High feasibility and antileukemic efficacy of fludarabine, cytarabine, and idarubicin (FLAI) induction followed by risk-oriented consolidation: A critical review of a 10-year, single-center experience in younger, non M3 AML patients

About 105 consecutive acute myeloid leukemia (AML) patients treated with the same induction-consolidation program between 2004 and 2013 were retrospectively analyzed. Median age was 47 years. The first induction course included fludarabine (Flu) and high-dose cytarabine (Ara-C) plus idarubicin (Ida), with or without gemtuzumab-ozogamicin (GO) 3 mg/m2 (FLAI-5). Patients achieving complete remission (CR) received a second course without fludarabine but with higher dose of idarubicin. Patients not achieving CR received an intensified second course. Patients not scheduled for early allogeneic bone marrow transplantation (HSCT) where planned to receive at least two courses of consolidation therapy with Ara-C. Our double induction strategy significantly differs from described fludarabine-containing regimens, as patients achieving CR receive a second course without fludarabine, to avoid excess toxicity, and Ara-C consolidation is administrated at the reduced cumulative dose of 8 g/m2 per cycle. Toxicity is a major concern in fludarabine containing induction, including the recent Medical Research Council AML15 fludarabine, cytarabine, idaraubicin and G-CSF (FLAG-Ida) arm, and, despite higher anti-leukemic efficacy, only a minority of patients is able to complete the full planned program. In this article, we show that our therapeutic program is generally well tolerated, as most patients were able to receive subsequent therapy at full dose and in a timely manner, with a 30-day mortality of 4.8%. The omission of fludarabine in the second course did not reduce efficacy, as a CR rate of 83% was achieved and 3-year disease-free survival and overall survival (OS) were 49.6% and 50.9%, respectively. Our experience shows that FLAI-5/Ara-C + Ida double induction followed by risk-oriented consolidation therapy can result in good overall outcome with acceptable toxicity. Am. J. Hematol. 91:755\u2013762, 2016. \ua9 2016 Wiley Periodicals, Inc

Innovative Clinical\u2010Organizational Model to Ensure Appropriateness and Quality in the Management of Medical Cannabis: An Italian Regional Case

This work focuses on the clinical\u2010organizational model implemented in an Italian region (Liguria) to streamline the access procedures to galenic cannabis preparations. The competent local health care authority that takes care of tracing a virtuous path to obtain common, uniform and shared protocols and ensure high standards of care is A.Li.Sa. (Azienda Ligure Sanitaria), a public organization with the function of coordination, direction and governance of the health care in the regional hospitals and health facilities. To this purpose, different working groups and a board meeting have been set up with the main role to define and develop technical standards to be applied to the prescription, preparation and dispensing of pharmaceutical forms based on therapeutic cannabis. In particular, the galenic preparations provided by the Italian Ministry of Health, described in detail in the regional standard operating protocols, are described and discussed. Moreover, the most significant data monitored from 2018 to 2020 and collected by hospitals and the evaluation of those derived from local pharmacies and health facilities are presented, discussed and compared in regards to their adherence and coherence with the Italian Institute of Health (ISS) data

Doxorubicin impairs the insulin-like growth factor-1 system and causes insulin-like growth factor-1 resistance in cardiomyocytes.

