Valeria Visconti

Ovarian cancer cytoreduction induces changes in T cell population subsets reducing immunosuppression

Surgery is the primary therapeutic strategy for most solid tumours; however, modern oncology has established that neoplasms are frequently systemic diseases. Being however a local treatment, the mechanisms through which surgery plays its systemic role remain unknown. We have investigated the influence of cytoreduction on the immune system of primary and recurrent ovarian cancer. All ovarian cancer patients show an increase in CD4+CD25+FOXP3+ circulating cells (CD4 Treg). CD4/CD8 ratio is increased in primary tumours, but not in recurrent neoplasms. Primary cytoreduction is able to increase circulating CD4 and CD8 effector cells and decrease CD4 naïve T cells. CD4+ Treg cells rapidly decreased after primary tumour debulking, while CD8+CD25+FOXP3+ (CD8 Treg) cells are not detectable in peripheral blood. Similar results on CD4 Treg were observed with chemical debulking in women subjected to neoadjuvant chemotherapy. CD4 and CD8 Treg cells are both present in neoplastic tissue. Interleukin (IL)‐10 serum levels decrease after surgery, while no changes are observed in transforming growth factor‐β1 and IL‐6 levels. Surgically induced reduction of the immunosuppressive environment results in an increased capacity of CD8+ T cells to respond to the recall antigens. None of these changes was observed in patients previously subjected to chemotherapy or affected by recurrent disease. In conclusion, we demonstrate in ovarian cancer that primary debulking is associated with a reduction of circulating Treg and an increase in CD8 T‐cell function. Debulking plays a beneficial systemic effect by reverting immunosuppression and restoring immunological fitness.

Monoclonal Antibodies in Gynecological Cancer: A Critical Point of View

During the last decades, several improvements in treating gynecological malignancies have been achieved. In particular, target therapies, mostly monoclonal antibodies, have emerged as an attractive option for the treatment of these malignancies. In fact, various molecular-targeted agents have been developed for a variety of malignancies with the objective to interfere with a precise tumor associated receptor, essential for cancer cell survival or proliferation, blocking its function, of the cancer cells. Alternatively, monoclonal antibodies have been developed to block immune suppression or enhance functions of immune effector cells. So far, several monoclonal antibodies have been tested for clinical efficacy for the treatment of gynecological cancers. Antibodies against Vascular Endothelial Growth Factor (VEGF) and Epidermal Growth Factor Receptor (EGFR) have been used in different neoplasms such as ovarian and cervical cancer. Catumazumab, a bivalent antibody against CD3 and EpCAM, is effective in the treatment of neoplastic ascites. Other antibodies are peculiar for specific cancer-associated antigen such as Oregovomab against CA125 or Farletuzumab against the folate receptor. Here we describe the preclinical and clinical experience gained up to now with monoclonal antibodies in tumors of the female genital tract and trace future therapeutic and research venues.

Past, Present and Future Strategies of Immunotherapy in Gynecological Malignancies

Recently, the combining of different drugs has greatly improved response and survival rates in gynecological malignancies. Results are however far from being satisfactory. Treatments used in case of advanced or recurrent disease offer limited results in terms of long-term responses. The urgent need for new and more effective treatments has prompted researchers to investigate and propose new therapeutic strategies. One of the most interesting approaches that are being explored is constituted by immunotherapy. Currently, immunotherapeutic strategies include vaccination with peptide, viral vectors, carbohydrates and antiidiotypic antibodies. In addition, cell based immunotherapy has been adopted in vitro activated lymphocytes and dendritic cells. Most experience has been acquired in ovarian cancer and cervical cancer. Little has been investigated in endometrial and rare gynecologic neoplasms.The clinical experiences and results achieved with immunotherapy in this setting of patients have been reviewed and the future avenues that are currently being explored have also been discussed.

Clostridium difficile Infection and Candida Colonization of the Gut: Is There a Correlation?

