Cancer Therapy Volume 6 Issue A

CANCER THERAPY

Volume 6 Number 1 June, 2008

CANCER THERAPY FREE ACCESS www.cancer-therapy.org

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Editor

Teni Boulikas Ph. D., CEO Regulon Inc. 715 North Shoreline Blvd.

Mountain View, California, 94043 USA Tel: 650-968-1129 Fax: 650-567-9082 E-mail: teni@regulon.org

Teni Boulikas Ph. D., CEO, Regulon AE. Gregoriou Afxentiou 7 Alimos, Athens, 17455 Greece Tel: +30-210-9853849 Fax: +30-210-9858453 E-mail: teni@regulon.org

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Editor Assistant

Maria Koutoudi, B.A. , M.A. Gregoriou Afxentiou 7 Alimos, Athens, 17455 Greece Tel: +30-210-9858454 Fax: +30-210-9858453 E-mail: maria@cancer-therapy.org

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Editorial Board

Ablin, Richard J., Ph.D., Arizona Cancer Center, University of Arizona, USA Armand, Jean Pierre, M.D. Ph.D., European Organization for Research and Treatment of Cancer (EORTC), Belgium Aurelian, Laure, Ph.D., University of Maryland School of Medicine, USA Berdel, Wolfgang E, M.D., University Hospitals, Germany Bertino, Joseph R., M.D., Cancer Institute of New Jersey, USA Beyan Cengiz, M.D., Gulhane Military Medical Academy, Turkey Bottomley, Andrew, Ph.D., European Organization for Research and Treatment of Cancer Data Center (EORTC), Belgium Bouros, Demosthenes, M.D., University Hospital of Alexandroupolis. Greece Cabanillas, Fernando, M.D, The University of Texas M. D. Anderson Cancer Center, USA Castiglione, Monica, MHA, SIAK/IBCSG Coordinating Center, Switzerland Chou, Kuo-Chen, Ph.D., D.Sc., Pharmacia Upjohn, USA Chu, Kent-Man, M.D., University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China Chung, Leland W.K, Ph.D., Winship Cancer Institute, USA Coukos, George, M.D., Ph.D., Hospital of the University of Pennsylvania, USA Darzynkiewicz, Zbigniew, M.D., Ph.D., New York

Medical College, USA Der Channing, J. Ph.D, Lineberger Comprehensive Cancer Center, USA Devarajan, Prasad M.D., Cincinnati Children's Hospital, USA Dritschilo, Anatoly, M.D., Georgetown University Hospital, USA Duesberg, Peter H., Ph.D, University of California at Berkeley, USA El-Deiry, Wafik S. M.D., Ph.D., Howard Hughes Medical Institute, University of Pennsylvania School of Medicine, USA Federico, Massimo, M.D. Università di Modena e Reggio Emilia, Italy Fiebig, Heiner H, Albert-Ludwigs-Universität, Germany Fine, Howard A., M.D., National Cancer Institute, USA Frustaci, Sergio, M.D., Centro di Riferimento Oncologico di Aviano, Italy Georgoulias, Vassilis, M.D., Ph.D., University General Hospital of Heraklion, Greece Giordano, Antonio, M.D., Ph.D., Sbarro Institute for Cancer Research and Molecular Medicine, Temple University, USA Greene, Frederick Leslie, M.D., Carolinas Medical Center, USA Gridelli, Cesare M.D., Azienda Ospedaliera, "S.G.Moscati", Italy Hengge, Ulrich, M.D., Heinrich-Heine-University Duesseldorf, Germany Huber, Christian M.D., Johannes-Gutenberg-

University, Germany Hunt, Kelly, M.D., The University of Texas M. D. Anderson Cancer Center, USA Kamen, Barton A., M.D. Ph.D, Cancer Institute of New Jersey, USA Kaptan, Kürsat, M.D., Gülhane Military Medicine Academy, Turkey Kazuma, Ohyashiki, M.D., Ph.D., Tokyo Medical University, Japan Kinsella, Timothy J. M.D., The research Institute of University Hospitals in Cleveland, USA Kmiec, Eric B, Ph.D., University of Delaware, USA Kosmidis Paris, M.D., "Hygeia" Hospital, Athens, Greece Koukourakis Michael, M.D., Democritus University of Thrace, Greece Kroemer, Guido, M.D. Ph.D., Institut Gustave Roussy, France Kurzrock, Razelle, M.D., F.A.C.P., M. D. Anderson Cancer Center, USA Leung, Thomas Wai-Tong M.D., Chinese University of Hong Kong, China Levin, Mark M.D., Sister Regina Lynch Regional Cancer Center, Holy Name Hospital, USA Lichtor, Terry M.D., Ph.D., Rush Medical College, USA Liebermann, Dan A., Ph.D., Temple Univ. School of Medicine, USA Lipps, Hans J, Ph.D., Universität Witten/Herdecke, Germany Lokeshwar, Balakrishna L., Ph.D., University of Miami School of Medicine, USA Mackiewicz, Andrzej, M.D., Ph.D., University School of Medical Sciences (USOMS) at Great Poland Cancer Center, Poland Marin, Jose J. G., Ph.D., University of Salamanca, Spain McMasters, Kelly M., M.D., Ph.D., University of Louisville, J. Graham Brown Cancer Center, USA Morishita, Ryuichi, M.D., Ph.D., Osaka University, Japan Mukhtar, Hasan Ph.D., University of Wisconsin, USA Ng, Eddie YK, Ph.D., Nanyang Technological University, Singapore Norris, James Scott, Ph.D., Medical University of South Carolina, USA Palu, Giorgio, M.D., University of Padova, Medical School, Italy Park, Jae-Gahb, M.D., Ph.D., Seoul National University College of Medicine, Korea Perez-Soler, Roman M.D., The Albert Einstein Cancer Center, USA Peters, Godefridus J., Ph.D., VU University Medical Center (VUMC), The Netherlands Poon, Ronnie Tung-Ping, M.D., Queen Mary Hospital, Hong Kong, China Possinger, Kurt-Werner, M.D., Humboldt University, Germany Rainov G Nikolai M.D., D.Sc., The University of Liverpool. UK Randall, E Harris, M.D., Ph.D., The Ohio State University, USA Ravaioli Alberto, M.D. Ospedale Infermi, Italy

Remick, Scot, C. M.D., University Hospitals of Cleveland, USA Rhim, Johng S M.D., Uniformed Services University of Health Sciences, USA Schadendorf, Dirk, M.D., Universitäts-Hautklinik Mannheim, Germany Schmitt, Manfred, Ph.D., Universität München, Klinikum rechts der Isar, Germany Schuller, Hildegard M., D.V.M., Ph.D., University of Tennessee, USA Slaga, Thomas J., Ph.D., AMC Cancer Research Center (UICC International Directory of Cancer Institutes and Organisations), USA Soloway, Mark S., M.D., University of Miami School of Medicine, USA Srivastava, Sudhir, Ph.D., MPH, MS, Division of Cancer Prevention, National Cancer Institute, USA Stefanadis, Christodoulos, M.D., University of Athens, Medical School, Greece, Stein, Gary S Ph.D., University Of Massachusetts, USA Tirelli, Umberto, National Cancer Institute, Italy Todo, Tomoki, M.D., Ph.D., The University of Tokyo, Japan van der Burg, Sjoerd H, Leiden University Medical Center, The Netherlands Wadhwa Renu, Ph. D., Nat. Inst. of Advan. Indust.

Sci. and Technol. (AIST), Japan Waldman, Scott A. M.D., Ph.D., USA Walker, Todd Ph.D., Charles Sturt University, Australia Watson, Dennis K. Ph.D., Medical University of South Carolina, Hollings Cancer Center, USA Waxman, David J., Ph.D., Boston University, USA Weinstein, Bernard I., M.D., D.Sci (Hon.), Columbia University, USA Werner, Jochen Alfred M.D., Philipps-University of Marburg, Germany Wieand, Harry Samuel Ph.D., National Surgical Adjuvant Breast and Bowel Project (NSABP), USA Yamada, Akira Ph.D., Kurume University Research Center for Innovative, Japan Yu, Dihua M.D., Ph.D., The Univ. Texas M. D. Anderson Cancer Center, USA Zagon, Ian, Ph.D., The Pennsylvania State University, USA

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Associate Board Members

Chen, Jiguo, Ph.D, The University of Texas Health Science Center at San Antonio, USA Chen, Zhong, M.D, Ph.D, National Institute of Deafness and other Communication Disorders, National Institutes of Health, USA Dietrich Pierre Yves, Hopitaux Universitaires de GenFve Switzerland Jeschke Marc G, M.D., Ph.D. Universität Erlangen-Nürnberg. Germany Limacher Jean-Marc, MD Hôpitaux Universitaires de Strasbourg, France Los Marek J, M.D., Ph.D. University of Manitoba, USA Mazda Osam, M.D., Ph.D. Kyoto Prefectural University of Medicine, Japan Merlin Jean-Louis, Ph.D Centre Alexis Vautrin, National Cancer Institute University Henri Poincaré France Okada Takashi, M.D., Ph.D. Jichi Medical School Japan Pisa Pavel, M.D, Ph.D. Karolinska Hospital, Sweden Squiban Patrick, MD Transgene SA France Taupin, Philippe, Ph.D., National University of Singapore, Singapore Tsuchida Masanori, M.D, Ph.D Niigata University Graduate School of Medical and Dental Sciences Japan Ulutin, Cuneyt, M.D., Gulhane Military Medicine Academy, Turkey Xu Ruian, Ph.D., The University of Hong Kong, Hong Kong

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For submission of manuscripts and inquiries: Editorial Office Teni Boulikas, Ph.D./ Maria Vougiouka, B.Sc. Gregoriou Afxentiou 7 Alimos, Athens 17455 Greece Tel: +30-210-985-8454 Fax: +30-210-985-8453 and electronically to maria@cancer-therapy.org

Instructions to authors: Cancer Therapy FREE ACCESS www.cancer-therapy.org

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Table of contents Cancer Therapy Vol 6 Number 1, June 2008

Pages

Type of Article

Article title

Authors (corresponding author is in boldface)

1-10

Review Article

Adnan Salim Abu-Surrah, Haitham H. Al-Sa’doni, Maher Y. Abdalla

11-24

Review Article

Palladium-based chemotherapeutic agents: !Routes toward complexes with good antitumor activity New directions in the management of renal cell carcinoma

25-34

Review Article

35-46

Review Article Research Article

47-54

55-66

Review Article

67-72

Research Article

73-80

Review Article

81-94

Review Article

95-102

Review Article

103-116

Review Article

117-130

Review Article

131-136

Review Article

137-148

Research Article

149-162

Review Article

Thiazolidinediones as anti-cancer agents Gene therapy for esophageal cancer Experience in the management of 52 patients with soft tissue sarcoma. The results of a median follow-up of seven years Tumor acidity and malignancy: novel aspects in the design of anti-tumor therapy Subclavian artery infusion as induction and adjuvant chemotherapy for breast conserving treatment of primary breast cancer Treatment of malignant pleural mesothelioma Diagnosis and multimodality management of stage III non-small cell lung cancer Targeted agents in Non Small Cell Lung Cancer The molecular bases of cannabinoid action in cancer General review of polysaccharopeptides (PSP) from C. versicolor: Pharmacological and clinical studies Therapeutic modalities for intraocular lymphoma DNA methylation in cancer: techniques and preliminary evidence of hypermethylation in canine lymphoma Estrogen receptor " mediates the protective effects of estrogen in colon cancer

Marco Antonio Arap, Ariel Galapo Kann, Gustavo dos Santos Fernandes, Antonio Carlos Buzaid, Sami Arap, Fernando Cotait Maluf Carmelo Blanquicett, Jesse Roman, C. Michael Hart Jong Chul Park, Chulso Moon E. George Elias, Sally D. Brown, William Joel Culpepper II

Elisabetta Iessi, Maria Lucia Marino, Francesco Lozupone, Stefano Fais, Angelo De Milito Karl R. Aigner, Sabine Gailhofer, Emir Selak

David F. Heigener*, Martin Reck, Ulrich Gatzemeier Kevin Sullivan, Zujun Li, John Rescigno, Michael Fanucchi Elizabeth Blanchard Stefano Fogli*, Maria Cristina Breschi King-Fai Cheng, Ping-Chung Leung

Sapna Gangaputra, Robert Nussenblatt, Grace Levy-Clarke Jeffrey N. Bryan, Kristen H. Taylor, Carolyn J. Henry, Kimberly A. Selting, Farah Rahmatpanah, Michael R. Lewis, Charles W. Caldwell Maria Marino*, Paola Galluzzo

163-166

Research Article

167-176

Review Article

177-180

Review Article

181-186

Review Article

187-192

Research Article

193-212

Research Article

214-220

Research Article

221-226

Research Article

227-238

Review Article

239-246

Review Article

247-256

Review Article

257-262

Case Report

263-270

Review Article

271-274

Case Report

275-284

Review Article

285-302

Review Article

Prediction of very short survival in patients with brain metastases from non-small cell lung cancer Veterinary radiation oncology: technology, imaging, intervention and future applications Canine cancer genetics: transitional cell carcinoma in Scottish Terriers Chemoimmunotherapy for canine lymphoma: tumor vaccines and monoclonal antibodies The association of hematologic changes and histological responses to preoperative chemoradiotherapy in oral cancer patients Targeting critical disease pathways in male breast cancer: a pharmacogenomics approach Hypoxic abdominal perfusion for recurrent platin refractory ovarian cancer Veterinary pathologists achieve 80% agreement in application of WHO diagnoses to canine lymphoma Waldenström’s Macroglobulinemia: new therapeutic options Shared pathogenesis of human and canine tumors - an inextricable link between cancer and evolution Radioimmunotherapy of B-cell nonHodgkin’s lymphoma

Single split-course Cycle of CHOP Chemotherapy resulting in long-term disease-free Survival in a Patient with advanced and aggressive T-cell NonHodgkin´s Lymphoma Immunological concepts applied to pathologic diagnosis of proliferative diseases of the immune system Toxic epidermal necrolysis, an unusual adverse effect of Capecitabine Is complete remission an important therapeutic aim in Multiple Myeloma?

Search for oncogenic retroviruses in wild mice and man: Historical reflections

Carsten Nieder*, Reinhard Thamm, Sabrina T. Astner, Michael Molls Ira K. Gordon, Michael S. Kent

Steven E. Crow Steven E. Crow

Kenji Yamagata*, Kojiro Onizawa, Toru Yanagawa, Hiroshi Yoshida

Debmalya Barh*, Kaberi Das

Karl R. Aigner, Sabine Gailhofer, Monika Schwarz, Norbert Hilger Victor E. O Valli

Aldo M. Roccaro, Xavier Leleu, Simona Blotta, Nicholas Burwick, Angelo Vacca, Domenico Russo, Irene M. Ghobrial Jaime F. Modiano, Matthew Breen

Caroline Bodet-Milin, Michel Chérel, Alain Faivre-Chauvet, Manuel Bardiès, Steven Le Gouill, Thomas Gastinne, Jean-François Chatal, David M. Goldenberg, Françoise KraeberBodéré Sebastian Fetscher, Jan Schmielau, Annette Schmitt-Gräff

Peter F. Moore

Nelson Matos-Fernández, Yelitza Ruiz, Jorge Rodríguez, Luís Báez, William Cáceres, Víctor López-Pinto, Glenda González Michelle Limei Poon, Wee Joo Chng Murray Gardner

303-306

Research Article

307-310

Case Report

311-320

Review Article

321-326

Case Report

327-340

Review Article

341-354

Review Article

355-360

Research Article

361-366

Research Article

Histopathological pattern of Nonmelanoma skin cancer at King Fahd Hospital of the University in the Eastern Region of Saudi Arabia during the years 1983 to 2002 Acute tumoral bleeding in recurrent falx meningioma after stereotactic radiosurgery: a case report Immunotherapy and radioimmunotherapy for nonHodgkin's Lymphoma Precordial pain: an unusual primary presentation of chondrosarcoma

Guidelines for the management of side effects of bevacizumab in patients with colorectal cancer The multidisciplinary treatment of nonmetastatic pancreatic cancer: a review The study on relation of Human Papillomavirus with bladder transitional cell carcinoma PCR detection and high risk typing of human papillomavirus DNA in cervical cancer in Iranian women

Omar M. Alakloby, Iqbal A. Bukhari, Mohamed A. Shawarby

Feng-Wen Su, Tao-Chen Lee, Yu-Ling Ting, Yu-Jie Huang, Hsiu-Yu Huang, Hung-Chen Wang, Yu-Jun Lin Chrissa Sioka, Andreas Fotopoulos

Vitorino Modesto dos Santos, Fernando Henrique de Paula, Francisco Plรกcido de Sousa, Eula Leisle Braz Lima, Natalia Wanderley Paes Barbosa, Ricardo Carneiro Amarante Fairooz Kabbinavar, Amil Shah

Suzanne Russo, Roger Ove, A. William Blackstock Gita Eslami, Maryam Golshani, Mohammad Rakhsh!n, Fatemeh Fallah, Hossein Goudarzi Gita Eslami, Maryam Golshani, Mohammad Rakhshan, Fatemeh Fallah, Hossein Goudarzi, Afsoun Taghavi

Cancer Therapy Vol 6, page 1 Cancer Therapy Vol 6, 1-10, 2008

Palladium-based chemotherapeutic agents: Routes toward complexes with good antitumor activity Review Article

Adnan Salim Abu-Surrah1,*, Haitham H. Al-Sa’doni2, Maher Y. Abdalla3 1

Department of Chemistry, Hashemite University, P. O. Box 150459, Zarqa-13115, Jordan Department of Chemistry, Al al-Bayt University, Al-Mafraq, Jordan.

3 Department of biology and Biotechnology, Hashemite University, P. O. Box 150459, Zarqa-13115, Jordan 2

__________________________________________________________________________________ *Correspondence: Adnan Salim Abu-Surrah, Department of Chemistry, Hashemite University, P. O. Box 150459, Zarqa-13115, Jordan; Tel: +962 5 390 3333 (Ext. 4315); Fax: +962 5 390 3349; E-mail: asurrah@hu.edu.jo Key words: Palladium complexes, Anticancer agents, Cytotoxicity, Chiral ligands Abbreviations: diethyl-2- quinolmethylphosphonate, (2-dqmp); mercaptopyridines, (MP); monoethyl-2-quinolmethylphosphonate, (2Hmqmp); structure-activity relationships, (SAR) Received: 21 November 2007; Revised: 18 December 2007 Accepted: 18 December 2007; electronically published: January 2008

Summary Chemical-, pharmacological-, and clinical-research on anticancer coordination complexes has yielded remarkable anticancer agents such as cisplatin, carboplatin, and oxaliplatin. Since the discovery of cisplatin, the development of analogue complexes has been an empirical task. Studies have shown that the range of platinum complexes with antitumor activity is not restricted to the structural analogues of cisplatin. The established structure-activity rules have been broken: active platinum complexes without NH groups, trans-platinum complexes, multinuclear complexes, cationic complexes, and several classes of palladium(II) complexes have emerged. The foremost target of most research groups was to find a convenient anticancer drug that can be used efficiently for the treatment of human tumors. This study gives an up to date overview of the anticancer chemistry of palladium compounds with an emphasis on the new strategies used in the development of new palladium antitumor agents.

different from that of cisplatin and its analogues. Their pattern of antitumor activity is also altered with respect to cisplatin. Comparison of common features and differences between different classes may point to some rules for the rational design of complexes with a different spectrum of clinical activity to cisplatin and activity to cisplatinresistant tumors.

The significant similarity between the coordination chemistry of palladium(II) and platinum(II) compounds has advocated studies of Pd(II) complexes as antitumor drugs (Rau et al, 1996). A key factor that might explain why platinum is most useful comes from the ligandexchange kinetics. The hydrolysis in palladium complexes is too rapid: 105 times faster than for their corresponding platinum analogues. They dissociate readily in solution leading to very reactive species that are unable to reach their pharmacological targets.

Compared to cisplatin, the corresponding cispalladium, cis-[Pd(NH3)2Cl2] and cis-[Pd(DACH)Cl2]

I. Introduction Cis-diaminedichloroplatinum(II), [cis-(NH3)2PtCl2], clinically called cisplatin is one of the most successful anticancer compound (Rosenberg et al, 1969). After the discovery of its activity, thousands of platinum complexes have been synthesized and evaluated for their anticancer activity. Research in the field of platinum-based cancer chemotherapy showed that cisplatin and its analogous compounds exhibit very similar patterns of antitumor sensitivity and susceptibility to resistance which means that most of them produce identical adducts with DNA. The determining factors of cytotoxicity thus do not always follow the original structure-activity relationships (SAR).

Possibly, the new clinically useful metal based anticancer agents should have novel structures unrelated to those agents assigned to platinum complexes. Therefore, several unconventional complexes that violate the SAR rules have been synthesized and evaluated (Abu-Surrah, 2007). The mechanism of action of nonclassical complexes is

1

Abu-Surrah et al: Palladium-based chemotherapeutic agents dqmp)2PdCl2] (1, Figure 1). The complexes of the diester 2dqmp were found to be more active than those of the monoesterbased ligand (2-Hmqmp). This may partly be ascribed to the greater leaving activity of the halogen ligands in the complex bearing the 2-dqmp ligand and to their greater lipophilicity or solubility.

(DACH: (1R,2R)-(–)-1,2-diaminecyclohexane) do not show antitumoral activity. It is well known that the former undergoes an inactive trans-conformation and that the two compounds hydrolyze very fast assuming that they interact in vivo with a lot of molecules particularly proteins preventing them to reach the DNA, their pharmalogical target (Butour et al, 1997, Wimmer, et al, 1989, Zhao, et al, 1999). This considerably higher activity of palladium complexes implies that if an antitumor palladium drug is to be developed, it must somehow be stabilized by a strongly coordinated nitrogen ligand and a suitable leaving group. If this group is reasonably non labile, the drug can maintain its structural integrity in vivo long enough.

Several review articles have appeared during recent years dealing with platinum-based anticancer agents (Suzanne et al, 1987; Fuertes et al, 2003; Reedijk, 2003; Wang et al 2005, Kostova, 2006). The biological mechanism of palladium(II) complexes with an emphasis on cyclopalladated complexes has recently been reviewed (Caires, 2007). In this review, the progress in the field of anticancer chemistry of palladium-based transition metal complexes during the last 10 years will be highlighted.

Methodologies for application of bulky aromatic or aliphatic nitrogen ligands, chiral organic moieties, chelates containing other donor atoms than nitrogen, and multinuclear palladium complexes will be discussed. The complexes that illustrated the prominent strategies utilized in the development of anticancer palladium-based agents will also be presented.

The synthesis and cytotoxicity evaluation of some trans-[(L)2Pd(X)2] complexes (2) (L = N,N-dimethyl-Oethylthiocarbamate: DMTC or N-methyl-Oethylthiocarbamate: MTC, X = Cl, Br) were reported (Furlani et al, 1996). Other palladium complexes based on 2-mercaptopyridines (MP) were also prepared. The [(MP)3Pd(Br)]+. Br! (3) is of potential therapeutic use since it has lower IC50 values on LoVo cell lines than cisplatin and around the same as its Pt(II) analogue (Carrara et al, 1996).

Palladium(II) complexes with alkyl phosphonates ligands derived from aniline and quinoline were reported.

Most of the aniline compounds (e.g. 4) showed cytotoxicity in vitro against animal and human tumor cell lines (Curic et al, 1996).

Complexes with naturally occurring compounds have also been utilized. The palladium complex which contains the bulky nitrogen ligand harmine (7-methoxy-1-methyl9H-pyrido[3,4-b]indole, trans-[Pd(harmine)(DMSO)Cl2] (5, Figure 1) exhibits a greater cytotoxic activity against P388, L1210 and K562 cell lines than cisplatin (Al-Allaf et al, 1998).

Recently, we reported about the synthesis and molecular structure of a new enantiometrically pure, chiral trans-palladium(II) complex, trans-[Pd{(R)-(+)-bornylamine}2Cl2] (6) (Figure 1) that bears the bulky amine ligand R-(+)-bornylamine (endo-(1R)- 1,7,7-trimethylbicyclo[2-2-1]-heptan-2-amine). The complex showed similar antitumor activity against HeLa cells when compared with the activity of the standard references, cisplatin, carboplatin and oxaliplatin (Abu-Surrah et al, 2002).

A trans-palladium complex of the general formula, trans-[Pd(L)2Cl2] (L = 2-chloro-6-[(2-methoxybenzyl)amino]-9-isopropylpurine) has been reported (TrĂĄvnĂ­"ek et al, 2007). The complex has been tested in vitro for its cytotoxicity against malignant melanoma (G361) cell lines. Promising in vitro cytotoxic effect has been found (IC50 = 15 #M).

Palladium(II) complexes of the form: trans-PdCl2L2, where L=3-hydroxypyridine, 2-hydroxypyridine and 4hydroxypyridine respectively have been investigated for antitumour activity against ovarian cancer cell lines: A2780, A2780cisR and A2780ZD0473R (Huq et al, 2007). The compounds were found to be less active than cisplatin but they are often found to be more active against the resistant cell lines than the parent cell line. The 2-hydroxypyridinebased complex was found to be most active against the three cell lines.

II. Palladium anticancer chemistry Numerous palladium complexes with promising activity against tumor cell lines have been synthesized (Graham et al, 1979; Rau et al, 1996). In general, the strategies that have been applied to design these agents were on the window of reactivity usually employed for the potential platinum antitumor drugs. Different types of monodentate ligands were applied in the synthesis of these complexes. In addition, several research groups have focused on the preparation of Pd(II) complexes bearing bidentate ligands as a way to stabilize these compounds and to prevent any possible cis-trans isomerism (Mansuri et al, 1992).

A. Trans-palladium(II) complexes Relatively bulky monodentate ligands have been utilized to produce the complexes of this family. Due to the steric effect that results from the bulk on the donor atoms, these ligands could minimize any possible cis-trans isomerism and insure the direct separation of the desired trans- Pd isomers (Abu-Surrah et al, 2002). In general, research results indicated that most of the trans-palladium complexes showed a better activity than the cisplatinum isomers and superior activity than that of the cispalladium isomers. More importantly, they showed activities equal to (or superior than) those of cisplatin, carboplatin, and oxaliplatin (the anti-cancer drugs in clinical use) in vitro.

A comparative study on antitumor activity was carried out between the Pd(II) dihalide complexes of monoethyl-2quinolmethylphosphonate (2-Hmqmp) and diethyl-2quinolmethylphosphonate (2-dqmp) (Tusek-Bozic et al, 1991).

The diester ligand has two potential donors, the N from quinoline and the O from phosphoryl giving the complex [trans-(2-

B. Palladium(II) complexes containing bidentate nitrogen ligands Navarro-Ranninger and colleagues reported the synthesis of square planar dichloro palladium(II) complexes with spermidine and spermine ligands

2

Cancer Therapy Vol 6, page 3 (Navarro-Ranninger et al, 1993). These types of chelating ligands have been used because of their relevant biological activity; they are involved in proliferation and differentiation of cells in DNA replication and membrane stabilization. Complexes of spermidine (7, Figure 2) give values of IC50 similar to cisplatin, whereas those of spermine have low antiproliferative activity.

Ethylendiamine-based palladium(II) complexes with pyridine (8, Figure 2) or its derivatives were also reported (Zhao et al, 1999). The increase of the electron donor properties of the substituents firstly led to an increase of the donor strength of the coordinated pyridines, which directly led to the increase of the cytotoxic activity of the palladium complexes.

An alternative method to the synthesis of the enantiomerically pure DACH-based palladium(II) complexes (DACH: (1R,2R)-(–)-1,2-diaminecyclohexane) was utilized (Abu-Surrah et al, 2002). In this method the desired organic bidentate ligand was allowed to react with [cis-Pd(PhNC)2Cl2], a palladium(II) starting material that is soluble in most organic solvents, in CH2Cl2 at 25°C. Following this procedure, the nucleophilic substitution

reaction of the complex [cis-Pd(PhNC)2Cl2] with (1R,2R)(–)-1,2-diaminecyclohexane afforded the square planar Pd(II) complex [(1R,2R)-(–)-(DACH)PdCl2] (9) in a high yield (Figure 3).The corresponding cationic, aqua complex, [(DACH)Pd(H2O)2]2+. 2NO3! (10) and the oxalate complex (oxalipalladium) [(DACH)Pd(C2O4)] (11) have also been isolated and characterized (Abu-Surrah et al, 2003).

A new approach to increase the stability of the palladium(II) complexes by forming two chelate rings around the central atom was applied. L-cysteine derived ligands such as py-CH2-accys (12, Figure 4) (accys: Nacetyl-S-methylene-2-(2-pyridine)-L-cysteine) have been applied (Rau et al, 1998).

The S,N-chelating mode of these ligands is of importance, since only the side chain of the amino acid is involved in metal coordination, whereas the amino acid function remains uncoordinated, leaving this functional group accessible for the attachment of other amino acid or peptides. It has been found that the reactivity of these palladium complexes compete with some platinum(II) complexes.

CH2 -PO(OEt) 2

OCON(CH3 ) 2 S

Cl

N Pd

Cl

Cl

N

CH 3CH2

CH2 CH3

(1)

PO(OEt) 2

N

N

Cl

Pd

SH Br

S

N (3)

OCON(CH3 )2

(OEt) 2OP CH2

Ph CH

Pd

HS

(2)

HS

CH3 CH3 CH3

NH

Cl N

CH3 O

Pd N

N

Pd

H

Cl

NH2

Cl

N

S

Cl

CH3

CH3 (4)

(5)

Cl

Pd NH 2

O (6)

Cl CH3

CH3 CH3

Figure 1. Structures of some trans-palladium(II) complexes (1-6).

+ Cl NH3

NH

NH2

(7)

(NO3)

Pd

Pd NH2

Cl

Cl

NH2

N

(8)

3

Figure 2. Palladium(II) complexes with ethylenediamine nitrogen ligand (7 and 8).

Abu-Surrah et al: Palladium-based chemotherapeutic agents

* *

* *

NH2

Cl

comparison among [(bipy)Pd(NO3)2] (14), [(AMP)Pd(NO3)2], [(AEP)Pd(NO3)2], [(DACH)Pd(Meorot)] (bipy = 2,2'-bipyridyl, AMP = 2-aminometylpyridine, AEP = 2-aminoethylpyridine, Meorot = 3methylorotate) showed that only [(DACH)Pd(Meorot)] (15) was active, giving a high activity for sarcoma 180 but a low one against P388 leukemia. Similarly, [(DACH)Pd(5-fluroorot)] reported later (Butour et al, 1997), displayed significant antitumor activity. These strong chelating ligands replacing chloro or nitro ligands induce a reduction in the rate of hydrolysis.

2,2'-dipyridylamine-based palladium(II) complexes containing glycine or L-alanine have been prepared and evaluated (Paul et al, 1993). The alanine based complex (16, Figure 4) showed better cytotoxicity against P388 lymphocytic leukemia cells than the glycine based one.

The aromatic ligands such as 1,10-phenanthroline, which is one of the most used ligands in coordination chemistry, has been utilized in the field of antitumortransition metal chemistry. Its planar nature enables its participation as a DNA intercalator. Several derivatives of it were prepared and used as tetradentate ligands. The activities of [(N,N-dialkyl-1,10-phenanthroline-2,9dimathanamine)Pd(II)] (17) (alkyl: Me, Ethyl, propyl, cyclohexyl) are significantly dependent on the nature of the alkyl substituents. The complexes bearing the bulkiest groups showed lower IC50 values than cisplatin (Zhao et al, 1998). Palladium(II) complexes containing S-donors (diethyldithiocarbamate: ddtc) in addition to the N-N ligands (bipyridine, phenanthroline, and DACH) have also been investigated (Mital et al, 1989). The most active were the bipyridine and phenanthroline-based complexes (18, Figure 4).

Pd Cl

NH2

(9)

NH2

OH2 Pd

(NO3)2

OH2

NH2 (10)

O * *

NH2

O

C

O

C

Pd NH2

O

(11)

Figure 3. Palladium(II) complexes with (1R,2R)-(–)-1,2diaminecyclohexane (DACH) (9-11).

Palladium compounds bearing two chelating N-N and O-O ligands were prepared (Mansuri-Torshizi et al, 1991). The N-N ligand did not influence the activity but the oxygen coordinated leaving group did. Selenite complexes were invariably better cytotoxic agents than tellurite complexes and cisplatin. The complex [bipy)Pd(SeO3) (13) was found to bind to DNA through a coordinate covalent bond.

The cytotoxic activity of palladium complexes bearing nitrate (NO3) in addition to a bidentate nitrogen ligand (Wimmer et al, 1989) was investigated. A

NH 2

(NO 3)2

N

N

Pd NH 2

Pd S

N

O

Pd

SeO O

N

ONO 2

* *

ONO 2

N

Pd O

NH 2 O

O

N H

(14)

(13)

COOH

O

O

NH 2

(15)

N

O

CH 3

(12) H N N

(Cl)2

(Cl) N

N

N

Pd NH 2

N

Pd O O

R

(16)

S Pd

NH

NH

C H3

C H3

(17)

S

N

(18)

Figure 4. Palladium(II) complexes containing different types of nitrogen ligands (12-18).

4

C N( CH 2C H 3)2

Cancer Therapy Vol 6, page 5 This was related to the flat structure of the aromatic N-N ligands and the more hydrophobic nature of the complex. Bipy and phen complexes showed IC50 values lower than cisplatin against P388 lymphocytic leukemia cells.

C. Palladium(II) phosphine ligands

complexes

(mercapto or amino) have been reported by Khan and colleagues in 1991. Methionene coordinates to Pd(II) through amino nitrogen and sulfur, thus leaving a carboxylic group free. It has been found that the complex [(methionine)Pd(2-merpy)Cl]+. Cl! (21, Figure 6) has in vitro IC50 value lower than 10 Âľg/ml, so it could act as a potential antitumor agent.

Heterocyclic thiosemicarbazones are of considerable interest due to their potential beneficial antineoplastic activity. It is assumed that the presence of some metallic ions may enhance their antitumor activity due to their ability to form chelates. The phenyl acetaldehyde thiosemicarbazone-based palladium complex (22, Figure 6) has been found to display an enhanced in vitro activity compared to its platinum analogue (Quiroga et al, 1998).

In addition, this complex is active in cisplatin resistant cell lines.

Other thiosemicarbazide derivatives have also been studied. [(Benzyl)Pd{bis(thiosemicarbazonate)}] (23, Figure 6) showed IC50 values in a concentration range similar to that of cisplatin and a notable activity in cisplatin-resistant cell lines (Matesanz, 1999).

Palladium complexes with 2-benzoylpyridine derived thiosemicarbazones with good antitumor activity were also reported (Rebolledo, et al, 2005).

Recently, the antitumor functions and mechanisms of a 1,2-naphthoquinone-2-thiosemi-carbazone-based palladium(II) complex were investigated against MCF-7 human breast cancer cells (Chen et al, 2004). The results revealed that the complex is an effective antitumor agent. The study of mechanism of action showed that the metal complex can only stabilize the single-strand nicked DNA, but not double-strand breakage intermediates.

The synthesis of a palladium(II) complex of the general formula [Pd(N-O)2] (N-O: 3-ethanimidoyl-2methoxy-2H-1,2-benzoxa-phospinin-4-ol-2-oxide) has also been reported (Budzisz, et al, 2004). The cytotoxic activity of this complex against the human leukemia cell lines, HL-60 and NALM-6 showed that the effects exhibited by this complex was comparable to those reported for cisplatin and carboplatin.

bearing

Some palladium(II) complexes showed a discrete antitumor activity in vitro compared to the platinum based drugs because of their extremely high lability in biological fluids (Navarro-Ranninger et al, 1993). Therefore, it has been suggested that the organometallic biphosphine-based cyclopalladated complexes that are more stable and less toxic could have a more specific antitumor activity in vivo (Caires et al, 1999). Some cyclopalladated complexs based on biphosphine ligands (19 and 20, Figure 5) have been prepared and investigated for their antitumor activity in a syngeneic B16F10 murine melanoma model (Rodrigues et al, 2003). The ionic complex (19) caused 100% tumor cell death at very low concentration (< 1.25 ÂľM).

Palladium and a broad series of group VIII transition metal complexes containing bidentate phosphine ligands of the general formula [L2 MXm]n+ nX! [L = Ph2P-A-PPh2, A = (CH2)2, (CH2)3 or cis-CH = CH; M = Fe, Co, Rh, Ir, Ni, Pd; X = Cl, Br, I, NO3, ClO4, CF3SO3; m = 0-2; n = 03] were prepared and evaluated for in vitro cytotoxicity, in vivo antitumor activity in murine tumor model and mechanism of action. The mechanism of these complexes appears different from that of cisplatin based on effects on DNA and lack of cross resistance with L1210/DDP, a line of L1210 murine leukemia resistant to cisplatin (Shurig et al, 1989).

Recently, it has been reported on a new palladium(II) complex bearing a bidentate P-N ligand which was formed via the condensation of 2-(diphenylphosphino)benzaldehyde and ethyl hydrazinoacetate (Male$evi% et al, 2006). The cytotoxic activity of the complex was similar to that of cisplatin.

D. Palladium(II) complexes mixed donor atom ligands

bearing

Palladium(II) complexes with mixed nitrogen-sulfur ligands such as methionine and substituted pyrimidines

(Cl) P

P

Pd

Pd P

CH3

P

N CH 3

Cl

N CH3 CH 3

CH3

(19)

(20)

Figure 5. Palladium(II) complexes bearing 1,2-bis(diphenylphosphino)ethane (dppe) (19 and 20).

5

Cl

Abu-Surrah et al: Palladium-based chemotherapeutic agents

CH3

NH2

(Cl)

Cl

S Pd COOH

NH2 HS

NH2

N Cl

S

N

S

Pd

HN

Pd

N

N

Cl

S

N N

(21)

(22)

NH2

(23)

Figure 6. Palladium(II) complexes with mixed donor ligands (21-23).

the putrescine complex is much more active than the spermidine one (Navarro-Ranninger et al, 1993).

Zhao and colleagues studied dinuclear palladium complexes containing two functional [Pd(en)(pyridine)Cl]+ units bridged by Se or S (Zhao et al, 1999). The complexes are water soluble. The Se-bridged Pd(II) dimer (26) has a lower IC50 than the S analogue or cisplatin against the HCT8 cancer cells line.

E. Multinuclear Palladium(II) complexes Navarro-Raninger and colleagues reported in 1993 that the synthesis of putrescine (24, Figure 7) and spermine (25)-based dinuclear palladium complexes. The complex (24) is a coordination complex of a dimer nature.

In 25, the 4 amino groups of the spermine coordinate to two cis-Pd-centers. The cytotoxicity results showed that

Cl

Cl Pd

Cl Pd Cl

NH2

NH2

NH2

NH2

H2N

Cl Pd

NH

NH

NH2

Pd Cl

Cl

Cl

(25)

(24) NH2

Cl Pd

NH2

N

Pd

(26)

Cl

2

Pd N CH 3

Pt H3N

Pd

CH3

NH3

Cl

Cl

Cl (27) (CH2) 4 NH2 NH2 OH Pt H3N N

H3N Pd

NH2

H2N

CH 3 CH3 CH3 N PPh

PPh 2 CH3

(NO3) 2

H 2N

N

Se

NH2

(CH2 )4 (28) Figure 7. Multinuclear palladium-based complexes (24-28).

6

NH3 Cl

(Cl)4

Cancer Therapy Vol 6, page 7 Dinuclear cyclopalladated organometallic complexes containing biphosphine ligands were also reported by Rodrigues et al. (Rodrigues et al, 2003). The dimer Pd(II) complex [Pd2(S(-)C2, N-dmpa)2(µ-dppe)Cl2] (27) (dmpa = enantiomer S(-) of N,N-dimethyl-1-phenylethylamine; dppe = 1,2-bis(diphenylphosphino)ethane) showed to be the most active in vivo compared to the corresponding mononuclear complexes. It delays tumor growth and prolongs animal survival.

Eddings and colleagues reported the first 2-cyano-2isonitroso-N-morpholinylacetamide (HMCO) based dimeric palladium (II) complex, [Pd(MCO)]2. (Eddings et al, 2004) The complex was tested in vitro on antiproliferating activity using human cervical cancer HeLa cell lines, and cisplatin as a positive control substance. It is found to be active compound inflicting death on 28% of the cells, with 55% value for the cisplatin under the same conditions.

Giovagnini and colleagues have reported the synthesis and in vitro cytotoxic activity of new palladium(II) derivatives of methylsarcosinedithiocarbamate and its S-methyl ester (Giovagnini et al, 2005).

The biological activity of these compounds, as determined by growth inhibition and apoptosis induction, has been investigated in both human leukemic promyelocites HL60 and human squamous cervical adenocarcinoma HeLa cell lines, and their activity has been compared to the wellknown platinum-based anticancer agent cisplatin. On the basis of these experimental results, [Pd(MSDT)X]n (MSDT = methylsarcosinedithiocarbamate; X = Cl, Br) complexes show a strong dose-dependent growth inhibition of both HL60 and HeLa cells, with IC50 values slightly higher than those recorded for cisplatin.

A trinuclear palladium complex has also been reported. The complex [{trans-PtCl(NH3)}2-#-{transPd(NH3)(2-hydroxypyridine)-(H2N(CH2)6NH2)2]4+.

4Cl! (28, Figure 7) was found to exhibit significant anticancer activity against the cell lines A2780 A2780cisR and A2780 (Cheng et al, 2006).

The compound is believed to form a range of interstrand GG adducts with duplex DNA that induces global changes in the DNA conformation, unlike cisplatin and ZD0473 ([cis-(2-methylpyridine)(ammine)dichloroplatinum(II)]) that form mainly intrastrand adducts that induces a local kink in a DNA strand.

potential antitumour palladium complexes have been emerged. The foremost target of most research groups was to find a convenient anticancer drug that can be used efficiently for the treatment of human tumors. The most profitable one could be that of good solubility in water and the ability to transport (through the membranes), fortitude in the cell, binding to the DNA, and eventually excretion from the body with minimum side effects.

Taking into consideration the similarities between platinum and palladium, the role of thiol compounds in drug resistance should thoroughly be studied. It has been shown that cellular thiols can sequester cisplatin, leading to a reduction in the levels of cisplatin–DNA damage.

Acknowledgment Financial support by the Hashemite University is gratefully acknowledged.

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Zhao G, Lin H, Yu P, Sun H, Zhu S, Su X, Chen Y (1999) Ethylenediamine-palladium(II) complexes with pyridine and its derivatives: synthesis, molecular structure and initial antitumor studies. J Inorg Biochem. 73, 145-149.

Zhao G, Sun H, Lin H, Zhu S, Su X, Chen Y (1998) Palladium(II) complexes with N,N -Dialkyl-1,10phenanthroline-2,9-dimathanamine: synthesis, characterization, and cytotoxic activity. J Inorg Biochem 72, 173-177.

Zhao G, Lin H, Zhu S, Sun H, Chen Y (1998) Dinuclear palladium(II) complexes containing two monofunctional [Pd(en)(pyridine)Cl]+ units bridged by Se or S. Synthesis, characterization, cytotoxicity and kinetic studies of DNAbinding. J Inorg Biochem 70, 219-226.

