Sabina Russo

Clinical and laboratory features of 103 patients from 42 Italian families with inherited thrombocytopenia derived from the monoallelic Ala156Val mutation of GPIbα (Bolzano mutation)

Background Bernard-Soulier syndrome is a very rare form of inherited thrombocytopenia that derives from mutations in GPIbα, GPIbβ, or GPIX and is typically inherited as a recessive disease. However, some years ago it was shown that the monoallelic c.515C>T transition in the GPIBA gene (Bolzano mutation) was responsible for macrothrombocytopenia in a few Italian patients. Design and Methods Over the past 10 years, we have searched for the Bolzano mutation in all subjects referred to our institutions because of an autosomal, dominant form of thrombocytopenia of unknown origin. Results We identified 42 new Italian families (103 cases) with a thrombocytopenia induced by monoallelic Bolzano mutation. Analyses of the geographic origin of affected pedigrees and haplotypes indicated that this mutation originated in southern Italy. Although the clinical expression was variable, patients with this mutation typically had a mild form of Bernard-Soulier syndrome with mild thrombocytopenia and bleeding tendency. The most indicative laboratory findings were enlarged platelets and reduced GPIb/IX/V platelet expression; in vitro platelet aggregation was normal in nearly all of the cases. Conclusions Our study indicates that monoallelic Bolzano mutation is the most frequent cause of inherited thrombocytopenia in Italy, affecting 20% of patients recruited at our institutions during the last 10 years. Because many people from southern Italy have emigrated during the last century, this mutation may have spread to other countries.

New orally active proteasome inhibitors in multiple myeloma.

Bortezomib is the first proteasome inhibitor approved for the therapy of multiple myeloma (MM). Although Bortezomib has renovated the treatment of MM, a considerable proportion of subjects fail to respond to Bortezomib treatment and almost all patients relapse from this drug either alone or when used in combination therapies. However, the good clinical outcome of Bortezomib treatment in MM patients gave impulsion for the development of second generation proteasome inhibitors with the ambition of improving efficacy of proteasome inhibition, enhancing antitumor activity, and decreasing toxicity, as well as providing flexible dosing schedules and patient convenience. This review provides an overview of the role of oral proteasome inhibitors including Marizomib, Oprozomib, Delanzomib, chemical proteasome inhibitors, and cinnabaramides, in the therapy of MM, focusing on developments over the past five years. These emerging drugs with different mechanisms of action have exhibited promising antitumor activity in patients with relapsed/refractory MM, and they are creating chances to target multiple pathways, overcome resistance, and improve clinical outcomes, mainly for those subjects who are refractory to approved agents. Future steps in the clinical development of oral inhibitors include the optimization of the schedule and the definition of their antitumor activity in MM.

Monoclonal antibodies: potential new therapeutic treatment against multiple myeloma

Despite recent treatments, such as bortezomib, thalidomide, and lenalidomide, therapy of multiple myeloma (MM) is limited, and MM remains an incurable disease associated with high mortality. The outcome of patients treated with cytotoxic therapy has not been satisfactory. Therefore, new therapies are needed for relapsed MM. A new anticancer strategy is the use of monoclonal antibodies (MoAbs) that represent the best available combination of tumor cytotoxicity, environmental signal privation, and immune system redirection. Clinical results in patients with relapsed/refractory MM suggest that MoAbs are likely to operate synergistically with traditional therapies (dexamethasone), immune modulators (thalidomide, lenalidomide), and other novel therapies (bortezomib); in addition, MoAbs have shown the ability to overcome resistance to these therapies. It remains to be defined how MoAb therapy can most fruitfully be incorporated into the current therapeutic paradigms that have achieved significant survival earnings in patients with MM. This will require careful consideration of the optimal sequence of treatments and their clinical position as either short‐term induction therapy, frontline therapy in patients ineligible for ASCT, or long‐term maintenance treatment.

