MITO END-3: Efficacy of Avelumab immunotherapy according to molecular profiling in first-line endometrial cancer therapy

BACKGROUND

Immunotherapy combined with chemotherapy significantly improves progression-free survival compared to first-line chemotherapy alone in advanced endometrial cancer, with a much larger effect size in microsatellite-instability high (MSI-H) cases. New biomarkers might help to select patients that may have benefit among those with a microsatellite-stable (MSS) tumor.

METHODS

In a pre-planned translational analysis of the MITO END-3 trial, we assessed the significance of genomic abnormalities in patients randomized to standard carboplatin/paclitaxel without or with avelumab.

RESULTS

Out of 125 randomized patients, 109 had samples eligible for next-generation sequencing (NGS) analysis, and 102 had MSI tested. According to The Cancer Genome Atlas (TCGA), there were 29 cases MSI-H, 26 MSS TP53 wild-type (wt), 47 MSS TP53 mutated (mut), and one case with POLE mutation. Four mutated genes were present in more than 30% of cases: TP53, PIK3CA, ARID1A, and PTEN. Eleven patients (10%) had a BRCA1/2 mutation (five in MSI-H and six in MSS). High TMB (≥10 Muts/Mb) was observed in all MSI-H patients, in four out of 47 MSS/TP53 mut, and no case in the MSS/TP53 wt category. The effect of avelumab on progression-free survival significantly varied according to TCGA categories, being favorable in MSI-H and worst in MSS/TP53 mut (P interaction=0.003); a similar non-significant trend was seen in survival analysis. ARID1A and PTEN also showed a statistically significant interaction with treatment effect, which was better in the presence of the mutation (ARID1A P interaction=0.01; PTEN P interaction=0.002).

CONCLUSION

The MITO END-3 trial results suggest that TP53 mutation is associated with a poor effect of avelumab, while mutations of PTEN and ARID1A are related to a positive effect of the drug in patients with advanced endometrial cancer.

The impact of COVID-19 pandemic control on vaccine-preventable invasive bacterial diseases in Piedmont (Italy)

Purpose

The impact of SARS-CoV-2 pandemic on other pathogens is largely unknown. We aimed to compare the prevalence of vaccine-preventable invasive bacterial infections before and during the pandemic in Piedmont (Italy).

Methods

We defined the monthly incidence of S. pneumoniae, H. influenzae and N. meningitides-invasive diseases from January 2010 to June 2021. Then, we compared the mean monthly cases during the previous 5 years (2015–2019) and the monthly cases in 2020 or 2021.

Results

We found significant reductions for invasive pneumococcal diseases (IPDs) in adults and H. influenzae-invasive diseases in 2020 and 2021 in comparison to the previous years, but not for invasive meningococcal diseases and IPDs in children.

Conclusions

Further data are needed to confirm these findings and define possible post-pandemic evolutions in the epidemiology of vaccine-preventable invasive bacterial diseases.

A multicenter validation of the revised version of the Milan system for reporting salivary gland cytology (MSRSGC)

INTRODUCTION

Fine-needle aspiration cytology (FNAC) is a basic step in the diagnosis of salivary gland tumors that have a wide variety of histological types. The recent Milan system for reporting salivary gland cytopathology (MSRSGC) can correlate the risk of malignancy with precise cytological features. A revised version was recently proposed to improve the surgical relevance and facilitate uniform management.

MATERIAL AND METHODS

A multicenter study retrospectively used the original and revised MSRSGC criteria to classify a series of patients who received surgery after FNAC.

RESULTS

We enrolled 503 patients from three tertiary centers. The risk of malignancy for the MSRSGC resulted 19.5% in cat. I, 14.3% in cat. II, 17.6% in cat. III, 3.6% in cat. IVa, 24.6% in cat. IVb, 66.7% in cat. V, and 96.8% in cat. VI. The results from the revised MSRSGC were consistent with the original values.

CONCLUSION

The MSRSGC is a promising classification system. In our opinion, the revised version of the MSRSGC supplements FNAC with some crucial clinical information and can better identify the appropriate treatment in each category.

Radiofrequency ablation of functioning and non-functioning thyroid nodules: a single institution 12-month survey

PURPOSE

Radiofrequency (RF) treatment has played an increasing role in the management of benign thyroid nodules in recent years. The aim of this retrospective study was to evaluate the efficacy of RF treatment on volume reduction in functioning and non-functioning thyroid nodules.

PATIENTS AND METHODS

We reviewed the medical records of patients who had thyroid nodule RF ablation at our department between August 2017 and May 2018. Patients underwent a periodical follow-up with ultrasound examinations and thyroid function tests at 1, 3, 6 and 12 months from RF. Complications were assessed using the reporting standards of Interventional societies.

RESULTS

43 patients were submitted to thyroid nodule RF ablation treatment. Patients were subdivided into two groups, those with functioning (17 patients) or non-functioning nodules. At baseline (i.e. pre-RF treatment), the two groups of patients were superimposable for gender, age, BMI, nodule volume and maximum nodule diameter. The volume reduction of all 43 nodules was 69.1 ± 17.3% (range 26.0-94.5%) with no difference between functioning and non-functioning lesions (72.9 ± 18.1% vs 66.7 ± 16.7%, p = 0.254). A total energy delivered per nodule was 16.5 ± 6.8 kJ, with no difference between functioning and non-functioning lesions (14.5 ± 7.2 kJ vs. 18.2 ± 6.3 kJ, p = 0.083, respectively). No major complications were observed.

CONCLUSIONS

Radiofrequency ablation is a clinically effective and safe outpatient treatment in patients with benign nodules. In particular, we showed that a single treatment is effective in restoring euthyroidism in patients with autonomously functioning thyroid nodules.

Carboplatin-paclitaxel compared to Carboplatin-Paclitaxel-Bevacizumab in advanced or recurrent endometrial cancer: MITO END-2 - A randomized phase II trial

OBJECTIVE

Increased Vascular Endothelial Growth Factor Receptor (VEGF) expression in endometrial cancer (EC) is associated with a poor prognosis. Preliminary clinical data reported Bevacizumab effectiveness in EC both as single agent and in combination with chemotherapy.

