Letermovir breakthroughs during the French Named Patient Programme: interest of monitoring blood concentration in clinical practice

OBJECTIVES

To analyse mechanisms of letermovir breakthrough during compassionate primary and secondary prophylaxis.

METHODS

Mechanisms of letermovir breakthrough during compassionate primary and secondary prophylaxis were analysed in four patients from the French Named Patient Programme by the French National Reference Centre for Herpesviruses.

RESULTS

Of three absolute resistance cases, two were associated with treatment interruption or low letermovir concentrations in blood. A fourth case of breakthrough was not associated with resistance. Next-generation sequencing (NGS) genotyping confirmed rapid emergence of resistant mutants, within 3 months of treatment initiation.

CONCLUSIONS

Measurement of letermovir concentration and genotyping should be recommended for patient follow-up during letermovir therapy.

Allogeneic stem cell transplantation for patients with mantle cell lymphoma who failed autologous stem cell transplantation: a national survey of the SFGM-TC

Poly-chemotherapy plus rituximab followed by autologous stem cell transplantation (auto-SCT) is standard care for untreated young patients with mantle cell lymphoma (MCL). Despite this intensive treatment, transplant patients remain highly susceptible to relapse over time. The French SFGM-TC performed a national survey on reduced-intensity conditioning allogeneic stem cell transplantation (RIC-allo-SCT) for fit relapsed/refractory patients who failed after auto-SCT (n=106). Median times of relapse after auto-SCT, and from auto-SCT to RIC-allo-SCT were 28 months and 3.6 years, respectively. Sixty per cent of patients received at least three lines of treatment before RIC-allo-SCT. Conditioning regimens for RIC-allo-SCT were heterogeneous. Twenty patients experienced grade III/IV aGvHD, extensive cGvHD was reported in 28 cases. Median follow-up after RIC-allo-SCT was 45 months. Median PFS after RIC-allo-SCT was 30.1 months and median overall survival was 62 months. Treatment-related mortality (TRM) at 1 year and 3 years were estimated at 28% and 32%, respectively. A total of 52 patients died; major causes of death were related to toxicity (n=34) and MCL (n=11). Patients in good response before RIC-allo-SCT experienced a better PFS and OS. Our work highlights the need for new RIC-allo-SCT MCL-tailored approaches to reduce TRM, and early and late relapse.

Abstract P4-01-05: 3’-deoxy-3’-[18F]fluoro-thymidine (18F-FLT) positron emission tomography (PET): An accurate and effective tool for assessing tumor response in breast cancer

Objectives : A French multicenter study was promoted by the national French cancer federation (Unicancer R&D) to assess the potential of [18F]FLT (positron emission tomography (PET) biomarker of proliferation)to manage breast cancer neoadjuvant chemotherapy (NAC). The main objective was to compare changes in tumor [18F]FLT uptake to histopathological changes induced by NAC, assuming an arrest of tumor growth related to the effectiveness of NAC.

Methods : 97 patients (age 48.6 +/- 10.2 y.) were included in 13 nuclear medicine centers. All patients were eligible to anthracycline-based NAC for a de novo unifocal breast cancer (ductal n = 84, lobular = 11, other type = 2; stage II n = 75, stage III n = 21 et stage IV n = 1). 90 patients underwent a baseline PET before the onset of NAC (PET1) and a final PET after the end of NAC and before surgery (PET3). PET acquisitions were performed 60±7min after FLT injection. SUVmax (maximum standardized uptake value), SUVpeak (1 cm3 ROI including pixel max) and SUV41 (isocontour 41% of pixel max) were computed. Changes in SUV on PET3 vs PET1 were analyzed in relation to histopathological findings at the end of NAC (Sataloff criteria).

Results : Tumor FLT uptake decreased markedly between TEP1 and TEP3 (SUVmax = 6.2±4.8 vs 1.3±1.2 respectively; SUVpeak = 4.6±3.2 vs 0.9±0.9; SUV41 = 3.6±2.8 vs 0.8±0.7). Total or near-total therapeutic effect (grade A) were obtained in 20 patients, more than 50% therapeutic effect but less than total or near-total effect (grade B) in 37 patients, less than 50% therapeutic effect but visible effect (grade C) in 22 patients, or no therapeutic effect (grade D) in 11 patients. SUVmax decreased dramatically (87.5%) to background levels in all patients with a complete response (grade A). Overall, changes in SUV differed depending on the type of histological response (p<0.01) i.e. SUVmax changes were more pronounced as pathological responses were good: 61% for grade D; 65.7% grade C and 69.8% grade B. The same results were obtained with the two other SUV types.

