•HIV-associated lymphomas with MYC rearrangement could be considered for an intensive therapeutic approach.•Standard (R)CHOP seems to give inferior complete remission rate and PFS in this subset of ...patients.
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Large B-cell lymphoma (LBCL) carrying MYC rearrangement, alone or together with BCL2 and/or BCL6 translocations, have shown a poor prognosis when treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in the HIV population. Scanty data are available on the prevalence and prognostic impact of MYC rearrangements in HIV-associated LBCL. We conducted a retrospective study to evaluate the clinical effect of MYC rearrangement in HIV-associated LBCL. We evaluated clinical characteristics, treatment received, and outcome of LBCL in patients with HIV with MYC rearrangement (MYC+) and without MYC rearrangement (MYC–). A total of 155 patients with HIV who had received fluorescence in situ hybridization analysis for MYC were enrolled in 11 European centers: 43 with MYC+ and 112 MYC–. Among patients with MYC, 10 had double-/triple-hit lymphomas, and 33 had isolated MYC rearrangement (single-hit lymphoma). Patients with MYC+ had more frequently advanced stage, >2 extranodal site at presentation, and higher proliferative index. There were no significant differences in overall survival and progression-free survival (PFS) between the 2 groups. However, patients with MYC+ received more frequently intensive chemotherapy (iCT) (44%) than (R)CHOP alone (35%) or infusional treatment (DA-EPOCH-R and R-CDE) (19%). Among patients with MYC+, those who received iCT achieved a better outcome than patients who received nonintensive treatment (complete remission, 84% vs 52%; P = .028; 5-year PFS, 66% vs 36%; P = .021). Our retrospective results suggest that HIV-associated LBCL with MYC+ could be considered for an intensive therapeutic approach whenever possible, whereas (R)CHOP seems to give inferior results in this subset of patients in terms of complete remission and PFS.
After the launch of the Prostate Cancer Programme in September 2004, the clinical management of prostate cancer (PCa) patients at Fondazione IRCCS Istituto Nazionale dei Tumori (INT), in Milan, ...became multidisciplinary, and multidisciplinary consultations and clinical case discussions were organized on a weekly routine basis. From the start it was clear that the model needed to be adaptable to meet new clinical and organizational needs. Magnani et al. (1) referred to the 2004-2011 experience. This abstract describes the initial multidisciplinary consultations and the clinical case discussions in terms of numbers, organization and access and the changes introduced in 2012-2017. From March 2005 to October 2017 an average of 350 multidisciplinary consultations per year were performed on a weekly basis. An urologist, a radiation oncologist and a psychologist were seeing 8 patients with a PCa diagnosis in any state of disease who refer to INT for the first time. Medical oncologists are also involved in advanced or metastatic PCa. From March 2005 to October 2017, an average of 340 clinical case discussions per year was performed on a weekly basis. At least one representative for urology, radiation oncology, medical oncology, the research nurse and the project manager participated mandatorily, while other professionals (for example imaging specialists, uropathologists, palliative care specialists) were called in on particular cases. Prostate Cancer Unit (PCU) was formalized in 2009 and updated in 2013. In February 2017 the collaboration between INT PCU and Urology Division at Policlinico, Milan, was made official to implement the PCa path of care of both institutes, also in line with Valdagni’s et al. papers on PCU (2, 3). Magnani et al. reported on INT multidisciplinary activities from March 2005 to March 2011 (1). Since 2012, an increase in very low-/lowrisk class patients (61.5% vs. 51%) and a decrease in highrisk (13% vs. 26%) and metastatic (1.5% vs. 5%) patients were observed, compared to the period 2005-2011. The percentage of intermediate-risk patients was maintained (26% vs. 24%). 9.5% of the patients had already received a PCa treatment before visit. The following changes were introduced in the organizational model: (i) Due to the lack of resources (psychologists are supported by a grant from a private donor) the individual counselling meeting with the psychologist after the first multidisciplinary consultation was interrupted in 2014. Patients who seemed to potentially benefit from psychological support were invited to meet the psychologist in the afternoon or schedule an appointment. (ii) Selection of cases for clinical case discussions: In the 2005-2011 period, all cases examined in the multidisciplinary clinic were discussed in the weekly tumour board to evaluate adherence to guidelines, check on the quality of the decisions formulated in the clinic, to tailor therapeutic or observational strategies and to facilitate the interdisciplinary collaboration and education. After carefully analyzing the data on the clinical case discussions and the changes applied to the decisions taken in the clinic, in 2014 we chose not to discuss all the cases examined in the first multidisciplinary consultations. Since 2014 clinical case discussions were mainly focused on patients who, after the multidisciplinary consultations, had to complete staging before therapeutic and observational options could be proposed and patients on active surveillance or watchful waiting with borderline situations with respect to institutional protocols. (iii) Since 2015 a research nurse has participated in the clinical case discussions, thus enabling the selection of patients to be included in clinical trials. In addition, the nurse became the contact person between clinicians and patients and follows up after the discussion to schedule appointments, to plan future steps and to inform patients and clinicians. (iv) The formalization of the PCU identified and named the specialists involved in the PCa path of care divided in core and non-core team, described the PCa dedicated activities and the participation in the PCU multidisciplinary activities. As regards the clinical case discussions, professionals of the non-core team needed on a particular case were receiving a request from the PCU Secretary and upon their confirmation the case was scheduled. (v) Since the formalization of INT PCUPoliclinico collaboration, urologists from Policlinico participate in the clinical case discussions presenting their cases. Multidisciplinary approach has proven successful to address PCa complexity. A flexible organizational model is necessary to meet new scenarios (both clinical and organizational). Monitoring is mandatory to detect bottle necks and criticisms.
