Personalised medicine: Development and external validation of a prognostic model for metastatic melanoma patients treated with ipilimumab

PurposeThe purpose of this study was to set up a prognostic model for the identification of survival predictors specific for melanoma patients treated with ipilimumab.Experimental designThe following prospectively collected data were utilised: patient and primary tumour characteristics, relapse-free-interval, site and number of metastases, previous therapies and level of serum biomarkers (lactic dehydrogenase (LDH), C-reactive protein, β2-microglobulin, vascular endothelial growth factor (VEGF), IL2, IL6, S-100, alkaline phosphatase (ALP), transaminases, leucocyte count, lymphocytes subpopulations). A multivariate prognostic model was developed using the Cox regression model fitted to the data of 113 consecutive metastatic patients treated with ipilimumab (3 mg/kg, q3w) at Veneto Institute of Oncology (IOV). External validation was obtained using the data of 69 and 34 patients treated at European Oncology Institute (IEO) and University of Torino (UT), respectively.ResultsMedian survival was 8.3, 4.9 and 7.1 months from first ipilimumab administration at IOV, IEO and UT, respectively. Both higher baseline levels of LDH (Hazard Ratio [HR] v = 1.36, 95% Confidence Interval [CI] 1.16–1.58, P < .001) and neutrophils (HR = 1.76, 95% CI 1.41–2.10, P < .001) were associated with worse prognosis. Model performance was satisfactory both upon internal validation (Dxy = 0.42) and external validation (Dxy = 0.40). Serum LDH and neutrophil count discriminated patients who lived more (low neutrophils and low LDH) or less (high LDH or neutrophils) than 24 months.ConclusionSerum LDH and neutrophil count were significant independent prognostic factors. This externally validated prognostic nomogram, could help clinicians to identify the patients who would benefit most from ipilimumab and consequently to improve resource allocation. These easily available biomarkers deserve further validation.     

The role of the CTLA4 blockade in the treatment of malignant melanoma

Metastatic melanoma remains a disease with few effective treatments. The anti-tumor immune response has long been felt to be important in the prognosis of melanoma, and much work has focused on harnessing the immune system to fight this disease. Tumor-specific vaccines, immunomodulatory cytokines and non-specific immunostimulants (such as Bacille Calmette Guerin/BCG) have all been investigated. A new strategy has been identified involving cytotoxic T-lymphocyte antigen-4 (CTLA4). This molecule is expressed on the surface of activated T-lymphocytes and exerts a suppressive effect on the induction of immune responses after interaction between T-cell receptor (TCR) and human lymphocyte antigen (HLA) molecules on the antigen-presenting cell (APC). Work in animal models demonstrated that antibody-mediated blockade of this target could lead to anti-tumor responses. Two fully human monoclonal antibodies, ipilimumab (MDX-010) and tremelimumab (CP-675, 206; formerly known as ticilimumab), are in clinical development. Both have demonstrated hints of clinical activity in metastatic melanoma. Both also have a toxicity profile consistent with their mechanism of action, involving inactivation of a normal immunosuppressive homeostatic mechanism: development of auto-immune breakthrough events (IBE). These include inflammatory bowel disease (IBD), uveitis, dermatitis, arthritis, and others. Generally, these events have been easily managed by cessation of therapy and intravenous or topical steroid therapy and supportive care in most patients, although colectomy had been required in several severe cases and there have been several deaths. Interestingly, patients who develop IBE seem to have the greatest likelihood of clinical benefit, but it is unclear whether clinical benefit and IBE are dissociable events. Other than IBE, no other pharmacodynamic measure has been able to predict response, although certain autoimmune antibody titers may have promise in this regard. Further research will confirm the clinical benefit of these agents alone and in combination with other agents, further define the safety profile and protocols for toxicity management, and identify pharmacodynamic parameters predicting clinical benefit and toxicity.     

