Numerous antiangiogenic agents are approved for the treatment of oncological diseases. However, almost all patients develop evasive resistance mechanisms against antiangiogenic therapies. Currently no predictive biomarker for therapy resistance or response has been established. Therefore, the aim of our study was to identify biomarkers predicting the development of therapy resistance in patients with hepatocellular cancer (n = 11), renal cell cancer (n = 7) and non-small cell lung cancer (n = 2). Thereby we measured levels of angiogenic growth factors, tumor perfusion, circulating endothelial cells (CEC), circulating endothelial progenitor cells (CEP) and tumor endothelial markers (TEM) in patients during the course of therapy with antiangiogenic agents, and correlated them with the time to antiangiogenic progression (aTTP). Importantly, at disease progression, we observed an increase of proangiogenic factors, upregulation of CEC/CEP levels and downregulation of TEMs, such as Robo4 and endothelial cell-specific chemotaxis regulator (ECSCR), reflecting the formation of torturous tumor vessels. Increased TEM expression levels tended to correlate with prolonged aTTP (ECSCR high = 275 days vs. ECSCR low = 92.5 days; p = 0.07 and for Robo4 high = 387 days vs. Robo4 low = 90.0 days; p = 0.08). This indicates that loss of vascular stabilization factors aggravates the development of antiangiogenic resistance. Thus, our observations confirm that CEP/CEC populations, proangiogenic cytokines and TEMs contribute to evasive resistance in antiangiogenic treated patients. Higher TEM expression during disease progression may have clinical and pathophysiological implications, however, validation of our results is warranted for further biomarker development.
e12517 Background: New markers in CSF are needed to improve the diagnostic accuracy for neoplastic meningitis (NM). The DKK-3 glycoprotein has been proposed to function as a secreted tumor suppressor. Here, we determined the value of Dkk-3 in CSF and serum as a marker for NM. Methods: Dkk-3 concentrations were measured by ELISA in matched samples of CSF and serum from 156 patients (pts): solid tumors/meningeosis carcinomatosa (MC, n = 33), meningeosis leucaemica/lymphomatosa (ML, n = 13), pts with cancer with or without brain metastases but in the absence of concomitant NM (non-NM, n = 25), bacterial (BM, n = 25) and viral (VM, n = 20) meningitis, multiple sclerosis (MS, n = 10), and pts with with tension type headache (HA, n = 30). Results: There were significant differences of CSF Dkk-3 levels (mean ± SEM) between the following groups (p = 0.0001, Kruskal-Wallis): MC 883 ng/mL ± 406, ML 1,499 ng/mL ± 1,579, non-NM 650 ng/mL ± 278, BM 683 ng/mL ± 290, VM 901 ng/mL ± 370, MS 587 ng/mL ± 226 and HA 579 ng/mL ± 320. In all groups significantly higher amounts of Dkk-3 in CSF compared to serum were found (HA mean 40 ng/mL ± 22, 14.6 times higher). CSF Dkk-3 levels were higher in ML than in MC pts (p = 0.041, students-T). CSF DKK3 significantly distinguishes MC/ML from non-NM (p = 0.017/p = 0.012), BM (p = 0.041/p = 0.016), MS (p = 0.034/p = 0.036) and HA (p = 0.001/p = 0.003) pts. VM pts also showed high CSF Dkk-3 levels, not discriminative between NM or VM. Furthermore, in VM pts serum Dkk-3 levels were significantly higher compared to all other groups (VM mean 53 ng/mL ± 18 vs. HA mean 40 ng/mL ± 22, p = 0.001). During intrathecal treatment CSF Dkk-3 levels correlated to treatment response. Conclusions: In NM and VM pts significantly higher amounts of Dkk-3 are released into CSF. This study provides first evidence that CSF Dkk-3 may be a useful biologic marker for both the diagnosis and treatment response evaluation of NM. Its specificity, however, is limited by similarly high CSF Dkk-3 levels in pts with VM. No significant financial relationships to disclose.