TO THE EDITOR—We read with interest the article of Manian and Bryant about the possible protective role of gut colonization by Candida species against Clostridium difficile infection (CDI) [1]. Although Candida has been involved as part of the normal intestinal microbiota [2], no recent data seem to confirm the authors’ results. Conversely, an opposite role for non-albicans Candida (NAC) colonization was suggested by Nerandzic et al in a trial on 548 patients with CDI [3]. Recent observations conducted in our 1300-bed teaching hospital Policlinico “Umberto I” in Rome showed that patients treated for severe CDI developed at least 1 episode of candidemia, thus hypothesizing a link between CDI and candidemia [4]. We designed a prospective casecontrol study in diarrheic patients with suspected CDI from November 2013 until June 2014 to investigate whether Candida colonization of the gut and CDI may be linked. Stool specimens (n = 140; Bristol stool chart 5–7 [5]) from consecutive patients were evaluated for glutamate dehydrogenase and CD toxin A/B by immunochromatography tests (C-Diff Quick Check Complete, Techlab); positive samples were screened for the C. difficile Pa-Loc gene and for 027 ribotype by reverse transcription polymerase chain reaction (RT-PCR) (GeneXpert, Cepheid, Sweden). Candida was revealed by plating 10 μL of all samples on Sabouraudchloramphenicol agar (Liofilchem, Italy), incubated for 24–48 hours at 37°C. Candida colonization was defined as the growth of ≥10 colony-forming units per milliliter of stool sample. The yeasts were typed through their biochemical profiles (Api ID 32 C, bioMérieux). Mantel-Haenszel test and Stata 11 software were used for statistical analysis; an α error <.05 was accepted. The 140 patients averaged 65 ± 22.98 years of age, and 52% were male. One hundred patients had negative results and 40 positive results for CDI, as revealed by both the immunochromatography reactivity and by the RT-PCR for the Pa-Loc gene presence, which showed that 10 patients were infected by the 027 ribotype. CDI was significantly associated with Candida colonization (83% CDI positive vs 67% CDI negative; χ = 3.91; P < .05). Candida albicans was the species more often implicated ( χ = 4.82; P = .02; Table 1). All except 1 of the ten 027 ribotype–infected patients were colonized by the yeast, 7 of which were C. albicans (χ = 0.37; P = .5). Our data provided evidence that Candida colonization and CDI are linked, thus suggesting a role for the yeast during CDI. The prevalence of yeasts observed in our study was higher than that reported by others [1, 3], probably due to differences in the cultural and typing methods, or to different study populations. Indeed, Manian and Bryant evoked a protective role for Candida in competing with C. difficile, as they observed a lower prevalence of Candida colonization in only 16.7% of the CDIpositive patients. Unfortunately, the authors did not perform any quantitative assessment of Candida growth, referring only to the overgrowth of the yeast covering >50% of an agar plate [1]. Similarly, the higher prevalence of NAC observed in Nerandzic et al’s study (68% NAC vs 32% of C. albicans) can be affected by the storage conditions used in their study [3]. Further studies are in progress to find out a correlation between CDI and candidemia and to reveal the pathogenic mechanisms underlying this association.

Triple peptide vaccination as consolidation treatment in women affected by ovarian and breast cancer: Clinical and immunological data of a phase I/II clinical trial

Vaccination with priming and expansion of tumour reacting T cells is an important therapeutic option to be used in combination with novel checkpoint inhibitors to increase the specificity of the T cell infiltrate and the efficacy of the treatment. In this phase I/II study, 14 high-risk disease-free ovarian (OC) and breast cancer (BC) patients after completion of standard therapies were vaccinated with MUC1, ErbB2 and carcinoembryonic antigen (CEA) HLA-A2+-restricted peptides and Montanide. Patients were subjected to 6 doses of vaccine every two weeks and a recall dose after 3 months. ECOG grade 2 toxicity was observed at the injection site. Eight out of 14 patients showed specific CD8+ T cells to at least one antigen. None of 4 patients vaccinated for compassionate use showed a CD8 activation. An OC patient who suffered from a lymph nodal recurrence, showed specific anti-ErbB2 CD8+ T cells in the bulky aortic lymph nodes suggesting homing of the activated T cells. Results confirm that peptide vaccination strategy is feasible, safe and well tolerated. In particular OC patients appear to show a higher response rate compared to BC patients. Vaccination generates a long-lasting immune response, which is strongly enhanced by recall administrations. The clinical outcome of patients enrolled in the trial appears favourable, having registered no deceased patients with a minimum follow-up of 8 years. These promising data, in line with the results of similar studies, the high compliance of patients observed and the favourable toxicity profile, support future trials of peptide vaccination in clinically disease-free patients who have completed standard treatments.

The Correlation Between Biofilm Production and Catheter-Related Bloodstream Infections Sustained by Candida. A Case Control Study

Biofilm forming capacity of yeasts colonizing the intravenous devices is considered a key factor involved in the pathogenesis of Candida catheter-related bloodstream infections (CCRBSI). The biofilm production of strains of Candida spp. isolated both from the CVC and from the blood of patients with CCRBSI was compared to that of strains isolated from patients not having CCRBSI. Results, expressed in terms of Biofilm Index (BI), revealed that biofilm-producing strains were isolated in the CCRBSI group with a frequency significantly higher than in the non-CCRBSI group (χ2 = 4.25, p = 0.03). The species more frequently cultured was C. parapsilosis complex (including C. parapsilosis sensu stricto, C. orthopsilosis and C. metapsilosis). When this species was isolated from the CVC tip cultures of the CCRBSI group it showed BIs significantly (p = 0.05) higher than those found in the non-CCRBSI group. All the strains of C. tropicalis isolated from the CCRBSI group produced biofilm. Instead most of the isolates of C. glabrata were non-producers. The cumulative BI of non-albicans Candida strains isolated from CCRBSI patients was significantly higher than that of non-albicans strains cultured from patients non-CCRBSI (χ2 = 6.91; p = 0.008). C. albicans was a biofilm producer both in the CCRBSI and in the non-CCRBSI group. When isolated from the blood it showed enhanced biofilm production in the CCRBSI group only, while when colonizing the CVC it displayed high BIs both in the CCRBSI group and in non-CCRBSI group. Our data seem to indicate that the biofilm production capacity should be considered in the clinical management of CCRBSI.

