Final results of DIADEM, a phase II study to investigate the efficacy and safety of durvalumab in advanced pretreated malignant pleural mesothelioma

BACKGROUND

Malignant pleural mesothelioma (MPM) is a cancer with a high mortality rate and few therapeutic options. After platinum-pemetrexed combination, no further promising drug seems to be effective. Immune checkpoint inhibitors may have some activity in pretreated patients and no data are available in this population about durvalumab.

MATERIALS AND METHODS

DIADEM was a multicenter, open-label, single-arm, phase II trial aimed at evaluating the efficacy and safety of durvalumab. Patients with locally advanced/metastatic MPM who progressed after platinum-pemetrexed chemotherapy were enrolled to receive durvalumab (1500 mg, intravenously Q4W) for 12 months or until evidence of disease progression or unacceptable toxicity. The primary endpoint was the proportion of patients alive and free from progression at 16 weeks (PFS_16wks) calculated from treatment initiation. Secondary endpoints were progression-free survival, overall survival, overall response rate, and safety.

RESULTS

Sixty-nine patients with a median age of 69 years (range 44-82 years) were enrolled; 62 patients (89.9%) had epithelioid histotype. As first-line treatment, all patients received platinum derivatives-pemetrexed combination (60.9% with carboplatin and 39.1% with cisplatin). As of March 2021, the median follow-up was 9.2 months (interquartile range 5.2-11.1 months). Six patients (8.7%) completed the 12-month treatment; 60 patients discontinued, of whom 42 for progressive disease, and 4 died. Seventeen patients (28.3%; 95% confidence interval 17.5% to 41.4%) were alive or free from progression at 16 weeks. Eleven patients (18.6%) had a grade 3 or 4 treatment-related adverse event (AE), and one (1.4%) had a grade ≥3 immune-related, treatment-related AE. There was one drug-related death.

CONCLUSION

Durvalumab alone in pretreated non-selected MPM did not reach a meaningful clinical activity, showing any new major safety issue signals.

A Novel Tool for the Early Identification of Frailty in Elderly People: The Application in Primary Care Settings

BACKGROUND

Frailty is a pre-disability condition in older persons providing a challenge to Health-Care Systems. Systematic reviews highlight the absence of a gold-standard for its identification. However, an approach based on initial screening by the General Practitioner (GP) seems particularly useful. On these premises, a 9-item Sunfrail Checklist (SC), was developed by a multidisciplinary group, in the context of European Sunfrail Project, and tested in the Community.

OBJECTIVES

- to measure the concordance between the judgments of frailty (criterion-validity): the one formulated by the GP, using the SC, and the one subsequently expressed by a Comprehensive Geriatric Assessment Team (CGA-Team); - to determine the construct-validity through the correspondence between some checklist items related to the 3 domains (physical, cognitive and social) and the three tools used by the CGA-Team; - to measure the instrument's performance in terms of positive predictive value (PPV) and negative predictive value (NPV).

DESIGN

Cross-sectional study, with a final sample-size of 95 subjects.

SETTING

Two Community-Health Centers of Parma, Italy.

PARTICIPANTS

Subjects aged 75 years old or more, with no disability and living in the community.

MEASUREMENTS

We compared the screening capacity of the GP using the SC to that one of CGA-Team based on three tests: 4-meter Gait-Speed, Mini-Mental State Examination and Loneliness Scale.

RESULTS

95 subjects (51 women), with a mean age of 81±4 years were enrolled. According to GPs 34 subjects were frail; the CGA-Team expressed a frailty judgment on 26 subjects. The criterion-validity presented a Cohen's k of 0.353. Construct-validity was also low, with a maximum contingency-coefficient of 0.19. The analysis showed a PPV of 58.1% and a NPV equal to 84.6%.

CONCLUSIONS

Our data showed a low agreement between the judgements of GP performed by SC and CGA-Team. However, the good NPV suggests the applicability of SC for screening activities in primary-care.

