Real-time investigation of an influenza A(H3N2) virus outbreak in a refugee community, November 2022

OBJECTIVES

To report epidemiological and virological results of an outbreak investigation of influenza-like illness (ILI) among refugees in Northern Italy.

STUDY DESIGN

Outbreak investigation of ILI cases observed among nearly 100 refugees in Northern Italy unvaccinated for influenza.

METHODS

An epidemiological investigation matched with a differential diagnosis was carried out for each sample collected from ILI cases to identify 10 viral pathogens (SARS-CoV-2, influenza virus type A and B, respiratory syncytial virus, metapneumovirus, parainfluenza viruses, rhinovirus, enterovirus, parechovirus, and adenovirus) by using specific real-time PCR assays according to the Centers for Disease Control and Prevention (CDC) protocols. In cases where the influenza virus type was identified, complete hemagglutinin (HA) gene sequencing and the related phylogenetic analysis were conducted.

RESULTS

The outbreak was caused by influenza A(H3N2): the attack rate was 83.3% in children aged 9-14 years, 84.6% in those aged 15-24 years, and 28.6% in adults ≥25 years. Phylogenetic analyses uncovered that A(H3N2) strains were closely related since they segregated in the same cluster, showing both a high mean nucleotide identity (100%), all belonging to the genetic sub-group 3C.2a1b.2a.2, as those mainly circulating into the general population in the same period.

CONCLUSIONS

The fact that influenza outbreak strains as well as the community strains were genetically related to the seasonal vaccine strain suggests that if an influenza prevention by vaccination strategy had been implemented, a lower attack rate of A(H3N2) and ILI cases might have been achieved.

Prevention of congenital Chagas disease by screening of mothers and monitoring of serological tests of neonates: the seven years' experience

Approximately 14000 immigrants coming from the Cochabamba area of Bolivia, with an increased risk of congenital Chagas Disease (CD), are currently living in Bergamo, Italy. According to the World Health Organization (WHO) recommendation (2011), prevention of congenital CD involves testing all pregnant women at risk of infection and performing follow-up of their newborns. In our study, all pregnant women of Latin American origin were tested for the presence of Trypanosoma cruzi antibodies and children, born to mothers found to be positive, were followed up after delivery. T. cruzi antibodies were detected using a chemiluminescence immunoassay. The test was also performed on siblings and fathers of children with CD, and women of childbearing age to prevent the congenital infection, as proposed by 2011 WHO recommendation. In the study period 1105 patients were tested for CD, using a serological test: 934 (85%) were females and 171 (15%) were males. Of the 62 newborns, from mothers who tested positive, 28 were females and 34 were males. The number of positive adults and siblings identified was 148 (14%). Among the adults and siblings born between 1991 and 2011 only 3 (2%) of females tested positive to serological test. All neonates, with the exception of one, were classified as non-infected according to the follow-up of index value of CD serology. This study confirms the usefulness of serological tests and of their index value as follow-up. The difference of positivity rate for CD antibodies between people born before and after 1990 should be further investigated to generate information that potentially improve the prevention and control of CD.

Impact of SARS-CoV-2 Omicron and Delta variants in patients requiring intensive care unit (ICU) admission for COVID-19, Northern Italy, December 2021 to January 2022

This multicenter observational study included 171 COVID-19 adult patients hospitalized in the ICUs of nine hospitals in Lombardy (Northern Italy) from December, 1st 2021, to February, 9th 2022. During the study period, the Delta/Omicron variant ratio of cases decreased with a delay of two weeks in ICU patients compared to that in the community; a higher proportion of COVID-19 unvaccinated patients was infected by Delta than by Omicron whereas a higher rate of COVID-19 boosted patients was Omicron-infected. A higher number of comorbidities and a higher comorbidity score in ICU critically COVID-19 inpatients was positively associated with the Omicron infection as well in vaccinated individuals. Although people infected by Omicron have a lower risk of severe disease than those infected by Delta variant, the outcome, including the risk of ICU admission and the need for mechanical ventilation due to infection by Omicron versus Delta, remains uncertain. The continuous monitoring of the circulating SARS-CoV-2 variants remains a milestone to counteract this pandemic.

Phylogeography and genomic epidemiology of SARS-CoV-2 in Italy and Europe with newly characterized Italian genomes between February-June 2020

The aims of this study were to characterize new SARS-CoV-2 genomes sampled all over Italy and to reconstruct the origin and the evolutionary dynamics in Italy and Europe between February and June 2020. The cluster analysis showed only small clusters including < 80 Italian isolates, while most of the Italian strains were intermixed in the whole tree. Pure Italian clusters were observed mainly after the lockdown and distancing measures were adopted. Lineage B and B.1 spread between late January and early February 2020, from China to Veneto and Lombardy, respectively. Lineage B.1.1 (20B) most probably evolved within Italy and spread from central to south Italian regions, and to European countries. The lineage B.1.1.1 (20D) developed most probably in other European countries entering Italy only in the second half of March and remained localized in Piedmont until June 2020. In conclusion, within the limitations of phylogeographical reconstruction, the estimated ancestral scenario suggests an important role of China and Italy in the widespread diffusion of the D614G variant in Europe in the early phase of the pandemic and more dispersed exchanges involving several European countries from the second half of March 2020.

<em>Scedosporium</em> species and <em>Lomentospora</em> prolificans in Italian cystic fibrosis patients: prevalence and distribution in seven centers using a selective medium

Background and aims. Scedosporium species and Lomentospora prolificans are the filamentous fungi isolated more frequently from the cystic fibrosis (CF) lower airways, after Aspergillus fumigatus. Previous studies showed that, in CF patients, Scedosporium species and Lomentospora prolificans are responsible for airways colonization/ infection, enhancing pulmonary deterioration, and for severe invasive infections in CF patients undergoing lung transplantation. Aims of our project were to evaluate the prevalence of Scedosporium and Lomentospora species in Italian patients with CF, and to evaluate the interest of the Scedosporium-selective colture medium SceSel compared to routinely used agar-based culture media, in order to improve laboratory diagnostic performances.Materials and methods. A total of 1977 sputum samples from 1154 CF patients were collected and processed according to CF Italian recommendations in the year 2017 (January 1st to December 31st). The SceSel agar was used in addition to the routine culture procedures to burst growth and isolation of Scedosporium/ Lomentospora species. The fungal isolates were identified by classical mycological methods and polymerase chain reaction-based DNA sequencing of ITS1 and ITS4 regions. Susceptibility of the isolates to antifungal drugs was investigated by E-test method. Results. Among the 1154 enrolled patients, 62 (5.3%) were positive for Scedosporium/Lomentospora species (median age: 27y; range 8-64y; 33 male). Out of 1977 samples, 93 were positive for Scedosporium/Lomentospora species, and 13 (13.9%) were recovered only on SceSel agar. According to molecular analyses, isolation rates of each species were: S. apiospermum 53.1%, S. boydii 37.5%, L. prolificans 6.3% and S. aurantiacum 3.1%. Amphotericin B minimum inhibitory concentration (MIC) values were above or equal to 2 mg/L in all strains. Voriconazole MIC values were below or equal to 0.38 mg/L in almost all strains, proving this drug to be the most effective antimycotic for members of Scedosporium species. Otherwise, Lomentospora prolificans showed to be resistant to all considered antifungal drugs, only Voriconazole seems to be active on some Lomentospora prolificans isolates. Conclusions. Our results suggest that SceSel agar should be used in combination with routine media as standard microbiological protocol and procedures are not always adequate to isolate Scedosporium and Lomentospora species in CF respiratory samples. Molecular identification and susceptibility tests are needed, especially for strains isolated from critical patients and those considered for transplantation, as they might develop invasive scedosporiosis.