From left to right: Maher Abdalla, Adnan Abu-Surrah, Haitham Al-Sa’doni

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Abu-Surrah et al: Palladium-based chemotherapeutic agents

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Cancer Therapy Vol 6, page 11 Cancer Therapy Vol 6, 11-24, 2008

New directions in the management of renal cell carcinoma Review Article

Marco Antonio Arap1, Ariel Galapo Kann2, Gustavo dos Santos Fernandes2, Antonio Carlos Buzaid2, Sami Arap1, Fernando Cotait Maluf2,* 1 2

Department of Urology, University of Sao Paulo Medical School, São Paulo, Brazil Oncology Center, Sirio Libanês Hospital, São Paulo, Brazil

__________________________________________________________________________________ *Correspondence: Fernando Cotait Maluf, Rua Adma Jafet 91 CEP 01308-050, São Paulo, São Paulo, Brazil; Tel/Fax: 55-11-31550210; e-mail: maluffc@uol.com.br Key words: Molecular target therapy, Motzer criteria, good, poor and intermediate prognosis, RCC patients, novel agents, Adjuvant therapy, cytoreductive nephrectomy Abbreviations: central nervous system, (CNS); Eastern Cooperative Oncology Group, (ECOG); interleukin 6, (IL-6); mammalian target of rapamycin, (mTOR); platelet-derived growth factor, (PDGF); Renal clear cell carcinoma, (RCCC); vascular endothelial growth factor, (VEGF); von-Hippel-Lindau, (VHL) Received: 29 October 2007; Revised: 24 December 2007 Accepted: 31 December 2007; electronically published: January 2008

Summary Renal cell carcinoma represents nearly 3% of all cancers, frequently affecting patients at the age of 50 to 70 years.

Few treatments options were available until recently for metastatic renal cell carcinoma. The 5-year median survival for those patients was estimated to be less than 10%. This review explored the data of the most relevant trials focused on new approaches with novel agents with several mechanisms of action such as: sunitinib, sorafenib, bevacizumab, temsirolimus and their combinations with traditional agents. We describe mechanism of action, activity and toxicity profile of all those agents as well as administration schedule. The surgical treatment was also revised, highlighting the data about nephrectomy in metastatic disease.

outcome in this aggressive disease that is generally chemo and immunotherapeutic-resistant.

A relevant knowledge was provided by a study that showed that there is a similar genetic profile between sporadic renal clear cell carcinoma (non inherited and responsible for 60 to 70% of all renal tumors) and RCC secondary to the von-Hippel-Lindau (VHL) syndrome (hereditary disease characterized by vascular tumors including RCC representing 1% to 4% of all renal tumors) (Kondo et al, 2001, 2002). In the VHL syndrome, the mutation, deletion or chemical modifications of the VHL gene lead to lower protein levels or even inactivation of this protein with consequent higher levels of hypoxia inductible factor alfa. As a result, the expression of growth factors such as vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) are markedly increased. Both VEGF and PDGF are intrinsically related to the promotion of angiogenesis, cancer invasiveness, and metastasis. Supporting prior findings, recent studies suggest that more than 60% of sporadic RCC have, as a critical point in their pathogenesis, somatically acquired mutations or methylation of the VHL gene (Kim WY et al, 2004), suggesting that may exist link between the VHL

I. Introduction Renal cell carcinoma represents nearly 3% of all cancers, frequently affecting patients at the age of 50 to 70 years. Renal clear cell carcinoma (RCCC) represents 60 to 70% of primary malignant renal tumors. In 2006, almost 35710 people in the United States developed renal cell carcinoma and 12480 died because of progression of disease (Cancer facts and figures, 1996). Epidemiologic data shows that in the last two decades the incidence of renal tumors has increased 2% to 4% each year (Kosary et al, 1993).

Few treatments options were available until recently for metastatic renal cell carcinoma. The 5-year median survival for those patients was estimated to be less than 10%. The objective response rate obtained with chemotherapy was only 5%. Higher objective responses were reported with interferon-! (objective response rate of 12%) as well as with high-dose interleukin-2 (objective response rate of 19%). After failure to prior cytokine based-therapy, the overall median survival was only 10 to 13 months (Motzer et al, 2004). Therefore, newer therapies were clearly necessary in order to improve

11

Arap et al: New directions in the management of renal cell carcinoma syndrome and sporadic RCC. In this review article we discuss the mechanisms of action, safety and role of novel agents both in the first-line and salvage, setting as well as the role of surgery in the treatment of advanced renal carcinoma (Schemes 1-3).

II. Molecular target therapy previously untreated patients

acceptable toxicity profile, easy schedule, and antitumoral activity. The use of sunitinib in patients with central nervous system (CNS) metastases was sometimes avoided because the potential risk of bleeding. However, this year one retrospective study suggested that anti-VEGF agents including sunitinib (13 patients) and sorafenib (10 patients) does not increase the risk of either intratumoral bleeding or any CNS bleeding when a local treatment, involving particularly radiation, was previously administered (Unnithan et al, 2007). Recently, two randomized phase III studies (Escudier et al, 2007b; Motzer et al, 2007b) and one randomized phase II study (Yang et al, 2003b) have been conducted comparing agents capable of VEGF inhibition (experimental arm) versus interferon-! (control arm) in metastatic renal cell

in

A. Patients with good or intermediate prognosis according to Motzer criteria Sunitinib is an oral drug that inhibits VEGF (types 13) and PDGF (! e !) receptors, as well as other tyrosinekinase proteins. Sunitinib according to a phase I study (Faivre et al, 2006), Sunitinib was associated with an

Scheme 1. Management of metastatic renal cell carcinoma regarding the role of surgery.

Scheme 2. Management of metastatic renal cell carcinoma in the first-line setting.

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Cancer Therapy Vol 6, page 13

Scheme 3. Management of metastatic renal cell carcinoma in the second-line setting.

carcinoma patients with good or intermediate prognosis according to Motzer criteria. This muticenter phase III study conducted by Motzer and colleagues included 750 patients with metastatic or unresectable renal cell carcinoma and no prior systemic treatment (Motzer et al, 2007b). Patients were randomized to receive interferon-! or sunitinib. Treatment with subcutaneous interferon-! was administered at the initial dose of 3MU three times a week (tiw) with drug escalation, if no toxicity, until 9MU tiw. Treatment with oral sunitinib was given daily at the dose of 50mg for four consecutive weeks followed by two weeks of rest with cycles administered every six weeks.

Patients were randomly assigned according to LDH (1.5 " versus > 1.5 x normal superior limits), Eastern Cooperative Oncology Group (ECOG) performance status (0 versus 1), presence or absence of prior nephrectomy.

The primary end point of this study, with an statistical power of 90%, was to demonstrate if the experimental arm would increase progression-free survival by 35% over to the control arm (from 4.6 to 6.2 months). Secondary endpoints included: overall survival, response rate and toxicity. The efficacy and safety data was evaluated by an independent committee in addition to the investigators.

Patient characteristics were similar in both arms. Nearly 90% of the patients had prior nephrectomy, 14% had prior radiotherapy, 60% had ECOG 0, and 75% of patients had lung involvement. According to Motzer criteria nearly 36% of patients had good prognostic factors, 58%

intermediate and only 6% had poor prognostic factors.

Patients assigned to sunitinib had superior response rates (31% versus 6%, p < 0.000001) as well as progression-free survival rates (11 months versus 5 months, HR 0.41, 95% CI, 0.32-0.53, p < 0.000001) compared to the control arm (Figure 1). Also, patients on sunitinib had a trend towards improvement in overall survival, though the OS has not been reached in either groups (HR 0.65, 95% CI, 0.440.94, p = 0.02). Subgroup analysis revealed an advantage in progression-free survival both in good (not reached versus 8 months, HR 0.37, 95% CI, 0.21-0.64) and intermediate (11 months versus 4 months, HR 0.39, 95% CI, 0.28-0.54) prognostic groups treated with sunitinib.

Update of these results confirmed prior findings (Motzer et al, 2007a). Sunitinib was associated with more frequent grade III and IV toxicities including diarrhea (5%), erythrodysesthesia (5%), fatigue (7%) and hypertension (8%). On the other hand, interferon-! was associated with more often grade III and IV fatigue (11%). It is important to recognize that sunitinib has been also associated with hypothyroidism. In one series fifteen of 42 patients (36%) who were receiving sunitinib developed clinically significant hypothyroidism during the course of treatment.

Abnormal results on blood tests indicating at least some level of hypothyroidism occurred in a total of 26 of 42 patients (62%). The longer sunitinib was administered, the greater was the chance of developing suppression of thyroid function (Desai et al, 2006).

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Arap et al: New directions in the management of renal cell carcinoma Figure 1. Kaplan-Meier analysis of progression-free survival of sunitinib and interferon-#.

Another study reported similar results (12 out of 55 patients) (Shaheen et al, 2006). Hypothyroidism can contribute to fatigue associated with sunitinib. Therefore, it is advised to monitor thyroid hormone levels in patients treated with this agent.

A randomized phase II trial (Yang et al, 2003b), including 116 previously treated patients evaluated the impact on progression-free survival of two different schedules of bevacizumab administered intravenously at 3mg/kg and 10mg/kg every two weeks in comparison to placebo. This trial demonstrated an advantage on progression-free survival rates for patients treated with high-dose bevacizumab compared to placebo (4.8 months versus 2.5 months, p < 0.001). More recently a phase III trial (Escudier et al, 2007a) accrued 649 metastatic renal cell carcinoma patients (including patients with predominant clear-cell component) not exposed to prior systemic therapy and who had prior nephrectomy, 322 patients were randomized to subcutaneous interferon-# (9MUI tiw) and 327 were assigned to receive interferon-# (9MUI tiw) plus bevacizumab (10mg/kg every 2 weeks).

Patients were stratified according to registration center and Motzer prognostic criteria. Primary end point of this study was overall survival. The aim of this study was to evaluate if the experimental arm would increase overall survival over interferon-# from 13 to 17 months with a statistical power of 80% (p < 0.05). Secondary end points included progression-free survival, time to progression, response rate and toxicity. Exclusion criteria included CNS involvement, cord compression and use of anti-coagulants.

Both arms were well balanced. Progression-free survival was higher in the interferon-# plus bevacizumab arm (10.2 versus 5.4 months, HR 0.63, p < 0.0001). A trend toward improved overall survival was observed with the addition of bevacizumab to interferon-# (p=0.0670) An advantage in progression-free survival was observed in almost all subgroups including those with favorable (12.9 months versus 7.6 months, HR 0.60, p = 0.004) and intermediate prognostic score (10.2 months versus 4.5 months, HR 0.55, p < 0.0001). Nevertheless, the addition of bevacizumab appeared not to favorably impact patients

with poor prognostic features (2.2 months versus 2.1 months, HR 0.81, p < 0.45). The addition of bevacizumab to interferon-# was associated with an advantage in progression-free survival regardless of age (<40 versus 4064 versus $ 65), gender and number of metastatic sites (" 2 versus > 2). Patients receiving the combination regimen had more grade III/IV toxicity (60%) when compared to the control group (45%) including fatigue (23% versus 15%), proteinuria (6.5% versus 0%), hypertension, (3.9% versus 0.7%) and hemorrhage (3.3% versus 0.3%). Despite that the combination arm was considered generally well tolerated. Based on these results, both sunitinib alone and bevacizumab plus interferon-# can be considered standard first-line therapy options in patients with unresectable or metastatic RCC with favorable or intermediate prognostic factors. Treatment costs, schedule profile, and patientâ&#x20AC;&#x2122;s and physicianâ&#x20AC;&#x2122;s preferences must influence the regimen of choice between these two regimens. Is important to mention that the combination of bevacizumab and interferon-# has not yet been approved for the Food and Drug Administration, limiting the use of this therapy in some countries including the United States.

Sorafenib is a bi-aryl urea orally active characterized

by Raf-1 serine-threonine kinase inhibition wich has inhibitory properties against VEGF (type 1-3) and PDGF receptors (! e !) (Mancuso et al, 2006). The activity of sorafenib was demonstrated in a phase III study including patients who failed prior systemic therapy (Escudier et al, 2007b). A randomized phase II study, including 189 patients, compared subcutaneous interferon-! at dose of 9MU tiw to oral sorafenib at the continuous dose of 400mg twice a day (bid) as first therapeutic line for RCC line. Primary end point included evaluation and comparison of progression-free survival between the two arms. Patient characteristics were similar in both arms.

Despite the fact that sorafenib arm had superior quality of life outcomes over interferon-! (p = 0.02), there were no differences in response rates (5% versus 9%) and progression-free survival (5.7 months versus 5.6 months, HR 0.88, 95% CI, 0.61-1.27, p = 0.5). Sorafenib was

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Cancer Therapy Vol 6, page 15 associated with greater grade III and IV non-hematologic toxicities including diarrhea (6%), erythrodysesthesia (11%), and skin rash (6%). On the other hand, interferon-! was associated with more frequent grade III and IV fatigue (11%), nausea (6%), constitutional symptoms (6%) and confusion (4%) (Escudier et al, 2006). An update of this trial, recently presented, evaluated the role of sorafenib dose-escalation to 600mg bid for 44 patients who progressed on the standard dose dose (400mg bid).

Surprisingly, patients on higher doses had a median progression-free survival of 4.1 months, any degree of tumor shrinkage in 44% of the cases, and reasonable tolerance (Szczylik et al, 2007). A phase II trial with intrapatient sorafenib dose-escalation up to 1200-1600mg a day (Amato et al, 2007) was presented this year. A total of 44 patients were included, 25 of them was not treated before, 91% of all patients could receive higher doses and the authors reported objective responses of 55%, including 19% of complete responses. These encouraging results suggest that higher doses of sorafenib might circumvent drug resistance of this agent administered at the conventional schedule, this trial also showed an increased dose dependent toxicity, the most common treatment related adverse events were: hand/foot syndrome, skin rash, diarrhea, alopecia, fatigue, hypertension, hypophosphatemia, and elevated amylase/lipase. These findings also raises the question regarding that the initial sorafenib doses evaluated in both phase II and III trials might be suboptimal and if this is true new studies should evaluate higher doses schedules.

dose of 3MU tiw with dose escalation, if no toxicity, until 18MU tiw. Single-agent weekly temsirolimus was given intravenously at the dose of 25mg. In the combination arm interferon-! was administered initially at the dose of 6MU tiw associated to weekly temsirolimus at the dose of 15mg. Patients were stratified according to registration center and absence or presence of prior nephrectomy.

Patients had to have at least three of the six unfavorable prognostic factors that included: performance status 60-70 (according to the Karnofsky scale), LDH > 1.5 x the superior normal limits, hemoglobin level lower than inferior normal limit, corrected serum calcium > 10mg/dL, time from the diagnosis to the study entry < 1 year, multiple sites of metastasis. The primary end point of this study was overall survival. With a statistical power of 90%, the design of this trial planned to show an increase in overall survival by 40%, in favor of temsirolimus arms (from 4.9 to 6.9 months, two-sided, p value < 0.025).

Secondary end points included: progression-free survival, response rates (including stable disease for the clinical benefit analysis), and toxicity. This study also had an independent review committee for reviewing the efficacy and safety data. The three arms were well balanced.

Nearly 67% of the patients had prior nephrectomy, 80% had clear cell histology, and more than 70% of the patients had unfavorable prognostic factors according to Motzer criteria. Overall survival in the combination arm was not superior compared to control arm (HR 0.96, 95% CI, 0.761.20; p = 0.70). Median overall survival rates in the interferon-!, temsirolimus, and combination arms were 7.3 months, 10.9 months, and 8.4 months, respectively (Table 1). Temsirolimus alone was associated with an advantage in overall survival (HR, 0.73, 95% CI, 0.580.92; p = 0.008) and progression-free survival (p < 0.001) over interferon-! alone. Single agent temsirolimus was well tolerated. Grade III or IV adverse events occurred in 67% of patients in the temsirolimus group, as compared with 78% of patients in the interferon group (P=0.02) and 87% of patients in the combination-therapy group (P=0.02). Most common grade III or IV toxicities from temsirolimus included hyperglycemia (10%) and anemia (12%) dyspnea and asthenia. Asthenia was most common in the two groups receiving interferon alone or in combination. Grade III or IV asthenia was reported in 11% of patients in the temsirolimus group, in 26% of those in the interferon group (P<0.001), and in 28% of those in the combination-therapy group (P<0.001). When compared with patients in the interferon group, mild to moderate rash, peripheral edema, and stomatitis affected more patients who received temsirolimus, either alone or in combination with interferon. Anemia, neutropenia, and thrombocytopenia were more common in the combinationtherapy group than in the interferon group (P<0.001 for anemia, neutropenia, and thrombocytopenia) or in the temsirolimus group (P<0.001 for neutropenia and thrombocytopenia, and P=0.002 for anemia).

Hyperglycemia, hypercholesterolemia, and hyperlipidemia were more common in the temsirolimus group and the combination-therapy group, reflecting inhibition of mTOR-regulated glucose and lipid metabolism. Based on these results single agent temsirolimus should be

B. Patients with poor and intermediate prognosis according to Motzer criteria Other important pathway involved in the biological cascade in RCC carcinoma is represented by a serine/threonine protein kinase knowed as mammalian target of rapamycin (mTOR). Overexpression of mTOR is associated with prolonged tumor cell survival as well as high cell proliferation rates. Temsirolimus (CCI-779) is an mTOR inhibithor, such action is explained by the interaction of the drug with mTOR forming a complex that inactivates the kinase through phosphorylation phosphorilation inhibition. This effect induces apoptosis, cell cycle arrest at the G1 phase as well as cell response to growth factors and nutrients. Temsirolimus also inhibits one of the most important mTOR promoters, the AKT (serine-threonine kinase), as well as their regulators (PI3 kinase and tumor suppressor gene PTEN). Several studies have demonstrated that both AKT and mTOR play a critical role in renal cell carcinoma tumorigenesis and biologic behavior. Also, temsirolimus is known as an inhibitor of the hypoxia induced-! factor that is associated with direct effects on both VEGF and PDGF (Smolewski, 2006; Rubio-Viqueira et al, 2007). A phase III trial was conducted (Hudes et al, 2007), including 626 treatmentna誰ve patients with metastatic renal cancer associated with poor and intermediate prognostic characteristics. Patients were randomized among interferon-! versus temsirolimus versus the combination of both agents. Treatment with subcutaneous interferon-! was administered initially at the

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Arap et al: New directions in the management of renal cell carcinoma considered the standard first-line therapy for patients with Confirming the activity of this class of agents, a phase II poor prognosis characteristics according to Motzer criteria. study evaluated everolimus at dose of 10mg orally and Table 1. Overall survival by treatment arm comparing interferon-#, temsirolimus, or both.

N Deaths, n (%) OS, median (95% CI), months Protocol-defined comparisons OS, hazard ratio (95% CI) OS, log-rank p

Overall Survival by Treatment Arm IFN (Arm 1) TEMSR (Arm 2) 207 209 149 (34) 141 (32) 7.3 (6.1, 8.9) 10.9 (8.6, 12.7)

TEMSR + IFN (Arm 3) 210 152 (34) 8.4 (6.6, 10.2)

NA

Arm 2: Arm 1

Arm 3: Arm 1

NA NA

0.73 (0.57, 0.92) 0.0069

0.95 (0.76, 1.20) 0.6912

INF = Interferon-#; TEMSR = Temsirolimus; OS = Overall Survival; N = number of patients; NA: Not Achieved

reported partial responses in 9 of 28 metastatic renal cell carcinoma patients exposed to prior systemic therapies (Amato et al, 2006).

Based on the fact that agents that inhibit multiple kinases involved on the VEGF and PDGF pathways have established activity in advanced disease, it is plausible as part of future strategies to evaluate synergistic interactions among them with other class of agents such as immunotherapeutic drugs. A phase II study, including 62 patients, evaluated the role of combining sorafenib 400mg orally bid continuously with interferon-! 10MU tiw as first-line therapy. Eligible patients had metastatic or unresectable renal carcinoma with a clear-cell component, no prior systemic therapy, performance status 0 to 1, and measurable disease. The primary end point was objective response. Twelve (19%) of 62 assessable patients achieved an objective confirmed response. An additional 31 patients (50%) had an unconfirmed partial response or stable disease as best response. The median progression-free survival was 7 months (95% CI, 4-11 months). The most common adverse events were fatigue, anorexia, anemia, diarrhea, nausea, rigors/chills, leukopenia, fever, and transaminases elevation (Ryan, 2007). Another phase II study was conducted including 40 patients who were treated with sorafenib and interferon-#, as first- or secondline therapy in metastatic renal cell cancer, on the same schedule of the previous study have the following results: response rate 33% (95% CI, 19% - 49%; 13 of 40 patients), including 28% partial responses (n = 11) and 5% complete responses (n = 2). The median duration of response was 12 months. With a median follow-up time of 14 months, median progression-free survival time was 10 months (95% CI, 8 - 18 months). Fatigue, anorexia, anemia, diarrhea, hypophosphatemia, rash, nausea, and weight loss were the most common toxicities. Grade IV toxicities were uncommon but included hypophosphatemia, neutropenia, rash, fatigue, and anemia.

Dose reductions were required in 65% of patients (Gollob et al, 2007). A phase III randomized study is ongoing, planning to accrual 499 patients with RCC, comparing daily sunitinib 50mg for 4 weeks followed by 2 weeks of rest versus daily sunitinib 37.5mg continuously for 6

weeks versus sunitinib at the conventional schedule combined with interferon-!. The primary goal of this trial is to evaluate if the combination arm will be associated with an improvement in time to progression from 8 to 12 months compared to the sunitinib alone arms (statistical power of 85%). This study will answer important questions regarding potential synergisms among different agents with distinct mechanisms of action as well as delineate the optimal sunitinib schedule. Another randomized phase II study has being conducted by ECOG, including 360 patients with RCC, comparing intravenous bevacizumab 10mg/kg given every 2 weeks versus bevacizumab at the same schedule associated with intravenous temsirolimus administered at the dose of 25mg weekly on days 1, 8, 15, and 22 or bevacizumab associated with sorafenibe 400mg bid continuously. The fourth arm of this trial consists of the combination of sorafenibe 400mg bid plus temsirolimus 25mg on days 1, 8, 15, and 22. The study primary end point includes the evaluation and comparison of progression free survival among the four arms.

III. Molecular target therapy previously treated RCC patients

in

Patients with metastatic renal cell carcinoma who failed immunotherapy have a poor prognosis (Flanigan RC et al, 2007). The activity of other immunological agents as well as cytotoxic chemotherapy is minimal and clearly new agents are necessary in order to increase overall survival, palliate symptoms and improve quality of life.

Two phase II studies including 168 patients were conducted to evaluate the activity of sunitinib in patients with RCC who failed prior cytokine therapy (interferon-!, interleukin-2, or both). Inclusion criteria included: ECOG 0 or 1, measurable disease, and absence of CNS involvement. Approximately 97% of patients had undergone prior nephrectomy. The response rates were classified according to the RECIST criteria and revised by an independent commission. The objective response rate was 42% with a median progression-free survival of 8.2 months (95% CI, 7.8-10.4 months). The toxicity profile of

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Cancer Therapy Vol 6, page 17 both trials evaluating sunitinib as second-line therapy is comparable to that observed with this agent in the first-line setting. (Motzer et al, 2006a,b).

An important phase III trial (Escudier et al, 2007b), in treatment refractory RCC, evaluated sorafenib at the standard schedule (400 mg BID) continuous orally) versus placebo. This study included 903 patients and the primary end point was overall survival. Secondary end points included the evaluation and comparison of progressionfree survival, response rate, toxicity and quality of life.

Inclusion criteria included: metastatic RCC, disease progression after one prior systemic treatment within the 8 months, ECOG 0 or 1, and absence of CNS involvement metastasis. Poor-risk patients according to Motzer prognostic score (Motzer et al 2004) were excluded from the trial. Patients were stratified according to Motzer criteria (low and intermediate) and country. Patients in both arms had a median age of 58 years, 77% had lung involvement, and 82% had received previous cytokinebased therapy. Prior radiotherapy and nephrectomy were performed in 25% and 94% of the patients, respectively.

Approximately 51% of the patients were low and 49% intermediate-risk. Update of this trial showed an overall survival benefit of sorafenib over placebo, however those results were limited only to patients who did not crossover to receive sorafenib after progression to placebo (17.8 months versus 14.3 months, HR 0.78, 95% CI, 0.62-0.97, p = 0.028) (Figure 2) (Bukowski et al 2007). The diseasefree survival in the sorafenib group was also superior compared to placebo (5.5 versus 2.8 months; HR 0.44, 95% CI, 0.43-0.60, p < 0.001) (Figure 3). Sorafenib was associated with an advantage in progression-free survival among all subgroups including age (< 65 years or $ 65 years), Motzer criteria (low or intermediate-risk), previous systemic treatment (cytokine or others), presence or absence of lung or liver metastasis, and time since diagnosis (< 1.5 years or $ 1.5 years).The most common adverse effects (all grades) were diarrhea (43%), cutaneous reactions (40%), erythrodysesthesia (30%), fatigue (37%), nausea (23%), and hypertension (17%).

Grade III and IV hematologic and non-hematological toxicities were uncommon (3%).

Figure 2. Kaplan-Meier analysis of overall survival sorafenib and placebo.

Figure 3. Kaplan-Meier analysis of progression-free survival sorafenib and placebo.

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Arap et al: New directions in the management of renal cell carcinoma sorafenib were similar despite the degree of tumor reduction. On the other hand, patients who had no tumor reduction (assessed by the sum of tumor axis) showed inferior progression-free survival rates. Similarly, a phase II trial (Ratain et al, 2006) was designed to evaluate the outcome of patients based on the response according to sorafenib treatment. Three groups of patients were classified according to the response as assessed by RECIST criteria and managed accordingly. Sorafenib was maintained for patients who had tumor reduction $ 25%.

On the other hand, sorafenib was discontinued for patients with tumor growth $ 25%. Patients who had tumor reduction < 25% or tumor increase < 25% were randomly assigned to sorafenib maintenance (32 patients) or placebo (33 patients) for an additional 12 weeks. Analyzing this last group of patients who were randomized, a total of 50% of patients on the sorafenib arm versus 18% on the placebo arm were progression-free at 6 months (p=0.007), respectively. These results reinforce previous findings that VEGF inhibitors should be probably maintained in patients without gross tumor progression or unacceptable toxicity, even if tumor size does not decrease dramatically.

Some preliminary data suggest the appearance of necrotic component during VEGF inhibitors treatment in prior solid lesions may be useful to evaluate the efficacy of these agents (Figure 4). Other authors suggest that changes in tumor vascularization during treatment as assessed by MRI (De Bazelaire et al, 2003; Morgan et al, 2003) or doppler ultrasonography (Lamuraglia et al, 2005) may also be useful as a criteria of response. These parameters must be evaluated prospectively and compared to the standard response criteria in order to better establish a relationship between image response and clinical benefit with these novel agents.

Lastly, as sunitinib, bevacizumab plus interferon-#, sorafenib, and temsirolimus have a major impact both in the first- and second-line setting, it is crucial to evaluate the activity of these agents in patients who failed other VEGF-inhibitor. A retrospective study (Sablin et al, 2007) evaluated the role of sunitinib in patients who progressed on sorafenib (68 patients) or vice-versa (22 patients). The objective response rate in these two groups of patients was 22.7% and 17.6%, respectively, suggesting that both agents may target different pathways rather than the VEGF cascade. As a result, both agents can be considered second-line options after failure to a VEGF inhibitor. In order to better evaluate prospectively the non-cross resistance activity of these agents, dose-response schedules, and potential synergism among these novel agents to revert resistance a phase II randomized trial is ongoing. In this trial, patients who had disease progression on sunitinib at the standard dose are randomized to increase the sunitinib dose versus association of bevacizumab to sunitinib versus switch to sorafenib at standard doses. Similarly, randomization for patients who had disease progression on sorafenib at standard doses includes increasing the sorafenib dose versus association of bevacizumab to sorafenib versus switching to sunitinib at standard doses. Also, based on the two standard firstline therapies, it is extremely important to evaluate the

IV. Unresolved questions raised by novel agents in renal cell carcinoma Despite the encouraging results both in the first- and second-line setting, clinical studies with sunitinib and sorafenib raise several questions regarding optimal doses and intervals, durability of response, impact on long-term survival, definition of biomarkers of response, efficacy in other histologies, safety of administration in patients with CNS metastasis, and whether the standard response criteria, such as RECIST, should be applied to this class of agents.

Despite daily dose of sunitinib at 50mg for 4 weeks every 6 weeks was reasonably well tolerated, fatigue occurred in 51% of the patients. Possibly, dose modifications may be necessary in order to maintain the safety drug profile in patients with a lower body surface area than the average patient population included in the sunitinib trials. Also, monitoring serum levels of this agent might help individualize the optimal dose for each patient (Houk et al, 2007). We agree with the reviewer comment and we re-wrote the sentence as a hypothesis.

Although a high number of patients achieved a response with sunitinib (and in a minor proportion with sorafenib), it seems that responses are not as durable as those observed with high-dose interleukin 2.

Approximately 8% of patients treated with high-dose interleukin-2 achieve complete responses (Yang et al, 2003a), and in 80% of those patients response duration lasts over 8 years. Recently, it was demonstrated that the carbonic anhydrase IX over-expression evaluated by immuno-histochemical analysis (Atkins et al, 2005) and the alveolar component (Upton et al, 2005) in RCC predict the response rates in patients treated with high-dose interleukin 2. Thus high-dose interleukin-2 should still be considered the standard first-line treatment for patients " 60 years, without significant co-morbidities and absence of CNS involvement in association with a favorable histological and molecular profile. Unfortunately, only a few patients meet these criteria. Prognostic features are under evaluation to predict the efficacy of agents that target VEGF and PDGF receptor tyrosine kinases.

The role of sunitinib and sorafenib in non clear-cell renal carcinoma and the safety of both agents in patients with brain metastasis are still uncertain. In a recent abstract (Plantade A et al, 2007), sunitinib (38%) and sorafenib (62%) were evaluated in patients with chromophobe (12 patients) and papillary (41 patients) renal cell carcinoma. The response rates achieved with both VEGF inhibitors in chromophobe and papillary subtypes were 25% and 4.8%, respectively.

The standard response criteria based on measurable disease (e.g. RECIST) were validated in large studies using cytotoxic agents and generally correlates with clinical benefit. However, it is uncertain whether these criteria are optimal to evaluate efficacy of these novel antiangiogenic agents who have both cytostatic and cytotoxic properties (Gore et al, 2006). In a retrospective analysis (Escudier et al, 2007a), patients who had tumor reduction > 0% and " 10% versus > 10% and " 20% versus > 20% had similar progression-free survival rates. As an example, progression-free survival curves in patients treated with 18

Cancer Therapy Vol 6, page 19 activity of bevacizumab (plus or minus interferon-#) in patients who have progressed on sunitinib and vice-versa.

A phase II trial (George et al, 2007) involving 61 bevacizumab-resistant patients evaluated the efficacy of sunitinib and reported objective responses and stable disease rates of 23% and 57%, respectively. The median duration of response and progression-free survival were 30 weeks and 36 weeks, respectively. A retrospective study (Drabkin et al, 2007) evaluated the activity of sorafenib in patients previously treated with bevacizumab. The objective response and stable disease were 2.5% and 77%, respectively. There is no data available regarding the activity of bevacizumab-based regimens sunitinib- or sorafenib-refractory patients.

How do we compare the results of these novel agents to immunotherapy or chemotherapy in the second-line setting? Escudier and colleagues reported a response rate with interferon-! of only 2% in 48 patients previously treated with interleukin-2. Similarly, the response rate to

interleukin-2 in 65 patients previously treated with interferon-! was only 4% (Escudier et al, 1999). Another study including 251 patients treated with second-line agents (including immunotherapy and chemotherapy) reported a response rate of only 4% (Motzer et al, 2002).

In summary, these novel agents that inhibit important pathways related to the mutation or methylation of the VHL gene represent a new paradigm in the treatment of metastatic RCC. The disease-free survival observed with sunitinib (8.2 months) or sorafenib (5.5 months) in prior treated patients are significantly better than those observed with other â&#x20AC;&#x153;oldâ&#x20AC;? agents (2.4 months). Therefore, these novel agents represent an important progress in the treatment of metastatic RCC (Table 2). Surprisingly, the response rates and progression-free survival seems not to correlate whether patients received prior treatment or not.

These findings suggest that these agents may have noncross resistance properties with other agents such as immunotherapy and chemotherapy.

Figure 4. Patient with metastatic renal clear cell carcinoma involving the pancreas. Pre- and post-treatment with sunitinib showing a significant difference of density among the lesions due to necrosis/liquefaction after treatment despite the fact that no change in tumor diameter.

Table 2. Summary of results of anti-VEGF therapies and conventional therapy as second-line treatment (Escudier et al, 1999, 2007; Motzer and Russo, 2000; Yang et al, 2003b; Motzer et al, 2006a,b, 2007b).

Treatment

Author

Response

Progression-free survival

Motzer Escudier Yang

Number of patients 168 451 39

Sunitinib Sorafenib Bevacuzimab (high dose) Several (historic data) Immunotherapy (second-line) Interferon-! (first-line)

40% 10% 10%

8.2 months 5.5 months 4.8 months

Motzer

251

4%

2.4 months

Escudier

113

3%

NR

Motzer

463

11%

4.7 months

19

Arap et al: New directions in the management of renal cell carcinoma immunologic responses may be impaired by the overproduction of interleukin 6 (IL-6), IL-8, IL-10, GMCFS, and other cytokines.

Other hypothetical benefits of nephrectomy before systemic treatment are palliation of paraneoplastic syndromes, prevention of complications caused by locally advanced disease, the shed of tumor cells and the interruption of cytokine release by the primary tumor, which might be also involved in the growth of metastases.

Many retrospective studies of pre-immunotherapy cytoreductive nephrectomy before systemic treatment have been reported. As the response to cytoreductive nephrectomy is variable, most authors reinforce the importance of patient selection and preoperative evaluation of different criteria believed to be predictive of good outcome, such as ECOG performance status and the presence of liver, bone or central nervous system metastasis (Fallick et al, 1997) Other studies showed that multiple organ metastasis (Han et al, 2003). low Karnofsky performance status, hemoglobin level lower than the normal limits, corrected serum calcium level >10 mg/dL (Motzer et al, 1999), tumor grade, preoperative white blood cell count, partial thromboplastin time, and lymph node metastases are also prognostic (Pantuck et al, 2003).

The most important problems associated to surgery are the peri-operative mortality rate (that varies from 0 to 17%) and the inability to receive post-operative systemic therapy due to poor performance status (Bennett et al, 1995). The largest retrospective series is from the National Cancer Institute and included 195 patients who underwent nephrectomy before undergoing interleukin-2 therapy. The overall response was 18%, mortality was 1% and 38% of patients were unable to undergo interleukin-2 treatment due to poor performance status, post-operative complications and tumor progression (Walther et al, 1997).

Two important prospective and randomized trials were reported regarding cytoreductive nephrectomy (Flanigan et al, 2001; Mickisch et al, 2001). The trials conducted by SWOG and EORTC used the same protocol (cytoreductive nephrectomy followed by interferon-! or interferon-! alone) and both demonstrated longer survival in the nephrectomy groups. In addition, the trials definitively showed in a well-selected patient population that surgery was rarely a limitation to start systemic therapy, and that the response rate to systemic therapy was similar in both groups. There is no data regarding a potential role for cytoreductive nephrectomy for patients with metastatic disease treated with VEGF tyrosine kinase inhibitors. However, all positive trials that showed a benefit of VEGF, PDGF, and mTOR kinase inhibitors over immunotherapy or placebo included mostly patients who had prior nephrectomy. In conclusion, the role of nephrectomy before systemic therapy for metastatic renal cancer is still to be defined. However, nephrectomy is justified in the palliation of local symptoms, in patients with solitary metastases or low disease burden and in patients with good performance status and limited disease who candidates to receive systemic therapy including newer agents.

V. Adjuvant therapy with molecular target therapy According to the established activity of the VEGF and PGDF tyrosine kinase inhibitors in metastatic disease, clinical studies are ongoing to explore the role of these agents in reducing tumor recurrence, improving survival, and changing (for the first time) the natural history of this disease for high-risk patients in the adjuvant setting. The study, coordinated by the ECOG, plans to accrual 1332 patients with $T1B renal cell carcinoma and randomized them among three arms: sorafenib (400 mg bid on days 142) versus sunitinib (50 mg qd on days 1-28 every 42 days) versus placebo. In all three arms, treatment was given for a total of 9 cycles. The primary end point of this study is to evaluate and compare the disease-free survival curve rates among the three arms. Patients have being stratified by pathologic staging and histological subtype (clear cell or non-clear cell). This trial aim to answer two important questions: if these novel agents are superior to placebo and define the VEGF inhibitor of choice. Another phase III three-arm trial ongoing, plan to accrue 1420 high or intermediate risk patients. The three arms of this trial include continuous three-year sorafenib (400 mg bid) versus one-year sorafenib (400 mg bid) versus placebo.

The primary end point of this study is to evaluate and compare the disease-free survival rates among the three arms. This study raises two different questions: whether the target agent impacts on the natural history of disease and the optimal treatment duration these novels agents.

A third randomized trial involving another molecular target agent is ongoing, with a planned accrual of 600 patients, comparing the role of a chimeric antibody against carbonic anhydrase protein given intravenously weekly for 24 weeks versus placebo for patients with intermediateand high-risk of relapse. The carbonic anhydrase protein is overexpressed in more than 80 to 95% of the renal tumors and has direct biologic implications in renal clear cell carcinoma biology and behavior. A recent phase II trial (Bleumer et al, 2004) reported response rate and stable disease in 33% of treated patients. The primary end point includes the evaluation and comparison of disease-free survival and overall survival rates between the two arms.

VI. The role of cytoreductive nephrectomy in metastatic renal cell carcinoma To date, cytokine-based immunotherapy is still considered an option for patients with metastatic renal clear cell carcinoma. The role of nephrectomy in this situation, either before or after systemic treatment, remains controversial. The rationale for cytoreduction before immunotherapy is based on the ability of renal cell carcinoma to manipulate hostâ&#x20AC;&#x2122;s natural immunity. It is known that the primary lesion rarely responds to systemic treatment, even in patients who present with regression of metastases (Rackley et al, 1994). Lymphocytes from patients with metastatic renal cancer have increased apoptosis (Cardi et al, 1998; Uzzo et al, 1999) defective Tcell receptors (Finke et al, 1993) and poor signal transduction (Li et al, 1994; Ng et al, 2002). In addition, 20

Cancer Therapy Vol 6, page 21 Escudier B, Chevreau C, Lasset C, Douillard JY, Ravaud A, Fabbro M, Caty A, Rossi JF, Viens P, Bergerat JP, Savary J, NĂŠgrier S (1999) Cytokines in metastatic renal cell carcinoma, is it useful to switch to interleukin-2 or interferon after failure of a first treatment? Groupe Francais d'Immunotherape. J Clin Oncol 17, 2039-43.

Escudier B, Eisen T, Stadler WM, Szczylik C, Oudard S, Siebels M, Negrier S, Chevreau C, Solska E, Desai AA, Rolland F, Demkow T, Hutson TE, Gore M, Freeman S, Schwartz B, Shan M, Simantov R, Bukowski RM; TARGET Study Group (2007) Sorafenib in Advanced Clear-Cell Renal-Cell Carcinoma. N Engl J Med 356, 125-134.

Escudier B, Koralewski P, Pluzanska A (2007) A randomized, controlled, double-blind phase III study (AVOREN) of bevacizumab/interferon-#2a vs placebo/interferon-#2a as first-line therapy in metastatic renal cell carcinoma (Abst 3a).

J Clin Oncol, 2007 ASCO Annual Meeting Proceedings Part I. Vol 25, No 18S (June 20 Supplement).

Escudier B, Szczylik C, Eisen T, Stadler WM, Schwartz B, Shan M, Bukowski RM (2005) Randomized Phase III trial of the Raf kinase and VEGFR inhibitor sorafenib (BAY 43-9006) in patients with advanced renal cell carcinoma (RCC) (Abst 4510). J Clin Oncol, 2007 ASCO Annual Meeting Proceedings Part I. Vol 25, No 18S (June 20 Supplement).

Faivre S, Delbaldo C, Vera K, Robert C, Lozahic S, Lassau N, Bello C, Deprimo S, Brega N, Massimini G, Armand JP, Scigalla P, Raymond E (2006) Safety, pharmacokinetic, and antitumor activity of SU11248, a novel oral multitarget tyrosine kinase inhibitor, in patients with cancer. J Clin Oncol 24, 25-35.

Fallick ML, McDermott DF, LaRock D, Long JP, Atkins MB (1997) Nephrectomy before interleukin-2 therapy for patients with metastatic renal cell carcinoma. J Urol 158, 1691.

Finke JH, Zea AH, Stanley J, Longo DL, Mizoguchi H, Tubbs RR, Wiltrout RH, O'Shea JJ, Kudoh S, Klein E, et al (1993) Loss of T-cell receptor zeta chain and p56lck in T-cells infiltrating human renal cell carcinoma. Cancer Res 53, 5613-6.

Flanigan RC, Salmon SE, Blumenstein BA, Bearman SI, Roy V, McGrath PC, Caton JR Jr, Munshi N, Crawford ED (2001) Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med 345, 1655-9.

Folkman J (1990a) What is the evidence that tumors are angiogenesis dependent? J Natl Cancer Inst 82, 4-6.

Folkman J (1990b) Endothelial cells and angiogenic growth factors in cancer growth and metastasis. Introduction.

Cancer Metastasis Rev 9, 171-174.

Folkman J (1971) Tumor angiogenesis, Therapeutic implications.

N Engl J Med 285, 1182-1186.

George DJ, Michaelson MD, Rosenberg JE (2007) Phase II trial of sunitinib in bevacizumab-refractory metastatic renal cell carcinoma (mRCC), Updated results and analysis of circulating biomarkers (Abst 5035). J Clin Oncol, 2007 ASCO Annual Meeting Proceedings Part I. Vol 25, No 18S (June 20 Supplement).

Gollob JA, Rathmell WK, Richmond TM, Marino CB, Miller EK, Grigson G, Watkins C, Gu L, Peterson BL, Wright JJ (2007) Phase II trial of sorafenib plus interferon alfa-2b as first- or second-line therapy in patients with metastatic renal cell cancer. J Clin Oncol 25, 3288-95.

Gore ME, Escudier B (2006) Number of metastatic sites rather than location dictates overall survival of patients with nodenegative metastatic renal cell carcinoma. Urology 61, 314-9 Han KR, Pantuck AJ, Bui MH, Shvarts O, Freitas DG, Zisman A, Leibovich BC, Dorey FJ, Gitlitz BJ, Figlin RA, Belldegrun AS (2003) Exposure-response of sunitinib in metastatic renal cell carcinoma (mRCC), A population

VII. Conclusions Recently several advances have been made on both basic and clinical knowledge about renal cell carcinoma, such data allows to see knew horizons and build a more positive future for those patients achieved for this severe disease. In spite of those advances, metastatic RCC is considered incurable and the continue development of knew strategies is mandatory.

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Cancer Therapy Vol 6, page 35 Cancer Therapy Vol 6, 35-46, 2008

Gene therapy for esophageal cancer Review Article

Jong Chul Park1, Chulso Moon1,2,â&#x20AC; ,* 1

Department of Otolaryngology and Head and Neck Cancer Research Institute, Department of Oncology, The Johns Hopkins University School of Medicine and the Sidney Kimmel Cancer Center, Baltimore, MD 21218 2

__________________________________________________________________________________ *Correspondence: Chulso Moon, M.D., Ph.D., The Head and Neck Cancer Research Division, Department of Otolaryngology, The Johns Hopkins University, CRBII, 5M03, 1550 Orleans St. Baltimore MD 21231,USA; Tel: (410) 502 5153; Fax: (410) 614 1411: Email: cmoon5@jhmi.edu â&#x20AC; Present address: Cangen Biotechnologies, Inc., 300 E. Lombard Street, Suite 840 Baltimore, MD 21202 Key words: esophageal cancer, molecular biology, gene therapy Abbreviations: 5-fluoro-2'-deoxyuridine 5'-monophosphate, (5-FdUMP); 5-fluorouracil triphosphate, (5-FUTP); 5-fluorouracil, (5-FU); adenocarcinoma, (ADC); adenovirus-expressing wild-type p53, (Ad-p53); cell growth ratio, (CGR); cyclin-dependent kinases, (CDKs); cyclooxygenase-2, (COX-2); cytotoxic T lymphocyte, (CTL); enhanced green fluorescent protein, (EGFP); epidermal growth factor receptor, (EGFR); esophageal adenocarcinoma, (EAC); esophageal squamous cell carcinoma, (ESCC); ganciclovir, (GCV); gap junctional intercellular communication, (GJIC); gastroesophageal reflux disease, (GERD); loss of hetrozygosity, (LOH); onditionally replicative adenoviruses, (CRAd); secretory leukoprotease inhibitor, (SLPI); squamous cell carcinoma, (SCC); Terminal Deoxynucleotidyl Transferase-MediatedNick End-Labeling, (TUNEL); thymidine kinase, (HSV- TK); Uracil phosphoribosyltransferase, (UPRT)

The article was supported in part by the SPORE grant P50 CA96784-01 (to C.M.), Cancer Research Grant from Pyung-Ya Foundation (to C.M.)