METHODS

In a phase II trial, patients with advanced (FIGO stage III-IV) or recurrent EC were randomized to receive Carboplatin-Paclitaxel standard dose for 6-8 cycles vs Carboplatin-Paclitaxel and Bevacizumab 15 mg/kg in combination with chemotherapy and maintenance until disease progression or unacceptable toxicity. The primary endpoint was progression free survival (PFS).

RESULTS

108 patients were randomized; PFS (10.5 vs 13.7 months, HR 0.84 p = 0.43), overall response rate (ORR 53.1% vs 74.4%) and overall survival (OS) (29.7 vs 40.0 months, HR 0.71 p = 0.24) resulted in a non-significant increase in Bevacizumab treated patients. The PFS increase became significant when an exploratory analysis with the Breslow test was used. Moreover, patients treated with Bevacizumab experienced a significant increase in 6-month disease control rate (70.4% vs 90.7%). Cardiovascular events were more frequent in the experimental arm ("de novo" grade ≥2 hypertension 21% vs 0% and grade ≥2 thromboembolic events 11% vs 2% in the Bevacizumab vs standard treatment arm, respectively).

CONCLUSIONS

Bevacizumab combined with chemotherapy in the treatment of advanced/recurrent EC failed to demonstrate a significant increase in PFS in the MITO END-2 trial. Nevertheless, these preliminary data suggests some effectiveness of the antiangiogenic agent which merits further exploration in a larger population with a better molecular characterization.

CXCL12 blockade preferentially regenerates lost podocytes in cortical nephrons by targeting an intrinsic podocyte-progenitor feedback mechanism

Insufficient podocyte regeneration after injury is a central pathomechanism of glomerulosclerosis and chronic kidney disease. Podocytes constitutively secrete the chemokine CXCL12, which is known to regulate homing and activation of stem cells; hence we hypothesized a similar effect of CXCL12 on podocyte progenitors. CXCL12 blockade increased podocyte numbers and attenuated proteinuria in mice with Adriamycin-induced nephropathy. Similar studies in lineage-tracing mice revealed enhanced de novo podocyte formation from parietal epithelial cells in the setting of CXCL12 blockade. Super-resolution microscopy documented full integration of these progenitor-derived podocytes into the glomerular filtration barrier, interdigitating with tertiary foot processes of neighboring podocytes. Quantitative 3D analysis revealed that conventional 2D analysis underestimated the numbers of progenitor-derived podocytes. The 3D analysis also demonstrated differences between juxtamedullary and cortical nephrons in both progenitor endowment and Adriamycin-induced podocyte loss, with more robust podocyte regeneration in cortical nephrons with CXCL12 blockade. Finally, we found that delayed CXCL12 inhibition still had protective effects. In vitro studies found that CXCL12 inhibition uncoupled Notch signaling in podocyte progenitors. These data suggest that CXCL12-driven podocyte-progenitor feedback maintains progenitor quiescence during homeostasis, but also limits their intrinsic capacity to regenerate lost podocytes, especially in cortical nephrons. CXCL12 inhibition could be an innovative therapeutic strategy in glomerular disorders.

Fourteen-Day Infusion of Ifosfamide in the Management of Advanced Breast Cancer Refractory to Protracted Continuous Infusion of 5-Fluorouracil

Aims and background

Ifosfamide is an active drug in advanced breast cancer. Short-term continuous infusion schedules have been evaluated with encouraging results. The aim of the study was to evaluate in patients with advanced breast cancer a 14-day infusion schedule previously tested at our center in soft tissue sarcomas.

Methods

From July 1998 to February 2000, 26 consecutive patients with heavily pretreated breast cancer, progressing during protracted continuous infusion of fluorouracil, were treated with ifosfamide at the dose of 800 mg/m2/day for 14 consecutive days by means of an eiastomeric pump via an indwelling Groshong catheter. The median age of the patients was 52 years (range, 32-67) and median PS was 1 (range, 1-3). All patients were pretreated with anthracyclines or taxanes; the median number of chemotherapy lines in the metastatic phase was 2 (range, 1-4). Predominant metastatic sites were soft tissues in 5 patients, lung in 6, liver in 7 and serosal cavities in 3.

Results

Twenty-four patients were assessable for response. Two complete responses and 2 partial remissions were noted, for an overall 16.6% response rate. The duration of responses was 3+, 5, 8 and 10 months, respectively. Stabilization or minor response was observed in 2 more patients. The main toxic effect was myelosuppression (grade 1-2 in 15 patients, grade 3-4 in 4). Other toxicities included nausea in 14 patients (grade 3 in 2) and grade 1-2 vomiting in 2 patients. Hair loss or alopecia was universal.

Conclusions

The regimen yielded some clinically useful responses with acceptable toxicity. Its evaluation in less advanced cases appears to be warranted.

Continuous Infusion Fluorouracil in the Management of Advanced Breast Cancer: A Phase II Study

AIMS AND BACKGROUND

The evaluation of unconventional schedules of well-known drugs represents a promising avenue in the search for new regimens with a better therapeutic index in metastatic breast cancer. In particular, protracted continuous infusion (PCI) of 5-fluorouracil (5-FU) has yielded interesting results in gastrointestinal malignancies and in breast cancer.

METHODS

From March 1996 30 consecutive patients with heavily pretreated breast cancer were treated with PCI 5-FU at a daily dose of 250 mg/m2 by means of disposable elastomeric pumps until progression or toxicity. The median age was 54 years (range, 28-71) and median performance status was 1 (range, 0-3). All patients but four were pretreated with anthracycline-containing regimens or taxanes; the median number of chemotherapy lines was 3 (range, 2-4). Metastatic sites were predominantly visceral in 60% of the patient population.

RESULTS

All 30 patients were evaluable for response and toxicity. The median duration of PCI was 20 weeks (range, 2-36 weeks). Two complete responses (7%) and eight partial remissions (26%) were observed, giving an overall response rate of 33%. The median duration of response was six months (range, 4-9 months). Stabilization was observed in seven patients (23%) with a median duration of seven months (range, 3-9 months). The main toxic effects were grade I-II mucositis and hematologic toxicity, while grade 3 hand-foot syndrome was observed in eight patients (27%).

CONCLUSIONS

This study confirms the efficacy and safety of 5-FU at this dosage and schedule in heavily pretreated women with advanced breast cancer. In order to improve on these results further studies are needed in a less advanced stage of the disease and together with other active drugs.