Blood stream infections during the first wave of COVID-19. A short microbiological retrospective picture at Papa Giovanni XXIII Hospital, Bergamo, Italy

This paper aims to describe the etiology of bloodstream infections in COVID-19, Papa Giovanni XXIII Hospital, Bergamo, Italy. Two periods were evaluated: February 22-May 21, 2019/2020. We considered: the number of patients and blood culture sets, species of isolates (bacteria, specifically those indicated by EARS criteria; CoNS; Candida albicans) and their antibiotic sensitivity. In 2020 Escherichia coli and Carbapenemase-producing Klebsiella pneumoniae disappeared. Candida albicans and MDR Pseudomonas aeruginosa, Enterococcus faecium and Acinetobacter baumannii were largely present. The analysis shows: 1. BSIs number was the same; 2. In the first month of the COVID-19 period, BSIs were uncommon; 3. Microbial etiologies were different; 4. MDR isolates were less common.

SARS-CoV-2 infection in persons living with HIV: A single center prospective cohort

Information about severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection in HIV‐infected individuals is scarce. In this prospective study, we included HIV (human immunodefeciency virus)‐infected individuals (people living with HIV [PLWHIV]) with confirmed SARS‐CoV‐2 infection and compared them with PLWHIV negative for SARS‐CoV‐2. We compared 55 cases of SARS‐CoV‐2 infection with 69 asymptomatic PLWHIV negative for SARS‐CoV‐2 reverse transcription‐polymerase chain reaction and/or serology. There was no significant difference between SARS‐CoV‐2 positive or negative patients for age distribution, gender, time with HIV infection, nadir CD4‐cell counts, type and number of co‐morbidities, current CD4 and CD8 counts and type of anti‐HIV therapy. Positive patients presented with a median of three symptoms (interquartile range, 1‐3). Most common symptoms were fever (76%), dyspnea (35%), anosmia (29%) non‐productive cough (27%), fatigue 22%), and ageusia (20%). Ten patients (18%) were completely asymptomatic. Four (7.2%) subjects died of coronavirus disease 2019. Factors significantly (P < .05) associated with death included age and number of co‐morbidities, while time from HIV infection and lower current CD4 counts were significant only in univariate analysis. HIV‐infected individuals are not protected from SARS‐CoV‐2 infection or have a lower risk of severe disease. Indeed, those with low CD4 cell counts might have worse outcomes. Infection is asymptomatic in a large proportion of subjects and this is relevant for epidemiological studies.

This study addresses the question if specific characteristics of HIV infection may raise the risk of SARS‐CoV‐2 infection by comparing infected persons living with HIV (PLWHIV), either symptomatic or not, with other PLWHIV who tested negative for SARS‐CoV‐2 infection. None of the parameters classically used to define immune suppression or risk of immune impairment in HIV positive subjects does correlate with the risk of acquiring SARS‐CoV‐2 infection. Although low CD4 counts were not associated with the positivity for SARS‐CoV‐2, relative immunosuppression did seem to affect disease severity, and it might be associated with adverse outcomes. By contrast, there was no evidence that any specific antiretroviral drug affected SARS‐CoV‐2 infection or COVID‐19 severity.

The disease may cover a vast range of clinical pictures, being almost one fifth of infected individuals asymptomatic and variables already described for the general population as risk factors for a more severe disease such as advanced age and the presence of multiple co‐morbidities do apply to PLWHIV, too.

HIV‐infected individuals should not be considered protected from SARS‐CoV‐2 infection or as having lower risk of severe disease. Indeed, those with low CD4 cell counts might have worse outcomes than individuals with restored immunity. Infection may be asymptomatic in a large proportion of subjects and this variable must be counted when epidemiological studies are implemented in PLWHIV.

HEV and HAV seroprevalence in men that have sex with men (MSM): An update from Milan, Italy

Hepatitis E virus (HEV) is a feco-orally transmitted pathogen and one of the most common cause of acute hepatitis worldwide. Recent studies in developed countries suggested that a direct human-to-human contact such as for sexually transmitted diseases may play a significant role in the HEV spread. The aim of this study was to investigate the seroprevalence of HEV and HAV in a group of MSM, including subjects HIV, and Treponema infected, in Milan, Italy. The overall anti HEV IgG seroprevalence in MSM was 10.2% (65/636), instead in the control group the detection rate was 5.2% (15/288) (P < 0.05); the anti HAV seroprevalence was 42.8% in MSM, when in the control group the positivity rate was 29.2% (P < 0.05). The rate of coinfection HEV/HAV was 14.6% in MSM and 1% in control group (P < 0.05). In the future, sexual history, HIV status, and STI risk might address specific investigations to prevent spread of pathogens such HEV in MSM, before becoming a substantial public health problem like for HAV outbreaks.

Phase II Study with Lonidamine in the Treatment of Hormone-Refractory Prostatic Cancer Patients

Twenty-one patients with metastatic prostate cancer who had become refractory to hormonal therapies received lonidamine (150 mg tid and 600 mg daily dose in 17 and 4 patients, respectively). In all but 4 patients, treatment was continued until disease progression or the development of severe toxicity. Toxicity was minimal and reversible (score 1 or 2) and included myalgia (8 cases), arthralgia (6 cases), gastrointestinal toxicity (11 cases), fatigue (14 cases) and testicular pain (9 cases). The response was evaluated after at least one month of therapy with lonidamine, according to NPCP-USA recommendations. Of 21 patients who entered the study, only 15 were evaluable for response; 2 died (1 for severe toxicity and 1 for drug-unrelated reasons). No objective response was obtained in the series. In fact, only 6 patients achieved stable disease and 9 progressed. Median survival time from the beginning of treatment was no longer than that of patients in a similar condition who were treated with standard palliative maneuvers. We conclude that this therapeutic approach with lonidamine is not active in hormone-refractory prostatic cancer patients with distant metastasis.