Received: 19 November 2007; Revised: 13 December 2007 Accepted: 16 January 2008; electronically published: February 2008

Summary Esophageal cancer is the ninth most common malignancy and the seventh leading cause of cancer death worldwide.

Its incidence is dramatically increasing especially that of esophageal adenocarcinoma. A variety of therapeutic strategies have been developed to improve survival for the patients with esophageal cancer but overall survival still remains poor with 5 year survival around 15%. Recent advances in molecular biology of esophageal cancer have documented the role of genetic alterations in tumorigenesis and have led to the development of potential new therapeutic approaches designed to target those genetic alterations. This article will review the molecular biology of esophageal cancer and the recent studies in the gene therapy for esophageal cancer.

decades in the United States. Until the 1970s, esophageal squamous cell carcinoma (ESCC) was the most common type of esophageal cancer and affected mostly African American men who had a long history of smoking and alcohol consumption. Over the last 2 decades, the incidence of adenocarcinoma of the distal esophagus and gastroesophageal junction has progressively increased and currently it accounts for more than 50% of all new cases of esophageal cancer. It affects mostly white men, and its pathogenesis is linked to gastroesophageal reflux disease (GERD) and the development of Barrett epithelium.

Surgical resection alone can be curative for localized tumors without evidence of distant metastases. However, only 20-30 % of the patients are candidates for a

I. Introduction Esophageal cancer is the ninth most common malignancy and the seventh leading cause of cancer death worldwide. The incidence of esophageal cancer varies widely according to geographical region and racial background. In the United States, the incidence is dramatically increasing especially that of esophageal adenocarcinoma (EAC), which has the fastest growing incidence rate of all cancers in the United States (DeWeese et al, 2001). In 2007 in the United States, 15,560 people are expected to be diagnosed with esophageal cancer and 13,940 will die of their disease (Jemal et al, 2007). The epidemiology of esophageal carcinoma has changed markedly over the past several 35

Park and Moon: Gene therapy for esophageal cancer potentially curative surgery and overall survival remains poor (Epperly et al, 2001). Recently, adjuvant modality, a combination of chemotherapy and radiation therapy, is often used for downstaging of the tumor and improving the prognosis after surgery (Geh et al, 2001). Despite surgery or chemoradiotherapy, prognosis of esophageal cancer still remains poor, with 5-year survival around 10 % (Enzinger and Mayer, 2003). The failure of conventional therapy occurs mostly because tumors develop resistance to chemotherapy or radiation and attempts to overcome resistance with higher doses of radiation and chemotherapeutics inevitably result in an unacceptable degree of toxicity and bystander damage to normal tissues. The major limitation of all these treatments and their combinations is the lack of specificity for the tumor cell and toxicity to the patient.

Recent advances in molecular biology of esophageal cancer have documented the role of genetic alterations in tumorigenesis and have led to the development of potential new therapeutic approaches designed to target those genetic alterations. This article will review the molecular biology of esophageal cancer and the recent studies in the gene therapy for esophageal cancer.

abnormal transcripts are common events that can serve as a potential diagnostic tool. Gene amplification of cyclin D is found preferentially in esophageal cancer, whereas gene amplification of cyclin E and c-met is frequently associated with gastric cancer. Mutations of the cyclindependent kinase inhibitor genes also occur in esophageal and gastric cancers. Cancer of the esophagus exists in 2 main forms with different etiological and pathological characteristics-squamous cell carcinoma (SCC) and adenocarcinoma (ADC) and as described in Table 1, both types shares common genetic changes. Overall, the most common alterations found in esophageal cancers include allelic losses at chromosomes 3p, 5q, 9p, 9q, 13q, 17p, 17q and 18q, as well as mutations of p53 (mostly missense).

Rb (deletions), cyclin DI (amplifications) and c-myc (amplifications). The sequence of occurrence of these alterations with respect to histopathological tumor progression has been well characterized.

Key checkpoints of cell cycle exist at the G1-S and G2-M phase transitions. Cell cycle is regulated by the complex of cyclin-dependent kinases (CDKs) and their association with specific regulatory subunits, the cyclins via the phosphorylation of its proper target; the cyclin A/CDK2 and cyclin B/CDK2 complexes manage the G2M phase transition, whereas the cyclin D1/CDK4 and cyclin E/CDK2 complexes maintain the G1-S checkpoint (Morgan, 1995). A number of factors are involved in the regulation of the G1- S phase transition. The c-myc protein enhances the progression into S phase and DNA replication while the retinoblastoma protein (Robert et al, 2000) sequesters the E2F transcription factor preventing the process. The p16 protein causes cell cycle arrest by inhibiting the association of CDK4 and cyclin D1, while p53 acts through p21WAF1 to sequester CDKs (Harper et al, 1995). Altered expression in any of these factors can lead to disruption in cell cycle regulation and eventually cause development of esophageal carcinoma (Table 1).

II. Molecular biology of esophageal cancer When developing gene therapy, it is essential to have precise information about the genetic etiology of the disease. The information can be very complex in the case of cancer because several mutational hits may have taken place during carcinogenesis. Many tumor suppressor genes and the oncogenes control the expression of proteins that function as cell cycle regulators.

Esophageal cancer involve genetic alterations in several oncogenes, tumor suppressor genes, and potentially DNA repair genes (Montesano et al, 1998) and shares certain common features with gastric cancer.

Inactivation of the p53 gene and expression of CD44

Table 1. Oncogenes and tumor suppressor genes commonly altered in esophageal cancer.

Tumor Related Gene Oncogene

Gene Cyclin D1 (11q13) ErbB-1 (7q12) ErbB-2 (17q21)

Tumor suppressor gene

p53 (17q13)

p21 (6p21)

p16 (9p21)

Reference ESCC EAC Metzger et al, 2004; Metzger et al, 2004; Kawakubo et al, 2005 Izzo et al, 2007 Hanawa et al, 2006; Sudo et Beilstein et al, 2002 al, 2007 al-Kasspooles et al, 1993; al-Kasspooles et al, Friess et al., 1999 1993; Friess et al, 1999 Audrezet et al, 1993; Putz et al, 2002 Kuwabara et al, 1998; Robert et al, 2000 Bahl et al, 2000; Nakashima et al, 2000; Heeren et al, 2004 Tokugawa et al, 2002 Kwong et al, 2004; Ishii et al, 2007

ESCC: Esophageal squamous cell carcinoma EAC: Esophageal adenocarcinoma

36

Cancer Therapy Vol 6, page 37 On top of the genetic changes directly involved in cell cycle, pathways related with apoptosis are also important in understanding molecular biology of esophageal cancer. For example, overexpression of E2F-1 can activate CPP32, one of the most important apoptosisinducing molecules, and can cause cleavage of the death substrate poly(ADP-ribose) polymerase, which suggests that activation of the caspase cascade may be a pivotal mechanism in E2F-1-mediated apoptosis (Fueyo et al, 1998). Moreover, this pathway seems separate from the p53-mediated pathway, because E2F-1 dose not increase the expression level of bax protein (a putative p53mediated apoptotic pathway.

Also, for the precise understanding for the molecular mechanisms of p53, both detailed information for each interaction between p53 and other key players like RB or MDM2 (Bates et al, 1998) and conceptual understanding that dynamic equilibrium and functional stability of p53 rather than p53 expression itself determines the outcome of p53 are critically important (Kubbutat et al, 1997). For example, a proto-oncogene MDM2, which can be induced by wt-p53 activity, binds to p53 and masks the p53 transcriptional activation domain (Oliner et al, 1993).

MDM2 targets p53 protein for degradation in the ubiquitin pathway, which results in abrogation of its antiproliferative and apoptosis-promoting effects. In addition, it has been shown that p14 binds to and induces the degradation of the proto-oncogene MDM2, which results in stabilization of p53 (Kubbutat et al, 1997).

Furthermore, cell-cycle arrest mediated by p14 can be abolished in cells lacking functional p53 (Pomerantz et al, 1993), which indicates that p14 may act upstream of p53.

apoptosis (Thompson, 1995). According to several studies, p53 gene alteration is observed in about half of ESCC (Audrezet et al, 1993; Kuwabara et al, 1998; Robert et al, 2000), and more than 100 mutations of ESCC have been reported in the IRAC p53 mutation database (Putz et al, 2002). Most of these mutations are located in four evolutionary conserved domains of the p53 gene, from exon 5 to exon 8, and more than 80% are point mutations.

Alterations in p53 are found in 60% of Barrettâ&#x20AC;&#x2122;s metaplasias and 95% of EAC (Putz et al, 2002). Its relevance as a prognostic factor is controversial; some studies suggest that the presence of mutant type p53 is correlated with a poor prognosis, while other studies found a lack of such correlation with a poor prognosis (Ito et al, 2001; Matsumoto et al, 2001; Shibata and Matsubara, 2001; Mathew et al, 2002).

C. p21WAF1 The functions of CDKs are inhibited by two families of CDK inhibitors. The first class comprises the CIP/KIP family (p21WAF1/CIP1, p27KIP1, and p57KIP2), and the other comprises the INK4 family proteins (p16INK4a, p15INK4b, p18INK4c, and p19INK4d).

The product of p21WAF1 gene is a cyclin-dependent kinase inhibitor and is thought to play a central role in tumor suppression. The p21WAF1 gene contains a p53binding site in its promoter, and the expression of p21WAF1 was directly regulated by p53; cells with loss of p53 activity due to mutational alteration were unable to induce p21WAF1 (Ohashi et al, 1997). Mutations and deletions of the p21WAF1 gene are rare in human cancers, although p21WAF1 polymorphisms have been seen in certain cancers. In ESCC, polymorphisms have been identified at codon 31 and codon 149 in exon 2 of the p21WAF1 gene, and may play an important role in esophageal tumorigenesis (Bahl et al, 2000). Some reports suggest that wild-type p53 concomitant with p21WAF1 expression is a predictor of a good response to chemotherapy or chemoradiotherapy in ESCC in vivo (Nakashima et al, 2000; Heeren et al, 2004).

A. Cyclins D1 Cyclin D1 is one of the most essential proteins for controlling the cell cycle in the p16-pRb pathway (Roncalli et al, 1998). Cyclin D1/CDK4 regulates mid to late G1 by phosphorylating Rb which allows E2F to activate genes for S-phase (Alt et al, 2000). Amplification of the Cyclin D1 gene or overexpression of the cyclin D1 protein can result in transformation to a malignant phenotype. In ESCC, cyclin D1 overexpression was found to start early in dysplasia and early cancers and play an important role in cell transformation (Kawakubo et al, 2005). Cyclin D1 protein is also increased significantly in Barrettâ&#x20AC;&#x2122;s metaplasia with nuclear accumulation and it increases the risk of progression to EAC by six- to sevenfold (Izzo et al, 2007). Overexpression and genomic amplification of cyclin D1 is found in 22-73% of ESCC and 22-64% of EAC tissues (Metzger et al, 2004).

Overexpression of cyclin D1 was also shown to be associated with poor prognosis such as lymph nodes/distant metastases, high tumor grade, poor response to chemotherapy and decreased survival (Lin et al, 2004).

D. p16INK4a p16INK4a is a tumor suppressor protein that inhibits the function of the cyclin D1/CDK4 and CDK6 complex, and causes p53-independent G1 arrest through the phosphorylation of pRb (Bruce et al, 2000). In human cancers, inactivation of the p16INK4a gene is a frequent event associated with homozygous deletion, genetic mutation, or aberrant DNA methylation (Guo et al, 2007; Jie et al, 2007; Milyavsky et al, 2007). Inactivation of the p16INK4a gene in ESCC is common, and caused by homozygous deletion and de novo methylation (Tokugawa et al, 2002). On the other hand, promoter hypermethylation with loss of hetrozygosity (LOH) is a common mechanisms for inactivation of p16INK4a in EAC (Kwong et al, 2004; Ishii et al, 2007).

B. p53 The p53 gene is the most frequently mutated gene identified in human esophageal cancer (Metzger et al, 2004). The p53 gene leads to cell cycle arrest through p21WAF1 induction which sequesters CDKs and by downregulating bcl-2 while upregulating Bax, it induces

E. Growth factors and their receptors The epidermal growth factor receptor (EGFR) family comprises erbB-1 (EGFR), erbB-2 (HER2), erbB-3, and erbB-4, all of which are tyrosine kinase receptors. These 37

Park and Moon: Gene therapy for esophageal cancer receptors translate proteins on the cell membrane, which act as receptors, and have intracellular tyrosine kinase activity and extracellular binding domains.

Overexpression of erbB-1 has been reported in many ESCC tumor samples and cell lines (29%-92%) (Hanawa et al, 2006; Sudo et al, 2007). The overexpression of erbB1 in patients with ESCC and EAC was correlated with a poor prognosis and poor response to chemoradiotherapy (Beilstein and Silberg, 2002; Gibson et al, 2003; Gotoh et al, 2007; Wang et al, 2007). The erbB-2 oncogene encodes a truncated form of EGFR, which contains continuously active tyrosine kinase. Cells expressing this oncogene behave as if they are being constantly stimulated by growth factors. While overexpression of erbB-2 at the protein level is seen in EAC, it is less frequent in ESCC and was found in 0% to 38% of tumors (al-Kasspooles et al, 1993; Friess et al, 1999).

F. E2F-1 Mutations that directly perturb the pRB3-mediated G1 restriction point. pRb is thought to exert its cell cycle regulatory effects by binding and sequestering the transcription factor, E2F-1 (Bates et al, 1998). E2F-1 has unique and somewhat paradoxical activities. E2F-1 promotes cellular proliferation by stimulating expression of a number of genes that promote transition from G1 to the S phase. For example, overexpression of E2F-1 stimulates quiescent cells to enter into the S phase, whereas inhibition of E2F-1 prevents entry into the S phase (Itoshima et al, 2000). However, overexpression of E2F-1 has also been shown to induce apoptosis in several cell types including esophageal cancer cells, indicating that E2F-1 plays a role not only in regulating cell growth, but in coordinating programmed cell death (Yang et al, 2000). Furthermore, recent studies with E2F-1 knockout mice suggested that E2F-1 functions as a tumor suppressor gene

G. E2F-1 and p53 combinations: E2F-1 as an apoptosis inducer Transfer of the wild-type p53 and E2F-1 genes efficiently induces apoptosis in human esophageal cancer cells and that E2F-1 overexpression directly activates expression of p14 (ARF), which inhibits MDM2-mediated p53 degradation, resulting in the stabilization of p53.

Infection of human three esophageal cancer cell lines with adenovirus vector-expressing E2F-1 (Ad-E2F-1) enhanced mRNA and protein expression of ARF and decreased MDM2 protein expression (Itoshima et al, 2000, Yang et al, 2000, Wang et al, 2000). Transfection of ARF plasmid decreased MDM2 protein expression, which in turn increased p53 protein expression. Infection of esophageal cancer cells first with adenovirus-expressing wild-type p53 (Ad-p53) and then with Ad-E2F-1 resulted in rapid induction of apoptosis; in contrast, simultaneous infection with Ad-E2F-1 and Ad-p53 had no significant antitumor effect. Furthermore, infection with suboptimal concentrations of Ad-E2F-1 induced the accumulation of exogenous p53 transduced by suboptimal concentrations of Ad-p53. Moreover, Ad-E2F-1-mediated ARF expression inhibited the up-regulation of MDM2 by overexpressed

p53 in esophageal cancer cells. Thus, overexpression of ectopic E2F-1 protein may stabilize endogenous as well as ectopic p53 protein via the E2F-1/ARF/MDM2/p53 regulatory pathway and, in this way, render cells more sensitive to apoptosis, an outcome that has important implications for the treatment of human esophageal cancers.

III. Corrective gene therapy A number of specific genetic alterations have been identified in esophageal cancer. These genetic events include amplification and/or overexpression of oncogenes, mutations and deletions leading to inactivation of tumor suppressor genes. The identification of these molecular alterations has allowed the development of new therapeutic approaches targeting specific differences between normal and malignant cells (Table 2).

A. p53-replacement gene therapy Transfection of wt-p53 is an appealing therapeutic strategy for esophageal cancer because of the high frequency of p53 mutations in both squamous cell carcinoma and adenocarcinoma developed in Barrett's esophagus and the central role of p53 in regulating growth and apoptosis (Metzger et al, 2004).

Tagawa and his colleagues in Chiba university in Japan demonstrated that when wild-type p53 gene was transduced to human esophageal cancer cells (T.Tn) bearing mutated p53 gene, the transduced cells (T.Tn/p53) which stably expressed wild-type p53 were markedly susceptible to radiation and chemotherapeutics (cisplatin and etoposide) compared with parental cells (Matsubara et al, 1999b). They evaluated the transduction efficacy and in vivo and in vitro antitumor efficacy of the recombinant adenoviral vector Ad5CMV-p53 on human ESCC (Shimada et al, 2001). Ad5CMV-p53 is replicationdeficient (del E1, del E3) adenovirus type 5 in which the E1 region is replaced with the cDNA of the p53 gene and is driven by a cytomegalovirus promoter. Ad5CMV-p53 has been extensively studied in various tumors, especially lung and head and neck cancer (Moon et al, 2003).

Ad5CMV-p53 was observed to successfully deliver and express p53 protein followed by p21 protein induction and apoptotic cell death was demonstrated by Terminal Deoxynucleotidyl Transferase-MediatedNick EndLabeling (TUNEL) staining. A significant growth suppression following an Ad5CMV-p53 infection was observed in human esophageal cancer cell lines with a p53 alteration (ECGI-10 and T.Tn) and in T.Tn xenografts in nude mice (Shimada et al, 2001).

However, the transduction efficiency was lower than that of other cell lines such as glioblastoma, breast cancer, and cervical cancer probably due to receptor variations and differences in membrane characteristics among different cell lines. So they also investigated the feasibility of plasmid-based p53 gene transfer using electric pulses (electroporation) (Matsubara et al, 2001b). Plasmid vectors are composed entirely of covalently closed circles of double-stranded DNA are substantially easier to massproduce and quality control than are viral vectors. Gene delivery with plasmid vectors do not depend on cell

Cancer Therapy Vol 6, page 39 Table 2. Gene therapy for esophageal cancer.

Strategy Gene replacement therapy

Suicide gene therapy

Immunogene therapy

Suicide/ Immunogene therapy Oncolytic therapy

Target gene p53 p53

Gene delivery Retrovirus Adenovirus

Modality +/- Radiation/chemotherapy Monotherapy

p53 p53

Electroporation Adenovirus

p21WAF1 p21WAF1 HSV-TK HSV-TK UPRT UPRT, HSV-TK (Double Suicide gene therapy) IL-2 GM-CSF IL-21, IL-23 TNF-!

IFN-!

Adenovirus Gene gun Retrovirus Retrovirus Adenovirus Adenovirus (AxCA.UT)

+/- Chemotherapy +/- Heavy carbonionradiation Monotherapy +/- Chemotherapy Monotherapy Monotherapy Monotherapy Monotherapy

GM-CSF, IL-2 HSV-TK, IL-21

Retrovirus Retrovirus Retrovirus Adenovirus Cationic multilamellar liposome Electroporation Electroporation

Virus HSV type-1 (NV1066) Adenovirus (Ad5/Ad3-chimeric Cox-2 promoter-driven conditionally replicative adenovirus)

surface receptors like viral vectors, however, gene delivery with plasmid vectors is highly inefficient unless the DNA is either associated with other molecules and/or physical energy is applied to aid cell entry. Electroporation increased gene expression by 100- to 1000-fold compared to injection of naked plasmid DNA (Aihara and Miyazaki, 1998). The exact mechanism by which delivery of plasmid into cells is enhanced is not certain although it is clear that membranes become effectively permeable once a critical voltage has been achieved (Neumann and Kakorin, 2002).

The growth of esophageal tumors was suppressed with electroporation-mediated chemotherapy (electrochemotherapy) with bleomycin compared with the treatment with bleomycin or electroporation alone.

Intratumoral injection of the wild-type p53 gene into p53mutated esophageal tumors followed by electroporation also inhibited tumor growth. When mice were administered with the wild-type p53 gene and an anticancer agent, subsequent electroporation produced a synergistic therapeutic effect (Matsubara et al, 2001b).

This group also reported that growth suppression was significantly potentiated by combined treatment with heavy carbon-ion beams and Ad5CMV-p53 as compared to that treated with either of them alone (Oohira et al, 2004).

The first clinical trial of Ad5CMV-p53 in patients with chemoradiation resistant advanced esophageal carcinoma was initiated in 2000 in Japan. The primary objective was to evaluate the antitumor effects, to observe

Ref Matsubara et al, 1999b Shimada et al, 2001 Shimada et al, 2006 Matsubara et al, 2001b Oohira et al, 2004 Fujii et al, 2001 Tanaka et al, 2004 Matsubara et al, 1999a Matono et al, 2003 Nakamura et al, 2001 Shimizu et al, 2001

Monotherapy Monotherapy Monotherapy +/- Radiation +/- Chemotherapy

Matsubara et al, 1998 Sugaya et al, 1998 Shan et al, 2004 Gupta et al, 2002 Tsunoo et al, 2002

Monotherapy Combination therapy

Matsubara et al, 2001a Hanari et al, 2007

Monotherapy Monotherapy

Stiles et al, 2003 Davydova et al, 2004

the biological responses to p53 gene transduction, and to evaluate the safety of this therapy. On a 28-day cycle, intratumoral injections of Ad5CMV-p53 (INGN 201; ADVEXIN) were administered on days 1 and 3 at four dose levels (10 x 10(11) particles to 25 x 10(11) particles) and treated for up to five cycles (Shimada et al, 2006).

Administration of multiple courses was feasible and welltolerated. Out of ten patients who received a total of 26 cycles, nine showed local tumor responses and one had progressive disease. The treatment was well-tolerated with no dose-limiting toxicity (Shimada et al, 2006).

B. p21WAF1-replacement gene therapy Fujii and colleagues in Kurume University evaluated the antitumor effect of exogenous expression p21WAF1 in esophageal cancer cells (Fujii et al, 2001). Adenovirusmediated expression of exogenous p21WAF-1 effectively reduced cell growth in cell lines with high cell growth ratio (CGR) KE3 and TE9, but not in low CGR cell lines (KE4 and TE11). p21WAF1-mediated growth suppression was associated with the induction of involucrin, a marker of squamous cell differentiation. This study suggested that the basal level, but not the stimulated level, of p21WAF1 expression play a pivotal role in abnormal growth in human squamous cell carcinoma of the esophagus.

Based on their previous study, they evaluated the effect of p21WAF1 gene therapy using gene gun technology (Tanaka et al, 2004). Gene delivery by gene gun utilizes a shock wave to accelerate plasmid-coated

39

Park and Moon: Gene therapy for esophageal cancer microparticles into target cells or tissues. As this method is cell surface receptor-independent, it can successfully deliver genes into a wide spectrum of mammalian cell types and has been used most extensively for the delivery of DNA vaccines to the skin. It was reported that the gene gun is less invasive and simpler than other gene delivery systems (Zhang et al, 2007). p21WAF1 transfection to KE3 and YES2 cells (weakly expressed p21Waf1 protein cells) showed a high expression of p21WAF1 protein after applying this gene gun technique and caused statistically significant growth inhibition in those cells (Tanaka et al, 2004). In KE3 and YES2 cells, significant growth inhibition was observed after combination therapy using p21WAF1 transfection and anticancer drug 5-FU compared with 5-FU alone (Tanaka et al, 2004).

disappeared. They suggested the p53 gene of tumor cells thereby may influence the efficacy of the HSV-TK/GCV system (Matsubara et al, 1999a). Matono and colleagues demonstrated the correlation of gap junctional intercellular communication (GJIC) and the extent of the bystander effect, suggesting that the degree of GJIC was predictive to identify a tumor as suitable for gene therapy with the HSV-TK/GCV system (Matono et al, 2003). They also showed that treatment with retinoic acid was associated with increased GJIC and augmented bystander killing, indicating that GJIC chemically-enhanced with retinoic acid might be useful to improve response in suicide gene therapy (Matono et al, 2003).

B. Uracil phosphoribosyltransferase/5fluorocytosine

IV. Suicide gene therapy

5-fluorouracil (5-FU) is one of the most widely applied chemotherapy agents used in the treatment of a variety of human cancers, such as cancer of the colon, breast, stomach, pancreas and lung. In mammalian cells, 5-FU is metabolized into either 5-fluorouracil triphosphate (5-FUTP) or 5-fluoro-2'-deoxyuridine 5'-monophosphate (5-FdUMP). 5-FUTP is then incorporated into RNA and interferes with RNA processing, while 5-FdUMP irreversibly inhibits thymidylate synthase and hence DNA synthesis (Evrard et al, 1999). However, the role of systemic 5-FU in cancer treatment has been limited by a low local concentration of the agent and systemic toxicities. Thus, a prodrug/enzyme suicide gene therapy approach was employed to overcome this limitation by increasing the sensitivity of 5-FU. Uracil phosphoribosyltransferase (UPRT) is a pyrimidine salvage enzyme that synthesizes a pyrimidine nucleotide precursor, uridine monophosphate, from uracil or phosphoribosylpyrophosphate (PRPP). This enzyme is present in bacteria Escherichia coli, but is absent in mammalian cells. UPRT can directly covert 5-FU to FUMP by bypassing rate-limiting reactions controlled by the cellular enzymes and greatly enhances the cytotoxicity of 5-FU. Nakamura and colleagues constructed a recombinant adenovirus containing the UPRT gene driven by a CAG (composed of a CMV immediate early enhancer and a modified chicken !-actin) promoter (AdCA-UPRT) (Nakamura et al, 2001). When the UPRT gene was transduced into cultured esophageal cancer cell lines, the sensitivities of all cultured cell lines to 5-FU were increased. When an AdCA-UPRT was directly injected into the tumors inoculated in nude mice followed by 5-FU administration, tumor proliferation was markedly inhibited compared with that in the group treated with 5-FU alone (Nakamura et al, 2001).

The suicide gene therapy involves transduction of tumor cells with a suicide gene followed by systemic administration of prodrug, usually the antiviral agent. The enzyme product encoded by the suicide gene converts potentially non-toxic prodrugs to highly toxic metabolites that subsequently kill the tumor cells.

A. HSV-tk/gnaciclovir The most frequently used suicide gene therapy protocol is the Herpes simplex virus type 1 thymidine kinase (HSV- TK)/ganciclovir (GCV) system. HSV- TK converts prodrug GCV to GCV monophosphate, which is further phosphorylated by cellular kinases, forming toxic GCV triphosphate. GCV triphosphate incorporates into the DNA and inhibits cellular DNA polymerase, leading to cell killing (Aghi et al, 2000). Mammalian cells lack HSVTK, thus GCV causes toxic effects only after cells are transfected with HSV- TK gene. Along with the HSV- TK gene transduced cells, neighboring non-transduced tumor cells are also observed to be killed thereby enhancing the efficacy of this system (Freeman et al, 1993). This â&#x20AC;&#x153;bystander effectâ&#x20AC;? involves various mechanisms including the direct cell-to-cell passage of toxic drug metabolites through the gap junctions, induction of apoptosis, and killing of tumor endothelial cells (Denning and Pitts, 1997). The applicability of the HSV- TK /GCV approach in cancer therapy was first demonstrated by Culver and colleagues who documented the regression of tumors in rats with a cerebral glioma after intratumoral injection of retrovirus-mediated HSV- TK, followed by treatment with GCV (Ram et al, 1993).

Matsubara and colleagues first examined the antitumor effect of HSV- TK /GCV suicide gene therapy on human esophageal cancer model (Matsubara et al, 1999a). Two human esophageal cancer cell lines, T.Tn cells which bears truncated p53 and TE2 cells with wildtype p53, were transduced with the HSV- TK gene (T.Tn/TK and TE2/TK) followed by GCV treatment. Both transduced cells, T.Tn/TK and TE2/TK, showed increased sensitivity to GCV compared with that of respective wildtype cells in vitro. However, the growth suppression of T.Tn/TK tumors was marginal in nude mice model and the tumors regrew thereafter while the growth of TE2/TK tumors was significantly inhibited and all the tumors

C. Double-suicide gene therapy The same group evaluated the antitumor activity and bystander effect of double gene transfer, the addition of HSV-TK to UPRT, using recombinant adenovirus vector (AxCA.UT) containing a UPRT/HSV-TK fusion gene (UT) (Shimizu et al, 2001). AxCA.UT treatment significantly enhanced the sensitivity of human esophageal cancer cells to and significantly enhanced the growth 40

Cancer Therapy Vol 6, page 41 inhibition effects of UPRT gene therapy in vitro.

Moreover, both 5-FU and GCV showed bystander effects on growth inhibition. In an in vivo study, the therapeutic outcome of AxCA.UT treatment significantly enhanced the antitumor activity of AdCA-UPRT treatment (Shimizu et al, 2001).

VI. Oncolytic therapy To overcome the low efficacy of tumor cell infection by replication-incompetent viral vectors, replicationcompetent viruses were exploited to proliferate specifically in malignant cells and spread within the tumor. These viruses act as direct cytotoxic agents using their ability to kill infected cells by cellular lysis. Their replication leads to amplification of the viral particles and subsequent release of newly made progeny to infect surrounding transformed cells after killing the infected cells, leaving normal cells unaffected. Thus, this process effectively amplifies gene transduction and achieves highlevel gene expression within tumor cells

V. Immunogene therapy The goal of cancer immunotherapy is to induce antibody and/or cytotoxic T lymphocyte (CTL) immune responses against cancer cells. Immunotherapy can be classified into two main categories; active immunotherapies (the stimulation of the immune system) and passive immunotherapies (the creation of immune cells). Active immunotherapies include specific active immunotherapy or vaccine therapy which elicits hostspecific anti-tumor immune responses. Non-specific active immunotherapy or immunomodulatory therapy, on the other hand, elicits a general immune system response to cancer using cytokines, such as GM-SCF and interleukins.

Passive immunotherapies include direct administration of monoclonal antibodies designed to target a specific receptor on the surface of a cancer cell. Most of attempts made for the therapeutic application of immune mechanisms for the treatment of esophageal cancer are through the use of immune-stimulatory cytokines.

The immunogene therapy is one of immunotherapeutic methods, which uses recombinant DNA constructs which encode cytokines, tumor antigens and accessory molecules. Numerous cytokines that modulate immune responses have been identified and evaluated for their antitumor effects in esophageal cancer.

The use of direct recombinant cytokine therapy, although highly effective at eradicating tumors, is generally of limited applicability due to its toxicity or subtherapeutic protein half-life. As a result, strategies using genetic methodology have been applied including cytokine gene transfection using viral vectors (Gupta et al, 2002; Matsubara et al, 1998; Shan et al, 2004; Sugaya et al, 1998) and cytokine plasmid DNA transfer using electroporation (Matsubara et al, 2001a) or cationic multilamellar liposomes (Tsunoo et al, 2002). IL-2 (Matsubara et al, 1998; Matsubara et al, 2001a), GM-CSF (Sugaya et al, 1998; Matsubara et al, 2001a), IFN-" (Tsunoo et al, 2002), IL-21 and -23 (Shan et al, 2004), and TNF-! (Gupta et al, 2002), either alone or in combination with other strategies, have shown an antitumor immune response which can be demonstrated by reduced tumor volume, intracranial T lymphocytes infiltration or a survival advantage in vivo.

Recently, Hanari and colleagues at Chiba University published the results of the combination of HSV- TK /GCV suicide gene therapy and IL-21 immune gene therapy. Plasmid DNA containing HSV-TK-suicide gene or IL-21 gene was injected into TE2 and Colon26 tumors developed in nude mice using in vivo electroporation.

They showed that IL-21-transduced tumors disappeared completely in syngeneic BALB/c mice but not in T-celldepleted nude mice, suggesting IL-21 induces T- and NKcell-dependent antitumor effects (Hanari et al, 2007).

A. Herpes simplex virus type-1 HSV-1 was described as the first genetically engineered virus for virotherapy for the treatment of esophageal cancer. HSV-1 has cytolytic property by nature and can infect a broad range of cell types. It has the large genome that can be replaced with multiple therapeutic transgenes without eliminating its oncolytic ability. In addition, many anti-herpetic drugs are available as a safeguard against unfavorable replication of the virus.

NV1066 is attenuated HSV mutant derived from strain F that has a deletion of the internal repeats. NV1066 also contains an insertion of the gene encoding enhanced green fluorescent protein (EGFP) under the control of a cytomegalovirus promoter, facilitating visualization of infected cells. NV1066 is attenuated primarily due to deletion of one copy of the diploid "neurovirulence" gene encoding ICP34.5. NV1066 effectively replicated within and killed BE3 esophageal adenocarcinoma cells in vitro and in subcutaneous and intraperitoneal mouse xenograft models (Stiles et al, 2003). Apart from its therapeutic effect, NV1066 showed the potential of localization of metastatic or locally advanced esophageal cancer. The expression of EGFP in infected cells can be used to visualize the virus and thus localize tumor deposits with the use of fluorescent laparoscopy and thoracoscopy (Stiles et al, 2003).

B. Adenovirus Adenovirus has been intensely investigated as a direct oncolytic agent against various types of human cancers and a variety of Phase I and II clinical trials have demonstrated the tolerability and safety of conditionally replicative adenoviruses (CRAd) administration; CV706 for prostate cancer (DeWeese et al, 2001), ONYX-015 for head and neck cancer (Nemunaitis et al, 2001), malignant glioma (Chiocca et al, 2004) and pancreatic cancer (Hecht et al, 2003). One common approach to target virus replication to a specific subset of cells is through the use of tissue- or tumor-specific promoters such as midkine, secretory leukoprotease inhibitor (SLPI), and cyclooxygenase-2 (COX-2) promoters. COX-2 is frequently expressed in neoplastic tissues and plays an essential role in many aspects of cancer progression in gastrointestinal cancers both directly and indirectly (Ono et al, 2005). Yamamoto and colleagues have constructed CRAd by controlling E1 gene expression with the COX-2

41

Park and Moon: Gene therapy for esophageal cancer promoter (Davydova et al, 2004). They also used infectivity enhancement based on incorporation of an RGD-4C motif into the HI loop of the adenoviral fiber knob domain as well as replacement of the Ad5 knob with the Ad3 knob (Ad5/Ad3-chimeric Cox-2 promoter-driven CRAds). Adenoviruses with the RGD-4C motif configured in the HI loop of the fiber-knob region showed superior infectivity in cells showing low CAR expression compared with vectors with wild-type Ad5 fiber. This enhancement is mainly mediated by the binding of the RGD motif onto integrins that are frequently overexpressed on the surface of the target cancer cells (Davydova et al, 2004).

Ad5/Ad3-chimeric Cox-2 promoter-driven CRAds selectively infected esophageal tumor cells and exhibited significantly improved oncolysis and progeny production compared with unmodified and RGD-modified vectors without sacrificing tumor selectivity in vivo and in vitro (Davydova et al, 2004).

promoter design and envelope modification (Ono et al, 2005), it remains to be seen whether any of these systems can be used for systemic delivery. On the other hand, a recent study has shown that liposomes have the potential for systemic delivery of genes to distant sites with minimal toxicity and it may be possible to use a liposome-based delivery system in conjunction with the other vector systems to effectively treat human cancers in vivo (Moon et al, 2003).

Other key factors in ensuring the success of gene therapy will be to develop a clear understanding of how it can best play a role in the clinic. For example, immunogene therapies are only ever likely to be effective in clinical situations where patients are at or have been returned to a state of low tumor burden and still have effective, functioning immune systems. Moreover, gene therapy is likely to be very effective in combination with pre-existing clinical regimens, such as chemotherapy and radiotherapy. A large number of studies are now showing great potential for combining gene therapy and pharmaceutical, immunological, and radiotherapeutic approaches to kill cells more effectively and in greater numbers.

In summary, there is still a long road ahead before the results gleaned from preclinical and clinical studies of gene therapy strategies approach their full potential in esophageal cancer and any other solid tumors, however, these strategies are already proving their worth as the next step in cancer treatment and, because gene therapy targets the etiology of the disease, may eventually have a role in cancer prevention.

VII. Conclusions Significant advances in understanding the molecular biology of esophageal cancer have led to the application of gene therapeutic methods where genetic material is transferred into human cells and expressed in those cells for a therapeutic purpose. However, the gene therapy in the field of esophageal cancer is in primitive stage compared to those in lung, head and neck and brain cancers. Majority of studies have been performed in Asian countries especially in Japan. That is mostly because the incidence of esophageal cancer varies among different regions and has been reported high in Asian regions (Asian esophageal cancer belt); 2-3 per million in North America and Europe, and 11.1 per million in Japan. There has been no reported result of clinical trial of gene therapy in patients with esophageal cancer yet except one report of a Phase I/II study of Ad5CMV-p53 therapy from Chiba University in Japan. Although limitations still exist, the preclinical findings have shown the great potential of gene therapeutic methods for the treatment of esophageal cancer. Initial concerns that the existence of multiple genetic lesions in cancer cells would prevent the application of gene therapy to cancer appear to be unfounded. Correction of a single genetic lesion has yielded significant tumor regression. Clinical trials of p53 gene replacement have provided information that will be useful in the design of future gene therapy strategies.

The ability to target delivery systems to tumor cells (targeting) distributed widely throughout a patientâ&#x20AC;&#x2122;s body would simultaneously increase efficacy and decrease potential toxicity; thus far, however, no such systemically targeted vectors exist (Neumann et al, 2002; Moon et al, 2003). Surface targeting would be optimal to prevent nonproductive binding and sequestration of vectors before they reach their target cells. It is now possible to activate infection through retroviral envelope binding only in tissues that express, for example, tumor-associated proteases and surface targeting is now also possible for adenoviral vectors. Promoters for transcriptional targeting of tumors need to be active in tumor cells and quiescent in normal cells. In the ideal case, the promoter would be tumor specific and despite impressive advances in both

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Elias et al: Management of soft tissue sarcoma assess correlates of survival: tumor size, grade, cell type and the primary site of the tumor.

space, 2 in the viscera, and 2 in the pelvis. Sarcomas that arose from buttocks or breast were considered truncal and were included in the torso region numbers.

II. Patients and Methods

C. Surgical management

This is a retrospective study of patients with STS of different cell types and various sites of origin. Patients with dermatofibrosarcoma protuberans, Kaposiâ&#x20AC;&#x2122;s sarcoma, gastrointestinal stromal tumors, uterine sarcoma, desmoid tumors, and sarcomas arising in subcutaneous tissues were excluded. Each case was microscopically diagnosed, identifying the cell type and grade on permanent sections. Histochemical staining was used when necessary to confirm the cell type.

Incisional biopsies were utilized to establish the diagnosis with the exception of retroperitoneal and intra-abdominal sarcomas. In most instances, these were resected without pre-operative tissue diagnosis. No frozen sections were utilized during surgery. All the patients underwent radical resections that included compartmental resections for extremity sarcomas or wide resections for truncal tumors. Sarcomas of the torso were widely resected with 5 cm margins. Small bowel sarcomas were resected with wide margins with the mesentery. Sarcomas of the colon or stomach were resected in standard radical fashions.

Retroperitoneal and pelvic sarcomas were resected (without prior tissue diagnosis) as far as the anatomical location allowed.

Margins of resections were free of tumor clinically and pathologically. In this study, we used the three grade system.

Post-operative radiation therapy was requested on patients with G2 and G3 sarcomas. None of the patients received pre-operative radiation therapy or brachytherapy. Six patients with T2 G3 STS (high grade and over 5 cm in size) received post-operative chemotherapy that consisted of mesna + doxorubicin + ifosfamide + dacarbazine (MAID) followed by radiation therapy.

All patients underwent surgical resections of the primary tumors by one senior surgical oncologist. Those with upper and/or lower extremities sarcomas were managed by compartmental resections. Some of the patients with large sarcomas of the forearms or legs underwent extended radical compartmental resections. An extended radical resection included the resection of more than one compartment and a large area of skin. Despite wide resections margins that were grossly free of tumor, wounds resulting from an extended radical resection were not closed by any tissue, but dressed open until the permanent pathology sections became available (Figure 1).

When negative margins of resection were confirmed, the large defects were closed with skin grafts. This method was utilized for several reasons: 1) to save as many normal functioning muscles in the event that the tumor had crossed the facial barrier between the muscular compartments, 2) allow granulation tissue to develop which helps in skin graft take, and 3) skin-grafts allow for easier visual inspection of the area for any evidence of local recurrence.

D. Tumor grade (G) and tumor size (T) The incidence of tumor grade correlated to tumor size is expressed in Table 1. Thirty-three patients (63%) had high-grade tumors, 9 (17%) had intermediate-grade, and 10 (19%) had low-grade.

III. Results The study population consists of fifty-two patients treated between July 1983 and March 2001. All were newly diagnosed with resectable primary STS. Most of the patients had somatic soft tissue sarcoma. Only ten patients had tumors of retroperitoneal or visceral origin. There were 24 men and 28 women. The ages ranged from 12 to 90 years with a median of 58. There were 6 AfricanAmericans and 46 Caucasians. Twenty patients were 60 years of age or older. The duration of follow-up ranged from three months (due to early death) to 22 years with a median of 7 years.

E. Post-operative therapy

adjuvant

radiation

Twenty-nine patients received post-operative radiation therapy (RT); 21 had G3 tumors (18 of them were T2), and eight had G2 tumors. Twenty-three of the 52 patients received no adjuvant irradiation; 10 had G1 tumors. The other thirteen did not receive adjuvant irradiation for a variety of reasons. These included: 1) patients refused radiation (n=3), 2) radiation oncologist felt there was no need for radiation (n=4), and 3) radiation therapy was not appropriate due to tumor location or patientâ&#x20AC;&#x2122;s condition (n=6).

A. Cell types The majority of patients had malignant fibrous histiocytoma (MFH) and liposarcoma (13 patients with each diagnosis). Other STS were less frequent [6 leiomyosarcoma, 5 angiosarcoma, 4 adult rhabdomyosarcoma, 3 synovial sarcoma, 2 malignant peripheral nerve sheath tumor (MPNST), i.e., malignant schwannoma]. There was one patient with each of the following diagnoses: Ewing's soft tissue sarcoma [primitive neuro-ectodermal tumor (PNET)], osteogenic soft tissue sarcoma, chondrosarcoma, alveolar soft tissue sarcoma, epitheloid sarcoma, and fibrosarcoma.

F. Survival Thirty-one patients (59.6%) are alive; 28 are disease free, and two are living with disease. Twenty-one patients (40.4%) died; three died from unrelated causes: stroke, heart attack, and metastatic carcinoma of the urinary bladder. Eighteen patients (36.5%) died of the disease, which were mostly high-grade sarcomas (Table 1). Four patients died during the first year of follow-up and seven died during the second year. Survival was correlated to tumor cell type, grade, and size. All patients with angiosarcoma, 10 of 13 with MFH, and three of six of the patients with leiomyosarcoma had G3 tumors. On the other hand, only five of 13 patients with liposarcoma had G3 (Table 2).

B. Anatomical sites of origin Five of the patients had sarcomas that originated in the head and neck area, 8 in the upper extremity, 9 in the torso, 20 in the lower extremity, 6 in the retroperitoneal

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Figure 1. Shows large defect in a forearm, status post-resection of rhabdomyosarcoma, dorsal aspect. This wound was dressed without tissue coverage for four days until the final pathology revealed no evidence of tumor at the margins of resection. This wound was then covered by autologous skin graft.

