Prognosis in advanced lung cancer - a prospective study of examining key clinicopathological factors

AbstractObjectivesIn patients with advanced incurable lung cancer deciding as to the most appropriate treatment (e.g. chemotherapy or supportive care only) is challenging. In such patients the TNM classification system has reached its ceiling therefore other factors are used to assess prognosis and as such, guide treatment. Performance status (PS), weight loss and inflammatory biomarkers (Glasgow Prognostic Score (mGPS)) predict survival in advanced lung cancer however these have not been compared. This study compares key prognostic factors in advanced lung cancer.Materials and methodsPatients with newly diagnosed advanced lung cancer were recruited and demographics, weight loss, other prognostic factors (mGPS, PS) were collected. Kaplan–Meier and Cox regression methods were used to compare these prognostic factors.Results390 patients with advanced incurable lung cancer were recruited; 341 were male, median age was 66 years (IQR 59–73) and patients had stage IV non-small cell (n=288) (73.8%) or extensive stage small cell lung cancer (n=102) (26.2%). The median survival was 7.8 months. On multivariate analysis only performance status (HR 1.74 CI 1.50–2.02) and mGPS (HR 1.67, CI 1.40–2.00) predicted survival (p<0.001). Survival at 3 months ranged from 99% (ECOG 0–1) to 74% (ECOG 2) and using mGPS, from 99% (mGPS0) to 71% (mGPS2). In combination, survival ranged from 99% (mGPS 0, ECOG 0–1) to 33% (mGPS2, ECOG 3).ConclusionPerformance status and the mGPS are superior prognostic factors in advanced lung cancer. In combination, these improved survival prediction compared with either alone

The effect of chemotherapy with or without the antiangiogenic agent Bevacizumab on the immunosuppressive cells in patients with non-small cell lung cancer

Introduction: Lung cancer (LC) is among the most frequent type of malignancies, accounting for 13% of the newly diagnosed cases worldwide in 2012. Non-small-cell lung cancer (NSCLC) represents almost 85% of the total number of LC diagnoses and can be further classified into different subtypes based on the expression of certain molecular and histological features. Cancer-related Inflammation has been identified as a hallmark of cancer. Host immune system interacts with tumor cells in a complex and paradoxical process that has been shown to consist of three phases: elimination, equilibrium and escape. During the escape phase tumor cells have acquired the ability to evade immune surveillance by establishing an immunosuppressive tumor microenvironment and begin to grow uncontrollably. A wide range of cytokines released by either tumor cells or other cells in the tumor stroma appear to disrupt the balance between the antitumor immune response and immune tolerance and play a crucial role in the development of potent immunosuppressive mechanisms by inducing immunosuppressive cells, including myeloid-derived suppressive cells (MDSCs) and regulatory T cells (Treg), in both the tumor microenvironment and the peripheral blood of cancer patients.Vascular endothelial growth factor (VEGF) is the principal mediator and key promoter of tumor angiogenesis. Recent data suggest a multifaceted inhibitory effect of VEGF on the development of a potent antitumor immune response. Mechanisms underlying the immunosuppressive capacity of VEGF have been found to include inhibition of maturation of dendritic cells, promotion of MDSCs migration and selective accumulation in tumor sites and induction of Treg proliferation and enhancement of their suppressive functionality. Taking into consideration the proposed link between VEGF and immunosuppression, it can be hypothesized that, the monoclonal antibody