Maria Grazia Viganò

The good and evil of HAART in HIV-related progressive multifocal leukoencephalopathy

The use of highly active anti-retroviral therapy in patients with HIV-related progressive multifocal leukoencephalopathy is associated with increased survival and disease stabilization. However, approximately half of the patients receive no benefit from these treatments. In a group of HIV-infected patients with histologically or virologically confirmed PML, we recognized two distinct patterns of response, i.e., long survivors versus nonresponders, but could not identify any factors at baseline predictive of PML outcome. In addition, the use of cidofovir did not substantially affect survival. However, the survival rate was higher during the first years of HAART, i.e., 1996–1997, with better outcomes observed in patients receiving a protease inhibitor-containing regimen either irregularly or after a switch from a 2-nucleoside reverse transcriptase inhibitor combination. In contrast, PML outcome was frequently poor in both HAART-naive and -experienced patients who responded promptly to anti-HIV therapy in terms of CD4 increase and viral load decrease. In addition, in a number of patients, PML onset was temporally associated with immune reconstitution. It may be that, in some patients, rapid immune reconstitution due to HAART paradoxically worsens the course of PML. Gradual reversal of immune deficiency might be associated with better outcome.

Phase II Study of Asparagine-Glycine-Arginine–Human Tumor Necrosis Factor α, a Selective Vascular Targeting Agent, in Previously Treated Patients With Malignant Pleural Mesothelioma

PURPOSE NGR-hTNF consists of human tumor necrosis factor alpha (hTNF-alpha) fused to the tumor-homing peptide asparagine-glycine-arginine (NGR) able to selectively bind an aminopeptidase N isoform overexpressed on tumor blood vessels. Hypervascularity is a prominent and poor-prognosis feature of malignant pleural mesothelioma (MPM). Currently, there are no standard options for patients with MPM who are failing a front-line pemetrexed-based regimen. We explored safety and efficacy of NGR-hTNF in this setting. PATIENTS AND METHODS Eligible patients had radiologically documented tumor progression and performance status < or = 2. Primary study aim was progression-free survival (PFS). NGR-hTNF 0.8 microg/m(2) was given intravenously every 3 weeks. A subsequent cohort of patients received 0.8 microg/m(2) on a weekly basis. RESULTS In the triweekly cohort (n = 43), only one grade 3 drug-related toxicity was noted, and the most common grades 1 to 2 were short-lived chills (71%). The median PFS was 2.8 months (95% CI, 2.3 to 3.3 months). Nineteen patients (44%) had disease control (one had partial response, and 18 had stable diseases) and experienced a median progression-free time of 4.4 months. In the weekly cohort (n = 14), there was no higher toxicity, and median PFS was 3.0 months (95% CI, 1.9 to 4.1 months). Seven patients (50%) had disease control (all stable diseases) and had a median progression-free interval of 9.1 months. In the overall study population (N = 57), median PFS was 2.8 months. Median progression-free time was 4.7 months in twenty-six patients (46%) who achieved disease control. Median survival was 12.1 months. CONCLUSION The tolerability and disease control of NGR-hTNF 0.8 microg/m(2) weekly warrant additional evaluation in patients with advanced MPM.

Epstein-Barr virus DNA load in cerebrospinal fluid and plasma of patients with AIDS-related lymphoma

Detection of Epstein-Barr virus (EBV) DNA in the cerebrospinal fluid (CSF) is associated with acquired immunodeficiency syndrome (AIDS)-related brain lymphoma. Real-time polymerase chain reaction (PCR) was performed to quantify EBV DNA in CSF and plasma from 42 patients with AIDS-related non-Hodgkin’s lymphoma (NHL). Twenty patients had primary central nervous system lymphoma (PCNSL) and 22 systemic NHL, including 12 with central nervous system involvement (CNS-NHL). As controls, 16 HIV-infected patients with other CNS disorders were examined. EBV DNA was detected in the CSF from 16/20 (80%) patients with PCNSL, 7/22 (32%) with systemic NHL, 8/12 (67%) with CNS-NHL, and 2/16 (13%) of the controls. The viral EBV DNA levels were significantly higher in the CSF from patients with PCNSL or CNS-NHL compared to patients with systemic NHL or controls. EBV DNA was detected in plasma from 5/16 (31%) patients with PCNSL, 9/16 (56%) with systemic NHL, 4/9 (44%) with CNS-NHL, and 4/15 (27%) controls. No difference in plasma viral load was found between patient groups. From the patients with CNS-NHL, plasma samples drawn prior to CNS involvement contained significantly higher EBV DNA levels than those from systemic NHL patients without subsequent CNS involvement. EBV DNA levels in the CSF, but not in plasma, from patients treated with antiherpes drugs were significantly lower than in untreated patients. High CSF EBV DNA levels were found in HIV-associated brain lymphomas and the viral load can be clinically useful. High plasma EBV DNA levels might predict CNS involvement in systemic NHL.