R75251 in Prostate Cancer Patients in Progression after First-Line Hormonal Treatment

Introduction

The therapeutic potential of R75251, a ketoconazole derivative which has shown marked antitumor activity in animals and in men, was investigated in 16 patients with advanced prostatic cancer progressing after one or more lines of hormone therapy.

Patients and methods

Patients were given the drug at 150 mg/b.i.d. for one month. After the first month of treatment, the dose was increased to 300 mg/b.i.d. In all patients, treatment was continued until disease progression or the development of severe toxicity. Clinical and biochemical assessments were performed on days 0, 14 and 28 and then repeated on a monthly basis.

Results

Of the 13 evaluable patients, 12 showed stable disease by strictly employing US-NPCP criteria. However, in 3 patients a clear effect was observed on the volume of their measurable lesions. In addition, 2 of them showed a more than 50% decrease of prostate-specific antigens (PSA). Overall, 50% of patients showed some decrease in PSA baseline levels. Overall tolerance to treatment was good.

Conclusions

Our results, although achieved in a small number of patients, suggest that R75251 has a moderate but definite activity in patients with hormone-refractory prostate cancer and that the value of this drug as second-line treatment in these patients should be further investigated.

Endocrine Effects of Tamoxifen in Postmenopausal Breast Cancer Patients

The effects of tamoxifen on plasma concentration of gonadotropins, prolactin (PRL), estrone (E1), estradiol-17β (E2), and sex hormone-binding globulin (SHBG) were studied in 40 postmenopausal breast cancer patients. In addition, the changes induced by the drug on endometrium and vaginal epithelium were investigated. After 6–8 weeks of tamoxifen treatment, a significant decrease in FSH, LH and PRL basal levels was observed, whereas the concentrations of E1 and E2 were not significantly affected. A significant increase in SHBG levels was induced by prolonged treatment with the drug. In addition, tamoxifen caused a partial estrogenization of vaginal smears, and a weak stimulatory effect on endometrium was also apparent. These findings indicate that tamoxifen produced agonistic effects on some targets and antagonistic effects on the others.

Phase II study of bevacizumab and nitrosourea in patients with recurrent malignant glioma: A multicenter Italian study

2012

Background: Bevacizumab (BV) has shown a promising activity in recurrent malignant gliomas (MG) in combination with irinotecan. Few data are available on the combination of bevacizumab and nitrosoureas, that represent the standard cytotoxic option at recurrence. Methods: In this ongoing phase II study patients with MG recurrent after surgery, radiation therapy, and temozolomide are eligible. The treatment consists of an induction phase with BV at 10 mg/kg intravenously on day 1 and 15 and fotemustine (FTM) (a nitrosourea with elevated lipophilic properties) at 75 mg/m2 intravenously on day 1 and 8, followed after a 3-week interval by a maintenance phase with BV at 10 mg/kg i.v. and FTM 75 mg/m2 i.v. every 3 weeks until tumor progression or unacceptable toxicity. Patients undergo clinical and MRI assessment 1 month after the start of treatment and thereafter every 2 months. Monitoring of CBV with perfusion MRI is performed in selected centers. The co-primary endpoints are objective response rate (ORR), based on Mc Donald's criteria (CR + PR) and progression-free survival at 6 months (PFS6), with secondary endpoints of safety time to tumor progression (TTP) and overall survival. Results: From April 2008 to December 2008, 34 patients were enrolled and 31 (22 glioblastomas and 9 anaplastic gliomas) are evaluable for response. Overall response rate (2 CR and 9 PR) was 35% (glioblastomas 33%, anaplastic gliomas 41.5%). Median time to maximal response was 1 month. Steroids were reduced in 50% of patients. Sixteen of 31 patients progressed with a TTP of 2.6 months (1–8.5). Patterns of progression were local in 10/16, local + leptomeningeal spread in 3/16 and gliomatosis in 3/16. Fifteen patients are free of tumor progression (from 2 to 8 months). Toxicities included grade III-IV neutropenia in three patients, grade III-IV piastrinopenia in five, and grade III thrombosis in two. Seventeen patients developed mild to moderate fatigue, six arterial hypertension, and three grade I intratumoral haemorrhage. Conclusions: Combination of bevacizumab and fotemustine in recurrent malignant gliomas is safe and promising. Updated results, monitoring of CBV with perfusion MRI, and correlations between MGMT promoter methylation and response/outcome will be presented.

No significant financial relationships to disclose.

Single-agent docetaxel (TXT) as first-line treatment in metastatic breast cancer (MBC)

11515

Background: Historically anthracyclines have been considered the most active agents in metastatic breast cancer (MBC). Docetaxel (TXT) has challenged this belief. Aims: Evaluate response rates, toxicity and time to progression in patients with MBC receiving single agent TXT as first line treatment. Methods: MBC patients received first line single agent treatment according to one of the following schedules: TXT 35 mg/m2 iv weekly for 6 wks q 8 wks (Group 1) or TXT 100 mg/m2 iv day 1 q 3 weeks (Group 2). Adjuvant chemotherapy was FAC (600,50,600) day 1 q 21 days for 6 courses in all cases so treated. Results: Conclusions: It appears that results with single agent TXT obtained in clinical practice are comparable to those reported in Phase II-III trials (Group 1 and Group 2, respectively ) using the same regimens.

[Table: see text]

No significant financial relationships to disclose.

Recurrent/progressive oligodendroglial tumors: A phase II study with temozolomide as first line chemotherapy

1561

Background: There are few data regarding the efficacy of first line temozolomide in recurrent oligodendroglial tumors, and responses range from 17% to 54%. The objective of this phase II study was to investigate the efficacy and toxicity of temozolomide in the “standard schedule” in patients with oligodendroglial tumors at first relapse after surgery alone or surgery plus radiotherapy. Methods: The main inclusion criteria were as follows: age ≥ 18 yrs, Karnofsky ≥ 70; diagnosis of oligodendroglioma or oligoastrocytoma (grade II or III) according to WHO. Temozolomide was administered in the standard regimen up to 24 cycles in responding or stable patients or to unacceptable toxicity. Primary endpoint was response basing on Macdonald’s criteria, whereas secondary end-points were time to tumor progression and progression-free survival at 6 and 12 months. Results: Fifty patients are evaluable, with a median age of 50 (range 19–72). A median of 12 cycles (range 1–24) were administered. Responses were as follows: CR 8/50 (16%); PR 13/50 (26%); mR (minor response, a tumor volume reduction of 20–40%) 7/50 (14%); SD 18/50 (36%); PD 4/50 (8%). The overall response rate (CR+PR+mR) was 56%. The maximum tumor response was observed after 3 cycles in 9/28, 6 cycles in 10/28, 9 cycles in 6/28, 12 cycles in 1/28, 15 cycles in 2/28. Fourteen of 28 responding (CR+PR+mR) patients (50%) and 8 of stable patients (44%) displayed a reduction of seizures. Eighteen of 35 (51%) oligodendrogliomas responded, including 7 patients with CR (5 grade III tumors and 2 grade II), compared to 10/15 (67%) oligoastrocytomas. Twenty of 35 enhancing tumors responded (57%) compared to 8/15 non-enhancing tumors (53%) and 57% of grade III responded compared to 55% of grade II. Median TTP was 17 months (range 2–37), with a PFS at 6 months of 40% and at 12 months of 29%. Grade III-IV myelotoxicity accounted for 22%. Conclusions: Temozolomide shows activity as first line treatment in oligodendroglial tumors at first relapse. A long term treatment with temozolomide is well tolerated.

