Podcasts about g csf

In this JCO Article Insights episode, host Jospeh Mathew summaries Pancreatic Adenocarcinoma: Long-Term Outcomes of Adjuvant Therapy in the ESPAC4 Phase III Trial, by Palmer, et al published December 5, 2024. Transcript Joseph Matthew: Hello and welcome to the Journal of Clinical Oncology Article Insights. I'm your host, Joseph Matthew, and today we will be discussing the article "Long-Term Survival in Resected Pancreatic Ductal Adenocarcinoma with Adjuvant Gemcitabine plus Capecitabine Compared to Modified FOLFIRINOX from the ESPAC-4 and the PRODIGE 24 Trials" by Dr. Palmer et al. To summarize the relevant evidence, the ESPAC-4 was a European phase 3 multicenter randomized clinical trial published in 2017 comparing adjuvant gemcitabine and capecitabine (GemCap) with gemcitabine monotherapy following macroscopic margin-negative resections for operable pancreatic ductal adenocarcinoma (PDAC). The trial had included non-metastatic patients aged 18 years or older, World Health Organization (WHO) performance scores of 2 or less, creatinine clearance of at least 50 mL/min, and a life expectancy of over three months who had not received any prior anticancer treatment. Patients who had undergone R2 resections were selectively excluded. Eligible participants were randomized 1:1 within 12 weeks of pancreatectomy to one of the two treatment arms, with chemotherapy initiated within two weeks from the date of randomization. The regimens involved six cycles, each lasting four weeks, for an overall duration of 24 weeks. In the monotherapy arm, gemcitabine dosed at 1 g/m² was given as an intravenous infusion once a week for three weeks, followed by one week off. In the GemCap arm, capecitabine dosed at 1660 mg/m² was added to gemcitabine, given daily for three weeks, followed by one week off. Patients were followed up every three months, with the primary endpoint being overall survival (OS). The study showed that at a median follow-up of 43.2 months, GemCap was associated with a significantly longer OS than gemcitabine alone. Subsequently, in 2018, the Phase 3 randomized PRODIGE 24 trial was conducted in centers across France and Canada, comparing adjuvant modified FOLFIRINOX (mFOLFIRINOX) with gemcitabine in a similar subset of patients with resected PDAC and reported longer OS with the mFOLFIRINOX regimen. This study, however, had more restrictive eligibility criteria when compared to ESPAC-4, including patients aged under 80 years, WHO performance status of 0 or 1, with no significant cardiovascular disease, and a postoperative serum CA 19-9 of less than 180 U/mL. There was hence a subset of ESPAC-4 patients who did not meet the eligibility criteria for mFOLFIRINOX as set by the PRODIGE 24. The present study was conducted to estimate the overall 5-year survival rates for patients of ESPAC-4 receiving GemCap and gemcitabine, further stratifying survival in either arm according to the status of the surgical margins (R status) and the resected nodes (N status), and also to investigate whether GemCap retained a survival benefit over gemcitabine in PRODIGE 24-ineligible patients. A total of 732 patients, evenly distributed between both arms, were followed up for a median period of 104 months. Adjuvant GemCap was found to retain its survival advantage over gemcitabine, with a significantly longer median OS of 31.6 months when compared to 28.4 months with gemcitabine alone. Further subgroup analysis was performed with reference to the resection margins and the nodal status. As a reminder, in the ESPAC-4 trial, 60% of patients were found to have microscopically positive margins (an R1 resection), and 80% were node-positive. The difference in survival was greater in patients undergoing microscopic margin-negative resections (R0) who experienced a median OS of 49.9 months with GemCap when compared to 32.2 months with gemcitabine. Node-negative patients also had a significantly greater 5-year OS rate with GemCap of 59% versus 53% with gemcitabine monotherapy. However, it is important to note that no significant difference in survival outcomes was observed in margin-positive (R1) or node-positive patients in the two arms. The investigators also evaluated GemCap in the subgroup of 193 patients (comprising 26.4% of the ESPAC-4 cohort) who were not considered to have met the eligibility criteria for PRODIGE 24. The survival benefit of combination therapy was retained in this group, with patients receiving GemCap experiencing a median survival of 25.9 months compared to 20.7 months with adjuvant gemcitabine. Although cross-trial comparisons have limited validity, good agreement was noted in adverse grade 3 or greater toxicity associated with the control gemcitabine arms of ESPAC-4 and PRODIGE 24, serving as the basis for a qualitative comparison of toxicities between mFOLFIRINOX and GemCap. Neutropenia was more prevalent in the GemCap arm, affecting 40.8% of patients compared to 28.4% with mFOLFIRINOX. However, granulocyte colony-stimulating factor (G-CSF) was administered to 62.2% of patients in PRODIGE 24. Palmar-plantar erythrodysesthesia (PPE) was also more prevalent with GemCap. Patients on mFOLFIRINOX were more likely to observe grade 3 or greater fatigue, diarrhea, nausea and vomiting, sensory peripheral neuropathy, and paresthesias. The investigators concluded that GemCap was the standard adjuvant treatment for patients with PDAC undergoing an upfront resection who were not feasible for mFOLFIRINOX. Further exploratory analysis revealed that patients under the age of 70 who had undergone a microscopic margin-negative (R0) resection for node-negative PDAC were likely to derive an OS benefit from the addition of capecitabine to gemcitabine in the adjuvant setting. In contrast, mFOLFIRINOX would be more effective than gemcitabine in patients with positive margins (R1) or involved nodes, as per the PRODIGE 24 trial. Thank you for listening to JCO Article Insights. Please come back for more interviews and article summaries, and be sure to leave us a rating and review so others can find our show. For more podcasts and episodes from ASCO, please visit ASCO.org/podcasts. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

This week, we move to our next phases of therapy for AML, which are consolidation and maintenance. Be sure to check out our prior episodes for a discussion on initial workup and how we incorporate recurrent genetic abnormalities into how we think about AML. Check out figure 1 from this paper for a helpful diagram!Episode contents: - A recap on approach to AML treatment- Who do we consider for allogeneic transplant? - What are common therapy-related AML cytogenetic abnormalities to be aware of? - How do we approach consolidation? Role of G-CSF? ****Have some time and want to make some extra money? Get paid to participate in market research surveys: https://affiliatepanel.members-only.online/FOC_24?utm_campaign=FOC&utm_source=email&utm_medium=email** Want to review the show notes for this episode and others? Check out our website: https://www.thefellowoncall.com/our-episodesLove what you hear? Tell a friend and leave a review on our podcast streaming platforms!Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Dr. Paul Sue is an associate professor of pediatrics at the Columbia University and Director of the Pediatric Transplant and Immunocompromised Host or “PITCH” Infectious Diseases Program at the Morgan Stanley Children's Hospital in NY.  He completed his pediatric residency at Jacobi Medical Center at the Albert Einstein College of Medicine in the Bronx, and his fellowship in pediatric infectious diseases at Johns Hopkins University in Baltimore. He then moved to UT Southwestern in Dallas TX, where he served as director of Pediatric ICH ID service for the next 8 years, prior to his recent move back to NY.  His research interests include the impact of invasive fungal and viral infections in the immunocompromised host,  leveraging measures of functional immunity to improve infectious disease outcomes in high-risk patients,  and the emergence of community acquired multidrug resistant (MDR) bacterial infections in immunocompromised children. Sara Dong, MD is an adult and pediatric infectious disease physician at Emory University School of Medicine & Children's Healthcare of Atlanta, where her clinical focus is transplant and immunocompromised host ID.  She earned her MD from the Medical University of South Carolina.  She completed her internal medicine and pediatrics (Med-Peds) residency and chief residency years at Ohio State University Wexner Medical Center and Nationwide Children's Hospital, followed by Med-Peds ID and Medical Education fellowships at Beth Israel Deaconess Medical Center and Boston Children's Hospital.  She is the creator and host of Febrile podcast and learning platform, co-host of the ID Puscast podcast, and the program director for the ID Digital Institute.Learning ObjectivesAfter listening to this episode on invasive candidemia, learners should be able to discuss:Treatment of candidemia in a critically-ill immunocompromised patient.Management of indwelling central catheters in critically-ill patients with candidemia.The role of immune adjuncts (e.g. G-CSF or granulocyte transfusions) in the management of persistent candidemia in an immunocompromised patient.References:https://febrilepodcast.com/ Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update bQuestions, comments or feedback? Please send us a message at this link (leave email address if you would like us to relpy) Thanks! -Alice & ZacSupport the Show.How to support PedsCrit:Please complete our Listener Feedback SurveyPlease rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show. Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.

Dr. Neeraj Agarwal and Dr. Rana McKay discuss promising studies in GU cancers featured at the 2024 ASCO Annual Meeting that highlighted improved outcomes in urothelial carcinoma, improved survival in renal cell carcinoma, and the role of ctDNA as a potential biomarker for predicting outcomes.   TRANSCRIPT Dr. Neeraj Agarwal: Hello and welcome to the ASCO Daily News Podcast. I'm Dr. Neeraj Agarwal, your guest host of the ASCO Daily News Podcast today. I am the director of the Genitourinary Oncology Program, a professor of medicine at the University of Utah's Huntsman Cancer Institute, and editor-in-chief of the ASCO Daily News.  I am delighted to welcome Dr. Rana McKay, a GU medical oncologist and associate professor at the University of California San Diego. Today, we'll be discussing some key GU abstracts featured at the 2024 ASCO Annual Meeting. Our full disclosures are available in the transcript of this episode. Rana, we're thrilled to have you on the podcast today to share your insights on key advances in GU oncology from ASCO24. Dr. Rana McKay: Thank you so much, Neeraj; it's a pleasure to be here. Dr. Neeraj Agarwal: So, Rana, let's start with some bladder cancer abstracts. Could you tell us about Abstract 4503, titled “Impact of exposure on outcomes with enfortumab vedotin in patients with locally advanced or metastatic urothelial cancer”? Dr. Rana McKay: Of course, I would be delighted to. First, I would like to remind our listeners that enfortumab vedotin (EV) was approved as a monotherapy for the treatment of locally advanced or metastatic urothelial cancer based on the results of EV-201 and EV-301 trials. In these pivotal studies, EV was initiated at a dose of 1.25 mg/kg, and dose modifications, such as reductions and interruptions, were used to manage adverse events. In the abstract presented at ASCO 2024, Dr. Daniel Petrylak and colleagues conducted a post-hoc exploratory analysis to evaluate the association between EV plasma exposure and outcomes. They used multiple pharmacokinetic samples collected during the first two cycles and pre-dose samples from 3 EV monotherapy studies, namely EV-101, EV-201, and EV-301, that were conducted in patients with previously treated locally advanced or metastatic urothelial carcinoma. Dose reductions to 1 mg/kg were required in 42.1% and 35.1% of patients in the EV-201 and EV-301 trials, respectively, and reductions to 0.75 mg/kg were required in 13.6% and 11.1% in the EV-201 and EV-301 trials, respectively. Higher EV exposure during the first two cycles was associated with a higher objective response rate. The ORR was 21.4% for the dose of 0.75 mg/kg, while it was 18.5% for the dose of 1.0 mg/kg. Interestingly, increasing the dosage to 1.25 mg/kg improved the ORR, which ranged from 40 to 51.1% across various studies. In the EV-301 trial, when comparing the efficacy of EV to chemotherapy, EV improved PFS and OS across all dose quartiles, and there was no evidence that recommended dose modifications impacted long-term efficacy outcomes. Dr. Neeraj Agarwal: Thank you, Rana, for this great summary. I would like to add that the meticulously conducted pharmacokinetic studies demonstrated that serum levels of EV correlated with responses. Importantly, patients who had to decrease the dose did not experience compromised outcomes as EV improved PFS and OS outcomes vs chemotherapy in across all exposure quartiles in the EV-301 trial where EV was compared with chemotherapy. These findings highlight the need to start at the recommended dose of 1.25 mg/kg and reduce it, if necessary, however, clinicians should not start at a lower dose.  Dr. Rana McKay: I totally agree with you, Neeraj. Now, moving on to a different setting in bladder cancer, what can you tell us about LBA4517, titled “Perioperative sacituzumab govitecan alone or in combination with pembrolizumab for patients with muscle-invasive urothelial bladder cancer: SURE-01/02 interim results”? Dr. Neeraj Agarwal: Of course! So, SURE was a multicohort, open-label, phase 2 study in patients with muscle-invasive bladder cancer assessing sacituzumab govitecan as a neoadjuvant therapy either alone in SURE-01 or as a combination with pembrolizumab followed by adjuvant pembro in SURE-02 in a flexible design allowing a bladder-sparing approach. In the abstract presented at ASCO 2024, Dr. Antonio Cigliola and colleagues report interim results of the SURE-01 study. Patients with cT2-4N0M0 urothelial carcinoma who were ineligible for or refused cisplatin-based neoadjuvant chemotherapy were planned to receive 4 cycles of neoadjuvant sacituzumab govitecan at a dose of 10 mg/kg followed by radical cystectomy.  An extensive assessment was performed at baseline and after the 4 cycles for response assessment. Patients with clinical complete response defined with negative MRI, cystoscopy and ctDNA assays refusing radical cystectomy were offered redo transurethral resection of the bladder tumor or repeat TURBT followed by observation in the absence of viable high-grade tumor in the bladder. The primary endpoint was pathological complete response rate, while secondary endpoints included pathological downstaging rate and safety. After the first 8 patients were enrolled, the protocol was amended due to the occurrence of grade 3 and 4 neutropenia and diarrhea in 75% and 50% of patients, respectively, and 2 deaths – one of which was deemed to be treatment-related due to sepsis. Key protocol changes included the reduction of the dose of sacituzumab govitecan to 7.5 mg/kg, the introduction of G-CSF as primary prophylaxis, and the exclusion of patients at high risk of febrile neutropenia per ASCO guidelines.  Among 21 patients who received at least one cycle of sacituzumab govitecan and included in the intention-to-treat population, 47.6% had a complete pathological response, and 52.4% had pathological downstaging. 11 patients underwent radical cystectomy, while 7 received repeat-TURBT due to complete clinical response or patient preference. Regarding the safety profile, grade 3 or more adverse events occurred in 42.5% of patients. Treatment-related adverse events leading to dose interruptions or discontinuations were more common before the protocol amendment. It is noteworthy that 3 patients died after treatment discontinuation, with one deemed treatment-related, as previously mentioned. Dr. Rana McKay: Thank you, Neeraj, for a great summary. The pathological complete responses observed show promising activity for sacituzumab govitecan as a neo-adjuvant therapy and a window for bladder-sparing approaches, which is definitely exciting news for our patients! However, although the 3 deaths encountered in a neo-adjuvant setting could be concerning, the improvement of the safety profile after protocol amendments is reassuring and supports the continuation of the study. Dr. Neeraj Agarwal: Before wrapping up the bladder cancer section, would you like to share your insights with our listeners on Abstract 4518, titled “Quantitative circulating tumor DNA (ctDNA) assessment in patients with advanced urothelial carcinoma treated with pembrolizumab or platinum-based chemotherapy from the phase 3 KEYNOTE-361 trial”?  Dr. Rana McKay: Sure. So, the KEYNOTE-361 trial was a randomized phase 3 study with 3 arms that included pembrolizumab plus chemotherapy, pembrolizumab monotherapy, or chemotherapy alone in patients with previously untreated advanced urothelial carcinoma. The results showed that neither the combination of pembrolizumab plus chemotherapy nor pembrolizumab monotherapy improved survival outcomes compared to the chemotherapy arm. So, in this exploratory analysis presented at ASCO24, Dr. Tom Powles and colleagues sought to assess the role of ctDNA as a potential biomarker between the pembrolizumab monotherapy arm and the chemotherapy arm. Tumor tissue mutations were evaluated using whole exome sequencing, and plasma ctDNA was assessed with the Guardant 360 assay. Changes in ctDNA from pre-treatment cycle 1 to on-treatment cycle 2, so 3 weeks post-baseline assessment, were quantified by the maximum variant allele frequency of tumor tissue-specific mutations.  Results showed that lower baseline ctDNA levels were associated with improved clinical outcomes of response in the pembrolizumab arm but not in the chemotherapy arm. This improvement in the pembrolizumab arm was also robust to adjustment for tumor mutational burden and PD-L1. Additionally, chemotherapy led to a ctDNA clearance rate of 41% compared to 11% in the pembrolizumab arm. Patients who had a large ctDNA reduction with pembrolizumab had significantly improved outcomes compared to those achieving a large reduction with chemotherapy with a hazard ratio of 0.25. However, this did not replicate in patients who did not achieve a large reduction, as these patients had similar outcomes across both arms. Let's switch gears to kidney cancer and start with Abstract 4508, reporting the final OS analysis from the JAVELIN Renal-101 trial. Neeraj, what would you like to tell us about this abstract? Dr. Neeraj Agarwal:  Well, as a quick reminder, the JAVELIN Renal-101 was a randomized phase 3 trial where patients with previously untreated advanced or metastatic clear cell renal cell carcinoma were randomized to receive either the combination of avelumab plus axitinib or sunitinib. In previous analyses, the combination of avelumab and axitinib significantly improved PFS compared to sunitinib and was subsequently approved by the FDA for the first-line treatment of patients with advanced RCC in 2019. This superiority in PFS was maintained across the different analyses; however, OS data remained immature. In the abstract presented at ASCO24 by Dr. Robert Motzer from Memorial Sloan Kettering Cancer Center and colleagues, the authors reported OS results at a median follow-up of around 73 months and a minimum of 68 months for all patients, which is the longest follow-up for any ICI-TKI combination in RCC. The final analysis in the overall population favored the combination of avelumab plus axitinib with a median OS of 44.8 months compared to 38.9 months with sunitinib, however, this did not reach statistical significance with a hazard ratio of 0.88. The PFS results and safety profile were consistent with previous analyses.  Dr. Rana McKay: Thank you, Neeraj, for such a nice overview of this abstract. These new data could make this regimen less optimal than other ICI-TKI combinations in the first-line mRCC setting.   Dr. Neeraj Agarwal: I concur, Rana. Moving on to perhaps one of the most exciting GU abstracts featured, Abstract 4506, titled “Circulating kidney injury molecule-1 biomarker analysis in IMmotion010: A randomized phase 3 study of adjuvant atezolizumab vs placebo in patients with renal cell carcinoma at increased risk of recurrence after resection.” Rana, what are your thoughts on this abstract? Dr. Rana McKay: Well, first, I would like to take a step back and remind our audience that in the IMmotion010 trial, patients with resected intermediate to high-risk RCC with clear cell and/or sarcomatoid component were randomized in a 1:1 ratio to receive either atezolizumab or placebo. Investigator-assessed disease-free survival, which was the primary endpoint, favored the atezolizumab arm but did not reach statistical significance. In the abstract featured at ASCO24, Dr. Laurence Albiges and colleagues build on data previously reported in the ASSURE and CheckMate 914 trials and report provocative findings regarding a molecule known as kidney injury molecule 1 or KIM-1, which is a type 1 membrane glycoprotein that has been identified as a minimally invasive potential peripheral blood circulating biomarker. The KIM-1 level of 86 pg/ml was identified as the optimized threshold for defining post-nephrectomy KIM-1 high vs KIM-1 low subgroups in the IMmotion010 trial. KIM-1 levels were measured at baseline or pre-treatment, at cycle 4 day 1, and at disease recurrence or discontinuation without disease recurrence. Baseline characteristics were balanced between the KIM-1 high and KIM-1 low groups, except perhaps for a slightly higher pathological stage in the KIM-1 high subgroup.  I would like to highlight 3 key takeaways from this abstract. First, KIM-1 high level was associated with significantly worse DFS with a hazard ratio of 1.75. Second, patients in the KIM-1 high subgroup receiving atezolizumab had a 28% reduction in the risk of recurrence or death compared to those receiving placebo, while those in the KIM-1 low subgroup had comparable outcomes across both treatment arms. Third, patients in the KIM-1 high subgroup receiving atezolizumab were significantly less likely to experience an on-treatment increase in KIM-1 levels, which was associated with worse DFS in both high and low KIM-1 subgroups, regardless of treatment arm. Thus, these findings support the use of KIM-1 as both a predictive and prognostic biomarker in patients with RCC. Dr. Neeraj Agarwal: Yes, Rana, this is amazing data! I would like to add that these results warrant larger and, ideally, prospective studies to validate the utility of KIM-1 as a noninvasive biomarker for identifying minimal residual disease after nephrectomy and for predicting outcomes to immune checkpoint inhibitors. Dr. Rana McKay: Also, in the field of biomarkers, 2 abstracts interrogating different biomarkers in a different setting, so in patients with advanced or metastatic RCC were presented. Neeraj, could you tell us more about these abstracts? Dr. Neeraj Agarwal: Of course! I think you are referring to Abstracts 4504 and 4505. In abstract 4504, Dr. Toni Choueiri and colleagues sought to assess the clinical implications of different biomarkers in the CLEAR trial, which was a randomized phase 3 trial that led to the approval of the combination of pembrolizumab plus lenvatinib in the first-line mRCC setting. On the other hand, in abstract 4505, Dr. Brian Rini presented biomarker results in KEYNOTE-426, which was also a randomized phase 3 trial based on which the combination of pembrolizumab plus axitinib was approved in patients with mRCC. The authors in both trials sought to investigate the role of biomarkers in predicting treatment outcomes from 3 different angles. Starting with PD-L1 expression, the superiority of the combination arms over sunitinib was not impacted by PD-L1 status in both trials. Moving on to RCC driver gene mutations on whole exome sequencing, such as VHL, SETD2, PBRM1, and BAP1, ICI combination therapies improved outcomes regardless of mutation gene status, and this improvement was statistically significant with PBRM1 mutations in KEYNOTE-426 compared to wild-type PBRM1, but this did not replicate in the CLEAR trial. Finally, using transcriptomic signatures derived from RCC trials, especially the IMmotion 151 and JAVELIN Renal 101 trials, where 7 clusters or molecular subtypes were identified, the combination arms outperformed sunitinib in all clusters in both trials and the magnitude of this benefit differed across clusters.  Dr. Rana McKay: Thank you for this very interesting summary and comparison of the results of these 2 abstracts. These findings support the use of ICI-based combinations in all patients with mRCC as a first-line option. Although these abstracts could not identify specific biomarkers that could guide us clinicians in treatment selection, they provide very interesting biological insights on these molecular biomarkers that are, however, not yet clinically actionable. Dr. Neeraj Agarwal: Very interesting point, Rana. Moving on to prostate cancer, let's start with abstract LBA5000 titled, “Cabazitaxel with abiraterone versus abiraterone alone randomized trial for extensive disease following docetaxel: The CHAARTED2 trial of the ECOG-ACRIN Cancer Research Group (EA8153).” Rana, what is your takeaway on this abstract? Dr. Rana McKay: As a reminder to our audience, the CHAARTED2 trial was a randomized open-label phase 2 study that compared the combination of cabazitaxel and abiraterone to abiraterone alone in patients with mCRPC previously treated with ADT plus docetaxel in the hormone-sensitive setting. The primary endpoint was progression-free survival. After a median follow-up of 47.3 months, Dr. Christos Kyriakopoulos and colleagues reported in LBA5000 that patients receiving the combination of cabazitaxel plus abiraterone had a 27% reduction in the risk of progression or death. However, there was no significant difference in overall survival between the two arms, with a median OS of 25 months in the cabazitaxel+abiraterone arm and 26.9 months in the abiraterone arm, although the study was underpowered for this endpoint. Regarding the toxicity profile, the combination of cabazitaxel and abiraterone was overall well tolerated with more cytopenias, as expected.  Dr. Neeraj Agarwal: Very nice summary of this abstract, Rana. I would like to add that the treatment landscape of patients with mHSPC has evolved since the design of the study and now includes combination therapies of ADT + ARPI with or without docetaxel, and ADT + docetaxel is no longer a standard of care, which limits the applicability of these results in clinical practice today.  Dr. Rana McKay: Excellent point, Neeraj. Let's discuss Abstract 5001, titled “CYCLONE 2: A phase 3 study of abemaciclib with abiraterone in patients with metastatic castration-resistant prostate cancer”. Dr. Neeraj Agarwal: Sure! In the abstract featured at ASCO24, Dr. Matthew Smith and colleagues report the primary results of the CYCLONE 2 trial, which was a randomized phase 2/3 study that investigated the combination of abemaciclib plus abiraterone versus abiraterone monotherapy in patients with mCRPC. Stratification factors included radiographic progression at study entry, presence of measurable disease, and prior docetaxel for mHSPC. Part 1 of the study established the recommended phase 2 dose of abemaciclib at 200 mg twice daily. In part 2, patients were randomized to placebo or abemaciclib, and an adaptive interim analysis using prespecified criteria was performed and recommended the expansion of the study to part 3. The primary endpoint was investigator-assessed radiographic progression-free survival by RECIST 1.1 and PCWG3 criteria in the intention-to-treat population. At the time of the primary analysis, adding abemaciclib to abiraterone did not improve rPFS, with a hazard ratio of 0.83. The median rPFS was 22 months for the combination arm and 20.3 months for the abiraterone arm. The combination was well tolerated, and the safety profile was consistent with the known adverse events. Dr. Rana McKay: So, the addition of abemaciclib to abiraterone did not improve outcomes in patients with mCRPC. These findings suggest that no further investigation is warranted for abemaciclib or CDK4/6 inhibitors in biomarker-unselected patients with prostate cancer.  Dr. Neeraj Agarwal: Rana, what's your take-home message on Abstract 5006, titled “Health-related quality of life results from PRESTO (AFT-19), a phase 3 randomized trial of intensification of androgen blockade in patients with high-risk biochemically relapsed castration sensitive prostate cancer”? Dr. Rana McKay: So, as a reminder to our audience, the PRESTO trial was a randomized phase 3 study that assessed the effects of intensified androgen receptor blockade in patients with biochemically recurrent prostate cancer following local therapies. Patients with a PSA doubling time of less than 9 months and no evidence of metastatic disease were randomized to receive either 52 weeks of ADT alone, ADT plus apalutamide, or ADT plus apalutamide plus abiraterone. In their paper published earlier this year in the Journal of Clinical Oncology, the authors showed that patients receiving ADT plus apalutamide with or without abiraterone had significantly longer PSA-progression-free survival than those receiving ADT alone. In the oral presentation featured at ASCO24, Dr. Ronald Chen and colleagues report health-related quality of life outcomes that were assessed using various questionnaires or scales at baseline, at cycle 7, which is around 6 months on treatment, and at the end of treatment. Results showed that this intensified approach with apalutamide did not significantly increase severe adverse events, did not lengthen the time to testosterone recovery, and did not meaningfully increase common treatment-related symptoms such as hormonal symptoms, sexual dysfunction, hot flash interference, and fatigue. Importantly, additional intensification with abiraterone did not further improve PSA-PFS but did increase the rate of serious adverse events, lengthened the time to testosterone recovery, and increased hot flash interference.  Dr. Neeraj Agarwal: So, in conclusion, the PRESTO trial supports using intensified androgen blockade with apalutamide to improve PSA-PFS in patients with high-risk biochemically recurrent prostate cancer without compromising health-related quality of life. However, adding abiraterone did not offer additional benefits and increased side effects.  Dr. Rana McKay: Let's move on to LBA5002 titled, “A randomized, double-blind, placebo-controlled trial of metformin in reducing progression among men on expectant management for low-risk prostate cancer: The MAST (Metformin Active Surveillance Trial) study.” Would you like to share your insights on this abstract with our listeners? Dr. Neeraj Agarwal: Absolutely. MAST was a randomized, double-blinded, placebo-controlled trial that investigated the impact of metformin on the progression of low-risk localized prostate cancer in patients choosing to undergo active surveillance. Eligible patients had biopsy-proven, low-risk, localized prostate cancer diagnosed within the past 6 months, characterized by a Gleason score of less than 6 observed in less than one-third of the total cores, less than 50% positivity in any one core, a PSA level of less than 10 ng/ml, and a clinical-stage between T1c and T2a. Patients were randomized in a 1:1 ratio to receive either metformin 850 mg twice daily or placebo for three years. All patients underwent repeat prostate biopsy at 18 and 36 months. The primary endpoint was time to progression, defined as the earliest occurrence of primary prostate cancer therapy, such as prostatectomy, radiation, hormonal therapy, or pathological progression on subsequent biopsies, which was defined as more than 1/3 of total cores involved, at least 50% of any one core involved, or Gleason pattern 4 or higher. The study included 407 patients, with 204 receiving metformin and 203 receiving a placebo. Results presented by Dr. Anthony Joshua showed no statistically significant difference in progression-free survival, including therapeutic and pathologic progression, with an unadjusted hazard ratio of 1.08.  Interestingly, there was a signal that patients with a BMI more than 30 had a detriment to taking metformin with a higher risk of progression compared to those receiving placebo with an unadjusted HR of 2.39 and a p-value of 0.01. Dr. Rana McKay: I would like to add that this study showed that metformin use does not prevent the progression of low-risk localized prostate cancer on active surveillance and could represent a potential detriment for patients with high BMI at study entry. Dr. Neeraj Agarwal: Yes, Rana, I concur. Any final remarks before we conclude today's podcast? Dr. Rana McKay:  Thank you, Neeraj; it's been wonderful being here with you today and you having me on the podcast to highlight these important advances and the amazing work that many investigators are conducting and the patients who were involved in the context of these trials. It's really excellent to see these updated results.   Dr. Neeraj Agarwal: Before we wrap up this podcast, I would like to say that we have reviewed a selection of abstracts addressing prostate, bladder, and kidney cancer, which are significantly impacting our medical practices now and in the near future. Rana, thank you for sharing your insights today. These updates are undoubtedly exciting for the entire GU oncology community, and we greatly appreciate your valuable contribution to the discussion. Many thanks. And thank you to our listeners for joining us today. You will find links to the abstracts discussed today on the transcript of this episode. Finally, if you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.   Find out more about today's speakers:    Dr. Neeraj Agarwal   @neerajaiims   Dr. Rana McKay  @DrRanaMcKay     Follow ASCO on social media:      @ASCO on Twitter      ASCO on Facebook      ASCO on LinkedIn         Disclosures:        Dr. Neeraj Agarwal:         Consulting or Advisory Role: Pfizer, Bristol-Myers Squibb, AstraZeneca, Nektar, Lilly, Bayer, Pharmacyclics, Foundation Medicine, Astellas Pharma, Lilly, Exelixis, AstraZeneca, Pfizer, Merck, Novartis, Eisai, Seattle Genetics, EMD Serono, Janssen Oncology, AVEO, Calithera Biosciences, MEI Pharma, Genentech, Astellas Pharma, Foundation Medicine, and Gilead Sciences     Research Funding (Institution): Bayer, Bristol-Myers Squibb, Takeda, Pfizer, Exelixis, Amgen, AstraZeneca, Calithera Biosciences, Celldex, Eisai, Genentech, Immunomedics, Janssen, Merck, Lilly, Nektar, ORIC Pharmaceuticals, Crispr Therapeutics, Arvinas      Dr. Rana McKay:   Consulting or Advisory Role: Janssen, Novartis, Tempus, Exelxis, Pfizer, Bristol-Myers Squibb, Astellas Medivation, Dendreon, Bayer, Sanofi, Merck, Vividion, Calithera, AstraZeneca, Myovant, Caris Life Sciences, Sorrento Therapeutics, AVEO, Seattle Genetics, Telix, Eli Lilly, Pfizer, Bayer, Tempus