Table 1. The overall survival correlated to tumor grade (G) and tumor size (T)

n

G1T1 0

G1T2 10

G2T1 4

G2T2 5

G3T1 7

G3T2 26

Alive

-

8

3

2

4

14

Dead

-

2(a)

1

3

3(b, c)

12

Totals 52 31 (59.6%) 21 (40.4%)

n = number of patients (a) = one patient died of stoke (b) = one patient died of heart attack (c) = one patient died of urinary bladder cancer

Ten patients had intra-abdominal sarcomas and their survival was correlated to tumor location, cell type, grade, and size (Table 3). All had T2 tumors (> 5 cm in size) and six of 10 had G3 tumors. Five of these 10 patients (50%) were alive. However, only two of the six patients with G3 sarcoma were living.

Nine of the 52 patients developed local recurrences as the first sign of failure. Of these, seven had G3 sarcomas, one with G2, and one had G1 (Table 4).

Seven had not received adjuvant radiation therapy and two had received adjuvant radiation therapy postoperatively. Seven of the nine patients underwent resection of their recurrences and four were living.

Adjuvant RT was not administered for previously stated reasons. In one instance, the radiation oncologist felt that the resection was more than adequate and the patient (grade 3 MFH of thenar muscles) developed local recurrence 3 years later. He underwent re-resection and received RT.

Sixteen patients developed distant metastases as the first sign of recurrence or treatment failure. Thirteen of the 16 had G3 and three had G2 tumors. The site of metastases include lungs (n = 10), lungs and liver (n = 2), intraperitoneal (n = 1), kidney (n = 1), regional lymph nodes (n = 1), and spleen, ribs, and viscera (n = 1). The time from the initial diagnosis to the development of metastases ranged from five to 72 months. Ten patients underwent resection of their metastases. Thirteen of the 16 patients died of their disease. Survival, after the first event, ranged from one to 9 years. Three are alive: two with no evidence of disease at 6 to 8 years post-resection of their metastases and one alive with disease 16 years postresection of the first metastases to the liver. This patient underwent resection of a second distant metastasis to the lung (Table 5).

It was noted that some cell types are extremely aggressive and have higher tendency for local recurrence and systemic metastases. These included angiosarcoma

49

Elias et al: Management of soft tissue sarcoma and MPNST. There were five patients with angiosarcoma (all G3) and four died of their disease. In addition, we encountered two cases of MPNST and both were grade 3 sarcomas. In one case, the primary site was in the thigh and the patient underwent compartmental resection of the quadriceps muscles. This tumor recurred 3 years later requiring re-resection with part of the femur, which was replaced by allogenic bone graft. This patient is alive and

free of disease 19 years later. The second patient who had MPNST (malignant schwannoma) had an unusual presentation. The tumor began in the pelvis and extended through the greater sciatic notch to the gluteal region in an hourglass formation. This was resected sacrificing the sciatic nerve. This tumor recurred one month later and the patient died within few months.

Table 2. The overall survival correlated to tumor cell type, grade (G), and size (T) Cell type

n

MFH Liposarcoma Leiomyosarcoma Angiosarcoma Rhabdomyosarcoma Synovial Sarcoma MPNST Others

13 13 6 5 4 3 2 6

G1T2 A/D 4/0 0/1 0/1

G2T1 A/D 2/0 1/0 1/0 0/1 -

G2T2 A/D 0/1 2/1 1/0 0/1

G3T1 A/D 0/2 2/0 1/0 1/1 1/0

G3T2 A/D 5/3 2/1 0/2 0/3 2/1 2/1 1/1 2/1

Totals A/D 7/6 11/2 3/3 1/4 2/2 2/1 1/1 3/3

n = number of patients; A/D = number alive over number dead; MFH = malignant fibrous histiocytoma Others included one of each: PNET (Ewingâ&#x20AC;&#x2122;s soft tissue sarcoma), Osteogenic Sarcoma, Chondrosarcoma, Alveolar Cell Sarcoma, Epitheloid Sarcoma, and Fibrosarcoma.

Table 3. The overall survival of patients with intra-abdominal sarcomas correlated to tumor cell type, grade (G), and size (T) Site of primary Retroperitoneal

# of patients 6

# alive 4

# dead 2

Visceral

2

0

2

Pelvic

2

1

1

Cell type Liposarcoma Liposarcoma Liposarcoma Liposarcoma Angiosarcoma MFH* Leiomyosarcoma* Leiomyosarcoma Leiomyosarcoma MPNST

G 3 3 1 1 3 3 1 3 2 3

T 2 2 2 2 2 2 2 2 2 2

A/D D A A A D A D D A D

* means received adjuvant chemo (MAID); MFH = malignant fibrous histiocytoma; MPNST = malignant peripheral nerve sheet tumor (malignant schwannoma); A = alive; D = dead

Table 4. The disease free and overall survival of the patients who developed local recurrence as the first sign of failure correlated to tumor cell type, grade (G), size (T) and site of origin Cell type

G

T

Site of origin

MFH MFH Leiomyosarcoma Leiomyosarcoma MPNST MPNST Liposarcoma Liposarcoma Liposarcoma

3 3 1 3 3 3 3 2 3

2 2 2 1 2 2 2 2 2

Hand Neck Viscera Thigh Thigh Pelvis Retroperitoneal Peri-parotid Retroperitoneal

DFS (mo) 36 15 12 120 36 1 48 weeks 48

OS (mo) 60 36 24 156 228 3 60 6 60

A/D A D D A A D D D A

DFS = disease-free survival; OS = overall survival; MFH = malignant fibrous histiocytoma; MPNST = malignant peripheral nerve sheet tumor (malignant schwannoma); A = alive; D = dead

50

Cancer Therapy Vol 6, page 51 Table 5. The disease-free and overall survival of patients who developed distant metastases as the first sign of failure correlated to tumor cell type, grade (G), size (T), site of origin, and site of metastases Cell type

G

T

Site of origin

MFH MFH MFH MFH Angiosarcoma Angiosarcoma Angiosarcoma Angiosarcoma Leiomyosarcoma Leiomyosarcoma Leiomyosarcoma Synovial synovial PNET Chondrosarcoma Rhabdomyosarcoma

3 2 3 3 3 3 3 3 2 3 3 3 3 3 2 3

2 2 1 2 2 1 2 2 2 2 2 2 2 2 2 1

forearm thigh leg thigh retroperitoneal neck thigh scalp pelvis groin viscera calf back thigh thigh forearm

DFS (mo) 12 24 12 17 12 5 12 7 48 24 72 36 6 21

OS (mo) 48 24 24 48 12 108 48 12 61 48 48 60 144 108 48 26

A/D

Site of metastases

D D D D D D D D A D D D A A D D

Lungs Lungs Popliteal L N Lungs Lungs Lungs Lungs Lungs Liver & lung Liver & lungs Peritoneal Lungs Lung metastases, resected Right kidney metastasis, resected * Lungs Spleen + ribs + viscera

* received chemotherapy before and after the nephrectomy DFS = disease-free survival; OS = overall survival; A = alive D= dead; LN = lymph nodes; PNET = primitive neuroectodermal tumor (Ewingâ&#x20AC;&#x2122;s sarcoma)

+ radiation therapy versus patients treated by the three modalities (surgery + chemotherapy + radiation therapy).

While no statistical differences were noted, the poorest outcome was observed in patients who were treated by surgery only with a median disease-free survival of 42 months (Figure 2), and a median overall survival of 54 months (Figure 3).

It was noted that that there was little difference between the disease-free survival and overall survival among all the treatment groups. However, our data suggest that the addition of chemotherapy may prove beneficial, but more data are needed. The results of the survival analysis comparing the different treatment groups are summarized in Table 6.

G. Adjuvant systemic chemotherapy Six patients received adjuvant systemic chemotherapy prior to RT. All had G3 tumors and 5 had tumors over 5cm in size (T2). Three of the six patients had MFH, 1 rhabdomyosarcoma, 1 leiomyosarcoma, and another had alveolar soft tissue sarcoma of the breast (G3 T1) with lung metastases. The chemotherapy administered was MAID, which consisted of mesna 2,500 mg/m2 per day for 4 days, doxorubicin 20mg/m2 per day for 3 days, ifosfamide 2,000 mg/m2 per day for 3 days, and dacarbazine 250mgm/m2 per day for 4 days. These were administered intravenously for a total of 4 courses followed by irradiation in the range of 44 to 50 Gy. After a period of follow-up that ranged from 31 to 72 months, three patients succumbed to their disease and three are alive (two free of disease and one with disease).

In addition, one patient with Ewingâ&#x20AC;&#x2122;s soft tissue sarcoma (PNET) of the thigh (G3 T2) developed metastases to the right kidney, received three courses of chemotherapy prior to nephrectomy and two courses after the nephrectomy.

Each course consisted of cyclophosphamide, vincristine, doxorubicin, and ifosfamide. This patient is alive free of disease 6 years later. Another patient with alveolar soft tissue sarcoma (G3 T1) of the breast was found to have lung metastases at the time of diagnosis. This patient underwent mastectomy, resection of the lung metastases, post-operative chemotherapy (MAID), and no radiation therapy. This patient is alive free of disease for over 5 years.

Life-table analysis was performed to determine if there was difference in the disease-free survival and overall survival rates among patients with G3 T2 sarcoma treated by surgery only versus those who received surgery

IV. Discussion The majority of the patients had somatic STS and only ten had sarcomas that originated from the retroperitoneum or viscera. We excluded sarcomas that arose from the skin or subcutaneous tissues. Dermatofibrosarcoma is a localized disease with a tendency for local recurrence with almost no potential for distant metastases. Kaposiâ&#x20AC;&#x2122;s sarcoma is managed primarily by irradiation. Gastrointestinal stromal tumors and uterine sarcoma constitute different and distinct clinical entities. Desmoids and sarcomas arising in subcutaneous tissue were excluded as these tumors have better survival than either somatic soft tissue sarcomas or visceral and retroperitoneal sarcomas. All 52 patients included in this study had deep sarcomas according to AJCC Cancer Staging Manual (Greene et al, 2001). It has been reported that the two most common STS are MFH and liposarcoma (Fletcher, 1992). In this study, there were

51

Elias et al: Management of soft tissue sarcoma

Figure 2. Disease-free survival by treatment groups of the 26 patients with large (over 5 cm) high-grade (G3) sarcomas. Note that those treated by surgery alone had the poorest outcome.

Figure 3. Overall survival by treatment groups of the 26 patients with large (over 5 cm) high-grade (G3) sarcomas. Note that those treated by surgery only had the poorest survival.

Table 6. Disease-free and overall cumulative probability of survival at 72 months follow-up Treatment Group Surgery only Surgery + irradiation Surgery + chemotherapy + irradiation

Disease-Free survival .50 .57 .83

Overall Survival .50 .75 .83

Incidental Findings: Three patients developed second malignancies. These included breast, urinary bladder and prostatic cancers.

13 MFHâ&#x20AC;&#x2122;s and 13 liposarcomas that constituted 50% of the study patients.

Several methods of establishing the diagnosis have been reported ranging from fine needle aspiration or a large bore needle biopsy to open incisional biopsy. Each method has its advantages and disadvantages. However, accurate diagnosis with grade must be established if neoadjuvant therapy is to be considered. A needle biopsy may not yield sufficient tissue to determine the accurate

diagnosis with the cell type and grade. It may suggest the presence of malignant cells and can be misleading. This is demonstrated by a case of a patient who presented with a large gluteal tumor. The radiologist felt that the tumor had the characteristics of a synovial sarcoma. The needle biopsy was interpreted as soft tissue chondrosarcoma.

After the resection, the final diagnosis was changed to MFH. The microscopical examination of the specimen revealed areas mimicking chondrosarcoma, but the 52

Cancer Therapy Vol 6, page 53 majority of the specimen revealed MFH. Therefore, some of STS may consist of a variety of tissues that may lead to misdiagnosis even after an open biopsy. Frozen sections should be avoided because the interpretation by the pathologist can be difficult.

The most common primary site of origin in this study was the lower extremity with 37% incidence, which is comparable to the national average. This was followed in frequency by intra-abdominal sarcoma, which included the retro-peritoneal space, viscera and pelvis. This was followed by the torso then upper extremity. It should be noted that primary sarcomas of the head and neck region are rare in the adult population.

The technique of dressing the wound without tissue coverage until the pathology report for the permanent sections becomes available may be beneficial. If further resection is not required, the surgical defect can be closed with autologous skin graft. This approach can potentially save function by sparing some uninvolved muscles. The use of a skin graft to cover the surgical defect permits future inspection of the site allowing early detection of local recurrence. This technique could be very beneficial in the management of large STS of forearms and legs.

We used the three-tiered system for grading (not the four-tiered system) because of its simplicity and the small study population. Sixty-two percent of the study patients had high-grade tumors and over 75% of the study population had sarcomas over 5 cm in size (T2). These two factors; grade and size, constituted the majority of the cases within the high-risk population. Our data suggests that patients with intermediate and high-grade sarcomas have almost similar survival and they are managed in the same fashion. This may justify the 2-grade (low and high) system proposed to the AJCC (Greene et al, 2001).

The status of the margins of resection is another prognostic indicator and correlates to the tumor size and the primary site. In this study, the margins of resection were sufficiently wide grossly and pathologically except for the retroperitoneal, intra-peritoneal, and pelvic sarcomas. In these areas anatomical locations and vital structures restricted resections. The limitation on resection for adequate margins explains the role of site of origin on overall outcome as patients with intra-peritoneal and retroperitoneal sarcomas have a poor prognosis (Heslin et al, 1997; Lewis et al, 1998; Jacque et al, 1990).

Furthermore, in this study, all retroperitoneal and intraperitoneal sarcomas were T2 and six of the ten patients had high-grade tumors. The overall survival of the patients with intra-abdominal sarcomas was 50%. The best results were noted in patients with G1 tumors (Table 3).

The incidence of local recurrence and distant metastases correlated well to tumor grade. Seven of nine patients with local recurrences had G3 tumors and 13 of 16 patients with distant metastases had G3 sarcomas. One patient with G1 tumor developed local recurrence in the viscera and died of the disease demonstrating that the primary site can be a prognostic factor. On the other hand, nine patients had G2 tumors; four died of their disease, and five are alive. It seems that the tumor size plays a secondary role in the outcome in every grade.

Patients who developed radiation-induced sarcomas have a very poor prognosis for two reasons: the patient cannot receive additional radiation therapy and the tumors are usually high-grade and aggressive with potential risk for local recurrence and distant metastases. The survival remains poor despite radical resections (Thijssens et al, 2005). Two patients developed G3 T2 STS in the neck in the field of previous RT for Hodgkinâ&#x20AC;&#x2122;s disease. One was 28 year-old who developed MFH and the other was 23 year-old who developed angiosarcoma. The patient with MFH developed local recurrence followed by systemic metastases and the patient with angiosarcoma developed systemic metastases as the first sign of failure. Both failed to respond to MAID chemotherapy. However, other systemic chemotherapy should be considered as different cell-types may respond to different agents. Another example of extremely aggressive behavior was noted in one patient with MPNST (G3 T2) of the pelvis that extended through the greater sciatic notch into the gluteal region that required the sacrifice of the lumbar-sacral roots and the sciatic nerve. This tumor recurred in the pelvis in less than 4 weeks. Neoadjuvant chemotherapy should be considered if a preoperative diagnosis can be made in these tumors.

Patients with G3 T2 sarcomas have the poorest survival as 12 of 26 (46%) died of systemic metastases, primarily to lungs (Table 1). In addition, certain cell types were recognized as always high-grade and patients with these cell types are at risk of recurrence and metastases.

Angiosarcoma and PNST have these tendencies and may be considered for preoperative (neo-adjuvant) chemotherapy if the diagnosis can be established prior to resection. Preoperative RT may not be effective in bulky tumors. RT is most effective when delivered to a very low tumor load. For this reason, it should be administered postoperatively. On the other hand, brachytherapy may play a role in reducing the incidence of local recurrence.

Even then, in high-grade sarcomas, post-operative irradiation is necessary regardless of the extent of the margins of resection. An example is one of our patients with high-grade MFH of the thenar muscles of the hand who was denied RT and developed local recurrence 3 years later. Overall, there were more local recurrences in patients who did not receive RT regardless of the tumor cell type.

Our results suggest that a short latent period (from diagnosis to first event) could signify poor prognosis. This was true for local recurrences (Table 4), as well as for distant metastases (Table 5). Recurrences that develop within a short time of the resection of the primary or a previous recurrence signifies poor outcome. A longer latent period could indicate a better prognosis.

The anatomical locations of some sarcomas strongly suggest that STS do arise from a primitive multipotenital mesenchymal cells that differentiate along different lines.

Examples of this include: 1) synovial sarcoma in the muscle of the back or calf away from any synovial membrane or joint, 2) Ewingâ&#x20AC;&#x2122;s sarcoma in the muscles of the thigh, away from any bone in an adult, and 3) chondrosarcoma in the muscles of the back away from any cartilage.

53

Elias et al: Management of soft tissue sarcoma Frustaci S, Gherlinzoni F, De Paoli A, Bonetti M, Azzarelli A, Comandone A, Olmi P, Buonadonna A, Pignatti G, Barbieri E, Apice G, Zmerly H, Serraino D, Picci P (2001) Adjuvant chemotherapy for adult soft tissue sarcomas of the extremities and girdles: Results of the Italian Randomized Cooperative Trial. J Clin Oncol 19, 1238-1247.

Greene FL, Page DL, Fleming ID, Fritz AG, Balch CM, Haller DG, Morrow M (eds.) (2002) Soft Tissue Sarcoma. AJCC Cancer Staging Manual, 6th Edition, (pp. 193-197) New York: Springer-Verlag.

Heslin MJ, Lewis JJ, Nadler E, Newman E, Woodruff JM, Casper ES, Leung D, Brennan MF (1997) Prognostic factors associated with long-term survival for retroperitoneal sarcoma: implications for management. J Clin Oncol 15, 2832-2837.

Jacque DP, Coit DG, Hajdu SI, Brennan MF (1990) Management of primary and recurrent softJemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ (2007) Cancer statistics, 2007. CA Cancer J Clin 57, 43-66.

Lewis JJ, Leung DH, Woodruff JM, Brennan MF (1998) Retroperitoneal soft tissue sarcoma. Analysis of 500 patients treated and followed at a single institution. Ann Surg 228, 355-366.

Mills SE (1995) Sometimes we don’t look like our parents Mod Path 8, 347.

Rosenberg SA, Tepper J, Glatstein E, Costa J, Young R, Baker A, Brennan MF, Demoss EV, Seipp C, Sindelar WF, Sugarbaker P, Wesley R (1983) Prospective randomized evaluation of adjuvant chemotherapy in adults with soft tissue sarcomas of the extremities. Cancer 52, 424-434.

Rossai J (1996) Soft tissues. Ackerman’s Surgical Pathology, 8th Edition, (pp 2021-2133) St. Louis: Mosby.

Thijssens KM, van Ginkel RJ, Suurmeijer AJ, Pras E, van der Graaf WT, Hollander M, Hoekstra HJ (2005) Radiationinduced sarcoma: A challenge for the surgeon. Ann Surg Oncol 12, 237-245.

Tierney, JF, Stewart, LA, Parmar, MKB (1997) Sarcoma metaanalysis collaboration. Adjuvant chemotherapy for localized resectable soft-tissue sarcoma of adults: meta-analysis of individual data. Lancet 350, 1647-1654.

While local recurrences and distant metastases carry guarded prognosis, surgical resection should be considered (if appropriate) followed by systemic therapy. This approach yielded some long-term survivals.

Adjuvant chemotherapy prior to RT was utilized in a small number of patients with high-risk sarcoma. This seems to be beneficial as four of six patients were alive.

The suggested benefit is displayed in Figures 2 and 3.

However, controversy continues to exist regarding the use of adjuvant chemotherapy. Early reports indicated that the use of single agent doxorubicin showed no benefit (Alvegard et al, 1989). However, later it was reported that the use of poly-chemotherapy resulted in borderline benefits (Rosenberg et al, 1983; Frustaci et al, 2001).

Several other reports followed showing the beneficial results of the use of postoperative adjuvant chemotherapy (Tierney et al, 1997; Eilber et al, 2005). The fact remains that, while tumor grade is an important prognostic factor, we must also correlate the cell type to survival. We must keep in mind that different cell types may respond differently to different chemotherapeutic or targeted therapeutic agents. Therefore, trials with chemotherapy and/or targeted therapy, utilizing new agents, should be tested in various cell types rather than restricting the use to doxorubicin and ifosfamide based chemotherapy for all cell types of STS as it was suggested over a decade ago (Elias, 1992). Several new agents have been suggested including gemcitabine, paclitaxel, ecteinascidin, vinorelbine, and imatinib, which showed activity in desmoid tumors and gastrointestinal stromal tumors (Dileo & Demetri, 2005). Adjuvant chemotherapy should be considered in high-risk patients who refuse RT or if the radiation is not recommended because of previous irradiation. Adjuvant chemotherapy could prove to be ideal in patients with visceral or retroperitoneal sarcomas in place of RT that may result in bowel injury.

References Alvegård TA, Sigurdsson H, Mouridsen H, Solheim O, Unsgaard B, Ringborg U, Dahl O, Nordentoft AM, Blomqvist C, Rydholm A, et al (1989) Adjuvant chemotherapy with doxorubicin in high-grade soft tissue sarcoma: A randomized trial of the Scandinavian Sarcoma Group. J Clin Oncol 7, 1504-1513.

Dileo P, Demetri GD (2005) Update on new diagnostic and therapeutic approaches for sarcoma. Clinical Advances in Hematology and Oncology 3, 781-791.

Eilber FC, Eilber FR, Eckardt J, Rosen G, Riedel E, Maki RG, Brennan MF, Singer S (2004) The impact of chemotherapy on the survival of patients with high-grade primary extremity liposarcoma. Ann Surg 240, 686-695.

Elias AD (1992) Future directions in the management of soft tissue sarcoma. Hemat Oncol 10, 53-60.

Fletcher CD (1992) Pleomorphic malignant fibrous histiocytoma: Facts or fiction? A critical reappraisal based on 159 tumors diagnosed as pleomorphic sarcoma. Am J Surg Pathol 16, 213-228.

E. George Elias

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Cancer Therapy Vol 6, page 47 Cancer Therapy Vol 6, 47-54, 2008

Experience in the management of 52 patients with soft tissue sarcoma. The results of a median followup of seven years Research Article

E. George Elias1,*, Sally D. Brown1, William Joel Culpepper II2 1

Surgical Oncology Center, The Harry and Jeanette Weinberg Cancer Institute at Franklin Square, Baltimore, Maryland.

Department of Epidemiology and Preventive Medicine, Division of Healthcare outcomes Research, University of Maryland, School of Medicine, Baltimore, Maryland.

2

__________________________________________________________________________________ *Correspondence: E. George Elias, M.D., The Harry and Jeanette Weinberg Cancer Institute Franklin Square, 9103 Franklin Square Drive, Suite 2300, Baltimore, Maryland 21237, USA; Telephone: 443-777-7911; FAX: 443-777-6311; E-Mail: george.elias@medstar.net Key words: Soft tissue sarcoma Abbreviations: malignant fibrous histiocytoma, (MFH); malignant peripheral nerve sheath tumor, (MPNST); mesna + doxorubicin + ifosfamide + dacarbazine, (MAID); primitive neuro-ectodermal tumor, (PNET); radiation therapy, (RT); Soft tissue sarcomas, (STS) Received: 3 October 2007; Revised: 17 December 2007; Accepted: 17 December 2007; electronically published: February 2008

Summary The prognosis of soft tissue sarcoma depends on several factors, which include the tumor-grade (cell differentiation), tumor size, margins of resection, and the site of the primary. Patients with well-differentiated tumors are managed by radical resection only. On the other hand, those with moderately differentiated and poorly differentiated sarcomas are managed by radical resections followed by postoperative adjuvant radiation therapy.

This has been our standard treatment. This study was carried out to determine the efficacy of this therapy on the survival. This is a retrospective study of patients with sarcomas of somatic soft tissues, retroperitoneal, and visceral origins. All the patients were managed by radical resections. The majority also received post-operative radiation therapy for moderately and poorly differentiated sarcomas. The duration of follow-up ranged from 3 months (due to early death) to 22 years with a median of seven years. Fifty-two consecutive patients were studied. Thirty-three patients had high-grade, nine had intermediate, and 10 had low-grade sarcomas. Twenty-one patients (40.4%) died, 18 of them succumbed to their disease. Six patients with high-grade sarcoma underwent resection of the tumor, received adjuvant systemic chemotherapy followed by radiation therapy. Four are alive free of disease at 4 - 7 years, and 2 died of their disease at 24 and 34 months. Radical resection and post-operative irradiation (two local therapeutic modalities) may be sufficient for local control. However, peri-operative adjuvant systemic therapy should be considered in patients with high-grade sarcomas who could succumb to systemic metastases.

lines (Mills, 1995; Rossai, 1996). The prognosis of these tumors depends on the adequate margins of resection, the site of origin, and the stage of the disease. The stage includes the tumor size (with T1 = ! 5 cm, and T2 = > 5 cm) and, more importantly, the tumor grade (G), i.e., cell differentiation. Patients with well-differentiated tumors, i.e., low-grade (G1) are managed by radical resection or wide excision. However, those with moderatelydifferentiated, i.e., intermediate grade (G2) and poorly differentiated, i.e., high-grade (G3) sarcomas are managed by radical resection and post-operative irradiation. This is to reduce the rate of local recurrence with the intent of improving survival. This study was carried out to determine the efficacy of this therapeutic approach and to

I. Introduction Soft tissue sarcomas (STS) are relatively rare malignancies. It is estimated that 9,220 new cases will be diagnosed and 3,560 will die of the disease in the U.S. in the year 2007 (Jemal et al, 2006). These tumors constitute a heterogeneous group of neoplasms with wide variation in propensity for aggressive behavior. At one time, it was thought that STS were related to normal soft tissues and arose from fat, fascia, smooth muscle, fibrous tissue, blood vessels, or nerves. However, it has been shown that the majority of STS arise from primitive multipotential mesenchymal cells, which during the malignant transformation undergo differentiation along one or more

47

Cancer Therapy Vol 6, page 55 Cancer Therapy Vol 6, 55-66, 2008

Tumor acidity and malignancy: novel aspects in the design of anti-tumor therapy Review Article

Elisabetta Iessi, Maria Lucia Marino, Francesco Lozupone, Stefano Fais, Angelo De Milito* Department of Drug Research and Evaluation, Section of Drug Resistance and Experimental Therapeutic, Istituto Superiore di Sanità

__________________________________________________________________________________ *Correspondence: Angelo De Milito, PhD, Department of Drug Research and Evaluation, Section of Drug Resistance and Experimental Therapeutic, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome Italy; Phone: +39 06 49902153; Fax: +39 06 49903691; Email: Angelo.demilito@iss.it Key words: pH regulators, glycolisis, acidic vesicles, tumor biology, Microvesicles, tumors, Chemoresistance, Cannibalism acidity, hypoxia, cellular metabolism, Cellular mechanisms, cancer therapy Abbreviations: acridine orange, (AO); acute lymphoblastic leukemia, (ALL); ATP binding cassette, (ABC); breast cancer resistance protein, (BCRP); extracellular matrix, (ECM); hypoxia-inducible factor-1, (HIF-1!); intracellular pH, (pHi); lung resistance protein, (LRP); magnetic resonance spectroscopy, (MRS); matrix metalloproteinases, (MMPs); multi-drug resistance associated protein-1, (MRP-1); multi-drug resistance, (MDR); Na+/H + exchanger, (NHE); P-glycoprotein, (P-gp or MDR-1); pH-low insertion peptides, (pHLIP); Proton Pump Inhibitors, (PPI); reactive oxygen species, (ROS); trans-Golgi network, (TGN); Vacuolar H +-ATPase, (VATPase); vascular endothelial growth factor, (VEGF) Received: 9 January 2008; Accepted: 17 January 2008; electronically published: February 2008

Summary The peculiar features of hypoxia and acidity characterizing tumor microenvironment represent key factors in tumor progression, metastasis and response to therapies. Studies aiming at dissecting the metabolic pathways leading to such a hostile microenvironment are still scanty despite the early intuition of the Nobel price Otto Warburg that tumors develop as a “metabolic disease” based on their selective use of glycolysis to generate energy.

As a result of the acid production through the glycolysis occurring also in the presence of oxygen, tumors need to extrude protons in order to survive. The mechanisms used to eliminate protons include up-regulation of ion pumps like Vacuolar H+-ATPase (V-ATPase) and Na+/H+ exchanger (NHE) and increased turn over of acidic vesicles.

However, such mechanisms are also involved in the generation of the malignant behaviour of tumors which include unresponsiveness or resistance to chemotherapy, metastatic and invasive potential and altered survival/apoptosis regulation. As a consequence, studies aimed at better understanding these mechanisms will help to develop new therapeutic strategies to target cancer. We discuss here recent results showing new and sometimes neglected aspects of tumor biology whose importance needs to be evaluated in the design and application of novel anti-cancer therapies.

blood supply and acidity, factors that contribute to the progression from benign to malignant growth and that normally are not permissive for growth of normal cells. In order to survive in the unfavourable environment created by them, tumor cells up-regulate several proton extrusion mechanisms (Izumi et al, 2003; Sennoune et al, 2004).

Among the cellular pH regulators whose activity is enhanced in many tumors are the V-ATPase (MartinezZaguilàn, 1993), the Na+/H+ exchanger (NHE) (Lee and Tannock, 1998) and the carbonic anhydrase (Robertson et al, 2004). As shown by several methods both in vitro and in vivo, the consequence of such an aberrant activity of ion

I. Introduction Classical model of carcinogenesis are based on a sequence of mutations or epigenetic changes in the expression or activity of oncogenes, protooncogenes, tumor suppressor genes or apoptotic pathways (Nowell, 1976; Fearon and Vogelstein, 1990; Gillies and Gatenby, 2007). Recently, the role of tumor microenvironment in determining tumor malignancy has received renewed interest with the suggestion that environmental conditions may drive the selection of the cancerous phenotype (Gillies and Gatenby, 2004; Gatenby and Gillies, 2007).

Features of tumor microenvironment include hypoxia, low 55

Iessi et al: Tumor acidity and malignancy pumps is that the extracellular tumor environment has an acidic pH whereas the intracellular (cytosolic) pH is alkaline, therefore resulting in a reversed pH gradient across the plasma membrane. In many tumors, the chronic exposure to acidic pHe has been reported to promote invasiveness (Martinez-Zaguilàn, 1996; Rofstad et al, 2006), metastatic behaviour (Martinez-Zaguilàn et al, 1996) and resistance to cytotoxic agents (Wachsberger et al, 1997; Raghunand et al, 2001). The specific mechanisms tumors use to acquire a malignant phenotype are still largely unknown but recent finding suggest that the abnormal pH control may regulate several biological functions like trafficking of acidic vesicles (Glunde et al, 2003), drug resistance (Martinez-Zaguilàn et al, 1999), activity of proteases to digest the extracellular matrix (Glunde et al, 2003) and ability to phagocyte (Lugini et al, 2003) and/or cannibalize cells (Lugini et al, 2006). This review will attempt to emphasize the importance of pH regulation in many tumor functions correlated to malignancy and to evaluate possible therapeutic strategies based on a new thinking of tumors as a chronic disease.

to survive in hypoxic-anoxic environment through the upregulation of hypoxia-inducible factor 1-! and the adaptation of a glycolytic phenotype with the generation of lactate (Gatenby and Gillies, 2004). However, some in vivo experiments have suggested that the production of lactate via glycolysis is likely not the major mechanism responsible for the development of an acidic environment within solid tumours (Newell et al, 1992; Yamagata et al, 1998; Provent et al, 2007).

1. Hypoxia and acidity It is commonly believed that hypoxia and acidity are a direct result of the chaotic and heterogeneous microvasculature structure of solid tumors (Gillies et al, 1999; Schornack and Gillies, 2003).

During carcinogenesis, solid tumors are hyper-proliferative and are separated several hundreds of microns from blood vessels. Blood vessels are the primary mode for delivery of glucose and O2 and for the removal of metabolic H+ and lactate (Schornack and Gillies, 2003). As a result, oxygen and glucose must diffuse from the vessels through layers of tumour cells, where they are metabolized (Gatenby and Gillies, 2004). Oxygen concentrations decreases with distance from a capillary and tumor cells are even more distant from their blood supply. Tumor cells generally are highly proliferative and then require a more robust source of nutrients than normal tissues. Therefore, pre-malignant lesions will inevitably develop hypoxic regions and with low blood supply. Hence, there is a clear requirement for new microvasculature in the growth of tumors. Recent evidence indicates that tumor cells secrete active angiogenesis factors (Knighton et al, 1983; Gillies et al, 1999) and the most important of these factors in tumors is the vascular endothelial growth factor (VEGF). The VEGF mRNA levels dramatically increase within a few hours after exposing cell cultures to hypoxia and return to background when normal oxygen supply is resumed.

VEGF is also induced by glucose deprivation (Shweiki et al, 1992).

Notably, hypoxia and low blood supply continuously translate into an altered pH gradient between the extracellular environment and the cytoplasm and between the cytoplasm and endo-lysosomal vesicles (Simon et al, 1994; Mahoney et al, 2003; Luciani et al, 2004). There is evidence that hypoxia up-regulates both the expression and activity of carbonic anhydrase in order to enhance the extracellular acidification (Svatova et al, 2004), in turn contributing to tumor progression. Hypoxia and low blood supply seem to be involved in cancer progression, but some reports showed that are not the major mechanisms responsible for the development of an acidic environment within solid tumors.

A. Tumor microenvironment: acidity, hypoxia and cellular metabolism The microenvironment of solid human tumors is characterized by heterogeneity in oxygenation and the establishment of hypoxia is believed to occur very early in the development of a tumor, producing a microenvironment that is hypoxic, acidic, and low in nutrients (Wouters BG, Seminars in Radiation Oncology 2003). Human tumors have long been considered acidic based on microelectrode measurement (Wike-Hooley et al, 1984). Non-invasive measurement of tumor pH in animal tumor models by magnetic resonance spectroscopy (MRS) using 3-aminopropylphosphonate and ZK-150471 and experiments performed in solid tumour xenografts have demonstrated that the pHi of tumour cells is neutralalkaline (7.0-7.4) while the pHe of the same tumours is acidic (6.0-6.9), indicating that solid tumours have an acid-outside pH gradient (Negendank, 1992; Gillies et al, 1994; McCoy et al, 1995; Raghunand et al, 1999a; Ojugo et al, 1999). Hence, tumors contain regions with large, acid-outside pH gradients, while normal tissues generally have alkaline-outside pH gradients. The causes for the acidic pH in tumors may include environmental factors which develop during tumor growth such as (i) deficiencies in tumor perfusion, due to the abnormal vascularization of the tumor mass; (ii) hypoxia and metabolic abnormalities associated with transformation and cell growth, and (iii) an increased capacity for transmembrane pH regulation. These environmental conditions may create a sort of vicious circle that favoring the selection of highly malignant tumor cells contributes to maintain the same hostile conditions. Notably, hypoxia and low blood supply continuously translate into an altered pH gradient between the extracellular environment and the cytoplasm and between the cytoplasm and endolysosomal vesicles (Simon et al, 1994; Mahoney et al, 2003; Svastova et al, 2004).

An important determinant of tumor acidity is the anaerobic metabolism which allows selection of cells able

2. Acidity and glycolisis Over 75 years ago Otto Warburg postulated that tumors are acidic due to their marked rate of lactic acid production (Warburg, 1956). He observed that tumour cells maintain a high glycolytic rate even in conditions of adequate oxygen supply (aerobic glycolysis or “Warburg effect”) and depend largely on this metabolic pathway for the generation of energy (i.e. ATP). He attributed this 56

Cancer Therapy Vol 6, page 57 metabolic alteration to mitochondrial ‘‘respiration injury’’ and considered this as the most fundamental metabolic alteration in malignant transformation or ‘‘the origin of cancer cells’’ (Warburg, 1956; Xu et al, 2005). The biochemical and molecular mechanisms underlying the “Warburg effect” are extremely complex and remain to be defined. Among the possible mechanisms, mitochondrial malfunction and hypoxia in the tumor microenvironment are considered two major factors contributing to it (Xu et al, 2005; Pelicano et al, 2006). A hypoxic environment within the tumor mass limits the availability of oxygen for use in mitochondrial respiration and synthesis of ATP and forces the cancer cells to up-regulate the glycolytic pathway as the main route of energy production (Guppi, 2002; Xu et al, 2005). Hypoxia favours a shift of glucose metabolism to less efficient glycolytic pathways in many cancer phenotypes (Gatenby and Gillies, 2004; Gatenby and Gillies, 2007), making glycolysis essential for tumour survival (Bartrons and Caro, 2007).

A key regulator of the glycolytic response is HIF-1! (hypoxia-inducible factor-1glycolytic response is HIF), a transcriptional activator that controls the expression of most of hypoxia-regulated genes. HIF-1glycolytic response is HIF is overexpressed in a variety of tumours and its expression appears to correlate with poor prognosis and responses to chemo or radiotherapy (Bartrons and Caro, 2007).

The adaptation to hypoxia through the up-regulation of glycolysis has a significant negative consequence, i.e. the increased acid production causing a significant decrease in extracellular pH. Since exposure to acidic microenvironment results in cell death, extracellular acidosis requires an additional adaptation through resistance to apoptosis and up-regulation of membrane ion channels in order to maintain intracellular pH in the range of normality (Gatenby and Gillies, 2004). Indeed, the unfavourable environment may favour tumor cells able to survive in acidic and hypoxic conditions via selection of cells that are resistant to hypoxia, acid-induced cell toxicity and hypoxia-induced, p53-dependent apoptosis (Kim et al, 1997). However, it is also known that the major cause of acidity in tumors it is not the lactic acid production, as also demonstrated in rat gliomas where sites of proton efflux and sites of glycolysis had a different distribution (Provent et al, 2007).

B. Cellular mechanisms altered in tumors 1. pH regulators Maintenance of the intracellular pH (pHi) is crucial to normal cell function because many cellular processes have a narrow pH optimum. Moreover, evidences have shown that tumor cells exist within an acidic microenvironment, probably due to accumulation and poor removal of metabolic acids such as lactic acid and protons derived from glycolysis (Figure 1).

Figure 1. Schematic representation of novel anti-tumor agents targeting metabolic pathways and pH regulation.

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Iessi et al: Tumor acidity and malignancy To survive and proliferate under these acidic conditions, tumor cells must up-regulate the proton extrusion mechanisms that maintain the pHi. The influence of pHi on many cellular functions has been studied with respect to cell growth (Helmlinger et al, 1997), cell motility (Martinez-Zaguilàn, 1998), tumorigenesis (Perona and Serrano, 1988), metastasis (Schlappack et al, 1991), apoptosis (Gottlieb et al, 1995), and drug resistance in cancer cells (Thiebaut et al, 1990; Martinez-Zaguilàn et al, 1999). Four major types of pHi regulatory mechanisms have been identified in tumor cells: Na+/H+ exchangers, bicarbonate transporters, proton-lactate symporters and proton pumps. These transmembrane proteins are ion pumps or ion exchangers and pump protons across the plasma membrane from the cytoplasm to the opposite site of the membrane, the extracellular space or the lumen of various organelles.

Among these proton pumps one of the most studied are the V-ATPases. V-ATPases are involved in maintaining a relative neutral pHi, an acidic luminal pH and an acidic pHe, through pumping protons into extracellular environment or within the lumen of some membrane-bound organelles (Nishi and Forgac, 2002).

These ATP-dependent proton transporters are ubiquitously expressed (Nishi and Forgac, 2002), not only in vacuolar membranes but also in plasma membranes (MartinezZaguilàn et al, 1993, Nishi and Forgac, 2002) of various specialized eukaryotic cells, in which they play important functions (Vaananen et al, 1990; Nanda et al, 1992; Gluck et al, 1996). Recent evidences suggest that V-ATPases are functionally expressed in plasma membranes of human tumor cells and may have specialized functions in cell growth, differentiation, angiogenesis, invasion and metastasis (Martinez-Zaguilàn et al, 1993, 1998). In tumor cells the extrusion of protons by V-ATPases causes intracellular alkalinization and extracellular acidification which are important mechanism favouring growth, resistance to apoptosis and invasion (Martinez-Zaguilàn et al, 1996, 1999). Such a mechanism contributes to the maintenance of an aberrant pH gradient between the alkaline cytosol and the acidic extracellular environment.

The low pH of tumor extracellular microenvironment may influence the increased secretion and activation of proteases. Moreover, low pHe may promote the degradation and remoulding of extracellular matrix (ECM) through the activation of proteolytic enzymes, including matrix metalloproteinases (MMPs), bone morphogenetic protein-1-type metalloproteinases, tissue serine proteases, and adamalysin-related membrane proteases, thus contributing to cancer invasion and metastasis (MartinezZaguilàn et al, 1996; Rofstad et al, 2006). Some data suggest that different use of ion exchanger may help to distinguish tumor cells with different metastatic behaviour (Sennoune et al, 2004). In fact, while breast cancer cells with low metastatic potential preferentially utilize Na+/H+ exchangers and HCO3--based H+-transporting mechanisms, highly metastatic cells preferentially use plasma membrane V-ATPases, suggesting that V-ATPases are important in the acquisition of a more metastatic and invasive phenotype (Sennoune et al, 2004). Furthermore, V-ATPases have been involved in the acquisition of the

multidrug resistance phenotype (Laurencot et al, 1995; Martinez-Zaguilàn et al, 1999; Raghunand et al, 1999b) and treatment with inhibitors of the V-ATPases (most of which are highly toxic) may reverse tumor resistance (Altan et al, 1998; Izumi et al, 2003; Ouar et al, 2003; Luciani et al, 2004; De Milito and Fais, 2005).

Specific inhibitors of V-ATPase like Bafilomycins have been reported to induce apoptosis in human cancer cells (Nakashima, 2003). Proton Pump Inhibitors (PPI) have been successfully used for the treatment of peptic diseases, due to their anti-acidic properties. After protonation in the acidic spaces of the stomach, PPI irreversibly bind the proton pump, dramatically inhibiting proton translocation and acidification of the extracellular environment. The specific targets of PPI are H+-ATPases contained within the lumen of gastric parietal cells and, though to a lesser activity, they inhibit the activity of VATPases, thus blocking proton transport across membranes. Recent data obtained by our group (De Milito et al, 2007) and by Lu and collaborators (Lu et al, 2005) strongly demonstrated that inhibition of the V-ATPase has an antineoplastic activity (Fais et al, 2007). In fact, the inhibition of V-ATPase function via knockdown of ATP6L (c subunit gene) expression using siRNA suppresses cancer metastasis by decreased proton extrusion and downregulated protease activity (Lu et al, 2005). Our group has shown that proton pump inhibitors induce cell death in human B cell tumors by a mechanism involving oxidative stress and lysosomal membrane perturbation (De Milito et al, 2007). Interestingly, these two different types of antineoplastic strategies resulted in delayed tumor growth in vivo as shown by i) inhibition of B cell lymphoma growth in PPI-treated SCID mice and ii) retarded tumor growth and suppressed cancer metastasis in nude mice. These data suggest that V-ATPases and its activity regulating the reversed tumor pH gradients may represent a potential target for cancer therapy (Izumi et al, 2003; Fais et al, 2007).

2. Role of acidic vesicles in tumor biology Metastatic behaviour of solid tumours has been associated with increased expression of extracellular lysosomal proteases, such as cathepsin D, L and B, and metalloproteases causing tissue remodelling (Sloane et al, 1981; Danö et al, 1985; Liotta et al, 1991; Fais et al, 2007). There is strong evidence indicating also a pivotal role of lysosomal-like vesicles in the degradation of ECM, cell invasion, and cell migration into ECM of some cancers, including breast cancer (Montcourrier et al, 1994; Montcourrier et al, 1997; Glunde et al, 2003). In breast cancer cell lines acidic pHe caused a significant redistribution of lysosomes from the perinuclear region to the cell periphery (Glunde et al, 2003). In malignant tumor cells, cathepsin B+ vesicles redistribution toward the cell periphery and constitutive secretion of active cathepsin B were observed at acidic pHe (Rozhin et al, 1994).