Author Correction: Conversion of human fibroblasts to angioblast-like progenitor cells

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Abstract 4079: EVT801: a selective VEGFR3 inhibitor with the potential for combination with immune-checkpoint therapies, preclinical evidences and plans for first-in-human evaluation

We have identified a highly selective VEGFR3 inhibitor drug candidate, which strongly inhibits angiogenesis without inducing hypoxia, reputed as one of the main causes of cancer-associated immunosuppression. Combination of EVT801 and Immune Checkpoint Therapy (ICT) could be synergistic as hypoxia-induced-immunosuppression should be avoided. We have demonstrated that EVT801 is a narrow spectrum inhibitor of the VEGFR3 tyrosine kinase with residual activity against VEGFR2 and TAK1 and with an activity on VEGFRs different from Fruquitinib and Lenvatinib. We then showed that EVT801 inhibited human endothelial cell proliferation in vitro and tumor angiogenesis on ex-vivo mouse ring aortic assay. EVT801 was active in vivo in the RIP1-Tag2 mouse model during the angiogenic switch. In comparison to sorafenib, EVT801 in 2 different tumors mouse model decreased tumor development without inducing increase of hypoxia which is in favor to a sustained blood vessel tumor normalization. In orthotopic 4T1 mammary carcinoma, we demonstrated that EVT801 in combination with PD1 mAb was significantly superior than single agent treatment and a decrease of lung metastasis spreading was observed. We observed that decrease of MDSCs in blood in response to EVT801 was correlated with decrease in tumor weight. By IHC analysis, we showed that treatment with EVT801 increases CD8+ T-cells infiltration inside the tumor. Taken together, these results indicated that EVT801 represents an innovative anti-angiogenic drug for cancer immunotherapy which may improve the frequency of response to ICT. Clinical trial design including patient stratification and biomarkers of activity has been proposed in order to be ready for first-in-human evaluation by mid-2019.

Citation Format: Pierre Fons, Michael Esquerre, Michael Paillasse, Virgile Visentin, Frederique Dol, Jerome Meneyrol, Gaelle Badet, Eric Cogo, Lionel Vidaud, Antoine Alam, Isabelle Blanc, Francoise Bono, Joanna Lisztwan, Muriel Poublanc, Thomas Filleron, Ian Hunneyball, Jean-Pierre Delord, Mark Whittaker. EVT801: a selective VEGFR3 inhibitor with the potential for combination with immune-checkpoint therapies, preclinical evidences and plans for first-in-human evaluation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4079.

Abstract 2753: Translation to the clinic of EVT801: A novel immune-oncology agent for addressing innate-driven immunosuppression into the tumor microenvironment and expanding patient population responding to immune checkpoint therapies

Amongst resistance mechanisms of immune checkpoint therapies (ICTs), expansion and recruitment of immunosuppressive innate cells and in particular Myeloid Derived Suppressor Cells (MDSCs) can be a major cause of resistance to ICTs. Here we describe joint efforts of clinicians and researchers to translate the promising EVT801 action on MDSCs into the clinic. We have identified a highly selective drug candidate targeting VEGFR3, EVT801, showing intermediate in vivo activity on tumours, accompanied by a decrease of MDSCs, when VEGFR3 is expressed in the tumour microenvironment. To evaluate the potential to combine with ICTs, the 4T1 orthotopic mammary carcinoma mouse model, was used. We have demonstrated that EVT801 increases the therapeutic activity of an anti-PD-1 antibody (Ab) on primary tumours as compared to single agent treatment but also results in a decrease of lung metastasis. Furthermore, the decrease of MDSCs in the blood in response to EVT801 is correlated with tumor shrinkage and therapeutic efficacy. In parallel, Immuno Histo Chemistry analyses have shown that treatment with EVT801 increases CD8+ T-cells infiltration inside the tumor. Taken together, these results indicate that EVT801 represents an innovative drug for cancer immunotherapy that improves the frequency of response to ICT by controlling MDSCs immunosuppressive activity and in turn by unleashing tumor-specific T-lymphocytes. To translate these promising results into the clinic, we have evaluated different biomarkers to properly select patients and monitor efficacy of EVT801: (1) We refined an antiPD1 Ab resistance gene signature and correlated it with VEGFR3 pathway gene overexpression. (2) We investigated VEGFR3 expression in the tumor microenvironment (TME) for different cancer indications. Taken together, these results will facilitate patient stratification as based on the PD1 resistance gene signature associated with VEGFR3 expression in the TME. (3) In non-small cell lung cancer patients, we validated that a high-level baseline of circulating M-MDSCs is associated with poor survival. In correlation with EVT801 activity on circulating MDSC as deciphered on preclinical mouse models, we propose that circulating MDSC levels could be a biomarker of activity for EVT801 in non-responder patients to ICTs. EVT801 represents a novel agent for cancer immunotherapy for non-responder patients to ICT. Patient stratification strategy, target engagement biomarker and biomarkers of activity have been identified and will enable the initiation of a planned Phase I clinical trial with EVT801.