It is commonly accepted that oncologic patients benefit from a multidisciplinary management that involves all the professionals participating in the path of care and facilitates timely access to ...therapy, rehab programs and counseling delivered by experienced experts. Multidisciplinary management implements simultaneous care and shifting from a disease-focused to a patient-centered approach in accordance with the policy statement of the European Partnership for Action Against Cancer (EPAAC) (1). This is most true for prostate cancer patients for whom, according to the state of disease, multiple therapies and observational strategies are available and several health care professionals have a role in the disease trajectory. This work describes the experience of Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Milan (Italy), which formalized the multidisciplinary management of prostate cancer patients running since 2004 in a Prostate Cancer Unit (PCU) and how the PCU affected assistance and care. The organization of multidisciplinary activities organized before (from March 2004, when the Prostate Cancer Program (PCP) was launched, to December 2013, when INT PCU, formalized in 2009, was updated) and after the PCU second formalization (from December 2013 until now) were analyzed. INT PCP redirected translational, preclinical, and clinical research according to diseasefocused shared strategies. In 2004, a multidisciplinary working group focused on writing diagnostic and therapeutic guidelines for evidence-based clinical decisions was established. In 2005, INT PCP started the weekly multidisciplinary clinics for newly referred patients, the weekly follow-up clinics for patients on active surveillance and watchful waiting and the weekly tumor boards. Specialists participating in the PCP were urologists, radiation oncologists, medical oncologists, and uropathologists. Experts in imaging were involved in particular cases, also in consideration of the personal commitment to PCP and the disease. Psychologists, participating as consultants, were supported by a grant from a private donor. In 2009, INT PCU was first formalized, identifying the Chair, the Vice Chair, the clinicians, and the researchers involved in the PCP research and clinical activities. In 2013 and then in 2017, the document was updated in line with Valdagni’s et al. reports on PCUs (2, 3) and in partial response to issues raised by the 2013 external audit (4), with a specific focus on clinical activities, personnel participating, responsibilities and work flows. In details: (i) PCU Chair, Vice Chair, and project manager were nominated. (ii) An agreement was reached between PCU Chair and the Heads of the specialties, concerning the dedication to the PU activities and the time to dedicate (for all the clinicians involved in the path of care). (iii) Clinicians were divided in core team, including specialties that have to attend the PCU activities on a routine basis and non-core team, consisted of specialties involved in specific steps of the disease trajectory; considering that the core team may mutually agree on documented exception to the rule, to optimize resources pathologists participated in selected cases. (iv) PCU clinics were described with respect to organization, clinicians’ participation, and responsibilities. (v) Interdisciplinary collaboration was described in details, including information about the involvement of the non-core team members in the PCU activities. The formalization and update of INT PCU allowed naming the clinicians participating in the PCU upon agreement between the PCU Chair and the directors of the specialties, specifying also the amount of time to be dedicated to the pathology and the PCP activities. Moreover, professionals such as experts in imaging, in nuclear medicine, rehab programs, support, and palliative care were involved, in line with the growing importance of emerging techniques, drugs and procedures. Core and non-core teams were distinguished in order to limit the participation in the PCU activities, thus optimizing effort and resources. In addition, formalization identified the activities and the responsibilities of administrative staff; it described multidisciplinary activities with respect to organization-, participation-, documentation- and communication-related