cells promote endothelial cell (EC) migration and angiogenesis but existing therapies targeting these pathways are not widely utilized. This underscores the need for additional characterization of KSHV-host interactions relevant to EC pathogenesis to identify new therapeutic targets. We recently demonstrated that de novo infection by KSHV promotes EC invasion through upregulation of extracellular matrix metalloproteinase inducer (emmprin)-a multifunctional glycoprotein previously shown to induce tumor cell invasion and regional angiogenesis through upregulation of signal transduction and promotion of tumor-stroma interactions. This study was undertaken to determine whether EC invasion for KSHV-infected cells is induced through activation of specific signal transduction pathways and proangiogenic factors by emmprin. We found that KSHV activation of emmprin induces PI3K/Akt- and mitogen-activated protein kinase (MAPK)-dependent secretion of vascular endothelial growth factor (VEGF). Functionally, EC invasion following de novo infection is induced by emmprin-dependent PI3K/Akt and MAPK activation of VEGF. These findings support the potential utility of targeting emmprin for reducing VEGF secretion and EC migration in the KS microenvironment.
Collapse
Affiliation(s)
- Lu Dai
- Department of Regenerative Medicine & Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | |
Collapse
|
14
|
Sgadari C, Bacigalupo I, Barillari G, Ensoli B. Pharmacological management of Kaposi's sarcoma. Expert Opin Pharmacother 2011; 12:1669-90. [DOI: 10.1517/14656566.2011.577066] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
15
|
Abstract
Thalidomide is approved for treating erythema nodosum leprosum and multiple myeloma, but it has also emerged as a useful treatment option for many refractory dermatologic disorders. Some of the innovative but off-label uses of thalidomide include aphthous stomatitis, Behçet's disease, lupus erythematosus, prurigo nodularis, sarcoidosis, actinic prurigo, graft-versus-host disease, Langerhans cell histiocytosis, erythema multiforme, lichen planus, Kaposi sarcoma, Jessner lymphocytic infiltrate, uremic pruritus, pyoderma gangrenosum, scleroderma, scleromyxedema, and necrobiosis lipoidica. This article reviews the background, pharmacology, and innovative uses of thalidomide in dermatology.
Collapse
Affiliation(s)
- Meng Chen
- Department of Dermatology, Baylor College of Medicine, BCM Debakey Building M220, One Baylor Plaza, Mail Stop BCM368, Houston, TX 77030, USA
| | | | | |
Collapse
|
16
|
Thalidomide: an emerging drug in oral mucosal lesions. Clin J Gastroenterol 2009; 2:149-155. [DOI: 10.1007/s12328-009-0089-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 04/21/2009] [Indexed: 10/20/2022]
|
17
|
Affiliation(s)
- Levi E Fried
- Department of Dermatology, Emory University School of Medicine, WMB 5309, 101 Woodruff Circle Atlanta, GA 30322, USA
| | | |
Collapse
|
18
|
Rubegni P, Sbano P, De Aloe G, Flori ML, Fimiani M. Thalidomide in the treatment of Kaposi's sarcoma. Dermatology 2007; 215:240-4. [PMID: 17823523 DOI: 10.1159/000106583] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Accepted: 01/15/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Kaposi's sarcoma (KS) is a lymphangioproliferative tumour. Therapy of KS depends on the characteristics of the disease, especially area and growth rate of lesions, and patient condition. Currently symptomatic resectable lesions are excised, whereas more advanced disease and unresectable lesions are treated with radiotherapy. If a large area or internal organs are affected or other treatments fail, chemotherapy is used. Recently some authors have reported their encouraging experience in the use of thalidomide in patients with AIDS-related KS. OBJECTIVE To evaluate the efficacy of thalidomide in 3 patients with non-AIDS-related KS. METHODS Two patients with classic widespread cutaneous and 1 with iatrogenic cutaneous and visceral KS were treated with thalidomide (100 mg/day) for 12 months. RESULTS In all 3 patients partial remission was evident after 4 months of thalidomide therapy; in 2 out of 3 complete remission was achieved after 12 months of treatment. CONCLUSIONS Our results seem to confirm the utility of thalidomide in the treatment of non-AIDS-related KS.
Collapse
Affiliation(s)
- Pietro Rubegni
- Department of Clinical Medicine and Immunological Sciences, Section of Dermatology, University of Siena, Siena, Italy.
| | | | | | | | | |
Collapse
|
19
|
Ben M'barek L, Fardet L, Mebazaa A, Thervet E, Biet I, Kérob D, Morel P, Lebbe C. A Retrospective Analysis of Thalidomide Therapy in Non-HIV-Related Kaposi’s Sarcoma. Dermatology 2007; 215:202-5. [PMID: 17823515 DOI: 10.1159/000106576] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 02/27/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thalidomide has antiangiogenic and immunomodulatory properties and has recently been used in the management of human malignancies. Several studies have suggested its interest for treating AIDS-related Kaposi's sarcoma. OBJECTIVES This study aimed to assess the efficacy and toxicity of thalidomide, an antiangiogenic agent, for the treatment of non-HIV-related Kaposi's sarcoma. METHODS Eleven patients were included in this retrospective study conducted in the Department of Dermatology of Saint Louis, Paris, between 2000 and 2003. Among them, 2 were immunosuppressed (1 renal transplant recipient and 1 patient with microscopic polyangiitis treated by oral steroids) with stable immunosuppressive regimens during the past 6 months. The median daily thalidomide dosage was 100 mg and the median duration of drug treatment was 16 weeks. RESULTS Three patients achieved a partial response and 4 had a stable disease. Although no grade 3 or 4 was observed, 3 (27%) out of 11 patients prematurely discontinued thalidomide because of grade 1 sensory neuropathy (paresthesia) and vertigo. CONCLUSIONS Our results show a true although modest interest of thalidomide in non-HIV-related Kaposi's sarcoma and prompt us to evaluate less toxic thalidomide analogues for this indication.