Conclusions : Pathologic response to NAC in breast cancer can be assessed accurately by FLT.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-05.

L-asparaginase-based treatment of 15 western patients with extranodal NK/T-cell lymphoma and leukemia and a review of the literature

BACKGROUND

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, and aggressive NK-cell leukemia are highly aggressive diseases with a poor outcome.

PATIENTS AND METHODS

We report a multicentric French retrospective study of 15 patients with relapsed, refractory, or disseminated disease, treated with L-asparaginase-containing regimens in seven French centers. Thirteen patients were in relapse and/or refractory and 10 patients were at stage IV.

RESULTS

All but two of the patients had an objective response to L-asparaginase-based treatment. Seven patients reached complete remission and only two relapsed.

CONCLUSION

These data, although retrospective, confirm the excellent activity of L-asparaginase-containing regimens in refractory extranodal NK/T-cell lymphoma and aggressive NK-cell leukemia. Therefore, L-asparaginase-based regimen should be considered as a salvage treatment, especially for patients with disseminated disease. First-line L-asparaginase combination therapy for extranodal NK/T-cell lymphoma and aggressive NK-cell leukemia should be tested in prospective trials.

Scintimammography: better detection of small-sized lesions with tomoscintigraphic than planar images, a phantom study

Planar (99)Tc(m)-methoxyisobutylisonitrile ((99)Tc(m)-MIBI) scintimammography has been used for several years to detect breast cancer tumours, but with low sensitivity for small lesions. Results of tomoscintimammography studies have not been conclusive. We conducted a phantom study to compare the detection of small-sized tumours with planar versus tomoscintigraphic images. We used a data spectrum anthropomorphic fillable breast phantom with two 9.8 mm and 12.4 mm spheres superficially or deep in the breast compartment with sphere/breast activity ratios varying from 3 to 6. We acquired planar and 180 degrees tomoscintigraphic images in each configuration using a double head standard gamma camera. In certain cases we varied different parameters (64x64 matrix or 360 degrees rotation) in a second series of tomoscintigraphic acquisitions. We simultaneously used filtered back-projection reconstruction (FBP) and iterative reconstruction (IR). Planar images were shown by the sphere in 10 out of 25 cases. Tomoscintigraphic images were shown by the sphere in nine out of 25 cases with FBP and in 18 out of 25 with IR. There was a significant difference between IR and FBP (P<0.01) and between planar and IR images (P<0.01), but no significant difference between planar and IR images. The noise/signal ratio was lower with planar images than with the two types of reconstruction (P<0.05) but was not significantly different between the two types of reconstruction. Contrast was lower on planar images than on the two types of reconstruction (P<0.05) and was also better on IR than on FBP images (P<0.05). Granularity was lower for planar images than for reconstruction images (P<0.01) and also lower for IR than for FBP (P<0.01). The tomoscintigraphic reconstructions acquired with a 64x64 matrix were only positive in four out of 10 cases, while they were positive in nine out of 10 with a 128x128 matrix. We concluded that, in this phantom study, tomoscintimammography with IR provides a significant improvement in the detection of small-sized breast tumours compared with planar images. In addition, for tomoscintigraphic images, a 128x128 matrix is preferable to a 64x64 matrix. Those results have, of course, to be confirmed in vivo in a large population of patients with small-sized breast lesions.

Synthesis and in vitro and in vivo antimalarial activity of new 4-anilinoquinolines

A new series of 4-anilinoquinolines with two proton-accepting side chains has been synthesized. Antimalarial activity and levels of cytotoxicity upon both MRC-5 cells and macrophages were found to be highly dependent upon the features of these side chains. Several compounds were found to be active in the low nanomolar range, against both chloroquine-sensitive and -resistant strains of Plasmodium falciparum in vitro. From among them, a morpholino derivative cured mice infected by Plasmodium berghei and displayed a lower toxicity than amodiaquine upon mouse macrophages.

