Thalidomide induces imbalances in T-lymphocyte sub-populations in the circulating blood of healthy males

The ratio between CD4 + and CD8 + cells in the peripheral blood of patients with hematological malignancies is not altered by thalidomide

Thalidomide is thought to have anti-angiogenic and immunomodulatory properties, including suppression of tumor necrosis factor-alpha, effects on interleukins and interferons, down-regulation of some cell adhesion molecules, and changes in the proportion of lymphocyte subsets. It is unclear whether the clinical response to thalidomide in patients with multiple myeloma (MM), idiopathic myelofibrosis (IM), and myelodysplastic syndromes (MDS) is related to its ability to inhibit angiogenesis or its immunomodulatory effects. We examined the effect of thalidomide on T-lymphocyte subsets in 18 patients with MDS, 6 patients with MM, 4 patients with IM, and 3 patients with angioimmunoblastic lymphoma (AILD). These patients had either a relapse or progressive disease following cytotoxic chemotherapy including high-dose chemotherapy with autologous stem cell support. Thalidomide was first administered at 100 mg/day p.o. and increased to 400 mg/day. T-lymphocyte subsets (CD4+, CD8+) were measured by fluorescence-activated cell sorter (FACS) before and during treatment with thalidomide. Twenty-six of 31 patients responded to thalidomide, most of them achieving partial remission. The median concentration of CD4+ cells was 443/microl, the median of CD8+ cells was 359/microl (CD3 992/microl). In our cohort, no significant changes in absolute numbers or proportions of CD3+ (P = 0.12), CD4+ (P = 0.668), or CD8+ (P = 0.143) cells were observed following the treatment with thalidomide. Although the CD4/CD8 ratio declined from 1.6 to 1.0 during 3 months of thalidomide treatment, this had no statistical significance (P = 0.1). Our findings show that an effect of thalidomide on the T lymphocytes studied is unlikely to be of major importance for the clinical effects.

Thalidomide: Current Role in the Treatment of Non-Plasma Cell Malignancies

Thalidomide, initially introduced as a sedative, was withdrawn from the market in the early 1960s after it was found to be a teratogen.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.

Salvage therapy for hepatocellular carcinoma with thalidomide

AIM: To evaluate the clinical benefit of thalidomide in patients with advanced hepatocellular carcinoma (hepatoma).

METHODS: From March 2000 to July 2002, patients who had advanced hepatocellular carcinoma and failed to or were unsuited for aggressive treatment, were enrolled and took thalidomide 150 to 300 mg/d. All cases were followed till April 2003. Data collection included viral hepatitis, grade of cirrhosis, total dosage of thalidomide, side effect, stage of hepatoma by Okuda and CLIP classification, and prognosis. The subjects were divided into A and B groups, depending on 5000 mg dosage of thalidomide. Survival time of all cases and in the two subgroups was evaluated.

RESULTS: Ninety-nine patients with hepatoma were enrolled, 81 men and 18 females with median age 58 ± 14.1 years. Eighty-six percent had viral hepatitis and one case was alcoholism. Hepatoma was diagnosed with histology, alpha-fetoprotein (aFP) > 400 ng/mL, or image examination, there were 30, 33 and 36 cases respectively. At the time of thalidomide therapy, more than 81% had cirrhotic status. Twenty-two patients were in group A (< 5000 mg) with median survival time about 25 days, for 77 cases in group B (≥ 5000 mg) the median survival time was about 109 days. Six subjects had partial response. Most adverse effects were skin rush, neuropathy, somnolence, and constipation.

CONCLUSION: Several patients responded to thalidomide therapy. As a single drug therapy, thalidomide might not have good therapeutic effect for all cases, but a small ratio of patients had exciting response, the resistance or tumor escape would develop after long-term use. Up to now, no defined facts could be used to predict response. The effect of thalidomide on hepatoma might be associated with the dosage. As salvage therapy, thalidomide has its value. Combination or adjuvant therapy will be the next trial.

Thalidomide as an anti-cancer agent

Thalidomide is a glutamic acid derivative initially introduced as a sedative hypnotic nearly forty years ago. It was withdrawn following numerous reports linking it to a characteristic pattern of congenital abnormalities in babies born to mothers who used the drug for morning sickness. It has gradually been re-introduced into clinical practice over the past two decades, albeit under strict regulation, since it was found to be useful in the management of erythema nodosum leprosum and HIV wasting syndrome. Recognition of its anti-angiogenic effect led to its evaluation in the treatment of various malignancies, where angiogenesis has been shown to play an important role. Numerous clinical trials done over the past four years have confirmed the significant anti-myeloma activity of this drug. It has also shown promise in preliminary trials in the treatment of a variety of different malignant diseases. The mechanisms of its antineoplastic effects continue to be the focus of ongoing research. It has become clear that even though its anti angiogenic effects play a significant role in the anti-tumor activity, there are other properties of this drug which are responsible as well. It also possesses anti-TNF alpha activity, which has led to its evaluation in several inflammatory states. In this concise review, we briefly describe the historical background and pharmacological aspects of this drug. We have concisely reviewed the current knowledge regarding mechanisms of its anti-neoplastic activity and the results of various clinical trials in oncology.