Safety of the Anti-CD19 antibody Tafasitamab in Long Term Responders from A Phase II Trial for Relapsed Lymphoma

Background: Information about the long-term tolerability of tafasitamab is still limited. Methods: 5 of 92 patients treated within a phase IIa study of single-agent tafasitamab in relapsed or refractory B NHL were followed for up to five years or longer for long-term tolerability. Results: Treatment was very well tolerated in an outpatient setting with no hospitalizations needed and mild and tolerable adverse events that occurred mostly within the first two years of treatment. Conclusions: Given the excellent tolerability and efficacy of tafasitamab this agent can be used to induce remission in relapsed or refractory lymphoma either alone or in combination with chemotherapy.     

Efficacy and safety of ipilimumab in elderly patients with pretreated advanced melanoma treated at Italian centres through the expanded access programme

Background

Elderly patients with metastatic melanoma have different disease characteristics and a poorer prognosis than younger patients. Data from clinical trials and expanded access programmes (EAPs) suggest ipilimumab confers a consistent survival benefit and has a similar safety profile across different age groups of patients with metastatic melanoma. Here we report the efficacy and safety of ipilimumab 3 mg/kg in elderly patients enrolled in an EAP in Italy.

Methods

Patients aged > 70 years with pretreated melanoma received ipilimumab 3 mg/kg every 3 weeks for four doses through an EAP. Tumour response was evaluated at baseline and after completion of induction therapy using immune-related response criteria and patients were monitored throughout the treatment period for adverse events (AEs), including immune-related AEs.

Results

The immune-related disease control rate among 188 evaluable patients was 38%, including four patients with an immune-related complete response, 24 with an immune-related partial response and 44 with immune-related stable disease. Median progression-free survival (PFS) was 4.0 months and the 1- and 2-year PFS rates were 21% and 12%, respectively. Median overall survival (OS) was 8.9 months; 1- and 2-year OS rates were 38% and 22%, respectively. The safety profile of ipilimumab was consistent with that observed in the general population of the Italian EAP and treatment-related AEs generally resolved within a median of 2 weeks with treatment as per protocol-specific guidelines.

Conclusions

These results suggest ipilimumab is a feasible treatment option in elderly patients with metastatic melanoma. Ipilimumab treatment was generally well tolerated and resulted in clinical benefit and extended survival in elderly patients treated at centres in Italy.     

A Phase I Study to Assess the Safety and Pharmacokinetics of Single-agent Lorvotuzumab Mertansine (IMGN901) in Patients with Relapsed and/or Refractory CD–56-positive Multiple Myeloma

Background

Despite therapeutic advancements that have significantly improved outcomes in multiple myeloma (MM), it remains an incurable disease. Patients with relapsed and/or refractory MM have an aggressive disease course, with inferior outcomes, necessitating the need for agents with novel therapeutic mechanisms. We present the results of a completed phase I trial of single-agent lorvotuzumab mertansine, a unique antibody-drug conjugate targeting CD56, which is frequently expressed in MM.

Current and future adjuvant immunotherapies for melanoma: Blockade of cytotoxic T-lymphocyte antigen-4 as a novel approach

The current treatment for melanoma with nodal involvement, but without distant metastasis, is surgical excision and lymph node dissection followed by adjuvant therapy. A number of systemic regimens have been evaluated for melanoma patients with a medium or high risk of disease recurrence following surgery. The only agent approved for the adjuvant therapy of melanoma is high-dose interferon (IFN)-α2b, which prolongs relapse-free survival, but its effects on overall survival remain controversial. Its use is also accompanied by significant toxicity. Thus, despite its approval, high-dose IFN-α2b is not always used for the adjuvant therapy of melanoma, particularly in countries other than the United States. Studies aimed at identifying subgroups of patients that have the greatest benefit-to-risk ratio with this regimen are ongoing. Several vaccines have been studied in the adjuvant setting for melanoma, but none has shown superiority to IFN-containing regimens. The GMK ganglioside vaccine, for instance, has actually been shown to be inferior to high-dose IFN-α2b. Therefore, a therapeutic regimen which improves overall survival with a favorable safety profile would be a major advance in the adjuvant therapy of melanoma. One approach that is currently being investigated is the potentiation of antitumour immune responses through blockade of cytotoxic T-lymphocyte antigen-4 (CTLA-4). Here, we provide an overview of the current unmet needs in the adjuvant therapy of melanoma and evaluate the potential of CTLA-4 blockade as a future therapeutic option in this setting.     