Lysosomes displacement to the cell periphery, detected in response to an acidic pHe, may be a mechanism to facilitate increased secretion of degradative enzymes (Glunde et al, 2003), thus facilitating tumor invasion and metastasis.

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Cancer Therapy Vol 6, page 59 Moreover, there is increasing evidence that acidic vesicles expressing typical lysosomal or endosomal markers are involved in phagocytic activity of tumor cells (Lugini et al, 2003). Furthermore, highly metastatic cells were found to express more lysosomal proteins, such as Lamp-1 and -2 on the cell surface (Saitonh et al, 1992). In breast cancers very large acidic heterophagosomes were observed, containing high levels of cathepsin D and sufficiently acidic to allow cathepsins activation and degradation of endocytosed proteins, whose presence is correlated with tumor invasion (Montcourrier et al, 1994).

Recent data have also shown that only cells derived from metastatic lesions exert a phagocytic activity (they can engulf, ingest and digest latex beads, yeast and apoptotic cells), suggesting that phagocytic behaviour enables malignant cells to survive in the lack of nutrients supply and may be considered an indicator of high-grade malignancy (Lugini et al, 2003). Altogether this data have shown that the phagocytic activity may represent a new tool in discriminating the level of aggressiveness of human malignant cells and the connection of phagosomal vesicles to the actin cytoskeleton supports the use of new antitumor strategies aimed at inhibiting the tumor phagocytic activity (Lugini et al, 2003).

4 Chemoresistance Acquired resistance to chemotherapeutic drugs, a phenomenon known like multi-drug resistance (MDR), is a major cause of treatment failure in cancer patients (Nielsen and Skovsgaard, 1992; Gottesman and Pastan, 1993). Mechanisms underlying drug-resistance are not yet entirely known but the major hypothesis involves biochemical and microenvironmental factors.

In classical multidrug resistance, cells exhibit resistance to a wide range of structurally and functionally unrelated compounds, including anticancer drugs such as vinca alkaloids, anthracyclines, taxoids, and other antimitotics (Dalton, 1994; Raghunand et al, 1999b). The MDR cells over-express a variety of transmembrane drug efflux pumps, belonging to the ATP binding cassette (ABC) transporters family, which include P-glycoprotein (P-gp or MDR-1) (Gottesman and Pastan, 1993), the multi-drug resistance associated protein-1 (MRP-1) (Cole et al, 1992), the lung resistance protein (LRP) (Scheper et al, 1993; Izquierdo et al, 1996) and the breast cancer resistance protein (BCRP) (Doyle et al, 1998). These proteins extrude against concentration gradient drug molecules from the cell to the extracellular environment and this phenomenon cause a significant decrease in intracellular drug retention. Although the increase in the expression and activity of these proteins is directly related to the in vitro generated MDR, the same relationship was not shown in the in vivo resistance of solid tumours to the various cytotoxic drugs, seriously opening severe doubts on the clinical relevance of this phenomenon (Leonard et al, 2003).

Another mechanism of resistance may be changes in the pH gradient between the extracellular environment and the cell cytoplasm and/or in the pH gradient between the cell cytoplasm and lysosomal compartments observed in tumors (Simon et al, 1994; Mahoney et al, 2003). Since the mechanisms of entry of drugs into the cell are dependent on both concentration gradients and pH gradients, the reversed pH gradients of tumors may severely affect drugs entry (Raghunand and Gillies, 2000; De Milito and Fais, 2005). It is well known that low pHe reduces the uptake of weakly basic chemotherapeutic drugs and, hence, reduces their cytotoxicity preventing weakly basic drugs to reach their intracellular target (Raghunand et al, 1999b).

As mentioned above, an important mechanism for chemoresistance involves acidic vesicles and the altered pH gradient between the cytoplasm and intracellular organelles. Many chemotherapeutic drugs such as the anthracyclines and vinca alkaloids are weak bases. They are membrane permeable in their neutral form and relatively membrane impermeant when protonated and charged. Upon entering any of the acidic compartments of the cell (such as the lysosome, recycling endosomes, trans-Golgi network (TGN), or secretory vesicles), they will be protonated and sequestered within these compartments. It is known that lysosomal-like vesicles present in MDR cells are more acidic respect to their counterpart in drug-sensitive cells (Altan et al, 1998). This suggests that after the entry of drugs into the cells, basic drugs are sequestered by acidic compartments and are

3. Microvesicles and tumors Exosomes are small microvesicles (50-100 nm) biologically active, originating from acidic vesicle turnover and released by cells upon fusion of multivesicular bodies with the plasma membrane (Keller et al, 2006; van Niel et al, 2006). Microvesicles play important regulatory role in a variety of cellular functions including immunomodulation, differentiation and antigen presentation (Keller et al, 2006; Valenti et al, 2007). Data have shown that exosomes produced by mouse dendritic cells pulsed with tumor peptide are able to mediate the rejection of established tumors (Zitvogel et al, 1998, 2000; Keller et al, 2006). Human malignant tumors can secrete exosomes able of inducing antigen-specific tolerance, Fasmediated T-cell apoptosis (Andreola et al, 2002; Abusamra et al, 2005; Taylor and Gercel-Taylor, 2005) and tumor immune escape through expression of functional apoptotic molecules in different types of human tumors (Huber et al, 2005; Valenti et al, 2007). Moreover, exosomes were also shown to play a role in the control of tumor growth and tumor invasion (Taylor and GercelTaylor, 2005; Koga et al, 2005; Liu et al, 2006). In fact, pretreatment of mice with exosomes derived from murine mammary carcinomas augumented tumor growth by inhibiting the cytolytic activity of NK cells.

Trafficking of acidic vesicles is also involved in the chemoresistance independently of P-glycoprotein (P-gp) expression (Dietel et al, 1990; Bobichon et al, 1996; Cleary et al, 1997; Bour-Dill et al, 2000). In fact, the increased acidification of lysosomal-like vesicles may substantially determine the sequestration and/or neutralization of drugs into acidic intracellular compartments and their elimination through increased activity of the secretory pathway (Raghunand et al, 1999c, 2003).

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Iessi et al: Tumor acidity and malignancy secreted from the cell through the normal pathways of vesicular traffic and secretion. Moreover, the possibility that basic drugs are directly protonated and neutralized by the acidic pHe of tumors has to be considered (De Milito and Fais, 2005).

Agents that disrupt or normalize the pH gradient in tumors may reverse MDR and/or directly inhibit tumor growth. For example, sodium bicarbonate treatment causes alkalinization of tumor growth in vivo (Raghunand et al, 1999b). Lysosomotropic agents that induce pH gradient modification and alkalinisation of acidic vesicles may reverse anthracycline resistance in multidrug-resistance cells (Ouar et al, 2003). Our group showed that pretreatment with PPI induced i) reversion of drug-resistance in chemoresistant human melanoma cells and ii) increased sensitivity to cytotoxic drugs in MDR cell lines (Luciani et al, 2004). These data suggest that the peculiar acidic pH of human cancers may represent a target mechanism of new and specific anticancer therapies aiming at “normalizing” the reversed pH gradient, thus depriving tumor cells of a crucial homeostatic mechanism for cell survival and proliferation (Fais et al, 2007).

C. New approaches for cancer therapy Recent studies aimed at investigating the mechanisms behind tumor malignancy will provide insights into the identification of novel targets for the treatment of human tumors (Figure 1). We already know that tumors have an alkaline-acidic outside pH gradient generated by the up-regulated activity of proton transporters that maintain an alkaline pHi and an acidic pHe. In cancer cells also the pH gradient between the cytoplasm (alkaline) and the lumen of intracellular vesicles (very acidic) is altered and its regulation is fully controlled by V-ATPases. The homeostatic regulation of such abnormal pH gradients by V-ATPases may represent a suitable and specific target for novel anticancer strategies (Fais et al, 2007). Furthermore, recent evidence has shown that pHi is critical for the cytotoxicity of anticancer agents and V-ATPase has been implicated in the acquisition of the multidrug resistance phenotype (Laurencot et al, 1995; Martinez-Zaguilàn, 1999a,b).

Therefore, understanding the mechanisms regulating pHi and tumor acidity is important for developing new approaches to cancer therapy and V-ATPase may represent a potential target for cancer chemotherapy (Torigoe et al, 2002; Sennoune et al, 2004; Fais, 2007).

Because of the importance of the reversed pH gradients in malignant progression of tumor cells, the authors tested the specific effects of PPI on (i) drugresistance in a variety of human tumor cells and (ii) growth of B cell tumors, both in vitro and in vivo. Most chemotherapeutics are weak bases and accumulate either in the acidic tumor microenvironment or in the lumen of acidic intracellular vesicles, representing these two factors the bases for cellular resistance to drugs (Raghunand et al, 1999b; De Milito and Fais, 2005). We observed that physiologic concentrations of PPI significantly increase the pH of acidic intracellular vesicles and the pHe, inducing accumulation of acidic vesicles in the cell.

Indeed, pre-treatment with PPI in vitro and in vivo (i) reverted chemoresistance of different tumor cells to cisplatin, 5-fluorouracyle and doxorubicin, and (ii) increased the sensitivity of drug-sensitive cells to anticancer agents. These effects were mediated by the intracellular retention of chemotherapeutic agents, associated with a “normalization” of the pH gradients of the tumor cells (Luciani et al, 2004). In the acidic microenvironment of tumors, by analogy with the gastric compartment, PPI may undergo acidity-induced protonation, followed by transformation in the active form that blocks the H+-ATPase, in turn altering the tumor pH gradients. In fact, we found that PPI effect on tumor cells were directly related to the level of acidity of the culture medium (De Milito et al, 2007). PPI induced selective cytotoxicity in B cell tumors that passed through an early massive reactive oxygen species (ROS) activation and lysosomal membranes perturbation, leading to a caspaseindependent cell death (De Milito et al, 2007). PPI caused also alkalinization of acidic vesicles and acidification of the cytosol. The antineoplastic activity of PPI was observed also in pre-B acute lymphoblastic leukaemia cells obtained from patients with acute lymphoblastic

5 Cannibalism More recently malignancy of tumor cells has been related to another important feature, considered a survival option of malignant tumors that live in condition of nutrient deprivation, such as “cannibalism” (Lugini et al, 2006; Fais, 2007). Cannibalism is recognized as a phenomenon used by unicellular and higher organisms, even at single-cell level (Lugini et al, 2006). Cells with cannibalic behaviour have been identified in malignant tumors up to a century ago and recently have been detected in tumors of different histologies (DeSimone et al, 1980; Fujii et al, 1986; Kojima et al, 1998; Kumar et al, 2001). Some data indicate that cannibalism is a feature associated with malignancy but little is known about the mechanisms underlying this phenomenon. Some reports suggested that cannibal tumor cells contain other cells through which feed themselves (Monteagudo et al, 1997; Caruso et al, 2002; Lugini et al, 2006). A recent report showed that cannibalism, like phagocytosis, is an exclusively property of metastatic malignant cells (Lugini et al, 2006). This report demonstrated also that during cannibalism a live lymphocyte established a contact with melanoma cell and then sink into the tumor cells. This leads to the formation of large vacuoles where the lymphocyte remains alive but progressively undergoes necrosis and degeneration (Lugini et al, 2006). The endolysosomal compartment of cannibal cells is rich in caveolin-1, is more acidic and over-express cathepsin B, a proteolytic enzyme involved in tumor invasion and metastasis. Like in phagocytosis, the actin cytoskeleton have a key role in the cannibalic behaviour of metastatic cells, allowing the formation of the “cannibalistic vacuole” that contains a highly efficient digestive machinery (Lugini et al, 2006). Experimental data have shown that cannibalism is increased in acidic culture condition and then inhibition of tumor acidity may represent a further therapeutic approach against cannibalistic activity (Lugini et al, 2006; Fais, 2007).

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Cancer Therapy Vol 6, page 61 leukemia (ALL), as well as in SCID mice engrafted with B cell lymphomas, whose growth was significantly reduced following PPI oral administration (De Milito et al, 2007).

It is clear from those data that ROS accumulation is an early event in the PPI-mediated antineoplastic effect and that permeabilization of acidic vesicles is a crucial event in this cascade, that is rapidly followed by the acidification of cytosol, with a possible massive activation of protease and other very dangerous lytic enzymes leading the cells to dead through a sort of autodigestion. However, these results provided the proof of concept that PPI may be considered, not only chemosensitizer agents, but also a new class of antineoplastic drugs. Other pharmacological inhibitors of V-ATPases activity have been used in the past with high level of efficacy in vitro but their potential application in clinical settings is hampered by predicted toxicity on normal cells (De Milito and Fais, 2005). PPI are not toxic to normal cells while they exert their action against tumor cells and this is proven to occur in vivo as well (De Milito et al, 2007). The great potential of PPI as V-ATPases inhibitors is that they need (i) an acidic or at least unbuffered medium to work as anticancer drugs and (ii) protonation to be transformed in the active drug (De Milito and Fais, 2005). This in turn means at least two important things: (i) they are recruited by the acidic compartments and (ii) only in these compartments they are activated in order to work as antiacid drugs.

Like the V-ATPases, other cellular pH regulators (NHE, MCT, CA) are important in the maintenance of pH homeostasis in cancer cells (Lee and Tannock, 1998; Izumi et al, 2003; Robertson et al, 2004) and may represent suitable targets for anticancer strategies. For each of them, inhibitors have been identified to date but little is known about their cellular mechanism of action.

Among the NHE inhibitors, amiloride and its derivatives have been shown to induce apoptosis in leukemic cells but not in normal cells (Izumi et al, 2003). It has been recently shown by that CA IX may control acidification of the tumoral extracellular pH under hypoxic conditions (Svastova et, 2004) and this process can be perturbed by inhibiting CA IX with selective sulfonamide inhibitors (Winum et al, 2007). Many biological and pharmacological data point to the possible use of the inhibition of tumor associated CA IX in the management of hypoxic tumors, which do not respond or poorly respond to the classical chemo- and radiotherapy.

However, further experimentation is needed to fully understand whether this approach will lead to new class of antitumor drugs (Winum et al, 2007).

In addition, acridine orange (AO) and pH-low insertion peptides (pHLIP) have been proposed as novel intriguing antitumoral strategies employing tumor acidity as a delivery system. In a model of osteosarcoma, AO selectively accumulates in the tumor tissue due to reversed pH gradients, and following photo-dynamic therapy AO is activated and selectively kills cancer cells (Kusukaki et al, 2007). Recently, interesting nanotechnology data identified peptides able to selectively insert into the membrane of cancer cells only at acidic pH, thus providing a powerful tool for selective delivery of

therapeutic agents to the acidic site of the tumors (Andreev et al, 2007).

The ability of cancer cells to phagocyte and cannibalize living cells provides another potential target whose regulation is likely dependent on acidic vesicles trafficking and pH (Fais, 2007). These activities are an exclusive property of cells derived from malignant lesions and are regulated by the actin cytoskeleton. In particular, the ERM proteins, known to link membrane proteins to the actin cytoskeleton, are important in the connection of the phagocytic machinery to the actin cytoskeleton (Lugini et al, 2003, 2006). These novel data support the use of new antitumor strategies aimed at inhibiting the tumor phagocytic/cannibal activity through targeting components of the cannibal framework (Fais, 2007).

Another class of anticancer agent for new therapeutic strategies could be the inhibitors of glycolytic pathway, important for ATP generation. These drugs have a broad therapeutic application and are particularly effective against cancer cells with mitochondrial defects or under hypoxic conditions, which are frequently associated with cellular resistance to conventional anticancer drugs and radiation therapy (Xu et al, 2005). The glycolytic inhibitors known include the 2-deoxyglucose, an analogue of glucose and able to bind and suppress hexokinase II (Geschwind et al, 2004) and arsenate compounds that cause arsenolysis in the glyceraldehyde-3-phosphate dehydrogenase reaction, although they seem to have toxic effects. It was recently shown that inhibition of hexokinase II by 2-deoxyglucose causes a depletion of cellular ATP, leading to blockage of cell cycle progression and cell death in vitro, and exhibits antitumor activity in vivo (Maher et al, 2004; Maschek et al, 2004). 3bromopyruvate (3-BrPA), another potent inhibitor of hexokinase II (Ko et al, 2001; Geschwind et al, 2004), seems to effective kill liver cancer cells in animal models when given by local infusion (Geschwind et al, 2002).

Recent evidence have showed that inhibition of glycolysis by 3-BrPA led to the activation of an apoptotic cascade (Xu et al, 2005). The ability of 3-BrPA to preferentially kill cancer cells with mitochondrial defects and that live in a hypoxic environment provides a biochemical basis to further develop this class of compounds as novel anticancer agents with potentially promising therapeutic activity and selectivity (Xu et al, 2005).

II. Conclusions Despite the great efforts of the scientific community in finding proper treatments for cancer, human tumors responsive to chemotherapy have not changed in the last three decades (e.g., lymphomas, leukemias and some pediatric tumors) while many others such melanomas and most adenocarcinomas still are unresponsive or poorly responsive to most types of therapies. After the partial failure of some approaches, the issue of resistance or refractoriness to chemotherapeutics has become a key problem in the therapy of tumor patients.

Our results and recent published observations indicate a new path to anticancer treatment and important suggestions are emerging from these new data. The mechanisms controlling the abnormal pH gradients in 61

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tumors should represent a selective and specific target in setting up new anticancer strategies. To our opinion, VATPases should be considered as the most important of these targets because of its crucial function in determining the acidification of tumor microenvironment. Moreover, tumor acidity should be considered as a specific delivery system for new antitumor strategies, based on drugs that are specifically recruited within acidic environment and activated in situ, thus hijacking an essential survival factor for tumors. Notably, tumor acidity is also related to cannibalism, an important tumor feature considered a survival option of malignant tumors.

The molecular basis for evolution of glycolytic phenotype, extracellular acidosis and altered metabolic pathways have to be better clarified and much additional work will be required to fully understand the complex pathways involved in cancer progression. Thus, studies aimed at investigating the major mechanisms involved in proliferation, tumorigenesis, drug-resistance and tumor progression will provide the knowledge to design new strategies in the treatment of human tumors based on the inhibition of mechanisms that allow them to survive in these unfavourable conditions. Among novel anti-cancer drugs, the authors have focused their attention on PPI, drugs able to normalize the pHi and pHe of human tumors, thus rendering tumor cells sensitive to the action of several cytotoxic drugs to which they are normally refractory.

However, recent results have provided the proof that PPI may be considered, not only as chemosensitizer agents, but also a new class of antineoplastic drugs. PPI may have an important effect on tumor homeostasis based on their ability to alkalinize the tumor microenvironment. Based on these results new investigations are needed to better understand the mechanisms of tumor acidification, a new and key target of future strategies in the treatment of human tumors.

Acknowledgements We are grateful to Roberta Terlizzi and Zaira Maroccia for excellent technical assistance

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Angelo De Milito

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Cancer Therapy Vol 6, page 67 Cancer Therapy Vol 6, 67-72, 2008

Subclavian artery infusion as induction and adjuvant chemotherapy for breast conserving treatment of primary breast cancer Research Article

Karl R. Aigner*, Sabine Gailhofer, Emir Selak Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstrasse 1, 84489 Burghausen, Germany

__________________________________________________________________________________ *Correspondence: Prof. Dr. Karl R. Aigner, Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstrasse 1, 84489 Burghausen, Germany; Tel: +49-(0)-8677-91600; Fax: +49-(0)-8677-9160120; E-Mail: info@profaigner.de Key words: breast cancer, regional chemotherapy, subclavian artery infusion, neoadjuvant chemotherapy, tumor downsizing, local recurrence Abbreviations: intraarterial chemotherapy, (IAC); subclavian artery infusion, (SAI) Received: 4 December 2007; Revised: 16 January 2008 Accepted: 24 January 2008; electronically published: February 2008

Summary In recent years the management of breast cancer experienced a tendency towards breast conserving surgery combined with chemotherapy and irradiation. Surgery combined with chemotherapy for downsizing was applied in order to achieve resectability in large tumors or to keep the surgical intervention minimal. However, achievement of impressive response in terms of downstaging is a longlasting procedure, accompanied by prolonged toxic chemotherapy. In an attempt to achieve increased local drug exposure intraarterial infusion chemotherapy of the internal mammary and the subclavian artery was performed in 53 patients with primary breast cancer. The therapy consisted of six cycles of the three drug combination Mitomycin, Adriamycin and Cis-Platin. 34/53 patients had undergone local tumor excision prior to i. a. chemotherapy (IAC), 19/53 patients received induction (neoadjuvant) IAC and restaging with lumpectomy after three treatment cycles. Complete response was noted in 26 % and overall response was 74 %. A significant shift from T3/T4 stages towards T1/T2 was observed within three treatment cycles. Quality of life was generally good and most patients were able to work between the treatment cycles. Main side-effect was drugstreaming causing skin burns, which initially occurred in about 30 % and in recent years in 4 %. Local recurrence rate was 17 % and median survival was not yet reached within the follow up time of 16 years.

et al, 1999). If systemic chemotherapy would be sufficiently effective in the entire organism, local relapse or distant metastases should not occur - the dose-response relationship is steepâ&#x20AC;? Emil Frei (Frei et al, 1980). If highdose chemotherapy could generate sufficient efficacy (GĂśrich et al, 1995; Merajver et al, 1997; Murakami et al, 2001) in the entire organism, resistant cell clones would no longer be resistant and could not survive. Regional chemotherapy, because of precalculated local drug concentrations, in many cases can generate the required drug exposure at the target site (Aigner, 1994; Sainsbury et al, 1990; Stephens, 1988; Stephens et al, 1980a,b; Wang, 1990)

I. Introduction The treatment strategy of breast cancer has changed remarkably during the past 3 decades. Radical surgery is no longer the treatment of choice. Breast cancer is considered a systemic disease already in early stages and therefore mutilating surgery has been abandoned to a great extent. Breast conserving surgery is aimed at whenever justifiable in most latest treatment protocols. Radical axillary dissection has been replaced by removal of the sentinel lymphnode in the first attempt. Radiotherapy maintained its position in combination therapies for destruction of potential axillary lymphnode metastases or for prevention of local recurrences. More importance is given to multidisciplinary management of disease (Carlson

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Aigner et al: Subclavian artery infusion as induction and adjuvant chemotherapy MMC, two times 15 mg ADM and two times 30 mg CDDP. During the first three cycles until local resection of the residual tumor, the first two days selective infusion of the internal mammary artery was performed with 10 mg each of Mitomycin and Adriamycin. Then the cycle was completed with subclavian artery infusion of Adriamycin and Cis-Platin according to the protocol.

In case the patient continued to be reluctant to any surgical intervention, angiographic therapy was continued throughout the six cycles. In case the patient agreed with surgical placement of a Jet Port Allround subclavian artery catheter (PfM Cologne), further therapies were performed through this catheter (Figure 1).

II. Material and Methods This study was performed in a series of 53 patients who refused mastectomy. In 19/53 patients, after three cycles of regional induction (neoadjuvant) chemotherapy a local excision of the lesion or the area of the prior lesion, respectively, was performed for pathological evaluation.

34/53 patients had had local tumor excision prior to regional chemotherapy. None of these patients had undersigned informed consent of mastectomy.

III. Treatment All patients initially underwent catheter placement in Seldingerâ&#x20AC;&#x2122;s technique and an arteriogram of the subclavian artery with its branches and the internal mammary artery was obtained. For contrast imaging of the vascular branches of the subclavian artery (Doughty et al, 1996), and as well to avoid infusion of the arm, a brachial pneumatic sphygmomanometer was inflated at least to 30 mm/Hg above the systolic pressure during the intraarterial infusion. In order to trace the target of intraarterial infusion and correct positioning of the catheter, indigocarmin blue was injected prior to each therapy. A total of six cycles of subclavian artery infusion (SAI) in four weeks intervals was performed with a three drug combination of mitomycin, adriamycin and cis-platin (Table 1). The average dose for one cycle was 10 mg

IV. Results Local response in terms of tumor downsizing was the leading parameter. In 34 patients the primary tumor (stages T1-3) had been resected prior to adjuvant arterial infusion. In 19 patients, who underwent regional induction (neoadjuvant) chemotherapy, most evidently there was a remarkable shift from larger tumorsizes (T3, T4) down to lower sizes (T1, T2). In 26 % a complete remission was noted histologically (Figures 2, 3) 9 patients (48 %) had a partial remission, whilst 32 % of pretherapeutic T4 tumors were reduced to a histologically confirmed 11% T4 after

Table 1. Protocol of Subclavian Artery Infusion for Breast Cancer. Six cycles in four weeks intervals Day

Drug

Dosage

Infusion Time

1

Mitomycin C

0,17 mg/kg

15 min

2

Adriamycin

0,25 mg/kg

15 min

3

Adriamycin

0,25 mg/kg

15 min

4

Cisplatin

0,50 mg/kg

15 min

5

Cisplatin

0,50 mg/kg

15 min

Figure 1. End-to-side implantation of subclavian artery Jet Port catheter

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Cancer Therapy Vol 6, page 69 arterial chemotherapy. Vice versa, after arterial infusion of all patients the number of T1 sized tumors had increased from initially 10,5 % to 32 % after intraarterial chemotherapy (Table 2). Local recurrence rate after 16 years was 17 %. Kaplan Meier survival estimate is shown

in Figure 4. After a 16 years follow-up the median survival time has not yet been reached. 9/53 patients (17 %) had a local relapse and 7 patients died from relapse and/or distant metastases.

Figure 3. Complete remission after three cycles of intraarterial chemotherapy.

Figure 2. T4 primary breast cancer before therapy

Table 2. Downsizing of primary tumors after 3 cycles of subclavian artery infusion (SAI).

TNM-Stage before SAI (n = 19)

after SAI (n = 19) CR n = 5 (26 %) pT1 n = 6 (32 %)

cT1

n = 2 (10,5 %)

cT2

n = 9 (47 %)

pT2

n = 3 (15,75 %)

cT3

n = 2 (10,5 %)

pT3

n = 1 (5,25 %)

pT4

n = 2 (10,5 %) n = 2 (10,5 %)

cT4

n = 6 (32 %) unknown

Figure 4. Kaplan Meier Survival estimate curve after SAI for primary breast cancer

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Aigner et al: Subclavian artery infusion as induction and adjuvant chemotherapy Side-effects in general were moderate. There was no substantial haematologic toxicity that required antibiotic prophylaxis or substitution of blood components.

Tiredness or fatigue have never been observed and patients usually were able to go to work between the treatment cycles. Hairloss mostly was moderate and normally did not occur. Only two patients had visible hairloss (4 %), one of them alopecia. The only real complication, causing problems, was drugstreaming, which, in the beginning had happened in every third case, but could be reduced later on to 4 % after applying the total amount of drug through a constant flow pump within 15 minutes.

account that also T3/4 stages have been included in the study, and that all patients have been treated with local excision only, but without mastectomy. The survival estimate with seven deaths out of 53 treated patients throughout sixteen years suggests that the rate of distant metastases after i. a. infusion is not higher than has to be expected after systemic chemotherapy. This leaves one question open: Is systemic exposure from i. a. infusion as efficient as systemic exposures from systemic chemotherapy, or are both systemic exposures inefficient?

Regional chemotherapy for breast cancer is not at all a new method but all the same it never has had its breakthrough (Eedwinek et al, 1981; Carter et al, 1988; Noghuchi et al, 1988; Stephens, 1989, 1990; Wang et al, 1990; Dycker de et al, 1991; GĂśrich et al, 1993, 1995; Takatsuka, 1994; Chrysos et al, 2001; Fiorentini et al, 2003).

Data from various published studies report approximately the same response rates as have been noted in our studies (Koyama et al, 1975; Koyama et al, 1985; Iwasa et al, 1988; Aigner et al, 1991, 1988; Dycker de et al, 1991; Nitz et al, 1993; Koyama, 1994; Morandi et al, 1996; Cakmakli et al, 1997; Mohrmann et al, 1999, 2000).

At good quality of life they vary around 70%, a number that hardly can be achieved with other therapies without causing severe side-effects. This should be an argument to include the method into guidelines. The pioneers of intraarterial chemotherapy, Biermann and Klopp, after observing the local effect, called intraarterial chemotherapy, a â&#x20AC;&#x153;chemical irradiationâ&#x20AC;? (Biermann and Klopp, 1951). Indeed it is as effective, and it does not cause tissue fibrosis.

But most evidently irradiation is easier to handle, and there are not sufficient clinical studies on intraarterial infusion for breast cancer, enough to justify inclusion of the method into treatment guidelines.

One of the main reasons might be the adverse effect encountered in most studies, which was drugstreaming and skin burns after internal mammary artery infusion (Ashaishi, 1994; Doughty et al, 1995; McCarter et al, 1995, 1998), we were confronted with the same complications and finally found out, that although a relatively small total dose was infused into the internal mammary artery, the local concentration that was generated was by far above the tissue tolerance. This complication can only be avoided by dilution of the total amount of drug to be applied in a bit larger volume, in combination with corticosteroids given the same route with a constant flow pump (Fiorentini et al, 2003) and not in a small volume through a hand syringe.

In conclusion, intraarterial infusion therapy for primary breast cancer can be an important tool, once the technique of application is standardized, allowing excellent results within a short time in favour of breast conservation and non-disturbed quality of life.

V. Discussion Breast cancer is considered a potentially systemic disease and therefore regional chemotherapy has been ranked as non adequate, treating only part of the area to be treated. The problem arising, however is, that systemic chemotherapy, in case of a bulky primary tumor, can hardly generate drug exposures, required for definite tumor eradication. And if so, dose- intense chemotherapy has to be intensified in such a way that toxicity becomes intolerable.

Regional chemotherapy, however, in terms of intraarterial infusion is not an isolated procedure, confined exclusively to one well defined segment of the body-like surgery or irradiation. Intraarterial infusion is a systemic therapy given with its first pass through the area to be treated firsthand, the target, which is the primary tumor in the breast and all its lymphatic drainages. The first pass through the arterial supply causes a concentrationdependent higher tissue uptake of cytotoxics in the area to be treated, but also a systemic drug exposure from the cytotoxics exiting the tumor area through the venous drainage.

The relatively small doses applied intraarterially are highly effective due to the drug concentrations achieved in arteries with comparatively moderate blood-flow, like the internal mammary artery.

It has been shown in a previous study (Aigner, 1994), that in locoregional therapy of breast cancer there is a steep dose-response relationship (Fiorentini et al, 2003), dependent on the applied technique. Therefore in the neoadjuvant cases, it was important to combine subclavian artery infusion with infusion of the internal mammary artery, the diameter of which is much smaller than the diameter of the subclavian artery and thus many generate a much higher and efficient drug concentration at the tumor site.

As a consequence, intraarterial application of drugs is more effective in terms of local control, when compared to systemic chemotherapy, where the same, or even higher doses are given intravenously (Stephens et al, 1980).

Regarding the response rates in the study presented herein, it is obvious that within only three cycles of regional chemotherapy a substantial response could be achieved, translating into a 26% complete remission and 74 % overall remission rate and a significant shift from large to small tumor diameters. Moreover, the recurrence rate of 17% over 16 years is remarkably low, taking into

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Fiorentini G, Tsetis D, Bernardeschi P, Varveris C, Rossi S, Kalogeraki A, Athanasakis E, Dentico P, Kanellos P, Biancalani M, Almarashdah S, Zacharioudakis G, Saridaki Z, Chalkiadakis G, Xynos E, Zoras O (2003) First-line intraarterial chemotherapy (IAC) with Epirubicin and Mitoxantrone in locally advanced breast cancer. Anticancer Research 23, 4339-4346.

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Iwasa Z, Matsunami N, Saeki Y, Kurooka K, Yamato M, Okuno K, Sagara N, Matsuda T, Yasutomi M (1988) The follow up study of intra-arterial infusion chemotherapy with local vein blocking as a surgical neo-adjuvant treatment for locally advanced breast cancer. Jpn J Surg 18, 131-135.

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Koyama H, Nishizawa Y, Wada T, Kabuto T, Shiba E, Iwanaga T, Terasawa T, Wada A (1985) Intra-arterial infusion chemotherapy as an induction therapy in multidisciplinary treatment for locally advanced breast cancer: a long term follow-up study. Cancer 56, 725-729.

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McCarter DHA, Doughty JC, Cooke TG, McArdle CS, Reid AW (1998) Selective angiographically delivered regional chemotherapy in patients with locally advanced or recurrent breast cancer: A feasibility study. JVIR 9, 91-96.

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Karl R. Aigner

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Cancer Therapy Vol 6, page 73 Cancer Therapy Vol 6, 73-80, 2008

Treatment of malignant pleural mesothelioma Review Article

David F. Heigener*, Martin Reck, Ulrich Gatzemeier Department of Thoracic Oncology, Krankenhaus Grosshansdorf, Germany

__________________________________________________________________________________ *Correspondence: David F. Heigener, Krankenhaus Großhansdorf, Woehrendamm 80, 22927 Großhansdorf, Germany; Tel: 0049 4102 601 261; Fax: 0049 4102 601 247; E-Mail: d.heigener@kh-grosshansdorf.de Key words: Malignant Mesothelioma, Diagnosis, Therapy Abbreviations: endothelial-growth factor-receptor, (EGFR); International mesothelioma interest group, (IMIG); Malignant Pleural Mesothelioma, (MPM); nuclear magnetic resonance imaging, (NMR); overall survival, (OS); positron-emitting tomography, (PET); Serum mesothelin-related protein, (SMRP); simian-virus 40, (SV-40) Received: 13 January; Revised: 30 January Accepted: 4 February; electronically published: February 2008

Summary Malignant Pleural Mesothelioma is an asbestos-related disease with rising incidence. Diagnosis is often late in the course of the disease because of its insidious onset. Treatment is difficult because of the natural resistance of this tumor-entity. The diagnostic work-up as well as therapeutic options are outlined in this review article.

to 7.8% of exposed patients given more than 20ml of Thorotrast developed MPM (Andersson et al, 1995). There is also a higher incidence of MPM in survivors of the Hiroshima and Nagasaki nuclear attacks (White and Abratt 2005).

In summary, the most important risk factor for MPM is undoubtedly asbestos which is responsible for approximately 70-90% of cases (Yates et al, 1997).

MPM is a devastating disease with a grim prognosis.

Median survival ranges from approximately 4 to 18 months depending on the histological subtype (sarcomatous has a worse prognosis compared to epithelial subtype), tumour stage and some patient derived factors (general condition, age, weight loss, pain, platelets, asbestos exposure) (Manegold et al, 2006). In a series of 49 consecutive patients at our institution median progression free survival was 8 months (Figure 1).

I. Introduction Before 1950, Malignant Pleural Mesothelioma (MPM) was a very rare condition. With the rising use of asbestos after World War II it became more frequent. In the early nineteen-sixties the link between asbestosexposure and MPM was first recognized (Wagner and Sleggs, 1960; Thomson 1963). Asbestos exposure is either occupational or environmental. The latter can be due to air pollution by asbestos-processing facilities or “natural” exposure in the soil (Constantoupolos et al, 1985).

Although the use of asbestos was widely abandoned since 1980 in the western countries, the incidence of MPM will continue to rise until approximately 2020 (Peto et al, 1999). This is due to the long latency between asbestos exposure and development of MPM (up to 58 years) (Kroidl et al, 2000).

Other risk factors for the development of MPM are the simian-virus 40 (SV-40) and ionizing radiation. SV-40 DNA can be found in approximately 60% of MPM but also in ependymomas, brain and bone tumours (Rizzo et al, 1998). The virus is a potent inhibitor of tumoursuppressor genes and is considered a co-factor in carcinogenesis. Simian virus 40 was a contaminant in polio vaccines administered to 10-30 million people in the United States, mostly children, between 1955 and 1963 (Stratton et al, 2002). However, the role of the virus in the pathogenesis of MPM is yet unproven (MacLachlan 2002; Price and Ware 2004).

The use of the radioactive, alpha-emitting contrast medium 232ThO2 (Thorotrast®) is another risk factor. Up

II. Diagnosis of MPM A. Signs and Symptoms The onset of symptoms in MPM is subtle and nonspecific, so diagnosis is often late in the course of disease.

The majority of patients present with dyspnea and/ or chest pain (Lee et al. 2000). Fatigue, fever and night sweats are also common.

B. Imaging techniques The first diagnostic step after clinical examination is a chest X-ray. The most frequent finding here is a pleural effusion (Lee et al, 2000).

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Heigener et al: Treatment of malignant pleural mesothelioma

Figure 1. Progression free survival of 49 consecutive patients with MPM at our institution in months.

In one series the majority of MPM is located on the right side, in five percent of cases there is a bilateral involvement (Antman 1981). However in our patients there were no bilateral manifestations and 65% right-sided locations in a series of 49 consecutive patients (unpublished data).

The next diagnostic step when MPM is suspected should be a computed tomography or a nuclear magnetic resonance imaging (NMR) of the chest. The former is more available than the latter and of nearly similar accuracy. NMR provides little more information concerning chest wall and diaphragm invasion (Heelan et al, 1999). The addition of positron-emitting tomography (PET) can help distinguish between benign pleural thickening and foci of malignancy and makes mediastinal lymph-node staging more accurate (Wang et al, 2004).

However this method is not readily available in many institutions.

MPM is characterized by local spread involving the mediastinal lymph nodes. There are many case reports about distant metastases in MPM, however in general they seldom occur. Therefore we do not perform any routine imaging technique (i.e. bone-scintigraphy or NMR of the brain) beyond thoracical imaging.

Staging should be done based on the TNM staging system by the International mesothelioma interest group (IMIG): the T-descriptors are designated as T1 to T4 describing the local extend of the tumour. T1 is localized disease on the pleura (T1a: parietal pleura only; T1b: involvement of visceral pleura), T2 describes diaphragmal or direct lung involvement, T3 describes involvement of the endothoracic fascia or mediastinal fat (locally advanced but technically resectable) and T4 the diffuse invasion of the chest wall, peritoneum, spine, peri- or myocard as well as the contralateral pleura (locally advanced, unresectable). The N-descriptors N1 to N3 are identical as the ones used in the staging of lung cancer: N1 describes ipsilateral pulmonary or hilar nodes, N2 ipsilateral or subcarinal mediastinal nodes and N3 contralateral mediastinal or supraclavicular nodes. M0 denotes the absence and M1 the presence of distant

metastases. The corresponding stages are shown in Table 1 (Rusch 1995).

B. Achievement of a tissue diagnosis Evidence of MPM in pleural fluid is found in 3384% of cases (Whitaker 2000). Aspiration-cytology of pleural fluid (if present) is specific but lacks sensitivity.

The latter can be improved with the measurement of hyaluronic acid in the pleural fluid which is markedly elevated in MPM compared to other malignant effusions (Welker et al, 2007). Nevertheless, obtaining a histological specimen is often necessary for an exact diagnosis. Image guided, trans -thoracical core-biopsies lack direct visualisation of the tumor and therefore carry a higher risk of false-negative results compared to direct thoracoscopic forceps-biopsy either in local anaesthesia or video-assisted under general anaesthesia (VATS). Immunhistochemistry should be performed for an exact diagnosis. Typical positive markers are calretinin (epithelial subtype), MNF 116 and AE1/ AE3 cytokeratins, vimentin and many more (Mueller 2005).

C. Serum markers Two markers deserve special consideration: Serum mesothelin-related protein (SMRP) and serum osteopontin. SMRP has a sensitivity of 83% and a specifity of 95% in detecting MPM in one study. There are also level-changes parallel to the tumour size, suggesting that it might be a good diagnostic tool for monitoring (Robinson, 2005). The addition of the tumour-marker CA125 did not improve sensitivity (Creaney et al, 2007).

Serum osteopontin is significantly elevated in patients with asbestos exposure and MPM compared to patients with asbestos exposure alone (Pass, 2005). It seems to have a lower diagnostic accuracy than SMRP due to its Table 1. Stages of MPM (Rusch, 1995) Stage Ia Ib II III IV

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TNM T1aN0M0 T1bN0M0 T2N0M0 Any T3M0; any N1M0; any N2M0 Any T4, any N3; any M1

Cancer Therapy Vol 6, page 75 low specifity (Grigoriu, 2007). However, by now -lacking large validation series- both markers are not routinely used in our clinical practise.

of MPM. Focussing on remission there were some agents with moderate efficacy: the anthracyclines, platinum compounds, alkylating agents, mitomycin C and antimetabolites. However, these results were only based on small case series. No large randomized controlled trials were available and the impact on survival was not clarified (Ryan et al, 1998). There were also some case series with combination therapies but there was no clear evidence for superiority over monotherapies (Ryan et al, 1998).

III. Therapy of MPM A. Role of radiation therapy External beam radiation of the hemithorax as a single treatment of MPM has no effect on survival (Baldini 2004). However some series suggest that it might have its place in a multimodality approach to improve local control, especially when using modern techniques (see below) (Rice et al, 2007; Lee et al, 2002; Rusch et al, 2001). Another questionable indication for radiotherapy in MPM is the irradiation of surgical wounds and drainagesites, fearing that otherwise the tumour will spread to the subcutaneous layer along the surgical tract. There are three small randomized controlled trials and some case series.

One of the controlled trials showed a small benefit on local control (Boutin et al,1995) and the other two showed no benefit at all (Bydder et al, 2004; O´Rourke et al, 2007). In one case series of 85 consecutive patients treated with different chemotherapy regimens without radiation none developed surgical tract metastasis (Pinto et al, 1995). As a result, the practise is discussed with considerably controversy and we do not recommend this procedure routinely although it is implemented in the guidelines of the British Thoracic Society (British Thoracic Society Standards of Care Committee, 2007).

External beam radiation is moderately effective in the reduction of pain due to MPM. In one case series of 189 patients 50% had a benefit in terms of pain control when 36 Gray in 4- Gray fractions were used. However pain recurred in a median of 69 days (de GraafStrukowska et al, 1999). In a review on that topic, pain relief is described for 50 to 70% of patients (Baldini 2004).

2. Vinca-Alkaloids Two modern vinca-alkaloids show promising activity in phase II-trials in MPM: Vinorelbine and vinflunine.

Vinorelbine was tested in a weekly infusion regimen in 29 patients. 24% of patients achieved a partial response and 55% had stable disease. There was also some improvement in quality of life (Steele et al, 2000).

However the patient number was small and phase III studies are clearly needed. 67 patients were enrolled in a phase- II study with vinflunine. Response rate was 13.8% and median survival was 10.8 months (Talbot et al, 2007).

3. Gemcitabine There are several Phase-II studies of either gemcitabine alone ore in combination with cisplatin (Kindler et al, 2002). Monotherapy failed to show significant activity in two trials (van Meerbeeck et al, 1999; Kindler et al, 2001). The combination achieved up to 47.6% partial responses (Byrne et al, 1999). However, as with vinorelbine, phase-III data are lacking.

4. Taxanes There is only sparse data on paclitaxel in MPM. One trial showed only 9% remissions with high-dose paclitaxel (Vogelzang et al, 1999). Docetaxel also showed at most mildly efficacy as monotherapy (Vorobiof et al, 2002; Belani et al, 2004). Also in combination with irinotecan, the results are disappointing (Knuutila et al, 2000).

B. Role of surgery There are mainly two surgical approaches to MPM. First there is a quite aggressive option, the extrapleural pleuropneumectomy (EPP) or a solely cytoreductive procedure: decortication and/ or pleurectomy. The latter can sometimes be performed via VATS. A case series describing the trimodality approach of EPP plus consecutive chemoradiation showed a five-year survival rate of 22%. However this was a selected group of patients and a control group was lacking (Sugarbaker and Norberto 1998). In another trial the two surgical procedures were compared, showing a benefit in progression free survival for EPP (319 vs. 197 days, p= 0.019) but only a non significant benefit favouring EPP in overall survival (497 vs. 327 days, p=0.079) (Stewart et al, 2004). In both papers the involvement of mediastinal lymph nodes was a predictor of poor survival. To date a large randomized trial is ongoing to clarify the role of radical surgery in MPM (Treasure et al, 2006).