Novel therapeutic strategies in multiple myeloma: role of the heat shock protein inhibitors

Despite advances in understanding the molecular pathogenesis of multiple myeloma and promising new therapies, almost all patients eventually relapse with resistant disease. There is therefore a strong rationale for combining novel therapies that target intrinsic molecular pathways mediating multiple myeloma cell resistance. One such protein family is the heat shock proteins (HSP), especially the HSP90 family. Heat shock protein inhibitors have been identified as promising cancer treatments as, while they only inhibit a single biologic function, the chaperone–protein association, their effect is widespread as it results in the destruction of numerous client proteins. This article reviews the preclinical and clinical data, which support the testing of HSP90 inhibitors as cancer drugs and update the reader on the current status of the ongoing clinical trials of HSP90 inhibitors in multiple myeloma.

Nanoparticles in Oncology: The New Theragnostic Molecules

Cancer nanotherapeutics have shown promise in resolving some of the limitations of conventional drug delivery systems such as nonspecific biodistribution and targeting, lack of water solubility, low therapeutic indices, and poor oral bioavailability. Moreover, cancer nanotechnology has the potential of improving current approaches to cancer detection, diagnosis, and imaging. Recently, nanotechnology and molecular imaging have been combined to generate nanoparticles that simultaneously facilitate cancer therapy and diagnosis, the so called theragnostic nanoparticles. The aim of our review is to highlight recent developments within the context of the current knowledge of nanotechnology, to recall the experimental steps that have brought to the clinical development and application of nanoparticles, and explain the biological rationale for their use with oncologic patients. In particular, we summarize recent findings with respect to possible new applications for therapy and diagnosis, and their specific properties. Moreover, we report the more recent prospects in gene therapy, the possibility of using new drug delivery methods, the action of nanoparticles on the immune system and apoptosis, and the concrete possibility of detecting and characterizing circulating tumor cells or of developing new technologies in drug discovery.

Anticancer Activity of Curcumin and Its Analogues: Preclinical and Clinical Studies

ABSTRACT Curcumin has been shown to have a wide variety of therapeutic effects, ranging from anti-inflammatory, chemopreventive, anti-proliferative, and anti-metastatic. This review provides an overview of the recent research conducted to overcome the problems with the bioavailability of curcumin, and of the preclinical and clinical studies that have reported success in combinatorial strategies coupling curcumin with other treatments. Research on the signaling pathways that curcumin treatment targets shows that it potently acts on major intracellular components involved in key processes such as genomic modulations, cell invasion and cell death pathways. Curcumin is a promising molecule for the prevention and treatment of cancer.

Reduced IL-33 plasma levels in multiple myeloma patients are associated with more advanced stage of disease.