This week's episode will be focusing on hematopoietic growth factors, including G-CSF, TPO agonists, and ESAs. This is another episode in our series on supportive care, and a highly testable and frequently discussed topics on consults and in clinic.

În cadrul ediției de pe 5 martie 2024 a emisiunii Știința360 de pe Radio România Cultural, Dr. Marius Geantă, Președintele Centrului pentru Inovație în Medicină, a comentat cele mai recente noutăți din domeniul medical publicate pe Raportuldegardă.ro. Puteți asculta emisiunea live, în fiecare marți, ora 14:00. Vaccinurile oncologice personalizate de tip lizat tumoral cresc semnificativ supraviețuirea în absența bolii (DFS, disease free survival) și supraviețuirea generală (OS, overall survival) la pacienții cu melanom rezecat în stadiul III/IV, cu un profil de siguranță favorabil. Aceste rezultate raportate în abstractul publicat în Journal for ImmunoTherapy of Cancer cuprind datele colectate pe o perioadă de 36 de luni, în cadrul studiului de fază 2, aflat în curs de desfășurare. Studiul a inclus aproape 200 de pacienți, împărțiti în patru grupuri de aproximativ 40-50 de persoane. Un grup a primit vaccinul de tip TLPO (tumor lysate particle only), un alt grup a primit vaccinul TLPLDC (tumor lysate, particle-loaded, dendritic cell), al treilea grup a primit vaccinul TLPLDC plus G-CSF, iar ultimul grup a primit placebo. Deşi aceste rezultate sunt promiţătoare, este necesară investigarea vaccinului în cadrul studiilor clinice de fază III. Pe baza rezultatelor obţinute în studiile clinice de fază II, FDA a autorizat iniţierea studiului clinic de fază III, care va include 500 de persoane, pe parcursul a trei ani. Studiul clinic de fază III va fi lansat anul acesta. Mai multe detalii despre subiectele discutate: ▶ Supraviețuire de 95% la 3 ani pentru pacienții cu melanom stadiul III/IV, în urma administrării unui vaccin oncologic personalizat ▶ Remisiunea diabetului zaharat de tip 2 prin scăderea în greutate reduce riscul de boli cardiovasculare și renale ▶ Episoadele de hipoglicemie la conducătorii auto cu diabet, depistate înainte de apariția simptomelor cu ajutorul AI ▶ Persoanele care sunt mai active seara decât dimineața au un risc mai mare de evenimente cardiovasculare și calcificare arterială