Citation Format: Pierre Fons, Michael Esquerre, Julien Mazieres, Philippe Rochaix, Anne Gomez-Brouchet, Antoine Alam, Florie Bertrand, Celine Poussereau-Pomie, Jerome Meneyrol, Anne Pradines, janick selves, Isabelle Rouquette, Isabelle Blanc, Francoise Bono, Donogh P. O'Brien, Michael Paillasse, Joanna Lisztwan, Mark Whittaker. Translation to the clinic of EVT801: A novel immune-oncology agent for addressing innate-driven immunosuppression into the tumor microenvironment and expanding patient population responding to immune checkpoint therapies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2753.

The Structure of Synthetic Oligosaccharides in Relation to Factor IXa Inhibition

We investigated the effect of various oligosaccharides (OS) on the inhibition of factor IXa by antithrombin (AT) in a purified system. The OS comprised the AT-binding pentasaccharide sequence prolonged by saccharide chains with various lengths and charges. We show that factor IXa inhibition depended on the molecular weight of the OS. Factor IXa was not inhibited by the AT-binding pentasaccharide alone, but was inhibited if it was prolonged by a sulphated dodecasaccharide at the non-reducing end. The overall charge was also important since factor IXa inhibition was negligible if the pentasaccharide was prolonged by a non-sulphated dodecasaccharide. Using compounds containing a non-sulphated spacer, we showed that the central part of the OS was not critical. This study therefore demonstrates that the minimal OS structure necessary for catalysing factor IXa inhibition by AT is close to that required for catalysing thrombin inhibition.

Pharmacokinetics of New Synthetic Heparin Mimetics

Pharmacokinetics of oligosaccharides displaying various affinities for antithrombin (AT) allowed us to show that there was a close relationship between the plasma half-life of these antithrombotic oligosaccharides and their affinity for AT. Recently, we have described new heparin mimetics comprising an AT binding domain and a thrombin binding domain separated by a neutral methylated saccharide sequence. These compounds displayed strong anti-Xa and anti-IIA activities and, in contrast to heparin, escaped neutralisation by platelet factor 4. The aim of this work was to compare the pharmacokinetics of several of these heparin mimetics in rats. These compounds differed by their length, charge and affinity for AT (AT-binding domain). The results obtained indicate that the prolongation of the AT binding domain did not modify significantly their affinities for AT. However, an increase in the number of charges leads to a decrease in the half-life. When a methylated spacer was added in order to minimise the non-specific interactions to other proteins, half-lives of the heparin mimetic were in the same range than that of the pentasaccharide used as an AT binding domain.

In conclusion, this study shows the influence of the charge of the oligosaccharides on their pharmacokinetics and underlines the importance of minimising their non-specific binding to plasma proteins in order to obtain compounds with predictive pharmacokinetics.

Abstract 3076: A novel nanoparticle formulation of doxorubicin is clearly differentiated from free doxorubicin in overcoming resistance mechanisms in chemo-resistant tumors

Background and Aims. Chemo-resistance in hepatocellular carcinoma (HCC) tumor cells can be mediated by several mechanisms including P-gp efflux pumps and drug sequestration by the autophagy process. This study investigates the potential of doxorubicin loaded nanoparticle (NP) to reverse chemo-resistance by these mechanisms compared to free doxorubicin. We present the preclinical evaluation of anti-tumor effects of NP as monotherapy and in combination with standard agents used in treatment of HCC, pancreatic and sarcoma cancers. A phase III clinical study comparing NP to Best Standard of Care (Relive study) in patients with advanced HCC is in the final stages of recruitment with preliminary results expected in 2H 2017.

Methods. Tumor cell lines were incubated with drugs in cell proliferation assay. In vivo efficacy of NP alone (4-8 mg/kg) or in combination with current and investigational treatments for pancreatic cancer (e.g. Gemcitabine, Erlotinib, Abraxane) and HCC (Sorafenib, Regorafenib and Lenvatinib) were performed in mouse tumor models using tumor weight as primary endpoint. In all experiments NP was compared to administration of free doxorubicin. Doxorubicin quantification in tumor and organs to asses PK and biodistribution was also performed using an LC/MS based method. Autophagy was measured by cell proliferation in the presence of inhibitors e.g.. Concanamycin A, Hydroxychloroquine sulfate added 30 min before incubation with the test compound.