Multiple myeloma (MM) is a clonal neoplasm of the bone marrow-resident long lived plasma cells. Like normal plasma cells, MM cells depend on their interactions with bone marrow stromal cells for the survival and production of essential cytokines (Minges Wols et al, 2002). Interleukin-33 (IL-33) is an IL-1 family member that is constitutively expressed by endothelial and epithelial cells (Joshi et al, 2010) and which appears to drive T helper cell type 2 (Th2) responses in several organs (Cevikbas & Steinhoff, 2012). This study analysed the plasma levels of IL33 in 44 MM patients (19 males, 25 females; mean age 66 9 years) and in 13 patients with monoclonal gammopathy of undetermined significance (MGUS; five males, eight females; mean age 63 12 years). No patients had received any treatment for MM during the previous seven days. The study was conducted according to the principles of the Declaration of Helsinki. Informed written consent was obtained. Plasma from 63 sex-matched and age matched normal subjects (35 males, 28 females; mean age 64 11 years) were also included as controls. None of the patients or control subjects had symptoms or laboratory signs of active infections, inflammatory diseases, diabetes, obesity, neurological diseases or severe uraemia. According to the Durie–Salmon staging system, 13 patients were MM disease stage I, 13 patients were stage II, and 18 patients were disease stage III. The paraprotein class was immunoglobulin G (IgG) in 24 patients and IgA in 18 patients; two patient had non-secretory disease. 26 subjects had lytic bone disease and/or pathological fractures. Thirty patients presented an Eastern Cooperative Oncology Group (ECOG) performance status <2 while 14 patients had an ECOG >2. Median plasmocytosis of bone marrow was 47% (range 35–90%). Of the 13 MGUS subjects, the paraprotein class was IgG in 9 and IgA in 4. IL-33 protein levels were measured using the commercially available DuoSet enzyme-linked immunosorbent assay Development System kits (R&D Systems; Minneapolis, MN, USA). The detection limit was 4 0 pg/ml. Data are presented as interquartile range (IQR) and range, except age, which is presented as mean standard deviation. Differences between data series were analysed by the Mann– Whitney test; differences between categorical groups were analysed by the Pearson chi square (v) test. Correlation between two variables was evaluated with Spearman’s rho. Statistical significance was set at P < 0 05. Twenty three of 44 (52 27%) MM patients, eight of 13 (53 33%) MGUS patients and 36 of 63 (57 14%) controls showed detectable levels of IL-33; there was no statistical significant difference in detectability between the three groups (v = 0 365, P = 0 833). IL-33 levels were statistically significantly different between the MM patients (297 8 and 1491 5 pg/ml) and MGUS patients (312 775 and 1579 9 pg/ml) and those measured in controls (1375 3 and 2035 4 pg/ml) (P = 0 001 and (P = 0 03, respectively) (Fig 1). The IL-33 levels in MM patients with kidney failure (creatinine level >88 4 lmol/l) were not statistically significantly different to MM patients who did not have kidney failure (creatinine level 88 4 lmol/l) (1151,75 and 1488 1 vs. 254 175 and 1002 8 pg/ml, P = 0 322). There was no statistically significant difference in IL-33 levels between MM patients with bone lesions and those without (205 1 and 1002 8 vs. 936 55 and 1483 2 pg/ml, P = 0 096). MM patients showed a negative correlation between IL-33 level and stage (P = 0 006, correlation coefficient = 0 692), but not between IL-33 level and Hb concentration (P = 0 301, correlation coefficient = 0 298), b2 microglobulin level (P = 0 817, correlation coefficient = 0 068), and monoclonal component (P = 0 091, correlation coefficient = 0 468). The development of MM involves a series of changes in the bone marrow microenvironment, favouring the growth of the tumour and failure of local immune control. Quantitative and functional alterations in CD4 and CD8 T cells have been described in MM, and cellular immune defects in MM have been shown to negatively correlate with survival (Pratt et al, 2007). A significant impairment of T-cell function has been also described for patients with MGUS (Prabhala et al, 2006). Cytokines and their receptors play essential roles in the development, maintenance and proper functioning of the immune system. In MM, these interactions may have tumour-promoting consequences (J€ ohrer et al, 2012). IL-33 is a recent addition to the ever-growing family of cytokines. To the best of our knowledge, this is the first study to demonstrate decreased concentrations of IL-33 in patients with MM, which might contribute to the changes in the immune system found in these patients. On the other

Age influences initial dose and compliance to imatinib in chronic myeloid leukemia elderly patients but concomitant comorbidities appear to influence overall and event-free survival