No significant financial relationships to disclose.

[Immunologic effects of exposure to low levels of inorganic mercury]

OBJECTIVE

The immune system is a target for the toxic effects of inorganic mercury, both in humans and animals. In humans it has been observed that occupational and environmental exposure to inorganic mercury may cause both clinical (autoimmunity, hypersensitivity) and subclinical effects (cellular and humoral immunologic variable modifications). To obtain a better definition of these effects with respect to the exposure levels, a multicentre study was performed on 117 workers exposed to very low doses of inorganic mercury and 172 subjects from the general population of the same geographical area with environmental exposure to mercury from dental amalgams and dietary fish intake.

RESULTS

The white blood cell count was included in the normality range for all subjects and there was no difference between exposed and non exposed subjects. The immunologic variables studied showed an increase of the CD4+ and CD8+ number in exposed workers compared to non-exposed subjects, with a statistically significance only for CD4+, while no difference was observed regarding CD4+, CD8+, NK+ percentage and CD4+/CD8+ ratio. A significative decrease of serum IL-8 and an inverse correlation between serum levels of this cytokine and HgU were observed in exposed workers compared to non exposed subjects. No association between immunologic variables and both dental amalgams and dietary fish intake was found in subjects not occupationally exposed to inorganic mercury.

DISCUSSION

The decrease in IL-8 serum levels observed in exposed workers might suggest an immunosuppressive effect of occupational exposure to very low doses of inorganic mercury. This result suggests the need to revise of current HgU BEI after further definition of its prognostic significance.

[Adaptation of the TriTEST TM for the investigation of blood samples for a multicenter study taken to a single laboratory]

BACKGROUND

Immunotoxicological studies in humans are usually carried out via the determination of some selected immune parameters in subjects occupationally and/or environmentally exposed to immunotoxic substance. One of the most often measured parameters is the determination of lymphocyte subsets, which needs to be carried out in a very short time (a few hours) after blood collection. This is the major problem limiting the determination of lymphocyte subpopulations in field studies, where samples are usually collected directly at the workplace, and very often at the end of the workshift. Unfortunately, these collection modalities significantly prolong the time between collection and analysis. The problem is more evident in multicentric studies, where a further problem is represented by the time needed to send samples to the laboratory.

OBJECTIVE

Since an immune evaluation was planned, including the determination of lymphocyte subpopulations CD4 (T-helper), CD8 (T-suppressor cytotoxic) and CD16/CD56 (natural killer) in the project "Assessing health effects in man from exposure to low doses of inorganic mercury in environmental and occupational settings", a method was developed for performing cytofluorimetric analysis in "field studies".

METHODS

The method is based on commercially-available kits, and involves in loco treatment. Whole blood is labeled with monoclonal antibodies, and fixed samples immediately after collection. After the treatment, the samples are ready for flow cytometric analysis, which may be performed after a two-day period from sample collection.

RESULTS AND CONCLUSION

The method described is adequate for immunotoxicity testing in field studies because it prolongs the maximum latency time from collection and cytofluorimetric analysis up to 48 hours. A second interesting characteristic of the method is the possibility of using whole blood, without any need of either complex manipulations or particular equipment.

Fetal and maternal white cells and B- and T-lymphocyte subpopulations in pregnant women with recent infection

OBJECTIVE

To study maternal and fetal white cell counts, B- and T-lymphocyte subpopulations in pregnant women with evidence of recent infection.

METHODS

Thirty-seven pregnant women with recent infection and 38 controls were studied. All were referred for fetal blood sampling to exclude congenital infection, or to perform fetal chromosome analysis. There were 16 infected fetuses: 9 cytomegalovirus (CMV), 4 rubella, and 3 toxoplasmosis. Maternal and fetal blood was taken and white cell counts, the percentage of CD3+, CD4+, CD8+, CD56+, HLADR+CD3+ T-lymphocyte subpopulations and CD19+ B lymphocytes were measured.

RESULTS

The percentage of CD3+, CD8+, and HLADR+CD3+ lymphocytes were significantly higher in infected mothers compared to controls, while CD19+ and the CD4+/CD8+ ratio were lower. Infected mothers carrying infected fetuses had significantly lower white blood cell counts compared to those infected mothers without fetal infection. The percentage of HLADR+CD3+ T lymphocytes was significantly higher and the CD4+/CD8+ ratio lower in infected fetuses compared to controls and noninfected fetuses of infected mothers. Abnormal CD4+/CD8+ ratios and/or increased HLADR+CT3+ T lymphocytes were found in 8 of 10 fetuses with structural abnormalities and/or hematological/biochemical signs of systemic damage, and in 7 of 27 without (RR = 3.1, 95% CI = 1.5-6.3).

CONCLUSION

Both infected fetuses and their mothers have significant identifiable changes in white cell counts and T-lymphocyte subpopulations compared to controls. These tests may help in diagnosing maternal and fetal infection.

Accelerated-intensified cyclophosphamide, epirubicin, and fluorouracil (CEF) compared with standard CEF in metastatic breast cancer patients: results of a multicenter, randomized phase III study of the Italian Gruppo Oncologico Nord-Ouest-Mammella Inter Gruppo Group

PURPOSE

To evaluate whether an accelerated-intensified cyclophosphamide, epirubicin, and fluorouracil (CEF) chemotherapy regimen with the support of granulocyte colony-stimulating factor (G-CSF) induces a higher activity and efficacy compared with standard CEF in metastatic breast cancer patients.

PATIENTS AND METHODS

Stage IV breast cancer patients were randomized to receive as first-line chemotherapy either standard CEF (cyclophosphamide 600 mg/m(2), epirubicin 60 mg/m(2), and fluorouracil 600 mg/m(2)) administered every 21 days (CEF21) or accelerated-intensified CEF (cyclophosphamide 1,000 mg/m(2), epirubicin 80 mg/m(2), and fluorouracil 600 mg/m(2)) administered every 14 days (HD-CEF14) with the support of G-CSF. Treatment was administered for eight cycles.

