[Emergencies in cancer immunotherapy]

BACKGROUND

Immunomodulatory therapies are becoming increasingly important in uro-oncology. For this reason, we will probably be increasingly confronted with side effects. In addition, there is an increasing number of combinations with other mechanisms of action. Immune-mediated side effects may occur as a consequence of this therapy. These are different from the side effects of chemotherapy and other targeted therapies and therefore require different treatment strategies.

AIM

Based on the current literature, the data on graduation and stage-dependent management will be presented as well as illustrated with examples from practice.

MATERIALS AND METHODS

Literature review on the detection and therapeutic management of adverse events mediated in the setting of immuno-oncologic therapy.

RESULTS

Treatment-related events can in principle affect all organ systems. Toxicities in the area of the skin, such as rash or pruritus, hypo- or hyperthyreosis, arthritis, muscle pain and gastrointestinal symptoms are frequently seen. In terms of frequency, most side effects are grade 1 to 2, but grade 3 to 4 toxicities are also generally well treatable if detected early. Rare complications such as neurological toxicities, pneumonitis or carditis can develop a fulminant course if diagnosed too late.

CONCLUSIONS

Even emergencies are manageable if we know the most important side effects and the therapeutic options. Immune-mediated side effects are of particular importance because they can affect any organ system. However, as long as we consider the possibility of toxicity from checkpoint inhibitors when the patient presents with symptoms, most side effects are easy to treat and therefore manageable.

Analysing the tumor transcriptome of prostate cancer to predict efficacy of Lu-PSMA therapy

RATIONALE

177Lu-PSMA ([177Lu]Lutetium-PSMA-617) therapy is an effective treatment option for patients with prostate specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer, but still shows a non-responder rate of approximately 30%. Combination regimes of programmed death-ligand 1 (PD-L1) inhibition and concomitant 177Lu-PSMA therapy have been proposed to increase the response rate. However, the interplay of immune landscape and 177Lu-PSMA therapy efficacy is poorly understood.

METHODS

Between March 2018 and December 2021, a total of 168 patients were referred to 177Lu-PSMA therapy in our department and received a mean total dose of 21.9 GBq (three cycles in mean). All patients received baseline PSMA positron emission tomography to assess the PSMA uptake. The histopathological specimen of the primary prostate tumor was available with sufficient RNA passing quality control steps for genomic analysis in n=23 patients. In this subset of patients, tumor RNA transcriptomic analyses assessed 74 immune-related features in total, out of which n=24 signatures were not co-correlated and investigated further for outcome prognostication.

RESULTS

In the subset of patients who received 177Lu-PSMA therapy, PD-L1 was not significantly associated with OS (HR per SD change (95% CI) 0.74 (0.42 to 1.30); SD: 0.18; p=0.29). In contrast, PD-L2 signature was positively associated with longer OS (HR per SD change 0.46 (95% CI 0.29 to 0.74); SD: 0.24; p=0.001; median OS 17.2 vs 5.7 months in higher vs lower PD-L2 patients). In addition, PD-L2 signature correlated with PSA-response (ϱ=-0.46; p=0.04). The PD-L2 signature association with OS was significantly moderated by L-Lactatdehydrogenase (LDH) levels (Cox model interaction p=0.01).

CONCLUSION

Higher PD-L2 signature might be associated with a better response to 177Lu-PSMA therapy and warrants further studies investigating additional immunotherapy. In contrast, PD-L1 was not associated with outcome. The protective effect of PD-L2 signature might be present only in men with lower LDH levels.

High fibroblast-activation-protein expression in castration-resistant prostate cancer supports the use of FAPI-molecular theranostics

Purpose

To evaluate fibroblast-activation-protein (FAP) expression in different clinical stages of prostate cancer (PC) with regards to utility of [⁶⁸ Ga]Ga-FAPI-04 PET/CT imaging in patients with castration-resistant PC (CRPC).

Methods

Tissue microarrays (TMAs) were constructed from prostatic tissue from 94 patients at different stages of PC (primary PC, patients undergoing neoadjuvant androgen deprivation therapy, CRPC, and neuroendocrine PC (NEPC)) and were stained with anti-FAP monoclonal antibody. A positive pixel count algorithm (H-Index) was used to compare FAP expression between the groups. Additionally, three men with advanced CRPC or NEPC underwent [⁶⁸ Ga]Ga-FAPI-04 PET/CT, and PET positivity was analyzed.

