MicroRNA-7 Regulates Migration and Chemoresistance in Non-Hodgkin Lymphoma Cells Through Regulation of KLF4 and YY1

The discovery and description of the role of microRNAs has become very important, specifically due to their participation in the regulation of proteins and transcription factors involved in the development of cancer. microRNA-7 (miR-7) has been described as a negative regulator of several proteins involved in cancer, such as YY1 and KLF4. We have recently reported that YY1 and KLF4 play a role in non-Hodgkin lymphoma (NHL) and that the expression of KLF4 is regulated by YY1. Therefore, in this study we analyzed the role of miR-7 in NHL through the negative regulation of YY1 and KLF4. qRT-PCR showed that there is an inverse expression of miR-7 in relation to the expression of YY1 and KLF4 in B-NHL cell lines. The possible regulation of YY1 and KLF4 by miR-7 was analyzed using the constitutive expression or inhibition of miR-7, as well as using reporter plasmids containing the 3 'UTR region of YY1 or KLF4. The role of miR-7 in NHL, through the negative regulation of YY1 and KLF4 was determined by chemoresistance and migration assays. We corroborated our results in cell lines, in a TMA from NHL patients including DLBCL and follicular lymphoma subtypes, in where we analyzed miR-7 by ISH and YY1 and KLF4 using IHC. All tumors expressing miR-7 showed a negative correlation with YY1 and KLF4 expression. In addition, expression of miR-7 was analyzed using the GEO Database; miR-7 downregulated expression was associated with pour overall-survival. Our results show for the first time that miR-7 is implicate in the cell migration and chemoresistance in NHL, through the negative regulation of YY1 and KLF4. That also support the evidence that YY1 and KLF4 can be a potential therapeutic target in NHL.

Overexpression of hypoxia-inducible factor 1 alpha impacts FoxP3 levels in mycosis fungoides--cutaneous T-cell lymphoma: clinical implications

Mycosis fungoides (MF) is the most common variant of primary cutaneous T-cell lymphoma, and decreased forkhead box P3 (FoxP3) expression has been reported in MF late stages. Hypoxia-inducible factor 1 alpha (HIF-1α) may regulate FoxP3 expression; however, it is unknown whether HIF-1α is expressed in the CD4(+) T cells of MF patients and how it could affect the expression of FoxP3. Therefore, we evaluated the expression of HIF-1α and FoxP3 in CD4(+) T cells obtained from the skin lesions of MF patients. We found increased cell proliferation and an increase in CD4(+) T cells with an aberrant phenotype among early stage MF patients. HIF-1α was overexpressed in these CD4(+) T cells. In addition, we found a decrease in the percentage of FoxP3(+) cells both in the skin of MF patients, when compared with control skin samples, and with disease progression. In addition, a negative correlation was established between HIF-1α and FoxP3 expression. Skin HIF-1α expression in MF patients correlated with the extent of the affected area and increased with the disease progression. Finally, we showed that ex vivo inhibition of HIF-1α degradation increases the percentage of FoxP3(+) T cells in skin lesions. Our results suggest that overexpression of HIF-1α affects the levels of FoxP3 in MF patients, which could have relevant implications in terms of disease outcome.

Randomized clinical trial of zoledronic acid in multiple myeloma patients undergoing high-dose chemotherapy and stem-cell transplantation

BACKGROUND

A growing body of evidence is demonstrating that the nitrogen-containing bisphosphonate zoledronic acid (zol) improves clinical outcomes in various cancer settings, including multiple myeloma. Those findings provided the rationale for conducting an open-label randomized controlled phase iii trial to evaluate the effect of zol on overall survival (os) and progression-free survival (pfs) in patients with previously untreated high-risk multiple myeloma.

METHODS

The trial randomly assigned 308 adult patients less than 65 years of age with previously untreated symptomatic multiple myeloma (1:1) to receive zol 4 mg intravenously once every 28 days for 24 months (n = 151) or no zol (n = 157). Before autologous stem-cell transplantation (asct), all patients received a high-dose noncytotoxic induction regimen of dexamethasone, all-trans-retinoic acid, and interferon alpha 2b.