Collapse
|
20
|
Pujol JL, Breton JL, Gervais R, Tanguy ML, Quoix E, David P, Janicot H, Westeel V, Gameroff S, Genève J, Maraninchi D. Phase III Double-Blind, Placebo-Controlled Study of Thalidomide in Extensive-Disease Small-Cell Lung Cancer After Response to Chemotherapy: An Intergroup Study FNCLCC cleo04–IFCT 00-01. J Clin Oncol 2007; 25:3945-51. [PMID: 17761978 DOI: 10.1200/jco.2007.11.8109] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This randomized, double-blind, placebo-controlled phase III study aimed to determine whether thalidomide prolongs survival of patients with extensive-disease small-cell lung cancer (SCLC). Patients and Methods One hundred nineteen patients received two courses of etoposide, cisplatin, cyclophosphamide, and 4′-epidoxorubicin (PCDE). Responder patients who had recovered from chemotherapy toxicity were randomly assigned to receive four additional PCDE cycles plus thalidomide (400 mg daily) or placebo. Results After the first two PCDE cycles, objective response rate was 81.5%, and 92 patients were randomly assigned to placebo (n = 43) or thalidomide (n = 49). Median exposure duration to placebo was 4.5 months, and median exposure to thalidomide was 4.9 months. Patients treated with thalidomide had a longer survival compared with patients who received placebo, although the difference was not statistically significant (minimal follow-up, 3 years; median survival time, 11.7 v 8.7 months, respectively; log-rank test: hazard ratio [HR] = 0.74; 95% CI, 0.49 to 1.12; P = .16). Patients with a performance status (PS) of 1 or 2 who received thalidomide had a significantly longer survival (HR = 0.59; 95% CI, 0.37 to 0.92; P = .02). The disease also progressed slower in patients with PS of 1 or 2 receiving thalidomide (HR = 0.54; 95% CI, 0.36 to 0.87; P = .02), whereas the difference did not reach statistical significance for the whole population (HR = 0.74; 95% CI, 0.49 to 1.12; P = .15). Neuropathy occurred more frequently in the thalidomide group compared with the placebo group (33% v 12%, respectively). Conclusion Treatment with thalidomide was not associated with a significant improvement in survival of SCLC patients. There was pronounced heterogeneity in survival outcomes between groups of patients. Some benefit was observed among patients with a PS of 1 or 2 (exploratory analyses), deserving further studies targeting angiogenesis in this disease.
Collapse
|
21
|
|
22
|
Jeng BH, Holland GN, Lowder CY, Deegan WF, Raizman MB, Meisler DM. Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease. Surv Ophthalmol 2007; 52:329-68. [PMID: 17574062 DOI: 10.1016/j.survophthal.2007.04.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.
Collapse
Affiliation(s)
- Bennie H Jeng
- The Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
| | | | | | | | | | | |
Collapse
|
23
|
Varker KA, Campbell J, Shah MH. Phase II study of thalidomide in patients with metastatic carcinoid and islet cell tumors. Cancer Chemother Pharmacol 2007; 61:661-8. [PMID: 17589846 DOI: 10.1007/s00280-007-0521-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 05/07/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Carcinoid and islet cell tumors are known to be highly vascular. There is no effective systemic therapy currently available for metastatic disease. We conducted a phase II trial to evaluate the efficacy of the anti-antiangiogenic agent thalidomide in metastatic neuroendocrine tumors. PATIENTS AND METHODS Eighteen patients with measurable, histologically proven metastatic carcinoid neuroendocrine carcinomas (well-differentiated, n = 13; moderately-differentiated, n = 5) were enrolled on this study. The majority of the patients had gastrointestinal primaries (small bowel, 8; pancreas, 5; colon, 1). All but one patient had hepatic metastases, and 12 patients (67%) had carcinoid syndrome. All patients had Eastern Cooperative Oncology Group performance status of zero or one. Eight patients (44%) had received previous hepatic artery chemoembolization and 11 (61%) had undergone surgical resection. Patients were started on oral thalidomide at a daily dose of 200 mg that was escalated to the target dose of 400 mg daily after 2 weeks. Tumor response was assessed at 12-week intervals using RECIST criteria. Planned treatment duration was 24 weeks unless unacceptable toxicity or disease progression was observed. RESULTS No patient achieved a partial remission or a complete remission. Best response was stable disease (SD) in 11 of 16 response-evaluable patients (69%). Serum pancreastatin results did not correlate with clinical response. Grade 3 toxicities included dizziness with orthostatic hypotension (n = 5), sensory neuropathy (n = 2), fatigue (n = 2), hemorrhagic cystitis (n = 1), and deep venous thrombosis (n = 1). Frequent Grade 1-2 toxicities were: fatigue (n = 13), constipation (n = 13), dry mouth (n = 12), somnolence (n = 12), dizziness/syncope (n = 10), weight gain (n = 5), and peripheral neuropathy (n = 5). CONCLUSIONS Thalidomide was fairly well tolerated in patients with metastatic carcinoid/islet cell tumors, but failed to reveal any objective responses. The single stage design of the trial makes it difficult to determine whether observed SD in a subset of patients was attributable to the indolent nature of these tumors, or to beneficial effect of thalidomide.
Collapse
Affiliation(s)
- Kimberly A Varker
- Division of Hematology-Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, A438 Starling-Loving Hall, 320 West 10th Avenue, Columbus, OH 43210, USA
| | | | | |
Collapse
|
24
|
Hansen A, Boshoff C, Lagos D. Kaposi sarcoma as a model of oncogenesis and cancer treatment. Expert Rev Anticancer Ther 2007; 7:211-20. [PMID: 17288530 DOI: 10.1586/14737140.7.2.211] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Kaposi sarcoma is the most common cancer among HIV-infected individuals and one of the most common cancers in sub-Saharan Africa. Kaposi sarcoma lesions are highly vascularized, and comprised of spindle-shaped tumor cells. Kaposi sarcoma herpesvirus is etiologically linked to Kaposi sarcoma development and encodes genes that contribute to cellular transformation, evasion of apoptosis, aberrant angiogenesis and an inflammatory tumor microenvironment. The study of Kaposi sarcoma herpesvirus-driven malignancies has provided a model of oncogenesis and identified some of the key steps and, therefore, therapeutic targets of Kaposi sarcoma development. However, current Kaposi sarcoma treatments are not specific and rely on reconstitution of the immune system and systemic administration of cytotoxic agents. Recent studies have demonstrated that mechanism-based therapeutics, such as vascular endothelial growth factor A or mammalian target of rapamycin inhibitors, are promising therapeutic approaches bridging basic research with clinical practice.