Results. NP showed a dose-dependent inhibition of cell proliferation in all resistant cancer cell lines tested with a superior activity compared to free doxorubicin and other tested drugs. In contrast to free doxorubicin, NP showed consistent anti-proliferative activity in the absence/presence of inhibitors of P-gp pumps and autophagy. In a range of in vivo models, NP was preferentially taken up by the tumor tissue and significantly reduced tumor growth when compared with free doxorubicin and with at least equivalent reduction in tumor growth compared to current treatments. Furthermore NP administered in combination with current treatments significantly increased the inhibitory effect of each drug without additional toxicity (as measured by no change in body weight). The results comparing efficacy of NP alone and in combination in HCC, pancreatic and sarcoma cancer models will be presented.

Conclusions. These results demonstrate that NP is clearly differentiated from free doxorubicin, in 1) overcoming resistance mechanisms linked to efflux and autophagy, and 2) having a superior biodistribution profile both of which results in significantly enhanced activity on chemo-resistant tumors. NP also provides an opportunity to combine with other agents, enhancing activity without increasing toxicity. The implications of these results on the further development of NP will be discussed.

Citation Format: Véronique Trochon-joseph, Christelle Zandanel, Caroline Lemarchand, Vincent Hayes, Séverine Rochas, Yamina Rayah, Jean-Louis Labernardière, Graham Dixon, Francoise Bono. A novel nanoparticle formulation of doxorubicin is clearly differentiated from free doxorubicin in overcoming resistance mechanisms in chemo-resistant tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3076. doi:10.1158/1538-7445.AM2017-3076

Abstract B25: “TargetDBR”—A DNA repair drug and target discovery collaboration: Exploiting synthetic lethal, high content, and functional cellular reporter assays to accelerate DNA repair targeted drug discovery

Most cancer therapies involve a component of treatment that inflicts DNA damage in tumor cells, such as double-strand breaks (DSBs), which are considered the most serious threat to genomic integrity. Inhibition of DSB repair sensitizes cells to these therapies. Mutations have been reported in nearly every DNA repair pathway and these pathways often exhibit redundancy. Inhibition of functional repair factors can induce synthetic lethality in repair-deficient tumors even in the absence of exogenous DNA damage and whilst sparing healthy tissue. We demonstrate a compound and target discovery platform comprising the integration of isogenic cell line screening, high content repair foci assays and relative DSB repair pathway reporting cells, along with chemical biology and medicinal chemistry.

Two diverse drug-like compound library screens have been conducted. Screening for synthetic lethality with deficiency in FANCD2 and BRCA2 led to a hit series broadly active against a range of homologous recombination (HR) repair deficiencies, which is now undergoing medicinal chemistry optimization and target deconvolution studies. Outcome of these initial chemoproteomic target pulldown experiments will be presented. A second cellular screen, (50k compounds) for inhibition of BRCA1 and Rad51 foci formation following radiomimetic drug induced DNA damage, has led to identification of compounds that inhibit damage response after ionizing radiation and selectively inhibit HR repair.

Focusing on therapeutic targeting of proliferating tumor cells, our research platform has enabled novel hit compound identification, mechanistic profiling, hit-to-lead optimization chemistry and proof of concept efficacy in in vitro tumor models. Effects on tumor cell clonogenic survival and sensitization towards chemotherapeutics and ionizing radiation will be presented, along with comparisons to known DNA repair inhibitors that demonstrate these compounds' differentiated mechanisms of action.

TargetDBR has created a technology platform focused on DNA repair inhibitor discovery and has identified differentiated hits and lead series with potential for development and opportunity to meet the need for new druggable targets in oncology.

Citation Format: Jonathan J. Hollick, Laura Abriola, Francoise Bono, Denise Hegan, Pamela Klingbeil, Yanfeng Liu, Ranjini Sundaram, Yulia V. Surovtseva, Mark Whittaker, Ranjit S. Bindra, Peter M. Glazer. “TargetDBR”—A DNA repair drug and target discovery collaboration: Exploiting synthetic lethal, high content, and functional cellular reporter assays to accelerate DNA repair targeted drug discovery [abstract]. In: Proceedings of the AACR Special Conference on DNA Repair: Tumor Development and Therapeutic Response; 2016 Nov 2-5; Montreal, QC, Canada. Philadelphia (PA): AACR; Mol Cancer Res 2017;15(4_Suppl):Abstract nr B25.