5. Antifolates Alpha folate receptor protein is overexpressed in MPM-Cells in approximately 70% of cases. This might explain the responsiveness to antifolate drugs (Bueno et al, 2001) as shown in a group of 60 patients receiving high dose methotrexate. There were 37% responses with one complete response (Solheim et al, 1992).

In the beginning of this century, a new multi-targeted antifolate, pemetrexed, was evaluated for its efficacy in MPM. A phase II -trial including 64 patients showed an overall response rate of 14.1% for monotherapy with the substance. Interestingly, overall survival (OS) was higher in those patients who were supplemented with folic acid and vitamin B12 (13 months OS vs 8 months in the not supplemented group). Moreover, neutropenia was lower in the supplemented group (4 grade ! neutropenias in the supplemented group vs. 11 in the non-supplemented group) (Scagliotti et al, 2003). However, because of the small subgroups no definite conclusion could be drawn on the impact of vitamin supplementation. A phase III trial with 456 enrolled patients compared pemetrexed and cisplatin with cisplatin alone (Vogelzang et al, 2003). This

C. Role of medical therapy 1. “Older” Regimens Numerous trials have been conducted in the 1980´s and 1990´s with various cytotoxic agents in the treatment

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Heigener et al: Treatment of malignant pleural mesothelioma was the first trial ever in MPM showing a significant survival advantage for a chemotherapy regimen with a median survival of 12.1 months for the cisplatin/ pemetrexed-arm vs 9.3 months for cisplatin alone (p=0.02). Again, toxicities were significantly reduced after adding folic acid and vitamin B12 to the regimen. The combination of cisplatin and pemetrexed can now be considered standard first line therapy in MPM in those patients, who can tolerate this fairly toxic regimen.

Because of the considerably toxicity of cisplatin, it is sometimes replaced by carboplatin for patient comfort in this palliative setting (Figure 2). Another combination with an antifolate drug with some efficacy in a phase II trial are oxaliplatin and ralitrexed. 70 patients were enrolled, the overall response rate was 20% and one year survival was 26% (Fizazi et al, 2003).

There is one case series suggesting that pemetrexed also has efficacy in second-line treatment after a platinumcontaining doublet (mostly platinum/ vinorelbine). In patients treated with carboplatin + pemetrexed (n=11) there were 18% responses with a median time to progression of 32 weeks. In patients treated with pemetrexed alone the numbers were 21% and 21 weeks respectively. Median survival was 39 weeks and 42 weeks respectively (Sorensen et al,2007).

D. Multimodality treatment As described above, multimodality treatment approaches seem to be promising in a selected group of MPM patients, those in a good performance status (Sugarbaker and Norberto, 1998). In another case series focussing on prognostic factors in MPM, the data suggest that surgery within a multimodality approach improves survival more than surgery alone (pleurectomy or EPP: 10.3 months median survival; pleurectomy or EPP plus chemotherapy and external beam radiotherapy: 20.1 months median survival). There was no statistical significant difference between pleurectomy and EPP in terms of survival when used as a single-modality (median survival 15.8 vs. 14.3 months) (Flores et al, 2007).

In a phase-II trial the combination of hyperthermia (41.8° Celsius body temperature) with chemotherapy (ifosfamide, carboplatin and etoposide) resulted in a response rate of 20% and a two-year survival of 20% (Bakhshandeh et al, 2003). However to date, no phase-III data were present to support this approach.

E. Palliative Treatment Because of the devastating course of the disease almost all patients need sufficient palliative care. Main symptoms are pain and dyspnoea. Pain can be either neuropathic due to infiltration of intercostal nerves or somatic due to chestwall involvement. Often there is a combination of both.

Somatic pain responds to non-steroidal analgesic drugs and opiates. Neuropathic pain should be managed with opiates and co-analgesics like antidepressants (i.e. amitryptiline) or anticonvulsants (i.e. carbamazepine, pregabaline; Doyle et al. 2004).

Dyspnoea results from pleural effusion as well as entrapment of the lung by the pleural tumor. Pleurodesis either by VATS or pleuroscopy should be done in the former case. However the latter needs symptomatic treatment with opioids (Lee, YC, 2002).

6. â&#x20AC;&#x153;Biologicalsâ&#x20AC;?

Although endothelial-growth factor-receptor (EGFR) is overexpressed in the majority of MPM (Dazzi et al, 1990), the inhibition of the downstream signalling of EGFR by means of erlotinib does not seem to work. In a study with 64 patients with MPM, 75% of tumours showed high expression of EGFR. However treatment with erlotinib did not result in any objective remission (Garland et al, 2007). The reason might be, that simple overexpression of EGFR is not predictive of response to erlotinib in other cancers. Only EGFR-mutations seem to have some predictive value.

The antisense-oligonucleotide ranpirnase blocks the 30S-subunit of the ribosome and interferes with protein synthesis. In a phase-II trial a median survival time of 18.5 months was observed (Mikulski et al, 2002). These results encouraged to perform a phase-III study comparing doxorubicin and ranpirase with doxorubicin alone. The recruitment was finished recently and the results are pending.

IV. Summary MPM is notoriously resistant to therapy. Moreover the natural course can vary widely from only a few months of survival to several years. Because of the diffuse growth pattern, treatment response is not easy to evaluate and inter-observer differences can be great.

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Figure 2. CT-scans before (left) and after (right) four cycles of carboplatin and pemetrexed. pleural mesothelioma. A randomized All these factors make good clinical trials difficult to radiotherapy. Chest 108, 754-758. perform and many issues remain unanswered. As a

practical approach we recommend to establish the diagnosis via VATS in patients with adequate performance status or via pleuroscopy. With the former, pleurectomy/ decortication can be done. The role of radical surgery (EPP) needs to be clarified. Afterwards chemotherapy with platinum and pemetrexed should be made.

Radiotherapy is indicated for palliative reasons (i.e. pain control) but not for tumour reduction. In patients with poor performance status monotherapy with pemetrexed is a reasonable option. However, these recommendations lack clear evidence which will hopefully come with further clinical trials.

trial

of

local

British Thoracic Society Standards of Care Committee: BTS Statement on malignant mesothelioma in the UK, 2007.

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Bydder S, Phillips M, Joseph DJ, Cameron F, Spry NA, DeMelker Y, Musk AW (2004) A randomised trial of singledose radiotherapy to prevent procedure tract metastasis by malignant mesothelioma. Br J Cancer 91, 9-10.

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David F. Heigener

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Cancer Therapy Vol 6, page 81 Cancer Therapy Vol 6, 81-94, 2008

Diagnosis and multimodality management of stage III non-small cell lung cancer Review Article

Kevin Sullivan, Zujun Li, John Rescigno, Michael Fanucchi* St. Vincentâ&#x20AC;&#x2122;s Comprehensive Cancer Center and New York Medical College, New York, NY

__________________________________________________________________________________ *Correspondence: Michael Fanucchi, MD, St. Vincent's Comprehensive Cancer Center, 325 West 15th Street, New York, NY 10011, USA; Tel: (212) 604-6011; Fax: (212) 604-6038; e-mail: Mfanucchi@aptiumoncology.com Key words: Diagnosis, staging, Treatment, N2 disease, Preoperative chemotherapy, Preoperative chemoradiotherapy, radiotherapy, neoadjuvant therapy, Adjuvant therapy, Superior sulcus tumors, Satellite nodules, Mediastinal invasion, Targeted therapy, Immunotherapy, Prophylactic cranial irradiation Abbreviations: 3-dimensional, (3D); Adjuvant Navelbine International Trialist Association, (ANITA); American Society of Clinical Oncology, (ASCO); Cancer and Leukemia Group B, (CALGB); Cancer Care Ontario, (CCO); central nervous system, (CNS); computed tomography, (CT); disease free survival, (DFS); Eastern Cooperative Oncology Group, (ECOG); Electromagnetic navigation bronchoscopy, (ENB); endobronchial ultrasound-guided transbronchial needle aspiration, (EBUS-TBNA); epidermal growth factor receptor, (EGFR); European Organization for Research and Treatment of Cancer, (EORTC); European Society of Thoracic Surgeons, (ESTS); fine needle aspiration, (FNA); Fluoro-Deoxy-Glucose, (FDG); granulocyte macrophage colony stimulating factor, (GM-CSF); hazard ratio, (HR); hyperfractionated RT, (HART); intensity modulated radiotherapy, (IMRT); International Adjuvant Lung Cancer Trial, (IALT); International Association for the Study of Lung Cancer, (IASLC); International Staging System, (ISS); magnetic resonance imaging, (MRI); median survival, (MS); National Comprehensive Cancer Network, (NCCN); Non-Small Cell lung cancer, (NSCLC); overall survival, (OS); performance status, (PS); Positron emission tomography, (PET); progression free survival, (PFS); Prophylactic cranial irradiation, (PCI); Radiation Therapy Oncology Group, (RTOG); radiation therapy, (RT); response rate, (RR); Southwest Oncology Group, (SWOG); time to progression, (TTP); tumor-node-metastasis, (TNM); video-assisted thoracoscopic surgery, (VATS) Received: 31 December 2007; Revised: 30 January 2008 Accepted: 1 February 2008; electronically published: February 2008

Summary Stage III non-small cell lung cancer (NSCLC) encompasses a heterogeneous patient population with locoregionally advanced disease. The multimodality management of patients with this stage of disease is reviewed, including diagnosis, staging and treatment. Evidenced-based treatment approaches are emphasized including chemotherapy and radiotherapy in the neoadjuvant, adjuvant and definitive setting. The role of surgery in select patients is discussed.

International Association for the Study of Lung Cancer (IASLC) (Rami-Porta et al, 2007), the ISS, which was last revised in 1997, is still in current use. Stage III NSCLC is defined as locoregionally advanced disease, due to involvement of mediastinal lymph nodes, involvement or invasion of extrapulmonary structures, or the presence of a malignant pleural or pericardial effusion, without evidence of distant metastatic disease. Stage III NSCLC is subdivided into Stage IIIA and IIIB disease. Stage IIIA disease is a T1 or T2 tumor with involvement of ipsilateral mediastinal lymph nodes (N2), or a T3 lesion with hilar (N1) or mediastinal (N2) lymph node involvement. Stage IIIA patients are further clinically subdivided into bulky and non-bulky disease. Bulky disease includes lymph nodes which are >2cm in diameter as measured by

I. Introduction In the United States, lung cancer is the leading cause of cancer death in both men and women. An estimated 213,380 new cases of lung cancer were diagnosed in 2007, with 68,280 patients having stage IIIA/B disease (Jemal et al, 2007). Non-Small Cell lung cancer (NSCLC) represents about 80% of all histological types of lung cancer and includes adenocarcinoma (including its subset, bronchioloalveolar carcinoma), squamous cell (epidermoid) carcinoma, and large cell carcinoma (Fraire, 1996; Travis et al, 2004).

The International Staging System (ISS) is the most commonly used staging system for NSCLC (Mountain, 1997). Although there is a proposal to modify the TNM staging of lung cancer under consideration by the 81

Sullivan et al: Diagnosis and multimodality management of stage III non-small cell lung cancer computed tomography (CT), or conglomeration of multiple smaller lymph nodes (Robinson et al, 2003).

Patients with non-bulky N2 disease may be rendered disease free by surgical resection, whereas patients with bulky disease are generally inoperable due to extent of nodal disease. Stage IIIB disease is based upon the presence of a T4 tumor, or involvement of supraclavicular lymph nodes or contralateral mediastinal or hilar lymph nodes (N3). Stage IIIB disease due to the presence of a malignant pleural or pericardial effusion is managed primarily with chemotherapy alone and will not be discussed here.

mediastinal lymph nodes (Chin et al, 1995). PET scan was compared with CT scan for accuracy in identifying N2 and N3 disease, and the PET scan was found to be more sensitive (81%) versus CT scan (76%) (Kerstine et al, 1998). The most accurate method of clinically staging the mediastinal lymph nodes is integrated PET/CT (Lardinois et al, 2003). Integrated PET/CT provided additional information in 41% of patients beyond that provided by visual correlation of PET and CT. Patients that have a negative PET/CT evaluation of the mediastinal lymph nodes may proceed to surgical resection without preoperative mediastinoscopy (Vansteenkiste 2006). The European Society of Thoracic Surgeons (ESTS) recommends invasive staging despite a negative PET/CT evaluation of mediastinal lymph nodes in cases of central tumors, Fluoro-Deoxy-Glucose (FDG)-avid hilar lymph nodes, low FDG uptake of the primary tumor and lymph nodes greater than or equal to 16 millimeters (mm) on CT scan (De Leyn et al, 2007). Most clinicians recommend pathologic evaluation of FDG-avid mediastinal lymph nodes, particularly for patients with non-bulky disease by CT. Endoscopic ultrasound imaging permits rapid and accurate identification and subsequent needle biopsy of mediastinal lymph nodes. Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have been useful for lymph node staging of lung cancer (Vilmann et al, 2005). EBUSTBNA was compared with CT and PET for evaluating mediastinal and hilar nodes in patients with lung cancer and had a sensitivity and specificity of 92% and 100% respectively (Yasufuku et al, 2006). Transesophageal ultrasound-guided lymph node biopsy was compared to surgical mediastinoscopy and was shown to be highly sensitive for the detection of metastatic nodes, especially in the paratracheal and subcarinal regions (Larsen et al, 2005). Endoscopic ultrasound with FNA is being increasingly used in lung cancer staging, and may decrease the need for mediastinoscopy.

Lung cancer causes brain metastases in 18-64% of patients during the course of their illness (Lassman, 2003).

At presentation, 10% of all patients with NSCLC have central nervous system (CNS) involvement, with up to 20% of patients with adenocarcinoma having occult brain metastases (Newman, 1974; White et al, 1981). Brain magnetic resonance imaging (MRI) to evaluate for asymptomatic brain metastases is recommended in those patients with clinical stage III disease (Mayr et al, 1995), as outlined in the National Comprehensive Cancer Network (NCCN) guidelines (NCCN Clinical Practice Guidelines in Oncology, 2008).

II. Diagnosis and staging evaluation The diagnosis of NSCLC requires a tissue biopsy to identify the histopathologic subtype as well as proper staging of the tumor, according to tumor-node-metastasis (TNM) descriptions (Fossella et al, 2003). Tissue specimens may be obtained via bronchial washings, bronchial brushings, fine needle aspiration (FNA) biopsy, core needle biopsy, endobronchial biopsy, or transbronchial biopsy. Electromagnetic navigation bronchoscopy (ENB) can be used to biopsy peripheral lesions with a higher accuracy and lower risk of pneumothorax than CT-guided percutaneous FNA biopsy (Eberhardt et al, 2007). Occasionally, mediastinoscopy, parasternal mediastinotomy, video-assisted thoracoscopic surgery (VATS) or open thoracotomy is required to obtain tissue.

CT scanning of the chest and upper abdomen is often used for the initial assessment of disease stage, but there are limitations in the evaluation of hilar and mediastinal lymph node involvement (Patterson et al, 1987). Node positivity is based on the size of the lymph nodes in CT scanning assessment. Because of this, small metastases that do not cause nodal enlargement will be missed. A 16% false negative result in metastases to lymph nodes that were found to be normal in size on CT scanning has been reported, with subsequent pathologic confirmation of N2 or N3 disease (Arita et al, 1995). Chest CT scans have a sensitivity and specificity of 69% and 71%, respectively, for identifying N2 disease (Dillemans et al, 1994).

Another study found a sensitivity of 40-65% and specificity of 45-90% for CT scan detection of mediastinal lymph node involvement, depending on the clinical scenario (McLoud et al, 1992). An additional study reported a positive predictive value of 43% and negative predictive value of 92% for chest CT scans identifying mediastinal lymph node involvement (Seely et al, 1993).

Currently, mediastinoscopy is the gold standard for the pre-operative evaluation of mediastinal lymph nodes, and is appropriate to confirm node positivity in those with a positive CT scan.

Positron emission tomography (PET) scans detect tumor physiology rather than tumor anatomy, and may therefore be more sensitive than CT scans for clinical staging (Kerr et al, 1992). PET imaging scans have been useful in providing more accurate clinical staging and for evaluating the extent of disease. PET scans have been found to be 78% sensitive and 81% specific, with a negative predictive value of 89% when used to stage the

III. Treatment The treatment plan depends on whether the patient was diagnosed with stage III disease before or after surgical resection. Patients with clinical stage I or II NSCLC that undergo surgical resection, may then be reclassified as stage III based on metastases in mediastinal lymph nodes in the final pathology specimen. These patients are recommended to receive adjuvant 82

Cancer Therapy Vol 6, page 83 chemotherapy to reduce the risk of recurrence (see â&#x20AC;&#x153;Adjuvant Therapy in Resected Patientsâ&#x20AC;? discussed below). Patients who are confirmed to have mediastinal lymph node involvement prior to resection are recommended to have either preoperative therapy or definitive chemotherapy and radiation therapy (RT) without surgical resection.

randomized study of 60 patients with clinical stage IIIA NSCLC comparing perioperative chemotherapy (with cisplatin, cyclophosphamide and etoposide) vs. surgery alone (Roth et al, 1994). The perioperative chemotherapy group received 3 cycles of chemotherapy followed by surgical resection. Three additional cycles of postoperative chemotherapy were given to those patients who responded to the preoperative treatment. The patients in the chemotherapy group had a median survival of 64 months compared with 11 months in the surgery alone group (p<0.008). Two and three year survival rates in the perioperative chemotherapy group were 60% and 56% vs.

25% and 15% respectively in the surgery along group.

Rosell and colleagues studied 60 patients with stage IIIA NSCLC randomly assigned to receive surgery alone vs. 3 cycles of chemotherapy with cisplatin, ifosfamide and mitomycin followed by surgery (Rosell et al, 1994). All patients had postoperative mediastinal RT. Median survival was 26 months in the chemotherapy group vs. 8 months in the surgery alone group (p<0.001). In the Spanish Lung Cancer Group Trial 9901, Garrido and colleagues reported survival results for 129 patients with stage IIIA (N2) and IIIB (T4 N0-1) NSCLC receiving induction chemotherapy with three cycles of cisplatin, gemcitabine and docetaxel followed by surgery in responding patients (Garrido et al, 2007). The patients had an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0-1. In this study 50.7% were stage IIIA and 49.3% were stage IIIB. Seventy percent of the patients underwent surgery, with 68.9% of the patients undergoing complete resection. Median overall survival (OS) was 15.9 months, 3-year and 5-year survival rate was 36.8% and 21.1% respectively, with no significant survival differences between stage IIIA and IIIB patients.

Median survival time was 48.5 months for 62 completely resected patients, 12.9 months for 13 incompletely resected patients and 16.8 months for 15 nonresected patients (p=0.005). Survival rates at 3 and 5 years were 60.1% and 41.4% for completely resected patients, 23.1% and 11.5% for incompletely resected patients, and 31.1% and 0% for nonresected patients.

A. Clinically evident but potentially resectable N2 disease For patients with non-bulky mediastinal lymph node involvement and T1-3 primary tumors, a combined modality treatment approach is recommended for management. Treatment options include preoperative induction therapy with chemotherapy or chemoradiotherapy; or definitive treatment with chemotherapy and radiotherapy given in a sequential fashion or concurrently. As per the NCCN guidelines, induction chemotherapy with or without RT could be considered for patients with T1-2 N2 disease. Definitive concurrent chemoradiotherapy could also be considered for this type of lesion, and is recommended for patients with T3 N2 disease. Additionally, the NCCN recommends the consideration of surgical resection if there has been an excellent response to the induction/definitive treatment (NCCN Clinical Practice Guidelines in Oncology, 2008).

1.

Preoperative chemotherapy preoperative chemoradiotherapy

vs.

It is unknown whether neoadjuvant chemoradiotherapy is superior to neoadjuvant chemotherapy. This issue is being addressed by the Swiss Group for Clinical Cancer Research conducting a phase III randomized trial of preoperative cisplatin and docetaxel chemotherapy versus chemoradiotherapy with the same agents followed by surgical resection in patients with stage IIIA NSCLC. Radiation Therapy Oncology Group (RTOG) trial 0412 and Southwest Oncology Group (SWOG) trial S0332 is a phase III randomized trial in favorable prognosis patients with stage IIIA NSCLC comparing preoperative chemotherapy (with cisplatin and docetaxel) to preoperative concurrent chemoradiotherapy (50.4 Gy thoracic RT with the same chemotherapy agents). Both arms receive postoperative chemotherapy with docetaxel. This study closed prematurely due to slow accrual.

Several small phase II and III studies substantiate the benefit of preoperative chemotherapy. Skarin and colleagues reported a median survival of 32 months with 1-year survival of 75% in 41 patients receiving neoadjuvant cyclophosphamide, adriamycin, and cisplatin chemotherapy followed by RT and subsequent resection (Skarin et al, 1989). Pass and colleagues reported a prospective, randomized trial in 27 patients with stage IIIA (N2) NSCLC comparing preoperative etoposide-platinum chemotherapy followed by surgery and postoperative chemotherapy with surgery followed by postoperative mediastinal RT (Pass et al, 1992). A trend toward increased survival was reported for the preoperative chemotherapy group (28.7 months vs. 15.6 months, p=0.095). Roth and colleagues performed a prospective,

2. Surgical resection vs. following neoadjuvant therapy

radiotherapy

The role of surgical resection, in comparison to RT, following induction therapy in patients with stage IIIA disease is unclear. Two large randomized phase III trials have not found a survival benefit for surgery in comparison to RT following chemotherapy or for surgery following concurrent chemoradiotherapy.

Chemoradiotherapy in this setting may be sufficient.

The European Organization for Research and Treatment of Cancer (EORTC) study 08941 examined the issue of radiotherapy versus surgical resection following induction chemotherapy in patients with clinical stage IIIA-N2 NSCLC (van Meerbeeck et al, 2007). In this study, 579 patients received induction chemotherapy with three cycles of platinum-based chemotherapy. Following chemotherapy, 332 patients with at least stable disease were randomized to receive definitive RT [60-62.5 Gray (Gy) to the primary tumor and involved mediastinum with 83

Sullivan et al: Diagnosis and multimodality management of stage III non-small cell lung cancer 40-46 Gy to the uninvolved mediastinum] vs. surgical resection. Surgical resection did not improve OS or progression free survival (PFS) compared with RT. The Intergroup 0139 trial evaluated 429 patients with stage IIIA NSCLC that were treated initially with concurrent RT (45 Gy) plus chemotherapy with cisplatin (50 mg/m2 on days 1, 8, 29, and 35) plus etoposide (50 mg/m2 on days 1 to 5, and 29 to 33); 396 patients with at least stable disease were then randomized to surgical resection or a continuation of RT (to 61 Gy) (Albain et al, 2005). Two additional cycles of chemotherapy were given to both groups. A planned interim analysis, reported in abstract form, revealed that surgery was associated with a significant increase in five-year PFS (22 vs. 11 percent), but only a trend toward better OS (27 vs. 20 percent, p=0.10) due to increased post-operative deaths in patients in the surgery arm who required pneumonectomy. Over one-fourth of the patients who required pneumonectomy (n=54) died within 30 days post-operatively, but the survival curves crossed at approximately 18 months follow-up, and the hazard ratio for death was 0.87 for those randomized to surgery (p=0.24). Local relapse was significantly less in patients who underwent surgery (10% vs. 22%, p=0.002). Five-year survival for patients â&#x20AC;&#x153;downstagedâ&#x20AC;? to node negative was 41% as compared to 24% for those with residual nodal disease. Approximately 13%

suffered isolated brain metastases and the overall distant metastases rate was 40%.

Table 1 summarizes the OS data comparing surgery with RT. These data suggest that surgery does not have an established role in the treatment of patients with clinical N2 disease. However, surgery may have a role after preoperative chemoradiation in patients who do not require pneumonectomy, particularly if there has been a response to the preoperative therapy. Additionally, there may be a role for surgery in patients with small volume N2 disease who receive preoperative chemotherapy or preoperative chemoradiotherapy. There is not a consensus from the NCCN in this regard27. Re-staging should be considered following neoadjuvant treatment, but it is unclear if complete elimination of N2 disease is a requirement to benefit from surgery.

B. Unresectable Stage III NSCLC In patients with unresectable stage III NSCLC due to T4 primary tumors, bulky N2 disease, or N3 disease, chemotherapy and RT have been combined in various algorithms in an effort to treat both locoregional and micrometastatic disease. Table 2 summarizes the median and 5-year survival rates comparing RT alone, sequential chemoradiotherapy and concurrent chemoradiotherapy in select studies.

Table 1. OS at 5 years comparing surgery with radiotherapy after induction therapy.

Study EORTC 08941 Intergroup 0139

Randomized patients 332 396

Surgical resection 15.7% 27%

Radiotherapy

P value

Reference

14% 20%

0.60 0.10

van Meerbeeck et al, 2007 Albain et al, 2005

Table 2. Outcomes of sequential and concurrent chemoradiotherapy compared with radiotherapy alone. *NA = Not Available.

Study

Randomized patients

Median survival (mos) 10

5-year survival rate (%) 6

Sequential Chemoradiotherapy

14

17

Radiotherapy

11.4-12

5-6

Sequential Chemoradiotherapy

13.2

8

10

3

12

6

NA*

2 (3-year)

NA*

16 (3-year)

8

2 (3-year)

14

10 (3-year)

Treatment Radiotherapy

CALGB 8433

155

Intergroup

432

French

353

EORTC

331

Cakir et al

176

Radiotherapy Sequential Chemoradiotherapy Radiotherapy Concurrent Chemoradiotherapy Radiotherapy Concurrent Chemoradiotherapy

84

P value

0.01

0.04

0.02

0.009

0.00001

Reference Dillman et al, 1996 Sause et al, 2000 Le Chevalier et al, 1994 SchaakeKoning et al, 1992 Cakir, 2004 Dillman et al, 1996 Sause et al, 2000 Le Chevalier et al, 1994 SchaakeKoning et al, 1992

Cancer Therapy Vol 6, page 85 progression at nodes not clinically involved at the time of diagnosis. In this regard, potential improvements in the ability of radiation to eradicate known locoregional sites of disease through dose-escalation, and perhaps looking forward, improved chemosensitization and more effective systemic treatment for occult distant disease, will force a re-evaluation of the role of elective nodal irradiation.

3-D conformal therapy techniques allow the development of complex multiple field radiotherapy plans that decrease the amount of normal tissue exposed to high doses. The feasibility of delivering much higher doses of radiotherapy with modern techniques has been demonstrated in phase I and II studies. A dose escalation study reported by Haymen and colleagues involved 104 patients, most of whom had stage III disease (Hayman et al, 2001). The dose escalation schema depended on the amount of normal lung in the radiation field based on the 3-D conformal therapy plan. For patients with the greatest quintile of normal lung exposed to radiation, a maximum tolerated dose of 65.1 Gy at 2.1 Gy per day was reached; however, for the other four groups, continued escalation beyond 75.6 Gy and up to more than 100 Gy in the two quintiles with the lowest normal lung exposure was associated with acceptable toxicity.

The RTOG conducted a phase I/II dose-escalation trial that incorporated 3D conformal therapy in 179 patients (Bradley et al, 2005). Concurrent chemotherapy was not given. Dose escalation was based on the volume of lung exposed to 20 Gy, which is near the tolerance dose of normal lung and has been shown to correlate with pneumonitis risk. Radiation was delivered at 2.15 Gy per daily fraction. Doses of 77.4 Gy were found to be tolerable, and in patients with low-volume disease, doses of 83.8 Gy were feasible. Local failure at two years was 38%. However, there have been no randomized phase III trials demonstrating that dose escalation improves survival.

Better delineation of the target volume can be achieved with FDG-PET, and modern RT treatment planning systems can accommodate target definition using fused PET and CT images. The target volume when PET is used has been shown to change in a significant proportion of patients as compared with CT planning alone. The RT target volume can decrease (due to the ability of PET to differentiate atelectatic lung from tumor) or increase (due to FDG uptake at mediastinal lymph nodes that were not positive by CT size criteria alone) (Lavrenkov et al, 2005; Nestle et al, 2006). In the increasingly common situation today when elective nodal irradiation is avoided, more accurate definition of involved sites of disease with PET decreases the likelihood that tumor bearing nodes will not be encompassed in the target volume.

The use of techniques that account for mobility of the tumor with respiration take on greater importance when 3D conformal treatment planning is utilized. By accounting for tumor motion on an individualized basis, smaller margins can be utilized, thereby decreasing exposure to normal lung tissue. One approach to this problem is the use of respiratory gating or breath hold technique. Gating the treatment with the respiratory cycle

1. Radiotherapy techniques and definitive radiotherapy Definitive RT is a treatment option for patients with stage III NSCLC who are not candidates for combined modality therapy due to poor PS or medical conditions.

The RTOG 73-01 was designed to assess optimal dose of radiotherapy for patients with locally advanced disease (Perez et al, 1987). Local control and 2 year survival were better with 60 Gy in 6 weeks compared with lower doses. RTOG 83-11 tested whether improved results could be obtained with higher RT doses and twice-daily fractionation (hyperfractioned accelerated RT-HART), a technique that could potentially spare normal tissues from late toxicity (Cox et al, 1990). In this study, 840 patients were treated with 1.2 Gy twice daily with 4-6 hours between fractions to total doses ranging from 60-79.2 Gy. The best results were obtained with HART of 69.6 Gy at 1.2 Gy twice daily over 6! weeks. In patients with N2 disease, weight loss of 5% or less, and good performance status, 3 year survival of 20% was achieved with HART as compared with 7% survival for similar patients treated on earlier RTOG trials of standard fractionation.

Saunders and colleagues conducted a phase III randomized trial comparing 60 Gy in 6 weeks and 54 Gy given at 1.5 Gy three times daily (six hour interfraction interval), seven days per week (continuous hyperfractionated accelerated radiotherapy-CHART) (Saunders et al, 1999). Three year survival was 20% with CHART vs. 13% with standard RT, at the expense of more moderate and severe acute dysphagia. This trial validated the concept of accelerated hyperfractionation as safe and appeared to be more effective than standard fractionation when RT is used as single modality therapy, however this was the only trial that showed improved results and has not been confirmed.

Efforts have also been made to increase the efficacy of RT through dose-escalation, which is made possible by decreasing the volume of normal tissue in the radiation field. The use of 3-dimensional (3D)-conformal techniques, which are now standard, has made possible a decrease in normal tissues receiving high doses. It has also raised the question of whether reductions in radiation target volume by avoidance of elective nodal irradiation may be appropriate. Since most locoregional failures occur at the sites of initial gross disease, exclusion of elective nodal irradiation (so-called involved-field radiotherapy) has become increasingly utilized. A recent study by Rosenszweig and colleagues found only 6.1 % isolated failure at nodes that were outside the high dose radiation volume in 524 patients treated with 3D conformal radiotherapy (Rosenzweig et al, 2007). This is, however, at odds with surgical data suggesting high rates of occult involvement of mediastinal nodes even with small primary tumors. A therapeutic benefit from lower dose incidental radiation of nearby nodal stations when multiple-field 3D dose-escalated conformal techniques are used in conjunction with chemotherapy may effectively treat subclinical nodal disease. However, competing risks of progression at distant metastatic sites and death from both local recurrence and distant metastases are likely to be the primary reasons few patients are reported to have 85

Sullivan et al: Diagnosis and multimodality management of stage III non-small cell lung cancer or treating with breath hold can help to reduce the planning target volume or avoid marginal miss. Another method incorporates so-called 4D imaging. Use of rapid spiral CT scanning and acquisition of multiple images during breathing allows for better definition of the target volume, so that changes in the shape and location of the tumor during the breathing cycle can be taken into account in radiation delivery. With this technique temporal changes in tumor position and anatomy are incorporated into the treatment planning process.

Radiotherapy delivery that adjusts in real-time to changes in tumor and normal anatomy holds further promise to decrease the necessary tumor margin and exposure to uninvolved lung. Image guided radiotherapy may also improve the therapeutic ratio. Accurate patient set-up with the use of radiopaque markers placed in the tumor by ENB or VATS, or use of daily CT scan imaging can essentially eliminate any additional margin that might otherwise be needed for daily patient set-up variability.

Adaptive radiotherapy can also be employed, in which the radiation treatment plan is modified to account for dimunition in the size of the primary tumor or mediastinal lymph nodes during the course of treatment. Use of intensity modulated radiotherapy (IMRT) is also being studied. With this technique, the intensity of the beam is varied across the two dimensions of each field, and delivery is accomplished using multiple fields at different angles. The advantage of IMRT is that high dose gradients between target and normal tissue can be generated. The primary disadvantage is that a greater volume of normal tissue gets low doses. Since the normal lung has low tolerance to even small doses, this technique has not gained general acceptance in the treatment of locally advanced non-small cell carcinoma. There are additional unsolved technological problems of moving targets and the necessity of using time-consuming respiratory gating.

other two arms of the study. The HART arm, although better, was not statistically superior in survival compared with the standard RT arm. Two year survival was 32 % with induction chemotherapy, 24 % for HART, and 19 % for standard RT. Three year survival was 17 %, 14 %, and 11 %, respectively. Five year survival was 8%, 6%, and 5%, respectively.

A French randomized trial of 353 patients with stage III disease compared 3 cycles of induction chemotherapy with vinblastine-cisplatin-cyclophosphamide and 65 Gy thoracic RT followed by 3 more cycles of the same chemotherapy vs. RT alone to the same dose (Le Chevalier et al, 1994). Three year survival was improved with the use of induction and consolidation chemotherapy (12 % vs. 4 %, p=0.02), as was 5 year survival (6% vs. 3 %, p<0.02). This is the only study that employed systematic post-treatment bronchoscopy to evaluate locoregional control. Only 16% of patients were locally controlled at one year post-treatment, with no difference between arms, suggesting that the survival benefit afforded by chemotherapy was mainly due to its impact on occult distant metastases.

A study from the EORTC reported a 3 year survival of 16 % for patients receiving chemoradiotherapy with daily concurrent cisplatin, 13 % with weekly concurrent cisplatin, and only 2 % for RT alone (p=0.009 for comparison of daily concurrent cisplatin vs. RT alone) (Schaake-Koning et al, 1992). A more recent study of 176 patients revealed improvement in 3 year survival from 2% to 10% in patients who received daily cisplatin on weeks 2 and 6 of RT (total dose 64 Gy) (Cakir, 2004).

All of these trials used standard radiation doses of 55 to 60 Gy and were performed prior to the modern era of 3D conformal therapy, which allows safe delivery of higher doses. Nonetheless, these trials, summarized in Table 2, established the use of induction chemotherapy followed by RT, or concurrent chemoradiotherapy, as superior to RT alone.

2. Sequential and conurrent chemotherapy and RT vs. RT alone

3. Concurrent chemotherapy and RT vs. sequential chemotherapy and RT

Clinical trials have established the superiority of sequential therapy compared with RT alone. In Cancer and Leukemia Group B (CALGB) trial 8433, cisplatinvinblastine for two cycles followed by thoracic radiotherapy to a dose of 60 Gy in 6 weeks was compared with the same radiotherapy alone in 155 randomized patients (Dillman et al, 1996). Induction chemotherapy improved median survival (13.8 months vs. 9.7 months, p=0.007), 3 year survival (23 % vs. 10 %, p=0.01) and 7 year survival (13 % vs. 6 %, p=0.01). This was the first study to demonstrate a survival benefit with the use of induction chemotherapy followed by radiotherapy for patients with good PS (ECOG 0-1) and weight loss of less than 5%. These results were confirmed in an intergroup study of 452 patients with stage III NSCLC (also with ECOG PS 0-1 and weight loss of less than 5%) randomized to the positive arm of the CALGB trial (induction vinblastine-cisplatin followed by RT) vs. the best arm of RTOG 83-11 (HART alone to 69.6 Gy) vs. standard fractionation RT of 60 Gy in six weeks (Sause et al, 2000). OS was statistically superior for the patients receiving induction chemotherapy followed by RT vs. the

Concurrent chemoradiotherapy has become the standard treatment for most unresectable patients with stage III disease based on randomized trials that have established the superiority of this approach compared with sequential therapy in patients with good PS (Table 3). To illustrate this, a Japanese study randomized 320 patients with unresectable stage III NSCLC to cisplatin, vindesine, and mitomycin concurrent with split course RT (56 Gy total dose, 10 day break) versus the same chemotherapy followed by continuous course RT to the same total dose (Furuse et al, 1999). Over 90% of the patients had an ECOG PS of 0-1. Concurrent therapy was associated with significantly better response rate (RR) of 84 vs. 66 percent, median survival (MS) of 17 vs. 13 months, and two- and five-year survival of 35 vs. 17 percent and 16 vs.

9 percent. Patients who received concurrent treatment had more myelosuppression, however there was no difference in esophagitis rates, perhaps because the concurrent radiation was given split course. Zatloukal and colleagues performed a randomized phase II trial involving 102 86

Cancer Therapy Vol 6, page 87 patients to compare concurrent or sequential cisplatin and vinorelbine with RT to a dose of 60 Gy (Zatloukal et al, 2004). Improved median survival of 16.6 months vs. 12.9 months was found with concurrent administration (p=0.02). RTOG 9410 is the largest trial assessing the value of concurrent vs. sequential therapy (Curran et al, 2003). In this trial, 610 patients with unresected stage III disease were randomized to three arms: the positive arm of the CALBG trial reported by Dillman and colleagues (induction cisplatin-vinblastine for two cycles followed by RT to 63Gy) vs. the same chemotherapy given concurrently vs. a third arm of oral etoposide and weekly cisplatin given concurrently with 69.6 Gy hyperfractionated RT (HART). Four-year survival was significantly improved with concurrent cisplatinvinblastine and standard fractionated RT vs. sequential therapy and standard fractionated RT (21% vs. 12%). The rates of acute grade 3-4 non-hematologic toxicities were higher with concurrent than sequential therapy, but late toxicities were similar (1-3% with esophagitis and 11-13% with pneumonitis). Table 4 summarizes the acute toxicities in this trial comparing concurrent vs. sequential therapy. Huber and colleagues compared concurrent chemoradiotherapy (with weekly paclitaxel) with RT alone following induction chemotherapy with carboplatin and paclitaxel in 300 patients with stage III NSCLC (Huber et al, 2006). Median time to progression (TTP) favored the chemoradiotherapy group (11.5 months vs. 6.3 months), although there was not a survival advantage observed in this trial. For patients with a compromised PS, the greater acute toxicities with concurrent therapy make sequential therapy a better choice.

4. Induction chemotherapy prior to definitive chemoradiotherapy The CALGB examined the issue of adding platinumbased induction chemotherapy prior to concurrent chemoradiotherapy in a phase III trial of 366 patients (Vokes et al, 2007).

Immediate concurrent chemoradiotherapy with carboplatin AUC of 2 and paclitaxel 50 mg/m2 given weekly during 66 Gy of chest RT was compared with induction chemotherapy with two cycles of carboplatin AUC 6 and paclitaxel 200 mg/m2 administered every 21 days followed by identical chemoradiotherapy.

The addition of induction chemotherapy did not provide a survival benefit over concurrent therapy alone and was associated with an increased toxicity. This is the only prospective study comparing induction chemotherapy prior to concurrent chemoradiotherapy with concurrent chemoradiotherapy alone. However, the survival times were inferior to previously reported values for patients with stage III disease treated with concomitant chemoradiotherapy. The only other study addressing the role of induction chemotherapy was by Huang and colleagues who published a retrospective outcome analysis of 265 patients treated with definitive chemoradiotherapy for unresectable, locally advanced NSCLC, of whom 127 patients received induction chemotherapy (Huang et al, 2006). The induction chemotherapy group had an improved median OS of 1.9 years vs. 1.4 years for the group that did not receive induction chemotherapy. Five year survival rate significantly favored the induction chemotherapy group (25% vs. 12%; p<0.001). A subgroup analysis revealed that the survival benefit was isolated to those with adenocarcinoma or large cell carcinoma, but not squamous cell carcinoma. Thus, there may be a role for induction chemotherapy prior to chemoradiotherapy, but this is as yet undefined.

Table 3. Outcomes of "equential vs. concurrent chemoradiotherapy.

Study West Japan Lung Cancer Group RTOG 9410

Randomized patients

Chemoradiotherapy treatment Concurrent

Median survival (mos)

Survival rate (%)

17

16 (5-year)

320

610

Sequential

13

9 (5-year)

Concurrent Sequential

17 14.6

21 (4-year) 12 (4-year)

P value

Reference

0.039

Furuse et al, 1999

0.046

Curran et al, 2003

Table 4. Grade 3 or greater acute toxicities comparing sequential chemoradiotherapy with concurrent chemoradiotherapy in RTOG 9410 (Curran et al, 2003).

Toxicity (grade) Esophagitis (3-4) Pneumonitis (3-5) Neutropenia (4-5) Thrombocytopenia (4-5) Any Grade 5

Sequential chemoradiotherapy (%) 4 7 56 2 3

87

Concurrent chemoradiotherapy (%) 25-47 3-4 48-58 4-8 2-3

Sullivan et al: Diagnosis and multimodality management of stage III non-small cell lung cancer versus observation in 1867 patients of whom 39% had stage III disease (Arriagada et al, 2004). With a median duration of follow-up of 56 months, the chemotherapy group had a significantly improved disease free survival (DFS) of 39.4% vs. 34.3% and OS of 44.5% vs. 40.4% compared with the observation group. The Adjuvant Navelbine International Trialist Association (ANITA) looked at adjuvant chemotherapy with cisplatin and vinorelbine versus observation in 799 patients with stage IB, II, or IIIA NSCLC, of whom 39% had stage IIIA disease (Douillard et al, 2006). RT was optional and was administered to 24% of patients in the chemotherapy group and 33% in the observation group. The median survival was significantly increased with chemotherapy, at a median follow-up of 76 months (66 vs. 44 months with observation). The absolute OS benefit with adjuvant chemotherapy was 8.6 percent at five years and 8.4 percent at seven years. The survival benefit was limited to patients with pathologic stage II or IIIA disease.

Pathologic N2 disease was present in 27% of patients.

Five year survival for the N2 subset was 40% (95% CI 3049%) with chemotherapy vs. 19% (95% CI 11-27%) without chemotherapy. Of patients with N2 disease randomized to chemotherapy and who also received RT (n=73) 5 year survival was 47% as compared to 34% in those patients who did not receive RT (n=152). Of patients with N2 disease randomized to observation who received RT (n=128), 5 year survival was 21% as compared to 17% in those patients who did not receive any adjuvant therapy.

Adjuvant chemoradiotherapy has not been shown to be beneficial over surgery alone in a randomized study of patients with completely resected stage II and stage IIIA NSCLC, suggesting a possible detriment from the RT component (Keller et al, 2000). However, if numerous mediastinal lymph nodes are involved, patients may benefit from adjuvant RT to the mediastinum. In a population-based cohort study, Lally and colleagues found in a subset analysis that post-operative RT was associated with a significant improved survival for patients with N2 disease (Lally et al, 2006). For patients with N0 or N1 disease, post-operative RT was associated with a significant decrease in survival. An American intergroup trial and an EORTC trial are presently underway to reevaluate the role of radiotherapy for patients with N2 disease using conformal techniques. The NCCN recommends adjuvant chemotherapy, for patients with stage IIIA disease after resection, with a cisplatin-based doublet but there is disagreement among panel members regarding the role of RT (NCCN Clinical Practice Guidelines in Oncology, 2008). A recent Cancer Care Ontario (CCO) and ASCO guideline recommends adjuvant cisplatin-based chemotherapy for patients with stage IIIA disease (Pisters et al, 2007). Due to the lack of prospective, randomized clinical trial data evaluating its efficacy, adjuvant RT was not recommended for patients with stage IIIA disease (Pisters et al, 2007).

5.

Consolidation or maintenance chemotherapy following chemoradiotherapy Consolidation chemotherapy was incorporated in a treatment regimen for patients with unresectable stage IIIA/B disease by the SWOG, but recent studies do not support a survival benefit. Two phase II nonrandomized SWOG studies suggested that treating patients with three cycles of docetaxel consolidation therapy, following completion of definitive treatment with cisplatin and etoposide with concurrent thoracic RT, might improve survival (Albain et al, 2002; Gandara et al, 2003). Despite a lack of randomized studies, consolidation docetaxel has been used by 50% of surveyed oncologists (Green, 2007).