RESULTS

After a median follow-up of 69.8 months (range: 36.5-96 months), the 10-year pfs (66% vs. 52%, p < 0.001) and os (67% vs. 48%, p < 0.001) rates were significantly higher in treated patients than in control patients. Overall response (77% zol vs. 75% control), complete response (52% vs. 46%), and very good partial response (25% vs. 29%) rates were similar between the groups. Treatment was generally well tolerated, with no reports of renal impairment or osteonecrosis of the jaw.

CONCLUSIONS

In symptomatic previously untreated multiple myeloma patients, zol combined with high-dose therapy followed by asct improved os and pfs without appreciable toxicity. These findings provide additional evidence of the meaningful anticancer activity of zol in this patient population.

Long-term evaluation of cardiac function in children who received anthracyclines during pregnancy

BACKGROUND

The use of anthracyclines in patients with cancer has been associated with the presence, even when standard doses were employed, of cardiac toxicity, most frequently after 5 years of therapy. Treatment of cancer during pregnancy remains a dilemma because cytotoxic therapy has been associated with the presence of severe side-effects. The outcome of children that received antracyclines during pregnancy, including during the first trimester, remain unknown because long-term follow-up is not available.

PATIENTS AND METHODS

Eighty-one children whose mothers (29 acute leukemia, 33 malignant lymphoma and 19 Hodgkin's disease) were treated with cytotoxic drugs, including anthracyclines, during pregnancy were evaluated to detect cardiac toxicity, including clinical evaluation and echocardiogram [all parameters were evaluated, but fraction shortening (FS) was taking as the best parameter to evaluate cardiac toxicity in children] every 5 years after birth until 29 years of age.

RESULTS

Children with actual age of 9.3-29.5 years (mean 17.1) did not show any clinical date of cardiac disfunction, in all cases echocardiogram was normal and FS did not showed any abnormality during the follow-up.

CONCLUSIONS

The use of anthracyclines did not show any clinical or echocardiogram evidence of late cardiac toxicity. We hope that the present report increases the number of reports of the long-term follow-up of children who received cytotoxic drugs, in order to define the best treatment in this special patient setting.

Biological modifiers as cytoreductive therapy before stem cell transplant in previously untreated patients with multiple myeloma

BACKGROUND

High dose chemotherapy with supporting autologous stem cell transplantation is now considered the treatment of choice in patients with multiple myeloma <65 years old. The best regimen appears to be VAD (vincristine, doxorubicin and dexamethasone), but acute and late toxicity can limit the use of this combination. The use of biological modifiers has not been considered in this situation. We developed a new cytoreductive regimen, in an attempt to retain clinical efficacy but reduce toxicity.

PATIENTS AND METHODS

Thirty-six patients, previously untreated with diagnosis of multiple myeloma were enrolled to received the DAI regimen (dexamethasone 30 mg/m(2), i.v., days 1-4, all-trans-retinoic acid 45 mg/m(2), p.o., days 5-14 and interferon alpha 2a, 4.5 MU s.c., days 5-14) administered every 28 days for six cycles before high-dose chemotherapy (melphalan 200 g/m(2)) and autologous stem cell transplantation.

RESULTS

Overall response was observed in 29 cases (80%), complete response in 19 and partial response in 10 patients. Five patients were >65 years old and were treated with dexamethasone/thalidomide. Twenty-four patients underwent transplants. At a median follow-up of 31.6 months, no relapse or disease progression was observed, thus actuarial curves at 3-years showed that event-free survival was 86% and overall survival was 94%. Toxicity was mild.

CONCLUSIONS

This regimen appears to be an excellent alternative as cytoreductive treatment before high-dose chemotherapy and autologous stem cell transplantation with excellent overall response and minimal toxicity. Controlled clinical trials are warranted to define the role of this new therapeutic approach.