Insulin-like growth factor-1 (IGF-1) promotes the survival of cardiomyocytes by activating type 1 IGF receptor (IGF-1R). Within the myocardium, IGF-1 action is modulated by IGF binding protein-3 (IGFBP-3), which sequesters IGF-1 away from IGF-1R. Since cardiomyocyte apoptosis is implicated in anthracycline cardiotoxicity, we investigated the effects of the anthracycline, doxorubicin, on the IGF-1 system in H9c2 cardiomyocytes.Besides inducing apoptosis, concentrations of doxorubicin comparable to those observed in patients after bolus infusion (0.1-1 µM) caused a progressive decrease in IGF-1R and increase in IGFBP-3 expression. Exogenous IGF-1 was capable to rescue cardiomyocytes from apoptosis triggered by 0.1 and 0.5 µM, but not 1 µM doxorubicin. The loss of response to IGF-1 was paralleled by a significant reduction in IGF-1 availability and signaling, as assessed by free hormone levels in conditioned media and Akt phosphorylation in cell lysates, respectively. Doxorubicin also dose-dependently induced p53, which is known to repress the transcription of IGF1R and induce that of IGFBP3. Pre-treatment with the p53 inhibitor, pifithrin-α, prevented apoptosis and the changes in IGF-1R and IGFBP-3 elicited by doxorubicin. The decrease in IGF-1R and increase in IGFBP-3, as well as apoptosis, were also antagonized by pre-treatment with the antioxidant agents, N-acetylcysteine, dexrazoxane, and carvedilol.Doxorubicin down-regulates IGF-1R and up-regulates IGFBP-3 via p53 and oxidative stress in H9c2 cells. This leads to resistance to IGF-1 that may contribute to doxorubicin-initiated apoptosis. Further studies are needed to confirm these findings in human cardiomyocytes and explore the possibility of manipulating the IGF-1 axis to protect against anthracycline cardiotoxicity

Targeting the Epidermal Growth Factor Receptor Can Counteract the Inhibition of Natural Killer Cell Function Exerted by Colorectal Tumor-Associated Fibroblasts

Mesenchymal stromal cells (MSC) present in the tumor microenvironment [usually named tumor-associated fibroblasts (TAF)] can exert immunosuppressive effects on T and natural killer (NK) lymphocytes, favoring tumor immune escape. We have analyzed this mechanism in colorectal carcinoma (CRC) and found that co-culture of NK cells with TAF can prevent the IL-2-mediated NKG2D upregulation. This leads to the impairment of NKG2D-mediated recognition of CRC cells, sparing the NK cell activation through DNAM1 or FcγRIIIA (CD16). In situ, TAF express detectable levels of epidermal growth factor receptor (EGFR); thus, the therapeutic anti-EGFR humanized antibody cetuximab can trigger the antibody-dependent cellular cytotoxicity of TAF, through the engagement of FcγRIIIA on NK cells. Importantly, in the tumor, we found a lymphoid infiltrate containing NKp46+CD3− NK cells, enriched in CD16+ cells. This population, sorted and cultured with IL-2, could be triggered via CD16 and via NKG2D. Of note, ex vivo NKp46+CD3− cells were able to kill autologous TAF; in vivo, this might represent a control mechanism to reduce TAF-mediated regulatory effect on NK cell function. Altogether, these findings suggest that MSC from the neoplastic mucosa (TAF) of CRC patients can downregulate the immune cell recognition of CRC tumor cells. This immunosuppression can be relieved by the anti-EGFR antibody used in CRC immunotherapy

Titolazioni dei preparati galenici oleosi a base di cannabis in Regione Liguria: progetto sperimentale dei laboratori di riferimento regionale

Analysis of cannabinoids concentration in cannabis oil galenic preparations in the Liguria Region: experimental project of the regional reference laboratories. Introduction: the medical use of cannabis is increasingly being applied in the treatment and support of several diseases and syndromes. In the Liguria Region, olive oil galenic preparations are mainly prepared by hospital pharmacies, according to common standard procedures. The preparations must be analyzed in order to establish the concentration of the two main active compounds (delta-9 tetrahydrocannabinol, THC and cannabidiol, CBD) thus allowing the correct setting of the therapeutic prescription. Liguria Region is at the forefront in the use of medical cannabis with a high number of patients treated (>1000). The aim of this work is to describe the organization of the titration activity centralized at the two regional reference laboratories (Central Laboratory of Analyses of Giannina Gaslini Institute, Genova and Toxicology Laboratory of Sarzana, La Spezia), coordinated by the inter-hospital department (DIAR) of the Laboratories Area. Methods: the phases of the analytical process (pre-analytical, analytical and post-analytical) have been identified and described. The analysis of the workflow has been carried out including the methods to prepare cannabis oil in the pharmacies, the intervals and production volumes, the medical-legal handling requirements and operational responsibilities. The definition of the pre-analytical phase foresees the methods of packaging, transport and recording of the samples and related responsibilities. Results: the analytical phase included the development and validation of the analytical method Ultra High Performance Liquid Chromatography coupled to tandem mass spectrometry, (UHPLC-MS/MS) in the two laboratories, with common procedures and the comparison of results conducted both on reference material and real samples of olive oil galenic preparations. The definition of the post-analytical phase included the reporting procedures. Discussion: the experimental phase has been concluded at the end of 2019 and the implementation phase of the project has started in march 2020