Preliminary results from a study by Carter and colleagues, found a worse survival with the use of carboplatin, paclitaxel, and radiotherapy followed by consolidative weekly taxol vs. no consolidation therapy, primarily due to toxicity associated with consolidative therapy (Carter et al, 2006). Recently, the Hoosier Oncology Group randomized 203 patients who did not progress on cisplatin-etoposide and radiotherapy to 3 cycles of consolidation docetaxel vs. no consolidation. There was no difference between arms in survival (3 year survival 28%), and docetaxel consolidation was associated with increased toxicity (Bedano et al, 2007; Hanna et al, 2007). Kelly and colleagues evaluated 243 patients in 2007 with Stage III NSCLC treated with chemoradiotherapy with cisplatin and etoposide followed by docetaxel consolidation therapy, who were then randomized to receive Gefitinib maintenance therapy or placebo. Gefitinib maintenance therapy was associated with an inferior survival compared with placebo.

C. Adjuvant therapy in resected patients Patients who are thought to have stage I or II disease preoperatively, who undergo surgical resection, may be discovered to have stage III disease in the final pathology specimen when mediastinal lymph node involvement is discovered. In one study, 13% of patients with clinical stage IA disease, who had a pre-operative high resolution CT scan without enlargement of mediastinal lymph nodes, were reclassified as stage IIIA disease after resection (Yoshino et al, 2006). Patients with stage III NSCLC that have been completely resected are at high risk of local recurrence and the development of distant metastatic disease. Improved survival with adjuvant chemotherapy with platinum-based drug regimens was confirmed in a meta-analysis that was presented at the American Society of Clinical Oncology (ASCO) annual meeting in June 2006 (Pignon et al, 2006) This meta-analysis pooled data from 5 large clinical trials, all of which used platinumbased chemotherapy and included 4584 patients. Three of the included trials allowed the use of thoracic RT at the discretion of the treating physician. Adjuvant chemotherapy was associated with an absolute increase in survival of 4.2 percent (hazard ratio [HR] 0.89, 95% CI 0.82-0.96) at a median follow-up of 5.1 years. The data did not sort out the best agent to combine with cisplatin, and differing doses of cisplatin were used, depending on the trial. The International Adjuvant Lung Cancer Trial (IALT) examined cisplatin-based adjuvant chemotherapy

D. Special situations/considerations 1. Superior sulcus tumors Patients with superior sulcus (Pancoast) tumors with hilar lymph node involvement (T3, N1) are uncommon.

88

Cancer Therapy Vol 6, page 89 Improved outcomes with chemoradiotherapy in the treatment of non-Pancoast, locally advanced, stage III NSCLC has led to its use in patients with superior sulcus tumors. Comparison to historical controls indicate that these patients should be treated with concurrent chemoradiotherapy, followed by surgical resection if there has not been progression of disease, and this is the approach recommended by the NCCN (NCCN Clinical Practice Guidelines in Oncology, 2008). A cooperative intergroup study evaluated concurrent chemotherapy (2 cycles of cisplatin and etoposide) with thoracic RT (45Gy in 25 fractions) followed by resection 3-5 weeks later (in those without progression of disease) and two additional cycles of postoperative chemotherapy in 111 patients with pathologically proven T3-4, N0-1 NSCLC presenting in the superior sulcus (Rusch et al, 2001, 2007). The percent of patients with N1 disease was not provided in the report, but 28% of patients had T4 tumors. Mature results of the study revealed a five year survival of 44% for all patients with no difference between T3 and T4 tumors. Japan Clinical Oncology Group Trial 9806 was a phase II study examining the efficacy and safety of preoperative chemoradiotherapy with two cycles of cisplatin, mitomycin, vindesine and 45Gy RT to the primary tumor and ipsilateral supraclavicular nodes in 76 patients with superior sulcus NSCLC (Kunitoh et al, 2008). Seventy four percent of the patients had T3 tumors and 26% had T4 disease. All of the T4 cases involved the spine.

Induction therapy was completed in 95% of the patients and 76% underwent surgical resection. Complete resection was accomplished in 68% of the patients and 12 patients had a pathologic complete response. DFS and OS at 5 years was 45% and 56% respectively.

of tumors that respond to the neoadjuvant treatment (Albain et al, 1995). The NCCN is in agreement with this approach (NCCN Clinical Practice Guidelines in Oncology, 2008). The Spanish Lung Cancer Group Trial 9901 (described above) included 34 patients with tumor infiltration of the great vessels, 2 patients with tracheal infiltration, 6 patients with invasion of the carina, 2 patients with infiltration of the esophagus, 4 patients with invasion of the heart and 22 patients with mediastinal invasion (Garrido et al, 2007). The patients received induction chemotherapy followed by surgery in responding patients. The survival was similar to that of stage IIIA (N2) patients (median survival of 15.6 and 16.8 months for patients with stage IIIA and IIIB disease, respectively).

4. Targeted therapy The tyrosine kinase signaling pathway, including the epidermal growth factor receptor (EGFR) is known to be altered in NSCLC. EGFR is overexpressed in a variety of tumors including NSCLC. Erlotinib, a small molecule EGFR inhibitor, is approved for use as second-line treatment of metastatic NSCLC (Shepherd et al, 2005).

Additionally, the anti-vascular endothelial growth factor inhibitor bevacizumab has improved survival in first-line treatment of metastatic NSCLC when combined with carboplatin and paclitaxel (Sandler et al, 2006). The optimal use of targeted therapies in the neoadjuvant, adjuvant or definitive treatment of stage III NSCLC remains to be defined.

5. Immunotherapy A goal of cancer research has been to incite an immune response against cancer cells. Tumor antigens can stimulate an immune response and the use of tumor vaccines may have a role in resectable and unresectable NSCLC in conjuction with conventional therapies. Tumor vaccines have been used to target known tumor-specific antigens and, in an autologous fashion, to target unique antigens derived from a patientâ&#x20AC;&#x2122;s own tumor. Dendritic cells are antigen-presenting cells under investigation in tumor vaccine development and have been shown to have therapeutic potential (Hirschowitz et al, 2004, Ishikawa et al, 2005). Encouraging results in NSCLC patients immunized with an autologous tumor cell vaccine expressing granulocyte macrophage colony stimulating factor (GM-CSF) support the rationale for further investigation (Nemunaitis et al, 2004). Muc 1 is a cell surface glycoprotein overexpressed in NSCLC and has been administered as a liposomal vaccine to stimulate an immune response. A phase II trial in patients with advanced stage NSCLC showed a trend toward improved survival with use of the vaccine compared with best supportive care (Butts et al, 2005). A phase III trial is underway. Further investigation of immunotherapy in NSCLC is warranted.

2. Satellite nodules Patients with T4N0-1 lesions, based upon the presence of satellite nodules within the same lobe as the primary tumor, may be candidates for surgical resection as the primary method of treatment. To illustrate this, Port and colleagues conducted a retrospective review of 53 patients with resected lung cancer containing intralobar satellite lesions and reported a 5-year OS rate of 47% for all patients in the study and an OS of 58% for those with N0 disease (Port et al, 2007). Treatment modalities other than surgery were not reported in this study. Osaki and colleagues conducted a retrospective review of 76 patients with surgically resected T4 NSCLC lesions, 36 of whom had satellite nodules. A 5-year OS rate of 26.7% was reported for the 36 patients, fifteen of whom received adjuvant chemotherapy and/or RT (Osaki et al, 2003). For resectable T4, N0-1 tumors due to satellite lesions, the NCCN recommends surgical resection followed by adjuvant chemotherapy (NCCN Clinical Practice Guidelines in Oncology, 2008).

3. Mediastinal invasion Patients with T4 tumors due to invasion of the mediastinum are generally unresectable and the standard treatment is chemoradiotherapy. Anecdotal experience suggests that neoadjuvant treatment with chemotherapy or chemoradiotherapy may be beneficial, enabling resection

6. Prophylactic cranial irradiation (PCI) Patients with stage III NSCLC are at high risk of developing CNS metastases, suggesting a role for PCI. A SWOG retrospective study found that 26% of patients 89

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with stage III NSCLC subsequently develop brain metastases and were more common in patients under the age of 60 and with non-squamous histologies(Gaspar et al, 2005). A German randomized trial with 112 patients examined the role of PCI following a trimodality treatment protocol of chemotherapy, chemoradiotherapy and surgery in patients with operable stage IIIA NSCLC (PĂśttgen et al, 2007). PCI significantly reduced the probability of brain metastases as the first site of failure (7.8% vs. 34.7% at 5 years, p=0.02) and reduced the overall brain relapse rate (9.1% vs. 27.2% at 5 years, p=0.04). There was no difference in 5-year OS (18%). Neurocognitive late effects in 11 long-term survivors were not significantly different between those patients treated with or without PCI. The RTOG is presently conducting a study of patients with stage III non-small cell carcinoma who do not have progressive disease to evaluate the potential benefit of PCI. Patients will be randomized to 30Gy in 15 fractions vs. observation after definitive local therapy. The primary endpoint is survival and secondary endpoints are the rate of CNS metastasis, quality of life, and neurocognitive effects.

IV. Conclusions Patients with stage III NSCLC encompass a heterogeneous group whose optimal management approach is dependent on multiple factors and remains to be defined for some patients. A combined modality approach with concurrent chemoradiotherapy with a platinum-based regimen has become the preferred treatment for the majority of patients with stage III disease detected clinically. The role of surgery in patients with pre-operatively detected but non-bulky mediastinal lymph node involvement and T1-3 primary tumors who respond to chemotherapy or chemoradiotherapy remains unclear, but seems reasonable in those patients with down-staged nodal disease after induction therapy who do not require pneumonectomy. Adjuvant platinum-based chemotherapy should be offered to those patients found to have stage III disease at the time of surgery. There is vast room for improving outcomes for patients with this disease. A multidisciplinary approach to managing this diverse group of patients is recommended.

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Cancer Therapy Vol 6, page 95 Cancer Therapy Vol 6, 95-, 2008

Targeted agents in Non Small Cell Lung Cancer Review Article

Elizabeth Blanchard Caritas St Elizabethâ&#x20AC;&#x2122;s Medical Center, Division of Hematology/Oncology and Tufts University School of Medicine

__________________________________________________________________________________ *Correspondence: Elizabeth Blanchard, MD, Caritas St Elizabethâ&#x20AC;&#x2122;s Medical Center, Division of Hematology/Oncology, Assistant Professor of Medicine, Tufts University School of Medicine, 736 Cambridge Street, Boston, Massachusetts 02135, USA; e-mail: elizabeth.blanchard@caritaschristi.org Key words: Angiogenesis, angiogenesis inhibitors, epidermal growth factor receptor, Clinical performance, tyrosine kinase inhibitors, Predictors of response Abbreviations: chronic myelogenous leukemia, (CML); epidermal growth factor receptor, (EGFR); Non small cell lung cancer, (NSCLC); overall response rate, (ORR); time to progression, (TTP); tyrosine kinase inhibitors, (TKIs); vascular endothelial growth factor receptor, (VEGFR); vascular endothelial growth factor, (VEGF) Received: 9 July 2007; Revised: 27 October 2007 Accepted: 7 November 2007; electronically published: February 2008

Summary Non small cell lung cancer (NSCLC) is a common and often devastating cancer. For patients with disease that cannot be managed surgically, particularly those with metastatic disease, options have traditionally been limited to chemotherapy, which provides a modest survival benefit. Recently, there have been several new agents that appear to improve survival without introducing unmanageable toxicity. Bevacizumab is an anti-angiogenesis agent that has been shown to improve survival in selected patients with metastatic NSCLC when used with a traditional chemotherapy doublet. The small molecule tyrosine kinase inhibitors (TKIs) have been fairly extensively studied over the past several years in several different settings and erlotinib has emerged as a beneficial drug in second line treatment of metastatic NSCLC. Much work remains, however. Clinical characteristics and tumor specific markers are currently under study in an effort to understand which patients might derive the most benefit from these agents.

Research efforts are focusing on tumor biology and genetics to better characterize tumors, which will lead to better targeted agents and more effective, less toxic therapy for this often difficult disease. This review discusses the evidence for the use of targeted agents in non small cell lung cancer in various settings as well as the molecular basis for the use of such therapies and the challenges faced in determining the optimal targeted therapy for individual patients and tumor types.

with resulting treatment regimens that are more effective and, often, less toxic. This overview will examine the mechanisms and data behind the use of targeted therapy in NSCLC including small molecule tyrosine kinase inhibitors (TKIs) as well as the use of the vascular endothelial growth factor (VEGF) inhibitor bevacizumab in first line therapy for non small cell lung cancer with standard chemotherapy.

I. Introduction Lung cancer is the leading cause of cancer related mortality worldwide with approximately 1.3 million deaths per year (World Health Organization). Non small cell lung cancer (NSCLC) is the most common type of lung cancer diagnosed and includes the histologies of adenocarcinoma, squamous cell carcinoma and large cell carcinoma. Often, lung cancer is diagnosed at an advanced stage when treatment options have traditionally been limited and life expectancy poor. Chemotherapy has been the mainstay of treatment for metastatic lung cancer, while chemotherapy and radiation are often employed for locally advanced lung cancer not amenable to surgical resection.

Chemotherapy can offer a modest survival advantage in patients of good performance status with metastatic disease, though the therapy itself has many side effects (Non-small Cell Lung Cancer Collaborative Group, 1995).

The past several years have increasingly seen the use of targeted agents in advanced non small cell lung cancer

II. Angiogenesis Angiogenesis is a complicated and multifaceted process that plays an integral and crucial role in tumor growth of many cell types, including non-small-cell lung cancer. It is this process of new blood vessel growth, which in turn facilitates passage of oxygen, nutrients, growth factors and hormones allowing tumor cells to survive and disseminate (Folkman 1989; Fidler and Ellis, 1994; Hicklin and Ellis, 2005). Indeed, vascularization of a tumor marks the ability of the tumor to grow and 95

Blanchard et al: Targeted agents in Non Small Cell Lung Cancer metastasize (Fidler and Ellis, 1994). Increased markers of angiogenesis such as tumor expression of VEGF and vascular endothelial growth factor receptor (VEGFR) as well as tumor microvessel density are associated with diminished survival. In one series of patients with lung cancer, patients whose tumors expressed VEGF and VEGFR had shortened survival times compared with patients whose tumors did not express either VEGF or VEGFR (Seto et al, 2006). Another series (Fontanini et al, 1997) looked at tumor microvessel density in patients with NSCLC and found that the highest levels of microvessel density were associated with diminished survival and that progressively increasing microvessel counts correlated with increasingly poor survival. Microvessel counts were noted in this study to be an independent poor prognostic sign in multivariate analyses as well.

cisplatin/gemcitabine, bevacizumab 15mg/kg plus cisplatin/gemcitabine and cisplatin/gemcitabine plus placebo. Notably, bevacizumab was continued after chemotherapy until disease progression in the experimental arm and crossover to bevacizumab was not allowed for patients in the placebo arm. Progression free survival was significantly improved in the group randomized to cisplatin/gemcitabine plus bevacizumab 7.5mg/kg with a hazard ratio of 0.75 (95% CI 0.62, 0.91; p value of 0.0026). Interestingly, PFS was also increased in the group receiving bevacizumab 15mg/kg compared with placebo in similar proportions to the 7.5mg/kg dose.

Median survival was 6.7 months in the group receiving bevacizumab 7.5mg/kg plus chemotherapy, 6.5 months in the group receiving bevacizumab 15mg/kg plus chemotherapy and 6.1 months in the group receiving chemotherapy alone. Overall survival data are awaited. It does raise the question, however, as to what the optimal dose of bevacizumab is in this setting.

III. Use of angiogenesis inhibitors Observations such as these have led to the use of angiogenesis inhibitors for clinical use. Though many are under investigation, bevacizumab is the most commonly used in clinical practice. Bevacizumab is a recombinant IgG antibody of approximately 149 kilodaltons with human and murine components that binds to VEGF and inhibits its contact with VEGF receptors, thus neutralizing the function of VEGF, including its role in angiogenesis (Package insert, bevacizumab; Margolin et al, 2001).

In a phase II study of patients with advanced lung cancer, the addition of bevacizumab to a standard chemotherapy regimen of carboplatin and paclitaxel was associated with increased time to progression and better response rates compared with carboplatin and paclitaxel alone (Johnson et al, 2004). Of note, six patients on the arm containing bevacizumab had major bleeding, including four fatal events. Bleeding episodes were found to be associated with squamous histology, central tumors located near major blood vessels and cavitary lesions.

Minor mucocutaneous bleeding was also more common in the arm that included bevacizumab. These results led to the large randomized phase III trial of similar design, though patients with squamous histology, clinically significant hemoptysis or brain metastases were excluded from the trial (Sandler et al, 2006). This pivotal study showed increased response rates and increased time to progression with the addition of bevacizumab to a standard chemotherapy regimen of paclitaxel and carboplatin as well as improved survival in the group treated with all three agents. Notably, though, there was more clinically significant bleeding and more treatment related deaths in the bevacizumab containing arm. This has now become the first line standard of care in patients who have stage IV NSCLC with a good performance status, non-squamous histology, no risk factors for major bleeding and no history of hemoptysis.

Recently, preliminary results from the AVAiL trial were presented at the American Society of Clinical Oncology meeting in June 2007 (Manegold et al 2007).

This multinational and multicenter trial enrolled more than 1000 patients with advanced NSCLC (stage IIIb or IV) who had not been treated previously. There were three trial arms: bevacizumab 7.5mg/kg plus

IV. Targeting the epidermal growth factor receptor The mutation or alteration of tyrosine kinases has been discovered to play an integral role in the pathogenesis of a wide variety of cancer types. For example, in chronic myelogenous leukemia (CML), the fusion of Bcr and Abl to form the abnormally activated intracellular tyrosine kinase is the cause of CML and also a target for its treatment (Smith et al, 2003). In breast cancer, over expression of the HER-2/neu receptor, which is a transmembrane tyrosine kinase in the same family as the epidermal growth factor receptor (EGFR), is associated with a poor prognosis and is also a target for therapy (Aguilar et al, 1999). In NSCLC, mutations in the EGFR are well described (Sequist et al, 2007) and therapeutic agents that target the EGFR have been shown to improve survival (Shepherd et al, 2005).

The EGFR is a transmembrane receptor with an extracellular portion that is involved in ligand binding and an intracellular portion that contains the tyrosine kinase function, which is composed of two segments: one that binds ATP and magnesium and an activation segment.

When the extracellular domain is bound by its ligand, the activation segment becomes phosphorylated, which changes the conformation of the intracellular portion resulting in an increase in enzymatic activity and various signaling processes are initiated. (Krause and Van Etten 2005) Small molecule TK inhibitors, such as gefitinib and erlotinib antagonize this process. Gefitinib competes for the ATP binding site on EGFR and once bound, it effectively blocks the normal epidermal growth factor induced activity of phosphorylation and thereby shuts down further signaling (Wakeling et al, 2002). Similarly erlotinib is also a competitive inhibitor of ATP on EGFR and inhibits subsequent phosphorylation. It has been shown to both decrease cell proliferation and induce apoptosis in tumor cell lines in vitro (Moyer et al, 1997).

After exposure to erlotinib, an increase of the percentage of cells in the cell cycle phase G1 was noted, with a decrease in the percentage of cells in other phases of the cell cycle including mitosis, implying an arrest in G1. It is 96

Cancer Therapy Vol 6, page 97 speculated that the loss of EGFR signaling (blocked by erlotinib) is responsible for the inability of the cells to progress through the cell cycle and thus proliferate.

Further evidence from the same in vitro study also demonstrated increased apoptosis in tumor cell lines exposed to erlotinib that was similar to the degree of apoptosis induced by exposure to cisplatin in the same tumor cell lines. This implies that TKIs have both cytostatic as well as more direct cytotoxic effects on tumor cells.

V. Clinical performance tyrosine kinase inhibitors

of

improvement rate in both groups, though symptom improvement was correlated with response to therapy.

Diarrhea and skin toxicities were most common, though no cases of interstitial lung disease were observed. Based on this data, a phase III trial looking at overall survival was launched. The ISEL (Thatcher et al, 2005) (Iressa Survival Evaluation in Lung Cancer) trial enrolled 1692 patients from multiple centers worldwide and randomized them in a 2:1 fashion to gefitinib (at 250mg daily) or placebo with best supportive care. Patients with locally advanced or metastatic NSCLC treated with at least one prior chemotherapy regimen and found to be either refractory or intolerant were eligible. Survival was the primary end point. Median survival among all patients enrolled was 5.6 months for the gefitinib arm and 5.1 months for the placebo arm, a difference that was not statistically significant. Patients who were of Asian origin or who had never smoked did have an improvement in overall survival in a planned subset analysis, though the subgroup of patients with adenocarcinoma histology did not show an overall survival benefit when treated with gefitinib when compared with placebo. As a result, the use of gefitinib has now been restricted to patients who were previously treated with gefitinib and are responding to the medication.

Newer data may broaden its use, however. Results from the INTEREST trial were recently presented at the 12th World Conference on Lung Cancer. This multi-center, multi-national trial included more than 1400 patients with previously treated locally advanced or metastatic NSCLC. All patients had a platinum incorporated into their prior regimen and approximately 20% of patients enrolled were of Asian origin. After enrollment, patients were randomized to either docetaxel or gefitinib. Adverse events were the expected toxicities associated with both of these agents including an increased incidence of rash and diarrhea in the gefitinib group and increased neutropenia, fatigue, nausea and alopecia in the docetaxel group.

Gefitinib was found to be non-inferior to docetaxel with a median overall survival of 7.6 months compared with 8 months in the docetaxel group, but was associated with improved symptoms and quality of life in two out of three models used. Of note, subgroup analyses of patients with EGFR mutations, high EGFR gene copy number or EGFR expression showed no difference in survival irrespective of their treatment group.

Erlotinib has also shown benefit in patients with advanced NSCLC who have failed chemotherapy (Table 1) and is often used as second or third line therapy. The BR.21 study (Shepherd et al, 2005) was a randomized, double blind, placebo controlled phase III trial which enrolled 731 previously treated patients with NSCLC. More than 90% had been treated with a platinum in prior regimens and more than half had been treated with two prior chemotherapy regimens. Patients were randomized in a 2:1 ratio, with two patients randomized to erlotinib for every one patient randomized to the placebo arm. The response rate (CR and PR) was 8.9% in the erlotinib group compared with <1% in the placebo group. Overall survival was also better in the erlotinib group with a median survival of 6.7 months in the erlotinib group compared

the

Several dose finding phase I trials demonstrated that the small molecule TKI gefitinib was safe and well tolerated, which led to the phase II trials of Iressa Dose Evaluation in Advanced Lung Cancer trials (IDEAL-1 and IDEAL-2). IDEAL-1 (Fukuoka et al, 2003) was a non-US, multicenter phase II trial that included patients with nonsmall-cell lung cancer that was metastatic or locally advanced following progression on one or more chemotherapy regimens, one of which had to have included a platinum. More than 200 patients were randomized in a double blind fashion to gefitinib 250mg or 500mg. Of note, about half of the patients were of Japanese origin. Response rates and disease related quality of life were measured. Response rates did not differ between doses (18.4% and 19% in the 250mg and 500mg groups respectively) nor did disease control rate (54.4% and 51.4%). Disease control rate referred to the best response of CR, PR or SD that persisted for 4 weeks or longer. Symptom improvement was noted and was similar between the dose groups with increasing symptom improvement rates with increasing responses. The main toxicities were the expected adverse effects of skin reactions, diarrhea and elevated transaminases. In addition, pulmonary interstitial type illness was seen in two patients.

IDEAL-2 (Kris et al, 2003) was a similar phase II trial with multi-center participation in the US. There are some important differences in the patient populations of the IDEAL 1 and 2 trials. IDEAL-2 included patients with stage IIIb or Stage IV NSCLC if they had progressed or had unacceptable toxicity after two or more prior chemotherapy regimens containing a platinum agent and docetaxel. Enrollment in this trial came entirely from centers based in the United States. In addition, patients were only eligible if they had symptomatic and measurable disease. Approximately 20% were ECOG performance status of 2, the remainder were 0-1. In the IDEAL-1 trial, approximately 40% of patients had failed two prior treatment regimens, while all had failed one.

About 65-70% of patients were symptomatic at study entry. Less than 15% of patients were performance status 2, the remainder were 0-1. As part of the study design, half of patients were Japanese.

In the IDEAL-2 trial more than two hundred patients were enrolled and randomized to either 250mg or 500mg of gefitinib. There were no complete responses and a partial response rate of 12% and 9% for the 250mg and 500mg doses of gefitinib respectively. In addition, there was a 25% overall increase in the symptomatic 97

Blanchard et al: Targeted agents in Non Small Cell Lung Cancer

Table 1. Selected Phase III trials involving erlotinib and gefitinib Trial TRIBUTE TALENT BR.21

Type Phase III Phase III Phase III

ISEL

Phase III

INTEREST

Phase III

Patients Untreated stage IIIB/IV NSCLC Untreated stage IIIB/IV NSCLC Previously treated patients with stage IIIB/IV NSCLC Previously treated patients with stage IIIB/IV NSCLC Previously treated patients with locally advanced or metastatic NSCLC

Treatment Carboplatin paclitaxel vs. carboplatin/paclitaxel/erlotinib Cisplatin/gemcitabine vs. cisplatin/gemcitabine/erlotinib Erlotinib vs. placebo

Results No difference in RR, TTP or MS No difference in RR, TTP, OS, QoL Increased RR, PFS and OS in erlotinib group

Gefitinib vs. placebo

No difference in median survival between the two groups Similar median survival, but less toxicity in gefitinib group

Gefitinib vs. docetaxel

RR=response rate, TTP=time to progression, MS=median survival, OS=overall survival, QoL=quality of life

with 4.7 months in the placebo group (adjusted hazard ratio of 0.70; 95% CI: 0.58-0.85, p<0.001). In addition, the median time to symptom worsening was longer for patients taking erlotinib including the cancer related symptoms of cough, dyspnea and pain.

Several studies have investigated the value of adding tyrosine kinase inhibitors with chemotherapy. INTACT-1 (Giaccone et al, 2004) and INTACT-2 (Herbst et al, 2004) trials were phase III trials of patients with advanced NSCLC who were chemotherapy na誰ve and treated with either chemotherapy or chemotherapy plus gefitinib. In INTACT-1, more than one thousand patients were enrolled and randomized to a standard chemotherapy doublet of cisplatin/gemcitabine or the same doublet plus gefitinib at a dose of either 250mg or 500mg. There was no significant difference in response rates, time to progression or survival between the groups. INTACT-2 was a similar large phase III trial that randomized patients with advanced NSCLC to carboplatin/paclitaxel versus carboplatin/paclitaxel plus gefitinib. The results were also similar: no significant difference in response rates, time to progression or overall survival. The TRIBUTE study (Herbst et al, 2005) randomized previously untreated patients to standard chemotherapy with carboplatin and paclitaxel vs. the same chemotherapy plus concurrent erlotinib. More than one thousand patients were enrolled.

Response rates, time to progression and overall survival were not statistically different between the two arms.

Similarly, adding erlotinib to another common doublet used in advanced non-small-cell lung cancer, cisplatin and gemcitabine, did not yield any added benefit to chemotherapy alone in terms of response rate, time to progression or survival as reported in the TALENT study (Gatzemeier et al, 2007). It does not appear therefore that adding tyrosine kinase inhibitors to standard chemotherapy schedules offers any benefit.

In one of the few large intergroup trials in stage III NSCLC, the investigators of SWOG 0023 looked at maintenance gefitinib after treatment with

cisplatin/etoposide and concurrent radiation, followed by consolidation with docetaxel (Kelly et al 2007). After consolidation, patients were randomized to gefitinib or placebo. The primary endpoint was overall survival. In patients who were randomized, progression free survival was statistically similar, but survival was greater in the placebo arm with median survival of 23 months in the gefitinib arm and 35 months in the placebo arm (P value of 0.01, HR 0.63, 95% CI 0.44-0.91). The main cause of death was overwhelmingly cancer related, and toxicity was not felt by the investigators to be a significant cause of diminished survival in the gefitinib arm. The use of maintenance gefitinib in stage III disease should be limited to clinical trials.

VI. Predictors of response to tyrosine kinase inhibitors Several clinical characteristics have consistently predicted for response to the small molecule TKIs including a history of never smoking, Asian origin, female gender and adenocarcinoma histology (Kris et al, 2003; Shepherd et al, 2005; West et al, 2006). Molecular correlates have also been studied extensively.

Retrospective data, particularly (though not exclusively) out of Asia, supports the notion that the presence of an EGFR mutation is associated with improved survival when those patients are treated with a tyrosine kinase inhibitor (gefitinib or erlotinib), (Cortes-Funes et al, 2005; Han et al, 2005) but prospective phase III trials have not been able to confirm this. In the several phase III clinical trials that have evaluated the use of TKIs in advanced non small cell lung cancer, most of them have also included molecular correlates as part of the study design. From the IDEAL-1 (Fukuoka et al, 2003) and IDEAL-2 (Kris et al, 2003) trials, samples from 155 patients out of 425 enrolled were available for analysis of EGFR mutational status and presence of EGFR amplification. There were 666 tumor samples available from the more than two thousand

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Cancer Therapy Vol 6, page 99 participants in the INTACT trials that were subjected to analysis for EGFR mutation status and amplification.

Between 59-86% of samples were subsequently successfully analyzed (Bell et al, 2005). EGFR mutations were found in 18% of the analyzed samples from the IDEAL trials and 10% from the INTACT trials. Consistent with other studies of mutations in EGFR, most of the mutations were in frame deletions found in exon 19, followed by missense mutations in the L858R in exon 21 followed by a small percentage of novel variants. Similar to other series, in both the IDEAL and INTACT trials mutations were found more frequently in patients with known clinical predictors of response to therapy including adenocarcinoma histology, women, non smokers and Asian patients. In contrast, the presence of EGFR gene amplification was not associated with any of the previously described characteristics associated with clinical response.

In the IDEAL series, the overall response rate to gefitinib was higher in the group of patients whose tumors were found to have an EGFR mutation (46% compared with 10%, p=.005) (Bell et al, 2005). In addition, patients whose tumors contained mutations had a longer median time to progression (TTP) compared with patients whose tumors did not contain EGFR mutations, but there was no difference in overall survival between the groups. The numbers of patients with gene amplifications was very small, limiting the comparison, but there was no statistically significant difference in response to treatment between patients with high gene copy numbers and lower copy numbers. In the INTACT trial series, neither mutational status nor the presence of gene amplification seemed to impact response rates to chemotherapy plus gefitinib, as they were not statistically different in patients with or without the mutation or gene amplification. The addition of gefitinib did not affect overall survival in patients who were mutation positive (hazard ratio 1.77; 95% CI, 0.5-6.23).

Similarly, several trials have looked at erlotinib and molecular correlates that may predict for response. The BR.21 (Shepherd et al, 2005) trial was a phase III study in patients with previously treated NSCLC who progressed after chemotherapy and were randomized to either erlotinib or placebo. Three different aspects of EGFR were investigated using tumor samples from this trial: expression of EGFR by the tumor, EGFR gene amplification and EGFR mutations (Tsao et al, 2005).

Expression of EGFR protein was established by immunohistochemistry and considered positive if 10 percent of tumor cells had staining of any intensity.

Mutational analysis was carried out first with amplification by PCR, followed by sequence analysis.

EGFR gene copy number was determined by FISH, with FISH positive tumors corresponding to high degree of amplification. In multivariate analysis, expression of EGFR was associated with increased responsiveness to erlotinib, but neither expression of EGFR, EGFR gene amplification nor the presence of an EGFR mutation predicted for improved survival in patients treated with erlotinib. Of the 1079 patients enrolled in the TRIBUTE (Eberhard et al, 2005) study, tumor specimens from 274 of

these patients were satisfactory and available for DNA sequencing. EGFR mutations, when detected, were confirmed with independent PCR and sequencing. EGFR mutations were found in 12.2% of the tumor samples available and the presence of a mutation was associated with improved overall response rate (ORR) in patients who had an EGFR mutation and were treated with erlotinib (53% vs. 18% p<.01). Patients with EGFR mutations who were treated with CP plus erlotinib had a numerically increased time to progression compared with patients with EGFR mutations treated with CP alone (12.5 months vs. 6.6 months) but the difference was not statistically significant (p=.092, 95% CI for HR 0.2-1.2).

Overall survival was not different in patients who were mutation positive regardless of if they received chemotherapy alone or in combination with erlotinib. The outcome parameters and analysis were limited by the small number of EGFR mutation positive patients (29 total). Interestingly, patients with EGFR mutations had improved ORR, TTP and survival independent of their treatment groups compared with patients whose tumors did not have EGFR mutations.

One major challenge in attempts to determine molecular correlates to clinical responses to targeted therapy is the analysis process itself. Investigators are limited by small amounts of tissue as fine needle aspirates are increasingly used for diagnosis, the fixatives used to preserve the tissue and the limitations of the analytic methods (Sequist et al, 2007). One prime example is the mutation analysis done in the BR.21 study that found new mutations in 53% of patients who were mutation positive (Tsao et al, 2005) which is indicative of the presence of artifacts. This led the investigators of that trial to reevaluate their mutation analysis (Tsao et al, 2006) in which they included only mutations already described in exon 19 and in exon 21. In the new analysis, the results were similar: patients whose tumors had mutations in those two â&#x20AC;&#x153;classicâ&#x20AC;? areas had better response rates than patients without such mutations, but there was no difference in overall survival (HR for death 0.52 with 95% CI 0.21-1.31, P=0.16).

Investigation into new targeted agents continues and there are several currently in clinical trials. AZD2171 is an oral antiangiogenesis drug that inhibits VEGFR tyrosine kinases and has been looked at in multiple phase I and II trials in several different solid tumors and has shown some efficacy in NSCLC (Goss et al 2007). A phase II/III trial is now accruing using this agent plus a carboplatin/paclitaxel doublet and comparing it with the chemotherapy doublet plus placebo. Sunitinib, a multitargeted tyrosine kinase inhibitor best known for its use in renal cell cancer has shown promise in NSCLC in phase II trials (Brahmer et al 2007) and is now being studied in combination with erlotinib in a phase III study now accruing. ZD6474 is an oral tyrosine kinase inhibitor that targets both VEGF and the epidermal growth factor, now being investigated in several phase III trials after showing superior progression free survival versus gefitinib (Natale et al 2006). Active clinical trials can be accessed at www.cancer.gov.

There is tremendous potential in newer targeted agents, though challenges still lay ahead. One major

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Blanchard et al: Targeted agents in Non Small Cell Lung Cancer Giaccone G, Herbst RS, Manegold C, Scagliotti G, Rosell R, Miller V, Natale RB, Schiller JH, Von Pawel J, Pluzanska A, Gatzemeier U, Grous J, Ochs JS, Averbuch SD, Wolf MK, Rennie P, Fandi A, Johnson DH (2004) Gefitinib in combination with gemcitabine and cisplatin in advanced nonsmall-cell lung cancer: A phase III trial-INTACT-1. J Clin Oncol 22, 777-784.

Goss GD, Laurie S, Shepherd F, Leighl N, Chen E, Gauthier I, Reaume N, Feld R, Powers J, Seymour L (2007) IND 175: Phase I study of daily oral AZD2171, a vascular endothelial growth factor receptor inhibitor (VEGFRI), in combination with a gemcitabine and cisplatin (G/C) in patients with advanced non-small cell lung cancer (ANSCLC): a study of the NCIC clinical trials group (Abstr 7649). J Clin Oncol 25, (Supp No. 18S).

Han SW, Kim TY, Hwang PG, Jeong S, Kim J, Choi IS, Oh DY, Kim JH, Kim DW, Chung DH, Im SA, Kim YT, Lee JS, Heo DS, Bang YJ, Kim NK (2005) Predictive and Prognostic Impact of Epidermal Growth Factor Receptor Mutation in Non–Small-Cell Lung Cancer Patients Treated With Gefitinib. J Clin Oncol 23, 2493-2501.

Herbst RS, Giaccone G, Schiller JH, Natale RB, Miller V, Manegold C, Scagliotti G, Rosell R, Oliff I, Reeves JA, Wolf MK, Krebs AD, Averbuch SD, Ochs JS, Grous J, Fandi A, Johnson DH (2004) Gefitinib in combination with paclitaxel and carboplatin in advanced non-small-cell lung cancer: A phase III trial-INTACT-2. J Clin Oncol 22, 785-794.

Herbst RS, Prager D, Hermann R, Fehrenbacher L, Johnson BE, Sandler A, Kris MG, Tran HT, Klein P, Li X, Ramies D, Johnson DH, Miller VA; TRIBUTE Investigator Group (2005) TRIBUTE: a phase III trial of erlotinib hydrochloride (OSI-774) combined with carboplatin and paclitaxel chemotherapy in advanced non-small-cell lung cancer. J Clin Oncol 23, 5892-5899.

Hicklin DJ, Ellis LM (2005) Role of the vascular endothelial growth factor pathway in tumor growth and angiogenesis. J Clin Oncol 23, 1011-1027.

Johnson DH, Fehrenbacher L, Novotny WF, Herbst RS, Nemunaitis JJ, Jablons DM, Langer CJ, DeVore RF, Gaudreault J, Damico LA, Holmgren E, Kabbinavar F (2004) Randomized Phase II Trial Comparing Bevacizumab Plus Carboplatin and Paclitaxel With Carboplatin and Paclitaxel Alone in Previously Untreated Locally Advanced or Metastatic Non-Small-Cell Lung Cancer. J Clin Oncol 22, 2184-2191.

Kelly K, Chansky K, Gaspar LE, Jett JR, Ung Y, Albain KS, Crowley JJ, Gandara DR (2007) Updated analysis of SWOG 0023: A randomized phase III trial of gefitinib versus placebo maintenance after definitive chemoradiation followed by docetaxel in patients with locally advanced stage III non-small cell lung cancer (Abstr 7513). J Clin Oncol 25, (Supp No. 18S).

Krause DS, Van Etten RA (2005) Tyrosine kinases as targets for cancer therapy. New Engl J Med 353, 172-187.

Kris MG, Natale RB, Herbst RS, Lynch TJ Jr, Prager D, Belani CP, Schiller JH, Kelly K, Spiridonidis H, Sandler A, Albain KS, Cella D, Wolf MK, Averbuch SD, Ochs JJ, Kay AC (2003) Efficacy of gefitinib, an inhibitor of the epidermal growth factor receptor tyrosine kinase, in symptomatic patients with non-small cell lung cancer. JAMA 290, 21492158 Manegold C, von Pawel J, Zatloukal P, Ramlau R, Gorbounova V, Hirsh V, Leighl N, Mezger J, Archer V, Reck M, the BO17704 study group (2007) A randomized, double-blind, phase III study of bevacizumab in combination with cisplatin and gemcitabine in chemo-naïve patients with advanced or recurrent non-squamous NSCLC (Abstr LBA7514). J Clin Oncol 25, (Supp No. 18S).

challenge is to determine which patients and tumor types will derive more or less benefit from particular therapies.

Future trials have already begun to attempt to better characterize lung tumors with the goal of finding more specific therapies that are tailored to a particular tumor type as determined by molecular and or genetic signatures.

Ideally, this will result in more effective and less toxic therapies, which are very much needed in the difficult disease of advanced NSCLC.

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World Health Organization

Elizabeth Blanchard

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The molecular bases of cannabinoid action in cancer Review Article

Stefano Fogli*, Maria Cristina Breschi Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, 56126-Pisa, Italy

__________________________________________________________________________________ *Correspondence: Stefano Fogli, PharmD, PhD, Assistant Professor of Pharmacology, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa; Via Bonanno, 6; Pisa, PI 56126, Italy; Phone: ++39-050-2219511; Fax: ++39050-2219609; E-mail: s.fogli@med.unipi.it Key words: Cannabinoids, cancer, apoptosis, angiogenesis, inflammation Abbreviations: 2-arachidonoylglycerol, (2-AG); apoptotic protease-activating factor-1, (APAF-1); arachidonoyl-serotonin, (AA-5-HT); cannabinoid type 1, (CB1); cannabinoid type 2, (CB 2); carcinoma-associated fibroblasts, (CAFs); cyclin-dependent kinase, (cdk); cyclooxygenase, (COX-2); extracellular signal-regulated kinase, (ERK); fatty acid amide hydrolase, (FAAH); fibroblast growth factors, (FGFs); inducible form of nitric oxide synthase, (iNOS); interleukin, (IL); mitogen-activated protein kinase, (MAPK); nerve growth factor, (NGF); nuclear factor-!B, (NF-!B); proHeparin-binding EGF-like growth factor, (proHB-EGF); prostaglandin E 2, (PGE2); protein kinase A, (PKA); retinoblastoma protein, (pRb); stromal cell-derived factor 1, (SDF-1); tetrahydrocannabinol, (THC); TNF-" converting enzyme, (TACE); transient receptor potential vanilloid type 1 receptor, (TRPV1); tumor necrosis factor, (TNF); vascular endothelial growth factor, (VEGF) Received: 15 December 2007; Revised: 17 December 2007 Accepted: 31 December 2007; electronically published: February 2008

Summary In the last two decades, research in the cannabinoid field has generated a rich body of knowledge revealing a role of the endocannabinoid system in the regulation of several processes involved in cancer development and progression.

Cannabimimetic drugs have been shown to inhibit tumor growth by modulating pivotal regulatory circuits in the genetically altered malignant cells and in their supporting coconspirators in the stromal compartment. Nonetheless, the complexity of the integrative actions of these pleiotropic molecules in tumor cells, mesenchymal cells and cells of the immune system makes difficult to understand the precise mechanism of action responsible of their effects. In this review, we highlight the molecular mechanisms of cannabinoid action in cancer by focusing on key cellular and molecular processes that collectively dictate the molecular signature of the basic machinery of cancer.

understand the molecular bases of cannabinoid action should be encouraged. This issue appears to be particularly relevant if considering that both mitogenic and antimitogenic potentials of cannabinoid-based treatments have been observed, with the type of biological response depending on a number of extrinsic and intrinsic factors, such as the specific tumor phenotype (e.g, receptor status and dependence on growth signaling), the pharmacological profile of cannabinoid compounds (e.g, receptor subtype selectivity and agonist or antagonist properties) and the mechanism involved in their action (e.g, receptordependent or receptor-independent effects).

A great number of derivatives of different origin, including endogenous lipids (endocannabinoids) as well as plant- and synthetic-derived compounds with cannabinoidlike activity, bind specific receptor subtypes to induce cannabimimetic responses on target tissues. Three endocannabinoid receptors have been characterized; these are cannabinoid type 1 (CB1) and type 2 (CB2) receptors and transient receptor potential vanilloid type 1 receptor

I. Introduction The investigation of the therapeutic effects of cannabinoids on some cancer-related disorders has provided evidence of their effectiveness in the alleviation of several symptoms observed in cancer patients, such as chemotherapy-induced nausea and vomiting, appetite loss and neuropathic pain (Hall et al, 2005). Beyond the palliative effects induced by these compounds, recent advances in the knowledge of the biological role of endocannabinoids and novel insights into the molecular signaling of cannabinoid receptors, support the participation of the endocannabinoid system in the regulation of key processes involved in the development of cancer, including cell growth and apoptosis (Bifulco and Di Marzo, 2002; Guzman et al, 2002), angiogenesis (Pisanti et al, 2007), inflammation and immune cell function (Klein, 2005). However, despite the potential therapeutic application of these findings, caution is required when envisaging new options in cancer therapy and more intense research efforts aimed to better 103

Fogli and Breschi: Cannabinoids and cancer (TRPV1) ion channels (for review see Pacher et al, 2006).