Collapse
Affiliation(s)
- Amy Hansen
- Cancer Research UK Viral Oncology Group, Wolfson Institute for Biomedical Research, UCL, London, UK.
| | | | | |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW More therapeutic options are needed for bone and soft tissue sarcomas, especially for patients with metastatic disease. Recent randomized clinical trials conducted in colon, breast and lung cancer have shown the anti-vascular endothelial growth factor agent, bevacizumab, alone or in combination with chemotherapy, improves response and survival. Preclinical studies have demonstrated the anti-tumor effects of varied anti-angiogenic agents in sarcoma cell lines and tumor models. RECENT FINDINGS Preclinical studies in sarcomas have evaluated the role of targeted agents including platelet-derived growth factor, matrix metalloproteinases, urokinase receptor and varied small-molecule tyrosine kinase inhibitors. Novel angiogenesis inhibitors are being studied in the treatment of sarcoma, including monoclonal antibodies against vascular endothelial growth factor, cis- and trans-retinoic acids, thalidomide, and tyrosine kinase inhibitors. Phase I, II and III clinical trials continue to evaluate these agents alone, in combinations together and combined with standard chemotherapy. We review herein the preclinical rationale and clinical trial results of anti-angiogenesis therapy in the treatment of soft tissue and bone sarcoma. SUMMARY Preclinical mechanistic study and clinical trials are continuing in order to evaluate the therapeutic role and ultimately validate the efficacy of the varied anti-angiogenesis agents in soft tissue and bone sarcoma.
Collapse
Affiliation(s)
- Lakshmi Balasubramanian
- Northwestern University Feinberg School of Medicine and the Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois 60611, USA
| | | |
Collapse
|
26
|
Greene W, Kuhne K, Ye F, Chen J, Zhou F, Lei X, Gao SJ. Molecular biology of KSHV in relation to AIDS-associated oncogenesis. Cancer Treat Res 2007; 133:69-127. [PMID: 17672038 PMCID: PMC2798888 DOI: 10.1007/978-0-387-46816-7_3] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
KSHV has been established as the causative agent of KS, PEL, and MCD, malignancies occurring more frequently in AIDS patients. The aggressive nature of KSHV in the context of HIV infection suggests that interactions between the two viruses enhance pathogenesis. KSHV latent infection and lytic reactivation are characterized by distinct gene expression profiles, and both latency and lytic reactivation seem to be required for malignant progression. As a sophisticated oncogenic virus, KSHV has evolved to possess a formidable repertoire of potent mechanisms that enable it to target and manipulate host cell pathways, leading to increased cell proliferation, increased cell survival, dysregulated angiogenesis, evasion of immunity, and malignant progression in the immunocompromised host. Worldwide, approximately 40.3 million people are currently living with HIV infection. Of these, a significant number are coinfected with KSHV. The complex interplay between the two viruses dramatically elevates the risk for development of KSHV-induced malignancies, KS, PEL, and MCD. Although HAART significantly reduces HIV viral load, the entire T-cell repertoire and immune function may not be completely restored. In fact, clinically significant immune deficiency is not necessary for the induction of KSHV-related malignancy. Because of variables such as lack of access to therapy noncompliance with prescribed treatment, failure to respond to treatment and the development of drug-resistant strains of HIV, KSHV-induced malignancies will continue to present as major health concerns.
Collapse
Affiliation(s)
- Whitney Greene
- Tiumor Virology Program, Children's Cancer Research Institute, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | | | | | | | | | | |
Collapse
|
27
|
Sharma RA, Steward WP, Daines CA, Knight RD, O'Byrne KJ, Dalgleish AG. Toxicity profile of the immunomodulatory thalidomide analogue, lenalidomide: phase I clinical trial of three dosing schedules in patients with solid malignancies. Eur J Cancer 2006; 42:2318-25. [PMID: 16899362 DOI: 10.1016/j.ejca.2006.05.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 05/15/2006] [Indexed: 10/24/2022]
Abstract
Thalidomide is an anti-angiogenic agent currently used to treat patients with malignant cachexia or multiple myeloma. Lenalidomide (CC-5013) is an immunomodulatory thalidomide analogue licensed in the United States of America (USA) for the treatment of a subtype of myelodysplastic syndrome. This two-centre, open-label phase I study evaluated dose-limiting toxicities in 55 patients with malignant solid tumours refractory to standard chemotherapies. Lenalidomide capsules were consumed once daily for 12 weeks according to one of the following three schedules: (I) 25 mg daily for the first 7 d, the daily dose increased by 25 mg each week up to a maximum daily dose of 150 mg; (II) 25mg daily for 21 d followed by a 7-d rest period, the 4-week cycle repeated for 3 cycles; (III) 10 mg daily continuously. Twenty-six patients completed the study period. Two patients experienced a grade 3 hypersensitivity rash. Four patients in cohort I and 4 patients in cohort II suffered grade 3 or 4 neutropaenia. In 2 patients with predisposing medical factors, grade 3 cardiac dysrhythmia was recorded. Grade 1 neurotoxicity was detected in 6 patients. One complete and two partial radiological responses were measured by computed tomography scanning; 8 patients had stable disease after 12 weeks of treatment. Fifteen patients remained on treatment as named patients; 1 with metastatic melanoma remains in clinical remission 3.5 years from trial entry. This study indicates the tolerability and potential clinical efficacy of lenalidomide in patients with advanced solid tumours who have previously received multi-modality treatment. Depending on the extent of myelosuppressive pre-treatment, dose schedules (II) or (III) are advocated for large-scale trials of long-term administration.
Collapse
Affiliation(s)
- R A Sharma
- Department of Radiotherapy, Royal Marsden Hospital NHS Foundation Trust, Downs Road, Sutton, Surrey London, SM2 5PT, UK.
| | | | | | | | | | | |
Collapse
|
28
|
Lee CP, Patel PM, Selby PJ, Hancock BW, Mak I, Pyle L, James MG, Beirne DA, Steeds S, A'Hern R, Gore ME, Eisen T. Randomized Phase II Study Comparing Thalidomide With Medroxyprogesterone Acetate in Patients With Metastatic Renal Cell Carcinoma. J Clin Oncol 2006; 24:898-903. [PMID: 16484699 DOI: 10.1200/jco.2005.03.7309] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTo investigate escalating doses of thalidomide compared with medroxyprogesterone in patients with metastatic renal cell carcinoma (RCC), who had either progressed after first-line immunotherapy or who were not suitable for immunotherapy.Patients and MethodsThalidomide was started at 100 mg/d orally (PO) and escalated by 100 mg/d every 2 weeks to the maximum dose of 400 mg/d. Medroxyprogesterone was given at a fixed dose of 300 mg PO daily.ResultsSixty patients were entered (thalidomide:medroxyprogesterone = 29:31; median age, 59 [thalidomide], 60 [medroxyprogesterone]; No. of patients assessable for response, 22 [thalidomide], 26 [medroxyprogesterone]). In the thalidomide arm, there was no objective response seen. The best response was SD in three patients lasting 5+, 6+, and 12 months, respectively. All patients in the medroxyprogesterone arm progressed. There was no difference in overall survival between the two arms; median survival in the thalidomide arm was 8.2 months compared with 4.8 months in the medroxyprogesterone arm (P = .62). Hazard ratio was 0.88 (95% CI, 0.67 to 1.94). Median duration of treatment was 73 days (range, 14 to 364 days) in the thalidomide arm, and 84 days (range, 7 to 175 days) in the medroxyprogesterone arm. The high incidence of toxicity in the thalidomide arm, mainly somnolence, constipation, fatigue and paraesthesia, meant that only 30.8% of patients were able to tolerate the maximum dose of 400 mg/d of treatment.ConclusionThalidomide is not superior to medroxyprogesterone acetate in patients with metastatic RCC. Its risk/benefit ratio does not favor its use in this patient population.