Dr. Greg Kalemkerian joins us on the ASCO Guideline Podcast to discuss the newest ASCO – Ontario Health (Cancer Care Ontario) Guideline on systemic therapy for small-cell lung cancer (SCLC). He reviews the evidence-based recommendations from the panel, including guidance on systemic therapy options for resected, limited-stage, extensive-stage, and relapsed SCLC, and NSCLC with an EGFR mutation that has transformed to SCLC, recommendations for older adults with poor performance status, the role of biomarkers, and the use of myeloid supportive agents. Dr. Kalemkerian also highlights future research for systemic therapy options for SCLC, and the impact of guidelines on both clinicians and patients with SCLC. Read the full guideline, “Systemic Therapy for SCLC: ASCO-OH (CCO) Guideline” at www.asco.org/thoracic-cancer-guidelines." TRANSCRIPT This guideline, clinical tools, and resources are available at http://www.asco.org/thoracic-cancer-guidelines. Read the full text of the guideline and review authors' disclosures of potential conflicts of interest disclosures in the Journal of Clinical Oncology, https://ascopubs.org/doi/10.1200/JCO.23.01435  Brittany Harvey: Hello and welcome to the ASCO Guidelines podcast, one of ASCO's podcasts delivering timely information to keep you up to date on the latest changes, challenges, and advances in oncology. You can find all the shows, including this one, at asco.org/podcasts.   My name is Brittany Harvey, and today I'm interviewing Dr. Greg Kalemkerian from the University of Michigan, co-chair on “Systemic Therapy for SCLC: American Society of Clinical Oncology – Ontario Health Guideline.” Thank you for being here, Dr. Kalemkerian.  Dr. Greg Kalemkerian: Thank you. Brittany Harvey: Before we discuss this guideline, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The disclosures of potential conflicts of interest for the guideline panel, including Dr. Kalemkerian, who has joined us here today, are available online with the publication of the guideline in the Journal of Clinical Oncology, which is linked in the show notes.  So then, to move into what we're here today to discuss, Dr. Kalemkerian, can you provide an overview of both the scope and the purpose of this guideline? Dr. Greg Kalemkerian: So, the guideline is meant to update the systemic treatment for small-cell lung cancer. There have been several changes in the last couple of years. For the first time in quite a few decades, we actually have some newer drugs that have demonstrated benefits in this disease. So we're really focusing on the systemic therapy. And ASCO does endorse the ASTRO guidelines for the radiotherapy involved in patients with small-cell lung cancer. Brittany Harvey: Great. That's great to hear that there's new systemic therapy options for patients with small-cell lung cancer.  So then I'd like to review the key recommendations of this guideline. This guideline reviews eight clinical questions in total, so we can go through the key points of the recommendations for each question. So let's start with what is recommended for adjuvant systemic therapy in patients with resected small-cell lung cancer? Dr. Greg Kalemkerian: So, to start with, only fewer than 5% of people have what would be considered resectable small-cell lung cancer, and that's stage I small-cell lung cancer. So tumors less than 5 cm in size without any lymph node involvement, either hilar or mediastinal lymph node involvement. So purely the very early stages, which are rare in small-cell. And if patients undergo surgical resection for such tumors, the recommendation afterward is to provide adjuvant chemotherapy with four cycles of either cis-or carboplatin plus etoposide in order to try and improve longer-term survival for those patients.  The other part of the recommendation is we do recommend that treatment be started within eight weeks of surgery. There is little data on timing in small-cell lung cancer, but that's derived from extrapolating from non-small cell lung cancer as well. Brittany Harvey: Understood. I appreciate you reviewing those recommendations for resectable small-cell lung cancer.  So then, moving along, what does the panel recommend for patients with limited-stage small-cell lung cancer? Dr. Greg Kalemkerian: So, the treatment with limited-stage small cell lung cancer unfortunately has not changed in quite some time. We recommend that patients receive four cycles of either cisplatinum or carboplatin and etoposide concurrently with radiotherapy. Preferably the radiotherapy should be given early and concurrently with the chemotherapy, though we do not recommend that people wait for the radiation to get started in order to start the chemotherapy. So we do recommend that the chemotherapy get started as soon as possible and then the radiation can be added in on the second cycle of chemotherapy. Brittany Harvey: Then to follow that up, what is recommended for patients with extensive stage small-cell lung cancer? Dr. Greg Kalemkerian: So, extensive stage small-cell lung cancer now is probably the most straightforward of the portions of this. Based on the data from two trials thus far, the IMpower 133 trial and the CASPIAN trial, we now recommend chemotherapy with immunotherapy. The chemotherapy should be cisplatinor carboplatin plus etoposide along with concurrently either atezolizumab or durvalumab as the immunotherapy for four cycles of the combined chemo-immunotherapy followed by maintenance with the immunotherapy drug of choice. With regard to the choice of either cisplatin or carboplatin, meta-analysis has demonstrated that there is no significant difference between the two and our belief is that carboplatin is likely the more reasonable drug in the palliative treatment situation based on its better non-hematologic toxicities. Brittany Harvey: Appreciate you sharing those recommendations and some of the rationale behind those.  So then moving along, what options are available for patients with relapsed small-cell lung cancer? Dr. Greg Kalemkerian: So relapsed small-cell lung cancer gets a little more potentially complicated. One of the main drivers of outcome in patients with relapsed small cell lung cancer is the time since they completed their initial chemotherapy. Patients who have had a longer time since chemotherapy do better and have better responses to subsequent therapy. For patients who relapse with a short interval within 90 days or three months of completion of prior chemotherapy, our recommendation is that they be treated with single-agent chemotherapy. There are two drugs that are currently FDA approved for use in relapsed small cell lung cancer, topotecan and lurbinectedin, and either one of those is the preferred agent as a single-agent treatment in this scenario. For people with a longer chemotherapy-free interval, so beyond the 90 days or three months, one could either use combination chemotherapy, so reinitiation or re-induction with the regimen such as carboplatin and etoposide, or one could use single-agent chemotherapy with the preferred agents being topotecan or lurbinectedin again. The use of combination chemotherapy has been shown to improve response rates in this situation over topotecan alone. However, we have not been able to demonstrate that there is a significant improvement in overall survival. So one has to look at the individual patient and make some judgment on whether you think that the added potential toxicity of combination chemotherapy is beneficial for that individual.  For people who have progression of disease while they are on maintenance therapy with immunotherapy for extensive stage small-cell lung cancer, we do not recommend continuation of the immunotherapy. So if people progress while they're on the immunotherapy, even if they're nine months out on that, then treatment with second-line chemotherapy, either with the combination agent or with single agents, would be what we would recommend, and not continuing the immunotherapy. If patients had previously been treated for limited-stage small-cell lung cancer where immunotherapy is not part of the initial treatment at this time, and they relapse, say, six months or nine months out from their initial chemotherapy and radiation therapy treatment, then it would be reasonable to perhaps initiate carboplatin etoposide and one of the immunotherapy agents as appropriate treatment, because that patient is immunotherapy naive.  However, the single-agent immunotherapy does not have a role in the treatment of patients with relapsed small-cell lung cancer.  Brittany Harvey: Understood. It sounds like some of the treatment options are individualized to the specific patient then.  So the next question also addresses specific groups of patients. So what did the panel recommend for older adults with small cell lung cancer or for those with poor performance status? Dr. Greg Kalemkerian: Approximately half of people who have small-cell lung cancer are over the age of 70 years old, so it is a disease of older smokers. Many of these people have comorbidities that can limit our ability to use standard treatments. Many of these individuals also have poor performance status because the disease is an aggressive disease that causes a lot of problems for people. So the issue of older individuals and people of poor performance status is something that we run into on a regular basis in treating people with small-cell lung cancer.  For patients with limited-stage small-cell lung cancer who are older and have a performance status of 0 to 2, it is very reasonable to utilize standard treatment with standard chemo and radiotherapy with curative intent. For people with limited-stage small-cell lung cancer who have a performance status of 3 or 4, and this would include people who might be in an ICU with an obstructive airway, then it is reasonable to initiate chemotherapy in order to try and shrink the cancer down and improve their situation. Small-cell lung cancer is a disease that is very sensitive to chemotherapy initial treatment, so many of these people will have shrinkage of tumor and improvement of their symptoms. If the poor performance status is due to the small-cell lung cancer, it has potential to get better. So we do recommend for people at limited-stage small-cell lung cancer and a poor performance status that is felt to be due to the disease, the cancer, then it is reasonable to initiate treatment with chemotherapy. And depending on the person's response and recovery and improvement in their performance status, then one could add radiotherapy later on or do it sequentially with the definitive radiotherapy for the limited-stage small-cell lung cancer.  For older individuals with extensive stage small cell lung cancer who have a performance status of 0-2, it is very reasonable to utilize the standard chemotherapy and immunotherapy as we outlined previously in treating that. For individuals who have a poorer performance status, so performance status 3 or 4, one really needs to individualize the situation. If the poor performance status is due to the cancer, then again, it would be reasonable to attempt chemotherapy in an effort to try and shrink the cancer. There is no data on the use of chemo plus immunotherapy in this patient population. But the use of standard chemotherapy, obviously, in the older individuals preferring carboplatin over cisplatinum with etoposide would be a reasonable option, taking into account abnormalities in organ function that may require dose adjustments or reductions. Because small-cell lung cancer is a disease that is quite sensitive and responds well to  chemotherapy, then one can individualize in those situations for patients with poor performance status to see if they can improve their overall situation and have some period of time of optimized quality of life. Clearly, it is a very individualized decision-making whether or not to treat these patients. That requires clearly the patient's input as well, as a primary driver of what is done.  Brittany Harvey: Absolutely. That nuance is helpful for patient-clinician shared decision-making, depending on the factors that you mentioned.  So then, switching to the next topic that the expert panel addressed, what does the panel recommend for patients with non-small cell lung cancer with an EGFR mutation that has then transformed to small-cell lung cancer?  Dr. Greg Kalemkerian: The EGFR mutant non-small cell lung cancer transformation to small-cell lung cancer is relatively rare. I think in the real world, this probably is occurring in 2%-3% of people with EGFR mutant non-small cell lung cancer, but we do see it. Now, these patients are initially being treated with EGFR inhibitor therapy for their mutant non-small cell lung cancer and then they develop a more aggressive progression of disease. It is important to note that when people progress in that situation, it is important to get a biopsy in order to see whether or not transformation has occurred and whether or not there are any other new driver mutations that might be targetable. If the patient has a small cell lung cancer transformation, then the recommendation is to treat them as we treat patients with small cell lung cancer with chemotherapy consisting of platinum and etoposide for four to six cycles, as we usually do. It does not appear that there is a role for immunotherapy in this situation, though we clearly have a paucity of data on these patients. So we do not yet have any trials that have looked at the management of this population. We do have several series that have presented these individuals and what their outcomes are with treatment. And their outcomes are very similar to people with de novo small-cell lung cancer. So not a very good situation, but we do recommend that they be treated with standard chemotherapy, platinum plus etoposide.  Another question that arises is do you continue with the targeted therapy with the EGFR inhibitor. And the honest answer is we don't know. We don't have data on that. We do know from case reports, the series, and from personal experiences, that some people, in fact, I think many people, if not most of these individuals, have a mix of both EGFR mutant adenocarcinoma and small-cell lung cancer at the time that they transform. So not every tumor in their body is transforming, so that EGFR mutant tumor is still present in their body. So even though the small-cell lung cancer component, because it's progressing, is clearly not responsive to the EGFR inhibitor any longer, the adenocarcinoma component most likely is still sensitive to the EGFR inhibitor. So it is not unreasonable to continue with the EGFR-targeted therapy along with the small cell lung cancer-directed chemotherapy. Even though we don't have any strong data supporting one way or the other. Brittany Harvey: I appreciate that guidance, even with the dearth of data in this relatively rare scenario.  So then we've talked a bit about individualized treatment, and often in that conversation, biomarkers come up. So what does the guideline say regarding the role of biomarkers for patients with small-cell lung cancer? Dr. Greg Kalemkerian: This is pretty straightforward. Thus far, in people with de novo small-cell lung cancer - so we're not talking about the transformed patients from EGFR mutant, we're talking about people who present with small-cell lung cancer - we have no evidence that molecular diagnostic testing would help guide treatment or improve patient outcomes at this time. So we do not support obtaining molecular diagnostic testing for the routine care of patients with de novo small-cell lung cancer. I would love to talk for the next half hour about what's coming down the pipeline in small-cell lung cancer with regard to identifying subsets of patients and trying to identify the vulnerabilities within those subsets of patients that may lead to better-targeted therapy based on molecular diagnostics, but in the current environment, there is no role for molecular diagnostics.  Brittany Harvey: Understood. We'll look for that in future guideline updates instead, then.  So then the last clinical question that the guideline addressed - what myeloid supportive options may be offered for patients with small cell lung cancer? Dr. Greg Kalemkerian: So this has to be couched initially with whether or not one thinks that myeloid suppressive agents are necessary in the treatment of patients with small-cell lung cancer. So in extensive-stage disease with the use of chemotherapy, say, carboplatin and etoposide, the majority of patients likely don't require myeloid supportive agents. However, if one believes that the patient, because of their own individual characteristics, or in a patient who has already developed myelosuppressive problems, then one could either utilize trilaciclib, which was FDA-approved a couple of years ago and was shown to improve the blood counts in people with small cell lung cancer treatment, or one could utilize G-CSF. So either trilaciclib or G-CSF could be utilized to support the patient's bone marrow. In patients who have limited-stage disease, for many years, we have recommended against using G-CSF in combination with chemotherapy and radiotherapy due to concerns for increasing toxicities, including thrombocytopenia. Recent data suggests that this may not necessarily be a hard and fast rule and that if one feels that the patient requires or would benefit from some myeloid support, then G-CSF may be offered to patients undergoing chemotherapy and radiotherapy. I do not think that the standard patient that we see who is starting on treatment requires such support, but some subsets of patients or patients who have already proven that they're getting into trouble with their counts, G-CSF could be utilized in this situation.  So with regard to this recommendation, overall, it's that for patients with extensive stage disease, trilaciclib or G-CSF could be used if one feels they're necessary. And for limited-stage small cell lung cancer, G-CSF could be utilized if you feel it's necessary.  Brittany Harvey: Thank you for reviewing those options and all of these recommendations. The panel was certainly hard at work reviewing the evidence and developing these recommendations.  In your view, Dr. Kalemkerian, what is the importance of this guideline for both clinicians and for patients with small-cell lung cancer? Dr. Greg Kalemkerian: Well, I think it's not just small-cell lung cancer, but when you look at guidelines overall, I think they are very important to have evidence-based guidelines as well as expert consensus-based guidelines because, quite honestly, the field is moving very quickly, the field of oncology. Now, small-cell lung cancer hasn't moved as quickly as we would like compared to other aspects of oncology, but it's very hard for the clinician who is trying to care for patients with lots of different tumor types to keep up with all of the flood of literature, the flood of new FDA approvals that are coming out every week. So I do think that utilizing the guidelines is important in order to see what the standard approach might be.  Now, I also have to couch that with saying that guidelines are never enough. We have to look at the individual sitting across the exam table from us. We have to personalize the treatment to that individual. I will say that in my own practice, there are very few people who walk in the door who are the optimal patient, who are the person who has outstanding physical function. And in lung cancer, that's even more true because patients tend to be older smokers, and they have a lot of comorbidities and other things that you have to personalize therapy towards in them. So the guidelines are a very good starting point in order to know what the optimal treatment might be and then to adjust that accordingly to the person sitting in the room with you.  Brittany Harvey: Definitely, we hope guidelines are a place that clinicians can turn to for evidence-based recommendations and succinct recommendations, but individualized patient and clinician decision-making is paramount to each of our guidelines.   So then, Dr. Kalemkerian, we've already talked about this a little bit when you mentioned molecular testing advances down the road. So maybe I'll ask what are the most pressing, unanswered questions about systemic therapy for small-cell lung cancer? Dr. Greg Kalemkerian: Yeah, so one of them I'll come back to limited-stage small-cell lung cancer. So, obviously, in the extensive stage, we've now incorporated immunotherapy. And yet I didn't talk about immunotherapy in the limited-stage setting, and neither do the guidelines because thus far we don't have any data on the use of immunotherapy in limited-stage small-cell lung cancer. We are expecting data to be coming down the line within the next year hopefully, definitely, within the next two years, because a number of trials that are either ongoing or have recently been completed looking at incorporating immune checkpoint inhibitors into the treatment of limited-stage small-cell either concurrently with chemoradiation or as consolidation after chemoradiotherapy. So that data is anxiously anticipated. And we're hoping that that might move the needle a little bit further in limited-stage small-cell lung cancer and hopefully improve that long-term survival or cure rate that we see in that disease.  Other avenues coming down the line – many of us have made a career of doing negative trials in small-cell lung cancer, myself included, and a lot of that has had to do with trying to target therapies to specific molecular abnormalities, and none of those have really panned out thus far. But coming down the line, as we start to molecularly subtype lung cancers, and the best molecular subtyping that we have thus far is not based on mutational analysis, but more based on expression, gene expression analysis, expression of particular transcriptional factors within different subsets of small cell lung cancer, we're now starting to see some vulnerabilities. So one of these subsets in the small cell lung cancer array has a high expression of DLL3, which is part of the Notch pathway, and we can target that. We haven't figured out how to target it as far as its activity goes, but we can target it as a homing device in order to get either drugs delivered by use of antibody-drug conjugates, or to use a BiTE—a T-cell engaging type molecule—that targets both DLL3and T cells in order to try and amplify that immune response in small cell lung cancers. So recently a compound called tarlatamab had data presented at ASCO and also published in JCO that shows some response, about 20-25% response, in people with relapse small cell lung cancer. These were heavily pretreated patients. So that's moving the needle a bit in favor of a specific targeted therapy. And we're hoping that will lead to further avenues to look at the vulnerabilities of different subsets and be able to develop newer targeted treatments for these diseases, trying to amplify that immunotherapy response as well.  Small cell lung cancer is a little bit of an outlier in that it does not respond well to immunotherapy compared to other tumors. Not what we expected based on the high tumor mutational burden and the aggressiveness of the disease. But we know that it does not express a lot of PD-L1. We know that it doesn't have MHC class I molecules. So there are a number of reasons why it doesn't respond, and there is work going on to try and amplify that immune response as well. So I think those three things: the use of immunotherapy in limited-stage, the development of targeted therapies based on subsets, and trying to amplify that immune response are the things that I look forward to in the next few years. Brittany Harvey: That's great to hear. We'll await the data to provide answers to those outstanding questions.  So I want to thank you so much for your work to develop these evidence-based guidelines, and thank you for sharing your perspective with me today, Dr. Kalemkerian.  Dr. Greg Kalemkerian: Thank you, Brittany. And thanks to ASCO for getting these guidelines together and getting the outstanding group of people we had to work on it and getting them out in a timely manner so they can help our patients. Brittany Harvey: And also, thank you to all of our listeners for tuning in to the ASCO Guidelines podcast. To read the full guideline, go to www.asco.org/thoracic-cancer-guidelines.  You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in the Apple App Store or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.    

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.06.29.547089v1?rss=1 Authors: Araki, D., Chen, V., Redekar, N., Salisbury-Ruf, C., Luo, Y., Liu, P., Li, Y., Smith, R., Dagur, P., Combs, C., Larochelle, A. Abstract: Granulocyte colony stimulating factor (G-CSF) is commonly used as adjunct treatment to hasten recovery from neutropenia following chemotherapy and autologous transplantation of hematopoietic stem and progenitor cells (HSPCs) for malignant disorders. However, the utility of G-CSF administration after ex vivo gene therapy procedures targeting human HSPCs has not been thoroughly evaluated. Here, we provide evidence that post-transplant administration of G-CSF impedes engraftment of CRISPR-Cas9 gene edited human HSPCs in xenograft models. G-CSF acts by exacerbating the p53-mediated DNA damage response triggered by Cas9-mediated DNA double-stranded breaks. Transient p53 inhibition in culture attenuates the negative impact of G-CSF on gene edited HSPC function. In contrast, post-transplant administration of G-CSF does not impair the repopulating properties of unmanipulated human HSPCs or HSPCs genetically engineered by transduction with lentiviral vectors. The potential for post-transplant G-CSF administration to aggravate HSPC toxicity associated with CRISPR-Cas9 gene editing Cas9 should be considered in the design of ex vivo autologous HSPC gene editing clinical trials. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

The Cancer Advances podcast is joined by Abhay Singh, MD, MPH, a physician with the Department of Hematology and Medical Oncology at Cleveland Clinic to talk about his study, which aimed to identify risk factors for secondary malignancy in breast cancer survivors. This study was presented at the American Society of Hematology (ASH) 2022 annual meeting. Listen as Dr. Singh explains how he explored the different risk factors, such as G-CSF exposure, how the CHIP Clinic might be able to monitor patients, and the long-term goal to figure out which therapies patients should try to avoid.

1:25 Labiotech.eu news3:02 GPCR Therapeutics22:16 eClinical Solutions31:04 Orbsen TherapeuticsThis week, our guests are Katrina Rice, chief delivery officer, biometrics services at eClinical Solutions; Pina Cardarelli, president and CSO of GPCR Therapeutics; and Larry A Couture, CEO of Orbsen Therapeutics.GPCR Therapeutics launches multiple myeloma trial GPCR Therapeutics, Inc., a drug discovery company targeting G Protein Coupled Receptors (GPCR) pairs, recently started its phase 2 trial in the U.S. for its lead small molecule asset, GPC-100.  GPC-100 targets CXCR4, one of the most prevalent chemokine GPCRs overexpressed in more than 23 cancers.This randomized, open-label phase 2 study assesses the efficacy of GPC-100 and propranolol, with and without granulocyte colony-stimulating factor (G-CSF) for the mobilization of stem cells in patients with multiple myeloma undergoing autologous stem cell transplant. Survey looks at biotech challengeseClinical Solutions, a provider of digital clinical software and biometrics services, has published a survey detailing insights from 60 biopharmaceutical clinical operations and biometrics professionals on the most pressing trends, challenges, and opportunities that are shaping the clinical data landscape. Some key takeaways include: 64% of respondents are leveraging 6 or more external data sources; harnessing automation is the top overarching industry priority for more than one-third (36%) of respondents; and speed (30%) and quality (30%) are reported as the largest pain points for electronic data capture (EDC) database build.Orbsen TherapeuticsOrbsen Therapeutics is an Irish-headquartered company working in stromal cell immunotherapy. The company has leveraged its proprietary technology platform, which is based on highly purified stromal stem cells, to establish a specific portfolio of early-stage product candidates. Orbsen's allogeneic or 'off-the-shelf' cell product candidates target significantly advanced stages of diseases where there are high unmet medical needs, including moderate-severe acute respiratory distress syndrome (ARDS), autoimmune disease and Stage 3 DKD.

In this JCO Article Insights episode, Davide Soldato summarizes two articles from the January 10th, 2023 Journal of Clinical Oncology issue: “Low-Intensity Chemotherapy for Early Breast Cancer in Older Women: Results From the Prospective Multicenter HOPE Trial” and “Inflammation and Clinical Decline After Adjuvant Chemotherapy: Results From the Hurria Older Patients Prospective Study .” Both articles report on clinical outcomes of elderly patients treated with chemotherapy for early-stage breast cancer. TRANSCRIPT Davide Soldato: Thank you for joining JCO Article Insights. I'm Davide Soldato. Today I will be providing summaries for two different articles focused on elderly patients treated for early-stage breast cancer. Both articles are reported from the Hurria Older Patients With Breast Cancer Study. This study is also known as the HOPE Study, and it was a multicenter, prospective, study of patients aged 65 years and older treated with current standard (Neo)adjuvant chemotherapy regimens for early-stage breast cancer. The study captured several detailed geriatric clinical and treatment data from 500 patients that were recruited between September 2011 and May 2017 in 16 sites across the United States. The first article is titled ‘Low-intensity Adjuvant Chemotherapy for Breast Cancer in Older Women'. In this article, Dr. Sedrak and colleagues used data from the HOPE Study to investigate the incidence of chemotherapy administration with low relative dose intensity, associated risk factors, and relationship with survival outcomes. Previous data already showed that the receipt of chemotherapy with a low relative dose intensity is associated with inferior survival outcomes, and the commonly used threshold to define a low relative dose intensity is 85%. And this same threshold was used inside of the study that I am reporting. Elderly patients that are treated with chemotherapy are at higher risk of receiving chemotherapy with low relative dose intensity because of toxicity. However, previous data on the topic was mainly retrospective in nature and reported heterogeneous rates of low relative dose intensity up to 75%. And also, little information was available on risk factors and on the impact on survival outcomes. So, considering the paucity and the quality of the previous data and the potential clinical implication for survival outcomes, results of the HOPE Study are extremely relevant to clinical practice as they provide novel insight on the topic from a prospective multicenter study. In the analysis that was reported in the January issue of JCO, the authors excluded patients with HER-2 positive disease, those receiving nonstandard chemotherapy regimens, and those with upfront chemotherapy dose reduction. The final analytic cohort included 322 patients with a median age of 70 years, 44% with stage II, and 22% with stage III disease. Docetaxel and cyclophosphamide, and anthracycline-based chemotherapy, and this one, either alone or with subsequent paclitaxel, were the most commonly used chemotherapy regimens. Additionally, 85% of patients received a primary prophylaxis with G-CSF. Relative dose intensity was variable in the study. More than half of the patients received full course chemotherapy with 100% relative dose intensity. However, the incidence of low relative dose intensity in the HOPE study was still 21%, thus identifying a subset of patients who received chemotherapy with a suboptimal dose intensity. The rates of low relative dose intensity were higher for patients receiving either anthracycline-based chemotherapy and those with a planned treatment duration over 12 weeks. The authors developed a multivariable logistic regression model with stepwise selection to identify risk factors associated with low relative dose intensity. The results of this analysis showed that an age higher than 76 years, administration of anthracycline and CMF-based regimens, and a physician-rated Karnofsky Performance Status under 90 were associated with higher risk of low relative dose intensity ranging from 3 to 5 times greater compared to reference categories. Then the authors realized another model where they used the previously mentioned three variables, but they also adjusted for relevant clinical characteristics, including age, stage, liver and renal function, and also previous cardiovascular disease. And in this model, the three variables that were observed previously— age, type of chemotherapy, and Karnofsky Performance Status—remained significantly associated with higher risk of receiving chemotherapy with a low relative dose intensity. Finally, the Authors evaluated the association between a low relative dose intensity and survival outcomes, specifically breast cancer-specific mortality, non-breast cancer-specific mortality, and overall survival. Patients who received the chemotherapy with a low relative dose intensity had a significantly lower overall survival, and this association persisted even after excluding patients older than 76 years. A higher risk of both breast cancer and non-breast cancer mortality was observed in patients with low relative dose intensity chemotherapy. However, the number of cause-specific events was too low to obtain statistical significance for both these endpoints. In conclusion, the study by Dr. Sedrak and colleagues provides several relevant information for clinical practice. First, the HOPE study demonstrates that the administration of chemotherapy to elderly patients while maintaining an appropriate relative dose intensity is feasible. However, 1 in 5 patients received chemotherapy with a low relative dose intensity. So the results of this study reinforced the need to identify upfront patients most likely to require dose reduction. And these patients should be proactively supported during the administration of chemotherapy to ensure that appropriate toxicity management can reduce the risk of low relative dose intensity. Second, in the study, the authors observed a significant association between a low relative dose intensity and the CARG and CARG-BC scores. These scores were previously validated to predict chemotherapy toxicity. The presence of this association is important because it suggests that these validated scores can be used routinely in clinical practice to identify patients that might benefit from a comprehensive geriatric assessment to optimize comorbidities treatments and assure optimal delivery of chemotherapy. Finally, longer follow-up will provide the opportunity to establish if the higher mortality that was observed in the HOPE study in patients receiving chemotherapy with a low relative dose intensity is consequent to the low chemotherapy efficacy or to a clinical decline that might be consequent to chemotherapy itself. I will now move to the second article titled ‘Inflammation and Clinical Decline After Adjuvant Chemotherapy in Older Adults With Breast Cancer'. This article was published by Dr. Ji and colleagues, and it describes a secondary analysis of the HOPE study. In this specific manuscript, the authors wanted to evaluate the potential predictive role of baseline inflammatory biomarkers on the risk of clinical decline after administration of chemotherapy. In the HOPE study, the authors collected information on frailty stages, pre and post-chemotherapy using the Deficit-Accumulation Index (DAI): this is a 50-item scale that evaluates deficits in physical activity of daily living, instrumental activities of daily living, psychosocial status, nutrition, frequency of falls, number of medications, comorbid conditions, social support, and laboratory values. The inflammatory biomarkers that were evaluated in the current study were CRP and IL-6, and their levels were determined on pre-chemotherapy blood specimens. Using the deficit accumulation index score, patients were categorized pre-chemotherapy as being robust, pre-frail, or frail; this is important because previous studies already demonstrated that there is a significant association between this categorization and morbidity and mortality outcomes in older adults. The primary outcome of the study was a chemotherapy-induced clinical decline that was defined as a decline from a robust stage pre-chemotherapy to a pre-frail or frail status after chemotherapy. The overall analytic cohorts included 295 robust women. The median age was 69, 62% of patients had stage II or III disease, median number of comorbidities was 1.9, and mean BMI was 28.5. One in 4 older women included in the study experienced a chemotherapy-induced decline in frailty status, so this means that they transitioned from a robust status pre-chemotherapy to a pre-frail or frail status after chemotherapy. This decline in frailty status was more frequent among patients with a higher BMI, those with more comorbidities, and those with stage II and III disease. Additionally, the patients who experienced chemotherapy-induced decline had higher baseline levels of both IL-6 and CRP. Univariate analysis also showed that patients with high IL-6 and CRP had a threefold higher risk of experiencing chemotherapy-induced decline in frailty stages. This association between higher inflammation and the decline in frailty status remained significant in a multivariable logistic regression analysis that was adjusted for relevant clinical and demographic characteristics, including age, stage, race, education, BMI, breast cancer surgery, anti-inflammatory medication, and number of comorbidities. Specifically, the results of these models showed that patients who had both high CRP and IL-6 at baseline had a threefold higher risk of experiencing a decline in frailty status. So, in conclusion, this study shows a significant association between systemic inflammation and a decline in frailty status in elderly patients receiving chemotherapy for early-stage breast cancer. From a biological perspective, these higher levels of systemic inflammation might be a direct byproduct of a more advanced biological aging following the accumulation of senescent cells. There are several intriguing future perspectives that come from this study. First, if validated in additional cohorts, these findings might lead to higher treatment personalization thanks to the identification of patients at risk of clinical decline based on clinical characteristics but also on systemic inflammation. And these patients could be then proactively supported during chemotherapy to try and reduce the appearance of the clinical decline. Second, we know that inflammation is a potentially targetable pathway, and previous data obtained in breast cancer patients showed the potential of behavioral, exercise, and dietary interventions in modulating systemic inflammation. So, based on this new information, if validated in additional cohorts, future research should then evaluate if this interventions can be used to treat and eventually prevent the decline in frailty status in patients with high baseline systemic inflammation before receiving chemotherapy. This is Davide Soldato in this episode of JCO Article Insights. We discussed two publications: ‘Low-intensity Adjuvant Chemotherapy for Breast Cancer in Older Women: Results from the Prospective Multicenter HOPE Trial',  and the second one, ‘Inflammation and Clinical Decline After Adjuvant Chemotherapy in Older Adults with Breast cancer: Results from the Hurria Older Patients Prospective Study'. Thank you for your attention, and stay tuned for the next episode. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guests' statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.    Like, share and subscribe so you never miss an episode and leave a rating or review. Articles Low-intensity Adjuvant Chemotherapy for Breast Cancer in Older Women Inflammation and Clinical Decline After Adjuvant Chemotherapy in Older Adults With Breast Cancer Find more articles from the January 10 issue.