"One-pot" synthesis and antimalarial activity of formamidine derivatives of 4-anilinoquinoline

Amodiaquine (AQ) is an antimalarial which is effective against chloroquino-resistant strains of Plasmodium falciparum but whose clinical use is severely restricted because of associated hepatotoxicity and agranulocytosis. "One-pot" synthesis of formamidines likely to be transformed into AQ derivatives is reported. Compared with AQ, the new compounds were devoid of in vitro cytotoxicity upon human embryonic lung cells and mouse peritoneal macrophages. One showed a potent in vivo activity in mice infected with P berghei. Transformation of this compound by reductive amination led to a new type of AQ derivatives that displayed an in vitro activity similar to that of AQ but did not lead to toxic quinone-imines.

Antimalarial in-vivo activity of bis(9-amino-6-chloro-2-methoxyacridines)

In the fight against malaria, chemotherapy using bisacridines may represent an alternative method to overcoming chloroquine-resistance. Eight bis(9-amino-6-chloro-2-methoxyacridines), in which acridine moieties were linked by polyamines substituted with a side chain, were tested for their in-vivo activity upon mice infected by Plasmodium berghei. Three of the compounds revealed antimalarial activity but no relationship could be deduced from a comparison of in-vitro and in-vivo activities. N-alkylation of the central amino group generated toxicity and, therefore, only compounds N-acylated in this position can be selected as leads.

Antiplasmodial activity and cytotoxicity of bis-, tris-, and tetraquinolines with linear or cyclic amino linkers

Bisquinoline heteroalkanediamines were structurally modified in order to study the effects of enhanced bulkiness and rigidity on both their activity on strains of Plasmodium falciparum expressing different degrees of chloroquine (CQ) resistance and their cytotoxicity toward mammalian cells. While cyclization yielded molecules of greater rigidity that were not more active than their linear counterparts, they were characterized by an absence of cytotoxicity. Alternatively, dimerization of these compounds led to tetraquinolines that are very potent for CQ-resistant strains and noncytotoxic.

Potent and specific inhibitors of trypanothione reductase from Trypanosoma cruzi

In order to optimise the activity of bis(2-aminodiphenylsulfides) upon trypanothione reductase (TR) from Trypanosoma cruzi, a new series of bis(2-aminodiphenylsulfides) possessing three side chains was synthesized. Various moieties were introduced at the end of the third side chain, including acridinyl or biotinyl moieties for fluorescent labeling studies. TR inhibition was improved: the most potent inhibitor (IC50 = 200 nM) was selective towards TR versus human glutathione reductase and corresponded to a single myristyl group. Compounds were also tested in vitro upon Trypanosoma cruzi and Leishmania infantum amastigotes, upon-Trapanosoma brucei trypomastigotes, and for their cytotoxicity upon human MRC-5 cells. In the presence of serum, acridine derivative was no longer detectable in mass spectrometry and its antitrypanosomal activity no longer observed. This transformation might explain the absence of correlation between the potent TR inhibition and the in vitro and in vivo antiparasitic activity with both of the first generation of 2-aminodiphenylsulfides.

Cloning of Plasmodium falciparum protein disulfide isomerase homologue by affinity purification using the antiplasmodial inhibitor 1,4-bis[3-[N-(cyclohexyl methyl)amino]propyl]piperazine

A series of 10 1,4-bis(3-aminopropyl)piperazine compounds was found to display antiplasmodial activity with 50% growth inhibition between 30 and 250 nM, on three Plasmodium falciparum strains differently sensitive to chloroquine. By affinity chromatography using one of these compounds, a 52-kDa protein was isolated from P. falciparum, microsequenced and cloned. It corresponded to a single copy gene encoding a 453 amino acid protein displaying the typical features of protein disulfide isomerases, a thiol metabolizing enzyme belonging to the thiol: disulfide oxidoreductase superfamily, which was not previously described in malarial species.