Background: Assessment of patient-reported outcomes (PRO) has become essential for evaluation of the burden of disease and of the benefits and side effects of therapy. Aims: Here, we compare parameters of QoL in patients with relapsed/refractory multiple myeloma (RRMM) with an age-matched control population and evaluate the impact of relapse therapy with ixazomib, thalidomide and dexamethasone (IxaThalDex) followed by ixazomib maintenance therapy on several dimensions of QoL. Methods: PRO was assessed using the EORTC QLQ-C30 and the EORTC QLQ-MY20 instruments at baseline and at the beginning of each cycle of induction and maintenance therapy. Eighty-nine patients were enrolled and started on induction therapy receiving ixazomib (4 mg [3 mg in pts ≥75 yrs], d 1,8,15), thalidomide (100 mg [50 mg in pts ≥75yrs] daily) and dexamethasone (40 mg [20 in pts ≥75yrs]/week) for 8 cycles and ixazomib maintenance therapy (4 mg d1, 8, 15) for 12 months. Score interpretation regarding what was considered a clinically meaningful difference was guided by recommendations by Cocks et al., JCO, 2010. Differences between baseline and end of induction therapy were analyzed in all 43 patients who completed all 8 cycles. 2.337 individuals aged 60–69 years of the general population served as controls (Nolte et al., Eu J Cancer, 2019). Differences were assessed by T test. Results: In comparison to the general population, significant impairment in several QoL dimensions was noted in our patients with RRMM, such as physical (Δ −12.4, p < 0.0001), role (Δ-26.6, p < 0.0001), and social function (Δ-17, p < 0.0001), while no clinically relevant differences were seen in global QoL (Δ-6.5, p = 0.0059), emotional (Δ-6.5, p = 0.0038) and cognitive function (Δ-5.9, p = 0.0014). During induction therapy, global health-related QoL and physical function remained fairly stable, while a clinically relevant reduction in pain (Δ-13.2, p = 0.0285) and an increase in polyneuropathy (PNP) (Δ+23.7, p = 0.0002) were noted (baseline vs end of induction) (figure 1). During maintenance treatment (figure 1), a tendency for an improvement in most evaluated dimensions, like global health-related QoL, or physical functioning (significant for cycle 8 only (Δ+12.9, p = 0.0398)) was observed. For cognitive functioning, a clinically relevant difference was observed at cycle 11 and at end of maintenance, while for social functioning a Δ ≥+10 was noted at cycles 4, 9, 10 and at end of maintenance. Regarding the symptom scales, clinically relevant improvements were observed for pain (Δ ≥-10 at cycle 9 and end of maintenance) and fatigue (Δ ≥-10 at cycle 8 and at end of maintenance), while PNP remained stable during maintenance therapy.Summary/Conclusion: This study shows a significant impairment of several, but not all, dimensions of QoL in patients with RRMM compared to the general population of similar age. In particular, our data show a significant impairment in physical, role, and social function, while emotional wellbeing and other dimensions were only marginally impaired, indicating that patients are able to adapt emotionally even to the very heavy burden of their disease and to maintain almost ‘normal’ emotional wellbeing. During relapse therapy with IxaThalDex, most dimensions of QoL remained stable, or showed improvement, with the exception of PNP, which worsened significantly. During ixazomib maintenance treatment, health related QoL, physical functioning, and fatigue improved supporting the good tolerance of ixazomib, while no improvement in the presumably thalidomide-induced PNP was noted.
Abstract Purpose: The forkhead box transcription factor FoxP3 is specifically expressed in T cells with regulatory properties (Treg). Recently, high numbers of Treg were described to be associated with poor survival in different malignancies. The aim of the presented study was determine the prognostic effect of FoxP3 mRNA expression (reflecting the tissue content of Treg) in ovarian carcinoma and its relation with cytokines, such as IFN-γ. Experimental Design: Total RNA was isolated from 99 ovarian carcinoma and from 14 healthy ovarian biopsies. Real-time PCR for FoxP3 was done and correlated with IFN-γ-, CD3-, IRF-1-, SOCS-1-, HER-2-, and iNOS expression as well as patients' outcome. The mRNA data was corroborated by FoxP3 immunohistochemistry. Results: Quantitation of FoxP3 expression identified a patient subgroup (>81th percentile), which is characterized by a significantly worse prognosis in terms of overall survival (27.8 versus 77.3 months, P = 0.0034) and progression-free survival (18 versus 57.5 months; P = 0.0041). FoxP3 expression correlated with IFN-γ, IRF-1, and CD3 expression. High FoxP3 expression represents an independent prognostic factor for overall survival (P = 0.004) and progression-free survival (P = 0.004). Conclusions: High expression levels of FoxP3 might represent a surrogate marker for an immunosuppressive milieu contributing to tumor immune escape. Strategies selectively depleting Treg might improve the antitumor activity of endogenously arising tumor-reactive T cells and immunotherapies using vaccines or antibodies.