Endocycle-related tubular cell hypertrophy and progenitor proliferation recover renal function after acute kidney injury

Acute kidney injury (AKI) is considered largely reversible based on the capacity of surviving tubular cells to dedifferentiate and replace lost cells via cell division. Here we show by tracking individual tubular cells in conditional Pax8/Confetti mice that kidney function is  recovered after AKI despite substantial tubular cell loss. Cell cycle and ploidy analysis upon AKI in conditional Pax8/FUCCI2aR mice and human biopsies identify endocycle-mediated hypertrophy of tubular cells. By contrast, a small subset of Pax2+ tubular progenitors enriches via higher stress resistance and clonal expansion and regenerates necrotic tubule segments, a process that can be enhanced by suitable drugs. Thus,  renal functional recovery upon AKI involves remnant tubular cell hypertrophy via endocycle and limited progenitor-driven regeneration that can be pharmacologically enhanced.

Abstract P2-11-05: Not presented

This abstract was not presented at the symposium.

Feeding preferences and voluntary feed intake of dairy cows: Effect of conservation and harvest time of birdsfoot trefoil and chicory

Bioactive forages contain compounds, such as tannins, that are active against pathogens. They have been successfully used in ruminants to control parasite infections. Because cattle may find bioactive forages unpalatable, it is of interest to know if an afternoon harvest time, which has been shown to increase the percentage of nonstructural carbohydrates (NSC), hence palatability, may mitigate this. The objectives of this study were to quantify voluntary intake and preference of dairy cows for 2 bioactive forages, harvested in the morning and evening, in addition to determining their time spent grazing on each forage species. The forage species evaluated were fresh chicory harvested at 0700 h (FCAM) and 1800 h (FCPM), fresh birdsfoot trefoil harvested at 0700 h (FBAM) and 1800 h (FBPM), birdsfoot trefoil baleage harvested the previous summer at 0700 h (BBAM) and at 1800 h (BBPM), and third-cut alfalfa baleage harvested the previous summer and used as control (CON). Single forages were offered ad libitum in 30-min tests to 14 dairy cows to determine intake in a 7 × 7 Latin square (experiment 1). Every possible pair of forages (21 pairs) was then presented for a 30-min test to 8 different dairy cows, and feed intake was measured (experiment 2). Finally, time spent grazing on chicory and birdsfoot trefoil was measured on 12 dairy cows (experiment 3). The tests consisted of 2 d of restriction on 1 of the 2 fields for 1h, and 2 d of free-choice sessions (1h) between the 2 fields adjacent to each other. Grazing time and location of the animals on the field was assessed through 2-min scan sampling. In experiment 1, the highest voluntary intakes were for CON, BBPM, and BBAM. In experiment 2, BBPM was preferentially consumed over all other forages followed by CON and BBAM. Multidimensional scaling showed that preference for BBPM, CON, and BBAM in dimension 1 was positively associated with dry matter and nitrogen content, and negatively associated with hemicellulose and soluble N/total N. No relationships between dimension coordinates and any of the measured chemical composition variables could be found for the other 2 dimensions. In experiment 3, cows spent 71% of their time grazing in the birdsfoot trefoil field and 23% in the chicory field during the free-choice sessions. In conclusion, cows in the present experiments showed an overall preference toward baled forages compared with fresh forages, most notably toward birdsfoot trefoil baleage. Cow preference did not appear to be linked to harvest time (a.m. vs. p.m.).

Diagnostic role of (18)F-FDG-PET or PET/CT in salivary gland tumors: A systematic review

Salivary gland tumors are rare neoplasms that have not been extensively studied with (18)F-FDG-PET- or PET/CT up to now. This review aims to evaluate the diagnostic performance of PET in this particular setting, analyzing the available literature. A comprehensive literature search in the PubMed/MEDLINE, Embase and Scopus databases was performed including articles up to November 2014, resulting in the selection of 22 articles. The studies selected suggest that: (1) PET is not useful in discriminating benign from malignant SGTs because of the overlap of uptake in both conditions; (2) PET not only is complementary to conventional imaging techniques for the staging and restaging but in some cases could also be superior to them; (3) PET may often have a highly positive impact on clinical decision making. Despite many limitations affecting the analysis, PET seems to be useful in SGTs. However, more extensive studies and cost-effectiveness analyses are desirable to determine its correct position in the diagnostic flow chart.

How much can the tubule regenerate and who does it? An open question

The tubular compartment of the kidney is the primary site of a wide range of insults that can result in acute kidney injury (AKI), a condition associated with high mortality and an increased risk to develop end-stage renal disease. Nevertheless, kidney function is often quickly recovered after tubular injury. How this happens has only partially been unveiled. Indeed, although it has clearly been demonstrated that regenerated epithelial cells arise from survived intratubular cells, the true entity, as well as the cellular source of this regenerative process, remains mostly unknown. Is whichever proximal tubular epithelial cell able to dedifferentiate and divide to replace neighboring lost tubular cells, thus suggesting an extreme regenerative ability of residual tubular epithelium, or is the regenerative potential of tubular epithelium limited, and mostly related to a preexisting population of intratubular scattered progenitor cells which are more resistant to death? Gaining insights on how this process takes place is essential for developing new therapeutic strategies to prevent AKI, as well as AKI-related chronic kidney disease. The aim of this review is to discuss why the answers to these questions are still open, and how further investigations are needed to understand which is the true regenerative potential of the tubule and who are the players that allow functional recovery after AKI.

Improved Natural Killer cell activity and retained anti-tumor CD8(+) T cell responses contribute to the induction of a pathological complete response in HER2-positive breast cancer patients undergoing neoadjuvant chemotherapy

Background

Locally advanced HER2-overexpressing breast cancer (BC) patients achieve a high rate of pathological complete responses (pCR) after neoadjuvant chemotherapy (NC). The apparently unaltered immune proficiency of these patients together with the immune-modulating activities of NC drugs suggest a potential contribution of host immunity in mediating clinical responses. We thus performed an extensive immunomonitoring in locally advanced BC patients undergoing NC to identify immunological correlates of pCR induction.