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.01.24.525450v1?rss=1 Authors: Qiu, X., Ping, S., Kyle, M., Chin, L., Zhao, L.-R. Abstract: Severe traumatic brain injury (TBI) causes long-term disability and death in young adults. White matter is vulnerable to TBI damage. Demyelination is a major pathological change of white matter injury after TBI. Demyelination which is characterized by myelin sheath disruption and oligodendrocyte cell death leads to long-term neurological function deficits. Stem cell factor (SCF) and granulocyte colony-stimulating factor (G-CSF) treatments have shown neuroprotective and neurorestorative effects in the subacute and chronic phases of experimental TBI. Our previous study has revealed that combined SCF and G-CSF treatment (SCF+G-CSF) enhances myelin repair in the chronic phase of TBI. However, the long-term effect and mechanism of SCF+G-CSF-enhanced myelin repair remain unclear. In this study, we uncovered persistent and progressive myelin loss in the chronic phase of severe TBI. SCF+G-CSF treatment in the chronic phase of severe TBI enhanced remyelination in the ipsilateral external capsule and striatum. The SCF+G-CSF-enhanced myelin repair is positively correlated with the proliferation of oligodendrocyte progenitor cells in the subventricular zone. These findings reveal the therapeutic potential of SCF+G-CSF in myelin repair in the chronic phase of severe TBI and shed light on the mechanism underlying SCF+G-CSF- enhanced remyelination in chronic TBI. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

In our final stop in our Cytopenias series, we discuss the ins and outs of neutropenia. This is another very commonly seen issue in the clinic and in the hospital so most definitely high yield!Why is neutropenia dangerous?Prone to infections, especially gut translocation of bacteriaDefinition of neutropenia:NORMAL: WBC 4400-11000 cells/microL; neutrophils make up 40-70% of thatNeutropenia defined by ANC: WBC (cells/microL) x percent (PMNs + bands) ÷ 100 Breakdown:Neutropenia: ANC

C. Glenn Begley MBBS (MD-equivalent), PhD, FRACP, FRCPA, FRCPath, FAHMS is a physician and hematologist/medical oncologist, with a PhD in cell and molecular biology. He currently serves as an independent biotechnology consultant, and is Head of Biology at California-based BridGene Biosciences, and co-Founder and Head of Discovery at Boston-based Parthenon Therapeutics. For 4 years, until March 2021, he served as inaugural CEO of BioCurate, a joint startup initiative of Monash and Melbourne Universities. Prior to that he served as Chief Scientific Officer at Akriveia Therapeutics (now Xilio), California (2016-2017), and TetraLogic Pharmaceuticals, Pennsylvania (2012-2016). He also served as non-Executive Director at Oxford BioTherapeutics (2012-2017) and several other biotech companies in the USA. He was Vice-President and Global Head of Hematology/Oncology Research at Amgen, Thousand Oaks, California (2002-2012), with responsibility at Amgen's 5 research sites. His scientific responsibilities included Amgen marketed products (filgrastim, pegfilgrastim, erythropoietin, darbepoetin alpha, palifermin, ancestrim, romiplostim, denosumab). Over 25 clinical-stage molecules emerged from his group including fully human monoclonal antibodies, small molecules, protein ligands, antibody-drug conjugates. He was also the internal oncology advocate for in-licensed molecules including, the bi-specific T-cell engager (BiTE) blinatumomab, and the oncolytic virus talimogene laherparepvec (T-Vec). While at Amgen he highlighted the issue of research integrity and scientific reproducibility. He has made multiple presentations on this subject including to President Obama's Science Council, the White House, US National Institutes of Health, US Academies of Science, US National Institute of Standards and Technology, Wellcome Trust, NHMRC, and numerous Universities, Research Institutes and companies. Prior to Amgen, he had over 20 years of clinical and research experience in medical oncology/hematology. His early research first described human G-CSF. In later clinical studies he first demonstrated that G-CSF-"mobilized" blood stem cells hastened hematopoietic recovery compared with bone marrow transplantation (so called "stem cell transplantation"). His honors include being elected as the first Foreign Fellow to the American Society of Clinical Investigation (2000), the Association of American Physicians (2008), to the Research "Hall of Fame" at his alma mater, the Royal Melbourne Hospital (2014), to the Australian Academy of Health and Medical Sciences (2014). He has published over 200 papers that have been widely cited (~25,000 citations; h-index 77; i10-index 188, source Google Scholar, August 2020). His TED-x seminar “The Complex Biology of Cancer” has >100,000 views.

What does the body of evidence have to say on the topic of the immune system? Plus: the omicron variant and its accompanying public health measures, and we go over what happens when scientists try to fulfill one of the promises of science: replicating results.   Block 1: (2:46) Immunity: what it does, self versus non-self, antigens, HLA, innate versus adaptive, fever, skin   Block 2: (12:07) Immunity: Geert Vanden Bossche, eosinophils, neutrophils, G-CSF, immune boosters, vitamin C, antibodies, T and B cells, immune memory, vaccines   Block 3: (30:40) Omicron, public health measures, and booster doses   Block 4: (48:34) Reproducibility of cancer studies     * Jingle by Joseph Hackl * Theme music: “Fall of the Ocean Queen“ by Joseph Hackl. * Assistant researcher: Nicholas Koziris   To contribute to The Body of Evidence, go to our Patreon page at: http://www.patreon.com/thebodyofevidence/.   To make a one-time donation to our show, you can now use PayPal! https://www.paypal.com/donate?hosted_button_id=9QZET78JZWCZE   Patrons get a bonus show on Patreon called “Digressions”! Check it out!     References:   1) Driving doggos: https://www.bbc.com/news/av/uk-15864761   2) Explanatory videos on the immune system: https://www.osmosis.org/learn/Introduction_to_the_immune_system   3) Understanding how vaccines work: https://www.cdc.gov/vaccines/hcp/conversations/understanding-vacc-work.html   4) Understanding how COVID-19 vaccines work: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/how-they-work.html   5) Cochrane review on vitamin C for the common cold: https://www.cochrane.org/CD000980/ARI_vitamin-c-for-preventing-and-treating-the-common-cold   6) Measles vaccine information: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-12-measles-vaccine.html#p4c11a4 and https://www.canada.ca/en/public-health/services/publications/diseases-conditions/measles-rubella-surveillance/2021/week-46.html   7) Interview with Dr. Paul Offit for New York Mag's Intelligencer: https://nymag.com/intelligencer/2021/12/omicron-dr-paul-offit-is-skeptical-of-boosters-for-all.html   8) Brian Nosek paper 1: https://elifesciences.org/articles/67995   9) Brian Nosek paper 2: https://elifesciences.org/articles/71601   10) New Scientist article: https://www.newscientist.com/article/2300455-investigation-fails-to-replicate-most-cancer-biology-lab-findings/   11) Amgen's paper on the lack of replicability of cancer research: https://www.nature.com/articles/483531a   12) Jonathan's paper on circulating microRNA signatures for cancer: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5528532/     Music Credits:   Just Deep 2 by Sascha Ende® Link: https://filmmusic.io/song/312-just-deep-2 License: https://filmmusic.io/standard-license  

This is the eleventh of a series of short videos on Low dose Medicine and in particular Cytokines. This video introduces the cytokine Granulocyte colony-stimulating factor (G-CSF or GCSF). Granulocyte colony-stimulating factor is a glycoprotein which stimulates the the proliferation and differentiation of hematopoietic progenitor cells from the bone marrow into granulocytes (white blood cells) and neutrophils. G-CSF is produced by monocytes, macrophages, and neutrophils after cell activation and it is also produced by stromal cells, fibroblasts, and endothelial cells. G-CSF triggers the reactivity and raises the sensitivity of the immune system, and it enhances the antibody-dependent cell mediated cytotoxicity of granulocytes against tumor cells. More information about this and other health topics can be found in my books "Low Dose Medicine" and "Cure Without Side effects" by following these links: ►►►https://amzn.to/3Bbx8fd ►►►https://amzn.to/36iaqDU To check the Low dose Medicine health kit follow this link: ►►►https://kit.co/cureswithoutsideffect/low-dose-medicine DISCLAIMER: Nothing contained in this video is intended nor can be taken to diagnose, treat, or cure any disease. It is for informational purposes only. This episode is also available as a blog post: https://cureswithoutsideffects.wordpress.com/2021/12/17/cytokines-series-granulocyte-colony-stimulating-factor/ --- Send in a voice message: https://anchor.fm/cureswithoutsideeffects/message

Can We Afford Not To? Optimizing Use of G-CSF Biosimilars in Supportive Cancer Care in Canada

We've got a neutropenic fever and the only cure is...more cowbell? LIVE! It's neutropenic fever (aka febrile neutropenia) deconstructed with infectious diseases expert, Dr. Susan Seo (Memorial Sloan Kettering Cancer Center). Topics: identifying low vs high risk patients, initial labs & imaging, empiric antibiotic therapy, when to add antifungals, de-escalation, and the G-CSF controversy.  Free CME for this episode at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME! Credits Writer and Producer: Matthew Watto MD, FACP Infographic: Edison Jyang Cover Art: Kate Grant MBChb, MRCGP Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP    Reviewer: Matthew Watto MD, FACP Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com Guest: Susan Seo MD Sponsor: American College of Physicians acponline.org/100curb ACP CME 100 virtual video package includes 75 hours of practice-changing updates by expert faculty from Internal Medicine Meeting 2021 acponline.org/100CURB. Plus enjoy an exclusive: 25 bonus CME sessions and access until June 1, 2024! Sponsor: BetterHelp betterhelp.com/curb ​​Special offer for Curbsiders listeners: get 10% off your first month at betterhelp.com/curb                 CME Partner: VCU Health CE The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org. Show Segments Intro, disclaimer, guest bio Guest one-liner, Picks of the Week* Case from Kashlak; Definitions Initial workup for neutropenic fever  Low risk neutropenic fever High risk neutropenic fever When to add antifungal coverage, G-CSF Audience questions Outro

Today's episode is dedicated to Critical Illness In Children With Hematopoietic Stem Cell Transplants. We are delighted to be joined by Dr. Muna Qayed, Associate Professor of Pediatrics Emory University School of Medicine , Atlanta, GA. She is also the Director of the Blood and Marrow Transplant Program at the Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta. Our Case: A 10 year old female with refractory high-risk ALL s/p mismatched unrelated donor transplantation T+13 days presents as a transfer to the PICU with abdominal distention, worsening jaundice, and escalating nasal cannula requirements. The patient's post-transplant course was complicated by gram-negative bacteremia requiring fluid resuscitation. A CXR upon transfer to the PICU is notable for bilateral airspace disease, a right sided pleural effusion, and hypoexpanded lung fields. The patient is promptly intubated, sedated and started on renal replacement therapy. Echo labs, and further imaging are pending. What are the classic pediatric indications for BMT? Autologous BMT (where donor cells are from the patient/recipient) is used as consolidation in some solid tumors such as High risk neuroblastoma, brain tumors like medulloblastoma, and germ cell tumors, and are a standard treatment approach in relapsed Hodgkin lymphoma Allogeneic BMT-where in the donor cells are derived from another individual are typically used for hematologic malignancies. ALL and AML are most common pediatric indications. Also allogeneic BMT are used for wide spectrum of nonmalignant hematology conditions such as hemoglobinopathies ( Sickle cell disease, Thalassemia), and severe aplastic anemia, and inherited bone marrow failure syndromes, as well as some metabolic disorders and immune-deficiency disorders such as SCID, HLH and other primary immune regulatory disorders. The sources of graft in BMT? Stem cells (which give rise to different types of blood cells - red cells, white cells and platelets are derived from the bone marrow. Thus the overall process is known as Bone Marrow Transplantation. Stem cells can be also derived from peripheral blood - when the donor is treated with granulocyte colony stimulating factor or G-CSF. There are some key advantages here, which include the ability to collect a much higher stem cell dose, with faster hematopoietic recovery. However the downside is a higher T cell content of the graft with subsequent increased risk of graft versus host disease. Umbilical cord blood is also used as a source of stem cells. Mega doses of stem cells are used to overcome histocompatibility barriers of mismatched transplantation. Majority of T cells have to be removed from donor pool to prevent severe GVHD., Increase risk of infection and relapse of patients original disease. Explain the human leucocyte antigen (HLA) and its role in BMT? The Major Histocompatibility complex (MHC) system known as the human leukocyte antigen (HLA) in humans is located on the short arm of chromosome 6 and contains the most polymorphic gene cluster of the entire human genome. The HLA consists of regions designated as "classes". Class I and class II are relevant to stem cell transplant. The main function of HLA class I gene products (HLA-A, -B, and -C) is to present endogenous peptides to responding CD8+ T Cells, HLA class I antigens are expressed on all nucleated cells and platelets. While the class II coded molecules HLA-DR, -DP, and –DQ have restricted expression and process exogenous peptides for presentation to CD4+ helper T Cells, and are expressed on antigen presenting cells. HLA-A, HLA-B, HLA-C and HLA-DR are traditionally the loci critical for matching for stem cell donor. In addition to deciding on the source of the graft, we have to make decisions on who the donor will be. If a matched sibling donor is not available (or in some inherited conditions that may not be an option as a donor), then matched unrelated donors or matched cord blood...

Dr. Hernandez reviews a case of Coronavirus disease in a 44 year old B cell ALL patient with chronic Hepatitis B infection status post chemo. He was diagnosed with COVID-19 infection and developed severe pancytopenia during his disease course. She details the evaluation of the patient’s bone marrow deficiency, including the differential diagnosis, appropriate work up tools, and how the treating providers determined the cause to be SARS CoV 2 related pancytopenia and neutropenia, a recently recognized sequela of the disease. Other published cases are also presented and some of the pitfalls of G-CSF use are mentioned.

In this episode, we review how PD-L1 inhibitors and COVID-19 have changed the management of non-small cell lung cancer (NSCLC). Jeffrey Crawford, MD, and Susan Blackwell, PA, both of Duke Cancer Institute, join host David H. Henry, MD, to discuss the use of pembrolizumab in NSCLC, two studies of PD-L1 inhibitors presented at ESMO 2020, and how COVID-19 has affected NSCLC care, particularly the use of granulocyte colony-stimulating factor (G-CSF). Diagnosis and treatment of NSCLC What information should be obtained from a biopsy? Is this lung cancer? If so, what kind of lung cancer is it: Small-cell lung cancer or NSCLC? Which subtype? Molecular studies for targets, including ALK, KRAS, EGFR, PD-L1. Treatment with pembrolizumab: If, for example, a patient has NSCLC and is positive for PD-L1, the treatment of choice is pembrolizumab. A multidisciplinary approach is essential to provide comprehensive education and care to patients taking pembrolizumab (and other immunotherapies). Pembrolizumab can have many side effects, including itching, fatigue, thyroiditis progressing to hypothyroidism, hypophysitis, or another off-target “-itis.” Ms. Blackwell and Dr. Crawford recommend listening to patients, checking the thyroid routinely, and checking cortisol based on index of suspicion. NSCLC studies presented at ESMO 2020 KEYNOTE-024 5-year OS update: First-line (1L) pembrolizumab (pembro) vs platinum-based chemotherapy (chemo) in patients (pts) with metastatic NSCLC and PD-L1 tumour proportion score (TPS) ≥50%. The 5-year survival is greater than 30% with pembrolizumab in this study. Historically, 5-year survival has been 1% to 2% in patients treated with chemotherapy alone, Dr. Crawford said. In the control arm of this study, patients received chemotherapy and then crossed over into the pembrolizumab arm, so overall survival was 16% at the 5-year mark. The results suggest immunotherapy should be used first-line if patients meet criteria, Dr. Crawford said. Source: Abstract LBA51. https://bit.ly/3mMYLTK. EMPOWER-Lung 1: Phase III first-line (1L) cemiplimab monotherapy vs platinum-doublet chemotherapy (chemo) in advanced non-small cell lung cancer (NSCLC) with programmed cell death-ligand 1 (PD-L1) ≥50%.  The PD-L1 inhibitor cemiplimab improved overall and progression-free survival in NSCLC patients when compared with chemotherapy alone. Abstract LBA52. https://bit.ly/3mLT6xb. The effects of COVID-19 on NSCLC care Logistically, it’s more difficult to see patients during the pandemic, Dr. Crawford noted, but the many potential side effects of immunotherapy make it necessary to see patients regularly in person. How has COVID-19 affected the concern of febrile neutropenia and the use of G-CSF? Dr. Crawford said the pandemic has heightened the concern about infection risk. Prior guidelines for G-CSF: Before the pandemic, guidelines suggested routine prophylactic G-CSF in patients with a greater than 20% risk of febrile neutropenia. In patients with 10% to 20% risk, the recommendation was to consider the use of G-CSF based on the patient population and risk factors. Pandemic-specific guidelines for G-CSF: The National Comprehensive Cancer Network (NCCN) recommended relaxing guidelines during the pandemic. If the risk is greater than 20%, NCCN still recommends giving G-CSF. If the risk is 10% to 20%, NCCN recommends giving G-CSF even in the absence of additional risk factors. Dr. Crawford noted that lung cancer patients receiving chemotherapy are typically in the 10% to 20% risk category. Download the COVID-specific NCCN guidelines: https://bit.ly/3jQIco5. G-CSF biosimilars The most common complaint with biosimilars is bone pain. Ms. Blackwell advises first treating bone pain with acetaminophen or ibuprofen and warm blankets. For refractory pain, she suggests a low-dose narcotic or dexamethasone. Consider an antihistamine for prophylaxis, as patients report this can help with symptoms. Show notes written by Ronak Mistry, DO, a resident at Pennsylvania Hospital, Philadelphia. Disclosures: Dr. Crawford is on advisory boards at Amgen and Merck, makers of Onpro/Neulasta (pegfilgrastim) and Keytruda (pembrolizumab). Ms. Blackwell and Dr. Henry have no conflicts of interest. * * * For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd

VIALE-A: Veneoxlax + azacitidine, a new standard of care for elderly or unfit AML patients, is now published. Lots of supportive care and management concerns to discuss: tumor lysis syndrome, prophylactic anti-microbials, G-CSF use (?), and dose modification for hematologic toxicity. Link: https://doi.org/10.1056/nejmoa2012971

No atual cenário de pandemia do novo coronavírus, o número de casos de pacientes sobreviventes de câncer ou que estão em tratamento tem aumentado entre os pacientes diagnosticados com COVID-19 em estágio grave, de acordo com um estudo publicado recentemente no The Lancet Oncology. Recomendações com relação aos cuidados dos pacientes oncológicos têm sido realizadas pela ASCO, entre elas o tratamento profilático com G-CSFs (fatores estimulantes de colonização de granulócitos) como terapia de suporte para neutropenia febril. No Brasil, uma importante opção disponível é o lipegfilgrastim, um G-CSF recombinante de longa ação que pode ser aplicado uma vez a cada ciclo de quimioterapia pelo paciente em sua própria residência, evitando a exposição aos ambientes hospitalares. Confira o episódio com comentários do Dr. Antonio C. Buzaid.