The Italian Dystonia Registry: rationale, design and preliminary findings

The Italian Dystonia Registry is a multicenter data collection system that will prospectively assess the phenomenology and natural history of adult-onset dystonia and will serve as a basis for future etiological, pathophysiological and therapeutic studies. In the first 6 months of activity, 20 movement disorders Italian centres have adhered to the registry and 664 patients have been recruited. Baseline historical information from this cohort provides the first general overview of adult-onset dystonia in Italy. The cohort was characterized by a lower education level than the Italian population, and most patients were employed as artisans, builders, farmers, or unskilled workers. The clinical features of our sample confirmed the peculiar characteristics of adult-onset dystonia, i.e. gender preference, peak age at onset in the sixth decade, predominance of cervical dystonia and blepharospasm over the other focal dystonias, and a tendency to spread to adjacent body parts, The sample also confirmed the association between eye symptoms and blepharospasm, whereas no clear association emerged between extracranial injury and dystonia in a body site. Adult-onset dystonia patients and the Italian population shared similar burden of arterial hypertension, type 2 diabetes, coronary heart disease, dyslipidemia, and hypothyroidism, while hyperthyroidism was more frequent in the dystonia population. Geographic stratification of the study population yielded no major difference in the most clinical and phenomenological features of dystonia. Analysis of baseline information from recruited patients indicates that the Italian Dystonia Registry may be a useful tool to capture the real world clinical practice of physicians that visit dystonia patients.

The influence of ictal cutaneous allodynia on the response to occipital transcutaneous electrical stimulation in chronic migraine and chronic tension-type headache: a randomized, sham-controlled study

OBJECTIVE

The objective of this article is to determine whether cutaneous allodynia (CA) influences the response to treatment with occipital transcutaneous electrical stimulation (OTES) in chronic migraine (CM) and chronic tension-type headache (CTTH).

METHODS

One hundred and sixty consecutive patients with CM or CTTH were randomized to be treated with real or sham OTES stimulation three times a day for two consecutive weeks. All patients completed the validated 12-item allodynia symptom checklist for assessing the presence and the severity of CA during headache attack. Primary end-point was change (≥50%) in number of monthly headache-free days.

RESULTS

There was a significant difference in the percentage of responders in the real OTES compared with sham OTES group (p <0.001). Importantly, there was not a significant change of monthly headache-free days in the allodynic patients with CM and CTTH treated both with real and sham OTES, while the number of headache-free days per month was significantly reduced in the real (86%) but not in the sham group (7%) of non-allodynic patients with CTTH and CM.

CONCLUSIONS

Severe CA is associated with decreased response to treatment with OTES in patients with CM and CTTH.

SAR216471, an alternative to the use of currently available P2Y₁₂ receptor inhibitors?

P2Y12 antagonism is a key therapeutic strategy in the management and prevention of arterial thrombosis. The objective of this study was to characterize the pharmacodynamic (PD) and pharmacokinetic (PK) properties of SAR216471, a novel P2Y12 receptor antagonist. SAR216471 blocks the binding of 2MeSADP to P2Y12 receptors in vitro (IC50=17 nM). This inhibition was shown to be reversible. It potently antagonized ADP-induced platelet aggregation in human and rat platelet-rich plasma (IC50=108 and 62 nM, respectively). It also inhibited platelet aggregation when blood was exposed to collagen or thromboxane A2. Its high selectivity was demonstrated against a large panel of receptors, enzymes, and ion channels. Despite its moderate bioavailability in rats, oral administration of SAR216471 resulted in a fast, potent, and sustained inhibition of platelet aggregation where the extent and duration of platelet inhibition were directly proportional to its circulating plasma levels. Pre-clinical study of SAR216471 in a rat shunt thrombosis model demonstrated a dose-dependent antithrombotic activity after oral administration (ED50=6.7 mg/kg). By comparison, ED50 values for clopidogrel, prasugrel and ticagrelor were 6.3, 0.35 and 2.6 mg/kg, respectively. Finally, the anti-hemostatic effect of SAR216471 and its competitors was investigated in a rat tail bleeding model, revealing a favorable safety profile of SAR216471. Together, these findings have established a reliable antiplatelet profile of SAR216471, and support its potential use in clinical practice as an alternative to currently available P2Y12 receptor antagonists.

