Safety and Efficacy of Subcutaneous Rituximab in Previously Untreated Patients with CD20+ Diffuse Large B-Cell Lymphoma or Follicular Lymphoma: Results from an Italian Phase IIIb Study.

Subcutaneous (SC) rituximab may be beneficial in terms of convenience and tolerability, with potentially fewer and less severe administration-related reactions (ARRs) compared to the intravenous (IV) form. This report presents the results of a phase IIIb study conducted in Italy. The study included adult patients with CD20+ DLBCL or FL having received at least one full dose of IV RTX 375 mg/m2 during induction or maintenance. Patients on induction received ≥4 cycles of RTX SC 1400 mg plus standard chemotherapy and FL patients on maintenance received ≥6 cycles of RTX SC. Overall, 159 patients (73 DLBCL, 86 FL) were enrolled: 103 (54 DLBCL, 49 FL) completed induction and 42 patients with FL completed 12 maintenance cycles. ARRs were reported in 10 patients (6.3%), 3 (4.2%) with DLBCL and 7 (8.1%) with FL, all of mild severity, and resolved without dose delay/discontinuation. Treatment-emergent adverse events (TEAEs) and serious adverse events occurred in 41 (25.9%) and 14 patients (8.9%), respectively. Two patients with DLBCL had fatal events: Klebsiella infection (related to rituximab) and septic shock (related to chemotherapy). Neutropenia (14 patients, 8.9%) was the most common treatment-related TEAE. Two patients with DLBCL (2.8%) and 6 with FL (7.0%) discontinued rituximab due to TEAEs. 65.2% and 69.7% of patients with DLBCL and 67.9% and 73.6% of patients with FL had complete response (CR) and CR unconfirmed, respectively. The median time to events (EFS, PFS, and OS) was not estimable due to the low rate of events. At a median follow-up of 29.5 and 47.8 months in patients with DLBCL and FL, respectively, EFS, PFS, and OS were 70.8%, 70.8%, and 80.6% in patients with DLBCL and 77.9%, 77.9%, and 95.3% in patients with FL, respectively. The switch from IV to SC rituximab in patients with DLBCL and FL was associated with low risk of ARRs and satisfactory response in both groups. This trial was registered with NCT01987505.

Feasibility, Tolerability and Efficacy of Carfilzomib in Combination with Lenalidomide and Dexamethasone in Relapsed Refractory Myeloma Patients: A Retrospective Real-Life Survey of the Sicilian Myeloma Network.

Background: The ASPIRE (NCT01080391) phase 3 trial showed the efficacy of carfilzomib, lenalidomide and dexamethasone (KRd) triplet for relapse and refractory multiple myeloma (RRMM). However, little is known about safety and efficacy of KRd outside a clinical trial context. Methods: Herein we report real life results of KRd given to 130 RRMM patients from 12 Sicilian Centers. Results: Median age was 62 years; patients had received a median of two previous lines of treatment (range 1-10) and 52% were refractory to previous treatment. Median number of KRd cycles was 12 (2-29), with a mean duration of treatment of 12 months; 21 patients had received at least 18 cycles. Overall response rate was 61%, including 18% complete response. Median PFS was 22.9 months, median OS was not reached. Creatinine clearance >30 mL/min, quality of the best achieved response and standard Fluorescence In Situ Hybridization (FISH) risk were independent predictors of favorable outcome. Patients who received the full-dosage of carfilzomib in the first two cycles had a better outcome. Conclusions: KRd was effective and well tolerated and in a considerable proportion of patients, therapy continued beyond the 18th cycle. The finding of a better outcome in patients with the higher cumulative dose of carfilzomib in the first two cycle encourages to maintain the maximum tolerated dose.

Old and new immunophenotypic markers in multiple myeloma for discrimination of responding and relapsing patients: The importance of "normal" residual plasma cell analysis.