Gudrun talks with Changjing Zhuge. He is a guest in the group of Lennart Hilbert and works at the College of applied sciences and the Beijing Institute for Scientific and Engineering Computing (BISEC) at the Beijing University of Technology. He is a mathematician who is interested in system biology. In some cases he studies delay differential equations or systems of ordinary differential equations to characterize processes and interactions in the context of cancer research. The inbuilt delays originate e.g. from the modeling of hematopoietic stem cell populations. Hematopoietic stem cells give rise to other blood cells. Chemotherapy is frequently accompanied by unwished for side effects to the blood cell production due to the character of the drugs used. Often the production of white blood cells is hindered, which is called neutropenia. In an effort to circumvent that, together with chemotherapy, one treats the patient with granulocyte colony stimulating factor (G-CSF). To examine the effects of the typical periodic chemotherapy in generating neutropenia, and the corresponding response of this system to given to G-CSF Changjing and his colleagues studied relatively simple but physiologically realistic mathematical models for the hematopoietic stem cells. And these models are potential for modeling of other stem-like biosystems such as cancers. The delay in the system is related to the platelet maturation time and the differentiation rate from hematopoietic stem cells into the platelet cell. Changjing did his Bachelor in Mathematics at the Beijing University of Technology (2008) and continued with a PhD-program in Mathematics at the Zhou-Peiyuan Center for Applied Mathematics, Tsinghua University, China. He finished his PhD in 2014. During his time as PhD student he also worked for one year in Michael C Mackey's Lab at the Centre for Applied Mathematics in Bioscience and Medicine of the McGill University in Montreal (Canada). References C. Zhuge, M.C. Mackey, J. Lei: Origins of oscillation patterns in cyclical thrombocytopeniaJournal of Theoretical Biology 462,432-445, 2019. C. Zhuge, X. Sun, J. Lei: On positive solutions and the Omega limit set for a class of delay differential equations. Discrete and Continuous Dynamical Systems - Series B, 18(9), 2487~2503, 2013. C. Zhuge, M.C. Mackey, J. Lei: Neutrophil dynamics in response to chemotherapy and G-CSF Journal of Theoretical Biology 293, 111-120 2012.Podcasts L. Hilbert, G. Thäter: Zellkerne, Gespräch im Modellansatz Podcast, Folge 206, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2019. M. Gonciarz, G. Thäter: Portrait of Science, Gespräch im Modellansatz Podcast, Folge 197, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2019. G. Thäter, K. Page: Embryonic Patterns, Gespräch im Modellansatz Podcast, Folge 161, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2018. L. Adlung, G. Thäter, S. Ritterbusch: Systembiologie, Gespräch im Modellansatz Podcast, Folge 39, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2016. Omega Tau-Podcast 072: Forschung in der Zellbiologie, 2011. J. Schmoranze, I. Wessolowski: Beim Herrn der Mikroskope – AMBIO Core Facility, Sciencekompass Podcast, Episode 009 B, 2017.

Gudrun talks with Changjing Zhuge. He is a guest in the group of Lennart Hilbert and works at the College of applied sciences and the Beijing Institute for Scientific and Engineering Computing (BISEC) at the Beijing University of Technology. He is a mathematician who is interested in system biology. In some cases he studies delay differential equations or systems of ordinary differential equations to characterize processes and interactions in the context of cancer research. The inbuilt delays originate e.g. from the modeling of hematopoietic stem cell populations. Hematopoietic stem cells give rise to other blood cells. Chemotherapy is frequently accompanied by unwished for side effects to the blood cell production due to the character of the drugs used. Often the production of white blood cells is hindered, which is called neutropenia. In an effort to circumvent that, together with chemotherapy, one treats the patient with granulocyte colony stimulating factor (G-CSF). To examine the effects of the typical periodic chemotherapy in generating neutropenia, and the corresponding response of this system to given to G-CSF Changjing and his colleagues studied relatively simple but physiologically realistic mathematical models for the hematopoietic stem cells. And these models are potential for modeling of other stem-like biosystems such as cancers. The delay in the system is related to the platelet maturation time and the differentiation rate from hematopoietic stem cells into the platelet cell. Changjing did his Bachelor in Mathematics at the Beijing University of Technology (2008) and continued with a PhD-program in Mathematics at the Zhou-Peiyuan Center for Applied Mathematics, Tsinghua University, China. He finished his PhD in 2014. During his time as PhD student he also worked for one year in Michael C Mackey's Lab at the Centre for Applied Mathematics in Bioscience and Medicine of the McGill University in Montreal (Canada). References C. Zhuge, M.C. Mackey, J. Lei: Origins of oscillation patterns in cyclical thrombocytopeniaJournal of Theoretical Biology 462,432-445, 2019. C. Zhuge, X. Sun, J. Lei: On positive solutions and the Omega limit set for a class of delay differential equations. Discrete and Continuous Dynamical Systems - Series B, 18(9), 2487~2503, 2013. C. Zhuge, M.C. Mackey, J. Lei: Neutrophil dynamics in response to chemotherapy and G-CSF Journal of Theoretical Biology 293, 111-120 2012.Podcasts L. Hilbert, G. Thäter: Zellkerne, Gespräch im Modellansatz Podcast, Folge 206, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2019. M. Gonciarz, G. Thäter: Portrait of Science, Gespräch im Modellansatz Podcast, Folge 197, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2019. G. Thäter, K. Page: Embryonic Patterns, Gespräch im Modellansatz Podcast, Folge 161, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2018. L. Adlung, G. Thäter, S. Ritterbusch: Systembiologie, Gespräch im Modellansatz Podcast, Folge 39, Fakultät für Mathematik, Karlsruher Institut für Technologie (KIT), 2016. Omega Tau-Podcast 072: Forschung in der Zellbiologie, 2011. J. Schmoranze, I. Wessolowski: Beim Herrn der Mikroskope – AMBIO Core Facility, Sciencekompass Podcast, Episode 009 B, 2017.

Nesta edição do Vídeo-MOC, o assunto em pauta é o uso de lipegfilgrastim, um importante G-CSF recombinante de longa ação aprovado pelo EMA em 2013 e pela ANVISA em 2015.

Dr. Begley is the inaugural CEO of BioCurate, a joint initiative of Monash and Melbourne Universities and created to provide commercial focus in the early phases of drug development. He served as Chief Scientific Officer at Akriveia Therapeutics, California (2016-2017) and TetraLogic Pharmaceuticals, Pennsylvania (2012-2016). From 2002-2012, he was Vice-President and Global Head of Hematology/Oncology Research at Amgen, responsible for building, directing and integrating Amgen's 5 research sites. There he highlighted the issue of research integrity and scientific reproducibility. Since then he has made multiple presentations on the subject of scientific integrity including to President Obama's Science Council, the White House, US National Institutes of Health, US Academies of Science, US National Institute of Standards and Technology, the British Broadcasting Company, Australian National Health and Medical Research Council, and numerous Universities, Research Institutes and companies. Before Amgen he had over 20 years of clinical experience in medical oncology and hematology. His personal research focused on regulation of hematopoietic cells and translational clinical trials. His early studies, in Prof Donald Metcalf's department first described human G-CSF, and in later clinical studies, performed in Professor Richard Fox's Department at the Royal Melbourne Hospital, the group first demonstrated that G-CSF-"mobilized" blood stem cells hastened hematopoietic recovery, a finding that revolutionized bone-marrow transplantation. His honors include being elected as the first Foreign Fellow to the American Society of Clinical Investigation in 2000, to the Association of American Physicians in 2008, and in 2014 to the Research "Hall of Fame" at his alma mater, the Royal Melbourne Hospital and to the Australian Academy of Health and Medical Sciences.

Dr. Begley is the inaugural CEO of BioCurate, a joint initiative of Monash and Melbourne Universities and created to provide commercial focus in the early phases of drug development. He served as Chief Scientific Officer at Akriveia Therapeutics, California (2016-2017) and TetraLogic Pharmaceuticals, Pennsylvania (2012-2016). From 2002-2012, he was Vice-President and Global Head of Hematology/Oncology Research at Amgen, responsible for building, directing and integrating Amgen’s 5 research sites. There he highlighted the issue of research integrity and scientific reproducibility. Since then he has made multiple presentations on the subject of scientific integrity including to President Obama's Science Council, the White House, US National Institutes of Health, US Academies of Science, US National Institute of Standards and Technology, the British Broadcasting Company, Australian National Health and Medical Research Council, and numerous Universities, Research Institutes and companies. Before Amgen he had over 20 years of clinical experience in medical oncology and hematology. His personal research focused on regulation of hematopoietic cells and translational clinical trials. His early studies, in Prof Donald Metcalf’s department first described human G-CSF, and in later clinical studies, performed in Professor Richard Fox’s Department at the Royal Melbourne Hospital, the group first demonstrated that G-CSF-"mobilized" blood stem cells hastened hematopoietic recovery, a finding that revolutionized bone-marrow transplantation. His honors include being elected as the first Foreign Fellow to the American Society of Clinical Investigation in 2000, to the Association of American Physicians in 2008, and in 2014 to the Research "Hall of Fame" at his alma mater, the Royal Melbourne Hospital and to the Australian Academy of Health and Medical Sciences.

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses. In this podcast, Cancer.Net Associate Editor Dr. Michael Williams will discuss some of the new research in lymphoma that was presented at the 2018 American Society of Hematology Annual Meeting, held December first through fourth in San Diego, California. Dr. Williams is the Chief of the Hematology/Oncology Division and Director of the Hematologic Malignancies Program at the UVA Cancer Center, and Byrd S. Leavell Professor of Medicine and Professor of Pathology at the University of Virginia School of Medicine. ASCO would like to thank Dr. Williams for discussing this topic. Dr. Williams: Hello. This is Michael Williams. I'm a professor at the University of Virginia Health System in Charlottesville, Virginia, and I'm reporting today on some exciting advances in lymphoma that were presented at the Annual Meeting of the American Society of Hematology, which was held in San Diego, California in early December 2018. Well, there were a number of areas of lymphoma that had important reports, and I'm going to just give you a small sampling of these today. We'll start with a new treatment option for patients with follicular lymphoma. Traditionally, this type of lymphoma, when it's symptomatic and needs therapy, the treatment of choice has been chemotherapy combined with a monoclonal antibody such as rituximab or obinutuzumab. But investigators, in a multicentered trial, decided to test whether you could use a chemotherapy-free treatment approach for patients like this by using rituximab combined with lenalidomide, which is also known as Revlimid, as a substitute for chemotherapy. And this is based on the fact that Revlimid plus rituximab has synergistic activity in patients with relapsed disease, so maybe we could see acceptable, high responses when it would be compared directly with rituximab plus chemotherapy. So the way the trial worked is this. Patients who needed therapy, who had advanced-stage follicular lymphoma—they had never had any therapy before—were randomized to either the rituximab-lenalidomide combination or a rituximab-chemotherapy combination that could include the regimens CVP or cyclophosphamide, vincristine, prednisone, the same combination given with daunorubicin, or the CHOP regimen, or rituximab combined with bendamustine. So over 1,000 patients were treated in this multinational study and the goal of the treatment, of the study was to prove that, actually, the ritux-lenalidomide was superior to the chemotherapy regimens. So the results showed, not superiority, but comparability. The complete remission rate between rituximab-len and ritux-chemotherapy were really identical, 48 and 53 percent, and the 3-year likelihood that the patients were progression-free, so had had no recurrence of their disease, was identical as well: 77 to 78 percent. There was no difference in survival which was 94% at 3 years in both arms. The toxicities differed, however. There was more rash with the lenalidomide combination, whereas low blood counts and the need for growth factor support such as G-CSF was greater with chemotherapy. And it was also interesting that some of the traditional risk factors didn't seem to apply, as much, for lenalidomide. So what would be considered higher risk patients treated with chemotherapy, seemed to do somewhat better with the lenalidomide combination. The importance for a patient with untreated follicular lymphoma who needs therapy is that a chemotherapy-free approach with rituximab plus lenalidomide can be considered equivalent to rituximab-chemotherapy. It’s worth discussing this with your oncologist when you're considering what treatment to use initially. The next subtype of lymphoma that I want to discuss is diffuse large B-cell lymphoma, and there's 2 presentations that I'm going to summarize. One, in patients with advanced stage disease, meaning stage III or IV. This identifies patients who have disease both above and below the diaphragm, to make it stage III, or stage IV means they've got bone marrow or other sites of involvement such as liver or bone. And the question being asked in this trial, which was part of the International GOYA trial, will take just a moment to explain. So the original GOYA trial compared whether a newer form of anti-CD20 monoclonal, namely obinutuzumab, which is also called Gazyva, how that would compare with the standard established monoclonal antibody, rituximab. And the initial findings of this study found that there was no benefit for the newer antibodies. So rituximab and CHOP chemotherapy was equivalent to obinutuzumab and CHOP chemotherapy in overall outcomes. But there was an opportunity with this trial to answer a question that's been out there for many years, and that is how many cycles of treatment does one need? So the investigators took advantage of this large study which included 712 patients who were randomized to rituximab plus CHOP. Just over 500 of them received 6 cycles, and the remaining 186 received 8 cycles. Even the patients who got 6 cycles of CHOP chemotherapy also got an additional 2 doses of rituximab, so the immunotherapy monoclonal antibody was equivalent between the 2 arms. And the results of this showed that there was really no difference at all with a followup of about 3 years. Response rates were equivalent and there was no difference in the patients staying in remission. It didn't matter in terms of survival which was excellent in both arms. There was, however, more toxicity in patients who received 8 cycles, including cardiac problems, infections, etc. These results showed that, I think we can finally put to rest the use of 8 cycles of rituximab-CHOP chemotherapy for advanced-stage large cell lymphoma. It's been an unknown entity because we never had a direct comparison of these. So we can now say that 6 cycles plus the additional 2 doses of rituximab is a standard for advanced-stage diffuse large B-cell lymphoma. Now, what about patients who have limited-stage, so stage I or II diffuse large cell lymphoma? That means just a single lymph node area's involved or 2 adjacent lymph node areas. In the past, these were treated either with 6 cycles of rituximab-CHOP or sometimes cycles of R-CHOP plus local radiation therapy. And in this study, which took a long time to complete; it began in 2005, but it enrolled 592 patients who were then randomized to either 4 cycles or 6 cycles of treatment. Radiation therapy was not planned for any of these patients except for very specific locations of involvement such as testicular DLBCL where radiation therapy is a standard. So the take-home message after over 5 years of follow-up for patients on this study showed that 4 versus 6 were identical. So 89% of patients were still in remission at 3 years after completing treatment, and the overall survival was really impressive, 98 to 99 percent in the 2 arms. So there was no benefit with limited-stage favorable disease. Now, who are these patients? So younger than age 60, stage I or II disease, and normal LDH. They did not have bulky disease, meaning there was no nodal mass more than 7 and a half centimeters. So if you fit those criteria, then you can benefit from a de-escalation of treatment and be spared the additional 2 cycles of R-CHOP. Now, sticking with the topic of diffuse large B-cell lymphoma, a challenging problem in our field is for patients who relapse after their initial therapy, or in some cases, fail to respond to a treatment like rituximab-CHOP or an equivalent immuno-chemotherapy regimen. And a very exciting advance in the field, over the past few years, has been the development of chimeric antigen receptor T cells or CAR Ts. Traditionally, what we've done with patients who relapse or have resistant diffuse large cell lymphoma is to give them a second-line, high-dose chemotherapy regimen, and if they showed a good response to that, they could then go to a dose-intensive treatment with a follow-up consolidation by autologous stem cell transplantation. And with that, you can cure, overall, about 40% or so of patients. The CAR T-cell approach takes a very novel immunotherapy effort, and that is that a patient's own T-cells are removed from the peripheral blood, and then in the laboratory, they're modified and reprogrammed so they can attack the patient’s diffuse large B-cell lymphoma cells that are resistant to chemotherapy. So there were 2 important follow-up studies, each of them involved 1 of the agents, the CAR T-cell products, that are approved by the Food and Drug Administration for patients with relapsed or refractory diffuse large cell lymphoma. The first used the CAR T known as axicabtagene ciloleucel. It's quite a complex name, but it goes by the abbreviation of axi-cel or the trade name is Yescarta. So in this study, the investigators wanted to show that this is a treatment that can be extended to many centers with the product, the CAR T being made in a central facility by the pharmaceutical company. So it was a retrospective study of 295 patients at 17 international centers: a lot of patients across a broad spectrum of sites in North America and Europe. Virtually all the patients were able to develop and obtain a CAR T product. It included patients with some of the higher risk forms of the DLBCL such as double and triple-hit lymphoma. About 3% of patients died during the treatment, although only 1% of these were felt to be related to the treatment itself. The response rates were quite good, with about 80% of people responding. The complete remission rates at 30 days after the CAR T infusion were 47%. So it proved that you can use this centrally manufactured product. So the patients T-cells are collected at the local center, they're shipped to the manufacturing facility, the CAR Ts are generated, sent back to the home institution, and then infused. And I'll say a word in a moment, after I introduce the next paper, to explain some of the side effects of this treatment. So the second study was also presented at the ASH meeting and published simultaneously in the New England Journal of Medicine in early December 2018. So this used the second FDA approved CAR T known as tisagenlecleucel or Kymriah. In this study, there were 93 patients who were able to receive a CAR T-cell infusion, 40% of them achieved a complete remission, and another 12% had a partial response. And that a year after their documented response, two-thirds of these patients were maintaining the response, including 79% of those who achieved a complete remission. So this trial again confirmed across multiple centers that CAR T-cells can be an effective therapy. The side effects of both of these drugs can include something called cytokine release syndrome where the immunologic effects, essentially, release cytokines into the blood that can mediate a capillary leak, respiratory troubles, and low blood pressures, that can, in some cases, require intensive care unit support. This can be managed by other mediators that tamp down the cytokine effect such as an interleukin-6 antagonist. The other toxicity which is less well understood and problematic can be neurologic effects which can include confusion, speech alterations and even coma. But again, approaches and treatments to identify and manage this are being developed. So CAR Ts have become established. They're available at a number of centers, but it's important to consider this as a treatment option in the setting of relapsed or refractory diffuse large cell lymphoma. The long-term curability is still unknown, although it's encouraging that patients with very resistant disease who'd get a good response can maintain that response out to a year and more. So we're going to be very interested to see how the longer-term follow-up comes together. The final topic I wanted to mention today is Waldenstrom macroglobulinemia. So this is a unique form of indolent B-cell lymphoma where the lymphoma cells release a monoclonal immunoglobulin into the blood known as IGM. Now, IGM is a very large antibody, and because of that, when the levels are very high, patients can have problems with high viscosity or thickening of the blood, which can cause confusion, vision changes, sometimes respiratory problems. And these patients also can become anemic or develop enlarged lymph nodes or enlarged spleen. So one of the standard treatments for this disease is, again, the immunotherapy monoclonal antibody rituximab, but the responses are typically incomplete and somewhat short-lived. So it was exciting, a couple of years ago, when the targeted tyrosine kinase inhibitor, ibrutinib, which targets the bruton tyrosine kinase in malignant B-cells. This is an agent that's approved in chronic lymphocytic leukemia, and certain lymphomas such as mantle cell, marginal zone, as well as lymphoplasmacytic lymphoma or Waldenstrom macroglobulinemia. So here's the study. Investigators had shown that if you combine rituximab with ibrutinib, that the response rates were improved as compared with rituximab by itself. And in a follow-up study that looked at this over a longer period of time, these benefits of the combined therapy were confirmed. These included patients without prior treatment or with prior treatment, with either chemotherapy or rituximab. And there was a confirmed benefit for the ibrutinib-rituximab combination in patients, whether they had had treatment before or not, and regardless of certain genetic markers that we use to assess risk in Waldenstrom. It was also shown that because these treatments continue indefinitely, as long as patients are responding and tolerating therapy, that the response rates improved over time. The side effects of treatment with ibrutinib are well-known, now, after several years of use across a variety of diseases, as mentioned, and include diarrhea, sometimes rash. You can see problems with easy bruising or bleeding, atrial fibrillation, and sometimes skin rash, or muscle and joint aches. But most patients are able to continue therapy and to benefit from it over an extended period of time. So the combination of ibrutinib plus rituximab was shown to add benefit compared with rituximab alone, and again, is a treatment approach and option that you could consider whether you have previously untreated or relapsed Waldenstrom macroglobulinemia. So overall, it was a very exciting meeting. We've had practice-changing data presented, and I've given you just a sampling of those. I think it's important for anyone dealing with lymphoma, or related malignancy, such as CLL or multiple myeloma to be very encouraged by the progress in the field, the opportunity to get much better responses with less toxicity and with minimal or no use of traditional chemotherapy. So we're pleased to be able to offer these treatment approaches for our patients. And I thank you for your taking part in the podcast and hope you found it useful. Thanks again. ASCO: Thank you, Dr. Williams. Learn more about lymphoma at www.cancer.net. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play. Cancer.Net is supported by ASCO’s Conquer Cancer Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/support.