issues, and rationalized the access to clinical case discussion sessions by identifying categories of patients that need to be evaluated multidisciplinarily. Furthermore, formalization facilitated the decisions on reports exiting from multidisciplinary clinics, as well as, the clinical case discussions assessing the participation of multiple professionals. Finally, the importance of periodically reassessing PCU with respect to personnel, activities, and organization, paying particular attention to emerging techniques and procedures and bottlenecks, was appreciated, as well as the importance of having an agreement on evidence-based clinical decisions, coordination of treatments, procedures, professionals and communication within the team and with the patients. Our experience of multidisciplinary approach and PCU activities, however, suggests that there are the following points that need improvement. (i) Although the PCU is formalized, the organizational model is functional, thus determining tasks, roles, and responsibilities, but with limited capacity of Chair and Vice Chair to act on professionals who report on a divisional structure model. (ii) Time for active participation in the PCU should be protected, with the possibility of reassessing it based on unmet needs that may come up from the clinical routine. (iii) Solutions should be found to allow the participation of multiple PCU professionals in the clinical case discussions, making them lively sessions also for educational purposes. Conclusion: The formalization of INT PCU proved helpful 1) to improve the efficacy and efficiency of the multidisciplinary organizational model, 2) to optimize resources and procedures, 3) to facilitate interprofessional collaboration and synergy. However, efforts should be made by Admin as well as experts in organization, management, and human resources to overcome the limitation of functional organization. Solutions to boost motivation and permit the participation of professionals in the clinical case discussions as often as possible should also be found. Activities and participation should be checked on a routine basis to identify bottlenecks and criticisms that might hinder the multidisciplinary synergy.
Hepatocellular carcinoma (HCC) is a very angiogenic and malignant cancer. Conventional chemotherapy is poorly effective because of the abnormal structural organization of HCC-infiltrating vessels. In ...previous work, we demonstrated that HCC angiogenesis is driven by transforming growth factor beta-1(TGF-β1)/CD105 axis, stimulating liver-derived microvascular endothelial cells (Ld-MECs) migration. As TGF-β1 also affects mural cells (MCs) recruitment and maturation, we asked whether it may contribute to HCC-induced vascular abnormalities. HCC and adjacent non-neoplastic liver (nNL) biopsies obtained from 12 patients were analyzed by immunohistochemistry for angiogenic markers CD105, TGF-β1, CD44 and vascular endothelial growth factor-a (VEGFa) and for MC markers NG2, α-smooth muscle actin (αSMA) and neural cell adhesion molecule (NCAM). The same markers were also investigated by immunocytochemistry on cultured HCC-derived stromal cells (HCC-StCs) and nNL-derived StCs (nNL-StCs) isolated from the same liver biopsies. Angiogenic factors released by StCs were analyzed by ELISA and the interaction between StCs and Ld-MECs by adhesion assay. Compared with nNL, HCC biopsies showed increased angiogenic markers and αSMA that was localized in vessels. By contrast, NG2 and NCAM were substantially localized in tumor cells but absent in vessels and stroma. Cultured HCC-StCs showed less expression of NG2, αSMA and NCAM. They also demonstrated a lower capacity to release angiogenic factors and adhered on Ld-MECs. HCC-StCs and nNL-StCs treated with TGF-β1 or with of HepG2 (a human hepatoma cell line) derived conditioned medium (CM), down-modulated NCAM expression, whereas anti-NCAM antibodies significantly reduced the adhesion of StCs to Ld-MECs. By further blocking TGF-β1 with anti-TGF-β1 antibodies or with Ly-364947 (a specific inhibitor TGF-β1-receptor) adhesion to Ld-MECs and NCAM expression respectively was partially restored. TGF-β1 contributes to HCC-induced vascular alterations by affecting the interaction between HCC-StCs and Ld-MECs through a down-modulation of NCAM expression.