RESULTS

A total of 151 patients were randomized (74 patients on the CEF21 arm and 77 on the HD-CEF14 arm). In both arms, the median number of administered cycles was eight. The dose-intensity actually administered was 93% and 86% of that planned, in CEF21- and HD-CEF14-treated patients, respectively. Compared with the CEF21 arm, the dose-intensity increase in the HD-CEF14 arm was 80%. Both nonhematologic and hematologic toxicities were higher in the HD-CEF14 arm than in the CEF21 arm. During chemotherapy, four deaths occurred in the HD-CEF14 arm. No difference in overall response rate (complete plus partial responses) was observed: 49% and 51% in the CEF21 and HD-CEF14 arms, respectively (P =.94). A slightly non-statistically significant higher percentage of complete response was observed in the HD-CEF14 arm (20% v 15%). No difference in efficacy was observed. The median time to progression was 14.3 and 12.8 months in the CEF21 and HD-CEF14 arms, respectively (P =.69). Median overall survival was 32.7 and 27.2 months in the CEF21 and HD-CEF14 arms, respectively (P =.16).

CONCLUSION

In metastatic breast cancer patients, an 80% increase in dose-intensity of the CEF regimen, obtained by both acceleration and dose intensification, does not improve the activity and the efficacy compared with a standard dose-intensity CEF regimen.

Induction chemotherapy followed by alternating chemo-radiotherapy in stage IV undifferentiated nasopharyngeal carcinoma

In locally advanced undifferentiated nasopharyngeal carcinoma (UNPC), concomitant chemo-radiotherapy is the only strategy that gave better results over radiation alone in a phase III trial. Adding effective chemotherapy to a concomitant chemo-radiotherapy programme may be a way to improve the results further. 30 patients with previously untreated T4 and/or N2-3 undifferentiated nasopharyngeal carcinoma were consecutively enrolled and initially treated with 3 courses of epidoxorubicin, 90 mg/m2, day 1 and cisplatin, 40 mg/m2, days 1 and 2, every 3 weeks. After a radiological and clinical response assessment patients underwent 3 courses of cisplatin, 20 mg/m2/day, days 1-4 and fluorouracil, 200 mg/m2/day, days 1-4, i.v. bolus, (weeks 1, 4, 7) alternated to 3 courses of radiation (week 2-3, 5-6, 8-9-10), with a single daily fractionation, up to 70 Gy. WHO histology was type 2 in 30% and type 3 in 70% of the patients. 57% had T4 and 77% N2-3 disease. All the patients are evaluable for toxicity and response. All but one received 3 courses of induction chemotherapy. Toxicity was mild to moderate in any case. At the end of the induction phase 10% of CRs, 83.3% of PRs and 6.7% of SD were recorded. All the patients but one had the planned number of chemotherapy courses in the alternating phase and all received the planned radiation dose. One patient out of 3 developed grade III-IV mucositis. Haematological toxicity was generally mild to moderate. At the final response evaluation 86.7% of CRs and 13.3% of PRs were observed. At a median follow-up of 31 months, 13.3% of patients had a loco-regional progression and 20% developed distant metastases. The 3-year actuarial progression-free survival and overall survival rates were 64% and 83%. Induction chemotherapy followed by alternating chemo-radiotherapy is feasible and patients' compliance optimal. This approach showed a very promising activity on locally advanced UNPC and merits to be investigated in phase III studies.

Paclitaxel plus ifosfamide in advanced ovarian cancer: a multicenter phase II study

BACKGROUND

While ovarian cancer is one of the most sensitive cancers to cytotoxic drugs, with objective response rates of 60-80% routinely being reported in previously untreated patients, the majority of individuals with advanced disease ultimately relapse. Paclitaxel, a new and novel antimicrotubule agent, has shown activity as a salvage therapy in epithelial ovarian cancer. More importantly, in a prior study, it has been shown to be active in tumors that have displayed resistance to platinum compounds, with a reported response rate of 20%. Ifosfamide has shown activity in the treatment of patients who previously demonstrated clinical resistance to a platinum-cyclophosphamide combination. Recently, a synergistic activity of Taxol combined with ifosfamide has been reported in ovarian cell lines. Based on these data, a phase I/II study of a combination treatment with paclitaxel and ifosfamide was performed.

PATIENTS AND METHODS

Thirty-one patients with recurrent ovarian cancer or ovarian cancer refractory to cisplatin (CDDP)-containing regimens were treated with paclitaxel at a dose of 135 mg/m2 on day 1; ifosfamide was administered at 1 g/m2 on days 2 and 3 for the first cycle and 1.5 and 2 g/m2 with the same schedule in cycles 2 and 3, respectively. In the absence of toxicity, the dose of ifosfamide was maintained at 2 g/m2 for the last three cycles. Cytotoxic therapy was repeated every 3 weeks.

RESULTS

A 30% overall objective response rate was achieved in the 30 patients assessable for response. Among 21 platinum-resistant patients, 4 partial responses (19%) were observed, while in the 9 platinum-sensitive patients 2 complete responses and 3 partial responses (55%) were observed. Myelosuppression was the predominant toxicity. Leukopenia (WHO grade 3-4) occurred in 10% of patients who received ifosfamide at a dose of 1 g/m2 and in 18% of patients treated with ifosfamide at 1.5 g/m2.

CONCLUSION

Our results confirmed a low activity of paclitaxel in platinum-resistant patients. The results of this combination treatment with paclitaxel-ifosfamide in our platinum-sensitive patients support further investigations in a randomized study of the combination regimen against paclitaxel alone or retreatment with organoplatinum compounds.

Partial inhibition of platelet aggregation by nebulized pentamidine in severe haemophiliacs

The antiparasite agent pentamidine has been shown to inhibit human platelet aggregation in vitro at concentrations that (potentially) may be attained in patient plasma after the administration of the drug by nebulizer. We measured platelet aggregation in platelet-rich plasma (PRP) before and after the administration of 300 mg nebulized pentamidine to 10 HIV-positive patients with severe haemophilia on prophylaxis against Pneumocystis carinii pneumonia. All patients had normal platelet counts. PAF-acether, U46619, collagen and ADP at different concentrations were used as agonists. Platelet aggregation was lower in PRP samples taken at the end of pentamidine administration and 1 h thereafter than in samples taken at the same time points in control experiments (without the administration of pentamidine). The inhibition of platelet aggregation was mild and tended to be overcome by higher concentrations of platelet agonists. The bleeding time was prolonged from 5 to 15 min in one patient but did not change in the remaining nine patients. In conclusion, this controlled study shows that nebulized pentamidine inhibits platelet aggregation in HIV-positive haemophiliacs without significantly affecting their bleeding times. Although this mild inhibitory effect may not be clinically relevant in haemophiliacs with normal platelet counts despite their defect in intrinsic coagulation, patients with HIV-related thrombocytopenia should be monitored to detect any excessive prolongation of their bleeding times after nebulized pentamidine.