BACKGROUND: Multiple myeloma is an incurable disease characterized by proliferation of clonal malignant plasma cells (CPCs), which can be immunophenotypically distinguished from polyclonal plasma cells (PPCs) by multiparameter flow cytometry (MFC). The utility of PPCs analysis in detecting prognostic and predictive information is still a matter of debate. METHODS: we tested the ability of 11 MFC markers in detecting differences in the immunophenotype of CPCs and PPCs among patients in various disease stages; we verified if these markers could be associated with disease stage/response to therapy despite the role of clinical parameters. RESULTS: significant changes in the expression of markers occurred both in CPCs and PPCs. CD58 on PPCs of responding patients was downregulated compared with PPC of relapsing group. Fraction of CD200 expressing PCs was lower in control subjects than in PPCs from MGUS and myeloma groups. CD11a levels of expression on both CPCs and PPCs showed an upregulation in newly diagnosed and relapsing patients versus PCs of controls; CD20 was less expressed on control PCs than on MGUS CPCs and PPCs. CD49d revealed to be advantageous in discrimination of PPCs from CPCs. In our multiple regression model, CD19 and CD49d on CPCs, and CD45, CD58 and CD56 on PPCs maintained their association with groups of patients independently of other prognostic variables. CONCLUSIONS: we provide a feasible start point to put in order ranges of expression on PPCs in healthy and myeloma subjects; we propose a new approach based on PPC analysis to monitor the stages of the disease.

Nanoscale structure of the cell wall protecting cellulose from enzyme attack.

The cell wall structure protects cellulose from enzymatic attack and its successive fermentation. The nature of this protection consists in the very complex macroscopic and microscopic structure of cell wall that limits transport. Explaining this kind of protection is critical in future research to improve cell polymer availability for enzymatic attack. This research shows that the complete description of the cell wall topography at a nanoscale level allows a mechanistic understanding of cellulose protection. For this purpose, we used gas adsorption methods (CO(2) at 273 K and N(2) at 77 K) to detect mesoporosity (pore size of 1.5-30 nm diameter; MeS) and microporosity (pore size of 0.3-1.5 nm diameter; MiS) of the cell wall of five energy crops, i.e., giant cane, rivet wheat straw, miscanthus, proso millet, and sorghum. The presence of both hemicelluloses in the spaces between cellulose fibrils and the unhydrolyzable and highly cross-linked lignocarbohydrate complex (LCC) determines a microporous (80% pores having diameters below 0.8 nm) structure of the cell wall that prevents the cellulase enzymes from coming into direct contact with the cellulose, as their sizes exceed the cell wall pore size. On the other hand, the removal of the hemicelluloses and of the LCC complex determines a reduction of the MiS and an increase of the available surface for enzymatic attack, i.e., pores >5 nm diameter. This was confirmed by the good negative (r = -0.87, P < 0.001, n = 11) and positive (r = 0.78, P < 0.005, n = 11) correlations found for microporosity and mesoporosity (pores of diameters >5 nm), respectively, vs the glucose production, by cellulase enzyme attack in specific enzymatic hydrolysis tests performed on biomass samples.

Localization of the sentinel lymph node in breast cancer: prospective comparison of vital staining and radioactive tracing methods.

The aim of the study was to evaluate possible differences in accuracy between the radioactive tracing and vital staining method in the search for sentinel nodes in patients with breast cancer. From January 1999 to December 2000, 102 patients with T1 N0 breast carcinoma were recruited into the study for localization of sentinel nodes with vital blue dye staining and radioactive tracing and were then submitted to lumpectomy and axillary dissection. For the two methods, we estimated the percentage of sentinel nodes localized, the false-negative rate, the predictive negative and positive value and the accuracy. The vital blue dye staining method permitted localization of the sentinel node in 73% of patients with a false-negative rate of 8%, a predictive negative value of 92% and 92% accuracy. The radioactive tracing method permitted localization of the sentinel node in 97% cases with a false-negative rate of 0%, a predictive negative value of 100% and 100% accuracy (P<0.0005). The method that offers the better results is radioactive tracing. Currently, many authors use both techniques, since, in common practice, staining helps to identify the sentinel node with the probe.

Targeting multiple myeloma cells and their bone marrow microenvironment.