Results

The mean H-index for benign tissue, primary PC, neoadjuvant androgen deprivation therapy before radical prostatectomy, CRPC, and NEPC was 0.018, 0.031, 0.042, 0.076, and 0.051, respectively, indicating a significant rise in FAP expression with advancement of disease. Corroborating these findings [⁶⁸ Ga]Ga-FAPI-04 PET/CT was highly positive in men with advanced CRPC.

Conclusion

Increased FAP tissue expression supports the use of FAP inhibitor (FAPI)-molecular theranostics in CRPC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05423-y.

Acute inflammation and psychomotor slowing: Experimental assessment using lipopolysaccharide administration in healthy humans

Data from clinical and cross-sectional studies suggest that inflammation contributes to psychomotor slowing and attentional deficits found in depressive disorder. However, experimental evidence is still lacking. The aim of this study was to clarify the effect of inflammation on psychomotor slowing using an experimental and acute model of inflammation, in which twenty-two healthy volunteers received an intravenous injection of lipopolysaccharide (LPS, dose: 0.8 ​ng/kg body weight) and of placebo, in a randomized order following a double-blind within-subject crossover design. A reaction time test and a go/no-go test were conducted 3 ​h after the LPS/placebo injection and interleukin (IL)-6 and tumor necrosis factor (TNF)-α concentrations were assessed. No effect of experimental inflammation on reaction times or errors for either test was found. However, inflammation was related to worse self-rated performance and lower effort put in the tasks. Exploratory analyses indicated that reaction time fluctuated more over time during acute inflammation. These data indicate that acute inflammation has only modest effects on psychomotor speed and attention in healthy subjects objectively, but alters the subjective evaluation of test performance. Increased variability in reaction time might be the first objective sign of altered psychomotor ability and would merit further investigation.

Immunological and behavioral responses to in vivo lipopolysaccharide administration in young and healthy obese and normal-weight humans

Obesity is associated with an increase prevalence of neuropsychiatric symptoms and diseases, such as depression. Based on the facts that pro-inflammatory cytokines are able to modulate behavior, and that obesity is characterized by a chronic low-grade inflammatory state, inflammation has been hypothesized to contribute to the neuropsychiatric comorbidity in obese individuals. However, a causal link between inflammation and the development of neuropsychiatric symptoms is hard to establish in humans. Here, we used an inflammatory stimulus, i.e. the intravenous injection of lipopolysaccharide (LPS), in a double-blind placebo-controlled design, to determine the vulnerability of obese individuals to inflammation-induced behavioral changes. The hypothesis was that obese individuals would show heightened behavioral response compared to normal-weight subjects for the same inflammatory stimulus, reflecting an increased sensitivity to the behavioral effects of pro-inflammatory cytokines. LPS (dose 0.8 ng/kg body weight, adjusted for estimated blood volume in obese subjects) and placebo (saline) were intravenously injected in 14 obese healthy subjects and 23 normal-weight healthy subjects in a within-subject, randomized, crossover design. LPS administration induced, in both groups, an acute increase in blood concentrations of cytokines (interleukin-6, tumor necrosis factor-α, and IL-10), as well as in body temperature, cortisol, norepinephrine, sickness symptoms, fatigue, negative mood, and state anxiety. There were little differences in the immune and behavioral responses to LPS between obese and normal-weight subjects, but the cortisol response to LPS was strongly attenuated in obese individuals. Higher percentage of body fat was related to a lower cortisol response to LPS. Taken together, the population of young and healthy obese individuals in this study did not exhibit an increased behavioral sensitivity to cytokines, but an attenuated cortisol response to the immune challenge. Future studies will need to determine whether additional physiological and psychological factors interact with the state of obesity to increase the risk for inflammation-induced neuropsychiatric symptoms.