Methods

The immune profile of 40 HER2-positive and 38 HER2-negative BC patients was characterized at diagnosis and throughout NC (Paclitaxel and Trastuzumab, or Docetaxel and Epirubicin, respectively). The percentages of circulating immune cell subsets including T and B lymphocytes, Natural Killer (NK) cells, regulatory T cells, T helper 17 lymphocytes, were quantified by multiparametric flow cytometry. NK cells functional activity was evaluated through the analysis of NF-kB nuclear translocation by Multispectral flow cytometry, and with the in vitro monitoring of Trastuzumab-mediated antibody-dependent cell cytotoxicity (ADCC). CD8⁺ T cell responses against six different tumor-associated antigens (TAA) were characterized by IFN-γ ELISPOT and IFN-γ/IL-2 DualSpot assays.

Results

After NC, HER2-positive patients showed a significant increase in the number of NK cells and regulatory T cells irrespective of the pathological response, whereas patients undergoing a pCR disclosed higher percentages of T helper 17 cells. Notably, a significant increase in the number of activated NK cells was observed only in HER2-positive patients achieving a pCR. Characterization of anti-tumor T cell responses highlighted sustained levels of CD8⁺ T cells specific for survivin and mammaglobin-A throughout NC in patients undergoing a pCR in both arms. Moreover, HER2-positive patients achieving a pCR were characterized by a multi-epitopic and polyfunctional anti-tumor T cell response, markedly reduced in case of partial response.

Conclusions

These results indicate that maintenance of functional T cell responses against selected antigens and improvement of NK cell proficiency during NC are probably critical requirements for pCR induction, especially in HER2-positive BC patients.

Trail registration: Trial registration number: NCT02307227, registered on ClinicalTrials.gov (http://www.clinicaltrials.gov, November 26, 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-015-0567-0) contains supplementary material, which is available to authorized users.

Human Urine-Derived Renal Progenitors for Personalized Modeling of Genetic Kidney Disorders

The critical role of genetic and epigenetic factors in the pathogenesis of kidney disorders is gradually becoming clear, and the need for disease models that recapitulate human kidney disorders in a personalized manner is paramount. In this study, we describe a method to select and amplify renal progenitor cultures from the urine of patients with kidney disorders. Urine-derived human renal progenitors exhibited phenotype and functional properties identical to those purified from kidney tissue, including the capacity to differentiate into tubular cells and podocytes, as demonstrated by confocal microscopy, Western blot analysis of podocyte-specific proteins, and scanning electron microscopy. Lineage tracing studies performed with conditional transgenic mice, in which podocytes are irreversibly tagged upon tamoxifen treatment (NPHS2.iCreER;mT/mG), that were subjected to doxorubicin nephropathy demonstrated that renal progenitors are the only urinary cell population that can be amplified in long-term culture. To validate the use of these cells for personalized modeling of kidney disorders, renal progenitors were obtained from (1) the urine of children with nephrotic syndrome and carrying potentially pathogenic mutations in genes encoding for podocyte proteins and (2) the urine of children without genetic alterations, as validated by next-generation sequencing. Renal progenitors obtained from patients carrying pathogenic mutations generated podocytes that exhibited an abnormal cytoskeleton structure and functional abnormalities compared with those obtained from patients with proteinuria but without genetic mutations. The results of this study demonstrate that urine-derived patient-specific renal progenitor cultures may be an innovative research tool for modeling of genetic kidney disorders.

Comparison between liquid and tablet levothyroxine formulations in patients treated through enteral feeding tube

BACKGROUND

The majority of clinicians suggest that enteral feedings should be held 1-2 h prior to and after L-T4 administration despite lack of data for continuous enteral nutrition.

AIM

The aim of this study was to: (1) compare the thyroid hormonal profile in patients submitted to L-T4 treatment in tablets or liquid formulation with an enteral feeding tube; (2) evaluate the nursing compliance with the two different formulations.

SUBJECTS AND METHODS

20 euthyroid patients submitted to total laryngectomy and thyroidectomy consecutively started L-T4 treatment in tablets (Group T) or in liquid formulation (Group L) with enteral feeding tube the day after surgery. Tablets were crushed before administration and enteral feeding was stopped for 30 min before and after L-T4 treatment, whereas liquid formulation was placed into the nasoenteric tube immediately. A questionnaire about the preparation and administration of thyroxine replacement therapy was given to the nurses.

RESULTS

No difference of TSH, fT4 and fT3 before and after L-T4 treatment was observed among patients of Group L. A slightly serum TSH increase was observed in Group T, but not reaching statistical significance (2.50 ± 1.18 vs 2.94 ± 1.22 mUI/L), whereas no difference in fT4 and fT3 levels was found. Preparation and administration of liquid L-T4 was considered excellent by 12/13 nurses, whereas tablet formulation was considered poor by 10/13.

CONCLUSIONS

Our data showed that liquid L-T4 formulation can be administered directly through feeding tube with no need for an empty stomach, with a significant improvement in therapy preparation and administration by nurses.

Spontaneous muscle haematomas: management of 10 cases

This is a retrospective study about the treatment of spontaneous muscle haematomas (SMH) that are an uncommon disease that occurs especially in elderly patients with acquired coagulopathy. We report the management of 10 cases admitted to our Emergency Surgical Unit (ESU) between March 2011 and October 2012. For this analysis we have considered some parameters such as age, drug history, current symptoms, location of the haematoma, cause, and imaging examination. Our attention focused on: clinical presentation, differential diagnosis, diagnostic imaging techniques and treatments.

Inverse problems in 1D hemodynamics on systemic networks: a sequential approach

In this work, a sequential approach based on the unscented Kalman filter is applied to solve inverse problems in 1D hemodynamics, on a systemic network. For instance, the arterial stiffness is estimated by exploiting cross-sectional area and mean speed observations in several locations of the arteries. The results are compared with those ones obtained by estimating the pulse wave velocity and the Moens-Korteweg formula. In the last section, a perspective concerning the identification of the terminal models parameters and peripheral circulation (modeled by a Windkessel circuit) is presented.