against VEGF, bevacizumab may be useful in reversing tumor-induced immune tolerance.There is a growing body of evidence that links MDSC-, Treg- and VEGF-induced immunosuppression to tumor development and progression. Accumulating data suggest that the presence of these cells in the peripheral blood and in the tumor microenvironment is significantly associated with the patients’ clinical outcome and survival. However, there is no consensus on the phenotypic and functional characterization of these cells in NSCLC patients. Furthermore, there are limited data regarding the effect of first-line chemotherapy, with or without anti-VEGF therapy, on the frequency and functionality of these cells in patients with NSCLC. The aim of this study was to identify, phenotypically and functionally characterize subpopulations of MDSCs and Treg in the peripheral blood of NSCLC patients, determine their frequency at diagnosis and evaluate their prognostic significance. Additionally, the methodology developed allowed the study of the effect of chemotherapy, with or without the addition of bevacizumab, on the functionality and the levels of circulating immunosuppressive cells (Treg/MDSCs) and the correlation of their changes with the clinical outcome. Patients and methods: Peripheral blood was collected from newly diagnosed, treatment-naïve patients with stage IIIB/IV NSCLC before initiation of treatment, after the 3rd cycle of chemotherapy, as well as at the time of disease progression. Blood samples from aged- and sex-matched healthy volunteers were used as normal controls. Various subpopulations of MDSCs and Treg were identified and analyzed using flow cytometry. Their immunosuppressive activity was assessed by demonstrating their inhibitory effect on IFN-γ production by activated T-cells. Results: Phenotypic characterization of MDSCs subpopulations with clinical significance and their prognostic role in treatment-naïve patients with NSCLC: A total of 110 patients were enrolled in this study. The patients’ median age was 68 years. Approximately, 84.5% were men, 51.8% had adenocarcinoma and 74.5% had stage IV disease. Briefly, three new subpopulations of MDSCs were identified in patients with NSCLC: two monocytic [CD14+CD15−CD11b+CD33+HLA-DR−Lin− (CD15−M-MDSCs) and CD14+CD15+CD11b+CD33+HLA-DR−Lin− (CD15+ M-MDSCs)] and one granulocytic [CD14−CD15+CD11b+CD33+HLA-DR−Lin− (G-MDSCs)]. The levels of these MDSCs subpopulations were significantly increased in the peripheral blood of the patients compared to healthy donors [(CD15+ M-MDSCs, 3.5 ± 0.5% versus 0.5 ± 0.2%, p≤0.0001), (CD15− M-MDSCs, 5.2 ± 0.5% versus 3 ± 0.8%, p=0.04) and (G-MDSCs, 2 ± 0.5% versus 0.1 ± 0.02%, p≤ 0.0001)]. However, the difference in the frequency of these subpopulations among patients with stage III disease and those with stage IV disease was not statistically significant. Patients who progressed after 3 cycles of treatment had higher M-MDSCs levels prior to initiation of treatment (CD14+CD15+HLA-DR−Lin−: 1.1 ± 0.3% and CD14+CD15−HLA-DR−Lin−: 5.5 ± 1.1%) compared to those with disease control (CR, PR and SD) (0.6 ± 0.07%, p=0.02 and 2.9 ± 0.3%, p=0.02, respectively). Moreover, MDSCs’ percentage within the “normal range” (levels within the 90% of the healthy controls) prior to initiation of therapy was associated with a longer progression-free survival (PFS) and overall survival (OS) compared to increased (>90% of the healthy controls) MDSCs’ levels (10.87 versus 5.3 months, p=0.005 and 12.9 versus 7.1 months, p=0.008, respectively). In the multivariate analysis, increased frequency of circulating CD15+ Μ-MDSCs before treatment initiation was identified as an independent prognostic factor for poor survival (PFS: HR = 2.41, 95% CI: 1.37–4.24, p=0.002 and OS: HR = 2.35, 95% CI: 1.25–4.41, p=0.008). Finally, it was demonstrated that these MDSCs subpopulations are functional and suppress the production of IFN-γ by activated CD3+ T cells. Effect of treatment on the MDSCs’ subpopulations in the peripheral blood of patients with NSCLC: A total of 46 patients were included, 33 on the chemotherapy arm and 13 on the chemotherapy plus bevacizumab arm. The patients’ median age was 68 and 85% were male. After 3 cycles of treatment, 24% of the patients experienced PR, 67% SD and 9% PD.Overall, chemotherapy did not appear to have a uniform or significant impact on the levels or the functionality of the various subpopulations of circulating MDSCs. However, three cycles of bevacizumab-based chemotherapy resulted in a statistically significant decrease in the levels of the G-MDSCs subpopulation compared to regimens that did not include bevacizumab (mean change in percentages of G-MDSCs with the bevacizumab-based versus non–bevacizumab-based regimens: –0.68% ± 0.34% versus 0.69% ± 0.38%, p=0.0086). Furthermore, after 3 cycles of treatment, patients experiencing PD had significantly increased levels of all three MDSCs subpopulations compared to the levels in patients that responded (CR+PR+SD) to treatment. Interestingly, patients with PD had a statistically significant increase in the percentage of CD15+ M-MDSCs compared to the pre-treatment levels (p=0.03). Phenotypic characterization of Treg subpopulations with clinical significance and their prognostic role in treatment-naïve patients with NSCLC: A total of 156 patients with NSCLC were enrolled in this study. The patients’ median age was 62 years, 82.1% were male, 57.6% had adenocarcinoma and 82.1% had stage IV disease.Briefly, the levels of CD4+CD25+ Treg were significantly increased in the peripheral blood of the patients compared to healthy donors (24.81 ± 1% versus 14.67 ± 1.5%, respectively, p= 0.0002). Depending on the stage of activation and differentiation, three CD4+ Treg subtypes were further analyzed: naive, effector and terminal effector Treg. Patients with PD as best response to first line treatment had increased percentage of naive Treg (CD25highCD127-/lowCD152-FoxP3lowCD45RO–) prior to treatment initiation compared to those with disease control (CR, PR and SD) (3.17 ± 0.58% versus 0.81 ± 0.33%, respectively, p=0.003). Moreover, increased (>90% of the healthy controls) levels of naïve Treg at baseline were associated with significantly shorter OS compared to that of patients with Treg percentage within the normal range (levels within the 90% of the healthy controls) (OS: 18.37 versus 40.47 months, respectively, p=0.039). Similarly, patients with increased levels of effector Treg(CD25highCD127lowCD152+FoxP3+CD45RO+) before treatment initiation had significantly shorter PFS (6.8 versus 8.53 months, p=0.046) and OS (5 versus 15.37 months, p=0.037) relative to that of patients with Treg levels within the normal range. In contrast, patients experiencing PD had significantly lower levels of terminal effector Treg (CD25highCD127-CD152+FoxP3+CD45RO+) at baseline compared to those with disease control (PD versus CR+PR+SD: 7.48 ± 1.27% versus 14.08 ± 2.74%, respectively, p=0.04). Moreover, increased levels of terminal effector Treg were associated with longer PFS (16.2 versus 7.5 months respectively, p=0.03) and OS (undefined versus 12.63 months, respectively, p=0.049). Multivariate analysis revealed that increased frequency of circulating naive Treg at baseline is an independent prognostic factor for poor OS (HR = 8.632, 95% CI: 2.226-33.468, p=0.002). Finally, it was found that, all the above described, Treg subpopulations, regardless of their activation and differentiation stage, are functional and suppress the production