Treatment of acquired immunodeficiency syndrome-related lymphoma with a standard chemotherapy regimen

Sixty patients with poor-prognosis malignant lymphoma associated with acquired immunodeficiency syndrome (AIDS) were treated with a standard chemotherapy regimen: cyclophosphamide 600 mg/m2 i.v., day 1; vincristine 1.4 mg/m2 i.v., day 1; epirubicin 70 mg/m2 i.v., day 1; and bleomycin 10 mg/m2 i.v., on day 14. Granulocyte colony-stimulating factor, 5 microg/kg/day, was administered subcutaneously on days 4-14 to ameliorate severe myelosuppression. All patients were in an advanced stage of AIDS with <200 absolute CD4+ cells/mm3 and the presence of adverse prognostic factors related to lymphoma, such as high or high-intermediate clinical risk, multiple extranodal involvement, presence of bulky disease, and high levels of beta 2 microglobulin. Complete response (CR) was achieved by 33 patients (54%); no partial response was observed, and 27 cases were considered failures. All 27 died secondary to tumor progression without any response to salvage chemotherapy. Twenty patients in CR died of opportunistic infections related to AIDS. Actuarial 5-year survival shows that time to treatment failure for the 13 patients who remain in CR is 3.1 years. However, disease-free survival was 14.5 months. Overall survival for the entire group was 13.6 months. Side effects secondary to chemotherapy were frequent and severe, but no death related to treatment was observed. Infection-related granulocytopenia was observed in 27 cycles (8%). This study indicates that standard chemotherapy could be useful in patients with AIDS-associated lymphoma because CR rate, duration of remission, and survival were similar to those with other intensive, but more toxic, regimens. Until a new and better therapy for AIDS is found, treatment of patients with AIDS-related lymphoma will be regarded as palliative, and less toxic regimens will be considered. The use of a standard regimen appears to be an adequate therapeutic approach in this group of patients.

Maintenance therapy with interferon alfa 2b in Hodgkin's disease

We performed a randomized clinical trial to assess the efficacy and toxicity of interferon alfa 2b (IFN) as maintenance therapy in patients with advanced Hodgkin's disease in complete remission (CR) after conventional chemotherapy. One hundred and thirty-five patients (stage IIIB-IV B) were initially treated with EBVD (epirubicin, bleomycin, vinblastine, dacarbazine). IF CR was achieved they were randomly assigned to receive either maintenance therapy with IFN 5.0 MU three times a week for one year or no further treatment (control group). Clinical and laboratory characteristics at diagnosis were quite similar in both groups. After a median follow-up of 74.3 months (range 49 to 108), 61 out of 68 patients (91%; 95% confidence interval (CI): 76% to 97%) remain in first complete remission in the IFN-treated group compared to 38 out of 67 (58%; 95% CI: 49% to 71%) in the control group (p<.01). Overall survival was also better in the IFN treated group: 62 patients (92%; 95% CI: 82% to 97%) are alive free of disease at 7-years compared to 40 patients (67%, 95%: 55% to 76%) in the control group (p<.01). Toxicity secondary to IFN administration was mild and no dose modification was necessary during treatment. All patients received the planned dose of IFN. This was not an intent-to treat analysis. IFN administration as maintenance therapy was appears to be the only cause of improvement in outcome in these patients. We feel that IFN should be considered as maintenance therapy in patients with advanced Hodgkin's disease because this treatment improves the final outcome without the excessive toxicities of more aggressive therapeutic approaches such as bone marrow transplantation during first CR. We hope that IFN will be considered in future randomized clinical trials in order to define it's role in the treatment of Hodgkin's disease.

Epirubicin (CEOP-Bleo) versus idaurubicin (CIOP-Bleo) in the treatment of elderly patients with aggressive non-Hodgkin's lymphoma: dose escalation studies