We applied Charlson comorbidity index (CCI) stratification on a large cohort of chronic myeloid leukemia (CML) very elderly patients (>75 years) treated with imatinib, in order to observe the impact of concomitant diseases on both compliance and outcome. One hundred and eighty-one patients were recruited by 21 Italian centers. There were 95 males and 86 females, median age 78.6 years (range 75-93.6). According to Sokal score, 106 patients were classified as intermediate risk and 55 as high risk (not available in 20 patients). According to CCI stratification, 71 patients had score 0 and 110 a score ≥ 1. Imatinib standard dose was reduced at start of therapy (200-300 mg/day) in 68 patients independently from the evaluation of baseline comorbidities, but based only on physician judgement: 43.6% of these patients had score 0 compared to 34% of patients who had score ≥ 1. Significant differences were found in terms of subsequent dose reduction (39% of patients with score 0 compared to 53% of patients with score ≥ 1) and in terms of drug discontinuation due to toxicity (35% of patients with score 0 vs 65% of patients with score ≥ 1). We did not find significant differences as regards occurrence of hematologic side effects, probably as a consequence of the initial dose reduction: 39% of patients with score 0 experienced grade 3/4 hematologic toxicity (most commonly anemia) compared to 42% of patients with score ≥ 1. Independently from the initial dose, comorbidities again did not have an impact on development of grade 3/4 non-hematologic side effects (most commonly skin rash, muscle cramps and fluid retention): 62% of patients with score 0 compared to 52.5% of patients with score ≥ 1. Notwithstanding the reduced dose and the weight of comorbidities we did not find significant differences but only a trend in terms of efficacy: 66% of patients with score 0 achieved a CCyR compared to 54% of patients with score ≥ 1. Comorbidities appeared to have an impact on median OS (40.8 months for patients with score 0 vs 20.16 months for patients with score ≥ 1) on EFS and on non-CML death rate. Our results suggest that treatment of very elderly CML patients might be influenced by personal physician perception: evaluation at baseline of comorbidities according to CCI should improve initial decision-making in this subset of patients.

Increased serum levels of neutrophil gelatinase-associated lipocalin in patients with essential thrombocythemia and polycythemia vera

Neutrophil gelatinaase-associated lipocalin (NGAL) is a glycoprotein bound with matrix metalloproteinase-9 (MMP-9) in human neutrophils, and elevated tissue NGAL expression has been documented in different infectious and inflammatory conditions. Recent evidence suggests that NGAL expression is induced in many types of human cancer. Moreover, NGAL is required for BCR–ABL-induced tumorigenesis. The aim of the present study was to measure serum levels of NGAL in patients with essential thrombocythemia (ET) and polycythemia vera (PV). We also evaluated NGAL levels in patients with ET and PV with and without thrombotic events, to explore a possible correlation of NGAL with platelet and leukocyte activation, and in patients with sepsis. Serum NGAL levels in the study population were significantly higher than in healthy adults and in subjects with sepsis. A correlation between NGAL and the number of white cells and neutrophils was found in patients with PV and ET. NGAL serum levels were not different depending on the presence or not of the JAK2 mutation, and a mutant allele dosage effect was not observed for NGAL levels. Patients with PV and ET with thrombosis did not have significantly higher levels of NGAL. We were unable to demonstrate a significant association between serum NGAL levels and CD11b or CD62 expression. In conclusion, our study reports evidence demonstrating that increased levels of NGAL appear to be a characteristic of patients with PV and ET.

Epigenetic therapy in myelodysplastic syndromes

The wide spectrum of clonal hematopoietic disorders that fall under the broad diagnostic category of myelodysplastic syndromes (MDS) consist of a family of bone marrow malignancies – with ineffective, inadequate, and dysplastic hematopoiesis, and with an increased risk of life‐threatening infections, bleeding, and progression to acute myeloid leukemia (AML) – that are characterized by a deep heterogeneity on the clinical, biologic and prognostic level. The intrinsic complexity of this group of disorders and the frequent association with one or more comorbidities have limited for many years the number of effective treatment options available: most patients are, indeed, still managed by supportive care measures, with just a minority of them being eligible for allogeneic stem cell transplantation, which is still the only potentially curative modality. In the last two decades, the progressively better understanding of MDS biology has shown how an abnormal epigenetic modulation might play a crucial part in the pathogenesis and in the process of biologic evolution of these disorders. Moreover, pharmacological agents that target the so‐called epigenome have shown a significant clinical activity for diverse hematologic malignancies, including MDS. The aim of this review is to highlight recent developments within the context of current knowledge of MDS and its altered epigenetic regulation and to recall the experimental steps that have brought to the clinical development and application of epigenetic modifiers, such as azacytidine and decitabine, trying to explain the biologic rationale for their use in this setting.