of IFN-γ by activated CD4+ T cells. Effect of treatment on the Treg subtypes in the peripheral blood of patients with NSCLC: A total of 46 patients were included in this study, the same patients analyzed for the effect of treatment on MDSCs. Blood samples were obtained before initiation of first-line therapy and after 3 cycles of treatment. Overall, chemotherapy was not associated with a significant change in the levels of the CD4+CD25highCD127−CD152+FoxP3+ Treg, in the peripheral blood of the patients. However, after three cycles of bevacizumab-based chemotherapy, patients receiving bevacizumab had statistically significant decreased levels of CD4+CD25highCD127−CD152+FoxP3+ Treg compared to patients who did not receive bevacizumab (percentages after 3 cycles of treatment with bevacizumab-based versus non-bevacizumab-based regimens: 14.81 ± 4.615% versus 36.44 ± 4.506%, p=0.0058). In particular, regarding naive Treg, patients who received 3 cycles of bevacizumab-based treatment had statistically significantly lower cell counts compared to patients who did not receive bevacizumab (naive Treg percetnage after 3 cycles of treatment, bevacizumab versus non-bevacizumab based treatment: 0.6273 ± 0.345% versus 3.44 ± 1.076%, p=0.019). In contrast, non-bevacizumab based chemotherapy was associated with a statistically significant increase in the naive Treg levels in the peripheral blood of the patients (naive Treg pre- and after 3 cycles of treatment without bevacizumab: 1.456 ± 0.353% versus 3.44 ± 1.076% respectively, p=0.045). There was no statistically significant difference in the levels of effector Treg between patients treated with or without the addition of bevacizumab (mean change in effector Treg percentage, bevacizumab based versus non-bevacizumab based regimens: 0.3818 ± 1.54% versus -1.59 ± 3.2%, p=0.49). Finally, after 3 cycles of treatment, patients treated with bevacizumab had decreased levels of terminal effector Treg compared to patients who did not receive bevacizumab (terminal effector Treg percentage after 3 cycles of treatment, bevacizumab based versus non-bevacizumab regimens: 7.3 ± 2.958% versus 15.72 ± 3.128%, p=0.059). Conclusions: In conclusion, this study precisely defines, phenotypically and functionally, distinct MDSCs and Treg subpopulations with prognostic significance in the peripheral blood of patients with NSCLC. Quantification of their frequency in the peripheral blood has emerged as an independent prognostic factor for survival in patients with NSCLC, highlighting the potential clinical utility of the particular biomarker. The selective targeting of specific MDSCs and Treg subpopulations through bevacizumab-based treatment provides evidence for the immunomodulating effect of anti-angiogenic therapy and bevacizumab emerges as a promising agent in “taking the foot off the brake of immunosuppression”. Nevertheless, these experimental and clinical findings remain to be confirmed prospectively in future randomized clinical trials enrolling more patients with more homogeneity in the histological type, the disease burden and the treatment that they receive. At the same time, efforts should be mounted toward linking the levels of the circulating MDSCs and Treg with their frequency in the tumor microenvironment, where they exert their immunosuppressive action. Improving the understanding of the biology and the functionality of MDSCs and Treg is considered to be of paramount importance for the development of novel strategies to efficiently detect, quantify and, finally, target tumor-induced immunosuppression.