Caracterización del perfil inmunitario en sangre periférica y en tejido de carcinoma de mama con tratamiento neoadyuvante. Estudio de su potencial papel pronóstico y predictivo de respuesta

Introducción: Los estudios traslacionales permiten una correcta interrelación entre la investigación básica y la clínica. La imunología, y en concreto la caracterización del perfil inmunitario tanto en sangre como en tejido tumoral va, progresivamente, adquiriendo un papel destacado en la patología tumoral, postulándose que el sistema inmunitario de las pacientes con cáncer es diferente al de la población sana, con un perfil basal predominantemente inmunosupresor y pro-tumoral en las pacientes. En carcinoma de mama, muchos son los estudios donde se destacan mayores respuestas completas patológicas a quimioterapia neoadyuvante (QTNA) en tumores de mama con predominio linfocitario. No solo el porcentaje linfocitario infiltrante, sino los diferentes subtipos celulares del sistema inmunitario influyen en la respuesta a tratamiento y supervivencia de las pacientes con carcinoma de mama en tratamiento neoadyuvante. Así, un perfil inmunocompetente compuesto por linfocitos T CD8+ citotóxicos estaria en relación a mejores respuestas a quimioterapia neoadyuvante y mejores tasas de supervivencia, mientras que un perfil inmunosupresor compuesto por linfocitos T reguladores (Treg FOXP3+), neutrofilos asociados a tumor (TANs) y macrófagos asociados a tumor (TAMs) se asocian a peores resultados, respaldándose al sistema inmunitario como papel clave en la respuesta a la terapia oncológica. Objetivos: Caracterización del perfil inmunitario de las pacientes con carcinoma de mama candidatas a tratamiento neoadyuvante antes y después de la QTNA y comparativa con un grupo de personas sanas. Además, determinar su valor predictivo de respuesta a la QTNA, su valor pronóstico y su correlación con otras características como niveles de vitamina D, subtipo histológico y TNM clínico. Material y métodos: Estudio traslacional prospectivo, reclutándose, de enero de 2011 a mayo de 2013, un total de 47 pacientes con diagnóstico de carcinoma de mama en el Area Hospitalaria Virgen Macarena y consideradas subsidiarias de tratamiento neoadyuvante. Un total de 20 personas sanas formaron el grupo de poblacion sana. Las pacientes recibieron tratamiento neoadyuvante según guías de práctica clínica habitual. Se realizaron análisis de sangre periférica, biopsia de tejido tumoral al diagnóstico y estudio de la pieza quirúrgica post-tratamiento para la caracterización de las poblaciones celulares del perfil inmunitario en tejido mediante técnicas inmunohistoquímicas (linfocitos T CD8+ y Treg FOXP3+) y en sangre periférica mediante citometría de flujo (leucocitos, neutrófilos, linfocitos, monocitos, linfocitos T, linfocitos B, linfocitos NK, linfocitos T CD4+, linfocitos T CD8+, linfocitos Treg y ratios neutrófilos/linfocitos, linfocitos/monocitos, CD4/CD8, CD8/Treg), antes y despues del tratamiento neoadyuvante QTNA. Además, se recogieron las respuestas patológicas alcanzadas (sistema de gradación de Miller & Payne y sistema de estadio TNM patológico), características clinicohistológicas del tumor (inmunofenotipo tumoral y estadio TNM), así como los niveles de vitamina D. Resultados: En las pacientes con carcinoma de mama hay mayores niveles basales en sangre de leucocitos (p = 0.004), neutrófilos (p < 0.001), ratio neutrófilos/linfocitos (p < 0.001) y Treg pro-tumoral (p = 0.028) y menores niveles de células con acción anti-tumoral como linfocitos T (p < 0.001), linfocitos B (p = 0.009), T CD4+ (p < 0.001), T CD8+ (p = 0.001), ratio linfocitos/monocitos (p = 0.018) y CD8/Treg (p < 0.001), respecto a sanas. En las pacientes que no alcanzan RCp tras tratamiento neoadyuvante, se produce una disminución de T CD8+ en tejido y en sangre (p ≤ 0.044); además, hay disminución de Treg en sangre en RCp (p ≤ 0.044). En las pacientes que alcanzan mayor SLE y SG tras tratamiento neoadyuvante, hay descenso de Treg en sangre periférica (p < 0.05) y un aumento del ratio CD4/CD8 en sangre periférica (p = 0.028). No se ha encontrado correlación con los niveles de vitamina D. El subtipo HER2+ tiene una mayor densidad de TILs, en concreto T CD8+ pre/post-QTNA en tejido y en sangre (p = 0.045). Hay una mayor densidad de T CD8+ pre-QTNA en tejido en estadio III y mayor ratio CD4/CD8 post-QTNA en sangre periférica en estadio II (p = 0.002). Conclusiones: El perfil inmunitario de las pacientes con diagnóstico de carcinoma de mama es predominantemente inmunosupresor y diferente al de sanas. El descenso de las poblaciones celulares pro-tumorales y el aumento de las anti-tumorales tras tratamiento neoadyuvante tanto en tejido como en sangre periférica se correlaciona con una mayor RCp y mejor SLE y SG. Son necesarios más estudios con mayor poder estadístico para establecer definitivamente a las poblaciones celulares del sistema inmunitario como potenciales biomarcadores predictivos y pronósticos