Human endometrial stromal cells as a source of soluble intercellular adhesion molecule (ICAM)-1 molecules

Intercellular adhesion molecule (ICAM)-1-mediated cell-cell adhesion is essential for various immunological functions, including natural killer (NK) cell-mediated cytotoxicity against endometrium. The present study was designed to establish whether shedding of ICAM-1 from cultured endometrial stromal cells occurred and to characterize its potential functional significance in endometrial physiology and pathology. The shed sICAM-1 molecule was detected and quantified in supernatants from endometrial stromal cultures and in peritoneal fluid by a specific enzyme-linked immunosorbent assay. The results of this study indicate that cultured endometrial stromal cells constitutively shed ICAM-1 from their surface. This ability is regulated during the menstrual cycle, as it appears to be higher in the proliferative than in the secretory phase of the cycle (16.93 +/- 2.2 and 7.7 +/- 1.76 ng/ml respectively). In order to evaluate whether the release of sICAM-1 could interfere with cell-mediated lysis of endometrium we compared the determinations of sICAM-1 in endometrial supernatants with the ability of such supernatants to suppress NK cell-mediated cytotoxicity toward endometrial targets. A significant correlation (r = 0.6, P < 0.05) was found between the sICAM-1 concentration in endometrial supernatants and the percentage of inhibition of NK cell-mediated lysis exerted by the same supernatant samples. Finally, endometrial stromal shedding of sICAM-1 appears to be related to endometriosis since endometrial stromal cultures obtained from patients with advanced stages of the disease released significantly higher amounts of the soluble protein compared to the control group (P < 0.05). sICAM-1 is a soluble molecule which can interfere with immunological functions, and its shedding may be one of the mechanisms by which refluxed endometrial cells escape immunosurveillance.

Platelet activation in newborns detected by flow-cytometry

Platelet function was investigated in full-term infants on the first, the fourth and tenth days of life and compared to normal adult controls. Platelet function was analyzed through a new cytofluorimetric technique with two murine monoclonal antibodies, PAC-1 and anti-GMP-140, directed against two membrane proteins expressed on the activated platelets' surface. The percentage of activated platelets detected with PAC-1 and anti-GMP-140 was evaluated at basal condition and after in vitro stimulation with a weak agonist (ADP) and a strong Txa2 analogue inducer (U 46619). At day 1 platelet activation at basal condition was negligible and similar to adult controls both with PAC-1 (1.2 vs 1.1%) and anti-GMP-140 (2.6 vs. 3.3%). On the contrary, after ADP stimulation the percentage of PAC-1-positive activated platelets was significantly reduced in neonates compared to adults (22 vs. 66%; p < 0.001) and even more after U 46619 (11 vs. 72%; p < 0.001). The percentage of anti-GMP-140-positive activated platelets behaved similarly after adding both ADP (26 vs. 46%; p < 0.01) and U 46619 (37 vs. 67%; p < 0.001). The reduced platelet activation after ADP and U 46619 persisted at day 4 both with PAC-1 and with anti-GMP-140. On the contrary, at day 10 newborn platelets analyzed with anti-GMP-140 behaved similarly to the adult ones both at basal condition and after stimulation with ADP or U 46619 (6 vs. 3% at basal state, 42 vs. 46% after ADP addition, and 55 vs. 67% after U 46619). These data demonstrate that the reduced platelet activation present in newborns is restored by the tenth day after birth.

Alternating chemo-radiotherapy in bladder cancer: a conservative approach

PURPOSE

The aim of this Phase II study was to determine a bladder-sparing treatment in patients with invasive bladder cancer, allowing a better quality of life. Objectives were to test toxicity and disease-free and overall survival of patients given an alternated chemo-radiotherapy definitive treatment.

METHODS AND MATERIALS

Seventy-six patients with bladder cancer Stage T1G3 through T4 N0 M0 were entered in the same chemotherapy regimen (Cisplatin 20 mg/mq and 5-Fluorouracil 200 mg/mq daily for 5 days) alternated with different radiotherapy scheduling, the first 18 patients received two cycles of 20 Gy/10 fractions/12 days each; the second group of 58 patients received two cycles of 25 Gy/10 fractions/12 days each (the last 21 patients received Methotrexate 40 mg/mq instead of 5-Fluorouracil).

RESULTS

A clinical complete response was observed in 57 patients (81%), partial response in 7 patients (10%), and a nonresponse in 6 patients (9%). At a median follow-up of 45 months, 33 patients (47%) were alive and free of tumor. The 6-year overall survival and progression-free survival was 42% and 40%, respectively. Systemic side effects were mild, while a moderate or severe local toxicity was observed in 14 patients and 13 patients (about 20%), respectively.

CONCLUSION

Our conservative combination treatment allowed bladder-sparing in a high rate of patients and resulted in a survival comparable to that reported after radical cystectomy.

Hemostatic parameters and platelet activation by flow-cytometry in normal pregnancy: a longitudinal study

Nineteen pregnant women with uncomplicated pregnancies were studied during the first, second, and third trimesters. We measured the following hemostatic parameters: prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin III, protein C, protein S, platelet number and volume. Platelet function was examined by a cytofluorimetric method, using an anti-GPM-140 antibody which is directed against a platelet alpha granule membrane protein. Activated platelets were expressed as a percentage of the GMP-140-positive platelets over total platelets. Fibrinogen levels showed a steady increase during pregnancy; conversely prothrombin time, activated partial thromboplastin time, protein C, and antithrombin III showed no significant modifications and remained within the reference range. There was a decrease of protein S activity throughout pregnancy, although protein S antigen did not follow this trend. The decrease occurred early in pregnancy and persisted during the second and third trimesters, reaching a stable plateau. We observed no platelet volume change or activation: the percentage of activated platelets was within the normal reference range, even in late pregnancy.

Carboplatin, methotrexate, and vinblastine in the treatment of patients with advanced urothelial cancer. A phase II trial

BACKGROUND

A Phase II study with carboplatin, methotrexate, and vinblastine (CAMV) was conducted with patients who had advanced urothelial cancer to investigate the activity and toxicity of carboplatin when used in combination chemotherapy.

METHODS

Thirty-six patients with advanced urothelial cancer were treated with carboplatin 300 mg/m2 (day 1), methotrexate 40 mg/m2 (days 1 and 8) and vinblastine 4 mg/m2 (days 1 and 8) every 4 weeks. Characteristics of the patients were as follows: men:women, 32:4; median age, 65 years (range, 42-76 years); and median Eastern Cooperative Oncology Group performance status, 0 (range, 0-2). Thirty-six patients were evaluable for toxicity and 33 for response.