Collapse
Affiliation(s)
- Chooi P Lee
- Department of Medicine, Royal Marsden Hospital, London, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Wu JJ, Huang DB, Pang KR, Hsu S, Tyring SK. Thalidomide: dermatological indications, mechanisms of action and side-effects. Br J Dermatol 2005; 153:254-73. [PMID: 16086735 DOI: 10.1111/j.1365-2133.2005.06747.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thalidomide was first introduced in the 1950s as a sedative but was quickly removed from the market after it was linked to cases of severe birth defects. However, it has since made a remarkable comeback for the U.S. Food and Drug Administration-approved use in the treatment of erythema nodosum leprosum. Further, it has shown its effectiveness in unresponsive dermatological conditions such as actinic prurigo, adult Langerhans cell histiocytosis, aphthous stomatitis, Behçet's syndrome, graft-versus-host disease, cutaneous sarcoidosis, erythema multiforme, Jessner-Kanof lymphocytic infiltration of the skin, Kaposi sarcoma, lichen planus, lupus erythematosus, melanoma, prurigo nodularis, pyoderma gangrenosum and uraemic pruritus. This article reviews the history, pharmacology, mechanism of action, clinical uses and adverse effects of thalidomide.
Collapse
Affiliation(s)
- J J Wu
- Department of Dermatology, University of California, Irvine, Irvine, CA, USA
| | | | | | | | | |
Collapse
|
30
|
Morabito A, Carillio G, Longo R, Gasparini G. Thalidomide Is Inactive in Heavily Pretreated Patients with Metastatic Breast Cancer. Cancer J 2005; 11:248-51. [PMID: 16053669 DOI: 10.1097/00130404-200505000-00012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Experimental studies have demonstrated that thalidomide has anti-tumor activity mediated by blockage of angiogenesis, with clinical efficacy in multiple myeloma, glioblastoma multiforme, and renal cell cancer. We investigated the therapeutic activity and toxicity of thalidomide in patients with progressive metastatic breast cancer pretreated with chemotherapy. Inclusion criteria were metastatic breast cancer in progression of disease after at least two lines of chemotherapy, age > or = 18 years, performance status < or = 2, and adequate hematologic, renal, and hepatic functions. Twelve patients entered the study, eight of whom were pretreated with three or more lines of chemotherapy (66.7%). Thalidomide was well tolerated: the most common side effects were constipation and somnolence (58.3% of patients). No objective response or durable stable disease was observed. Median time to progression and median overall survival were 8 weeks (range, 4-10 weeks) and 16 weeks (range, 8-54 weeks), respectively. In conclusion, thalidomide is an ineffective treatment in patients with progressive metastatic breast cancer heavily pretreated with chemotherapy.
Collapse
|
31
|
Bamias A, Dimopoulos MA. Thalidomide and immunomodulatory drugs in the treatment of cancer. Expert Opin Investig Drugs 2005; 14:45-55. [PMID: 15709921 DOI: 10.1517/13543784.14.1.45] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Thalidomide has antiangiogenic and immunomodulatory properties and has recently been used in the management of human malignancies. Multiple studies have confirmed its activity in multiple myeloma, alone or combined with dexamethasone and/or chemotherapy as first- or second-line treatment. In addition, it may reduce the need for transfusions in patients with myelofibrosis or myelodysplastic syndromes. The activity of thalidomide in solid tumours is less prominent. The most promising results have been reported in Kaposi's sarcoma, malignant melanoma and prostate cancer, especially when it is combined with chemotherapy. Recently, thalidomide analogues (immunomodulatory drugs), with higher immunomodulatory activity and different toxicity profile, have been developed. They have already shown promising activity in multiple myeloma and are currently being evaluated in clinical studies.
Collapse
Affiliation(s)
- Aristotle Bamias
- University of Athens School of Medicine, Department of Clinical Therapeutics, 227 Kifissias Avenue, Kifissia, Athens, 14561, Greece
| | | |
Collapse
|
32
|
Bower M, Stebbing J. AIDS-associated malignancies. CANCER CHEMOTHERAPY AND BIOLOGICAL RESPONSE MODIFIERS 2005; 22:687-706. [PMID: 16110634 DOI: 10.1016/s0921-4410(04)22030-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Mark Bower
- Department of Oncology, Chelsea & Westminster Hospital, London, UK.
| | | |
Collapse
|
33
|
Abstract
Conventional chemotherapy regimens for the treatment of advanced Kaposi's sarcoma (KS) show limited efficacy and considerable toxicity. Liposomal anthracyclines with potential utility in KS include pegylated liposomal doxorubicin (Doxil/Caelyx [PLD]), daunorubicin citrate liposome (DaunoXome [DNX]), and nonpegylated liposomal doxorubicin (Myocet [NPLD]). Preclinical data showed that pegylated liposomes accumulate preferentially in highly vascularized KS lesions. In randomized clinical trials, PLD induced higher response rates than did the conventional combination chemotherapy regimens, bleomycin + vincristine (BV) and BV + conventional doxorubicin (ABV); DNX produced a response rate comparable to that of ABV. NPLD has not been compared with conventional chemotherapy for KS. PLD and DNX were associated with less toxicity compared with BV or ABV, including less alopecia and fewer gastrointestinal and neurologic side effects. Grade 3/4 myelosuppression was common with both PLD and DNX; stomatitis and infusion reactions occurred with PLD treatment, but hand-foot syndrome was relatively infrequent in the dose schedules used for KS. Health-related quality of life was improved in several domains in patients treated with PLD or DNX compared with ABV.