Lenalidomide plus R-GDP (R2-GDP) in relapsed/ refractory diffuse large B-cell lymphoma: final results of the R2-GDP-GOTEL trial and immune biomarker subanalysis

Artículo escrito por un elevado número de autores, solo se referencian el que aparece en primer lugar, el nombre del grupo de colaboración, si le hubiere, y los autores pertenecientes a la UAMPurpose: New therapeutic options are needed in relapsed/refracResults: After a median follow-up of 37 months, ORR was tory diffuse large B-cell lymphoma (R/R DLBCL). Lenalidomide-60.2% [37.1% complete responses (CR) and 23.1% partial based schedules can reverse rituximab refractoriness in lymphoma. responses (PR)]. Median OS was 12 months (47 vs. 6 months Patients and Methods: In the phase II R2-GDP trial, 78 in CR vs. no CR); median PFS was 9 months (34 vs. 5 months in patients unsuitable for autologous stem cell transplant received CR vs. no CR). In the primary refractory population, ORR was treatment with the following schedule: lenalidomide 10 mg Days 45.5% (21.2% CR and 24.3% PR). Most common grade 3–4 (D)1–14, rituximab 375 mg/m2 D1, cisplatin 60 mg/m2 D1, adverse events were thrombocytopenia (60.2%), neutropenia gemcitabine 750 mg/m2 D1 and D8, and dexamethasone 20 mg (60.2%), anemia (26.9%), infections (15.3%), and febrile neutroD1–3, up to 6 cycles (induction phase), followed by lenalidomide penia (14.1%). Complete responses were associated with a sharp 10 mg (or last lenalidomide dose received) D1–21 every 28 days decrease in circulating myeloid-derived suppressor cells and (maintenance phase). Primary endpoint was overall response regulatory T cells. rate (ORR). Secondary endpoints included progression-free Conclusions: R2-GDP schedule is feasible and highly active survival (PFS), overall survival (OS), safety, and monitorization in R/R DLBCL, including the primary refractory population. of key circulating immune biomarkers (EU Clinical Trials Reg-Immune biomarkers showed differences in responders versus ister number: EudraCT 2014-001620-29). progressorsThis research was funded by the Spanish Lymphoma Oncology Group (GOTEL) with the financial support of Celgene (Investigator Initiated Trials Program); no grant numbers applicable. L. Hontecillas-Prieto is supported by the Consejería de Salud y Familias, Junta de Andalucía (RH-0047-2021). The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fac

Circulating immune biomarkers in peripheral blood correlate with clinical outcomes in advanced breast cancer