RESULTS

Objective responses (OR) were achieved in 13 patients: 2 were complete responses (CR) (6%) and 11 were partial responses (33.4%). Median duration of OR was 7 months (range, 3-27 months). Median duration of CR was 10 months (range, 4-27 months), and median survival time for patients achieving complete response was 30.5 months (range, 28-33 months). Patients with a pretreatment creatinine clearance greater than or equal to 50 ml/minute showed a higher response rate: 48% OR and 10% CR. Toxicity was evaluated (World Health Organization criteria) on 164 cycles and was generally mild.

CONCLUSION

CAMV is an active and safe regimen in patients with advanced urothelial cancer, even in those with impaired renal function. It is recommended that future studies with this regimen be performed with pharmacokinetic modulation of carboplatin to improve the drug's tolerability and therapeutic activity.

Maternal and fetal platelet activation in normal pregnancy

OBJECTIVE

To study the platelet activation phase in normal pregnant women and their fetuses, both in vivo under basal conditions and in vitro after stimulation by adenosine diphosphate (ADP), a weak agonist, and U46619, a strong one.

METHODS

Platelet function was investigated in 39 normal pregnant women and their fetuses undergoing fetal blood sampling at 18-37 weeks' gestation, using flow cytometry and the anti-GMP140 monoclonal antibody. This combined technique allows platelets to be investigated in small aliquots of whole blood, and it detects platelet secretion regardless of aggregation. In all cases, the percentage of activated platelets was determined under basal conditions and after addition of platelet agonists: ADP at concentrations of 10 and 50 mumol/L, and U46619, a stable analogue of thromboxane A2, at 1 mumol/L.

RESULTS

Compared to nonpregnant controls, pregnant women had a significantly lower percentage of activated platelets after addition of U46619 (P = .02). Compared to their mothers, fetuses had significantly inferior platelet activation after addition of both platelet-activating factors at all concentrations used (ADP 10 mumol/L, P < .0001 and ADP 50 mumol/L, P < .0001; U46619, P < .0001). Maternal and fetal platelet activation did not change with duration of gestation. In the fetus, the percentage of activated platelets did not correlate with hematocrit, pH, or oxygen pressure, but it correlated significantly with platelet count after addition of U46619 (r = 0.45, P = .006).

CONCLUSIONS

Decreased platelet activation in both pregnant women and fetuses suggests the action of a plasma factor that selectively inhibits prostaglandin-dependent activation. Prostacyclin, which is known to decrease platelet aggregation and release reactions caused by agonists, might have a greater inhibitory effect in the fetus than in the mother, or be present in larger amounts in the fetus.

Prophylaxis of superficial bladder cancer with mitomycin or interferon alfa-2b: results of a multicentric Italian study

PURPOSE

Interferons have shown a definite activity in the intravesical treatment of residual papillary bladder cancer or carcinoma in situ (CIS). The purpose of the present study was to investigate the efficacy of interferon alfa-2b (IFN) as prophylactic treatment of superficial bladder cancer.

PATIENTS AND METHODS

Two hundred eighty-seven patients with primary pTa G2, pT1 G1 to G2 superficial bladder cancer, following complete transurethral resection (TUR), were randomly allocated to receive intravesical treatment, either with IFN (50 x 10(6) IU) or mitomycin (MIT-C; 40 mg). Drugs were instilled on a weekly basis for a total of 8 weeks.

RESULTS

MIT-C was superior to IFN treatment with respect to time to recurrence, relative recurrence rate, recurrence rate per 100 patients per month, and recurrence tumor rate per 100 patients per month. This difference was particularly evident in patients with pTa G2 tumors. After multivariate analysis, the number of primary tumors and tumor grade were the best predictors of recurrence, while allocated treatment had only a moderate effect. Intravesical treatment was well tolerated in both arms. However, more local toxicity was experienced by patients treated with MIT-C. On the other hand, fever occurred significantly more frequently in patients treated with IFN.

CONCLUSION

IFN was less effective, although locally better tolerated, than MIT-C as prophylactic treatment of primary superficial bladder cancer.

Long-term endocrine effects of administration of either a non-steroidal antiandrogen or a luteinizing hormone-releasing hormone agonist in men with prostate cancer

The claimed ability of non-steroidal antiandrogens to preserve libido and sexual potency is sought as a potential improvement in the palliative management of prostate cancer. A critical issue for the clinical use of these compounds is, however, the reported evidence in the rat of an excessive increase in testosterone concentrations as a consequence of the androgen negative feedback interruption. On the other hand, the recovery of testicular function after long-term inhibition by luteinizing hormone-releasing hormone (LHRH) analogs is also an important concern in view of the proposed use of these compounds for the treatment of several non-malignant conditions. We addressed these issues by studying the long-term endocrine effects induced by the administration of either the non-steroidal antiandrogen nilutamide or the depot preparation of D-Trp6-LHRH in men with prostate cancer. Treatment with the antiandrogen induced a marked increase in gonadotropin levels, LH concentrations rising from a mean (SEM) of 17.5 +/- 1.6 to a maximum of 56.6 +/- 6.9 kU/l (p < 0.001), while mean testosterone and 17 beta estradiol-concentrations rose only by about 50% and 70% over pretreatment values, testosterone levels reaching a plateau after 1 month of treatment. In the subjects treated with the LHRH agonist, 6 months after discontinuation of long-term administration the mean (+/- SEM) LH had risen to 36.9 +/- 6.8 IU/l while mean testosterone levels were still as low as 1.7 +/- 0.7 and rose only to a maximum of 4.2 +/- 1 nmol/l after high-dose human chorionic gonadotropin loadings.(ABSTRACT TRUNCATED AT 250 WORDS)

Carboplatin in advanced hormone refractory prostatic cancer patients

25 patients with measurable or evaluable metastatic prostate cancer, progressive after hormonal treatment, were treated weekly with carboplatin 150 mg/m2 intravenously. The weekly schedule allowed higher dose intensity carboplatin administration with respect to the common monthly cycles. Toxicity was manageable even in elderly patients with extensive bone metastases and consisted primarily of myelosuppression. 4 out of 24 evaluable patients (17%) had a partial response and 12 (50%) had disease stabilisation. The median response duration was 7 months. Prostate-specific antigen and prostatic acid phosphatase serial values showed a correlation with disease response in only 47 and 50% of patients, respectively. These results suggest that carboplatin possesses a moderate but definite activity in prostate cancer patients.