Comparison of Tc-99m-labelled antileukocyte fragment Fab' and Tc-99m-HMPAO leukocyte scintigraphy in the diagnosis of bone and joint infections: a prospective study

Between January and July 1998, we conducted a prospective study to compare Tc-99m-labelled antigranulocyte monoclonal antibody fragment Fab' (LEUKOSCAN) scintigraphy versus Tc-99m-hexamethylpropyleneamine oxime (Tc-99m-HMPAO)-labelled leukocyte scintigraphy (HMPAO-LS) for the diagnosis of unselected patients with bone and joint infection. Twenty-three patients (16 men and 7 women; mean age, 67 years) with suspected bone infection were explored successively with bone scintigraphy, HMPAO-LS and LEUKOSCAN scintigraphy. Thirty-two foci were studied (diabetic foot = 11, prosthetic material = 8, joint disease = 4, others = diagnosed in 18 cases, eight on the basis of bacteriological and histological examination of surgical or puncture specimens, with or without radiographic signs, and 10 on the basis of clinical course and radiographic findings. Overall sensitivity, specificity and accuracy were 86%, 72% and 78%, respectively, for LEUKOSCAN scintigraphy (12 true positives (TP), 13 true negatives (TN), 5 false positives (FP), 2 false negatives (FN)), 93%, 100% and 96%, respectively, for HMPAO-LS (13TP, 18TN, 0FP, 1FN), and 100%, 17% and 53.3%, respectively, for bone scintigraphy. In this small series, LEUKOSCAN scintigraphy was found to be less specific for the diagnosis of osteomyelitis than HMPAO-LS. In addition, the interpretation of LEUKOSCAN scintigraphy is more difficult than HMPAO-LS for the diagnosis of bone infection in the diabetic foot, and would appear to be less discriminating for differentiating soft tissue infection from osteitis in the case of plantar perforating ulcers.

Antimalarial, antitrypanosomal, and antileishmanial activities and cytotoxicity of bis(9-amino-6-chloro-2-methoxyacridines): influence of the linker

Forty bis(9-amino-6-chloro-2-methoxyacridines), in which acridine moieties are joined by alkanediamines, polyamines, or polyamines substituted by a side chain, were synthesized and tested for their in vitro activity upon the erythrocytic stage of Plasmodium falciparum, trypomastigote stage of Trypanosoma brucei, and amastigote stage of Trypanosoma cruzi and Leishmania infantum as well as for their cytotoxic effects upon MRC-5 cells. Results clearly showed the importance of the nature of the linker and of its side chain for antiparasitic activity, cytotoxicity, and cellular localization. Among several compounds devoid of cytotoxic effects at 25 microM upon MRC-5 cells, one displayed IC(50) values ranging from 8 to 18 nM against different P. falciparum strains while three others totally inhibited T. brucei at 1.56 microM.

Contribution of 99Tcm-DMSA scintigraphy to aetiological diagnosis in renal transplant recipients with impaired renal function

Routine 99Tcm-dimercaptosuccinic acid (DMSA) scintigraphy was performed in a series of 24 kidney transplant recipients with impaired renal function. Diagnostic findings on planar and tomoscintigraphic acquisitions obtained 3 and 4 h after the injection of 130-140 MBq 99Tcm-DMSA were compared with the diagnosis established by fine-needle biopsy in 13 patients and by clinical course and other examinations (ultrasonography, bacteriology) in 11 patients. Renal scintigraphy demonstrated segmental defects in patients with rejection (n = 2/6), immunosuppressor nephrotoxicity (n = 2/6), acute pyelonephritis (n = 3/3), renal artery stenosis (n = 1/1) and obstructive lymphocele (n = 1/1). Diffuse lack of uptake was observed in one patient with severe renal failure. The scintigram was normal in 14 patients, including three with lesions histologically compatible with graft rejection or immunosuppressor nephrotoxicity. 99Tcm-DMSA was thus found to contribute little to the differential diagnosis between graft rejection and immunosuppressor nephrotoxicity. However, it may be useful for identifying specific disease states, particularly acute pyelonephritis, seen as well-delimited systematized defects. 99Tcm-DMSA scintigraphy could also be used in late follow-up after pyelonephritis in renal transplant recipients.

Trypanothione reductase inhibition/trypanocidal activity relationships in a 1,4-bis(3-aminopropyl)piperazine series

A series of symmetrically substituted 1,4-bis(3-aminopropyl)piperazines was synthesized and tested towards trypanothione reductase and for its in vitro trypanocidal potency. The most trypanocidal amongst them was found to be totally inactive towards the enzyme and thus constitutes a lead structure for the identification of new potential Trypanosoma cruzi target(s).