Mitochondrial energetic and AKT status mediate metabolic effects and apoptosis of metformin in human leukemic cells

Previous reports demonstrate that metformin, an anti-diabetic drug, can decrease the risk of cancer and inhibit cancer cell growth. However, its mechanism in cancer cells is still unknown. Metformin significantly blocks cell cycle and inhibits cell proliferation and colony formation of leukemic cells. However, the apoptotic response to metformin varies. Furthermore, daily treatment with metformin induces apoptosis and reduces tumor growth in vivo. While metformin induces early and transient activation of AMPK, inhibition of AMPKα1/2 does not abrogate anti-proliferative or pro-apoptotic effects of metformin. Metformin decreases electron transport chain complex I activity, oxygen consumption and mitochondrial ATP synthesis, while stimulating glycolysis for ATP and lactate production, pentose phosphate pathway for purine biosynthesis, fatty acid metabolism, as well as anaplerotic and mitochondrial gene expression. Importantly, leukemic cells with high basal AKT phosphorylation, glucose consumption or glycolysis exhibit a markedly reduced induction of the Pasteur effect in response to metformin and are resistant to metformin-induced apoptosis. Accordingly, glucose starvation or treatment with deoxyglucose or an AKT inhibitor induces sensitivity to metformin. Overall, metformin elicits reprogramming of intermediary metabolism leading to inhibition of cell proliferation in all leukemic cells and apoptosis only in leukemic cells responding to metformin with AKT phosphorylation and a strong Pasteur effect.

Compound screening platform using human induced pluripotent stem cells to identify small molecules that promote chondrogenesis

Articular cartilage, which is mainly composed of collagen II, enables smooth skeletal movement. Degeneration of collagen II can be caused by various events, such as injury, but degeneration especially increases over the course of normal aging. Unfortunately, the body does not fully repair itself from this type of degeneration, resulting in impaired movement. Microfracture, an articular cartilage repair surgical technique, has been commonly used in the clinic to induce the repair of tissue at damage sites. Mesenchymal stem cells (MSC) have also been used as cell therapy to repair degenerated cartilage. However, the therapeutic outcomes of all these techniques vary in different patients depending on their age, health, lesion size and the extent of damage to the cartilage. The repairing tissues either form fibrocartilage or go into a hypertrophic stage, both of which do not reproduce the equivalent functionality of endogenous hyaline cartilage. One of the reasons for this is inefficient chondrogenesis by endogenous and exogenous MSC. Drugs that promote chondrogenesis could be used to induce self-repair of damaged cartilage as a non-invasive approach alone, or combined with other techniques to greatly assist the therapeutic outcomes. The recent development of human induced pluripotent stem cell (iPSCs), which are able to self-renew and differentiate into multiple cell types, provides a potentially valuable cell resource for drug screening in a "more relevant" cell type. Here we report a screening platform using human iPSCs in a multi-well plate format to identify compounds that could promote chondrogenesis.

The upper limit of normal CSF opening pressure is related to bilateral transverse sinus stenosis in headache sufferers

There are limited data on the relationship between normal cerebrospinal fluid (CSF) opening pressure and bilateral transverse sinus stenosis (BTSS); there are also several conflicting reports about the upper limit of normal CSF opening pressure. To evaluate the influence of BTSS on the upper limit of normal CSF opening pressure, we prospectively recorded lumbar CSF opening pressures in 217 adult patients with neurological symptoms who underwent cerebral magnetic resonance venography (MRV). The CSF opening pressures ranged between 65 and 286 mmH2O (mean = 149.3, s.d. = 47.5). The upper limit of opening pressure in patients with both normal appearance of transverse sinuses and unilateral transverse sinus stenosis on MRV ( n = 167) was 195 mmH2O with a range of 65–195 mmH2O. All patients with BTSS were headache sufferers, and the upper limit of opening pressure in patients with BTSS ( n = 50) was 286 mmH2O with a range of 91–286 mmH2O. All patients with opening pressures > 200 mmH2O displayed BTSS, whereas only 13% of patients with a pressure < 200 mmH2O displayed BTSS. Our findings demonstrate that the upper limit of normal CSF opening pressure is related to BTSS, and they also highlight that headache sufferers with opening pressures > 200 mmH2O should be tested for BTSS by MRV.

Renal hilus paraganglioma: a case report and brief review

Paraganglioma is a rare tumour that originates from any paraganglia. Among extra-adrenal paraganglioma, renal hilus is a rare location. The authors report a case of a 43-year-old female who was admitted for evaluation of a renal mass detected incidentally by ultrasound imaging. Suspecting malignancy, the patient underwent radical nephrectomy. Upon macroscopic examination, the lesion was located into the renal hilus. Histological study revealed a neoplasm constituted of nests of monomorphic cuboidal cells with basophilic granular cytoplasm and round to oval nuclei. Necrosis was absent. The proliferative index (Mib-1) was very low (< 5%). Immunohistochemical examination revealed reactivity for neuron specific enolase (NSE), chromogranin A and synaptophysin. The final diagnosis was renal hilus paraganglioma. The paper shows the difficulty in diagnostic approaches to paraganglioma in this atypical site.

