Immune-modulating effects of bevacizumab in metastatic non-small-cell lung cancer patients

The mPEBev is an anticancer regimen which combines a chemotherapy doublet, based on cisplatin and oral etoposide (mPE), with bevacizumab (mPEBev), a mAb targeting the vasculo-endothelial growth factor (VEGF). In previous studies, this regimen showed powerful anti-angiogenetic effects and significant antitumor activity in metastatic non-small-cell lung cancer (mNSCLC) patients. We also recorded the best benefit in patients exhibiting low-systemic inflammatory profile at baseline. On these bases, we hypothesized that mPEBev antitumor activity could be partially related to bevacizumab-associated immunological effects. For this reason, we performed an immunological monitoring in 59 out of 120 stage IIIb-IV NSCLC patients enrolled in the BEVA2007 phase II trial, who received fractioned cisplatin (30 mg/sqm days 1-3q21) and oral etoposide (50 mg, days 1-15q21) (mPE doublet) ±bevacizumab. In this group of patients, 12 received the mPE doublet alone and 47 the doublet in combination with bevacizumab (5 mg/kg on the day 3q21; mPEBev regimen). Blood cell counts, serum analysis, multiplex cytokine assay and immunocytofluorimetric analysis, performed on baseline and post-treatment on blood samples from these patients, revealed that bevacizumab addition to the doublet decreased levels of pro-angiogenic (VEGF, Angiostatin-1 and Follistatin) and inflammatory cytokines (interferon (IFN)γ, IL4 and IL17), improved in vivo and in vitro cytotoxic T-lymphocytes (CTL) response and promoted dendritic cell activation. These results suggest that the mPEBev regimen improve the micro-environmental conditions for an efficient antigen-specific CTL response, making it a feasible candidate regimen to be assessed in combination with immune-checkpoint inhibitors in NSCLC patients

Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome

Study QuestionWhat is the recommended assessment and management of women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference? Summary AnswerInternational evidence-based guidelines including 166 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of women with PCOS. What is Known AlreadyPrevious guidelines either lacked rigorous evidence-based processes, did not engage consumer and international multidisciplinary perspectives, or were outdated. Diagnosis of PCOS remains controversial and assessment and management are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. Study Design, Size, DurationInternational evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Appraisal of Guidelines for Research and Evaluation (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength. Participants/Materials, Setting, MethodsGovernance included a six continent international advisory and a project board, five guideline development groups (GDGs), and consumer and translation committees. Extensive health professional and consumer engagement informed guideline scope and priorities. Engaged international society-nominated panels included pediatrics, endocrinology, gynecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, public health and other experts, alongside consumers, project management, evidence synthesis, and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Twenty face-to-face meetings over 15months addressed 60 prioritized clinical questions involving 40 systematic and 20 narrative reviews. Evidence-based recommendations were developed and approved via consensus voting within the five guideline panels, modified based on international feedback and peer review, with final recommendations approved across all panels. Main Results and the Role of ChanceThe evidence in the assessment and management of PCOS is generally of low to moderate quality. The guideline provides 31 evidence based recommendations, 59 clinical consensus recommendations and 76 clinical practice points all related to assessment and management of PCOS. Key changes in this guideline include: (a) considerable refinement of individual diagnostic criteria with a focus on improving accuracy of diagnosis; (b) reducing unnecessary testing; (c) increasing focus on education, lifestyle modification, emotional wellbeing and quality of life; and (d) emphasizing evidence based medical therapy and cheaper and safer fertility management. Limitations, Reasons for CautionOverall evidence is generally low to moderate quality, requiring significantly greater research in this neglected, yet common condition, especially around refining specific diagnostic features in PCOS. Regional health system variation is acknowledged and a process for guideline and translation resource adaptation is provided. Wider Implications of the FindingsThe international guideline for the assessment and management of PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program.Peer reviewe

The relationship between organisational characteristics and the effects of clinical guidelines on medical performance in hospitals, a meta-analysis