Collapse
Affiliation(s)
- Susan E Krown
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
| | | | | | | |
Collapse
|
34
|
Abstract
Thalidomide, an oral agent with antiangiogenic and immunomodulatory properties, is being investigated extensively in the management of advanced cancer. Multiple studies with large numbers of patients have confirmed that this drug has significant activity in multiple myeloma. Some patients with myelofibrosis or myeodysplatic syndromes may reduce their need for transfusions after thalidomide treatment. The activity of thalidomide in solid tumors is less prominent. Studies in Kaposi's sarcoma, malignant melanoma, renal cell carcinoma and prostate cancer appear more promising especially when thalidomide is combined with biological agents or with chemotherapy. Limited activity was demonstrated in patients with glioma, while thalidomide appears to be inactive in patients with head and neck cancer, breast or ovarian cancer.
Collapse
|
35
|
Kumar S, Witzig TE, Rajkumar SV. Thalidomide: Current Role in the Treatment of Non-Plasma Cell Malignancies. J Clin Oncol 2004; 22:2477-88. [PMID: 15197211 DOI: 10.1200/jco.2004.10.127] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Thalidomide, initially introduced as a sedative, was withdrawn from the market in the early 1960s after it was found to be a teratogen. However, it later found use as an investigational agent in the treatment of erythema nodosum leprosum, oral ulcers, graft versus host disease, and wasting associated with the human immunodeficiency syndrome. Its antiangiogenic properties were recognized in the early 1990s during a period where the importance of angiogenesis became increasingly apparent as a critical step in the in the proliferation and spread of malignant neoplasms. This led to the evaluation of thalidomide as an antiangiogenic agent in the treatment of several cancers. Thalidomide has already become part of standard therapy for the treatment of patients with relapsed and refractory multiple myeloma. It has also been found to have varying degree of benefit in various other malignancies. Although more clinical trials are needed, Kaposi's sarcoma and myelofibrosis represent other malignancies in which thalidomide has already demonstrated promising activity. The mechanism of action of thalidomide in cancer is still unclear, but do appear to be mediated by several other mechanisms in addition to its anti-angiogenic properties. This article reviews the current status of thalidomide for the treatment of non-plasma-cell malignancies.
Collapse
Affiliation(s)
- Shaji Kumar
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN 55905, USA
| | | | | |
Collapse
|
36
|
Abstract
Despite its history as a human teratogen, thalidomide is emerging as a treatment for cancer and inflammatory diseases. Although the evolution of its clinical application could not have been predicted from the tragedy associated with its misuse in the past, its history serves as a lesson in drug development that underscores the need to understand the molecular pharmacology of a compound's activity, including associated toxicities. Here, we summarise the applications for thalidomide with an emphasis on clinical trials published over the past 10 years, and consider our knowledge of the molecular pharmacology of the drug in the context of clinical trial data, attempting to provide a mechanism-guided understanding of its activity.
Collapse
Affiliation(s)
- Michael E Franks
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20030, USA
| | | | | |
Collapse
|
37
|
Bartlett JB, Michael A, Clarke IA, Dredge K, Nicholson S, Kristeleit H, Polychronis A, Pandha H, Muller GW, Stirling DI, Zeldis J, Dalgleish AG. Phase I study to determine the safety, tolerability and immunostimulatory activity of thalidomide analogue CC-5013 in patients with metastatic malignant melanoma and other advanced cancers. Br J Cancer 2004; 90:955-61. [PMID: 14997189 PMCID: PMC2410215 DOI: 10.1038/sj.bjc.6601579] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We assessed the safety, tolerability and efficacy of the immunomodulatory drug, CC-5013 (REVIMID™), in the treatment of patients with metastatic malignant melanoma and other advanced cancers. A total of 20 heavily pretreated patients received a dose-escalating regimen of oral CC-5013. Maximal tolerated dose, toxicity and clinical responses were evaluated and analysis of peripheral T-cell surface markers and serum for cytokines and proangiogenic factors were performed. CC-5013 was well tolerated. In all, 87% of adverse effects were classified as grade 1 or grade 2 according to Common Toxicity Criteria and there were no serious adverse events attributable to CC-5013 treatment. Six patients failed to complete the study, three because of disease progression, two withdrew consent and one was entered inappropriately and withdrawn from the study. The remaining 14 patients completed treatment without dose reduction, with one patient achieving partial remission. Evidence of T-cell activation was indicated by significantly increased serum levels of sIL-2 receptor, granulocyte–macrophage colony-stimulating factor, interleukin-12 (IL-12), tumour necrosis factor-α and IL-8 in nine patients from whom serum was available. However, levels of proangiogenic factors vascular endothelial growth factor and basic foetal growth factor were not consistently affected. This study demonstrates the safety, tolerability and suggests the clinical activity of CC-5013 in the treatment of refractory malignant melanoma. Furthermore, this is the first report demonstrating T-cell stimulatory activity of this class of compound in patients with advanced cancer.
Collapse
Affiliation(s)
- J B Bartlett
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - A Michael
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - I A Clarke
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - K Dredge
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - S Nicholson
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - H Kristeleit
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - A Polychronis
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - H Pandha
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | | | | | - J Zeldis
- Celgene Corporation, Warren, NJ, USA
| | - A G Dalgleish
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK. E-mail:
| |
Collapse
|
38
|
Fraiman G, Ganti AK, Potti A, Mehdi S. Angiosarcoma of the small intestine: a possible role for thalidomide? Med Oncol 2004; 20:397-402. [PMID: 14716038 DOI: 10.1385/mo:20:4:397] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2003] [Accepted: 05/19/2003] [Indexed: 02/07/2023]
Abstract
An 85-yr-old male presented with complaints of a 40-lb weight loss and a dull left upper quadrant abdominal pain. He also complained of decreased appetite, generalized weakness, generally not feeling well, and a dull left upper quadrant abdominal pain that was not relieved by food. He had a ventral and a left-sided inguinal hernia. Laboratory investigations revealed iron deficiency anemia, the cause of which was not apparent despite extensive investigation including computerized tomographic scans, esophagogastroduodenoscopy, and small-bowel follow-through examination. Surgical exploration for possible angiodysplasia, malignancy, and/or mesenteric ischemia revealed an incarcerated hernia, and the histopathological examination of the surgical specimen revealed high-grade angiosarcoma. The tumor showed strong positivity for vimentin and CD31 and a focal positivity for Factor VIII and CD34. At that time he was found to have hepatic metastases. He was started on thalidomide as an experimental measure with no change in the performance status and increasing evidence of necrosis in the metastatic lesion.