Εισαγωγή: Ο καρκίνος του πνεύμονα είναι μία από τις συχνότερες νεοπλασίες, αντιπροσωπεύοντας το 13% των νέων διαγνώσεων καρκίνου παγκοσμίως κατά το έτος 2012. Ο ΜΜΚΠ είναι ο πιο συχνός τύπος καρκίνου του πνεύμονα (~85% των περιπτώσεων) και διακρίνεται περαιτέρω σε διάφορους υπότυπους (αδενοκαρκίνωμα, πλακώδες καρκίνωμα, κτλ) με βάση μοριακά και ιστολογικά χαρακτηριστικά. Ο κεντρικός ρόλος της φλεγμονώδους διαδικασίας και των κυττάρων του ανοσοποιητικού συστήματος κατά την καρκινογένεση έχει σε σημαντικό βαθμό ήδη αποδειχθεί. Το ανοσοποιητικό σύστημα του ξενιστή αλληλεπιδρά με τα καρκινικά κύτταρα μέσω μίας παράδοξης διαδικασίας που μπορεί να διακριθεί σε τρία στάδια: 1) το στάδιο της εξάλλειψης (elimination), 2) το στάδιο της ισορροπίας/ανοσοελέγχου (equilibrium) και 3) το στάδιο της ανοσοδιαφυγής (escape), όπου τα νεοπλασματικά κύτταρα εγκαθιστώντας ένα ανοσοκατασταλτικό μικροπεριβάλλον διαφεύγουν της ανοσολογικής επιτήρησης και πολλαπλασιάζονται πλέον ανεξέλεγκτα. Μεταξύ των ισχυρότερων αναστολέων της αντινεοπλασματικής ανοσολογικής απάντησης είναι τα Τ-ρυθμιστικά κύτταρα (Treg) και τα άωρα μυελοειδή κατασταλτικά κύτταρα (MDSCs). Ωστόσο, τα δεδομένα που υπάρχουν για το ρόλο των MDSCs και των Treg σε ασθενείς με ΜΜΚΠ είναι περιορισμένα.Ο VEGF είναι ο ισχυρότερος ρυθμιστής της νέο-αγγειογένεσης. Πρόσφατα δεδομένα υποστηρίζουν μία πολύπλευρη και ισχυρή κατασταλτική επίδραση του VEGF στην αντινεοπλασματική ανοσολογική απάντηση. Μεταξύ των προτεινόμενων μηχανισμών περιλαμβάνονται η αναστολή της ωρίμανσης των δενδριτικών κυττάρων, η προσέλκυση MDSCs στην περιοχή του όγκου και η προαγωγή του πολλαπλασιασμού των Treg. Λαμβάνοντας υπόψη την προτεινόμενη σχέση ανάμεσα στο VEGF και την ανοσοκαταστολή , το bevacizumab (μονοκλωνικό αντίσωμα έναντι του VEGF) μπορεί να έχει έναν ισχυρό ρόλο στην αναστροφή του «μικροπεριβάλλοντος ανοσολογικής ανοχής» που δημιουργεί ο καρκίνος.Με βάση τα προαναφερθέντα, γίνεται αντιληπτό ότι ένα ευρύ δίκτυο επικοινωνίας μεταξύ καρκινικών και ανοσοκατασταλτικών κυττάρων συμμετέχει και, πιθανώς, συνεισφέρει στην εξέλιξη της νεοπλασματικής νόσου. Τον ρόλο του διαμεσολαβητή σε αυτή την αλληλεπίδραση έχουν ποικίλες ουσίες, συμπεριλαμβανομένου και του VEGF, με τελικό στόχο την εγκατάσταση ενός συστήματος ανοσοδιαφυγής στον περιβάλλον του όγκου, που επιτρέπει τον απρόσκοπτο πολλαπλασιασμό των νεοπλασματικών κυττάρων. Η μελέτη του μηχανισμού επέκτασης, μετανάστευσης και τελικά εγκατάστασης των κυττάρων του ανοσοποιητικού συστήματος στην περιοχή του όγκου, η αναγνώριση και ο καθορισμός συγκεκριμένων υποπληθυσμών τους με σημαντική συμμετοχή στην ανοσολογική απάντηση και ο ενδελεχής προσδιορισμός της λειτουργικότητάς τους θα αποκαλύψει δυνητικά κομβικούς θεραπευτικούς στόχους έναντι της ογκο-επαγόμενης ανοσοκαταστολής. Σκοπός: Η παρούσα ερευνητική εργασία σχεδιάστηκε με στόχο την ανίχνευση και το φαινοτυπικό χαρακτηρισμό υποπληθυσμών ανοσοκατασταλτικών κυττάρων (Treg/MDSCs) στο περιφερικό αίμα ασθενών με ΜΜΚΠ, τον προσδιορισμό της συχνότητάς τους κατά τη διάγνωση και την αξιολόγηση της προγνωστικής τους αξίας. Κατόπιν, η μεθοδολογία που αναπτύχθηκε επέτρεψε τη μελέτη της επίδρασης της χημειοθεραπείας, με ή χωρίς την προσθήκη του bevacizumab, στη λειτουργικότητα και τα επίπεδα των κυκλοφορούντων ανοσοκατασταλτικών κυττάρων (Treg/MDSCs) και τη συσχέτιση των μεταβολών τους με την κλινική έκβαση. Ασθενείς και μέθοδοι: Στη μελέτη εντάχθηκαν νεοδιαγνωσθέντες ασθενείς με ΜΜΚΠ σταδίου IIIB/IV. Περιφερικό αίμα συλλέχθηκε από τους ασθενείς πριν από την έναρξη της θεραπείας, μετά το 3ο κύκλο της θεραπείας, καθώς και τη στιγμή που διαπιστώθηκε πρόοδος νόσου. Παρόμοιας ηλικίας και φύλου, υγιείς αιμοδότες χρησιμοποιήθηκαν ως φυσιολογικοί μάρτυρες. Διάφοροι υποπληθυσμοί MDSCs και Treg μελετήθηκαν μετά από σήμανσή τους με τα κατάλληλα αντισώματα και αναλύθηκαν χρησιμοποιώντας κυτταρομετρία ροής. Η ανοσοκατασταλτική τους δράση εκτιμήθηκε μέσω της ανασταλτικής τους επίδρασης στην παραγωγή IFN-γ από ενεργοποιημένα Τ-κύτταρα. Αποτελέσματα: Φαινοτυπικός προσδιορισμός υποτύπων MDSCs με κλινική σημασία στο ΜΜΚΠ και ο προγνωστικός τους ρόλος: Στη μελέτη εντάχθηκαν 110 ασθενείς. Η μέση ηλικία των ασθενών ήταν 68 έτη. Στην πλειοψηφία τους ήταν άρρενες (84.5%). Το 51.8% είχαν αδενοκαρκίνωμα και το 74.5 % είχαν νόσο σταδίου IV. Δείγματα αίματος από 19 υγιείς αιμοδότες χρησιμοποιήθηκαν ως μάρτυρες (controls).