HPV induced triple neoplasms: a case report

The incidence of multiple primary cancers has greatly increased in the last decade. We report the first case of a woman who suffered from 3 distinct HPV-induced neoplasms: cervical, vulvar, and head and neck carcinomas.

Candidaemia in a tertiary care academic hospital in Italy. The impact of C. parapsilosis complex on the species distribution and antifungal susceptibility

Purpose. To analyse the species distribution and the susceptibility profiles to the major antifungal agents of Candida isolated from bloodstream infections (BSIs) in both intensive care units (ICUs) and non‐ICU wards in a tertiary care hospital in Italy from 2010 until 2015. Methodology. Episodes of Candida BSI were recorded in a retrospective observational cohort study. Yeasts were isolated from both blood and intravascuIar devices (IVDs) and their susceptibility to antifungal drugs was tested using the microdilution method. Results. 514 Candida BSIs were evidenced and 19% of these episodes were associated with the presence of an IVD. The trend of the general incidence increased significantly throughout the study period, ranging from 1.42 to 3.63 (mean 2.52) episodes/1000 admissions. The incidence of Candida BSIs and IVD‐associated candidaemia was significantly higher in ICUs relative to the other wards. The most frequently isolated species were C. albicans and C. parapsilosis complex, with the latter presenting a significant increased trend of isolation. C. parapsilosis complex was most frequently involved in IVD‐related candidaemia, coinfections and late recurrent infections. Furthermore, the MIC50s of C. parapsilosis complex were significantly enhanced for echinocandins compared to the MIC50s for the same drugs and the other yeasts, while the MIC50s of C. albicans for amphotericin B showed a significant increase during the study period, ranging from 0.1 to 0.5 &mgr;g ml−1. Conclusions. A progressively enhanced incidence of Candida BSIs, a relatively high impact of C. parapsilosis complex and changes in the susceptibility profiles of the isolated yeasts were evidenced during the observation period.

Preliminary results of a triple peptide escalating dose vaccination phase I/II clinical trial as consolidation treatment in women affected by ovarian cancer.

Ovarian cancer remains one of the most lethal malignancies in developed countries and recently no improvement in disease free survival (DFS) and overall survival (OS) has been numbered for conventional therapies. Immunotherapy could be employed as consolidation treatment after standard therapies in patients in which disease and immune suppression is minimal. Furthermore, epitope spread and new adjutants have been found to significantly increase the efficacy of novel immunotherapic strategies.This Phase I/II study aimed to improve vaccine potency and enhance immune response of two mucins (MUC-1 and CEA) and Erb-B2 tumour associated antigens (TAAs), with the co-administration of a new adjuvant combination: Montanide ISA51 plus GM-CSF. Keyhole Limpet Hemocyanin (KLH) was adopted as immunological tracker.Ten disease-free HLA-A2 aplotype high-risk serous advanced stage ovarian cancer patients underwent a two-groups safety clinical trial vaccination protocol at “Sapienza” University of Rome from 2007 to 2010. CEA, Erb-B2 and MUC1 expression rates on primary tumours were 40%, 30% and 100%, respectively. Group A (8 patients) received 100μg of each peptide per dose accordingly to the immunohistochemically antigen expression, whereas GroupB (2 patients) was vaccinated with all the peptide regardless TAAs expression at the dose of 500μg each. Vaccination schedule included 6 consecutive peptide vaccine administrations and a recall dose at 3 months from the sixth dose. Results revealed the vaccine to be safe and feasible in ovarian cancer patients. Side effects accounts for ECOG scale 1-2 levels signs (itch, erythema and tumescence at injection site) and symptoms (fever, fatigue and malaise), for both the dose-administered. Good compliance was found to vaccine schedule in all patients enrolled. Secondary endpoints results revealed a 5 years 50% (3/6 patients) DFS and a 83% (5/6 patients) OS in FIGO stages IIIc-IV ovarian cancer patients (60%; 6/10 patients). Moreover, immunological and clinical correlation analysis revealed a significant increased IFNγ CD8+ specific T-cells production along with vaccination steps (χ2=6.67; p<0.009) in the subgroup of patients who did not recur vs. controls (mean follow up: 845.1 days; range 55-1523). The highest number of vaccine induced specific CD8+ cells were found at the end of the 6 doses although high levels of T-cells could be also re-induced by the recall boost. A significantly higher specific immune response was observed in the group B.