Proteinuria impairs podocyte regeneration by sequestering retinoic acid

In CKD, the risk of kidney failure and death depends on the severity of proteinuria, which correlates with the extent of podocyte loss and glomerular scarring. We investigated whether proteinuria contributes directly to progressive glomerulosclerosis through the suppression of podocyte regeneration and found that individual components of proteinuria exert distinct effects on renal progenitor survival and differentiation toward a podocyte lineage. In particular, albumin prevented podocyte differentiation from human renal progenitors in vitro by sequestering retinoic acid, thus impairing retinoic acid response element (RARE)-mediated transcription of podocyte-specific genes. In mice with Adriamycin nephropathy, a model of human FSGS, blocking endogenous retinoic acid synthesis increased proteinuria and exacerbated glomerulosclerosis. This effect was related to a reduction in podocyte number, as validated through genetic podocyte labeling in NPHS2.Cre;mT/mG transgenic mice. In RARE-lacZ transgenic mice, albuminuria reduced retinoic acid bioavailability and impaired RARE activation in renal progenitors, inhibiting their differentiation into podocytes. Treatment with retinoic acid restored RARE activity and induced the expression of podocyte markers in renal progenitors, decreasing proteinuria and increasing podocyte number, as demonstrated in serial biopsy specimens. These results suggest that albumin loss through the damaged filtration barrier impairs podocyte regeneration by sequestering retinoic acid and promotes the generation of FSGS lesions. Our findings may explain why reducing proteinuria delays CKD progression and provide a biologic rationale for the clinical use of pharmacologic modulators to induce regression of glomerular diseases.

Imiquimod 5% cream versus cold knife excision for treatment of VIN 2/3: a five-year follow-up

BACKGROUND

Vulvar intraepithelial neoplasia (VIN) is a premalingnant condition. For long time, surgery was considered the first-line therapy in the treatment of high grade VIN. Imiquimod was recently introduced as an alternative to surgery.

AIM

To compare the overall complete response, the recurrence rate and the risk factors for relapse among patients with VIN 2/3 treated with Imiquimod or surgical excision.

PATIENTS AND METHODS

Eighty women who had histological diagnosis of VIN 2 and VIN 3 were enrolled in this prospective study. Patients immunocompromised, with recurrent VIN, with well differentiated type VIN or VIN 1 and women treated more than once were excluded from the study. Patients were divided into two groups: group A was treated with Imiquimod, group B underwent surgical excision. Patients' characteristics analyzed were: age, smoking, degree of the primary lesion, state of margins, multifocal disease. We have evaluated the recurrence rate, the relapse rate, and the overall complete response, considering as recurrence the onset of a lesion after an initial complete response to Imiquimod and/or after the surgical treatment and as relapse all patients who had a recurrence plus those with medical treatment failure.

RESULTS

Multifocal lesions (p = 0.03) and VIN 3 (p = 0.002) were associated with a higher risk of relapse. The recurrence rate was higher in the group B (p = 0.009), but the relapse rate was higher in the group A (p = 0.04). The overall complete response was better in the group B (p = 0.04).

CONCLUSIONS

Although the advent of new medical options can decrease the morbidity associated with invasive surgical procedures, surgical treatments remain the best treatment modality for VIN with regard to relapse and overall complete response.

Evaluation of E6 and E7 mRNA expression in HPV DNA positive breast cancer

Several studies have suggested a possible role for HPV in the pathogenesis of the breast cancer. We investigated the presence of the HPV DNA in breast cancers and non malignant disease breast tissues by the use of a standard HPV detection method (INNO-Lipa HPV), in order to detect HPV DNA in metastatic nodes, to investigate a possible cervical HPV co-infection, and to evaluate the E6/E7 mRNA expression in HPV DNA positive breast cancer tissues. The rate of HPV infection was significantly higher in the cancer group than in controls (9/31 vs. 0/12, p = 0.04). One out of eight metastatic axillary nodes was positive for HPV infection; 2/3 of the positive HPV breast cancer patients were co-infected at the cervical site. The role of the virus in breast oncogenesis is still unclear, since our analysis failed in demonstrating the expression of viral E6 and E7 in positive HPV positive breast tumor tissues.

Isolated sphenoid inflammatory diseases associated with visual impairment: 15-year experience at a single institution

We present a retrospective series of 11 patients treated for isolated sphenoid inflammatory disease (ISID) with visual impairment in the period between 1994 and 2008. The series included 7 females and 4 males. All patients, preoperatively assessed by CT or MR, underwent endoscopic sinus surgery and broad-spectrum antibiotic therapy. The procedure was always performed in an emergency setting, with an interval from the onset of visual impairment ranging between 1 and 40 days (mean 9 days). The possibility of recovery was related to both the modality of onset and severity of the deficit. All patients with reduction of the visual field reported significant improvement after surgery. Patients with decreased visual acuity obtained partial or complete resolution, while in patients with preoperative blindness no improvement was observed. Moreover, no postoperative improvement was noticed in the case of severe deficits with sudden onset, whereas the treatment of mild deficits was successful even some weeks after their occurrence. In conclusion, although some factors may predict the likelihood of recovery, any patient with ISID associated with visual impairment should receive immediate medical and surgical treatment. Endoscopic surgery should be considered the technique of choice.

Biological Effects of Low Frequency High Intensity Ultrasound Application on EX Vivo Human Adipose Tissue

In the present work the effects of a new low frequency, high intensity ultrasound technology on human adipose tissue ex vivo were studied. In particular, we investigated the effects of both external and surgical ultrasound-irradiation (10 min) by evaluating, other than sample weight loss and fat release, also histological architecture alteration as well apoptosis induction. The influence of saline buffer tissue-infiltration on the effects of ultrasound irradiation was also examined. The results suggest that, in our experimental conditions, both transcutaneous and surgical ultrasound exposure caused a significant weight loss and fat release. This effect was more relevant when the ultrasound intensity was set at 100% (∼ 2.5 W/cm2 for external device; ∼19–21 W/cm2, for surgical device) compared to 70% (∼ 1.8 W/cm2 for external device; ∼13–14 W/cm2 for surgical device). Of note, the effectiveness of ultrasound was much higher when the tissue samples were previously infiltrated with saline buffer, in accordance with the knowledge that ultrasonic waves in aqueous solution better propagate with a consequently more efficient cavitation process. Moreover, the overall effects of ultrasound irradiation did not appear immediately after treatment but persisted over time, being significantly more relevant at 18 h from the end of ultrasound irradiation. Evaluation of histological characteristics of ultrasound-irradiated samples showed a clear alteration of adipose tissue architecture as well a prominent destruction of collagen fibers which were dependent on ultrasound intensity and most relevant in saline buffer-infiltrated samples. The structural changes of collagen bundles present between the lobules of fat cells were confirmed through scanning electron microscopy (SEM) which clearly demonstrated how ultrasound exposure induced a drastic reduction in the compactness of the adipose connective tissue and an irregular arrangement of the fibers with a consequent alteration in the spatial architecture. The analysis of the composition of lipids in the fat released from adipose tissue after ultrasound treatment with surgical device showed, in agreement with the level of adipocyte damage, a significant increase mainly of triglycerides and cholesterol. Finally, ultrasound exposure had been shown to induce apoptosis as shown by the appearance DNA fragmentation. Accordingly, ultrasound treatment led to down-modulation of procaspase-9 expression and an increased level of caspase-3 active form.