Για το φαινοτυπικό χαρακτηρισμό των MDSCs χρησιμοποιήθηκαν συνολικά 11 δείκτες. Συνοπτικά, τρεις νέοι υποπληθυσμοί MDSCs ταυτοποιήθηκαν στους ασθενείς με ΜΜΚΠ, δυο μονοκυτταρικής [CD14+CD15−CD11b+CD33+HLA-DR−Lin− (CD15−M-MDSCs) και ο CD14+CD15+CD11b+CD33+HLA-DR−Lin− (CD15+ M-MDSCs)] και ένας κοκκιοκυτταρικής προέλευσης [CD14−CD15+CD11b+CD33+HLA-DR−Lin− (G-MDSCs)]. Αυτοί οι πληθυσμοί ήταν αυξημένοι στο περιφερικό αίμα των ασθενών συγκριτικά με τους φυσιολογικούς αιμοδότες [(CD15+ M-MDSCs, 3.5 ± 0.5% έναντι 0.5 ± 0.2%, p≤0.0001), (CD15− M-MDSCs, 5.2 ± 0.5% έναντι 3 ± 0.8%, p=0.04) και (G-MDSCs, 2 ± 0.5% έναντι 0.1 ± 0.02%, p≤0.0001)]. Εντούτοις, η διαφορά στη συχνότητα των MDSCs μεταξύ των ασθενών με νόσο σταδίου ΙΙΙ και εκείνων με νόσο σταδίου IV δεν ήταν στατιστικά σημαντική. Με βάση την καλύτερη ανταπόκριση στη θεραπεία, οι ασθενείς που εμφάνισαν πρόοδο νόσου (PD) είχαν υψηλότερα επίπεδα Μ-MDSCs προ της έναρξης της θεραπείας (CD14+CD15+HLA-DR−Lin−: 1.1 ± 0.3%, CD14+CD15−HLA-DR−Lin−: 5.5 ± 1.1%) συγκριτικά με τους ασθενείς που ανταποκρίθηκαν (CR, PR και SD) στην θεραπεία (0.6 ± 0.07%, p=0.02 και 2.9 ± 0.3%, p=0.02 αντίστοιχα). «Φυσιολογικά» επίπεδα των CD15+ Μ-MDSCs (εντός του 90% των επίπεδων των φυσιολογικών αιμοδοτών) προ της έναρξης της θεραπείας συσχετίσθηκαν με μεγαλύτερο διάστημα επιβίωσης χωρίς πρόοδο νόσου (PFS) και μεγαλύτερη συνολική επιβίωση (OS), συγκριτικά με τα αυξημένα επίπεδα (10.87 έναντι 5.3 μήνες, p=0.005 και 12.9 έναντι 7.1 μήνες, p=0.008, αντίστοιχα). Στην πολυπαραγοντική ανάλυση διακύμανσης της επιβίωσης, τα υψηλά επίπεδα CD15+ Μ-MDSCs προ της έναρξης της θεραπείας ήταν ανεξάρτητος προγνωστικός παράγοντας πτωχής επιβίωσης (για το PFS: HR = 2.41, 95% CI: 1.37–4.24, p=0.002 και για το OS: HR = 2.35, 95% CI: 1.25–4.41, p=0.008). Τέλος, επιβεβαιώθηκε ότι αυτοί οι υποπληθυσμοί MDSCs είναι λειτουργικοί και καταστέλλουν την παραγωγή IFN-γ από ενεργοποιημένα CD3+ T κύτταρα. Επίδραση της θεραπείας στα επίπεδα των MDSCs στο περιφερικό αίμα των ασθενών με ΜΜΚΠ: Στην ανάλυση αυτή εντάχθηκαν συνολικά 46 ασθενείς, 33 στο σκέλος της χημειοθεραπείας και 13 στο σκέλος της χημειοθεραπείας με bevacizumab. Η μέση ηλικία των ασθενών ήταν 68 έτη. Στην πλειοψηφία τους ήταν άνδρες (85%). Μετά από 3 κύκλους χημειοθεραπείας το 24% των ασθενών εμφάνισε PR, το 67% SD και τέλος το 9% PD. Συνολικά, η χημειοθεραπεία δεν είχε κάποια ομοιόμορφη, καθολική επίδραση στον αριθμό των διαφόρων μονοκυτταρικών (M-) και κοκκιοκυτταρικών (G-) υποπληθυσμών MDSCs στο περιφερικό αίμα των ασθενών με ΜΜΚΠ. Εντούτοις, τρεις κύκλοι χημειοθεραπείας σε συνδυασμό με bevacizumab οδήγησαν σε στατιστικά σημαντική μείωση του αριθμού των G-MDSCs συγκριτικά με τα σχήματα που δεν περιελάμβαναν bevacizumab (μέση μεταβολή στη συχνότητα των G-MDSCs, θεραπεία με bevacizumab έναντι θεραπείας χωρίς bevacizumab: -0.68±0.34% έναντι 0.69±0.38%, αντίστοιχα, p=0.0086). Επίσης, μετά από τρεις κύκλους θεραπείας οι ασθενείς που εμφάνισαν PD είχαν αυξημένα επίπεδα όλων των υποπληθυσμών των MDSCs συγκριτικά με τους ασθενείς που ανταποκρίθηκαν στη θεραπεία. Μία άλλη ενδιαφέρουσα παρατήρηση από τη μελέτη αυτή ήταν ότι, μετά από 3 κύκλους θεραπείας, οι ασθενείς που παρουσίασαν PD είχαν στατιστικά σημαντική αύξηση των επιπέδων των CD15+ M-MDSCs, σε σχέση με τα επίπεδα προ της έναρξης της θεραπείας (p=0.03). Τέλος, η θεραπεία δεν επηρέασε την ανοσοκατασταλτική λειτουργία των κυττάρων. Φαινοτυπικός προσδιορισμός Treg με κλινική σημασία στο ΜΜΚΠ και ο προγνωστικός τους ρόλος: Στη μελέτη αυτή αναλύθηκαν δείγματα περιφερικού αίματος από 156 ασθενείς με ΜΜΚΠ. Η μέση ηλικία των ασθενών ήταν 62 έτη και στην πλειοψηφία τους ήταν άρρενες (82.1%). Το 57.6% είχαν αδενοκαρκίνωμα και το 82.1% είχαν νόσο σταδίου IV. Δείγματα αίματος από 31 υγιείς αιμοδότες χρησιμοποιήθηκαν ως μάρτυρες (controls).