Nucleoside 1, with an unusual tricyclic carbohydrate moiety, specifically inhibits HIV-1 replication while being inactive against HIV-2 or other (retro) viruses. In an attempt to increase the ...inhibitory efficacy against HIV-1, and to further explore the structural features required for anti-HIV-1 activity, different types of modifications have been carried out on this prototype compound. These include substitution of the ethoxy group at the C-4″ position by alkoxy groups of different length, branching, conformational freedom or functionalization. In addition, the 4″-ethoxy group has been removed or substituted by other functional groups. The role of the tert-butyldimethylsilyl (TBDMS) group at the 2′ position has also been studied by preparing the corresponding 2′-deprotected derivative or by replacing it by other silyl (tert-hexyldimethylsilyl) or acyl (acetyl) moieties. Finally, the thymine of the prototype compound has been replaced by N-3-methylthymine, uracil or thiophenyl. Some of these compounds were endowed with a 6- to 7-fold higher selectivity than the prototype 1. The tricyclic nucleosides here described represent a novel type of selective anti HIV-1 inhibitors, targeted at the HIV-1-encoded reverse transcriptase.
Several anti‐HIV drugs acting on different steps of virus replication were tested in our experimental model of primary monocyte/macrophages; the results were compared with the activity found in ...lymphocytes. Nucleoside analogues (AZT, ddl, ddC, d4T, PMEA, 3TC etc.) show greater activity in macrophages (M/M) than in lymphocytes. In particular, the EC50 of AZT, ddC, and ddI in M/M is 2‐ to 100‐fold lower than that found in lymphocytes. This greater efficacy of nucleoside analogues in M/M depends on the enhancement of their chain‐terminating activity by the low levels of endogenous deoxynucleoside‐triphosphates (dNTP) usually found in resting cells such as M/M. Non‐nucleoside reverse transcriptase inhibitors (NNRTI) do not act as chain terminators (thus their antiviral effect is not related to the intracellular concentrations of dNTP); as a consequence the activity of TSAO, HEPT, TIBO, and other NNRTI tested in M/M is similar to that found in lymphocytes. Regarding inhibitors of binding and fusion of HIV, we found that their anti‐HIV activity is markedly decreased (or even nullified) when M/M are treated with cytokine activators of M/M function and enhancers of HIV replication. More relevant from a clinical standpoint, protease inhibitors are able to inhibit HIV replication in chronically infected macrophages cells carrying the proviral genome already integrated in the host genome). All other inhibitors of late stage of virus life cycle tested (antisense‐rev, anti‐tat, interferon‐α and ‐γ, phosphorothioate analogues, GLQ‐223, etc.) were totally inactive in chronically infected macrophages. The different effects of various classes of HIV inhibitors in lymphocytes and macrophages suggests that AIDS therapy should consider all aspects of the pathogenesis of HIV infection and must be restricted to drugs, or combinations of drugs, active against both lymphocytes and M/M in all body compartments where the virus hides and replicates. J. Leukoc. Biol. 62: 138–143; 1997.
New 2‘,5‘-bis-O-(tert-butyldimethylsilyl)-β-d-ribofuranosyl-3‘-spiro-5‘ ‘-(4‘ ‘-amino-1‘ ‘,2‘ ‘-oxathiole-2‘ ‘,2‘ ‘-dioxide) (TSAO) derivatives substituted at the 4‘ ‘-amino group of the spiro moiety ...with different carbonyl functionalities have been designed and synthesized. Various synthetic procedures, on the scarcely studied reactivity of the 3‘-spiroaminooxathioledioxide moiety, have been explored. The compounds were evaluated for their inhibitory effect on both wild-type and TSAO-resistant HIV-1 strains, in cell culture. The presence of a methyl ester (10) or amide groups (12) at the 4‘ ‘-position conferred the highest anti-HIV-1 activity, while the free oxalyl acid derivative (11) was 10- to 20-fold less active against the virus. In contrast, the presence at this position of (un)substituted ureido or acyl groups markedly diminished or annihilated the anti-HIV-1 activity. Surprisingly, some of the target compounds also showed inhibition of human cytomegalovirus (HCMV) replication at subtoxic concentrations. This has never been observed previously for TSAO derivatives. In particular, compound 26 represents the first TSAO derivative with dual anti-HIV-1 and -HCMV activity.