Antioxidants reverse doxorubicin-initiated apoptosis and IGF-1R /IGFBP-3 perturbation.

<p>Frequency of apoptotic cells (A) and IGF-1R and IGFBP-3 expression (representative western blot in B and densitometry of western blot bands in C) 24 hours after no treatment (Ctr) or incubation of H9c2 cardiomyocytes with 1 μM doxorubicin (Dox) with or without pre-treatment with N-acetylcysteine (NAC), dexrazoxane (DEX), or carvedilol (CARV). *, P <0.05 vs. Ctr; **, P <0.01 vs. Ctr; ***, P <0.001 vs. Ctr; ****, P <0.0001 vs. Ctr. #, P <0.05 vs. Dox 1; ^, P <0.01 vs. Dox 1.</p

Effect of exogenous IGF-1 on doxorubicin-induced apoptosis of H9c2 cells: TUNEL and caspase 3/7 activity.

<p>Frequency of apoptotic cells, as assessed by TUNEL (A; representative microphotographs are shown in B) and fluorescence (AUF) produced by the cleavage of a substrate of activated caspase 3/7 (C), 24 hours after no treatment (Ctr) or incubation of H9c2 cardiomyocytes with doxorubicin (Dox) ± IGF-1 at the indicated concentrations. ***, P <0.001 vs. Ctr. c, P <0.001 vs. Dox 0.1; d, P <0.001 vs. Dox 0.5; e, P <0.01 vs. Dox 0.1; f, P <0.05 vs. Dox 0.5. ¥, P <0.001 vs. Dox 0.1 + IGF-1 100; ¢, P <0.001 vs. Dox 0.1 + IGF-1 100 and Dox 0.5 + IGF-1 100.</p

Involvement of p53 in the change in IGF-1R /IGFBP-3 levels caused by doxorubicin.

<p>(A) Representative western blot and band densitometry for p53 24 hours after no treatment (Ctr) or incubation of H9c2 cardiomyocytes with 0.1, 0.5, or 1 μM doxorubicin (Dox). (B and C) IGF-1R/IGFBP-3 expression (band densitometry and representative western blot, B) and annexin V/propidium iodide positivity (C) in H9c2 cardiomyocytes untreated or exposed to 1 μM Dox with or without pre-treatment with PFT-α. *, P <0.05 vs. Ctr; ***, P <0.001 vs. Ctr. ^, P <0.01 vs. Dox 1.</p

Effect of exogenous IGF-1 on doxorubicin-induced apoptosis of H9c2 cells: annexin V/propidium iodide.

<p>Frequency of apoptotic cells, as assessed by annexin V/propidium iodide staining, 24 hours after no treatment (Ctr) or incubation of H9c2 cardiomyocytes with doxorubicin (Dox) ± IGF-1 at the indicated concentrations. *, P <0.05 vs. Ctr; **, P <0.01 vs. Ctr; ***, P <0.001 vs. Ctr. e, P <0.01 vs. Dox 0.1; ¶, P <0.05 vs. IGF-1 0.01.</p