Goserelin acetate with or without flutamide in the treatment of patients with locally advanced or metastatic prostate cancer. The Italian Prostatic Cancer Project (PONCAP) Study Group

From March 1987 to December 1990, 373 patients with stage C and D prostate cancer were randomized to receive either goserelin acetate alone or goserelin acetate plus flutamide. At a median follow-up time of 24 months, there was no significant difference in the response rate, progression-free and overall survival between the two treatment groups. In particular, median time to progression was 18 months in the goserelin arm and 24 months in the combined treatment arm (P = 0.09). However, median time to progression in stage D patients was 12 months in both treatment groups. Median time to death was 32 and 34 months, respectively. The combination regimen produced a more rapid normalisation of prostatic acid phosphatase levels and a prompt relief of bone pain. However, significantly more patients in the combination arm experienced treatment-related side-effects such as diarrhoea and increases in transaminase levels. The concurrent use of goserelin acetate and flutamide does not seem to significantly improve the results that can be achieved with goserelin acetate alone.

B and T lymphocyte subsets in fetal and cord blood: age-related modulation of CD1c expression

Peripheral blood lymphocytes from fetal, term and adult subjects were analyzed with a panel of B- and T-lymphoid differentiation markers. CD1c +ve and CD5 +ve B cell (IgM +ve) percentage in fetal, cord and adult blood decreased significantly. Fetal and cord blood contained less CD2+ and CD3+ T lymphocytes and a higher percentage of CD38 +ve cells than adult blood. The phenotypic changes occurring during perinatal age in humans relate to the changes in the functional activities of the B and T lymphoid subsets from fetal to postnatal age.

Functional protein S in women with lupus anticoagulant inhibitor

Protein C (PC) and protein S (PS) are components of a potent, natural anticoagulant system. A deficiency of one of these two inhibitors is associated with thrombotic events in young people. A significant reduction in functional PS activity has been observed during normal pregnancy, and recurrent fetal loss may occur in women with lupus anticoagulant (LA) inhibitor. We measured functional PS activity and free PS antigen in 16 non pregnant patients with LA inhibitor and in 17 normal women as controls. A significant difference was observed between patients and controls in functional PS activity (65 +/- 23% vs 87 +/- 15%, p = 0.02) but not in free PS antigen (88 +/- 17% vs 93 +/- 17%). Functional PS activity decreased only in six patients (37%). Removal of IgG from plasma reduced the difference in functional PS activity between patients and controls. Immunologic IgG levels did not correlate with anti-phospholipid antibodies (APA) activities, activated partial thromboplastin time/kaolin clotting time (aPTT/KCT) data or functional PS activity.

Phase II study of the pure non-steroidal antiandrogen nilutamide in prostatic cancer. Italian Prostatic Cancer Project (PONCAP)

The activity of the pure non-steroidal antiandrogen nilutamide as a single agent was evaluated in 44 patients with metastatic carcinoma of the prostate. Objective (partial) response rates (95% confidence limits) were 38.5 (18.7)% in 26 previously untreated patients and 5.5 (11%) in 18 patients progressing on primary androgen suppressive procedures. The most frequent side-effects were decreased adaptation to darkness (29.5%), slight nausea (31.8%) and alcohol intolerance (18.2%). In addition, treatment was discontinued in 3 patients because of gastrointestinal symptoms. A non-significant increase in testosterone levels was shown in the untreated group during the first month of treatment, after which the levels remained stable. About half of the sexually active men claimed the maintenance of libido and sexual potency during treatment. Although our study confirms a significant incidence of visual disturbances, the activity data coupled with the ability of maintaining sexual interest suggest that single therapy with non-steroidal antiandrogens may deserve comparison to conventional endocrine treatment in controlled trials.

Monotherapy with nilutamide, a pure nonsteroidal antiandrogen, in untreated patients with metastatic carcinoma of the prostate. The Italian Prostatic Cancer Project

A total of 26 previously untreated patients with metastatic carcinoma of the prostate received the pure nonsteroidal antiandrogen nilutamide as a single agent. Objective response rate was 38.5 +/- 18.7% (95% confidence interval). Median progression-free survival and median survival were 9 and 23 months, respectively. Of 13 patients with progression on antiandrogen 5 showed an additional objective response to a second-line endocrine treatment. The drug was generally well tolerated, except for 2 patients who discontinued treatment because of moderate gastrointestinal symptoms. Approximately a third of the patients complained of decreased adaptation to darkness. An electroretinogram and dark adaptation test revealed the presence of functional damage and visual complaints reversed in all patients on cessation of therapy. The other most frequent side effects were slight nausea (26.9% of the patients) and alcohol intolerance (19.2%). A nonsignificant increase in testosterone levels was shown within 1 month of treatment, after which the levels remained stable. Approximately half of the sexually active men claimed maintenance of libido and sexual potency during treatment. A slightly significant increase in hemoglobin was observed during the long term, suggesting the occurrence of a trophic effect by androgens on erythropoiesis. The results indicate that nilutamide as a single agent has an acceptable toxicity and a moderate activity, and may maintain sexual interest in a discrete number of cases. Whether monotherapy with nonsteroidal antiandrogens offers a valid option in the palliation of advanced disease remains to be seen in comparative prospective trials.

Zoladex with or without flutamide in the treatment of locally advanced or metastatic prostate cancer: interim analysis of an ongoing PONCAP study. Italian Prostatic Cancer Project (PONCAP)

Since March 1987, 304 evaluable patients with stage C and D prostate cancer have been entered into a prospective trial comparing Zoladex and Zoladex plus flutamide. To date, there has been no significant difference in over-all and progression-free survival between the 2 treatment groups. However, combined treatment produced a higher response rate (particularly in stage D patients) and a more rapid normalization of abnormal prostatic acid phosphatase levels. In addition, more prompt relief of bone pain was evident in the Zoladex plus flutamide group. However, significantly more side-effects were associated with combined treatment. These findings should be considered with caution because they form an interim analysis, and follow-up time is short. The results do suggest, however, that there is no particular advantage in using a combination of Zoladex plus flutamide compared to adding flutamide on failure of treatment with Zoladex alone.

Evidence for testicular impairment after long-term treatment with a luteinizing hormone-releasing hormone agonist in elderly men

Testicular responsiveness to 5,000 IU of human chorionic gonadotropin was evaluated in 14 patients with prostate cancer who were being treated with a slow-release luteinizing hormone-releasing hormone agonist for a median of 21 months. Serum testosterone response to human chorionic gonadotropin was markedly reduced in most patients, with the median level increasing from 0.25 to 1.65 nmol. per l. A second human chorionic gonadotropin test was repeated later in 5 patients who had been off treatment for a median of 6 months. Median serum testosterone levels increased to a maximum of 2.6 nmol. per l. compared to 28.2 nmol. per l. in an age-matched control group (p equals 0.008). Therefore, we conclude that long-term treatment with luteinizing hormone-releasing hormone agonists in elderly men leads to gonadal impairment that may not be as reversible as generally suggested.