Purification of monoclonal antibody 3H11 against gastric cancer for in vivo use

Monoclonal antibody (McAb) 3H11 against gastric cancer was grown in the mouse ascites system. To acquire a clinical grade product for cancer radioimmuno-imaging was purified by two step high performance liquid chromatography (HPLC) protocol using protein A and high-performance hydroxylapatite (HPHT). An analysis of data reported shows the two step HPLC method to be the best purification procedure. This protocol satisfies purity and immunoreactivity requirement, and provides an sample sterility, free-pyrogens, free-mycoplasma and non-specific IgG contamination. This procedure described was capable of generating large amounts of clinical grade monoclonal antibody.     

Applications of novel monoclonal antibodies specific for synuclein-gamma in evaluating its levels in sera and cancer tissues from colorectal cancer patients

Overexpressions of synuclein-gamma (SNCG) in different cancers display stage-specific patterns. At present, appropriate anti-SNCG monoclonal antibodies (mAbs) with high specificity and affinity are unavailable for different immunoassays in clinical applications. In this study, we generated 10 mAbs against endogenous SNCG and evaluated SNCG levels in several colorectal cancer cell lines, serum samples and tumor tissues from colorectal cancer (CRC) patients. Elevated SNCG levels in cancer cell lines evaluated by a novel sandwich ELISA were consistent with data obtained from Western blot. Secreted SNCG protein levels in sera from CRC patients could be detected by the sandwich ELISA and were further confirmed by Western blot analysis following SNCG enrichment. Immunohistochemical results showed that SNCG was highly expressed in tumor cells of CRC patients, but was undetectable in the adjacent normal epithelium. Taken together, these novel anti-SNCG mAbs specifically recognized endogenous SNCG and were suitable for measuring SNCG levels in cell lysates, human serum samples, and tumor tissues. Elevated serum SNCG and overexpressed SNCG in tumor tissue from CRC patients suggest SNCG is a potential biomarker for CRC.     

CHANGES OF SERUM ALPHA FETOPROTEIN BEFORE AND AFTER RADIOIMMUNOTHERAPY IN PATIENTS WITH HEPATOCELLULAR CARCINOMA

ＣＨＡＮＧＥＳＯＦＳＥＲＵＭＡＬＰＨＡＦＥＴＯＰＲＯＴＥＩＮＢＥＦＯＲＥＡＮＤＡＦＴＥＲＲＡＤＩＯＩＭＭＵＮＯＴＨＥＲＡＰＹＩＮＰＡＴＩＥＮＴＳＷＩＴＨＨＥＰＡＴＯＣＥＬＬＵＬＡＲＣＡＲＣＩＮＯＭＡＺｅｎｇＺｈａｏｃｈｏｎｇ;曾昭冲;ＴａｎｇＺｈａｏ...     

Generation of novel monoclonal antibodies and their application for detecting ARD1 expression in colorectal cancer

Arrest defective 1 (ARD1) is an acetyltransferase involved in cell cycle control in yeast. ARD1 interacts with human N-acetyltransferase (NATH) to form a functional N-terminal acetyltransferase complex. Recently it had been linked with proliferation and apoptosis in mammalian cells, but its function in cancer development remains unclear. To evaluate significance of ARD1 expression in human colorectal cancer, we generated a panel of monoclonal antibodies (mAbs) with high specificity and sensitivity against ARD1. All of the 10 different clones could be used in ELISA and Western blot, and clone 10C12, 13G2, and 4D10 can interact with ARD1 in eukaryotic cells by immunoprecipitation (IP). Clones of 14D4 and 10C12 were strongly reacted to ARD1 in immunocytochemistry (ICH) and immunohistochemistry (IHC). ARD1 expression was evaluated in human colorectal cancer and colitis tissues by immunohistochemical analysis with mAb 14D4. Forty-one were ARD1-positive in 50 colorectal cancer tissues and only 12 were weak positive in the 50 matched normal tissues (P < 0.001). Moreover, ARD1 expression was not detectable in 20 cases of colitis tissue (P < 0.001). Furthermore, all of the six human colorectal cancer cell lines we examined were also ARD1-positive at mRNA and protein levels. Taken together, the novel mAbs against ARD1 we generated could be good tools for both basic and clinical studies, and ARD1 could be a potential biomarker in colorectal cancer.     