Biomolecular characterization of human glioblastoma cells in primary cultures: differentiating and antiangiogenic effects of natural and synthetic PPARgamma agonists

Gliomas are the most commonly diagnosed malignant brain primary tumors. Prognosis of patients with high-grade gliomas is poor and scarcely affected by radiotherapy and chemotherapy. Several studies have reported antiproliferative and/or differentiating activities of some lipophylic molecules on glioblastoma cells. Some of these activities in cell signaling are mediated by a class of transcriptional factors referred to as peroxisome proliferator-activated receptors (PPARs). PPARgamma has been identified in transformed neural cells of human origin and it has been demonstrated that PPARgamma agonists decrease cell proliferation, stimulate apoptosis and induce morphological changes and expression of markers typical of a more differentiated phenotype in glioblastoma and astrocytoma cell lines. These findings arise from studies mainly performed on long-term cultured transformed cell lines. Such experimental models do not exactly reproduce the in vivo environment since long-term culture often results in the accumulation of further molecular alterations in the cells. To be as close as possible to the in vivo condition, in the present work we investigated the effects of PPARgamma natural and synthetic ligands on the biomolecular features of primary cultures of human glioblastoma cells derived from surgical specimens. We provide evidence that PPARgamma agonists may interfere with glioblastoma growth and malignancy and might be taken in account as novel antitumoral drugs.

Thymidine phosphorylase expression is associated with time to progression in patients receiving low-dose, docetaxel-modulated capecitabine for metastatic breast cancer

BACKGROUND

Preclinical data have indicated a synergistic interaction between docetaxel and capecitabine by means of taxane-induced up-regulation of thymidine phosphorylase (TP). On the basis of such premises, we conducted a phase II trial to determine the activity and tolerability of weekly docetaxel plus capecitabine in patients with metastatic breast cancer (MBC). Furthermore, we explored the relationship between TP tumor expression and benefit from this regimen.

PATIENTS AND METHODS

Patients received docetaxel 36 mg/m(2) i.v. on days 1, 8, and 15 and capecitabine orally 625 mg/m(2) b.i.d. from days 8 to 21. Cycles were repeated every 4 weeks. In the correlative study, we evaluated the TP expression by immunohistochemistry and the TP messenger RNA expression by real-time RT-PCR in the primary tumor.

RESULTS

Forty-seven women were enrolled. In the intention-to-treat analysis, objective responses were achieved in 24 patients (51%). Fourteen additional patients (30%) had stable disease. The median time to progression (TTP) was 6 months (range 1-44 months). Median survival was 17 months (range 1-48 months). Overall, the treatment was well tolerated. The most common clinical adverse events (all grades) were alopecia (55%), nail changes (53%), fatigue/asthenia (51%), nausea/vomiting (51%), neutropenia (49%), and neuropathy (49%). A significantly higher TTP was observed in patients with TP-positive tumors (log-rank test, P = 0.009). Interestingly, a subgroup analysis confirmed this TTP benefit in patients with TP-positive tumors obtaining a tumor response (log-rank test, P = 0.03), whereas the statistical significance was lost in nonresponders (log-rank test, P = 0.3).

CONCLUSIONS

This study indicates that a regimen with low doses of capecitabine plus weekly docetaxel is active against MBC. The correlative analysis provides preliminary evidence that TP expression may be a predictive marker for therapeutic benefit.

Skull base inflammatory pseudotumour involving the rhinopharyngeal space

OBJECTIVE

To describe a rare case of inflammatory pseudotumour (IPT) at the skull base involving the right rhinopharyngeal space.

METHODS

A case is presented; the clinical and therapeutic issues of IPT are reviewed and discussed.

RESULTS

The mass resembled a malignant tumour or an aggressive infectious lesion; the final diagnosis was inflammatory pseudotumour. A complete regression of the mass was achieved after treatment with high dose oral steroids followed by maintenance steroid therapy.

CONCLUSIONS

IPT should be considered in the differential diagnosis of rhinopharyngeal malignancies in order to avoid inappropriate (surgical) treatment.

Treatment of liver toxicity in women undergoing adjuvant chemotherapy for breast cancer: A phase III, monocentric, prospective, randomised trial of ursodeoxycolic acid (UDCA) vs no treatment

9060

Background: Liver toxicity during adjuvant chemotherapy (CT) represents one of the causes of treatment delay and dose reduction, with impairment of dose intensity and of final results. UDCA, a hydrophilic bile acid, has been reported to be effective in cholestasis. Aim: to evaluate the efficacy of UDCA (12 mg/kg/die) plus CT discontinuation vs CT discontinuation alone in the treatment of liver toxicity. Methods: The study provided two arms of randomization: discontinuation of CT and administration of UDCA at the dosage of 12 mg/kg/day or discontinuation of CT. CT was resumed at normalization of liver tests. Pts with liver metastases, acute or chronic hepatopathy, heart or kidney failure, or PS<70 were excluded. During a 3 year period, 118/305 pts developed CT-induced hepatotoxicity and were enrolled into the study. Logistic multiple models and Fisher test or χ2 test and the Mann-Whitney test were used. Results: Out the 118 pts, 66% were treated with CMF, 29% with Anthracyclines alone or in sequence with CMF and 5% with Anthracyclines and Taxanes. Liver toxicity occurred respectively in 37 pts after the 1st cycle, in 35 after the 2nd, in 15 after the 3rd, in 19 after the 4th, in 9 after the 5th and in 3 after the 6th. CT was definitely stopped in 8% of pts. CT was delayed of 1 week in 53%, of 2 wks in 31% and of 3 or more in 16%. 95% of pts had a hepatocytolitic damage and nobody purely cholestatic. G1 toxicity was observed in 34%, G2 in 57%, G3 in 9%. Pts were randomized in two groups of 59 pts each. UDCA group: 3 pts (5%) stopped CT and 11 (19%) had dose reduction. Control group: 6 pts (10%) stopped CT and 7 (12%) had dose reduction. No statistically significant difference between UDCA group and control group was noted both for dose reduction (p = 0.31) and for CT stop (p = 0.30), even if twice as many pts of the control group had to stop CT (6/59). No correlation between alcohol use and liver damage was noted. Conclusions: Most cases of liver toxicity are of low or intermediate grade. No statistically significant difference was found between UDCA and control, even if there was a positive trend in reducing liver toxicity, that can have a positive impact on the final results of adjuvant CT.