One hundred and sixty nine untreated elderly patients (median age 69 years old; range 60-89 years old) with high or high-intermediate clinical risk non-Hodgkin's lymphoma were enrolled in a controlled clinical trial to evaluate escalated doses of epirubicin in a CEOP-Bleo regimen (cyclophosphamide, vincristine, epirubicin, prednisone and bleomycin), compared to escalated doses of idaurubicin in an CIOP-Bleo regimen (idaurubicin instead of epirubicin). Overall, 71% of the patients in the CEOP-Bleo arm achieved a complete response compared to only 48% in the CIOP-Bleo regimen (p < 0.01). At actuarial 3 year, 72% of the patients treated with the CEOP-Bleo regimen remained alive and free of disease, compared to 34% in the CIOP-Bleo arm (p < 0.01). Dose intensity was 0.86 in the epirubicin regimen, similar to 0.82 in the idaurubicin arm. Toxicities were more frequent and severe in the CEOP-Bleo regimen; however, no death-related treatment was observed in either groups. Cardiac toxicity was also similar in both arms. We conclude that treatment of elderly paitents with aggressive non-Hodgkin's lymphoma should be considered a curative attempt and not only palliative. The use of full doses of chemotherapy should be contemplated in elderly patients. Epirubicin, in escalating doses, is a drug with mild toxicity and improvement in outcome in this setting is observed. We cannot confirm the usefulness of idaurubicin, including escalating doses, in the treatment of patients with aggressive malignant lymphoma, because the complete response rate and survival were worse than other chemotherapy regimens. We feel that the CEOP-Bleo regimen with escalated doses of epirubicin is a useful option in the treatment of elderly patients with aggressive non-Hodgkin's lymphoma.

Bone marrow protection with amifostine in the treatment of high-risk malignant lymphoma

Based on preclinical and clinical studies which suggested that amifostine can protect against haematological toxicity of cyclophosphamide, we conducted a clinical trial of amifostine and intermediate doses of cyclophosphamide in patients with high-risk malignant lymphoma. 40 patients were enrolled to receive amifostine (910 mg/m2) before cyclophosphamide (1500 mg/m2) for two cycles (10 patients); 20 patients were allocated to receive amifostine/cyclophosphamide only on one cycle (patients were their own control) and 10 patients received cyclophosphamide alone without amifostine protection. Patients who received amifostine had fewer days of severe granulocytopenia (grade III or IV) and infectious episodes, and delay on treatment was minimal. Amifostine was well tolerated; only 2 patients developed transient and mild hypotension. The complete response rate was 72% (29/40). We conclude that amifostine is a good protector against haematological toxicity of cyclophosphamide and did not interfere with tumour response. Clinical trials with increasing doses of cytotoxic drugs or combination chemotherapy are needed to define the role of this myeloprotector agent in the treatment of patients with malignant lymphoma.

Intensive brief chemotherapy with hematopoietic growth factors as hematological support and adjuvant radiotherapy improve the prognosis in aggressive malignant lymphoma

An intensive brief chemotherapy and radiotherapy regimen including high doses of cyclo-phosphamide (5 g/m2), etoposide (1 g/m2), epirubicin (180 mg/m2), and ifosfamide (5 g/m2) administered in a period of 30 days followed by involved field radiotherapy to sites of initial bulky disease was administered to 46 untreated patients with high-intermedium and high-risk malignant lymphoma. G- or GM-CSF were used as hematological support instead of bone marrow transplantation. All patients had more than 3 adverse prognostic factors at diagnosis. Forty-one patients (89%) achieve complete response (33 after chemotherapy and 8 partial responses were converted to complete response after adjuvant radiotherapy). Acturial failure-free survival at 3 years is 83% and 37 of all patients started on therapy remain alive and in first remission at a median of 24.3 months from completion of treatment. Nearly all patients developed granulocytopenia grade IV; only 13 episodes of bacterial infection were documented. Because hematological recovery was very short (mean 13.6 days) no death related treatment and opportunistic infections were observed. Other non-hematological toxicities were scarce and well tolerated. No decrease > 10% was observed in the left ventricular ejection fraction. None have developed clinically evident congestion heart failure or other late side effects. These results showed that G- or GM-CSF can act as hematological support instead of bone marrow transplantation during intensive and brief chemotherapy. These regimens produce higher complete remission rate, and adjuvant radiotherapy will improve the outcome in patients with bulky disease.