Collapse
Affiliation(s)
- Genise Fraiman
- Department of Internal Medicine, Veterans' Affairs Medical Center, Fargo, ND 58102, USA
| | | | | | | |
Collapse
|
39
|
Nasca MR, Micali G, Cheigh NH, West LE, West DP. Dermatologic and nondermatologic uses of thalidomide. Ann Pharmacother 2003; 37:1307-20. [PMID: 12921515 DOI: 10.1345/aph.19255] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To review published data on thalidomide, with emphasis on current knowledge about mechanism of action, new and/or potential dermatologic and nondermatologic therapeutic applications, well-known and emerging adverse effects, and current indications for its safe use. DATA SOURCES Review articles, in vitro research studies, references from retrieved articles, case reports, and clinical trials were identified from a computerized literature search using MEDLINE and OVID (1966-January 2003) and on the Cochrane Clinical Trials Register (January 2003). Information available from meetings' abstract books, Internet, or pharmaceutical companies was also considered. STUDY SELECTION AND DATA EXTRACTION All articles identified as relevant, including those from non-English literature, were considered in an attempt to provide to the reader both the theoretical basis and practical guidelines for thalidomide pharmacotherapy. DATA SYNTHESIS Thalidomide has hypnosedative, antiangiogenic, antiinflammatory, and immunomodulatory properties. Moreover, it has been shown to selectively inhibit the production of tumor necrosis factor-alpha and reduce the expression of various integrin receptors on the membrane of leukocytes and other cell types in a dose-dependent fashion. Controlled trials demonstrated the efficacy of thalidomide in a number of diseases, including erythema nodosum leprosum, lupus erythematosus, aphthosis, graft-versus-host disease, prurigo nodularis, and actinic prurigo. Single case reports or studies in small series have also suggested a possible role for thalidomide in numerous other dermatologic and nondermatologic disorders. Possibly severe and sometimes irreversible risks related to the clinical use of thalidomide include teratogenicity and neurotoxicity. CONCLUSIONS Although teratogenicity and neurotoxicity are significant adverse effects requiring cautious use, thalidomide is an effective therapeutic modality in a variety of difficult-to-treat disorders and, providing careful selection of patients, should offer an acceptable risk-to-benefit ratio.
Collapse
Affiliation(s)
- Maria R Nasca
- Department of Dermatology, University of Catania, Catania, Italy
| | | | | | | | | |
Collapse
|
40
|
Fanelli M, Sarmiento R, Gattuso D, Carillio G, Capaccetti B, Vacca A, Roccaro AM, Gasparini G. Thalidomide: a new anticancer drug? Expert Opin Investig Drugs 2003; 12:1211-25. [PMID: 12831355 DOI: 10.1517/13543784.12.7.1211] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Experimental studies have demonstrated that thalidomide (Thal), a drug developed as a sedative, has antitumoural properties. The possible antitumour mechanisms of action involve: inhibition of angiogenesis, cytokine-mediated pathways, modulation of adhesion molecules, inhibition of cyclooxygenase-2 and stimulation of immuno response. Therefore, Thal is under clinical evaluation in oncology. This paper provides an overview of the data currently available in literature regarding, in terms of activity and toxicity, the use of Thal in cancer patients. Multiple myeloma is so far the most responsive malignancy. A moderate activity has been documented in certain solid tumours: glioblastoma multiforme, renal cell carcinoma and malignant melanoma. Tolerability is generally satisfactory with peripheral neuropathy being the most relevant dose-dependent toxicity. The more frequent, but moderate side effects are: somnolence, constipation, dizziness and fatigue. More studies are needed to properly evaluate the anticancer activity of Thal alone or in combination with other anticancer treatments. Preliminary studies suggest promising results of Thal in combinations with corticosteroids and cytotoxic drugs as front-line therapy of multiple myeloma. Regarding therapy of solid tumours in the adult, combination with chemotherapy, radiation therapy and molecular-targeting compounds are under investigation.
Collapse
Affiliation(s)
- Massimo Fanelli
- Division of Clinical Oncology, San Filippo Neri Hospital, Rome, Italy
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
Only a small number of the many agents with the potential to inhibit factors known to stimulate KS growth have been tested clinically, and many were investigated at a time when treatment options for HIV infection were relatively ineffective. The failure of some of these agents to induce KS regression may not signify failure to achieve a relevant biologic effect in all cases, but may simply mean that in a neoplasm that expresses a broad array of growth factors, inhibition of a single factor may be insufficient to achieve tumor regression. Moreover, agents that inhibit angiogenesis may be expected to stabilize tumors rather then eradicate them, but tumor stabilization is a difficult endpoint to quantify. In fact, given the redundancy of growth factors believed to be involved in KS development, it is perhaps remarkable that members of several classes of agents (eg, a synthetic retinoid, an MMPI, thalidomide, IL-12) have induced KS regression in a substantial minority of patients. It is likely, however, that drug combinations that target several pathogenetic mechanisms will be more effective than will single drugs in suppressing KS growth. A particular need. especially in the early evaluation of therapies aimed at specific pathogenic targets, is the development of assays to measure specific biologic effects (eg, changes in the activity of signal transduction pathways within tumor biopsy specimens) related to the agent's putative mechanism of action. Greater availability and clinical application of these types of markers of biologic efficacy may speed the identification of potentially active agents that could then be "fast tracked" into larger efficacy trials and combination studies.
Collapse
Affiliation(s)
- Susan E Krown
- Clinical Immunology Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
| |
Collapse
|
42
|
Abstract
Thalidomide currently is used to treat relapsed and refractory multiple myeloma. The drug also is being actively investigated in patients newly diagnosed with multiple myeloma. The therapeutic applications of thalidomide are expected to grow as clinical trials document its activity in treating other neoplastic disorders and diseases. Healthcare providers need to be well informed of its toxicities and able to identify their signs and symptoms immediately. They must have adequate knowledge about thalidomide administration and provide comprehensive patient education regarding thalidomide and its toxicities to ensure patient safety and compliance.