Association of rash with outcomes in a randomized phase II trial evaluating cetuximab in combination with mitoxantrone plus prednisone after docetaxel for metastatic castration-resistant prostate cancer

Purpose

Cetuximab (C), a chimeric monoclonal antibody that binds epidermal growth factor receptor (EGFR), is active against androgen-independent prostate cancer cell lines and might enhance the activity of chemotherapy. The efficacy of combining cetuximab with mitoxantrone (M) plus prednisone (MP) was evaluated in progressive metastatic castrate-resistant prostate cancer (CRPC) after receiving docetaxel.

Materials and Methods

Patients with progression after receiving docetaxel were eligible and randomized 2:1 to CMP or MP. Therapy was mitoxantrone 12 mg/m² intravenously (I.V.) on day 1, oral prednisone 10 mg daily in both arms, and cetuximab 250 mg/m² I.V. (400 mg/m² day 1, cycle 1) on days 1, 8, and 15 in the CMP arm. Cycles were repeated every 21 days. Radiologic assessments of disease and PSA (prostate-specific antigen) occurred every 4 cycles. The primary endpoint was time to progression (TTP).

Results

A total of 115 patients were enrolled, 75 in the CMP and 40 in the MP arm: the median TTP was 4.9 and 6.6 months, respectively; the measurable disease response rate was 2% and 4%, the PSA response rate 7.7% and 17.6%, and median survival 11.9 and 15.7 months, respectively. Key grade 3-4 toxicities were neutropenia 44% and 25.6%, anemia 6.7% and 7.7%, thrombocytopenia 6.7% and 2.6%, and fatigue 8% in both arms. In an unplanned exploratory analysis, median TTP with (n = 24) and without rash (n = 51) in the CMP arm was 10.3 months vs. 2.8 months (P = .004). On multivariable analysis,rash was significantly associated with TTP (hazard ratio [HR] = 0.43; P = .01).

Conclusions

The treatment with CMP is not recommended in unselected men with docetaxel-treated CRPC, although rash might help develop tailored therapy.     

Heterogeneity of Antigen Molecules Recognized by Anti-tax1 Monoclonal Antibody Lt-4 in Cell Lines Bearing Human T Cell Leukemia Virus Type I and Related Retroviruses

Using a monoclonal antibody, Lt-4, directed against human T cell leukemia virus type I (HTLV-I) trans -activator (tax₁) antigen, we examined the expression of tax₁ and related antigens in a variety of T cell lines bearing HTLV-I and related retroviruses, simian T cell leukemia virus type I (STLV-I) and HTLV-II, by immunofluorescence and immunoblot assays. Lt-4 reacted with all HTLV-I-bearing cell lines tested and five out of eight simian cell lines bearing STLV-I, but not with an HTLV-II-bearing cell line. Lt-4 detected 40 kd tax₁ antigen molecules in most HTLV-I-bearing cell lines except one cell line that expressed 39 kd tax₁ antigen. In the STLV-I-bearing T cell lines, tax₁-related antigen molecules detected by Lt-4 were heterogeneous, having molecular weights in the range of 36–41 kd.     

流式细胞术检测化疗前后卵巢癌细胞凋亡的临床意义

目的：探讨化疗前后卵巢癌细胞及外周血淋巴细胞凋亡的因子Ｆａｓ、Ａｐｏ２．７的含量及其临床意义。方法：从７５例化疗前后卵巢癌患者的腹水中提取富含癌细胞的悬液,用Ａｎｎｅｘｉｎ Ｖ－ＦＴＴＣ／ＰＩ双染法分辨凋亡的亡细胞及坏死细胞及坏死细胞,并以两种凋亡因子克隆抗体Ｆａｓ和Ａｐｏ２．７标记上述细胞,均用流式细胞仪检测。结果：化疗后卵巢癌细胞凋亡率显著高于化疗前的临床疗效好,反之疗效差,被Ｆａｓ及Ａｐｏ２     