New year, new chemo regimen to discuss. We go over mFOLFIRINOX for adjuvant pancreatic cancer from the recently published PRODIGE-24 study. We discuss out the regimen is modified, where to find dose reductions, and how many patients required G-CSF.

Show Notes for November 2018 – Episode 26 I’ve changed the intro music, obviously, let me know if you are annoyed by it or like it. Here is the list of papers: Acute Liver Failure of Indeterminate Etiology – Am J Gastro Efficacy of G CSF and NAC in patients with severe alcoholic hepatitis –… Continue reading GI Pearls – November 2018 – Episode 26 Gastroenterology Literature Review

ResearchToPractice.com/MTPMDS116 - Meet The Professors: A Case-Based Discussion on the Management of Myelodysplastic Syndromes. Discussion with Harry P Erba, MD, PhD, Guillermo Garcia-Manero, MD, Warren Brenner, MD, Neil I Morganstein, MD and Erik J Rupard, MD moderated by Neil Love, MD. Produced by Research To Practice.

Chemotherapy can make the white blood cell count drop, predisposing to infection. These drugs work to boost white blood cell production.

Dr. Sergio Golombek. Photo courtesy of Dr. Sergio Golombek. Episode 10 features Dr. Sergio Golombek, a Professor of Pediatrics and Clinical Public Health at the New York Medical College and an Attending Neonatologist at The Regional Neonatal Center, Maria Fareri Children’s Hospital at Westchester Medical Center (Valhalla, NY). During the episode, Dr. Golombek discusses: * How researchers are refining the definition of NEC, and other prematurity-associated complications that may currently fall under that umbrella term, * The evolution in prevention and diagnosis strategies of NEC, * The colonization of the intestinal microbiome, and the role it can play in immune system regulation, and inflammatory diseases like NEC, * Additional research trends in NEC, including his unit’s research of granulocyte-colony stimulating factor (G-CSF) in the prevention and treatment of NEC, and * The importance of individualized patient care in the NICU. Copyright © 2015 The Morgan Leary Vaughan Fund, Inc. This episode was produced in part by the TeacherCast Educational Broadcasting Network.

Background New therapeutic approaches with biologic agents such as anti-cytokine antibodies are currently on trial for the treatment of asthma, rhinosinusitis or allergic diseases necessitating patient selection by biomarkers. Allergic rhinitis (AR), affecting about 20 % of the Canadian population, is an inflammatory disease characterised by a disequilibrium of T-lymphocytes and tissue eosinophilia. Aim of the present study was to describe distinct cytokine patterns in nasal secretion between seasonal and perennial AR (SAR/PAR), and healthy controls by comparing cytokines regulating T-cells or stimulating inflammatory cells, and chemokines. Methods Nasal secretions of 44 participants suffering from SAR, 45 participants with PAR and 48 healthy controls were gained using the cotton wool method, and analysed for IL-1β, IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, IL-17, GM-CSF, G-CSF, IFN-γ, MCP-1, MIP-1α, MIP-1β, eotaxin, and RANTES by Bio-Plex Cytokine Assay as well as for ECP and tryptase by UniCAP-FEIA. Results Participants with SAR or PAR presented elevated levels of tryptase, ECP, MCP-1, and MIP-1β, while values of GM-CSF, G-CSF, IL-1β, and IL-6 did not differ from the controls. Increased levels of IL-5, eotaxin, MIP-1α, and IL-17 and decreased levels of IFN-γ, IL-12 and IL-10 were found in SAR only. RANTES was elevated in SAR in comparison to PAR. Interestingly, we found reduced levels of IL-4 in PAR and of IL-13 in SAR. Conclusions Elevated levels of proinflammatory cytokines were seen in both disease entities. They were, however, more pronounced in SAR, indicating a higher degree of inflammation. This study suggests a downregulation of T H 1 and T reg -lymphocytes and an upregulation of T H 17 in SAR. Moreover, the results display a prominent role of eosinophils and mast cells in AR. The observed distinct cytokine profiles in nasal secretion may prove useful as a diagnostic tool helping to match patients to antibody therapies.

Thu, 13 Mar 2014 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/16904/ https://edoc.ub.uni-muenchen.de/16904/1/Weinberger_Tobias.pdf Weinberger, Tobias ddc:610, ddc

Thu, 8 Nov 2012 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/15035/ https://edoc.ub.uni-muenchen.de/15035/1/Mehl_Ursula.pdf Mehl, Ursula

Thu, 25 Oct 2012 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/15063/ https://edoc.ub.uni-muenchen.de/15063/1/Vallaster_Markus.

A study in the March issue of Gastroenterology examined whether mobilization of bone marrow–derived stem cells with granulocyte colony–stimulating factor (G-CSF) might promote hepatic regeneration for patients with acute-on-chronic liver failure (ACLF).

In addition to forming the epithelial barrier against the outside environment keratinocytes are immunologically active cells. In the treatment of severely burned skin, cryoconserved keratinocyte allografts gain in importance. It has been proposed that these allografts accelerate wound healing also due to the expression of a favourable--keratinocyte-derived--cytokine and growth factor milieu. In this study the morphology and cytokine expression profile of keratinocytes from skin after acute burn injury was compared to non-burned skin. Skin samples were obtained from patients after severe burn injury and healthy controls. Cells were cultured and secretion of selected inflammatory mediators was quantified using Bioplex Immunoassays. Immunohistochemistry was performed to analyse further functional and morphologic parameters. Histology revealed increased terminal differentiation of keratinocytes (CK10, CK11) in allografts from non-burned skin compared to a higher portion of proliferative cells (CK5, vimentin) in acute burn injury. Increased levels of IL-1α, IL-2, IL-4, IL-10, IFN-γ and TNFα could be detected in culture media of burn injury skin cultures. Both culture groups contained large amounts of IL-1RA. IL-6 and GM-CSF were increased during the first 15 days of culture of burned skin compared to control skin. Levels of VEGF, FGF-basic, TGF-ß und G-CSF were high in both but not significantly different. Cryoconservation led to a diminished mediator synthesis except for higher levels of intracellular IL-1α and IL-1ß. Skin allografts from non-burned skin show a different secretion pattern of keratinocyte-derived cytokines and inflammatory mediators compared to keratinocytes after burn injury. As these secreted molecules exert auto- and paracrine effects and subsequently contribute to healing and barrier restoration after acute burn injury therapies affecting this specific cytokine/growth factor micromilieu could be beneficial in burned patients.

Background: Patients with nonallergic rhinitis with eosinophilia syndrome (NARES) show typical symptoms of persistent allergic rhinitis (PAR). The aim of the present study was to compare nasal cytokine patterns between NARES and PAR. Methods: Nasal secretions of 31 patients suffering from NARES, 20 patients with PAR to house dust mite and 21 healthy controls were collected using the cotton wool method and analyzed for interleukin (IL)-1 beta, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, granulocyte-macrophage colony-stimulating factor (GM-CSF), granulocyte colony-stimulating factor (G-CSF), interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), monocyte chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-1 beta (MIP-1 beta) by Bio-Plex Cytokine Assay as well as eosinophil cationic protein (ECP) and tryptase by UniCAP-FEIA. Results: NARES and PAR presented elevated levels of tryptase, while ECP was markedly increased solely in NARES compared to both the controls and PAR. Elevated levels of IL-1 beta, IL-17, IFN-gamma, TNF-alpha and MCP-1 were found in NARES compared to the controls as well as PAR. MIP-1 beta was elevated in NARES and PAR, while IL-4, IL-6 and G-CSF showed increased levels in NARES, and IL-5 was elevated in PAR only. Conclusions: In patients with NARES and PAR, eosinophils and mast cells appear to be the pivotal cells of inflammation, reflected by high levels of tryptase and ECP as well as IL-5 and GM-CSF as factors for eosinophil migration and survival. The elevated levels of proinflammatory cytokines in NARES may indicate the chronic, self-perpetuating process of inflammation in NARES which seems to be more pronounced than in PAR. IL-17 might be a factor for neutrophilic infiltration or be responsible for remodeling processes in NARES. Copyright (C) 2012 S. Karger AG, Basel

During acute bacterial infections such as meningitis, neutrophils enter the tissue where they combat the infection before they undergo apoptosis and are taken up by macrophages. Neutrophils show pro-inflammatory activity and may contribute to tissue damage. In pneumococcal meningitis, neuronal damage despite adequate chemotherapy is a frequent clinical finding. This damage may be due to excessive neutrophil activity. We here show that transgenic expression of Bcl-2 in haematopoietic cells blocks the resolution of inflammation following antibiotic therapy in a mouse model of pneumococcal meningitis. The persistence of neutrophil brain infiltrates was accompanied by high levels of IL-1beta and G-CSF as well as reduced levels of anti-inflammatory TGF-beta. Significantly, Bcl-2-transgenic mice developed more severe disease that was dependent on neutrophils, characterized by pronounced vasogenic edema, vasculitis, brain haemorrhages and higher clinical scores. In vitro analysis of neutrophils demonstrated that apoptosis inhibition completely preserves neutrophil effector function and prevents internalization by macrophages. The inhibitor of cyclin-dependent kinases, roscovitine induced apoptosis in neutrophils in vitro and in vivo. In wild type mice treated with antibiotics, roscovitine significantly improved the resolution of the inflammation after pneumococcal infection and accelerated recovery. These results indicate that apoptosis is essential to turn off activated neutrophils and show that inflammatory activity and disease severity in a pyogenic infection can be modulated by targeting the apoptotic pathway in neutrophils.

Thu, 18 Dec 2008 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/9510/ https://edoc.ub.uni-muenchen.de/9510/1/Theiss_Christine.pdf Theiss, Christine ddc:610,

Die koronare Herzkrankheit (KHK) stellt momentan die häufigste Krankheits- und Todesursache in Europa dar. Häufig kommt es als Folge einer KHK zum akuten Myokardinfarkt mit den gefürchteten Folgen, wie kardiogenem Schock und plötzlichem Herztod. Während sich die etablierten konservativen Therapiestrategien bislang auf eine Verminderung des pathologischen Remodellings beschränken, gewinnt die Forschung an alternativen Therapiemöglichkeiten zur längerfristigen Regeneration des geschädigten Myokards zunehmend an Bedeutung. Ein neuer bisher noch nicht zur Therapie des Herzinfarkts eingesetzter Kandidat könnte das Parathormon (PTH) sein. Dessen Fragment PTH (1-34) befindet sich bereits seit Jahren im klinischen Einsatz zur Bekämpfung schwerer Osteoporosen. Im Tiermodell verbesserte PTH durch Steigerung des myokardialen Blutflusses die Herzfunktion und verhinderte dadurch die Ausbildung eines kardiogenen Schocks. Kürzlich konnte darüber hinaus im Mausmodell gezeigt werden, dass PTH die Stammzellnische im Knochenmark reguliert. So führte die PTH-Gabe zu einem Anstieg verschiedener Stammzellpopulationen im Knochenmark und verminderte bei bestrahlten Mäusen nach Knochenmarktransplantation signifikant deren Mortalität. Ziel dieser Arbeit war es, den Einfluss von PTH (1-34) auf die Mobilisation von Knochenmarkstammzellen ins periphere Blut sowie mögliche Effekte auf Pumpfunktion und Remodelling nach akutem Myokardinfarkt im Mausmodell zu untersuchen. Die Behandlung mit PTH (1-34) führte zu einer Mobilisation verschiedener Stammzellpopulationen aus dem Knochenmark ins periphere Blut. Dabei kam es nach PTH-Gabe im Gegensatz zu Granulocyte-colony stimulating factor (G-CSF) nicht zum Abfall von CD45+/CD34+ Stammzellen im Knochenmark. Nach chirurgisch induziertem Myokardinfarkt führte die Gabe von PTH zu einer signifikanten Abnahme der Mortalität im Vergleich zu den Kontrolltieren. Dies war bei den PTH-Tieren assoziiert mit einer signifikanten Verbesserung der globalen Herzfunktion. So waren das Herzzeitvolumen und die Auswurffraktion nach PTH-Gabe deutlich gesteigert. Wir konnten anhand einer erniedrigten arteriellen Nachlast in den hämodynamischen Untersuchungen zeigen, dass PTH am arteriellen Gefäßbett zu einer Vasodilatation führt. Über diesen bekannten Einfluss von PTH auf den arteriellen Gefäßwiderstand kommt es zu einem gesteigerten myokardialen Blutfluss. Dadurch verbessert PTH in der Akutphase nach akutem Myokardinfarkt die Herzfunktion und schützt vor einem akuten Herzversagen. Auf histologischer Ebene fanden sich nach PTH-Behandlung kleinere Infarktgrössen und eine verminderte Abnahme der linksventrikulären Vorderwand im Vergleich zu den Kontrolltieren. Diese Veränderungen im Remodelling nach PTH-Behandlung waren durch eine Zunahme von CD31+ Kapillaren in der Grenzzone um den Infarkt (Borderzone) erklärbar. Die Gefäßneubildungen waren assoziiert mit einer gesteigerten Expression von Vascular Endothelial Growth Factor (VEGF) sowie des Insulin like Growth Factor-1 (IGF-1)-Rezeptors in der Borderzone. PTH bewirkt somit entweder direkt oder indirekt über die Mobilisation von Knochenmarkstammzellen eine vermehrte Sekretion von vaskulären Wachstumstumsfaktoren wie VEGF und IGF-1. So kommt es nach akutem Myokardinfarkt im Mausmodell zu einem abgeschwächten „Remodelling“ mit konsekutiver Verbesserung der myokardialen Pumpfunktion. Neben weiterer Untersuchungen bezüglich der Mechanismen, über die PTH zu den gezeigten Veränderungen im kardialen Remodelling führt, müßte in einem nächsten Schritt geklärt werden, ob PTH (1-34) beim Menschen in der zur Osteoporosebehandlung üblichen Tagesdosis von 20-40 µg oder in konsekutiv höheren Dosierungen zur Freisetzung verschiedener Populationen von Knochenmarkstammzellen ins periphere Blut führt (Phase I Studie).

Einleitung:In der Vergangenheit wurden Keratinozyten lediglich als Träger des epidermalen Rahmengerüsts angesehen. Heute weiß man, dass die Keratinozyten eine Vielzahl biologisch bedeutsamer Moleküle sezernieren, mit denen sie bedarfsweise aktiv und wesentlich an vielen, insbesondere entzündlichen und immunologischen Reaktionen mitwirken. Daher sind Proliferation und Immunaktivierung bei Keratinozyten nicht prinzipiell gekoppelt. Seit 1981 werden kultivierte epitheliale Transplantate (KETs) zur Behandlung von Brandverletzten eingesetzt. Neben autologem Material, das erst spät verfügbar ist, erlangen kryokonservierte allogene Keratinozytentransplantate, vor allem bei Schwerbrandverletzten, immer mehr an Bedeutung. Allogene KETs beschleunigen die Heilung thermischer Wunden. Allerdings verbleiben sie nicht dauerhaft auf der Wunde, sondern werden schrittweise durch autologe Zellen ersetzt. Ihr Effekt könnte deshalb auf der Exprimierung von Zytokinen und Wachstumsfaktoren beruhen. Material und Methode:Das Ziel vorliegender Studie war, vergleichend die zelluläre Zusammensetzung allogener KETs aus Mammareduktionsmaterial mit autologen aus wundnah gewonnenem Material Schwerstverbrannter zu untersuchen. Ausserdem sollten funktionelle Veränderungen hinsichtlich des in vitro Sekretionsmusters ausgewählter Mediatoren nach 5-, 10- und 15-tägiger Kultur, sowie nach Kryokonservierung charakterisiert und mit dem klinischen Verlauf korreliert werden. Die Erhebung der immunhistologischen Befunde erfolgte an gefärbten Zytospins nach HE- bzw. ABC-Methode. Zytokine und Wachstumsfaktoren in den Überständen der Keratinozytenkulturen wurden mit Bioplex Immunoassays quantifiziert. Die beiden Untersuchungskollektive stellten 17 Verbrennungspatienten mit > 25% TBSA, Grad II und/oder III und 17 zufällig ausgewählten Patientinnen, die sich einer Brustverkleinerung unterzogen. Resultate: Eine exemplarisch durchgeführte Histologie allogener KETs aus Mammareduktionsmaterial zeigte morphologisch heterogene Keratinozyten mit einem deutlich erhöhten Anteil terminal differenzierter suprabasaler Zellen, verglichen mit autologen aus Patientenmaterial (CK 10, 11 positiv). In den autologen Transplantaten waren gegenüber den allogenen vermehrt teilungsaktive Basalzellen nachweisbar (CK 5, Vimentin positiv). Leukozyten, Makrophagen, Dendritische Zellen, Endothelzellen und Fibroblasten konnten in autologen und allogenen KETs nicht nachgewiesen werden. IL-1a, IL-1b, IL-2, IL-4, IL-8, IL-10, IFN-g und TNF-a waren in den allogenen und autologen KET-Überständen nicht oder lediglich in Spuren nachweisbar. IL-1RA konnte in den Kulturen beider Gruppen in hohen Konzentrationen nachgewiesen werden. Die Sekretionsleistung von IL-6 und GM-CSF (Proliferationsschub der Keratinozyten, Chemotaxin) nach Verbrennungstrauma war während der ersten 15 Kultivierungstage gegenüber der Kontrollgruppe signifikant erhöht. Insbesondere die Gruppe der verstorbenen Patienten zeigte deutlich höhere Konzentrationen dieser Mediatoren in den Kulturüberständen während der ersten 15 Kulturtage im Vergleich zur Gruppe der überlebenden Patienten. VEGF, FGF-basic, TGF-ß und G-CSF zeigten in ihrem Sekretionsverhalten nur vergleichsweise minimale Unterschiede zwischen den beiden Kollektiven. Die Kryokonservierung führte zu einer verminderten Mediatorensynthese, mit Ausnahme signifikant erhöhter Konzentrationen der intrazellulär gespeicherten Mediatoren IL-1a und IL-1ß in der 24-stündigen Kultur nach dem Auftauen. Sie sind offensichtlich das Ergebnis physikalischer Freisetzung durch Zelldestruktion. Diskussion: Schweres Verbrennungstrauma führt zu einer erhöhten Teilungsaktivität von wundnahen epidermalen Basalzellen mit konsekutiv gesteigerter Mediatorenfreisetzung. Insbesondere die signifikant erhöhte in vitro Freisetzung des potenten Mitogens und proinflammatorischen Zytokins Interleukin-6 aus Keratinozyten nach schwerer Verbrennungsverletzung, verglichen mit solchen aus Mammareduktionsmaterial, ist ein deutlicher Hinweis, sowohl auf das entzündliche Geschehen, als auch auf die erhöhte Aktivität der thermisch beeinträchtigten Epithelzellen mit auto- und parakrinen Wirkungen.