We are grateful to our colleagues involved in the systematic review of guideline dissemination and implementation strategies across all settings especially Cynthia Fraser, Graeme MacLennan, Craig Ramsay, Paula Whitty, Martin Eccles, Lloyd Matowe, Liz Shirran. The systematic review of guideline dissemination and implementation strategies across all settings was funded by the UK NHS Health Technology Assessment Program. Dr Ruth Thomas is funded by a Wellcome Training Fellowship in Health Services Research. (Grant number GR063790MA). The Health Services Research Unit is funded by the Chief Scientists Office of the Scottish Executive Department of Health. Dr Jeremy Grimshaw holds a Canada Research Chair in Health Knowledge Transfer and Uptake. However the views expressed are those of the authors and not necessarily the funders.Peer reviewedPublisher PD

Prenylation Inhibition-Induced Cell Death in Melanoma: Reduced Sensitivity in BRAF Mutant/PTEN Wild-Type Melanoma Cells.

While targeted therapy brought a new era in the treatment of BRAF mutant melanoma, therapeutic options for non-BRAF mutant cases are still limited. In order to explore the antitumor activity of prenylation inhibition we investigated the response to zoledronic acid treatment in thirteen human melanoma cell lines with known BRAF, NRAS and PTEN mutational status. Effect of zoledronic acid on proliferation, clonogenic potential, apoptosis and migration of melanoma cells as well as the activation of downstream elements of the RAS/RAF pathway were investigated in vitro with SRB, TUNEL and PARP cleavage assays and videomicroscopy and immunoblot measurements, respectively. Subcutaneous and spleen-to-liver colonization xenograft mouse models were used to evaluate the influence of zoledronic acid treatment on primary and disseminated tumor growth of melanoma cells in vivo. Zoledronic acid more efficiently decreased short-term in vitro viability in NRAS mutant cells when compared to BRAF mutant and BRAF/NRAS wild-type cells. In line with this finding, following treatment decreased activation of ribosomal protein S6 was found in NRAS mutant cells. Zoledronic acid demonstrated no significant synergism in cell viability inhibition or apoptosis induction with cisplatin or DTIC treatment in vitro. Importantly, zoledronic acid could inhibit clonogenic growth in the majority of melanoma cell lines except in the three BRAF mutant but PTEN wild-type melanoma lines. A similar pattern was observed in apoptosis induction experiments. In vivo zoledronic acid did not inhibit the subcutaneous growth or spleen-to-liver colonization of melanoma cells. Altogether our data demonstrates that prenylation inhibition may be a novel therapeutic approach in NRAS mutant melanoma. Nevertheless, we also demonstrated that therapeutic sensitivity might be influenced by the PTEN status of BRAF mutant melanoma cells. However, further investigations are needed to identify drugs that have appropriate pharmacological properties to efficiently target prenylation in melanoma cells

Reduced telomere length in individuals with FMR1 premutations and full mutations

We reported previously that 10 older men (66.4±4.6 years) with premutation alleles (55–200 CGG repeats) of the FMR1 gene, with or without FXTAS, had decreased telomere length when compared to sex- and age-matched controls. Extending our use of light intensity measurements from a telomere probe hybridized to interphase preparations, we have now found shortened telomeres in 9 younger male premutation carriers (31.7±17.6 years). We have also shown decreased telomere length in T lymphocytes from 6 male individuals (12.0±1.8 years) with full mutation FMR1 alleles (>200 CGG repeats). These findings support our hypothesis that reduced telomere length is a component of the sub-cellular pathology of FMR1-associated disorders. The experimental approach involved pair-wise comparisons of light intensity values of 20 cells from an individual with either premutation or full mutation CGG-repeat expansions relative to an equivalent number of cells from a sex- and age-matched control. In addition, we demonstrated reduced telomere size in T-lymphocyte cultures from eight individuals with the FMR1 premutation by using six different measures. Four relied on detection of light intensity differences, and two involved measuring the whole chromosome, including the telomere, in microns. This new approach confirmed our findings with light intensity measurements and demonstrated the feasibility of direct linear measurements for detecting reductions in telomere size. We have thus confirmed our hypothesis that reduced telomere length is associated with both premutation and full mutation-FMR1 alleles and have demonstrated that direct measurements of telomere length can reliably detect such reductions