Although multiple myeloma (MM) is sensitive to chemotherapy and radiation therapy, long-term disease-free survival is rare, and MM remains incurable despite conventional and high-dose therapies. Direct (cell-cell contact) and soluble (via cytokines) forms of interactions between MM cells and bone marrow stroma regulate growth, survival, and homing of MM cells. These interactions also play a critical role in angiogenesis and in myeloma bone disease. In recent years, several studies have established the biologic significance of cytokines in MM pathogenesis and delineated signaling cascades mediating their effects, providing the framework for related novel therapies targeting not only the MM cell, but also the bone marrow microenvironment.

Flow cytometric immunophenotyping analysis of patterns of antigen expression in non-Hodgkin's B cell lymphoma in samples obtained from different anatomic sites.

Multiparametric clinical flow cytometry has evolved from two-parameter quantitative assessment of lymphocytes to assessment of many qualitative parameters of suspensions obtained from bone marrow, peripheral blood, and lymph nodes for hematopathology. Nowadays, lymphoma immunophenotyping is a necessary complement to morphology and molecular parameters in the diagnosis and monitoring of human hematopoietic malignancies. The aim of the present study was to determine whether immunophenotypic differences could be used to distinguish between non-Hodgkin's B cell lymphoma (NHL-B) and the normal B cell subpopulation by assessing the variability in the patterns of expression of some lymphoid antigens (CD5, CD19, FMC7, CD23, CD20, CD79b, CD38, CD22, CD10, sIgkappa, sIglambda, mIgA, mIgG, mIgM, and mIgD) in specimens obtained from patients with NHL-B. We have studied peripheral blood samples, lymph node suspensions, and bone marrow specimens from 20 patients with malignant lymphoma and from controls without oncohematologic disease. Some patients showed stable patterns of antigen expression that remained unchanged over time and were consistent from one specimen to another. Other patients showed more variability in the pattern of antigen expression from different specimens. The two-way cluster analysis of antigens revealed three patterns of expression: (1) most cells in most cases positive (CD5, CD19, CD20, CD23, CD45); (2) most cells in most cases negative (CD10, mIgG, CD22, CD23,CD38); and (3) a mixed pattern with a variable number of positive cases and a variable percentage of positive cells in individual cases (CD22, CD38, CD79b, FMC7, mIgD, mIgM, mIgA, mIgG, sIgkappa, sIglambda). The expression of several antigens was strongly interdependent, even when antigens belonged to entirely different gene families. Such antigen pairs were CD19/CD45; CD19/CD79b; CD23/Igkappa; and CD45/CD79b. Our results suggest that different factors may determine the stability or the variability of such multiantigen expression, particularly the biology and function of the different antigens and the mechanisms of disease dissemination and progression.

[Surgical treatment of melanoma: role of the sentinel lymph node]. / La terapia chirurgica del melanoma: ruolo del linfonodo sentinella.

The aim of this study was to evaluate the surgical therapy of melanoma of the head, neck, trunk or extremities, and the reliability of sentinel node biopsy. Forty-nine patients, 23 men and 26 women, mean age 59 (range: 22-89) years, with melanoma of the skin--the sites affected were the head and neck (7), trunk (17), upper extremities (8) and lower extremities (17)--and clinically negative lymph nodes, participated in the study from January 2000 to December 2002. The mean Breslow thickness was 2.1 mm, and the median thickness 2 mm. Preoperative dynamic and static lymphoscintigraphy, intraoperative blue dye and a gamma-ray detection probe were used. If the histological examination with haematoxylin and eosin revealed metastases, therapeutic lymph-node dissection was performed. Sentinel nodes were identified by lymphoscintigraphy in 47 patients (96%); 82 sentinel nodes (mean 1.65 per patient) were removed from 56 lymph-node stations. Four patients had tumour-positive sentinel nodes. During follow-up, nodal recurrence in a sentinel-node-negative station was documented in 1 patient. Melanoma of the skin can be safely excised with 1-2 cm margins. Therapeutic lymph-node dissection is performed only in node-positive patients. Sentinel-node biopsy allows accurate staging and yields important prognostic information.