Maligne Lymphomerkrankungen stellen lebensgefährliche Krankheitsbilder dar. Auch wenn mit der ersten Therapie nach Diagnosestellung bis zu 50 % der Patienten geheilt werden können. Patienten mit Rezidiverkrankungen haben eine deutlich niedrigere Überlebensrate. Daher kommen bei diesen Patienten, auch in der Ära der monoklonalen Antikörper, intensivere Therapieformen wie die PBSCT zum Einsatz, um die Überlebensraten zu erhöhen. Seit den ersten Transplantationen von PBPC bei Menschen in den Jahren 1985 und 1986, und damit dem Beweis der Durchführbarkeit dieser Therapieform, haben sich die Forschungsziele rasch geändert (Körbling et al., 1985); (Kessinger et al., 1986); (Juttner et al., 1985). Wenn auch keine Verbesserung der Überlebenszeiten im Vergleich zur ABMT nach¬gewiesen werden konnte, waren die klinischen und finanziellen Vorteile der PBSCT für die weitere Verbreitung Ausschlag gebend. Somit rückten die Einflüsse auf die Mobilisation, die Apherese und die Transplantation selbst in den Mittelpunkt des Interesses. In dieser Arbeit wurde vor allem die Auswirkung der zytostatischen Vortherapie auf die Mobilisation der PBPC untersucht. Aber es wurden auch andere, zumeist patientenunabhängige Parameter bezüglich ihres Einflusses auf die PBPC sowie die Beurteilung des Mobilisierungsschemas hinsichtlich Verträglichkeit und Ausschwemmung von BPC, analysiert. Die Untersuchung des Salvageschemas IEV mit Ifosfamid, Etoposid und Epirubicin ergab sehr gute Ergebnisse hinsichtlich der Mobilisierung von PBPC und der Aktivität gegenüber den Tumorzellen. Es wurden 37 Patienten evaluiert. Vier Patienten hatten ein T-Zell-Lymphom, acht ein centroblastisches NHL, vier Patienten hatten ein centroblastisches NHL nach Transformation aus einem centroblastisch/centrocytischem NHL, zwölf Patienten hatten centroblastisch/centrocytische NHL, vier Patienten hatten ein centrocytisches NHL, ein Patient hatte ein lymphocytisches NHL, zwei Patienten ein Plasmozytom und zwei waren am M. Hodgkin erkrankt. 14 Prozent der Patienten, d.h. fünf Patienten erreichten nach dem IEV-Schema eine komplette und 68 Prozent, d.h. 25 von 37 Patienten, eine partielle Remission.. Dies bedeutet eine Ansprechrate von 82 Prozent was 30 Patienten entspricht. Bei 7 Patienten, d.h. 18 Prozent wurde eine Progression festgestellt. Nur ein Patient verfehlte die vorgegebene Mindestanzahl an PBPC nach Mobilisierung mit IEV. Trotzdem konnte dieser Patient erfolgreich transplantiert werden und überlebte mindestens 51 Monate. In 29 % der Fälle mußte die IEV-Dosis reduziert werden, was die hämatologische Toxizität von 77% verdeutlicht. Von den fünf Todesfällen, was 12 Prozent der Patienten entspricht, verstarben vier der Patienten an den Folgen der Tumorprogression und ein Patient an einer Sepsis. Aufgrund der hohen Rate an Todesfällen sollte eine Dosisreduktion des IEV-Schemas vor allem bei Patienten über 60 Jahren erfolgen. Der signifikante Zusammenhang zwischen Überlebenszeit nach der Transplantation und der Anzahl der PBPC belegt die Wichtigkeit der Einflußfaktoren auf die Stammzellmobilisierung . Statistisch signifikante Zusammenhänge konnten wir in Bezug auf den zeitlichen Abstand zur Erstdiagnose sowie zur letzten Chemotherapie vor Salvagetherapie beobachten. Je größer die zeitlichen Abstände waren, umso höher war die Anzahl der PBPC. In Bezug auf die Vortherapie zeigten sich für Vincristin, Cyclophosphamid und Ifosfamid signifikante Korrelationen. Cyclophosphamid und eventuell auch Vincristin als Vortherapie verminderten die Stammzell¬ausbeute. Patienten, mit Ifosfamidgabe in der Anamnese, erzielten, sogar dosisbezogen, signifikant mehr PBPC als Patienten ohne diese Vortherapie. Tendenzielle Zusammenhänge konnten wir bei dem Geschlecht, Knochenmarksbefall, Stadium der Erkrankung, der Diagnose sowie vorheriger Bestrahlung und Gabe von Methotrexat erkennen. Männer erzielten eine doppelt so hohe Mobilisierung von CFU-GM als die Frauen unserer Studie. Auch Patienten mit Knochenmarksbefall wiesen tendenziell niedrigere Ergebnisse an PBPC auf als die ohne Knochenmarksbefall. Bei Erkrankten mit niedrigem Ann Arbor Stadium (A im Rezidiv bis B) konnten wir ebenfalls mehr als doppelt so hohe periphere BPC feststellen als bei Erkrankten mit fortgeschrittenem Tumorleiden (VA und B). Patienten mit niedrigmalignen Non-Hodgkin-Lymphomen erzielten weniger PBPC als jene mit M.Hodgkin, Plasmozytom oder hochmalignen NHL. Auch die Patienten, die eine Bestrahlung in der Vortherapie erhalten hatten, erreichten im Vergleich mit Patienten, die keine Bestrahlung erhalten hatten, weniger als die Hälfte an PBPC. Patienten nach Methotrexatgabe wiesen von der Tendenz her mehr PBPC auf als jene ohne anamnestische Methotrexatgabe. In Bezug auf das Alter, Überleben, Anzahl der Rezidive und Höhe der Laktatdehydrogenase des Patienten konnten wir keine Beziehungen zwischen der Anzahl der PBPC und den untersuchten Parametern erkennen. Auch die, vor der Salvagetherapie verabreichten Anzahl der Chemotherapieschemata oder der Chemotherapiezyklen sowie die Gabe und Dosis an Adriamycin, Procarbazin, Mitoxantron, Melphalan, Chlorambucil, Bleomycin und Etoposid hatten keinen Einfluß.

Die Regulation der endometrialen Zytokinexpression steht im Zentrum der aktellen Forschungen zum Phänomen rezidivierender Frühaborte. Ziel der Arbeit war es die Auswirkungen der endometrialen Regulationsmechanismen Hormonstimulation, Hormonentzug, Zytokinstimulation und Hypoxie auf die mRNA Expression dreier verschiedender, für die Implantation der Blastozyste bedeutsamer Zytokine, am Kulturmodell endometrialer Zellen zu untersuchen, wobei eine getrennte Kultivierung von epithelialen und stromalen Zellen erfolgte. VEGF hat eine wichtige Funktion bei der Regulation der Angiogenese und wird im humanen Endometrium v.a. von Epithelzellen exprimiert. IL-1ß beeinflußt maßgeblich die Rezeptivität des Endometriums und spielt eine wichtige Rolle beim embryo-maternalen Dialog. G-CSF ist wichtig für die utero-plazentare Kommunikation und die Dezidualisierung der Stromazellen. Die ungestörte endometriale Differenzierung ist Basis einer normalen Rezeptivität. Diese wird durch Steroidhormone gesteuert, weshalb wir in dieser Arbeit die Auswirkungen der Steroidhormone 17-ß-Östradiol und Progesteron auf die Expression der genannten Zytokine untersuchten. Entgegen der Ergebnisse vorausgehender Studien konnte hierbei kein Effekt der Steroide auf die Zytokinexpression festgestellt werden. Des Weiteren stellte sich uns die Frage einer unmittelbaren Beeinflussung durch andere autokrine oder parakrine Faktoren wie z.B. Zytokine. Die Stimulation der Zellen mit IL-1ß und IL-6 führte bei den Stromazellen zu einem signifikanten Anstieg der mRNA-Expression von IL-1ß und G-CSF. Schließlich untersuchten wir den Einfluß von Hypoxie, welche bereits in vielen vorausgehenden Studien als entscheidender Regulationsfaktor für eine gesteigerte endometriale VEGF Expression beschrieben wurde. Dies konnte durch unsere Untersuchungen bestätigt werden, was gleichzeitig als Beweis der Funktionsfähigkeit unserer Kulturmodelle bei hypoxischen Bedingungen diente. Darüberhinaus konnte durch Hypoxie auch für die Zytokine Il-1ß und G-CSF ein signifikanter Expressionsanstieg verzeichnet werden.

Thu, 22 Jun 2006 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/5537/ https://edoc.ub.uni-muenchen.de/5537/1/Hoetzl_Florian.pdf Hötzl, Florian ddc

Background: Prognosis of patients with metastatic soft tissue sarcomas (MSTS) is poor even after response to doxorubicin-based chemotherapy. We report phase II data of highdose chemotherapy and peripheral blood stem cell (PBSC) rescue in patients with MSTS responding to AI-G chemotherapy. Patients and Methods: From 1997 to 2002, 55 patients with MSTS were prospectively treated with 4 cycles of AI-G (doxorubicin 75 mg/m(2), ifosfamide 6 g/m(2) with G-CSF support). Responders received 2 further cycles of AI-G with collection of PBSCs. High-dose chemotherapy consisted of ifosfamide 12 g/m(2), carboplatin 1.2 g/m(2) and etoposide 1.2 g/m(2) (HD-ICE) followed by reinfusion of PBSCs. Results: Twenty-one of 55 patients (38%) were assessed as responders (3 complete response, 18 partial response). All but 2 patients refusing treatment received high-dose chemotherapy with PBSC rescue leading to grade IV hematologic toxicity without severe infections in all patients. No toxic death occurred. After a median follow-up time of 30 months, the median progression-free time was 12 months and survival time was 22 months for the entire group. By intent-totreat analysis the probability of 5-year progression-free survival was significantly higher for patients allocated to HD-ICE compared to patients receiving second-line chemotherapy after failure of AI-G (14 vs. 3%; p = 0.003). The estimated 5-year overall survival between the 2 groups was different (27% vs. not reached) but did not reach significance (p = 0.08). Conclusion: HD-ICE is feasible and promising in patients with chemosensitive MSTS. A randomized phase III trial is warranted to further define the role of HD-ICE as consolidation treatment in these patients.

Die Hochdosistherapie mit autologer Blutstammzelltransplantation besitzt einen gesicherten Stellenwert bei rezidivierten Lymphomen und multiplem Myelom. In dieser Arbeit wurde bei 101 Patienten die Stammzellsammlung aus dem Blut mit Leukapherese nach IEV-Chemotherapie und unter G-CSF Gabe untersucht und der prädiktive Wert der Leukozytenzahl vor Apherese für das Sammelergebnis bestimmt. Untersucht wurden insgesamt 307 Stammzellsammlungen. Pro Patient wurden im Median 3 (Bereich 1-8) Apheresen durchgeführt. Der Leukozytenwert vor Apherese lag im Median bei 22.300 Leukozyten/µL (Bereich 2.500-89.000/µL). Mit einer einzelnen Stammzellapherese konnten im Median 4,32 (Bereich 0,01-40,87) x 106 CD34+Zellen/kg gesammelt werden. Für die autologe Stammzelltransplantation ausreichende 2 x 106 CD34+Zellen/kg wurden bei 199 von 307 Apheresen (65 %) mit einer einzigen Apherese gewonnen. Eine optimierte Stammzelldosis von 5 x 106 CD34+Zellen/kg ergab sich bei 139 von 307 Apheresen (45 %). Es zeigte sich ein hochsignifikanter Zusammenhang zwischen der Leukozytenzahl im Blut vor Apherese und dem Sammelergebnis. Bei höheren Leukozytenwerten im Blut wurden signifikant bessere Stammzellausbeuten erzielt (p < 0,001). Als zweite Abhängigkeit ließ sich eine relative Effizienz des Leukozytenwerts für das Sammelergebnis bestimmen, die mit zunehmenden Zeitintervall ab Beginn der Mobilisierungschemotherapie kontinuierlich abnahm (p = 0,0004). Beide charakterisierten Abhängigkeiten ließen sich in einem prädiktiven Modell vereinen, dass neben der Leukozytenzahl im Blut eine Stratifizierung nach dem Apheresetag verwendet. Auf diese Weise kann das Sammelergebnis ohne vorherige Stammzellmessung im Blut in der Regel ausreichend genau vorhergesagt werden. Unsere Ergebnisse zeigen, dass effektive Stammzellsammlungen nach IEV-Chemotherapie und G-CSF-Gabe bei Patienten mit Lymphom und multiplem Myelom möglich sind und sich die erzielten Sammelergebnisse mit einem einfachen prädiktiven Modell vorhersagen lassen.

Overexpression of proto-oncogene c-jun and constitutive activation of the Jun NH2-terminal kinase (JNK) signaling pathway have been implicated in the leukemic transformation process. However, c-jun expression has not been investigated in acute myeloid leukemia (AML) cells containing the most common chromosomal translocations. t(8;21) is one of the most common AML-associated translocation and results in the AML1-ETO fusion protein. Overexpression of AML1-ETO in NIH3T3 cells leads to increased phosphorylation of Ser63 in c-Jun, which is generally JNK dependent. The role of the JNK signaling pathway for the functional properties of AML1-ETO is, however, unknown. In the present study we found high expression levels of c-jun mRNA in t(8;21), t(15;17) or inv(16) positive patient cells by microarray analysis. Within t(8;21) positive patient samples, there was a correlation between AML1-ETO and c-jun mRNA expression levels. In myeloid U937 cells, c-jun mRNA and c-Jun protein expression levels increased upon induction of AML1-ETO. AML1-ETO transactivated the human c-jun promoter through the proximal AP-1 site via activating the JNK signaling pathway. JNK targets c-Jun and ATF-2, which also bind to the proximal AP-1 site in U937 cells, were also phosphorylated upon AML1-ETO induction. Furthermore, AML1-ETO induction increased the DNA binding capacity of c-Jun and ATF-2 to the proximal AP-1 site of the c-jun promoter, which might result in their enhanced transactivation capacities. Interference with JNK and c-Jun activation by using JIP-1 or a JNK inhibitor reduced the transactivation capacity of AML1-ETO on the c-jun promoter and the pro-apoptotic function of AML1-ETO in U937 cells. AML1-ETO seems to activate the JNK signaling pathway by inducing the expression of a cytoplasmic factor, possibly G-CSF, because supernatant of AML1-ETO expressing cells was sufficient to induce phosphorylation of JNK and c-Jun in wildtype U937 cells. This data demonstrates a novel mechanism of how AML1-ETO might exert positive effects on target gene expression and identifies the proto-oncogene c-jun as a common target gene in AML patient cells.

The transcription factor C/EBPa regulates early steps of normal granulocyte differentiation since mice with a disruption of the C/EBPa gene do not express detectable levels of the G-CSF receptor and produce no neutrophils. We have recently shown that C/EBPa function is also impaired in acute myeloid leukemias. However, how the transcriptional activity of C/EBPa is regulated both in myelopoiesis and leukemogenesis, is not fully understood. The current study demonstrates that activated Ras enhances the ability of C/EBPa to transactivate the G-CSF receptor promoter and a minimal promoter containing only C/EBP DNA binding sites. Ras signaling activates C/EBPa via the transactivation domain, because it enhances the transactivation function of a fusion protein containing a Gal4 DNA binding domain and the C/EBPa transactivation domain, and does not change C/EBPa DNA binding. Ras acts on serine 248 of the C/EBPa transactivation domain, as it does not enhance the transactivation function of a C/EBPa serine 248 to alanine point mutant. Interestingly, serine 248 of C/EBPa is a PKC consensus site, and a PKC inhibitor blocks the activation of C/EBPa by Ras. Ras signaling phosphorylates C/EBPa on serine 248 in vivo. Finally, mutation of serine 248 to alanine obviates the ability of C/EBPa to induce granulocytic differentiation. These data suggest a model where Ras signaling enhances the activity of C/EBPa to induce granulocytic differentiation by phosphorylation of serine 248.

Due to enormous progress in recombinant DNA techniques and methodology, a multitude of biosynthetic, pharmaceutically relevant polypeptides and proteins became available in the past decade and have been employed in numerous pharmaceutical products. Concomitantly, substantial progress was made in pharmaceutical formulation development of peptides and proteins, inasmuch as many challenges in formulating these compounds in products with optimal therapeutic effects and shelf life were successfully approached. Additionally, new drug delivery systems – e.g., based on polymeric materials – will most likely enlarge the spectrum of future proteinic dosage forms, where today solutions and lyophilized products take center stage. Yet, due to the proneness of proteins to degradation - what can affect pharmaceutical relevant features such as biological activity and immunogenicity -, scrutinizing the homogeneity of protein formulations is of utmost importance. Hence, the development and implementation of new analytical techniques in order to keep pace is highly desired. It was the aim of this thesis to evaluate the applicability of asymmetrical flow field flow fractionation (AF4) in pharmaceutical protein analytics, to compare AF4 performance with established state-of-the-art methods and to reveal the effectivity of inherent AF4 characteristics in demanding analytical tasks. The Theoretical Section encompasses Chapter 2, wherein the family of field-flow fractionation techniques is introduced, as well as Chapter 3 (attending to protein aggregation) and Chapter 4, which provides an insight into multi-angle light scattering. The Theoretical Section is summarized in Chapter 5. Chapter 6 attends to the general applicability of (semi-)chromatographic AF4 in protein analysis. The correlation of cross flow progression with increased resolution was exemplified by the separation of human serum albumin (HSA), thereby rendering the (base-line) separation of HSA specimen into monomer, dimer, trimer and tetramer possible. Due to the AF4 feature to discretionarily alter the resolution power within one separation run, the fractionation of higherorder aggregates and insoluble, precipitated protein was successfully performed. System variables and parameters of fractionation were investigated, revealing that sample loads differing more than two orders of magnitude did not negatively affect data reproducibility. Whereas up to now cross flow intensity was deemed to predominantly account for contingent sample loss during AF4 experiments, analysis of proteins with varying hydrophilicity proved the preceding focusing step to contribute notably for that phenomenon. How to overcome potential drawbacks such as sample-membrane interactions by adequate choice of the ultrafiltration membrane as well as carrier liquid composition was illustrated. Chapter 11. Summary, conclusions and prospective 177 Given the background that effective AF4 fractionations are due to differences in analyte size – i.e., in diffusion coefficients -, the separation of equal-sized proteins is prima facie considered to be impractical. Yet, the retaining impact of sample-membrane interaction was evidenced to decrease the effective diffusion coefficient, resulting in successful fractionations of proteins differing ~1% in size (i.e., G-CSF, 19.6 kDa versus IFN-α2a, 19.4 kDa). In this realm, the normal mode elution order of smaller analytes eluting prior to larger ones was shown to be invertible, exemplified by the elution of a 40 kDa analyte prior to IFN-α2a. AF4 potency in analysis of insoluble high molecular weight (hmw) aggregates was compared with data derived by established methods such as light obscuration and Coulter technique, verifying the competitiveness of AF4. A comparative study of AF4 with size exclusion chromatography (SE-HPLC) unveiled SE-HPLC to inhere higher recovery rates and AF4 to exhibit greater resolution. Coupling both techniques with multi-angle light scattering (MALS) detection systems disclosed SE-HPLC to induce artifacts concerning hmw aggregate quantification. Moreover, in contrast to SE-HPLC, AF4 was capable of seizing undissolved and precipitated protein specimen, thus making AF4 a promising alternative in the analysis of protein pharmaceuticals. AF4´s ability to separate undissolved sample components proved to be an indispensable feature in the analysis of a pharmaceutical protein formulated within siliconized disposable syringes, which was attended to in Chapter 7. During long-term storage, visible particulate matter developed sporadically within the syringe volumes, raising the question of the particles´ origin. Since protein instabilities were not to be accounted for being the particle source – verified by several analytical methods -, silicone oil detachment and subsequent coalescence came into question, as the barrel siliconization process was lacking a final heat curing step. Thus, an AF4 application was developed, intending to separate μm sized silicone oil droplets. The task was approached by analysis of silicone oil emulsions, followed by the fractionation of ultrasoundstressed syringe volumes containing detached and coalesced silicone oil after stress exertion. Unambiguously, detached silicone oil was evidenced by AF4 to account for visible particulate matter in the syringe volumes, corroborated by MALS and refractive index detection as well as light microscopy and syringe frictional drag analysis. Subsequently to artificially induced protein aggregation of particle-containing syringe volumes, AF4 was able to separate silicone oil droplets, protein monomer and aggregates as individual fractions within one single run. Finally, AF4 enabled access to data on protein drug stability and insights into protein adsorption tendencies on coalesced silicone oil specimen – thereby providing valuable data which otherwise would have required a variety of various analytical techniques. Chapter 11. Summary, conclusions and prospective 178 In Chapter 8 the suitability of AF4 in overall-characterization of gelatin nanoparticles was explored. The efficacy of providing hmw gelatin bulk material by various desolvation steps was evaluated by SE-HPLC and AF4. Due to the absence of shear degradation phenomena, AF4 was demonstrated to enable more moderate separation conditions than SE-HPLC, verified by on-line determination of analyte molecular weight via MALS. Gelatin nanoparticles were characterized by means of AF4/MALS with respect to size and size distributions and the data were compared to results of photon correlation spectroscopy (PCS) and scanning electron microscopy (SEM). Because of the precedent separation step via AF4, data derived by MALS revealed a greater veracity than PCS results, where the size assessment of nanoparticles relied on batch experiments. Whereas PCS attributed unloaded and DNA plasmid loaded nanoparticles virtually unimodal size distributions, both AF4/MALS and SEM demonstrated the nanoparticles to span a broad size range. Furthermore, loaded and unloaded nanoparticles were unveiled to exhibit only minimal differences in size, thus providing information on the interplay of nanoparticles and plasmid strands. For the first time, the separation of nanocolloidal drug carrier and designated pharmaceutical payload was established. Additionally to drug carrier characteristics, data on the loading efficacy could be yielded. Furthermore, nanoparticle shelf life stability and extent of potential drug decomplexation could be determined. Bearing in mind colloidal, polymer-based drug delivery carriers gaining increasing importance, that very AF4 application is expected to accommodate the demand for accurate analytics, as the pharmaceutical product can be characterized in both qualitative and quantitative terms. In Chapter 9 a case study of particulate matter analysis of a pharmaceutical antibody solution is presented, wherein individual vials of one production lot developed visible components at random during long-term storage. In order to (a) provide evidence on the presence of the contamination, (b) to attempt particulate entitiy quantification and (c) to elucidate particles´ nature, a multiplicity of analytical techniques were applied, encompassing particle counting (optical inspection, light obscuration, light microscopy), protein characterization techniques (SE-HPLC, polyacrylamide gel electrophoresis, AF4, microcalorimetry) and particle separation techniques (sterile filtration, AF4). Attempts to isolate the particulate components by AF4 or filtration techniques provided no further indications of the particle´s origin. Virtually no alterations in protein characteristics were monitored between contaminated and particle-free vial volumes, respectively. Solely, microcalorimetric data of contaminated vial volumes resembled those of immunoglobulin solutions exposed to heat stress prior to analytics. Consequently, protein instabilities were assumed not to cause the visible contamination. Chapter 11. Summary, conclusions and prospective 179 The topic of liquid protein parenterals, protein instability and particulate matter was completed by presenting a formulation process of an immunoglobulin into a liquid formulation in Chapter 10. Prevalent strategies and mainstream trends of liquid protein formulation were introduced by reviewing latest publications on the issue. Parameters revealing decisive influence on the protein´s long-term stability such as solution pH as well as type and concentration of excipients were evaluated by means of accelerated stability studies at various storage temperatures. Additionally, processing parameters, e.g., freeze/thawing, were assessed evaluating criteria in terms of surfactant and buffer choice. The addition of NaCl was shown to detract from protein stability and to facilitate the formation of particulate matter. Non-deleterious alternatives of salt additives were discovered. On the other hand, the addition of polyols such as mannitol and sorbitol was demonstrated to notably contribute to the immunoglobulin stability. Preferential accumulation at the native state protein was thought to be the mechanism for reducing aggregation phenomena of the protein. Besides, the extent of fragmentation was reduced by polyols, indicating a second pathway of stabilization, which was hypothesized to be hampering of oxidation processes. Due to detailed investigations, a proposal pertaining an optimal formulation could be made in the course of that case study. This thesis has shown that asymmetrical flow field-flow fractionation (AF) can effectively be used to monitor protein stability in a broad variety of pharmaceutical formulations. Especially in the characterization of the most common outcome of physical instability – i.e., protein aggregation – the potential of AF4 has comprehensively been demonstrated. Moreover, AF4 applications and separation tasks within pharmaceutical analytics considered hitherto impractical or at least highly challenging were successfully performed. Facing increasingly complex liquid- or colloidal-based formulations, with this knowledge practice and research in pharmaceutical analytics can take a notable step forward.