Identification of the different elements intervening at the tumor microenvironment seems key to explain clinical evolution in several tumor types. In this study, a set of immune biomarkers (myeloid derived suppressor cells, regulatory T cells, and OX40 + and PD-1 + T lymphocytes counts) in peripheral blood of patients diagnosed with advanced breast cancer were analyzed along of first line antineoplastic therapy. Subsequently, a comparison between groups with clinical benefit versus progression of disease and with a healthy women cohort was executed. Results reflected that patients showed higher basal levels of myeloid derived suppressor cells (35.43, IR = 180.73 vs 17.53, IR = 16.96 cells/μl; p = 0.001) and regulatory T cells (32.05, IR = 29.84 vs 22.61, IR = 13.57 cells/μl; p = 0.001) in comparison with healthy women. Furthermore, an increase in the number of activated T lymphocytes (expressing OX40), a decrease of immune inhibitory cells (MDSCs and Tregs) and inhibited T lymphocytes (expressing PD-1) were observed along the treatment in patients with clinical benefit (p ≤ 0.001). The opposite trend was observed in the case of disease progression. These findings suggest that some critical immune elements can be easily detected and measured in peripheral blood, which open a new opportunity for translational research, as they seem to be correlated with clinical evolution, at least in ABC.Fundación Progreso y Salud. Junta de Andalucía (PI-0502-2014 FPS-2014

Role of Isolated Limb Perfusion in the Era of Targeted Therapies and Immunotherapy in Melanoma. A Systematic Review of The Literature

Background. Isolated limb perfusion (ILP) is a locoregional procedure indicated by the unresectable melanoma of the limbs. Its complexity and highly demanding multidisciplinary approach means that it is a technique only implemented in a few referral centers around the globe. This report aims to examine its potential role in the era of targeted therapies and immunotherapy by conducting a systematic review of the literature on ILP. Methods. PubMed, Embase and Cochrane Library were searched. The eligibility criteria included publications from 2000–2020 providing valid data o effectiveness, survival or toxicity. Studies in which the perfusion methodology was not clearly described, letters to the editor, non-systematic reviews and studies that applied outdated clinical guidelines were excluded. To rule out studies of a low methodological quality and assess the risk of bias, the following aspects were also required: a detailed description of the applied ILP regimen, the clinical context, follow-up periods, analyzed clinical endpoints, and the number of analyzed ILPs. The disagreements were resolved by consensus. The results are presented in tables and figures. Results. Twenty-seven studies including 2637 ILPs were selected. The median overall response rate was 85%, with a median complete response rate of 58.5%. The median overall survival was 38 months, with a 5-year overall survival of 35%. The toxicity was generally mild according to Wieberdink toxicity criteria. Discussion. ILP still offer a high efficacy in selected patients. The main limitation of our review is the heterogeneity and age of most of the articles, as well as the absence of clinical trials comparing ILP with other procedures, making it difficult to transfer its results to the current era. Conclusions. ILP is still an effective and safe procedure for selected patients with unresectable melanoma of the limbs. In the era of targeted therapies and immunotherapy, ILP remains an acceptable and reasonable palliative treatment alternative, especially to avoid limb amputations. The ongoing clinical trials combining systemic therapies and ILP will provide more valuable information in the future to clarify the potential synergism of both strategies

Circulating myeloid-derived suppressor cells and regulatory T cells as immunological biomarkers in refractory/relapsed diffuse large B-cell lymphoma: translational results from the R2-GDP-GOTEL trial

Background The search for immunological markers with ability of predicting clinical outcome is a priority in lymphomas, and in cancer in general. It is well known that some immunomodulatory cells, such as myeloid derived suppressor cells (MDSCs) or regulatory T cells (Tregs), are recruited by tumors, jeopardizing antitumor immunosurveillance. In this work, we have studied blood levels of these immunosuppressive cells in patients with relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL), prior to and along the course of the experimental rituximab, gemcitabine, dexamethasone, and cisplatin (R2- GDP) schedule, as a translational substudy of the R2-GDP GOTEL trial (EudraCT Number: 2014-001620-29), which included lenalidomide as an immunomodulator. Methods Blood samples were taken before treatment, at cycle 3 and end of induction. Samples were analyzed by flow cytometry. Non-parametric tests were used. Mann-Whitney U test was used to compare basal cells distributions, and Wilcoxon test was considered to compare cells distribution at different times. Spearman test was performed to measure the degree of association between cell populations. Results In this study, MDSC and Treg circulating concentration was found increased in all patients compared with a healthy control group and decreased after treatment only in patients with longest overall survival (>24 months), reaching the levels of the healthy group. Likewise, the number of inhibited T lymphocytes expressing Programmed Death-1 (PD-1) were increased in peripheral blood from patients and decreased on the treatment, whereas activated T lymphocytes increased after therapy in those with better overall survival. Conclusions In conclusion, blood concentration of MDSCs and Treg cells may be good prognostic markers for overall survival after 2 years in R/R DLBCL. These results point to a possible role of these elements in the immunosuppression of these patients, as assessed by the circulating activated and inhibited T lymphocytes, and therefore, they may be considered as therapeutic targets in DLBCL