Για το φαινοτυπικό χαρακτηρισμό των Treg χρησιμοποιήθηκαν συνολικά 9 δείκτες. Τα επίπεδα των CD4+CD25+ Treg στο περιφερικό αίμα των ασθενών ήταν αυξημένα συγκριτικά με τους φυσιολογικούς δότες (24.81 ± 1% έναντι 14.67 ± 1.5%, αντίστοιχα, p=0.0002). Ανάλογα με το στάδιο ενεργοποίησης και διαφοροποίησής τους, τρεις υπότυποι των CD4+ Treg (naive, effector και terminal effectors) μελετήθηκαν. Ασθενείς με PD, ως καλύτερη ανταπόκριση στη θεραπεία πρώτης γραμμής, είχαν στατιστικά σημαντικά αυξημένη συχνότητα naive Treg (CD25highCD127–/lowCD152–FoxP3lowCD45RO–) συγκριτικά με τους ασθενείς που ανταποκρίθηκαν (CR, PR και SD)

Myeloid-Derived Suppressor Cells in Prostate Cancer: Present Knowledge and Future Perspectives

Several lines of research are being investigated to better understand mechanisms implicated in response or resistance to immune checkpoint blockade in prostate cancer (PCa). Myeloid-derived suppressor cells (MDSCs) have emerged as a major mediator of immunosuppression in the tumor microenvironment that promotes progression of various tumor types. The main mechanisms underlying MDSC-induced immunosuppression are currently being explored and strategies to enhance anti-tumor immune response via MDSC targeting are being tested. However, the role of MDSCs in PCa remains elusive. In this review, we aim to summarize and present the state-of-the-art knowledge on current methodologies to phenotypically and metabolically characterize MDSCs in PCa. We describe how these characteristics may be linked with MDSC function and may influence the clinical outcomes of patients with PCa. Finally, we briefly discuss emerging strategies being employed to therapeutically target MDSCs and potentiate the long-overdue improvement in the efficacy of immunotherapy in patients with PCa

Myeloid-Derived Suppressor Cells in Prostate Cancer: Present Knowledge and Future Perspectives

Several lines of research are being investigated to better understand mechanisms implicated in response or resistance to immune checkpoint blockade in prostate cancer (PCa). Myeloid-derived suppressor cells (MDSCs) have emerged as a major mediator of immunosuppression in the tumor microenvironment that promotes progression of various tumor types. The main mechanisms underlying MDSC-induced immunosuppression are currently being explored and strategies to enhance anti-tumor immune response via MDSC targeting are being tested. However, the role of MDSCs in PCa remains elusive. In this review, we aim to summarize and present the state-of-the-art knowledge on current methodologies to phenotypically and metabolically characterize MDSCs in PCa. We describe how these characteristics may be linked with MDSC function and may influence the clinical outcomes of patients with PCa. Finally, we briefly discuss emerging strategies being employed to therapeutically target MDSCs and potentiate the long-overdue improvement in the efficacy of immunotherapy in patients with PCa

Emerging Role of YAP and the Hippo Pathway in Prostate Cancer