Reversible biotinylated oligosaccharides: a new approach for a better management of anticoagulant therapy

OBJECTIVE

In order to obtain a neutralizable antithrombotic, a chimeric molecule (SSR126517E) containing the sequence of a long-lasting antithrombin (AT)-dependent anti-factor Xa pentasaccharide, idraparinux, linked to a biotin molecule was synthesized and tested for anticoagulant and antithrombotic activity.

METHODS

SSR126517E was tested in several models in vitro and in vivo for its pharmacological properties as well as its ability to be neutralized by avidin.

RESULTS

SSR126517E displayed exactly the same properties as idraparinux. In vitro, SSR126517E had a very high affinity for AT (K(d) < 1 nm) and showed a potent anti-FXa effect and inhibition of thrombin generation with IC(50) values similar to those of idraparinux. Ex vivo, after intravenous administration to rats, SSR126517E produced a potent and long-lasting anti-FXa effect comparable to that obtained with idraparinux; as with idraparinux, the subcutaneous bioavailability was 100%. In vivo, SSR126517E was a potent antithrombotic in rat and mouse venous and arterial thrombosis models. Direct comparison in rats showed that SSR126517E was as active as idraparinux, when administered at the same molar dose. Furthermore, injection of avidin triggered the immediate elimination of SSR126517E from the bloodstream, resulting in complete neutralization of the antithrombotic activity of SSR126517E.

CONCLUSIONS

These results show for the first time that coupling an oligosaccharide with biotin has no effect on the former's pharmacokinetic and pharmacologic properties and renders neutralization easy by injection of avidin.

[Myeloid sarcoma in uterine leiomyoma]

In this case report we present a 44-year-old woman with a 2-weekhistory of vaginal bleeding. Gynaecological examination revealed the presence of a polypoid neoformation in the endometrial cavity with a maximum diameter of 4 cm. Histological analysis showed a classic leiomyoma infiltrated by a second monomorphic, highly undifferentiated neoplasia. Immunohistochemical analysis revealed a negative reaction for cytokeratin, CD10, inhibin, CD99, CD20, CD3, TdT and CD34, and positivity for CD45, MPO, CD68 and CD117. A diagnosis of myeloid sarcoma in myometrial leiomyoma was made. The following days the patient showed the onset of an acute myeloid leukaemia M5a. Forty days after diagnosis the patient died for complications related to immunodeficiency caused by therapy. Especially when a common antibody panel reveals negativity for epithelial, mesenchymal and lymphoid markers, this case underlines the importance of considering myeloid sarcoma in differential diagnosis of undifferentiated tumours arising in an extramedullary site in order to avoid errors and permit optimal therapeutic management.

The METIS project for generalist ultrasonography

Reorganization of the community healthcare system and the growing presence of group practices in the field of general medicine have increased the demands placed on primary-care medicine, in terms of the skills required and the level of responsibility. Satisfying the need for rapid, effective primary-care solutions to the health problems of citizens is easier thanks to technological and medical advances that provide high level equipment at costs within the reach of general practitioners (GPs). In the near future, trained GPs equipped with appropriate diagnostic scanners will be able to handle up to 40% of the requests of ultrasound examinations of each primary-care group (each PCG includes approximately 15,000-20,000 citizens). The Italian Federation of General Practitioners (Federazione Italiana dei Medici di Medicina Generale - FIMMG) and its Scientific Society, METIS, have organized national courses for those GPs who wish to become generalist ultrasonographers, in a joint effort with the two most important Italian scientific societies of imaging, the Italian Society of Ultrasonology in Medicine and Biology and the Italian Society of Medical Radiology.

A novel Angiogenin gene mutation in a sporadic patient with amyotrophic lateral sclerosis from southern Italy

Mutations in the Angiogenin gene (ANG) linked to 14q11.2 have been recently discovered to be associated with Amyotrophic Lateral Sclerosis (ALS) in Irish and Scottish populations. In our study we investigated the role of ANG gene in ALS patients from southern Italy. We found a novel mutation in the signal peptide of the ANG gene in a sporadic patient with ALS (SALS). The molecular analysis of the ANG gene also demonstrated an allelic association with the rs11701 single nucleotide polymorphism (SNP) in familial ALS (FALS) but not in SALS patients. Our finding supports the evidence that the ANG gene is involved in ALS.