GM-CSF instead of hematological support during high-dose chemotherapy for refractory malignant lymphoma

Patients with refractory malignant lymphoma (RML) have a poor prognosis when treated with conventional chemotherapy. The use of high-dose chemotherapy has been limited by secondary myelosuppression. We report the use of intensive and short-duration chemotherapy in patients with RML who received granulocyte-macrophage colony-stimulating factor (GM-CSF) instead of hematological support and salvage with bone marrow transplantation or infusion of peripheral blood stem cells. Thirty-one patients with RML were treated with cyclophosphamide: 7 g/m2, iv on day 1, followed by GM-CSF: 5 micrograms/kg/day, subcutaneously until hematological recovery (granulocytes > 1.8 x 10(9)/L) started on day 2. Methotrexate, 5 g/m2, was also given when the granulocytes and platelets counts were normal, followed by leucovorin rescue. Epirubicin, 180 mg/m2, iv, was given on day 29 if the granulocyte count was normal, and GM-CSF was started on day 30. Complete response was obtained in 21 out of 31 patients (67%) and partial response in 4 more, thus an overall response was achieved in 80% of the treated patients. Time to treatment failure was 24+ months, and the overall survival was 28+ months. Hematological toxicity grade IV, according to the WHO criteria was observed in all cycles, however hematological recovery was already evident on day 13 +/- 2. Eleven patients developed infection related to the treatment, but no therapy related death was observed. GM-CSF was well tolerated with minimal toxicity. Is evident that GM-CSF can act as hematological support after high-dose chemotherapy in patients who cannot undergo bone marrow transplantation programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of a randomized study of early stage Hodgkin's disease using ABVD, EBVD, or MBVD

From January 1986 to December 1989, 157 previously untreated patients, with Hodgkin's disease stage I or II without bulky disease, were enrolled in a clinical comparative study. The objectives of the study were to compare the efficacy and safety of using epirubicine or mitoxantrone instead of adriamycin in the combination chemotherapy regimen ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). The complete response rate was better in the patients treated with the ABVD or EBVD regimens compared to the MBVD arm. Also, differences in overall survival and relapse-free survival were better in the patients who received ABVD or EBVD compared to the MBVD regimen. Hematological, gastrointestinal and cardiac toxicity were similar in the three groups. Dose intensity, delays and complications were also similar in the three groups. The mitoxantrone-containing regimen was found to have less efficacy in comparison to the other regimens tested in the present study in patients with favorable stage I or II Hodgkin's disease.

Adjuvant radiotherapy to sites of previous bulky disease in patients stage IV diffuse large cell lymphoma

PURPOSE

To evaluate the usefulness of adjuvant radiotherapy to sites of previous bulky disease in patients with advanced diffuse large cell lymphoma (DLCL) who were in complete remission after chemotherapy.

METHODS AND MATERIAL

Two-hundred and eighteen patients were initially treated with combined chemotherapy CEOP-bleo (cyclophosphamide, epirubicin, vincristine, prednisone, bleomycin) alternating with DAC (dexamethasone, cytosine arabinoside, and cisplatinum). One hundred and fifty-five patients achieved complete remission. Eighty-eight patients with initial bulky disease were randomly assigned to either received (43 patients) or not received radiotherapy (45 patients). Dose ranged from 40-50 Gy.

RESULTS

The median time to treatment failure has not been reached in patients who received radiotherapy. At 5 years 72% of the patients treated with the combined therapy remain alive disease in free compared to only 35% in the control group. Projected survival at 5 years was better in the patients with adjuvant radiotherapy: 81% compared to 55% in the patients who received no radiotherapy. Toxicity was mild and manageable. No lethal toxicities were observed.

CONCLUSION

This treatment sequence produced durable control disease in patients with disseminated DLCL and bulky disease with acceptable toxicity. The role of radiation therapy in patients with disseminated DLCL will be confirmed in large clinical trials, but we felt that this sequence of treatment could be useful in patients with this clinical condition.