Lenalidomide plus R-GDP (R2-GDP) in relapsed/refractory diffuse large B-Cell lymphoma: final results of the R2-GDP-GOTEL trial and immune biomarker subanalysis

Purpose: new therapeutic options are needed in relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL). Lenalidomide-based schedules can reverse rituximab refractoriness in lymphoma. Patients and methods: in the phase II R2-GDP trial, 78 patients unsuitable for autologous stem cell transplant received treatment with the following schedule: lenalidomide 10 mg Days (D)1-14, rituximab 375 mg/m2 D1, cisplatin 60 mg/m2 D1, gemcitabine 750 mg/m2 D1 and D8, and dexamethasone 20 mg D1-3, up to 6 cycles (induction phase), followed by lenalidomide 10 mg (or last lenalidomide dose received) D1-21 every 28 days (maintenance phase). Primary endpoint was overall response rate (ORR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), safety, and monitorization of key circulating immune biomarkers (EU Clinical Trials Register number: EudraCT 2014-001620-29). Results: after a median follow-up of 37 months, ORR was 60.2% [37.1% complete responses (CR) and 23.1% partial responses (PR)]. Median OS was 12 months (47 vs. 6 months in CR vs. no CR); median PFS was 9 months (34 vs. 5 months in CR vs. no CR). In the primary refractory population, ORR was 45.5% (21.2% CR and 24.3% PR). Most common grade 3-4 adverse events were thrombocytopenia (60.2%), neutropenia (60.2%), anemia (26.9%), infections (15.3%), and febrile neutropenia (14.1%). Complete responses were associated with a sharp decrease in circulating myeloid-derived suppressor cells and regulatory T cells. Conclusions: R2-GDP schedule is feasible and highly active in R/R DLBCL, including the primary refractory population. Immune biomarkers showed differences in responders versus progressors

Case report

[Introduction] Leptomeningeal dissemination due to HER2-overexpressing breast cancer is a rare and hard to treat complication with short-term dismal prognosis.[Patient concerns] A 34-year-old female previously treated because of HER2+ breast cancer is admitted to the Neurology Department in December 2016 due to sensory-motor neurological semiology.[Diagnosis] A wide set of diagnostic tests is performed and finally cytologic findings after repeated CSF confirm leptomeningeal infiltration by breast carcinoma (panCK+, GATA3+).[Interventions] Weekly intrathecal triple therapy with methotrexate, cytarabine and hydrocortisone plus trastuzumab is carried out during 4 months.[Outcomes] Clinical and pathological response that lasts more than 24 months.[Conclusion] Leptomeningeal carcinomatosis is an oncological situation where conventional therapies have limited activity. In HER2+ advanced breast cancer patients, intrathecal therapy with anti-HER2 therapy (trastuzumab) is feasible and may reach long-term disease control, especially in cases of low-tumor burden

Tumor Immune Microenvironment in Lymphoma: Focus on Epigenetics.