The use of systemic therapies for the treatment of brain metastases in metastatic melanoma: Opportunities and unanswered questions

The development of brain metastases is common in patients with metastatic melanoma and heralds a particularly poor prognosis. The development of the immunological agent ipilimumab and targeted treatments such as the selective BRAF inhibitor vemurafenib have revolutionised the treatment of metastatic disease. Evidence from clinical trials suggest these drugs may be effective in the treatment of brain metastases from melanoma. However efficacy may be limited by a lack of penetration of the blood brain barrier (BBB) and by multi substrate efflux pumps expressed on the BBB. The role and sequencing of radiotherapy, both whole brain and stereotactic radiotherapy, is yet to be determined but combinations of radiotherapy and systemic therapies may further increase the effects of these drugs on brain metastases. Considering the impact of brain metastases on morbidity and mortality in metastatic melanoma, future research into systemic drug therapy for the treatment of brain metastases and improvements in BBB penetrance should be a priority.     

Comparison of Serum Assays for TAG-72, CA19-9 and CEA in Gastrointestinal Carcinoma Patients

Tumor-associated glycoprotein (TAG-72) has been shown to beexpressed in a wide variety of epithelial malignant tissues.We have investigated serum levles of TAG-72 antigen in patientswith gastrointestinal cancer with a solid phase radioimmunometricassay (RIA), CA72-4, utiliz ing murine monoclonal antibodiesCC49 and B72.3 which recognize the TAG-72 antigen. Elevatedlevels of serum TAG-72 antigen were found in 48% of 56 gastriccarcinoma patients and 67% of 45 colorectal carcinoma patients.The serum concentrations of TAG-72 were compared to those ofCA19-9 and CEA. The positive rates of CA19-9 in gastric carcinomaand colorectal carcinoma patients were 29% and 54%, and thoseof CEA were 52% and 60%, respectively. Elevated serum levelsof TAG-72, CA19-9 and CEA were observed in 7%, 14% and 24%,respectively, of patients with benign disease, thus indicatinga preferential expression of TAG-72, compared to CA19-9 andCEA, in gastrointestinal carcinoma patients versus in patientswith benign disorder. A cocktail of CA72-4, CA19-9 and CEA RIAsincreased positive rates to 68% in sera of gastric cancer patientsand 84% in sera of colorectal cancer patients. Combination assays using CA72-4, CEA and CA19-9 RIM for patients with benigngastrointestinal disorder, however, also increased the positiverate to 31%. These results indicate that CA72-4, CA19-9 andCEA RIA may be complementary in detecting circulating tumor-associatedantigens. It must be emphasized, however, that interpretationof the data provided by the combination serum as says requirescareful consideration.     

Autologous Bone Marrow Transplantation in Acute Lymphoblastic Leukemia following In Vitro Treatment with Monoclonal Antibodies and with Complement: Analyses for Two Cases of Failure

Two children with acute lymphoblastic leukemia (ALL) receivedautologous bone marrow transplantation (BMT) using remissionbone marrow treated in vitro with the monoclonal antibodies,CD24 (BA-1), CD9 (BA-2) and CD 10 (BA-3), and with rabbit complement. In one child with second remission ALL, hematopoietic recoveryafter BMT was prompt but, 81 days after BMT, isolated centralnervous system (CNS) relapse occurred. Bone marrow relapse developedthree months later, and she died 11 months after BMT. In patientswith CNS leukemia prior to BMT, as in the present case, moreintensive pretransplant CNS treatment and/or a conditioningregimen may reduce the risk of relapse. In the other patient, with primary refractory ALL in first remission,marrow reconstitution was slower. The patient developed interstitialpneumonitis with pleural effusion, and died 54 days after BMT.No infectious causes could be detected by culture or from serologicalstudies of the pleural effusion. The rationale for applying autologous BMT to children with secondremission ALL and first remission refractory ALL is discussed.     