Combined therapy for angioimmunoproliferative lesions

43 patients with a diagnosis of angioimmunoproliferative lesions (AIL) entered onto a prospective clinical trial to evaluate the use of combined therapy as a primary therapeutic approach. Patients were treated initially with involved field radiotherapy 40-55 Gy (40 patients received 45 Gy) followed by six cycles of chemotherapy which consisted of CEOP-Bleo (cyclophosphamide, epirubin, vincristine, prednisone and bleomycin). Complete response was achieved in 41 cases (95%). At a median follow-up of 40 months, 40 patients (91%) remain in first complete remission. 2 patients died during radiotherapy secondary to sepsis and tumour progression. Treatment was well tolerated. The treatment of AIL remains controversial. Our results show that combined therapy appears to be the best therapeutic approach in patients with this type of malignant lymphoma. More studies are necessary to define the role of combined therapy in patients with AIL.

Effect of granulocyte colony-stimulating factor in patients with diffuse large cell lymphoma treated with intensive chemotherapy

We investigated whether Granulocyte colony-stimulating factor (G-CSF) could prevent myelotoxicity or accelerate hematopoietic recovery after intensive chemotherapy in previously untreated patients with diffuse large cell lymphoma (DLCL). Forty-two patients were included in a prospective clinical trial in which alternating chemotherapy ESAP (etoposide, Solu-Medrol, cytosine arabinoside, cis-platinum), m-BECOD (low doses methotrexate, bleomycin, epirubicin, cyclophosphamide, vincristine, dexamethasone), MVPP-Bleo (mitoxantrone, vincristine, prednisone, procarbazine, bleomycin) were administered by 9 cycles. Each cycle was followed by 10 days of G-CSF (5 micrograms/kg/day) started five days after chemotherapy compared to a control group which received chemotherapy without G-CSF support. Leucocytes and granulocytes were significantly higher in patients receiving G-CSF compared to the control group. The total number of days of leukopenia (WBC counts below 2.0 x 10(9)/L and absolute granulocytes below 1.0 x 10(9)/L) were longer in the patients without G-CSF compared to those who received G-CSF (14.1 days versus 1.9 days). Delays in treatment were most frequent in the control group: 38% versus 4% in all cycles. Infection episodes occurred in 41 out of 168 cycles (25%) in the control group compared to 7 out of 172 (4%) in the G-CSF arm. Complete response was achieved in 12 out of 22 (54%) in the control group compared to 16 out 20 (80%) in the patients who received G-CSF. Toxicity secondary to G-CSF was mild. G-CSF can be administered safely to patients with DLCL and results in improved hematologic recovery after intensive chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Late cardiac toxicity of doxorubicin, epirubicin, and mitoxantrone therapy for Hodgkin's disease in adults

Cardiotoxicity is a well recognized side effect of anthracyclines (doxorubicin and epirubicin) or antracenadiones (mitoxantrone) at cumulative or high doses. However the side effects have not been evaluated in adults with Hodgkin's disease who received therapeutic doses of these drugs. We analyzed the cardiac function studying the left ventricular ejection fraction (LVEF) at rest in 136 patients with Hodgkin's disease treated with doxorubicin, epirubicin or mitoxantrone used in combination with vinblastine, bleomycin and decarbazine. No other risk factors, such as radiation therapy to the mediastinum, were considered. The follow-up is 5 to 8 years for patients in complete remission. Forty-five patients received doxorubicin (from 325 to 685 mg/m2, median 475 mg/m2), 51 patients received epirubicin (from 310 to 610 mg/m2, median 510 mg/m2) and 40 patients were treated with mitoxantrone (from 70 to 165, median 125 mg/m2). The median time between the end of treatment and the evaluation was 6.7 years. Thirty seven percent of the patients (similar rates in the three groups) showed abnormalities in the LVEF with decreased rates independent of the drug dosage. These were compared with two control groups, 46 patients treated with the MOPP combination (mechlorethamine, vincristine, prednisone and procarbazine) or LOPP (chlorambucil, for mechlorethamine) and 35 healthy volunteers. We believe that the use of anthracyclines or antracenadione will produce late cardiac effects in a fraction of patients independently of the doses used and that the indications for these drugs be carefully monitoring so as to evaluate the development of late side effects.