Prognostic value of circulating chromogranin A and soluble tumor necrosis factor receptors in advanced nonsmall cell lung cancer

Increased levels of chromogranin A (CgA), a protein secreted by many neuroendocrine cells, have been detected in sera of patients with neuroendocrine tumors or renal, hepatic, or heart failure. In patients with heart failure, serum CgA correlates with tumor necrosis factor‐α (TNF) and soluble TNF receptors (sTNF‐Rs), with important prognostic implications. The prognostic value of CgA and sTNF‐Rs was investigated in advanced nonsmall cell lung cancer (NSCLC), a histologically heterogeneous group of tumors that may undergo neuroendocrine differentiation.

Isolated bone marrow manifestation of HIV-associated Hodgkin lymphoma

Human immunodeficiency virus-associated Hodgkin lymphoma frequently involves the bone marrow and is usually recognized at staging after Hodgkin lymphoma diagnosis on a lymph node or other tissue biopsies, but occasionally the marrow involvement is the only apparent manifestation of disease. In the latter setting, diagnosis can be problematic. From a total of 42 patients with newly diagnosed human immunodeficiency virus–associated Hodgkin lymphoma, 22 subjects had positive marrow involvement at diagnosis; 16 of them had additional substantial histological and/or clinical extramedullary Hodgkin lymphoma. In the remaining 6 patients the bone marrow was the only site of disease at diagnosis. In all six cases, bone marrow biopsy revealed obvious lymphomatous involvement. Reed-Sternberg cells were identified both morphologically and immunophenotypically in all cases. Spared marrow tissue consistently showed fibrosis. All patients were males with a median age of 35 years (range, 31–58 years). All presented with fever, blood cytopenias, and severe CD4+ lymphocyte depletion (median, 70 cells/mm3). After diagnosis, all staging procedures were negative, and all patients were treated with chemotherapy. Median survival was 4 months (range, 2–118 mo). Longer survival was achieved in the patients who completed chemotherapy regimens; three subjects, however, died shortly before the full completion of chemotherapy, two of them from Hodgkin lymphoma. Isolated bone marrow HIV-associated Hodgkin lymphoma may be an underestimated condition in HIV-infected patients; in those individuals with unexplained fever and blood cytopenias, bone marrow biopsy should be performed with the aim of assessing for Hodgkin lymphoma, even in the absence of nodal and visceral lymphomatous involvement. A rapid diagnosis of isolated bone marrow HIV-associated Hodgkin lymphoma could expedite therapy.

Changes in Plasma Mass-Spectral Profile in Course of Treatment of Non-small Cell Lung Cancer Patients with Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors

Introduction: Our previous study showed that pretreatment serum or plasma Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry may predict clinical outcome of non-small cell lung cancer (NSCLC) patients treated with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). In this study, plasma proteomic profiles of NSCLC patients were evaluated in the course of EGFR TKIs therapy. Materials and Methods: Plasma samples were collected at baseline, in the course of gefitinib therapy and at treatment withdrawal. Samples were analyzed by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry. Acquired spectra were classified by the VeriStrat test into “good” and “poor” profiles. The association between VeriStrat classification and progression-free survival (PFS) and overall survival (OS), and types of clinical progression, was analyzed. Results: Plasma samples from 111 NSCLC patients treated with gefitinib were processed. VeriStrat “good” classification at baseline correlated with longer PFS (hazard ratio [HR], 0.54; 95% confidence interval, 0.35–0.83; p = 0.005) and OS (HR, 0.40; 95% confidence interval, 0.26–0.61; p < 0.0001), when compared with VeriStrat “poor.” Multivariate analysis confirmed longer PFS (HR, 0.52; p = 0.025) and OS (HR, 0.44; p = 0.001) in patients classified as VeriStrat “good”, when VeriStrat was considered as a time-dependent variable. About one-third of baseline “good” classifications had changed to “poor” at the time of treatment withdrawal; progression in these patients was associated with the development of new lesions. Conclusions: Our findings support the role of VeriStrat in the assistance in treatment selection of NSCLC patients for EGFR TKI therapy and its potential utility in treatment monitoring.

The cisplatin, epirubicin, 5-fluorouracil, gemcitabine (PEFG) regimen in advanced biliary tract adenocarcinoma

Biliary tract adenocarcinoma (BTA) is an uncommon tumor with a poor prognosis and no standard, systemic chemotherapy. The combined cisplatin, epirubicin, 5‐fluorouracil, and gemcitabine (PEFG) regimen is an effective, upfront treatment for advanced pancreatic cancer. In this study, the authors assessed the activity and safety of this combination regimen in patients with advanced BTA.