The metabolic and immunologic effects of short-term thalidomide treatment of patients infected with the human immunodeficiency virus

Thalidomide therapy has been shown to cause increases in body weight in patients with HIV and tuberculosis infections. To examine the nature of this weight gain and its immunological correlates in patients with HIV infection, we studied a cohort of 13 patients with minimally symptomatic HIV disease. Patients were admitted to the Rockefeller University General Clinical Research Center and maintained on strict isocaloric diets to achieve weight stabilization before a 14-day course of thalidomide treatment. Mean percentage weight increase was 3.6% on day 14 of thalidomide therapy (p = 0.002). Weight gain was associated with a reduction in mean daily urinary nitrogen excretion of 1.81 g (p = 0.017). Resting energy expenditure was unaffected by thalidomide. Body composition analysis suggested some extracellular fluid retention in the first week of thalidomide therapy, followed by an expansion of lean tissue mass during the second week. Remarkably, total lymphocyte counts and CD8+ T cell counts increased following treatment with the drug from 1578 +/- 185 to 2617 +/- 265 and from 938 +/- 146 to 1369 +/- 231, respectively. Modest increases in CD4+ T cell counts were also observed. Levels of circulating TNF-alpha were not elevated at baseline. A significant increase in mean plasma levels of soluble interleukin 2 receptor (sIL-2r), from 1918 +/- 250 to 3816 +/- 411 pg/ml (p = 0.0022), occurred in response to thalidomide, suggesting drug-induced immunological activation. In conclusion, thalidomide treatment of patients with HIV infection caused weight gain and lean tissue anabolism, even when caloric intake was kept constant. The nature of the association between thalidomide treatment-induced metabolic changes and the immunomodulatory effects of the drug has yet to be elucidated.

Thalidomide as replacement for steroids in immunosuppression after lung transplantation

Steroids have been implicated in postoperative complications after lung transplantation: infections, delayed wound healing, and poor bronchial anastomotic healing. Thalidomide (alpha-phthalimidoglutarimide), a sedative drug with known immunomodulatory properties, was used to replace corticosteroids after canine lung transplantation. Fifteen mongrel dogs underwent single-lung transplantation: group I (n = 5) received cyclosporin A (20 mg/kg twice a day), azathioprine (2.5 mg/kg once a day), and thalidomide (50 mg/kg twice a day). Group II (n = 5) received standard immunosuppression of cyclosporin A (20 mg/kg twice a day), azathioprine (2.5 mg/kg once a day), and prednisone (2 mg/kg once a day), and group III (n = 5) received cyclosporin A (10 mg/kg twice a day), azathioprine (2.5 mg/kg once a day), and thalidomide (50 mg/kg twice a day). Open lung biopsy and bronchoscopy were performed weekly until sacrifice on day 28. Serum thalidomide and cyclosporin A levels were followed up weekly. Group I showed essentially no rejection until week 2 and minimal rejection (grade 1) until day 28. Group II had moderate rejection (grade 2) of the graft at all time points. Group III animals had moderate to severe rejection (grades 3 to 4) after 21 days (p < 0.05 for group I versus groups II and III). The number of clinically evident episodes of pneumonia was also significantly lower in group I than in groups II and III (p < 0.05). We conclude that thalidomide appears to replace corticosteroids effectively in early postoperative immunosuppression after lung transplantation and is associated with a decreased incidence of pneumonia.(ABSTRACT TRUNCATED AT 250 WORDS)

T lymphocyte subsets in leprosy. A study of 24 Egyptian patients

Phenotypic analysis was done on 24 Egyptian leprosy patients and 11 healthy controls. The type of leprosy, duration of disease at the time of testing, and age were found to affect T cell subset distribution. As compared with controls, neural leprosy tended to have a decreased total T cell percentage, borderline leprosy an increased T suppressor cell percentage, and reactional borderline leprosy an increased T helper/suppressor ratio. Patients with the disease for less than 1 year had a higher mean percentage of T suppressor cells and a lower mean T helper/suppressor ratio than patients with leprosy for more than 1 year. The same was true in older (50-70 years old) versus younger (12-41 years old) patients.