Collapse
|
43
|
Abstract
BACKGROUND Thalidomide is best known as a major teratogen that caused birth defects in up to 12,000 children in the 1960s. More recently, this agent has been approved by the US Food and Drug Administration for the treatment of erythema nodosum leprosum (ENL) through a restricted-use program. Its immunomodulatory, anti-inflammatory, and antiangiogenic properties are currently under study in a number of clinical conditions. OBJECTIVE This article reviews the pharmacology of thalidomide; its approved and off-label uses in dermatologic, oncologic, and gastrointestinal conditions; and adverse events associated with its use. METHODS Relevant articles were identified through searches of MEDLINE (1966-June 2002), International Pharmaceutical Abstracts (1970-June 2002), and EMBASE (1990-June 2002). Search terms included but were not limited to thalidomide, pharmacokinetics, pharmacology, therapeutic use, and teratogenicity, as well as terms for specific disease states and adverse events. Further publications were identified from the reference lists of the reviewed articles. Abstracts of recent symposia were obtained from the American Society of Clinical Oncology Web site. RESULTS Thalidomide is thought to exert its therapeutic effect through the modulation of cytokines, particularly tumor necrosis factor-alpha. In addition to its approved indication for ENL, thalidomide has been studied in various other conditions, including graft-versus-host disease, discoid lupus erythematosus, sarcoidosis, relapsed/refractory multiple myeloma, Waldenstrom's macroglobulinemia, myelodysplastic syndromes, acute myeloid leukemia, myelofibrosis with myeloid metaplasia, renal cell carcinoma, malignant gliomas, prostate cancer, Kaposi's sarcoma, colorectal carcinoma, oral aphthous ulcers, Behçet's disease, Crohn's disease, and HIV/AIDS-associated wasting. Adverse events most frequently associated with its use include somnolence, constipation, rash, peripheral neuropathy, and thromboembolism. CONCLUSIONS Use of thalidomide is limited by toxicity, limited efficacy data, and restricted access. Evidence of its efficacy in conditions other than ENL awaits the results of controlled clinical trials.
Collapse
Affiliation(s)
- S James Matthews
- Department of Pharmacy Practice, School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts 02115, USA.
| | | |
Collapse
|
44
|
Toschi E, Sgadari C, Monini P, Barillari G, Bacigalupo I, Palladino C, Baccarini S, Carlei D, Grosso G, Sirianni MC, Ensoli B. Treatment of Kaposi's sarcoma--an update. Anticancer Drugs 2002; 13:977-87. [PMID: 12439331 DOI: 10.1097/00001813-200211000-00001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Kaposi's sarcoma (KS) is an angioproliferative disease of multifactorial origin arising in different clinic-epidemiologic forms, which show the same histopathological features. It generally starts as a hyperplastic reactive-inflammatory and angiogenic process, which may evolve into monomorphic nodules of KS cells that can be clonal (late-stage lesions) and resemble a true sarcoma. Infection with the human herpesvirus 8, cytokine- and angiogenic factor-induced growth together with an immuno-dysregulated state represent fundamental conditions for the development of this tumor. Several local therapies are used to eradicate early and confined skin lesions, whereas widely disseminated, progressive or symptomatic disease requires a more aggressive treatment. Although different chemotherapeutic agents have been used to treat aggressive KS, the growing understanding of the pathogenetic factors participating in KS development has provided a strong rationale for using less- or non-cytotoxic agents that block the mechanisms involved in KS pathogenesis. The angiogenic nature of KS makes it particularly suitable for using therapies based on anti-angiogenic agents. Of note on this goal, recent studies indicate that the highly active anti-retroviral therapy, including at least one human immunodeficiency virus (HIV) protease inhibitor (PI), is associated with a dramatic decrease in the incidence of AIDS-KS and with a regression of KS in treated individuals. Consistent with this, results from preclinical studies indicate that PIs have potent and direct anti-angiogenic and anti-KS activities, suggesting that they should be further investigated, alone or combined with other therapies, as a novel treatment for KS in both HIV seropositive or seronegative individuals.
Collapse
Affiliation(s)
- Elena Toschi
- Laboratory of Virology, Istituto Superiore di Sanità, 00161 Rome, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Abstract
Thalidomide is an effective agent to treat over 25 seemingly unrelated dermatological conditions that have an inflammatory or autoimmune basis. The main side-effects of teratogenesis and peripheral neuropathy limit its use. Currently, in Australia no assurance is given as to the quality, safety and efficacy of thalidomide. The use of thalidomide for toxic epidermal necrolysis can lead to an increase in mortality, and its use as a prophylactic agent for the prevention of chronic graft-versus-host disease following bone marrow transplantation has raised more speculations as to the safety of this notorious drug. A review of the therapeutic indications for thalidomide in dermatology as well as the mechanisms of action and side-effects of this drug are presented. The current suggested guidelines for its use in clinical practice in Australia are discussed.
Collapse
Affiliation(s)
- Nina Y Wines
- Department of Dermatology, Royal North Shore Hospital, St Leonards, Sydney, New South Wales, Australia.
| | | | | |
Collapse
|
46
|
Sarid R, Klepfish A, Schattner A. Virology, pathogenetic mechanisms, and associated diseases of Kaposi sarcoma-associated herpesvirus (human herpesvirus 8). Mayo Clin Proc 2002; 77:941-9. [PMID: 12233927 DOI: 10.4065/77.9.941] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Kaposi sarcoma-associated herpesvirus (KSHV) is a recently discovered and characterized member of the herpesvirus family. It is one of a few viruses proved to be associated with tumorigenesis in humans. Its causal association with 4 clinical and epidemiologic variants of Kaposi sarcoma (classic, endemic, iatrogenic, and acquired immunodeficiency virus-associated) as well as with several lymphoproliferative disorders (notably primary effusion lymphoma and multicentric Castleman disease) is reviewed critically. Issues related to the epidemiology, transmission, and molecular and serologic diagnosis are discussed. Several intriguing oncogenic mechanisms of KSHV infection have been identified. These are often dependent on the interaction of KSHV with other viruses, such as human immunodeficiency virus, Epstein-Barr virus, or both. However, important problems remain and once resolved will substantially enhance our understanding of oncogenesis in general and viral-induced oncogenesis in particular. This may also translate into improved treatment and perhaps prevention of this common and intriguing viral infection.