Inclusion of rituximab in treatment protocols for non-Hodgkin's lymphomas and risk for progressive multifocal leukoencephalopathy

Objectives. Rituximab is an anti-CD20 monoclonal antibody that promotes better treatment outcomes in patients with non-Hodgkin's lymphoma (NHL). Case series of progressive multifocal leukoencephalopathy (PML) in patients receiving rituximab within polychemotherapy regimens have led to the introduction of a black box warning, but no risk estimation has ever been provided. Methods. We performed a retrospective, monocentric cohort study on 976 NHL patients diagnosed in 1994-2008, including 517 patients who received at least one dose of rituximab. Results. Inclusion of rituximab into standard chemotherapy regimens for NHL caused a significantly higher incidence of PML cases (rate difference, 2.2 every 1,000 patient-years; 95% confidence interval, 0.1-4.3). Interpretation. Based on this finding, clinical surveillance of PML-related symptoms is recommended in NHL patients exposed to rituximab.     

mRNA Expression of Bax,Bcl-2, p53, Cathepsin B,Caspase-3 and Caspase-9 in the HepG2 Cell Line Following Induction by a Novel Monoclonal Ab Hep88 mAb: Cross-Talk for Paraptosis and Apoptosis

Monoclonal antibodies with specific antigens have been widely used as targeted therapy for cancer. Hep88 mAb is a monoclonal antibody which shows specific binding with anti-cancer effects against the HepG2 cell line. However, its mechanisms of action are still not completely understood. We examined cell cycling and apoptosis by flow cytometry and mRNA expression of factors involved in apoptosis and paraptosis in Hep88 mAb-treated HepG2 cells by real-time PCR. The cell-cycle analysis demonstrated that growth inhibitory activity was associated with G2/M cell cycle arrest. Hep88 mAb induced a significant increase in apoptotic cell populations in a dose- and time-dependent manner. The mRNA expression results also suggested that the process triggered by Hep88 mAb involved up-regulation of tumor suppressor p53, pro-apoptotic Bax, Cathepsin B, Caspase-3 and Caspase-9, with a decrease of anti-apoptotic Bcl-2 - thus confirming paraptosis and apoptosis programmed cell death. These findings represent new insights into the molecular mechanisms underlying the anti-cancer properties of Hep88 mAb in liver cancer cells.     

Analysis of tumor control and toxicity in patients who have survived at least one year after radiosurgery for brain metastases

PURPOSE: To better evaluate tumor control and toxicity from radiosurgery for brain metastases, we analyzed these outcomes in patients who had survived at least 1 year after radiosurgery. METHODS AND MATERIALS: We evaluated the results of gamma knife stereotactic radiosurgery (SRS) for 208 brain metastases in 137 patients who were followed for a median of 18 months (range 12-122) after radiosurgery. The median patient age was 53 years (range 3-83). Ninety-nine patients had solitary metastases. Thirty-eight had multiple tumors. Sixty-nine patients underwent initial SRS with whole brain radiotherapy (WBRT), 39 had initial SRS alone, and 27 patients had failed prior WBRT. The median treatment volume was 1.9 cm(3) (range 0.05-21.2). The median marginal tumor dose was 16 Gy (range 12-25). The most common histologic types included non-small-cell lung cancer, breast cancer, melanoma, and renal cell carcinoma, which comprised 37.0%, 22.6%, 13.0%, and 9.13% of the lesions, respectively. Forty-five tumors were associated with extensive edema. RESULTS: At 1 and 5 years, the local tumor control rate was 89.6% +/- 2.1% and 62.8% +/- 6.9%, distal intracranial relapse occurred in 23% +/- 3.6% and 67.1% +/- 8.7%, and postradiosurgical sequelae developed in 2.8% +/- 1.2% and 11.4% +/- 3.5% of patients, respectively. Multivariate analysis found that local control decreased with tumor volume (p = 0.0002), SRS without WBRT (p = 0.008), and extensive edema (p = 0.024); distal intracranial recurrence correlated with younger patient age (p = 0.0018); and postradiosurgical sequelae increased with increasing tumor volume (p = 0.0085). CONCLUSION: Long-term control of brain metastases and complication rates in this selective series of patients surviving >or=1 year after radiosurgery were similar to previously reported actuarial estimates. Large metastases and metastases associated with extensive edema can be difficult to control by radiosurgery, particularly without WBRT.