Immune-inflammatory markers predict the outcome of metastatic colorectal cancer patients treated with the thymidylate synthase poly-epitope peptide (TSPP) vaccine: results from a multi-arm TSPP/VAC phase lb program

Abstract Thymidylate synthase (TS) is a tumor-associated enzyme critical for DNA replication. TSPP is a poly-epitope-peptide vaccine to TS, which elicits a multi-epitopic CTL response with antitumor activity in preclinical models. TSPP has been tested in 50 advanced cancer patients enrolled in a multi-arm dose-finding TSPP/VAC1 phase Ib trial program (Eudract:# 2009-016897-33)(Table1) between May 2011 and January 2013. The trial results revealed that TSPP is safe and immune-biologically active, and provided preliminary evidence of a antitumor activity in pretreated mCRC patients (Cusi MG et al 2015 and Correale P et al 2015). This population of 41 patients presented a progression-free-survival and an overall-survival (OS) of 6.9 and 11.3 months, respectively, with a one-year survival rate of 32% (13 patients). We focused on mCRC patients as they represented the most relevant and homogeneous population in the trial. We performed Kaplan-Meier curves, log-rank tests and regression curves to correlate immunobiological findings and patients’ outcome. We found that their OS correlated with lower (under the median) ECOG scores (p:0.039), CEA levels (p:0.021), and serum levels of inflammatory markers (NLR, CRP, ESR, and LDH/LDHNR and ENA; p inferior 0.04) at baseline. Patients’ OS also correlated with greater (over the median) baseline levels of IL4 (p:0.028) and 17 (P:0.049), and with a post-treatment increase in anti-neutrophil-cytoplasm-antibodies/anti-proteinase-3 (Fold change to baseline values grater than 1; p:0.039). Activating K-ras mutations did not correlate with survival, however, inflammatory markers, cytokines, and autoantibodies lost their correlation with the survival in patients bearing these mutations. These results suggest that TSPP-antitumor activity in mCRC patients is affected by their baseline inflammatory/immunological status at baseline. TSPPVAC1 Phase Ib program; patients’ distributionARM A1. ADJ + TSPP 100 μg (n = 3)2. ADJ + TSPP 200 μg (n = 3)3. ADJ + TSPP 300 μg (n = 6)ARM B1. ADJ + TSPP 100 μg + IG-1 (n = 3)2. ADJ + TSPP 200 μg + IG-1 (n = 3)3. ADJ + TSPP 300 μg + IG-1 (n = 3)ARM C (DL1-3)1. GOLFIG + ADJ+TSPP 100 μg + IG-1 (n = 3)2. GOLFIG + ADJ+TSPP 200 μg + IG-1 (n = 3)3. GOLFIG + ADJ+TSPP 300 μg + IG-1 (n = 11)ARM C(DL0) 1. GOLFIG (12 courses) -&amp;gt; ADJ + TSPP 300 μg + IG-1 (n = 10)Figure legend: ADJ = montanide; n = number of patients; IG1 = sc. GM-CSF and sc. Aldesleukine; GOLFIG = gemcitabine + FOLFOX4 polychemotherapy + IG1 regimen Citation Format: Pierpaolo Correale, Cirino Botta, Elodia Claudia Martino, Valerio Nardone, Cristina Ulivieri, Claudia Gandolfo, Tatiana Cosima Baldari, Stefano Lazzi, Alessandro Ginori, Antonella Fioravanti, Giacomo Maria Guidelli, Luigi Pirtoli, Antonio Giordano, Pierfrancesco Tassone, Pierosandro Tagliaferri, Maria Grazia Cusi. Immune-inflammatory markers predict the outcome of metastatic colorectal cancer patients treated with the thymidylate synthase poly-epitope peptide (TSPP) vaccine: results from a multi-arm TSPP/VAC phase Ib program. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2232.</jats:p