No significant financial relationships to disclose.

High prognostic potential of glioblastoma stem cell analysis

10580

Background: Cancer stem cells (CSCs) are a rare cell population responsible for tumor development and maintenance. Recent studies have shown that glioblastoma stem cells express the CD133 marker and are resistant to radiotherapy and chemotherapy. However, clinical data based on the study of CSCs in patients with glioblastoma are not available yet. Methods: Glioblastoma samples from 44 patients treated with complete or partial tumorectomy, followed by radiotherapy and temozolomide were prospectively analyzed. Immunohistochemistry was performed to evaluate the prognostic value of the number of CD133+ cells present in tumors. Moreover, the relationship between the ability to generate long-term culture of tumorigenic cells in vitro and the clinical outcome of glioblastoma patients was tested. Results: CD133 expression did not show an overall prognostic value. CSC cultures were obtained from 14 of the 44 tumors (32%). The generation of CSCs emerged as significant independent prognostic factor by the Cox multivariate analyses, with an adjusted hazard ratio of 2.50 (95% CI, 1.04 to 6.06; P=0.004). The median overall survival among patients with tumors generating CSCs was 8.0 months (95% CI, 4.0 to 11.5), as compared with 15 months (95% CI, 11.0 to 19.0) among those without generation of CSCs (P=0.0002). The median progression-free survival was 3.5 months (95% CI, 2.0 to 6.0) for glioblastoma generating CSCs and 9.0 months (95% CI, 7.0 to 12.0) for glioblastoma not generating CSCs (P=0.0001). A higher CD133 expression significantly associated with tumors generating CSCs (P=0.006), and correlated with a higher risk of death in patients with tumors generating CSCs in vitro (hazard ratio of 1.65, 95% CI, 1.05 to 2.60; P=0.0285). Conclusions: Generation of long-term culture of tumorigenic CSCs in vitro from glioblastoma predicts a poor clinical outcome for patients, in terms of both overall and progression-free survival. In tumors generating CSCs, CD133 expression may have a prognostic value.

No significant financial relationships to disclose.

Results from the integrated surveillance system for the 2006 Winter Olympic and Paralympic Games in Italy

An integrated epidemiological surveillance and response system was set up for the 2006 Olympic Winter Games in Torino [1] between 1 February

EGF103009, a phase II trial of lapatinib monotherapy in patients with relapsed/refractory inflammatory breast cancer (IBC): Clinical activity and biologic predictors of response

502

Background: Data from preclinical studies and small numbers of IBC patients inPhase I clinical trials suggest that IBC may be particularly sensitive to the anti-tumor effects of lapatinib, an inhibitor of ErbB1/ErbB2 tyrosine kinases. EGF103009 was initiated to confirm and expand these initial observations and identify a tumor profile predicting for the sensitivity of IBC to lapatinib. Methods: Patients with relapsed/refractory IBC based on clinical criteria, were assigned to Cohort A (ErbB2 overexpressors: 2/3+ IHC/FISH+) or B (ErbB1 +/ErbB2 non-overexpressors) after analysis of a fresh tumor biopsy in a central reference lab. Patients received lapatinib daily (1500mg/d). Clinical response was documented at day 56 and in the case of CR/PR, confirmed on day 84 and every 8 weeks thereafter. Target lesions were assessed according to RECIST criteria and response in skin disease documented by digital photography. Tumor expression of ErbB2, p-ErbB2, ErbB1, p-ErbB3, IGF-IR, PTEN, ER/PR, E-cadherin, β-catenin, and Rho B/C was analyzed by quantitative IHC from a fresh, pre-treatment biopsy. Results: Of 34 patients enrolled, clinical response data is available from 22 patients of which 17 had biopsies analyzed at a reference lab and assigned to Cohorts A (N=11) and B (N=6). Eight of 11 patients (72%) in Cohort A had a clinical response (CR/PR) to lapatinib documented by RECIST, skin disease, or both. There were no responders in Cohort B. All responders (i) overexpressed ErbB2 (2/3+ IHC or FISH+), (ii) increased p-ErbB2 (2/3+), (iii) co-expressed IGF-IR, and (iv) expressed activated, p-ErbB3. PTEN status did not affect response to lapatinib. Toxicity was generally grade I/II skin and G.I. with one grade III cardiotoxicity necessitating withdrawal from study. Conclusions: ErbB2 overexpression but not ErbB1 expression alone, predicts for sensitivity to lapatinib in IBC. High ErbB2, p-ErbB2 and IGF-IR co-expression predict for clinical response to lapatinib monotherapy in patients with relapsed/refractory IBC, illustrating the importance of selecting patients based on biology rather than histology alone, to maximize the clinical efficacy of ErbB kinase inhibitors in breast carcinomas.

[Table: see text]

Innovative schedule of oral idarubicin in elderly patients with metastatic breast cancer: comprehensive results of a phase II multi-institutional study with pharmacokinetic drug monitoring

BACKGROUND

To determine if protracted low-dose oral idarubicin (IDA), feasible in a previous dose-finding study, would result in similar activity and a better toxicity profile in patients with metastatic breast cancer.