The Hippo pathway regulates and contributes to several hallmarks of prostate cancer (PCa). Although the elucidation of YAP function in PCa is in its infancy, emerging studies have shed light on the role of aberrant Hippo pathway signaling in PCa development and progression. YAP overexpression and nuclear localization has been linked to poor prognosis and resistance to treatment, highlighting a therapeutic potential that may suggest innovative strategies to treat cancer. This review aimed to summarize available data on the biological function of the dysregulated Hippo pathway in PCa and identify knowledge gaps that need to be addressed for optimizing the development of YAP-targeted treatment strategies in patients likely to benefit

Immune Checkpoint and EMT-Related Molecules in Circulating Tumor Cells (CTCs) from Triple Negative Breast Cancer Patients and Their Clinical Impact

Triple negative breast cancer (TNBC) is the most aggressive breast cancer subtype. There are few targeted therapies for these patients, leading to an unmet need for new biomarkers. The present study aimed to investigate the expression of PD-L1, CTLA-4, GLU, and VIM in CTCs of TNBC patients. Ninety-five patients were enrolled in this study: sixty-four TNBC and thirty-one luminal. Of these patients, 60 were in the early stage, while 35 had metastatic disease. Protein expression was identified by immunofluorescence staining experiments and VyCAP analysis. All the examined proteins were upregulated in TNBC patients. The expression of the GLU+VIM+CK+ phenotype was higher (50%) in metastatic TNBC compared to early TNBC patients (17%) (p = 0.005). Among all the BC patients, a significant correlation was found between PD-L1+CD45−CK+ and CTLA-4+CD45−CK+ phenotypes (Spearman test, p = 0.024), implying an important role of dual inhibition in BC. Finally, the phenotypes GLU+VIM+CK+ and PD-L1+CD45−CK+ were associated with shorter OS in TNBC patients (OS: log-rank p = 0.048, HR = 2.9, OS: log-rank p < 0.001, HR = 8.7, respectively). Thus, PD-L1, CTLA-4, GLU, and VIM constitute significant biomarkers in TNBC associated with patients’ outcome, providing new therapeutic targets for this difficult breast cancer subtype

Spatio-Temporal Variation of Lung Cancer in Crete, 1992&ndash;2013. Economic or Health Crisis?

(1) Background: This is the first population-based study in Greece, with the aim to measure the changing trends of lung cancer (LC) and the associated risk factors before and after the economic crisis. Among the main objectives were the identification of LC hot spots and high-risk areas; (2) Methods: The study was conducted in Crete, the biggest island in Greece. Data (5057 LC cases) were collected from the Cancer Registry of Crete (CRC). The age-standardized incidence and mortality rates (ASIR, ASMR/100,000/year) were estimated, while additional indexes were used, including the adjusted Charlson&rsquo;s comorbidity index (CCI%), the deprivation index (HPI-2), and the exposure to outdoor air pollution (OAP). The analysis was performed for two time periods (Period A: 1992&ndash;2008; Period B: 2009&ndash;2013); (3) Results: ASIR presented a significant increase during the economic crisis, while an even higher increase was observed in ASMR (Period A: ASMR = 30.5/100,000/year; Period B: ASMR = 43.8/100,000/year; p &lt; 0.001). After 2009, a significant increase in the observed LC hot spots was identified in several sub-regions in Crete (p = 0.04). The risk of LC mortality increased even more for smokers (RR = 5.7; 95%CI = 5.2&ndash;6.3) and those living in highly deprived geographical regions (RR = 5.4; 95%CI = 5.1&ndash;5.8) during the austerity period. The multiple effect of LC predictors resulted in adjusted RRs ranging from 0.7 to 5.7 within the island (p &lt; 0.05); (4) Conclusions: The increased LC burden after the onset of the economic crisis, along with a changing pattern of LC predictors stressed the urgent need of geographically oriented interventions and cancer control programs focusing on the most deprived or vulnerable population groups