The pharmacokinetics of liposomal encapsulated daunorubicin are not modified by HAART in patients with HIV-associated Kaposi's sarcoma.

Purpose: To investigate the pharmacokinetics of liposomal daunorubicin (DaunoXome) administered alone or in combination with antiviral therapy including protease inhibitors (PI) to HIV-positive patients affected by Kaposis sarcoma (KS). Patients and methods: A group of 18 patients with extensive or rapidly progressing AIDS-related KS received DaunoXome at a dose of 40 mg/m2 alone or in association with a triple combination therapy consisting of one PI plus two nucleoside reverse transcriptase inhibitors (NRTI). Daunorubicin pharmacokinetics were determined in a total of 23 cycles, 6 with DaunoXome alone, 9 in combination with indinavir, 6 with ritonavir and 2 with saquinavir. Plasma samples were obtained at different times during the 72 h after DaunoXome administration. Daunorubicin and daunorubicinol plasma levels were determined by high-performance liquid chromatography. Results: After the DaunoXome infusion, daunorubicin was rapidly cleared from the body following, in most cases, a one-compartment open kinetic model. The daunorubicin peak concentrations, clearances and elimination half-lives were (means ± SD): 16.3 ± 2.8 μg/ml, 0.3 ± 0.1 l/h per m2 and 5.6 ± 2.6 h after DaunoXome alone; 15.1 ± 4.9 μg/ml, 0.5 ± 0.3 l/h per m2 and 5.8 ± 2.1 h after the combination with indinavir; and 14.5 ± 2.8 μg/ml, 0.4 ± 0.2 l/h per m2 and 6.5 ± 3.9 h after the combination with ritonavir. In all groups, daunorubicinol plasma levels were approximately 25–30 times lower than those of the parent drug. Conclusion: Our data show that there are no significant differences in the pharmacokinetic parameters of daunorubicin in patients receiving DaunoXome in combination with indinavir and ritonavir compared with those in patients not receiving PIs. Therefore in patients affected by AIDS-related KS treated with Highly Active AntiRetroviral Therapy (HAART) there is no pharmacokinetic justification for reducing the doses of DaunoXome.

Clinical Significance of Skin Toxicity due to EGFR-Targeted Therapies

Many small molecules and monoclonal antibodies blocking the activity of Epidermal Growth factor receptor (EGFR) have been developed and have shown clinical activity in patients with non-small cell lung cancer (NSCLC), pancreatic cancer, and colorectal cancer (CRC), and are in clinical development for a range of other solid tumors. The toxicity profile of such agents is characterized by a typical pattern of cutaneous reactions. In this paper we reviewed the current available data regarding the clinical significance of skin reaction due to EGFR targeted agents. We show that skin toxicity can be considered as predictive marker of response to such drugs and that it is not disease specific; however its potential prognostic value is still to be proven.

Neurobrucellosis with spinal cord abscess of the dorsal tract: a case report

Neurologic manifestations of brucellosis occur in 2-5% of patients.l.* The clinical pictures of neurobrucellosis are characteristically protean: they include meningoencephalitis, meningovascular complications, parenchymatous dysfunctions, peripheral neuropathy/radiculopathy and various degrees of behavioral abnormalities, sometimes leading to acute psychosis. From the clinical series available, meningitis has been referred as the most frequent presentation of neurobrucellosis, occurring in at least the 50% of cases;‘,” meningitis is most often acute, but subacute or chronic presentations are not rare and may lead to disseminated encephalomyelitis with diffuse central nervous system (CNS) demyelinization.3*4 In contrast, Bruceh abscess formation within the CNS has been described up to now in just one child with multiple brain abscesses.’ We here report the first case of neurobrucellosis with intramedullary abscess in an adult. A 24-year-old man from Sicily was admitted to the regional Hospital for high degree continuous fever and night sweats; fever had lasted for about two months and had been treated with a one-week course of oral prednisolone, before the patient was admitted to hospital. The patient remembered eating some fresh goat’s cheese in the recent past. Thus, brucellosis was suspected and the Brucella melitensis serum agglutination test (SAT) was performed. This was positive at a 1:SOO titer. A six-week cycle of rifampin 600 mglday and doxycycline 100 mg b.i.d. was given; both the fever and the agglutinins normalized. Six months later he complained of abrupt onset of fever, hypostenia of the left leg, and paresthesias of the right leg, with consequent impaired walking. A contrast-enhanced magnetic resonance imaging (MRI) of the brain and the spinal cord showed a focal lesion of 15 mm diameter within the dorsal tract of the spinal cord, near to the third intervertebral space; the abscess was surrounded by perilesional edema, had a partially liquid core and a ring enhancement was evident after Gadolinium in-