Collapse
MESH Headings
- Castleman Disease/virology
- DNA, Viral/analysis
- Enzyme-Linked Immunosorbent Assay
- Herpesvirus 8, Human/genetics
- Herpesvirus 8, Human/isolation & purification
- Herpesvirus 8, Human/pathogenicity
- Humans
- Lymphoma, AIDS-Related/virology
- Lymphoma, B-Cell/virology
- Lymphoma, Large B-Cell, Diffuse/virology
- Multiple Myeloma/virology
- Polymerase Chain Reaction
- Sarcoma, Kaposi/complications
- Sarcoma, Kaposi/diagnosis
- Sarcoma, Kaposi/epidemiology
- Sarcoma, Kaposi/virology
Collapse
Affiliation(s)
- Ronit Sarid
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | | | | |
Collapse
|
47
|
Abstract
Thalidomide is having increasing application in the management of a wide spectrum of immunologically-mediated and infectious disorders. It is also suggested that this agent may also have be of importance in the treatment of solid and non-solid malignancies. The present article reviews the role of thalidomide in the management of malignancy and outlines its possible potential in the treatment of malignancy of the mouth.
Collapse
Affiliation(s)
- S R Porter
- Department of Oral Medicine, Eastman Dental Institute for Oral Health Care Sciences, UCL, University of London, 256 Gray's Inn Road, London, UK
| | | |
Collapse
|
48
|
Zhou S, Kestell P, Tingle MD, Paxton JW. Thalidomide in cancer treatment: a potential role in the elderly? Drugs Aging 2002; 19:85-100. [PMID: 11950376 DOI: 10.2165/00002512-200219020-00002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is increased interest in the treatment of cancer with thalidomide because of its antiangiogenic, immunomodulating and sedative effects. In animal models, the antitumour activity of thalidomide is dependent on the species, route of administration and coadministration of other drugs. For example, thalidomide has shown antitumour effects as a single agent in rabbits, but not in mice. In addition, the antitumour effects of the conventional cytotoxic drug cyclophosphamide and the tumour necrosis factor inducer 5,6-dimethylxanthenone-4-acetic acid (DMXAA) were found to be potentiated by thalidomide in mice bearing colon 38 adenocarcinoma tumours. Further studies have revealed that thalidomide upregulates intratumoral production of tumour necrosis factor-alpha 10-fold over that induced by DMXAA alone. Coadministration of thalidomide also significantly reduced the plasma clearance of DMXAA and cyclophosphamide. All these effects of thalidomide may contribute to the enhanced antitumour activity. Recent clinical trials of thalidomide have indicated that it has minimal anticancer activity for most patients with solid tumours when used as a single agent, although it was well tolerated. However, improved responses have been reported in patients with multiple myeloma. Palliative effects of thalidomide on cancer-related symptoms have also been observed, especially for geriatric patients with prostate cancer. Thalidomide also eliminates the dose-limiting gastrointestinal toxic effects of irinotecan. There is preliminary evidence indicating that the clearance of thalidomide may be reduced in the elderly. The exact role of thalidomide in the treatment of cancer and cancer cachexia in the elderly remains to be elucidated. However, it may have some value as part of a multimodality anticancer therapy, rather than as a single agent.
Collapse
Affiliation(s)
- Shufeng Zhou
- Division of Pharmacology and Clinical Pharmacology, School of Medicine, The University of Auckland, Auckland, New Zealand.
| | | | | | | |
Collapse
|
49
|
Hengge UR, Ruzicka T, Tyring SK, Stuschke M, Roggendorf M, Schwartz RA, Seeber S. Update on Kaposi's sarcoma and other HHV8 associated diseases. Part 1: epidemiology, environmental predispositions, clinical manifestations, and therapy. THE LANCET. INFECTIOUS DISEASES 2002; 2:281-92. [PMID: 12062994 DOI: 10.1016/s1473-3099(02)00263-3] [Citation(s) in RCA: 193] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Kaposi's sarcoma (KS) is a mesenchymal tumour involving blood and lymphatic vessels. Only recently has the pathogenesis of this extraordinary neoplasm been elucidated. Viral oncogenesis and cytokine-induced growth together with some state of immunocompromise represent important conditions for this tumour to develop. In 1994, a novel virus was discovered and termed human herpesvirus 8 (HHV8), also known as Kaposi's sarcoma-associated herpes virus, which can be found in all types of KS, whether related to HIV or not. In the era of highly active antiretroviral therapy (HAART), the incidence of AIDS-KS has considerably declined, probably due to enhanced immune reconstitution and anti-HHV8-specific immune responses. If HAART is able to prevent spreading of KS, local therapy of KS may become an essential component of patient management. Part 1 of the review covers the epidemiology, environmental predispositions, clinical manifestations, and therapy of KS. Newer treatments such as pegylated liposomal anthracyclines and experimental strategies are discussed. We also present rationales and graduated treatment algorithms for local and systemic therapy in patients with KS to appropriately meet the challenges of this extraordinary neoplasm. Part 2, to be published next month, will summarise recent insights in the pathogenesis of KS and will discuss other HHV8-related diseases such as Castleman's disease and primary effusion lymphoma.
Collapse
Affiliation(s)
- Ulrich R Hengge
- Department of Dermatology, Venereology and Allergology, University of Essen, Germany.
| | | | | | | | | | | | | |
Collapse
|
50
|
Arrieta O, Guevara P, Tamariz J, Rembao D, Rivera E, Sotelo J. Antiproliferative effect of thalidomide alone and combined with carmustine against C6 rat glioma. Int J Exp Pathol 2002; 83:99-104. [PMID: 12084046 PMCID: PMC2517668 DOI: 10.1046/j.1365-2613.2002.00219.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Thalidomide could have therapeutic applications in neoplasms and in other diseases, particularly those of autoimmune origin. The objective of this study was to investigate the effect of various doses of thalidomide on the growth of C6 glioma in rats, and to determine its effects on parameters of cell proliferation and angiogenesis. Additionally, we investigated a potential enhancement of the antitumoral action of thalidomide when combined with a low dose of the antineoplastic carmustine. C6 glioma cells were implanted subcutaneously in Wistar rats. A highly malignant glioma developed in 80% of animals. When the tumour reached 2.0 cm diameter thalidomide was administered at doses of 100, 200 or 400 mg/kg/day. When given at a dose of 400 mg/kg/day thalidomide significantly reduced the tumour volume, the mitotic index and cell proliferation but not the vascular density. The combination of thalidomide plus carmustine increased the inhibitory effect on tumoral growth. Our results indicate that thalidomide is effective against malignant glioma; apparently by an antiproliferative effect, rather than by inhibition of angiogenesis; when combined with carmustine it could increase the response of glioma to antineoplastic treatment.
Collapse
Affiliation(s)
- Oscar Arrieta
- Neuroimmunology Unit, National Institute of Neurology and Neurosurgery of México, México.
| | | | | | | | | | | |
Collapse
|