Progressive multifocal leukoencephalopathy (PML) is a rare but fatal demyelinating disease of the brain caused by the JC papovavirus (JCV), affecting mainly immunocompromised patients. Recently, an association between PML and the application of rituximab after autologous stem cell transplantation (SCT) has been discussed (1,2). We report the first case of PML after allogeneic SCT and posttransplantation administration of rituximab. A 32-year-old man with refractory diffuse large cell lymphoma received an unmanipulated blood SCT from an HLA-identical male sibling donor after conditioning with cyclophosphamide, carmustine, and etoposide. In addition, the patient was given 10 infusions of rituximab (375 mg/m2) between days 14 and 180. Except for a grade II acute graft-versus-host disease of the skin and mild cytomegalovirus infection, the posttransplantation period proceeded without complications, and after 11 months cyclosporine A was discontinued. However, recovery of B lymphocytes was significantly delayed, requiring prolonged substitution therapy with immunoglobulins. In contrast, recovery of CD4+ and CD8+ counts was unremarkable. Seventeen months after transplantation, the patient presented with progressive bulbar speech dysfunction and subfebrile temperatures. PML was suspected after magnet resonance tomography scanning and confirmed by brain biopsy and detection of JC viral DNA in the cerebrospinal fluid. Despite therapy with interleukin 2 (106 IU/day SC) in combination with cytosine arabinoside (40 mg/week intrathecally) and cidofovir (375 mg IV every other week), the patient's condition deteriorated continuously. He died after 3 months while still in complete remission concerning his lymphoma and without evidence of human immunodeficiency virus infection. PML arises upon JCV reactivation and has received increasing attention as a serious complication in immunocompromised subjects. In contrast to patients with human immunodeficiency virus or the cases reported recently after autologous SCT (1), CD4+ counts in our patient were normal, suggesting additional pathogenetic mechanisms in the development of PML. The onset of the first neurologic symptoms coincided with the recovery of B cells, which had been severely depressed because of rituximab administration. From recent findings concerning JCV trafficking (3) we speculate that latent JCV-bearing donor-derived B lymphocytes crossed the blood-brain barrier and transmitted JCV to brain tissue. Stimulation assays performed at the time of PML diagnosis revealed severely impaired lectin-reactive and alloreactive T-cell responses, reflecting profound suppression of cell-mediated immunity despite normal T-cell counts (Fig. 1). This is in accordance with previous reports demonstrating that functional capacities of T cells remain severely depressed for several months after autologous or allogeneic SCT (4). Figure 1: Functional assessment of T cells at the time of PML diagnosis. (A) Stimulation indices after incubation of patient's and a healthy controls' peripheral blood mononuclear cells with concanavalin A (ConA) at a dilution of 1:80 and stimulation with 1% phytohemagglutinin (PHA) as described previously (4). (B) Stimulation indices of patient's and a healthy control's peripheral blood mononuclear cells after allogeneic stimulation in a one-way mixed lymphocyte reaction as described previously (4).To date, prognosis of PML in transplant recipients is dismal, with an average survival of only a few months. Thus clinical management of PML in this group of patients needs to be improved (5). In conclusion, we report the first case of PML in the setting of posttransplantation rituximab in an allogeneic SCT recipient. This case together with other recent reports suggests that application of rituximab after SCT may result in delayed reconstitution of B cells. Prolonged SCT-associated functional T-cell defects render the patient at a high risk for late viral infections at the time of recovery of JCV-bearing autologous or donor-derived B lymphocytes. Michael Steurer1 Johannes Clausen1 Thaddaeus Gotwald2 Eberhard Gunsilius1 Guenther Stockhammer3 Guenther Gastl1 David Nachbaur1 4
Dickkopf-3 (Dkk3) has been proposed as tumour suppressor gene and a marker for tumour blood vessels. We analysed the expression and function of Dkk3 in platelets and megakaryocytes from healthy controls and patients with BCR-ABL1-negative myeloproliferative neoplasms (MPN). Dkk3 protein and gene expression in platelets was compared with endothelial and other blood cell populations by ELISA, real-time PCR, and immunofluorescence. Moreover, megakaryocytes were isolated from bone marrow aspirates by CD61 microbeads. Immunohistochemical studies of Dkk3 expression were performed in essential thrombocythemia (ET), polycythemia vera (PV), primary myelofibrosis (PMF) and control reactive bone marrow cases (each n=10). Compared to all other blood cell populations platelets showed the highest concentration of Dkk3 protein (150 ± 19 ng/mg total protein). A strong DKK3 gene and protein expression was also observed in isolated megakaryocytes. Dkk3 co-localised with VEGF in α-granules of platelets and was released similar to VEGF upon stimulation. Addition of recombinant Dkk3 had no influence on blood coagulation (aPTT, INR) and platelet aggregation. Significantly more Dkk3+ megakaryocytes/mm2 could be found in bone marrow biopsies from patients with MPN (ET 40 ± 10, PV 31 ± 4, PMF 22 ± 3) than in controls (15 ± 3). The mean proportion of Dkk3+ megakaryocytes was increased in MPN as well (ET 83% ± 15%; PV 84% ± 12%; PMF 77% ± 8%) compared to controls (53% ± 11%). Dkk3+ megakaryocytes correlated with microvessel density in PV and PMF. We conclude that Dkk3 might be involved in the pathogenesis of MPN.