Synthesis of polyamine derivatives for the preparation of affinity chromatography columns for the search of new Trypanosoma cruzi targets

The most potent trypanocidal compound of a series of symmetrically substituted 1,4-bis(3-aminopropylpiperazines) which displayed an IC50 value of 5 microM on Trypanosoma cruzi trypomastigotes, was inactive on trypanothione reductase. Two derivatives 6 and 12 of this compound, one symmetrical and one dissymmetrical, were synthesized via a reductive amination reaction, to prepare affinity chromatography columns, which allowed us to isolate three parasitic proteins. Among these, the major ligand 6- and 12-binding protein having an apparent molecular weight of 52 kDa has been identified as the thiol-disulfide oxido-reductase Tc52, previously characterized in Trypanosoma cruzi.

Identification of heparin oligosaccharides by direct coupling of capillary electrophoresis/ionspray-mass spectrometry

A direct coupling between capillary electrophoresis (CE) and ionspray (IS) mass spectrometry (MS) has been optimized to identify oligosaccharides obtained by enzymatic digestion of heparin. The separation electrolyte was made compatible with the requirements of a direct coupling using electrolytes made of ammonium acetate buffer, pH 3.5 and 9.2. The different parameters of the CE/IS interface were optimized using a standard mixture of disaccharides: flow rate and composition of the sheath liquid, flow rate of the sheath gas and position of the capillary in the needle. Different combinations of positive or negative CE voltage polarity and positive or negative MS ionization modes were investigated. They allowed for detection orders to be easily reversed and for complementary structural information to be gathered. Finally, the optimized methodology was applied to the separation and characterization of porcine mucosa heparin depolymerized by heparinases II and III.

Structure-activity relationships in 2-aminodiphenylsulfides against trypanothione reductase from Trypanosoma cruzi

In order to establish structural elements responsible for inhibition of trypanothione reductase (TR) from Trypanosoma cruzi by 2-aminodiphenylsulfides, a series of dissymmetrical derivatives, corresponding to the replacement of one aromatic moiety by different amines, was synthesized. TR inhibition studies revealed the importance of the aromatic rings and of the amino groups in the side chains for potent inhibition. Quinonic moities were also introduced with the aim of acting as TR redox-cycling substrates.

The use of photolabelled peptides to localize the substance-P-binding site in the human neurokinin-1 tachykinin receptor

The amino acid p-benzoyl-L-phenylalanine, (p-Bz)Phe, has been incorporated into substance P (SP), Arg-Pro-Lys-Pro-Gln-Gln-Phe-Phe-Gly-Leu-Met-NH2, to localize the agonist-binding domains of the human neurokinin-1 (NK-1) receptor overexpressed in a transfected mammalian cell line. The NK-1-specific agonist [Pro9]SP was modified at position 8 by (p-Bz)Phe and acylated at the N-terminus by a biotinyl sulfone reporter via a 5-aminopentanoyl spacer. After photolysis, the biotinyl sulfone moiety allowed easy and efficient removal of biotinylated fragments from the complex incubation mixture with streptavidin-coated beads. Direct elution from the beads with the matrix used for matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOFMS), which was facilitated by saturation of streptavidin sites with biotin, and subsequent MALDI-TOF mass spectrometry analysis allowed identification of the NK-1 fragments obtained after photolysis and proteolytic digestion. Trypsin digestion and combined trypsin/Staphylococcus aureus V8 protease enzymatic cleavage established that the site of covalent attachment of the photolabelled SP resides in the second extracellular loop Thr173-Arg177. Cyanogen bromide cleavage shows that the probe is covalently attached to the methyl group of a methionine residue from human NK-1. These experiments identified Met174 as the modified residue.

Coupling of MALDI-TOF mass analysis to the separation of biotinylated peptides by magnetic streptavidin beads

Extraction of biotinylated peptides by streptavidin magnetic beads has been directly coupled to the MALDI-TOF mass analysis. The elution of peptides from the beads is achieved by first mixing the beads with the MALDI matrix solution and removing, after a few minutes, the beads with a magnet; then, the matrix solution containing the biotinylated peptide is directly mass analyzed by MALDI. Three examples are presented to show the capabilities of this procedure to detect biotinylated peptides present at very low concentrations in complex mixtures. Detection limits of less than 100 finol can be achieved. Such a coupling strategy is of great interest to investigate peptide/ protein interactions.