Die vorliegende Arbeit befasst sich mit der Entwicklung von innovativen Trocknungstechniken für kleine Volumina relativ konzentrierter Protein-formulierungen. Ziel war es trockene, stabile und lagerfähige Produkte für zwei Modelproteine (rh G-CSF und rh EPO) zu erhalten. Hierzu wurde die Konvektionstrocknung mit erwärmtem Stickstoff im Endgefäß untersucht. Des Weiteren wurde, zur kontrollierten Beschichtung von Oberflächen, ein Prozess aus Applikation und Trocknung von Proteinmikrotropfen auf Oberflächen entwickelt. Um beide Techniken zu optimieren, wurden mehrere Verfahrensparameter und Formulierungen variiert und deren Einfluss auf die Produktqualität evaluiert.

High-dose chemotherapy with autologous peripheral blood stem cell transplantation is the standard treatment of patients with multiple myeloma today. In this study we used a combination mobilizing chemotherapy containing ifosfamide with G-CSF before stem cell collection. The chemotherapy regimen consisted of ifosfamide (2,500 mg/m(2) days 1-3), epirubicin (100 mg/m(2) day 1) and etoposide (150 mg/m2 days 1-3) followed by G-CSF (5 mug/kg from day 5). In 30 younger patients (median age 51 years; range 41-60 years) who received the IEV regimen in 100% dosage, a median of 11.15 x 10(6) CD34(+) cells/kg (range 0-44.60 x 10(6) CD34(+) cells/kg) was collected. In 22 elder patients (median age 64 years; range 59-72 years) similar collection results were obtained with a median of 10.82 x 10(6) CD34(+) cells/kg (range 0.99-42.22 x 10(6) CD34(+) cells/kg) after the IEV regimen in 75% dosage. The pretreatment chemotherapy cycles before mobilization were fewer in elder patients with a median of 0 cycles (range 0-7 cycles) compared with younger patients with a median of 4 cycles (range 0-7 cycles). These collection results were favorable and allowed to support a tandem transplantation procedure in younger and elder patients in 97 and 95%, respectively. In the majority of patients, the hematological toxicity of IEV was of WHO grade 3/4. The extramedullary toxicity was mild to moderate and there were only few cases (5-10%) of relevant nephrotoxicity or neurotoxicity associated with the application of ifosfamide. Copyright (C) 2003 S. Karger AG, Basel.

Bei der akuten myeloischen Leukämie (AML) stellen die unkontrollierte Proliferation und Reifungsblockade myeloider Vorläuferzellen, Expansion dieser Zellen in das periphere Blut, extramedulläre Manifestationen und verminderte Elimination der Leukämiezellen durch das Immunsystem grundlegende Pathomechanismen dar. Diese Vorgänge werden über ein komplexes Zusammenspiel von Zytokinen und Adhäsionsmolekülen reguliert. In dieser Arbeit wurde daher mittels Durchflußzytometrie die Expression von Zytokinrezeptoren, Adhäsions- und kostimulatorischen Molekülen in Knochenmarks(KM-) Proben von 103 AML-Patienten bei Diagnosestellung und acht gesunden Probanden untersucht. Zytokinrezeptoren weisen bei der normalen Hämopoese ein reifegradabhängiges und linienspezifisches Expressionsmuster auf. Es wurden daher zum einen Zytokinrezeptoren ausgewählt, die schon in der frühen Hämopoese exprimiert werden, wie der SCF-R (CD117), FL-R (CD135), IL-3-R (CD123) und zum andern Zytokinrezeptoren, die erst in späteren Differenzierungsstadien der monozytären Zelllinie (v.a. GM-CSF-R; CD116) und der granulozytären Zelllinie (v.a. G-CSF-R, CD114) exprimiert werden. Die gp130-Subunit (CD130) stellt die signaltransduzierende Untereinheit von IL-6, IL-11, LIF etc. dar und wirkt synergistisch auf allen Stufen der Hämopoese mit. Die untersuchten Adhäsionsmoleküle wurden in drei Gruppen unterteilt: a) Adhäsionsmoleküle, die den Kontakt zur KM-Matrix oder zu sich selbst beeinflussen: VLA-2 (CD49b), VLA-3 (CD49c) und die erst kürzlich auf hämopoetischen Zellen gefundenen Adhäsionsmoleküle PRR-1 und PRR-2. b) Adhäsionsmoleküle, die den Kontakt zum Endothel fördern: LFA-1 (CD11a), Mac-1 (CD11b), L-Selektin (CD62L) und UPA-R (CD87) c) kostimulatorische Moleküle, die eine Rolle bei der Interaktion der Leukämiezellen mit immunkompetenten Zellen spielen: ICAM-1 (CD54), LFA-3 (CD58), B7-1 (CD80), B7-2 (CD87) und NCAM (CD58). Eine KM-Probe wurde als positiv gewertet, wenn mehr als 20% der Blasten im Auswertefenster den entsprechenden Marker exprimierten. Ergebnisse: Der durchschnittliche Anteil Zytokinrezeptoren exprimierender Zellen war in KM-Proben von AML-Patienten deutlich höher als in KM-Proben von gesunden Probanden. Einzige Ausnahme bildete die gp130-Subunit, die nur auf durchschnittlich 4% der AML-Blasten exprimiert wurde, während durchschnittlich 23% der Zellen in gesunden KM-Proben die gp130-Subunit exprimierten. Bei den Adhäsionsmolekülen zeigte sich im Vergleich zu den gesunden KM-Proben bei der AML ein höherer Anteil von Zellen, die kostimulatorische und Endothel-Kontakt-fördernde Moleküle exprimierten, während der Anteil von Zellen, die das Stroma-Kontakt-fördernde ß1-Integrin VLA-2 exprimierten, vermindert war. VLA-3 konnte dagegen in keinem der untersuchten AML-Fälle und der gesunden KM-Proben als positiv gewertet werden. Innerhalb der AML-Subtypen konnte ein reifegrad– und linienabhängiges (monozytäres, granulozytäres) Verteilungsmuster der Zytokinrezeptoren festgestellt werden: Blasten unreifer Leukämien (M0; M1) exprimierten bevorzugt SCF-R und FL-R. Blasten von AML-Subtypen, die der granulozytären Differenzierungslinie zugeordnet werden (M2, M3), exprimierten v.a. G-CSF-R. Blasten monozytärer Leukämien (M4, M5) exprimierten v.a. GM-CSF-R und FL-R. Der IL-3-R wurde in fast allen AML-KM-Proben auf einem Großteil der Blasten exprimiert. Den größten Anteil positiver Zellen für Adhäsions- und kostimulatorische Moleküle (Integrine, B7-2, NCAM, UPA-R) wiesen die monozytären Leukämien auf. B7-1 wurde v.a. auf Blasten des FAB-Typs M3 exprimiert. L-Selektin, ICAM-1 und PRR-1/PRR-2 zeigten eine variable Expression innerhalb aller FAB-Typen. In der Gruppe der sekundären Leukämien waren signifikant mehr Fälle Mac-1-positiv als in der Gruppe der primären Leukämien (p = 0.074, Qui2-Test). Ansonsten zeigten sich zwischen primären und sekundären Leukämien keine signifikanten Unterschiede. Wichtig für die Entscheidung über Art und Intensität der Therapie bei der AML ist das Abschätzen der Prognose eines Patienten bei Diagnosestellung. Bislang werden Patienten v.a. anhand zytogenetischer Untersuchungen von Karyotypanomalien in Prognosegruppen eingeteilt. Da aber nur ca. 50-60% der AML-Patienten chromosomale Veränderungen aufweisen, besteht ein Bedarf an Karyotyp-unabhängigen Prognosekriterien. Zytogenetische Analysen wurden bei allen AML-KM-Proben durchgeführt und die Expression der Marker sowohl mit den zytogenetischen Risikogruppen als auch mit dem tatsächlichen klinischen Verlauf der Patienten korreliert. In die klinische Auswertung wurden nur Patienten (n = 55) eingeschlossen, die nach dem Therapieprotokoll der German AML-Cooperative-Group behandelt worden waren. In der zytogenetisch günstigen Prognosegruppe zeigten sich im Vergleich zur zytogenetisch ungünstigen Prognosegruppe signifikant mehr G-CSF-R-positive Zellen (p = 0.027, T-Test), signifikant weniger L-Selektin-positive Fälle (p = 0.037, Qui2-Test) und signifikant mehr Mac-1- und PRR-1-positive Fälle (p = 0.005; p = 0.009; Qui2-Test). Diese Marker zeigten aber keine signifikanten Unterschiede bezüglich Remissionrate und progressfreier Überlebenswahrscheinlichkeit der Patienten. Dies läßt sich auf die zum Teil geringe Fallzahl und die kurze Beobachtungsdauer von im Mittel 11 Monaten nach Remission erklären. Andere Marker zeigten dagegen keine Korrelation mit den zytogenetischen Risikogruppen, dagegen aber mit dem tatsächlichen klinischen Verlauf der Patienten: VLA-2-, NCAM-, UPA-R-positive Leukämien zeigten eine signifikant niedrigere Remissionsrate (p = 0.049, p = 0.03, p = 0.03, Qui2-Test). Patienten, in deren KM-Proben >85% der Blasten den FL-R oder >45,5% den SCF-R exprimierten, wiesen eine signifikant niedrigere Wahrscheinlichkeit für progressfreies Überleben auf, ebenso wie Patienten, in deren KM-Proben >60,5% der Blasten ICAM-1-, >15% B7-1-, >65% B7-2- und >8% NCAM-positiv waren. NCAM korrelierte als einziger Marker negativ sowohl mit der Remissionsrate, als auch mit der progressfreien Überlebenswahrscheinlichkeit, allerdings nicht mit der Einteilung in zytogenetische Risikogruppen. Auch für die übrigen Marker konnten Cut-off-Werte für den Anteil Marker-positiver Blasten ermittelt werden, bei denen aus dem Vergleich der entstandenen Gruppen ein deutlicher Unterschied in der Dauer der progressfreien Überlebenszeit hervorging. Diese Unterschiede waren allerdings aufgrund der geringen Fallzahl nicht signifikant, so dass sich eine eindeutige prognostische Aussagen nicht treffen ließ. Dabei wiesen Patienten mit einem höheren Anteil von G-CSF-R-, GM-CSF-R- und einem niedrigeren Anteil von IL-3-R-exprimierenden Blasten eine längere progressfreie Überlebenszeit auf. Patienten mit sehr hohem Anteil PRR-2- oder mit geringem Anteil PRR-1-positiver Blasten tendierten zu einer eher kürzeren progressfreien Überlebenszeit. Umgekehrt wies eine niedrige Expression von Endothel-Kontakt fördernden Oberflächenmolekülen, wie z.B. L-Selektin, Mac-1 und UPA-R auf eine schlechte Prognose hinsichtlich der Dauer des progressfreien Überlebens hin. Therapeutische Konsequenzen: Die in dieser Arbeit aufgezeigten Zusammenhänge zwischen der Expression bestimmter Oberflächenmarker und dem klinischen Verlauf der Patienten helfen, die Prognoseeinschätzung von Patienten - über die Zytogenetik hinaus - weiter zu spezifizieren: So stellt die NCAM-positive Leukämie eine eigene Entität mit prognostisch schlechtem Verlauf unabhängig vom Karyotyp dar. Bei UPA-R- und/oder VLA-2-positiven AML-Fällen sollten aufgrund der verminderten Remissionswahrscheinlichkeit intensivere therapeutische Induktionstherapien eingeleitet werden. Für die Remissionsdauer ist sowohl die hohe Expression kostimulatorischer Moleküle, als auch die hohe Expression von Zytokinrezeptoren, die v.a. auf Stammzellebene wirksam sind und die die Expression von diesen kostimulatorischen Molekülen fördern, prognostisch ungünstig. Diese Patienten sollten bei intensiver Konsolidierungstherapie engmaschig kontrolliert werden und die Indikation zur Knochenmarkstransplantation sollte frühzeitig gestellt weren. In der Zytokintherapie werden G-CSF und GM-CSF regelmäßig in der Klinik zur Verkürzung der Neutropeniephase nach Chemotherapie eingesetzt. Dagegen konnte mit dem Einsatz von G-CSF und GM-CSF als Priming-Medikamente bisher noch kein eindeutiger klinischer Benefit für die Patienten erzielt werden. Die in dieser Arbeit vorgestellten Ergebnisse einer linienspezifischen und reifegradabhängigen Expression der Zytokinrezeptoren legen nahe, dass G-CSF als Primingmedikament v.a. bei granulozytär-differenzierten AML-Subtypen und GM-CSF eher bei monozytär-differenzierten AML-Subtypen eingesetzt werden sollte. In der Supportivtherapie, bei der die Stimulation von AML-Blasten nicht mehr gewünscht ist, sollten G- und GM-CSF genau umgekehrt eingesetzt werden. Da eine hohe Expression von FL-R und SCF-R mit einer schlechten Prognose für die Dauer des progressfreien Überlebens korrelierte, kann sich eine Stimulation dieser Rezeptoren durch die Gabe von SCF und FL in der Supportivtherapie eher ungünstig auswirken, ebenso wie beim Priming, da auch gesunde Stammzellen stimuliert und damit sensibler gegen Zytostatika werden. Darüber hinaus geben diese Ergebnisse auch Hinweise auf mögliche pathobiologische Bedeutungen und damit verbundener neuer therapeutischer Strategien bei der AML: So kann die erhöhte FL-R-Expression - wie bei der Tandemduplikation des FL-R auch - zu einer erhöhten, prognostisch ungünstigen Phophorylierung von Tyrosinkinasen führen. Auch der SCF-R aktiviert intrazellulär Tyrosinkinasen. Neue Medikamente, wie z.B. Tyrosinkinase-Inhibitoren, oder Dexamethason, das die FL-R-Expression auf den AML-Blasten herunterreguliert, könnten bei diesen AML-Patienten neue benefit-bringende therapeutische Möglichkeiten darstellen. Ebenso scheint die Immunantwort bei AML-Patienten trotz, oder vielleicht sogar gerade bei Expression von kostimulatorischen Molekülen vermindert zu sein, was die Gabe von immunstimulierenden Medikamenten, wie rIL-2 oder CTLA-4-Inhibitoren im Bereich der Immuntherapie sinnvoll erscheinen lässt. So leistet diese Arbeit nicht nur einen Beitrag zur Diagnostik, Prognose und Biologie der AML, sondern entwickelt in Zusammenschau mit bereits publizierten Daten neue, therapeutische Möglichkeiten für die Behandlung der AML.

At diagnosis, clonal gene rearrangement probes {[}retinoic acid receptor (RAR)-alpha, major breakpoint cluster region (M-bcr), immunoglobulin (Ig)-JH, T cell receptor (TcR)-beta, myeloid lymphoid leukemia (MLL) or cytokine genes (GM-CSF, G-CSF, IL-3)] were detected in bone marrow samples from 71 of 153 patients with acute myelogenous leukemia (AML) (46%): in 41 patients with primary AML (pAML) (58%) and in 30 patients with secondary AML (42%). In all cases with promyelocytic leukemia (AML-M3) RAR-alpha gene rearrangements were detected (n = 9). Gene rearrangements in the Ig-JH or the TcR-beta or GM-CSF or IL-3 or MLL gene were detected in 12, 10, 16 and 12% of the cases, respectively, whereas only few cases showed gene rearrangements in the M-bcr (6%) or G-CSF gene (3%). Survival of pAML patients with TcR-beta gene rearrangements was longer and survival of pAML patients with IL-3 or GM-CSF gene rearrangement was shorter than in patients without those rearrangements. No worse survival outcome was seen in patients with rearrangements in the MLL, Ig-JH or M-bcr gene. In remission of AML (CR), clonal gene rearrangements were detected in 23 of 48 cases (48%) if samples were taken once in CR, in 23 of 26 cases (88%) if samples were taken twice in CR and in 23 of 23 cases (100%) if samples were studied three times in CR. All cases with gene rearrangements at diagnosis showed the same kind of rearrangement at relapse of the disease (n = 12). Our data show that (1) populations with clonal gene rearrangements can be regularly detected at diagnosis, in CR and at relapse of AML. (2) Certain gene rearrangements that are detectable at diagnosis have a prognostic significance for the patients' outcome. Our results point out the significance of gene rearrangement analyses at diagnosis of AML in order to identify `poor risk' patients - independently of the karyotype. Moreover, the persistence of clonal cells in the further course of AML can be studied by gene rearrangement analysis. Copyright (C) 2000 S. Karger AG, Basel.

Sat, 1 Jan 1994 12:00:00 +0100 https://epub.ub.uni-muenchen.de/6914/1/6914.pdf

In the present study we investigated the capability of human epidermal cells to generate granulocyte-activating mediators (GRAM). It could be shown that human epidermal cells as well as an epidermoid carcinoma cell line (A431) produce an epidermal cell-derived granulocyte-activating mediator (EC-GRAM) which stimulates human granulocytes to release significant levels of toxic oxygen radicals as measured by a lucigenin-dependent chemiluminescence (CL). For further characterization of EC-GRAM the A431 cell line was used. Supernatants of A431 cells usually contained maximal EC-GRAM levels within 24 h of incubation. Factor production was enhanced by bacterial lipopolysaccharide (LPS), but not by silica particles and PHA. Moreover, freeze-thaw lysates of A431 cells and extracts of heat-separated human epidermis contained significant levels of EC-GRAM. Preincubation of granulocytes with EC-GRAM resulted in an enhanced response to subsequent stimulation with the chemotactic peptide f-met-phe. In contrast EC-GRAM did not affect the response to PMA or zymosan particles. However, EC-GRAM treated granulocytes were unresponsive to restimulation with EC-GRAM. Upon high performance liquid chromatography (HPLC) gel filtration EC-GRAM eluted within two major peaks exhibiting a molecular weight of 17 kD and 44 kD. According to its biochemical and biological properties EC-GRAM can be separated from other cytokines such as ETAF/-interleukin 1, interleukin 2, interferons, granulocyte colony-stimulating factor (G-CSF) and tumor necrosis factor (TNF). However, an antibody to human GM-CSF neutralized about 75% of the activity. These results indicate that EC-GRAM activity stimulating the generation of reactive oxygen species by granulocytes is probably due to GM-CSF.