Objectives: The aim of this study was to investigate the development and progression of phenotypic resistance to the HIV-1-reverse transcriptase (RT) inhibitor lamivudine, and genotypic variations of ...HIV-1-RT occurring under lamivudine treatment in HIV-1-infected human primary monocytes–macrophages (M/M). Methods: Cellular passages in the presence of lamivudine were performed every 2 weeks by transferring supernatants of infected M/M to fresh M/M. A fitness assay using wild-type virus and a lamivudine-resistant HIV-1 virus (harbouring the M184V RT mutation) was performed in peripheral blood mononuclear cells. Culture supernatants were tested for p24 antigen production and RT activity. The M184V RT mutant virus was obtained by site-directed mutagenesis on a CCR5-using HIV-1 backbone. Results: The mutagenized M184V RT virus showed full resistance to lamivudine in M/M. However, no detectable phenotypic and genotypic resistance (neither virus breakthrough, nor RT resistance-related mutations) developed in M/M infected by HIV-1 and cultured for up to seven passages in vitro (i.e. 105 days). This inefficiency of M/M to develop M184V RT mutated virus is tightly related to the low 2′-deoxynucleotide (dNTP) pool in such cells, which in turn decreases the kinetics of HIV-1-RT. Despite this, the M184V RT mutant virus replicates in M/M, although with a 30% decreased efficiency compared with the wild-type. Conclusions: Our results show that the chances of development of resistance are far lower in M/M than in lymphocytes. This underlines the importance and the peculiar role of M/M as reservoirs of either wild-type or resistant strains in human organs.
The efficacy of 9-(2-phosphonylmethoxyethyl)adenine (PMEA) against the replication of human immunodeficiency virus (HIV) and
herpes simplex virus type 1 (HSV-1) and its cellular metabolism were ...investigated in human primary macrophages from seronegative
donors. PMEA potently inhibited the replication of both HIV and HSV-1 in macrophages, with similar EC50 values (0.025 and
0.032 microM, respectively), whereas the EC50 values of PMEA in lymphocytic C8166 cells and fibroblastoid Vero cells were
150-200-fold higher (3.5 and 7.9 microM, respectively). Granulocyte/macrophage colony-stimulating factor and macrophage colony-stimulating
factor, two cytokine enhancers of the replication of HIV (and HSV-1), decreased the activity of PMEA against both viruses,
yet EC50 values were still lower than in lymphocytes and fibroblasts. Thus, the selectivity index of PMEA in macrophages was
> 2 orders of magnitude higher than that in lymphocytes and fibroblasts and still > 1 log higher under conditions of enhancement
of virus replication in macrophages. The intracellular levels of 2'-deoxyadenosine-5'-triphosphate, the natural competitor
of PMEA-diphosphate at the level of viral DNA polymerase (either RNA or DNA dependent), were 5-12-fold lower in macrophages
than in other cells. Furthermore, intracellular concentrations of PMEA-diphosphate (the active metabolite of PMEA) were unusually
much higher in macrophages (with or without cytokines) than in lymphocytes and fibroblasts. Consequently, the ratio of PMEA-diphosphate
to 2'-deoxyadenosine-5'-triphosphate in monocytes/macrophages was approximately 2 orders of magnitude higher in macrophages
than in the other cells and correlated closely with the pronounced antiviral potency of PMEA. The dual potent activity of
PMEA against HIV and HSV-1 stresses the importance of clinical trials to assess the role of this drug in the therapy of HIV-related
disease.
Red blood cells (RBC) may act as selective carriers of drugs to macrophages, an important reservoir of viruses such as human immunodeficiency virus (HIV) and herpes simplex virus type 1 (HSV-1). We ...therefore assessed the incorporation of 9-(2-phosphonylmethoxyethyl)adenine (PMEA, a potent inhibitor of HIV and HSV-1) into RBC, its delivery to macrophages and its activity against HIV or HSV-1. Loading of PMEA in artificially aged opsonized RBC affords significant levels of intracellular PMEA. RBC metabolize PMEA to its active congener PMEA-diphosphate, although with low efficiency. Exposure of macrophages to RBC-encapsulated PMEA inhibits the replication of both HIV and HSV-1 (about 90% inhibition at the highest RBC:macrophages ratios) even if RBC were removed before virus challenge. By contrast, the antiviral activity of free PMEA removed before virus challenge was irrelevant at concentrations up to 150-fold higher than the 50% effective concentration (EC
50). Finally, the antiviral effect of RBC-encapsulated PMEA correlates with PMEA levels in macrophages about 500-fold higher than those achieved by free PMEA (at concentrations 10-fold higher than the EC
50). The efficacy of RBC-mediated delivery to macrophages of PMEA (and perhaps of compounds with shorter intracellular half-lives) warrants further studies in infectious diseases involving phagocytizing cells as main targets of the pathogen.
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