Lymphoma is a neoplasm arising from B or T lymphocytes or natural killer cells characterized by clonal lymphoproliferation. This tumor comprises a diverse and heterogeneous group of malignancies with distinct clinical, histopathological, and molecular characteristics. Despite advances in lymphoma treatment, clinical outcomes of patients with relapsed or refractory disease remain poor. Thus, a deeper understanding of molecular pathogenesis and tumor progression of lymphoma is required. Epigenetic alterations contribute to cancer initiation, progression, and drug resistance. In fact, over the past decade, dysregulation of epigenetic mechanisms has been identified in lymphomas, and the knowledge of the epigenetic aberrations has led to the emergence of the promising epigenetic therapy field in lymphoma tumors. However, epigenetic aberrations in lymphoma not only have been found in tumor cells, but also in cells from the tumor microenvironment, such as immune cells. Whereas the epigenetic dysregulation in lymphoma cells is being intensively investigated, there are limited studies regarding the epigenetic mechanisms that affect the functions of immune cells from the tumor microenvironment in lymphoma. Therefore, this review tries to provide a general overview of epigenetic alterations that affect both lymphoma cells and infiltrating immune cells within the tumor, as well as the epigenetic cross-talk between them

Increased Blood Monocytic Myeloid Derived Suppressor Cells but Low Regulatory T Lymphocytes in Patients with Mild COVID-19

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may produce a systemic disease, the coronavirus disease-19 (COVID-19), with high morbidity and mortality. Even though we do not fully understand the interaction of innate and adaptive immunity in the control and complications of the viral infection, it is well recognized that SARS-CoV-2 induces an immunodepression that impairs the elimination of the virus and favors its rapid dissemination in the organism. Even less is known about the possible participation of inhibitory cells of the innate immune system, such as the myeloid-derived suppressor cells (MDSCs), or the adaptive immune system, such as the T regulatory cells (Tregs). That is why we aimed to study blood levels of MDSCs, as well as lymphocyte subpopulations, including Tregs, and activated (OX-40+) and inhibited (PD-1) T lymphocytes in patients with mild COVID-19 in comparison with data obtained from control donors. We have found that 20 hospitalized patients with COVID-19 and no health history of immunosuppression had a significant increase in the number of peripheral monocytic MDSCs (M-MDSC), but a decrease in Tregs, as well as an increase in the number of inhibited or exhausted T cells, whereas the number of activated T cells was significantly decreased compared with that from 20 healthy controls. Moreover, there was a significant negative correlation (r = 0.496) between the number of M-MDSC and the number of activated T cells. Therefore, M-MDSC rather than Tregs may contribute to the immunosuppression observed in patients with COVID-19.S.-M. received support from Junta de Andalucia and University of Seville (PAIDI CTS-151 group), A.P. and J.R.-B. receive support for research from Plan Nacional de I+D+i 2013–2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), cofinanced by European Development Regional Fund “A way to achieve Europe,” Operative Program Intelligence Growth 2014–2020. LdC-M received support from the Asociación de Mujeres con Cáncer de Mama (AMAMA Sevilla), Fundación Sandra Ibarra, and Asociación de Cáncer de Mama de Brenes

Persistence of SARS-CoV-2 Infection in Severely Immunocompromised Patients With Complete Remission B-Cell Lymphoma and Anti-CD20 Monoclonal Antibody Therapy: A Case Report of Two Cases

Immunosuppressant conditions such as hematological malignancies increase the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It has been described in the literature that patients on anti-CD20 maintenance therapies for lymphoid malignancies are susceptible to having recurrent flares together with viral replication or reinfections, although these cases are scarce. These patients are not well represented in randomized controlled trials, and as a consequence, the evidence for the use of certain treatments in this scenario is lacking. We present two cases of patients with B-cell lymphoma on remission and treated with rituximab on maintenance. They developed at least 1 flare of coronavirus disease 2019 (COVID-19) after acute infection and always after receiving rituximab. RT-PCR was positive in the nasopharyngeal swab and also in plasma. Patients were treated during flares with remdesivir, hyperimmune plasma, and corticosteroids. These two cases showed the unresolved problem of COVID-19 in immunosuppressant patients and showed that despite the vast amount of information available on SARS-CoV-2, information in this subgroup of patients is lacking.This study was supported by Plan Nacional de I+D+i 2013‐2016, Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001)—cofinanced by the European Development Regional Fund “A way to achieve Europe”, Operative Program Intelligence Growth 2014‐2020.Peer reviewe