Teaching patients INs and OUTs

When patients don't understand how to care for their chronic illness, frequent hospitalization results. One example is the patient who is admitted to a medical nursing unit in end stage renal disease (ESRD), the common complications of which are hypervolemia, hypovolemia and associated electrolyte imbalances. To prevent further disease progression and frequent hospitalization, an accurate measurement of fluid intake and output is critical, as is the patient's ability to understand and take responsibility for his/her own care.

[Laparoscopic vs. open surgical lymphadenectomy in prostate cancer. Methodological comparison]

Bilateral laparoscopic pelvic lymph node dissection was performed in 27 consecutive patients with stage B prostatic carcinoma. The first 5 operations (learning phase) were compared with the next 22 procedures and with a group of 20 patients who had undergone conventional open lymphadenectomy previously. Retropubic radical prostatectomy was done in 22 patients with negative nodes. All residual lymphatic tissue was removed. During the learning phase the average operating time was 3 h 40 min. The mean number of laparoscopically removed nodes was 5.8 on both sides. At open operation we found 1.5 residual nodes on the right side and 5.3 residual nodes on the left. In one case one of the residual nodes was positive for tumor. Operating time in the next 22 patients was 2 h 20 min. The number of nodes removed laparoscopically was 8.3 on the right and 7.0 on the left. Residual nodes were found in only 3 patients. None of these nodes was positive for tumor. In both groups the number of nodes removed was greater than in the group of patients who underwent open lymphadenectomy. In one of the first 5 patients immediate open surgery was required because of bleeding. In 1 patient's nodes evidence of Hodgkin disease was found. This was the only patient to develop a lymphatic fistula. There were no lymphoceles. We feel that laparoscopic pelvic lymphadenectomy has a definite learning curve but is a safe staging procedure for prostatic cancer with results equivalent to those of the open operation.

[Cutaneous drug reaction caused by suramin in 4 patients with metastatic prostate cancer]

Suramin has long been used in the treatment of onchocerciasis and trypanosomiasis. Recent investigations showed an antiproliferative effect of suramin on prostate carcinoma cell lines. Ongoing clinical trials have confirmed the effect of suramin on metastasizing prostate carcinoma. Five patients with metastatic prostate carcinoma resistant to classic hormonal therapy were treated with high-dose suramin. Four of the five developed a papulovesicular or maculopapular rash within 2-4 weeks of starting therapy. The rashes disappeared after discontinuation of suramin within 10 days. In tumour therapy, high dosages of suramin are used to achieve a serum level of 200-300 micrograms/ml. Therefore, a toxic reaction to suramin is suspected as the explanation for the skin rashes.

Simple and rapid method for the determination of progesterone in rat plasma by gas-liquid chromatography with electron-capture detection

A method for estimating progesterone in rat plasma using gas-liquid chromatography (GLC) with electron-capture detection is described. By means of a column chromatographic technique for the extraction of progesterone from plasma, it is possible to isolate the steroid in such a specific way that, contrary to previously published methods, no additional chromatographic purification and separation steps are needed prior to the final GLC analysis. As a derivative for electron-capture detection we used the 3,20-di-O-pentafluorobenzyloxime of progesterone. This derivative is superior to those used hitherto with regard to sensitivity and stability. The high overall recovery (mean value, 89.4%) makes this method especially convenient for research work when only little plasma is available, or when the concentration of progesterone is very low.

An improved extraction method for plasma steroid hormones

An easy and rapid column chromatographic method for the extraction of steroid hormones from plasma is presented. It permits the nearly quantitative separation of the steroids in a single step with smaller expenditure of time and work as compared to the usual liquid-liquid extraction. Problems of emulsions are eliminated. Furthermore, fractionated separation of hormones from plasma is possible. A simple procedure for the selective extraction of estriol (isolated from estrone and estradiol) is described.

Effect of ovarian sex hormones on the pool of free amino acids in maternal tissues of pregnant rats fed a protein-free diet

The effects of s.c. injections of 5 mug oestrone/kg and 50 mg progesterone/kg on Days 5-7 of gestation were investigated in rats fed a protein-free diet. The decrease in essential and non-essential amino acid concentrations in maternal liver and the implantation site caused by dietary protein deficiency was restored to control values, whereas the alterations of the plasma free amino acid concentrations, except for arginine and glycine, were not reversed by hormone treatment.