PATIENTS AND METHODS

Elderly women (> or=65 years) with metastatic breast carcinoma were treated with 7.5 mg/day for 21 consecutive days, every 4 weeks. After the first fourteen patients, due to excessive toxicity, the protocol was amended to 5 mg/day. IDA and Idarubicinol (IDOL) plasma concentrations (C(trough)) were investigated in all patients.

RESULTS

Between April 1999 and June 2004, 47 elderly patients were accrued in this two-part study (14 and 33 patients respectively). The median age was 74 and 75 years respectively. Visceral involvement was present in most patients. A partial response was noted in 7/31 patients (22%; 95% CI, 9.6-41.1%). Eleven patients had stable disease (33%). At the dose of 5 mg/day the treatment was well tolerated. Neutropenia grade 4 was present in only 6% of patients; alopecia > grade 1 and cardiotoxicity did not occur. The median time to progression was 3 months and the median overall survival was 17 months. IDA C(trough) and IDOL C(trough) levels were significantly associated with haematologic toxicity.

CONCLUSION

This study shows that idarubicin at the dose of 5 mg/day for 21 consecutive days is feasible and effective in elderly breast cancer patients but do not demonstrate an improvement in efficacy. A determination of the IDA and IDOL plasma levels (C(trough)) is predictive for toxicity.

Dose-finding study of weekly docetaxel, anthracyclines plus fluoropyrimidines as first-line treatment in advanced breast cancer

BACKGROUND

The efficacy and safety of prolonged fluoropyrimidines, either intravenously or orally, prompted their integration with taxanes and anthracyclines in the treatment of advanced breast cancer (ABC). We conducted three subsequent dose-finding studies on first-line chemotherapy in ABC with anthracyclines, either epirubicin (E) or doxorubicin (A), and docetaxel (T), both given on days 1 and 8 every 3 weeks, plus continuous infusion (CI) 5-fluorouracil (F) or capecitabine (X).

PATIENTS AND METHODS

Sixty-two patients (37% dominant visceral disease, 48% locally advanced disease, 45% two or more sites involved), received different doses of T (60--80 mg/m(2)), A (40--50 mg/m(2)) or E (60--90 mg/m(2)) and X (1,650 and 2,000 mg/m(2)), or CI F at a fixed daily dose of 200 mg/m(2). Cardiac function was monitored at baseline and then every four cycles by echocardiography.

RESULTS

The median number of cycles per patient with all regimens was four (range one to eight). Haematological and gastrointestinal toxicity defined the maximum tolerated doses, at T-80/E-90 mg/m(2) with TEF, T-70/A50/X-2,000 mg/m(2) with TAX and T-70/E-80/X-1,650 mg/m(2) with TEX. Two patients treated with TEF developed transient cardiac toxicity (dilatative cardiomyopathy and coronary subtotal stenosis requiring stenting) after cumulative E doses of 400 mg and 1,100 mg/m(2), respectively. Fifty-nine patients were evaluable for response; the overall response rates (ORR) were comparable between regimens (54% with TEF, 71% with TAX and 86% with TEX), with an 81% ORR in 31 patients with locally advanced disease.

CONCLUSIONS

The addition of fluoropyrimidines to weekly, intermittent ET is well tolerated and active in ABC.

[Management of lymph node metastases in well-differentiated and medullary thyroid cancer: retrospective study on 52 cases]

OBJECTIVE

To define the surgical principles of neck dissections as applied to the head and neck squamous cell carcinomas, extending their rationale to treatment of lymph nodes metastases from thyroid carcinomas.

MATERIALS AND METHODS

Between January 1994 and June 2002, 52 patients affected by well-differentiated thyroid cancers (1 follicular, 9 medullary, and 42 papillary cancers) underwent uni- or bilateral neck dissections at our Department, for a total of 73 neck dissections. Patients were subdivided into 2 groups: 37 simultaneously treated on the thyroid and the neck (Group A), and 15 operated elsewhere on the thyroid and for a neck recurrence and/or persistence at our Department (Group B).

RESULTS

48 patients underwent a regular follow-up (range: 3-86 months, mean: 38). Among patients alive with disease, 5 in Group A and 4 in Group B had a local-regional recurrence. In particular, 2 patients for each group (2 medullary and 2 papillary cancers) had a regional recurrence on the N site, at the level of one or more lymph nodes "in field" as regards the neck dissection previously performed. Moreover, in all these patients a local recurrence on the T site has been observed.

DISCUSSION

Lymph nodes metastases have a minor prognostic impact in well-differentiated thyroid cancers in respect of the rest of head and neck cancers. Nonetheless, when performing a curative or elective neck dissection, the gold standard surgical principles must be the same. As a matter of fact, a 20% incidence of lymph nodes metastases at the V level, often not specifically addressed in neck dissections for thyroid cancers, it is noteworthy. Aim of such an aggressive surgical approach of the neck is to obtain a low incidence of "in field" regional recurrences, which become no more amenable of a subsequent surgical salvage.

CONCLUSION

Surgical techniques as lymphadenectomy or "pick-berry procedure" must be abandoned because they do not respect the basic anatomic, physiopathologic, and oncologic principles of neck dissections along cervical fasciae and spaces.

Protein interactions provide new insight into Nm23/nucleoside diphosphate kinase functions

Nm23-NDPKs besides contributing to the maintenance of the cellular nucleoside triphosphate pool, exert regulatory properties in a variety of cellular events including proliferation, invasiveness, development, differentiation, and gene regulation. This review focuses on recently discovered protein-protein interactions involving the Nm23 proteins. The findings herein summarized provide new and intriguing suggestions for a more extensive understanding of the biological functions of the Nm23 proteins.

Ifosfamide in Advanced/Disseminated Breast Cancer

Ifosfamide is an alkylating agent active in various tumor types including breast cancer. The availability of mesna (sodium 2-mercaptoethanesulfonate) has increased its safety, avoiding the main dose-limiting side effect, urotoxicity. Interesting activity as a single agent, with response rates ranging from 7 to 30%, is reported in pretreated patients; more attractive data derived from phase II studies on ifosfamide combined with drugs known to be active in advanced breast cancer show response rates always over 35%. This review has taken in consideration papers published after 1995 and available on PubMed medline: the data indicate a potential usefulness of ifosfamide in the clinical management of advanced breast cancer, even if the exact therapeutic role of the drug in this setting should be derived from randomized studies not yet available.