[Jugulotympanic paraganglioma]

Jugulo-tympanic paraganglioma is the most commonly recognized neoplasia involving the middle ear, arising from chemopressure receptors. Clinical presentation is variable, with otalgia, dizziness and cranial nerve palsies. This tumor usually occurs in middle aged women and its presentation may be familiar, sporadic, bilateral or multicentric. In the present case the patients presented with otalgia and bradyacusia diagnosed with chronic otitis. A bleeding polypoid lesion in middle ear was seen during surgery. Frozen section of intraoperative specimen showed monomorphic cells organized into nests, without aspects of malignancy, into a highly vascularized stroma. Immunohistochemical analysis revealed two type of cells: chief cells immunostained for chromogranin and synaptophysin and sustentacular cells immunostained for S-100 protein. Clinical presentation of jugulotympanic paraganglioma, when it isn't associated with evidence of hormone secretion, is referred prevalently to bradyacusia, dizziness, and cranial nerve palsies. In event of localized disease, paragangliomas often can be treated by surgical excision, but some cases need radiation therapy.

Bilateral transverse sinus stenosis predicts IIH without papilledema in patients with migraine

BACKGROUND

The headache profile of patients with idiopathic intracranial hypertension without papilledema (IIHWOP) may be indistinguishable from that of migraine. Bilateral transverse sinus stenosis (BTSS) has been found in the majority of patients with IIHWOP. The frequency of BTSS associated with IIHWOP in patients with migraine is unknown.

OBJECTIVE

To detect the frequency of BTSS in adult patients with migraine and to investigate whether the presence of BTSS identifies patients with IIHWOP.

METHODS

In a prospective study from December 2000 to November 2005, 724 consecutive patients with recurrent headaches who fulfilled International Headache Society diagnostic criteria for migraine underwent cerebral MR venography (MRV). A portion of these patients underwent a lumbar puncture (LP) to measure CSF pressure. MRV and LP were also performed in 70 age-matched control subjects.

RESULTS

Six hundred seventy-five of the 724 patients with migraines had normal MRV. Seventy of these 675 patients underwent LP, and all of them had normal CSF pressure. Forty-nine (6.7%) of the 724 patients with migraine had BTSS. Twenty-eight of these 49 patients with BTSS underwent LP, and 19 (67.8%) had IIHWOP. The headache profiles of patients with BTSS and IIHWOP did not differ from those of patients with normal MRVs and CSF pressures within normal limits. CSF pressure was normal in both patients and controls with normal MRV.

CONCLUSIONS

Of patients with migraine, 6.7% had bilateral transverse sinus stenosis; 67.8% of these patients had idiopathic intracranial hypertension without papilledema (IIHWOP). These results suggest that patients with migraine who present bilateral transverse sinus stenosis on cerebral MR venography should undergo lumbar puncture to exclude IIHWOP.

Transverse sinus stenoses persist after normalization of the CSF pressure in IIH

BACKGROUND

Bilateral transverse sinus (TS) stenosis has been found in more than 90% of patients with idiopathic intracranial hypertension (IIH).

OBJECTIVE

To evaluate whether TS stenosis changed after normalization of CSF pressure in patients with IIH during medical treatment.

METHODS

Fourteen consecutive patients with IIH with bilateral TS stenosis on cerebral MR venography (MRV) during the medical treatment were studied. Patients were followed for over a 6-year period. During the follow-up, patients underwent repeated lumbar punctures (LPs) and cerebral MRV. MRV was always performed before each LP.

RESULTS

TS stenosis persisted in all the patients during the follow-up. In 9 of 14 (64%) patients with IIH, CSF pressure normalized during medical treatment.

CONCLUSIONS

Transverse sinus (TS) stenoses, as revealed by MR venography, persist in patients with idiopathic intracranial hypertension after normalization of CSF pressure, suggesting the lack of a direct relationship between the caliber of TS and CSF pressure.

A novel Notch3 gene mutation not involving a cysteine residue in an Italian family with CADASIL

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary cerebrovascular disease leading to accumulating neurologic deficits and dementia. CADASIL has been linked to nucleotide substitutions and deletions in the Notch3 gene. All the mutations described until now lead to unpaired cysteine residue in the epidermal growth factor-like repeats. The authors report a family with CADASIL carrying a deletion in the Notch3 gene that did not involve a cysteine residue.