Information regarding novel non-CB1/CB2 receptors has been also recently provided; however, the molecular identity and function of these receptors remain substantially unclear (Brown, 2007). CB1 and CB2 are seven-transmembrane G-protein-coupled receptors (GPCR) that are coupled to Gi/Go heterotrimeric proteins and adenylyl cyclase, but other second messengers and signaling components are also involved in their activity (Bisogno et al, 2005; Demuth and Molleman, 2006). In this review article, we will summarize information on the molecular mechanisms of cannabinoid action currently available by focusing on the cross-talk between the CB1/CB2 signaling network and different target molecules in tumor cells and in the surrounding tissue that serve as protagonists and active collaborators in the neoplastic cell agenda. Such a viewpoint may be helpful in understanding the value of cannabinoid receptors as novel promising targets for therapeutic interventions aimed to disrupt cancer machinery.

highlighting the relevance of considering tumors as complex tissues in which different actors contribute to their phenotypic signature (Figure 1).

An illustrative example of this concept comes from evidence demonstrating that chronic inflammation is a pathophysiologic condition able to deregulate cellular homeostasis and drive carcinogenesis, particularly in epithelial-derived malignancies (Hussain et al, 2003; Angelo and Kurzrock, 2007); in this view, inflammatory cells attracted to sites of neoplasia may promote (rather than eliminate) cancer cells. As a matter of fact, the protective effect observed in cancer patients following the administration of the selective COX-2 inhibitor, celecoxib (Altorki et al, 2003), indicates that molecules interfering with inflammatory signaling pathways either in the tumor or in adjacent nontumor tissues which cooperate in the multiple events that characterize tumor growth, can effectively elicit antitumor effects. Concerning the molecular mechanisms underlying the complex interplay between inflammation and tumor development, it has been recognized that tumor-infiltrating lymphocytes such macrophages, T cells, B cells, natural killer cells, neutrophils and granulocytes, release a large amounts of inflammatory cytokines into the microenvironment. These cytokines may enhance the tumorigenic process by upregulating important mediators of angiogenesis, including vascular endothelial growth factor (VEGF) and interleukin (IL)-8, and/or may serve as autocrine and paracrine growth factors for several types of cancers. Of note, VEGF, in turn, increases vascularity at the site of inflammation causing the reaction to be more severe (Angelo and Kurzrock, 2007).

II. The heterotypic cell biology view of cancer Cancer death is caused by a number of molecular and biochemical processes which ultimately result in tumorcell metastatic spreading (Hanahan and Weinberg, 2000).

Several lines of evidence suggest that besides genetic and epigenetic signatures of a specific cancer cell type, the interactions between malignant cells and cells in the host microenvironment, appear to be critical in the selection and expansion of the tumor mass (for review see Liotta and Kohn, 2001; Orimo and Weinberg, 2006), thus

Figure 1. Overview of the multistep process involved in tumor progression. Cancer cell genotype deriving from genetic defects in regulatory circuits governing normal cell homeostasis drives the clonal expansion of different cell variants. Cytokine and enzyme exchange between cells populating the stromal compartment surrounding the tumor (i.e, immune, inflammatory and vascular cells) and neoplastic cells stimulates migration of both cell types towards each other which ultimately results in invasion and metastasis.

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Cancer Therapy Vol 6, page 105 The ability to induce and sustain angiogenesis is a fundamental step during tumor development and metastatic progression (Mehlen and Puisieux, 2006). The angiogenesis-initiating signals are exemplified by VEGF and fibroblast growth factors (FGFs) which interact with transmembrane tyrosine kinase receptors displayed by endothelial cells (Folkman, 2002). Of note, it has been recently demonstrated that host inflammatory responses induced by FGF-2 are associated with FGF-2-induced tumor progression (Tsunoda et al, 2007). Finally, FGF-2 is known for its mitogenic effects on human cancer cells and it is also a potent stimulator of cell survival (Vandermoere et al, 2007).

These notions highlight how a complete understanding of the complex interplay between different elements which play a pivotal role into the tumor-host interface circuit, might represent a rational basis for selecting innovative strategies in cancer therapy.

(Caffarel et al, 2006), prostate (Sarfaraz et al, 2006), colorectal (Ligresti et al, 2003), glioma (Massi et al, 2004), melanoma (Blazquez et al, 2006) and leukemia (McKallip et al, 2006), and with the notion that the endocannabinoids, 2-arachidonoylglycerol (2-AG; Nithipatikom et al, 2004) and anandamide (AEA; Ligresti et al, 2003), have been demonstrated to play a role as endogenous inhibitors of cancer cell proliferation.

In contrast with the abovementioned results, some published data seem instead to support a mitogenic role for endocannabinoids. For example, the extent of CB2 expression was directly related with tumor malignancy in biopsies from human astrocytomas (Sanchez et al, 2001), and real-time quantitative PCR analyses in human breast tumor samples demonstrated a correlation between CB2 expression and several prognostic markers such as histological grade of tumors, estrogen/progesterone receptor status, and expression of the HER2/neu oncogene (Caffarel et al, 2006). Despite the causative role of cannabinoid receptor expression cannot be establised by association studies, it should be noted that CB1 receptor antagonist SR141716A, when administered alone, did not enhance, but instead slightly inhibited, the growth of rat thyroid transformed cells both in vitro and in tumor xenografts induced in vivo (Bifulco et al, 2004). In line with this notion, CB1 antagonism by SR141716A induced a cytostatic effect on human breast cancer cell growth that was more pronounced in highly invasive metastatic cells than in less-invasive cells (Sarnataro et al, 2006). The antiproliferative effect of SR141716A was characterized by a G1/S-phase cell cycle arrest with a concomitant induction of the cyclin-dependent kinase inhibitor p27KIP1 (Sarnataro et al, 2006). Of note, such a mechanism has been also demonstrated for trastuzumab (Lane et al, 2000), a FDA-approved monoclonal antibody for the treatment of patients with metastatic breast cancer, whose tumors overexpress the HER2/neu protein (Bernard-Marty et al, 2006).

In summary, although their action may substantially depend on the cell type and pathophysiologic context, it is conceivable that endocannabinoids, through their receptors, may act as autocrine and/or paracrine growth factor-like molecules by promoting positive feedback loops which confer to cancer cells a self-sufficiency from other cells within the tissue, a mechanism shared by most types of human cancers. This hypothesis seems to be in agreement with evidence demonstrating that nanomolar concentrations of cannabinoids may elicit a receptormediated tumor cell proliferation (Hart et al, 2004), a mechanism most probably linked to the stimulation of mitogen-activated protein kinase (MAPK) (Bouaboula et al, 1995; Galve-Roperh et al, 2002) and phosphatidylinositol 3-kinase and Akt (PI3K/Akt) pathways (Sanchez et al, 2003; Fernandez-Ruiz et al, 2007) (Figure 2). Otherwise, overstimulation of these receptors induced by micromolar concentration of cannabimimetic drugs or increased amount of endocannabinoids (Nithipatikom et al, 2004) as well as receptor antagonism (Sarnataro et al, 2006), may promote disarray in the homeostatic regulation of receptor function and signaling that finally results in dismantling of the

III. The role of the endocannabinoid system in the regulation of neoplastic cell circuits A. Cannabinoid receptors in human cancer Several lines of evidence suggest that specific cannabinoid receptor subtypes play a determining role in hematological and solid malignancies. The differential expression of these receptors between normal and tumor tissues may therefore be of interest to better understand the role of the endocannabinoid system in the maintenance of the neoplastic cell phenotype. For example, it has been recently demonstrated that expression levels of both CB1 and CB2 were significantly higher in human prostate cancer cells than in prostate epithelial cells (Sarfaraz et al, 2005), and in human hepatocellular carcinoma samples, comparing to their counterpart in normal liver (Xu et al, 2006). While examination of a number of human leukemia and lymphoma cell lines revealed that they express CB2, but not CB1 (McKallip et al, 2002), results from other groups demonstrated a specific expression of CB1 in human lymphoma cells but not in normal human B lymphocytes (Ek et al, 2002; Islam et al, 2003; Flygare et al, 2005; Gustafsson et al, 2006). Furthermore, interesting and potentially very important findings considering the induction of CB1 gene expression via CB2 in human malignant T lymphocytes indicate the presence of a crosstalk between these two receptors, at the transcriptional level (Borner et al, 2007).

Regarding the pathogenetic significance of cannabinoid receptor overexpression in cancer development, Xu and co-workers demonstrated in 2006 that disease-free survival was significantly better in hepatocellular carcinoma patients with both high CB1 and CB2 expression levels compared with those with low CB1 and CB2 expression levels, thus suggesting that endocannabinoid system might be part of the anti-growth factor signaling circuit. This concept seems to be in line with most of the in vitro studies finding that ligandinduced activation of cannabinoid receptors reduces cell proliferation in different types of tumors including breast 105

Fogli and Breschi: Cannabinoids and cancer cancer cell network. As an illustrative example, the ability of both the CB1 agonist AEA (De Petrocellis et al, 1998) and the CB1 antagonist SR141716A (Sarnataro et al, 2006) to inhibit the proliferation of human breast cancer MCF-7 cells, has been demonstrated.

ligand-activated growth factor receptors, such as those observed in the SOS-Ras-Raf-MAPK mitogenic cascade (Medema et al, 1993). Furthermore, cross-talking connections with other pathways enable extracellular signals to elicit multiple cell biological effects, as demonstrated by the interaction of the Ras protein with the survival-promoting PI3K/Akt (Downward et al, 1998).

Therefore, it is generally assumed that activation of these signaling pathways leads to cell protection from death stimuli by acting either independently or in a coordinate manner (Figure 2). The endocannabinoid system has been demonstrated to be involved in the modulation of critical components of the downstream cytoplasmic circuitry, including PI3K/Akt (Gomez del Pulgar et al, 2000), extracellular signal-regulated kinase (ERK) (Bouaboula et al, 1995), c-Jun N-terminal kinase and MAPK cascades (Rueda et al, 2000). Of note, it appears that the time of cannabinoid exposure can affect the type of response observed. For example, CB1-mediated short-term ERK activation and PI3K stimulation protect glial cells from ceramide-induced apoptosis (Galve-Roperh et al, 2002), whereas sustained ERK activation promotes apoptosis (Galve-Roperh et al, 2000). Furthermore, inhibition of PI3K/Akt and ERK signaling pathways and activation of apoptosis in tumor cells, seems to be a common feature of cannabinoid action after sustained treatment with cannabinoid receptor ligands (Ellert-Miklaszewska et al, 2005; Jia et al, 2006), thus suggesting that prolonged exposure to these compounds may disrupt the interplay between mitogenic and antiapoptotic signaling molecules in tumor cells, in such a way that favors inhibition of cell proliferation and/or induction of cell death (Figure 2).

B. Interference with growth signaling pathways Many tumor cells acquire the ability to synthesize autocrine growth factors to which they are responsive, thus reducing their dependence from exogenous growth stimulation. Therefore, blocking the growth factor action on their cognate receptors represents a powerful means to arrest cancer cell proliferation. It has been reported that the endocannabinoid AEA, through CB1-like receptors, can exert a cytostatic effect on human breast cancer MCF7 and EFM-19 cells by downregulating the levels of the receptor of prolactin, a hormone which operates as an autocrine signal, in this cell type (De Petrocellis et al, 1998) (Figure 2). Likewise, autonomous production of nerve growth factor (NGF) by epithelial cancer cells, including those isolated from breast (Dolle et al, 2004) and prostate tumors (Djakiew et al, 2000) has an important role in malignant progression. AEA and 2-AG promoted a CB1-mediated inhibition of the NGF-induced proliferation of MCF-7 cells by suppressing the levels of the high affinity trk NGF receptors (Melck et al, 2000) (Figure 2).

Biological responses to cannabinoids critically depend on several factors, including drug concentration at the site of action and specific cell type examined. For instance, submicromolar concentrations of AEA and arvanil (CB1 agonist), potently inhibit the prolactininduced proliferation of prostate cancer cells, while inhibition of basal cell proliferation was observed only at high doses (i.e, #5 ÂľM) (Melck et al, 2000). Moreover, a concentration-dependent biphasic stimulant/inhibitory effect of the marijuana derivative !9-tetrahydrocannabinol (THC) on NGF production by prostate cancer cells has been also observed (Velasco et al, 2001). In contrast to the antiproliferative properties of cannabinoids mediated by negative regulation of growth factor signaling, evidence has been provided on the ability of several ligands such as THC, AEA, and the synthetic cannabinoids HU-210 and Win55,212-2, to rapidly induce epidermal growth factor (EGF) receptor and HER2/neu signal transactivation and proliferation in different cancer cell lines (Hart et al, 2004) (Figure 2). Of note, cannabinoid-promoted mitogenic action by transactivation processes has been mostly observed in cancer cell lines where the EGF signaling pathway plays a pivotal role in determining the neoplastic phenotype (Hart et al, 2004; Zhao et al, 2005). From the molecular viewpoint, signal cross-communication between cannabinoid and EGF receptors was mediated by shedding of proAmphiregulin (proAR) and/or proHeparin-binding EGF-like growth factor (proHB-EGF) by tumor necrosis factor (TNF)-" converting enzyme (TACE) (Hart et al, 2004) (Figure 2).

Beyond the autocrine growth factor production, another mechanism of self-sufficiency acquisition in growth signals comes from abnormalities in the cytoplasmic components that receive signals emitted by

C. Cell cycle and apoptosis At variance with normal tissues, malignant tumor cells can be hypothesized as being resistant to the antiproliferative signals. Much of the signaling pathways that enable normal cells to respond to antigrowth signals are associated with the mitotic cell cycle, specifically the components regulating the transit of the cell through the G1 phase. At the molecular level, antiproliferative signals target the retinoblastoma protein (pRb) that, in the hypophosphorylated state, negatively regulates cell proliferation by altering the function of E2F, a transcription factor essential for progression from G1 into S phase (Khidr and Chen, 2006) (Figure 2). Of note, the antiproliferative action of cannabinoids on melanoma cells is caused, at least in part, by cannabinoid receptormediated cell cycle arrest at the G1/S transition through inhibition of the prosurvival protein Akt and hypophosphorylation of the pRb (Blazquez et al, 2006).

Furthermore, on human prostate cancer cells, inhibition of cell growth and induction of apoptosis by WIN-55,212-2 has been related to cannabinoid receptor-mediated cell cycle arrest in the G0/G1 phase, downregulation of cyclins D, E and cyclin-dependent kinases (cdk)-2, -4, and -6, decrease in protein expression of pRb and downregulation of E2F (Sarfaraz et al, 2006) (Figure 2).

Apoptosis is a potent mechanism that limits the expansion of tumor cells by triggering their suicide, while defects in apoptosis underpin both tumorigenesis and 106

Cancer Therapy Vol 6, page 107 metastasis (Mehlen and Puisieux, 2006). Two independent pathways lead to the execution of programmed cell death: (i) the extrinsic apoptotic pathway, mediated by deathinducing signaling complex formation (e.g, FAS ligand/Fas receptor) and caspase-8 activation, and (ii) the intrinsic mitochondria-dependent pathway, characterized by the release of cytochrome c and synthesis of the ternary complex cytochrome c/procaspase-9/apoptotic proteaseactivating factor-1 (APAF-1). Both pathways then converge to activate the executioner enzyme, caspase-3, which ultimately leads to apoptotic cell dismantling (Fesik, 2005) (Figure 2).

Evidence has been obtained that stimulation of cannabinoid receptors by their ligands induces cell death by interfering with relevant signaling nodes of the apoptotic cascade. Exposure to the nonpsychoactive cannabinoid, cannabidiol, leads to CB2-dependent cell killing by activation of caspase-8 and caspase-9, which

precedes the activation of caspase-3 and the appearance of apoptosis in leukemia cells (McKallip et al, 2006). Despite these findings suggest that cannabinoids may affect both intrinsic and extrinsic mechanisms of apoptotic cell death, the intrinsic pathway seems to play a more critical role in the antitumor action of cannabinoids. Indeed, apoptosis after treatment of androgen-dependent and -independent prostate cancer cells with WIN-55,212-2 results from the cannabinoid receptor-mediated increase in Bax/Bcl-2 ratio, (Sarfaraz et al, 2006), and THC-induced apoptosis in Jurkat leukemia T cells takes place via translocation of the proapoptotic Bcl-2 family member, Bad, to mitochondria (Jia et al, 2006). Of note, data from Lombard and colleagues (2005) also suggest that the extrinsic pathway may facilitate apoptosis via cross-talk with the intrinsic pathway, since tumor cells deficient in FADD or caspase-8 were partially resistant to THC-induced apoptosis (Figure 2).

Figure 2. Central growth factor signaling pathways in tumor cells involved in the molecular mechanisms of cannabinoid action.

Ligand-induced activation or mutation of receptor tyrosine kinases (RTKs), promote the formation of protein complexes containing autophosphorylated growth factor receptors with adaptor proteins, including growth factor receptor bound-2 (GRB2) and exchange factors such as Son-of-sevenless (SOS) which, in turn, activate Ras. In its GTP-bound form, Ras stimulates the mitogen-activated protein kinase cascade (Raf, MEK, MAPK) resulting in the activation of different factors that regulate cell cycle progression (e.g, activation of the MAPK pathway induces cyclin D expression, retinoblastoma protein phosphorylation and E2F activation). This cascade is also linked via a variety of cross-talking connections with other pathways. For example, the direct interaction of the Ras protein with the PI3 kinase (PI3K) enables growth signals to concurrently evoke survival signals by the signaling kinase AKT, which provides strong antiapoptotic signals through its negative regulation of Bad. The apoptotic cell death is also regulated by ceramide generation via neutral sphingomyelinase (SMase) activation and enhanced synthesis de novo (see text for further details). FADD, Fas-associated death domain protein; pRb, retinoblastoma protein, i-E2F, inactive form of E2F; a-E2F, active form of E2F. Bcl2, Bax, and Bad are Bcl2 family members of apoptotic regulatory proteins. Solid and dashed lines indicate activation and inhibition of signaling pathways, respectively.

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Fogli and Breschi: Cannabinoids and cancer CB1 receptor is coupled to the generation of ceramide, a sphingosine-based lipid second messenger molecule critically involved in the regulation of apoptosis.

Particularly, short-term ceramide generation involves sphingomyelin hydrolysis via sphingomyelinase, while long-term ceramide generation might occur via serine palmitoyltransferase induction and enhanced ceramide synthesis de novo (Guzman et al, 2001) (Figure 2).

Experiments carried out using different C6 glioma cell subclones showed that sustained, but not acute, ceramide generation is responsible for cannabinoid-induced apoptosis (Galve-Roperh et al, 2000), indicating that de novo synthesis of ceramide may have a major role in the apoptotic response induced by these compounds. In line with this proposal, up-regulation of the stress-regulated protein p8, an essential mediator of cannabinoid inducedapoptosis, is dependent on de novo-synthesized ceramide (Carracedo et al, 2006).

Receptor-ligand binding appears to take a significant part in the proapoptotic effect induced by these molecules.

For instance, local administration of the selective CB2 agonist, JWH-133, induces a considerable regression of malignant tumors generated by inoculation of C6 glioma cells to RAG-2-deficient mice, a strain of genetically altered mice lacking B- and T-lymphocytes. Of note, in vitro experiments on the same cell line underline that selective activation of CB2, promotes apoptosis via enhanced ceramide synthesis de novo (Sanchez et al, 2001). Nevertheless, evidences obtained in cancer cells which express cannabinoid receptors underscore the irrelevance of receptor status in determining the proapoptotic response to cannabinoids (Sanchez et al, 1998; Ruiz et al, 1999; Fogli et al, 2006).

independent mechanism, regardless the type of response induced (Hinz et al, 2004; Gardner et al, 2003).

Since endocannabinoids are also substrates of COX-2 (Patrignani et al, 2005), the possible interplay between COX-2 and the endocannabinoid system might be mediated by intermediate metabolites involved in specific pathways regulating cell multiplication. In line with this notion, AEA can be metabolized to prostaglandinethanolamide by COX-2 in colorectal carcinoma cells (Kozak et al, 2002), and AEA-induced cytotoxicity in this type of neoplasia has been observed only in those cell lines overexpressing COX-2 (Patsos et al, 2005). Furthermore, selective inhibition of COX-2 enzyme activity by NS398 significantly reduced the antiproliferative effect of AEA, while blocking the enzyme responsible for the inactivation of AEA (i.e, fatty acid amide hydrolase) in combination with AEA treatment enhanced the cell death, as compared to AEA alone (Patsos et al, 2005). These findings suggest that upregulation of COX-2 may yield to a large amount of anandamide by-products (i.e, prostaglandinethanolamides) which may eventually account, at least in part, for the AEA-induced cell death.

With regard for the molecular mechanism responsible for the COX-2 modulation by cannabinoids, it has been shown that cAMP is able to activate protein kinase A (PKA) and other intracellular mechanisms that are implicated in the COX-2 basal or induced expression (Tang et al, 2001). Therefore, a cannabinoid receptormediated decrease in cAMP (i.e, the most frequently observed cannabinoid response) may contribute to the negative modulation of this enzyme with the consequent inhibition of cell proliferation (Figure 2). However, under particular circumstances yielding to a cannabinoidmediated increase in cAMP production (Glass and Felder, 1997; Tang et al, 2001), a mitogenic effect might also occur.

D. Cyclooxygenases The increased expression of the inducible isoform of cyclooxygenase (COX-2) was firstly demonstrated in human colon carcinoma (Eberhart et al, 1994) and afterwards, in other neoplastic cells (Chan et al, 1999).

Cannabinoid regulation of arachidonate metabolism and prostaglandin production may represent a mechanism by which these molecules modulate proliferative events in cancer cells. Despite the ability of cannabinoids to increase the formation of prostaglandins in tumor cells has been demonstrated, the consequence of such an effect is still unclear. For example, AEA and its metabolically stable analogue, met-AEA, cause apoptotic death of neuroglioma cells by a mechanism involving de novo expression of COX-2 (Hinz et al, 2004). Of note, since elevations of COX-2 mRNA and prostaglandin E2 (PGE2) levels were observed at the time of maximum apoptosis and the pro-apoptotic action of met-AEA was mimicked

by PGE2 (Hinz et al, 2004), it is conceivable that increased levels of this metabolite may play a role in the antitumor action of endocannabinoids. In contrast with these observations, met-AEA increases murine lung cancer growth by inducing COX-2 expression and elevation of PGE2 levels at the site of the tumor (Gardner et al, 2003), indicating that the type of response to prostaglandins may be tumor-specific. Of note, modulation of COX-2 expression by endocannabinoids occurs via a receptor-

E. Modulation meatabolism

of

endocannabinoid

Beside targeting cannabinoid receptors directly, the use of â&#x20AC;&#x153;indirectâ&#x20AC;? agonists, i.e, compounds that act by inhibiting the degradation of endocannabinoids has been proposed as promising therapeutic strategy against cancer (Bifulco et al, 2004; Nithipatikom et al, 2005). In vitro findings from Ligresti and colleagues demonstrated in 2003 that differentiation of the colorectal cancer cell line, CaCo-2, into noninvasive cells results in increased fatty acid amide hydrolase (FAAH) expression, decrease in endocannabinoid levels and no responsiveness to cannabinoids. Modulation of the endogenous levels of endocannabinoids by the selective FAAH inhibitor, arachidonoyl-serotonin (AA-5-HT), inhibited CaCo-2 cell proliferation and such an effect was antagonized by the CB1 antagonist SR141716A (Ligresti et al, 2003). These data were also confirmed in vivo, where pharmacological enhancement of endocannabinoid levels (through inhibition of endocannabinoid hydrolysis) reduced the growth of tumor xenografts induced by the subcutaneous injection of rat thyroid transformed cells (Bifulco et al,

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Cancer Therapy Vol 6, page 109 2004) as well as the development of precancerous lesions in the mouse colon (Izzo et al, 2007).

antitumor activity of cannabinoids have been performed by using immune-deficient mice, it has been demonstrated that intraperitoneal administration of THC to immunecompetent mice leads to an accelerated growth of tumor implants in murine lung cancer models (Zhu et al, 2000).

Such a mechanism has been related to the CB2-dependent inhibition of the ability of antigen-presenting cells and T cells to generate alloreactivity (Zhu et al, 2000). It should be noted that immunosuppressive effects of cannabinoids seem to be evident mainly in tumors that express low levels of cannabinoid receptors and are resistant to cannabinoid-induced cytotoxicity (McKallip et al, 2005), thus indicating that the balance between tumor progression and regression might critically depend on the intrinsic capacity of a specific type of tumor to respond to cannabinoid treatment.

The demonstrated ability of the immune system to affect the pathogenesis and development of cancer should be also taking into consideration to better understand the mechanism of cannabinoid action. For example, many tumor types are characterized by the presence of host leukocytes in tumor zones and in peritumoral regions, a process caused by tumor-derived chemokines, such as MCP-1 and RANTES, which are functional in inducing cell migration. Leukocytes then respond to the tumor by secreting IL-1$, IL-6 and TNF-" which, in turn, induces proliferation of the tumor cells and up-regulation of the VEGF gene (Angelo and Kurzrock, 2007) (Figure 3).

These proinflammatory cytokines also promote upregulation of COX-2 in stromal cells which, in turn, may contribute to cancer development by producing adhesion molecules and activating neoangiogenesis, particularly through the production of prostanoids (Cianchi et al, 2004). PGE2 has been implicated in carcinogenesis (Watanabe et al, 1999; Sheng et al, 2001) and thromboxane A2 has been reported to activate angiogenesis and tumor progression (Daniel et al, 1999), suggesting that pathophysiologic changes involved in chronic inflammation may facilitate cancer development and progression. Although cannabinoid-based drugs have been proposed as anti-inflammatory therapeutics (Klein, 2005), to the best of our knowledge, no substantial evidence has been provided on the relationship between the endocannabinoid system and the regulation of COX-2 signaling in adjacent nontumour tissues as well as on the biological relevance of such an effect. With regard for the type of response induced by cannabinoids, in terms of COX-2-stimulating or -inhibiting effect, contrasting evidences have been reported in several inflamation models. For example, the synthetic derivatives HU-210 and WIN-55,212-2 were able to inhibit COX-2 upregulation and PGE2 release in an animal model of arthritis (Mbvundula et al, 2006), while cannabidiol, a nonpsychoactive analog of THC, showed opposite effects in the rat paw edema (Costa et al, 2004). Furthermore, nanomolar concentrations of endogenous or synthetic cannabinoids induce COX-2 in mast cells derived from sensitized guinea-pigs (Vannacci et al, 2004), whereas micromolar doses of CB1 and CB2 synthetic agonists have been shown to inhibit COX-2 expression in bovine chondrocytes (Mbvundula et al, 2005).

IV. Relevance of the antiangiogenic, anti-inflammatory and immunoregulatory functions of cannabinoids in tumor progression A. Angiogenesis Angiogenesis, i.e, the process of blood vessel formation in adults, is essential for supplying nutrients to the tumor (Folkman, 2002) and much effort has been directed towards the development of antiangiogenic agents that disrupt this process. The prototype compound of this drug class is bevacizumab, an antibody against VEGF that has been licensed for the first-line treatment of metastatic colorectal cancer, in combination with 5-fluorouracilbased chemotherapy (Ellis, 2005).

Vascular endothelial cells express functional CB1 (Liu et al, 2000) and CB2 (Blazquez et al, 2003) receptors and the anticancer effect by cannabinoids has been associated with cannabinoid receptor-mediated deregulation of tumor angiogenesis in a variety of cancer models, in vitro and in vivo (Pisanti et al, 2007).

Concerning the molecular mechanism accounting for the antiangiogenic properties of cannabinoids, met-AEA significantly inhibited the expression of the VEGF and its receptor, flt-1/VEGFR-1, in rat thyroid carcinoma implanted in athymic mice, and these effects were antagonized by the selective CB1 antagonist, SR141716A (Portella et al, 2003). On the other hand, selective activation of the CB2 receptor by JWH-133 has been shown to be responsible for the antiangiogenic action of this compound in malignant glioma, which included the direct inhibition of vascular endothelial cell migration and survival, as well as the decrease in the expression of the pro-angiogenic factors, VEGF and angiopoietin-2 (Blazquez et al, 2003). Finally, local administration of the mixed CB1/CB2 agonist, WIN-55,212-2, or the selective CB2 agonist, JWH-133, induced a considerable growth inhibition of malignant tumors generated by inoculation of epidermal tumor cells into athymic mice (Casanova et al, 2003). Of note, such an effect was associated to the decrease in EGF receptor mRNA levels as well as receptor activation and in the expression of VEGF, placenta growth factor, and angiopoietin-2 (Casanova et al, 2003), suggesting that inhibition of angiogenesis plays a significant role in the antitumor action of cannabinoids (Figure 3).

B. Inflammation and immune system regulation It is widely recognized that natural and endogenous cannabinoid derivatives affect most of the components of the immune response system and regulate cytokine signaling (Klein, 2005; Massi et al, 2006). Cannabinoids may be immunosuppressive with the consequent inhibition of host antitumor immunity (Srivastava et al, 1998), a particular aspect of cannabinoid action that may represent a serious drawback in their eventual use as antitumor drugs. While most of the studies investigating the in vivo

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Fogli and Breschi: Cannabinoids and cancer

Figure 3. Cannabinoid action and the heterotypic cell biology view of cancer. Inflammatory cytokines, chemokines and lymphocytes represent critical elements of autocrine and paracrine signaling networks involved in tumor growth and metastasis. Tumor-derived chemokines, such as MCP-1 and RANTES, induce leukocyte cell migration into the tumor from the circulation, thus establishing the population of tumor-associated macrophages (TAMs). TAMs respond to the tumor by secreting various inflammatory cytokines including IL-1$, IL-6, and tumor necrosis factor-(TNF)-" which, in turn, promote proliferation of tumor cells, up-regulation of the VEGF gene, induction of COX-2 and prostaglandin E2 (PGE 2). VEGF and PGE2 released from tumor cells can then act on endothelial cells causing angiogenesis. TAM may also favor tumor escape from immune surveillance by producing immunotoxin molecules that induce dendritic cell inactivation. Stromal fibroblast fractions, named carcinoma-associated fibroblasts (CAFs), secrete elevated levels of stromal cell-derived factor 1 (SDF-1, also called CXCL12). This cytokine enhances CXCR4 receptor-mediated tumor progression trough recruitment of circulating endothelial progenitor cells (EPCs) into the tumor mass, angiogenesis stimulation, direct stimulation of tumor cells and homing of metastatic cells to specific organs. CB: a cannabinoid ligand.

Such discrepancies may be ascribed to a number of factors including the nature of the agonists, the drug concentration employed, the evidence or not of a receptor-mediated mechanism and the eventual receptor subtype involved (Croxford et al, 2005; Bifulco et al, 2006).

The cross-talk between nitric oxide (NO) and COX systems in the surrounding tissue has been recognized as one of the biological events that perpetuate the consequence of oncogenic stimuli (Hussain et al, 2003).

The nuclear factor-!B (NF-!B), a transcription factor that modulates the expression of several genes involved in apoptosis and in cytokine production (Gloire et al, 2006), represents a critical point of the potential synergism between COX-2 and the inducible form of nitric oxide synthase (iNOS). In several cell lines, particularly immune cells, NF-!B is a potent inducer of iNOS and COX-2 (Mollace et al, 2005) and the NO-derived peroxynitrite is able to induce NF-kB production which, in turn,

perpetuates iNOS and COX-2 activities. Furthermore, NF!B activates VEGF and IL-8 gene expression in tumor cells and inhibitors of NF-!B decrease the levels of VEGF produced in leukemia and glioma (Angelo and Kurzrock, 2007), thus suggesting that NF-!B targeting may elicit antitumor effects. It has been reported that THC inhibits NF-!B/Rel activation and iNOS expression in murine macrophages (Jeon et al, 1996), and activates NF-!Bdependent apoptosis in dendritic cells, thymocytes and splenocytes (Do et al, 2004). WIN55212-2 is able to reduce the release of IL-8 from the human epithelial cells by inhibiting the activation of NF-!B and such an effect may be mediated through the CB2 receptors (Ihenetu et al, 2003; Mormina et al, 2006). Since the deregulation of the COX-2/iNOS balance over a prolonged period of time may favor tumorigenesis (Hussain et al, 2003), these findings suggest that an interference with such a faulty

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Cancer Therapy Vol 6, page 111 mechanism by cannabinoids may be taken into account as a part of their antitumor action.

Finally, it has been demonstrated that carcinomaassociated fibroblasts (CAFs), i.e, stromal fibroblast fractions extracted from invasive human breast carcinomas, release elevated levels of stromal cell-derived factor 1 (SDF-1, also called CXCL12), which play a pivotal role in tumor growth and angiogenesis (Orimo and Weinberg, 2006). Such a chemokine is expressed in typical metastatic sites of breast cancer and acts on CXCR4-expressing breast tumor cells to direct their motility. Mostly important, CB2 activation yields to the inhibition of the CXCL12/CXCR4-induced chemotaxis and transendothelial migration of leukemia cells (Ghosh et al, 2006), thus highlighting the potential of cannabinoids to disrupt a mechanism that has been demonstrated to be relevant in directing metastatic organ preference (Muller et al, 2001) (Figure 3).

glioma cells they inhibit Akt (Gomez del Pulgar et al, 2002b).

VI. Conclusive remarks Beside the well-regognized palliative effect of cannabinoid derivatives observed in cancer patients, a great deal of preclinical data indicate that pharmacological interventions tailored on the endocannabinoid system can significantly affect a variety of signaling molecules in the neoplastic cell circuit that collaborate to the multistep process of tumorigenesis. Furthermore, the interference with cross-talk signals between tumor cells and critical elements in tissues surrounding the tumor mass may be also part of the molecular mechanism of action of these compounds. Nevertheless, much effort should be dedicated to better define the cellular and molecular context that might have the potential to improve the ability to predict the likelihood of cannabinoid response. With regard for this, investigations in the cannabinoid research field should be always performed by using specific cannabinoid receptor antagonists, in order to delineate the precise mechanism of action of these compounds in terms of CB1- and CB2-mediated effects (Table 1) or non-CBmediated effects. Furthermore, strategies by which tumor cells can be profiled for their genomic background may be helpful in studying the molecular signature that matches the mechanism of action of cannabinoids.

One of the most intriguing and clinically relevant aspects in the cannabinoid action regards the relationship between ligand concentration at the target site and the type of biological response obtained. In fact, micromolar levels of cannabinoid agonists promote a receptor-mediated decrease in tumor cell proliferation, while in the nanomolar range of concentrations, that seems more likely to reflect a therapeutically relevant situation (Grotenhermen, 2004), these compounds may also produce the opposite effect. This notion together with the fact that sustained, but not acute, exposure to cannabinoids is responsible for apoptosis induction, suggest that transdermal delivery should be preferred to inhalation or oral administration. To date, while intratumoral (Sanchez et al, 2001; Casanova et al, 2003) or peritumoral (Blazquez et al, 2006) injection of these compounds has been performed in several in vivo studies and very recently, THC delivery by intracranial route has been used in patients with glioblastoma multiforme (Guzman et al, 2006), systemic administration of cannabinoids have not been adequately investigated in the preclinical setting.

Development of less lipophilic cannabinoids should be also encouraged in order to allow their parental use and to reduce receptor-independent effects, a mechanism observed when using micromolar concentrations of these compounds.

Finally, in vitro investigations of combination schedules that allow obtaining increased sensitivity and/or decreased resistance to the chemotherapeutic agents routinely used in the management of cancer patients may provide information that would facilitate the design of randomized, add-on studies aimed to evaluate the clinical benefit of cannabinoid-based anticancer therapies.

V. Selective action towards tumor cells Fighting cancer by selective targeting of tumor cells is one of the most promising strategies to improve the therapeutic index of anticancer treatments. Therefore, when envisaging the potential clinical use of novel anticancer strategies, the comparison of drug action towards tumor cells with respect to their normal counterpart, represents a critical point that should be carefully examined.

Several reports indicate that cannabinoid action is selective for tumor versus nontumor cells (Bifulco et al, 2001; McAllister et al, 2005; Blazquez et al, 2006) and the presence of cannabinoid receptors and their expression levels are some of the fundamental elements which may provide a possible explanation for the selective effect of cannabinoid ligands. For instance, treatment of the human prostate cancer LNCaP cells with WIN-55,212-2 at 1-10 ÂľM for 24 and 48 h significantly decreased cell viability, while similar doses had no effect on the prostate epithelial PrEC cells (Sarfaraz et al, 2005). Of note in this study, expression levels of both CB1 and CB2 receptors were significantly higher in cancer cells than in normal cells (Sarfaraz et al, 2005). In addition, ligand-induced activation of CB2 receptors reduces human breast cancer cell proliferation, while the proliferation pattern of normal human mammary epithelial cells which do not express significantly this receptor subtype, was much less affected (Sarfaraz et al, 2005).

A number of data support the hypothesis that cannabinoid receptors may regulate cell survival pathways differently in tumor and nontumor cells that express cannabinoid receptors, a further mechanism that could account for the selectivity of cannabinoid action. Indeed, despite the nontumorigenic cell line of human melanocytes, Hermes 2b, expressed CB1 receptors at levels comparable to the tumorigenic A375 cell line, the antiproliferative effect of cannabinoids was selective for tumor cells and was related to inhibition of the prosurvival protein Akt (Blazquez et al, 2006). Interestingly, in primary astrocytes (Gomez Del Pulgar et al, 2002a) and oligodendrocytes (Molina-Holgado et al, 2002) transfected with the CB1 cDNA, cannabinoids activate Akt, while in 111

Fogli and Breschi: Cannabinoids and cancer Table 1. Type of response obtained after treatment with cannabinoids and specific receptor subtype involved.

Biological response Antiproliferative action

Tumor type Breast, prostate

Receptor subtype CB1

Melanoma Colon

CB1/CB2 CB1

References De Petrocellis et al, 1998; Melck et al, 2000 Blazquez et al, 2006 Ligresti et al, 2003

Apoptosis induction

Prostate Skin Glioma Leukemia

CB1/CB2 CB1/CB2 CB2 CB2

Sarfaraz et al, 2006 Casanova et al, 2003 Sanchez et al, 2001 McKallip et al, 2006

Mitogenic action

Astrocytoma, lung

CB1/CB2(?)*

Hart et al., 2004

Antiangiogenic effect

Thyroid Glioma Skin

CB1 CB2 CB1/CB2

Portella et al, 2003 Blazquez et al, 2003 Casanova et al, 2003

Inhibition chemotaxis

Leukemia

CB2

Ghosh et al, 2006

of

*Without using specific antagonists.

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Fogli and Breschi: Cannabinoids and cancer

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Cancer Therapy Vol 6, page 117 Cancer Therapy Vol 6, 117-130, 2008

General review of polysaccharopeptides (PSP) from C. versicolor: Pharmacological and clinical studies Review Article

King-Fai Cheng, Ping-Chung Leung* Institute of Chinese Medicine, The Chinese University of Hong Kong

__________________________________________________________________________________ *Correspondence: Prof. Ping-Chung LEUNG, DsocS(Hon), D.Sc, M.S, Director, Centre for Clinical Trials on Chinese Medicine 5/F, The CUHK Hong Kong Jockey Club School of Public Health Building, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR; Tel: (852) 2632 2723/ 2252 8872; Fax: (852) 2686 8463/ 2632 5441; E-mail: pingcleung@cuhk.edu.hk Key words: Coriolus Versicolor (Yunzhi); polysaccharopeptide (PSP); immunomodulation; anti-tumor Abbreviations: biological response modifiers (BRM); Coriolus versicolor (CV); cyclophosphamide (CPA); human immunodeficiency virus (HIV); Interleukine-2 (IL-2); intraperitoneal (i.p.); National Center for Complementary and Alternative Medicine (NCCAM); Natural Killer Cells (NK cells); Office of Dietary Supplements (ODS); polysaccharopeptide (PSP); polysaccharopeptide Krestin (PSK) Received: 20 December 2007; Revised: 30 January 2008 Accepted: 5 February 2008; electronically published: February 2008

Summary In China, C. versicolor is named Yun Zhi (meaning “cloud-like mushroom”). C. versicolor is mainly used as an adjuvant in the treatment of cancer. The active principle derived from C. versicolor belongs to a new class of elements called biological response modifiers (BRM) which are defined as agents capable of stimulating the immune system and thereby, they express various therapeutic effects. The best know commercial polysaccharopeptide preparations of C. versicolor are polysaccharopeptide Krestin (PSK) and polysaccharopeptide (PSP). One of the most important functions of PSP and PSK is their immunomodulatory and anti-cancer actions. The present paper reviewed and summarized the pharmacological and clinical properties, as well as its background of Coriolus versicolor or PSP.

According to the record of Ben Cao Gang Mu (!"#$) written during the Ming Dynasty (1368-1644), there were over 120 strain of C. versicolor (Hyde and Adams, 1960). Recent literatures report that more than 270 medicinal fungi are used in traditional Chinese medicine for their preventive and/or curative effects (Ding, 1987; Ying et al, 1987). In the clinical practice of traditional Chinese medicine, C. versicolor is recommended for various types of cancers, chronic hepatitis, and infections of the upper respiratory, urinary, and digestive tracts (Jong and Yang, 1999; Li, 2003).

In Asia, C. versicolor extract is available as a health supplement and can be purchased without a prescription.

In both China and Japan, health authorities regard C. versicolor extract as a valuable adjuvant for combination chemotherapy or radiotherapy in the treatment of various cancers (Mizuno, 1999; Yan et al, 2000; Chu et al, 2002).

The present paper reviews and summarizes the pharmacological and clinical properties, as well as its background of Coriolus versicolor or PSP.

I. Introduction Mushrooms have an established history of use in traditional oriental therapies. In Asian cultures, mushrooms are combined with herbal mixtures to treat cancer. The mushroom Coriolus Versicolor (C. versicolor) is a macrofungi belonging to the Basidiomycetes class, which encompasses about 20,000 and 25,000 known species (Gregory and Hirst, 1957; Hyde and Adams, 1960). In China, C. versicolor is named Yun Zhi (meaning “cloud-like mushroom”). Researches have found that this mushroom has antimicrobial, antiviral and anti-tumor properties (Jong and Birmingham, 1993; Ulrike et al, 2005). Nowadays C. versicolor is mainly used as an adjuvant in the treatment of cancer (Tsang et al, 2003; Hattori et al, 2004). It has been demonstrated that extracts obtained from this mushroom are likely to show stimulatory effects on the immune system and to inhibit the growth of cancer cells. Because of these properties, Yun Zhi is called a biological response modifier (BRM) (Leung et al, 2006).

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Cheng and Leung: General review of polysaccharopeptides (PSP) from C. versicolor PSP and PSK are light or dark brown powders that are soluble and stable in hot water. They are chemically similar and posse similar physiological activity profiles, PSK and PSP differ mainly in the presence of fucose in PSK and rhamnose and arabinose in PSP (Table 1).

II. Composition of C. versicolor The composition of the polysaccharopeptide is depending on the source of the material and the method of extraction used. For example, polysaccharopeptide Krestin (PSK) is obtained from the extraction of C. versicolor (CM-101) strains, while polysaccharopeptide (PSP) obtained from the extraction of C. versicolor (Cov-1) strains (Chu et al, 2002; Zhou et al, 2007).

The active principle derived from C. versicolor belongs to a new class of elements called BRM. BRM are defined as agents capable of stimulating the immune system and thereby, they express various therapeutic effects (Leung et al, 2006). Polysaccharides linked to a small protein (or peptide) are at the base of this immunomodulatory activity. This “polysaccharidepeptide” is termed polysaccharopeptide, or PSP in its abbreviated form. The strain used for PSP production is called Cov-1 and was obtained through careful selection of over 80 wild strains collected from various areas in China.

IV. Safety studies The toxicological experiments conducted with a variety of animals (dogs, monkey and guinea pigs) had shown negative results for acute, genetic, reproductive and chronic toxicity.

A. Acute toxicity The LD50 value of PSP is 26-300.36mg/kg for mice administered by intraperitoneous injection. The highest daily tolerant dose was over 18-20g/kg for mice (Jin, 1999; Ze et al, 2003). According to the “Procedures for Toxicological Assessment on Food Safety Acute Toxicity Test (GB15193.3-94)”, PSP is considered to be non-toxic (Procedures for Toxicological Assessment on Food Safety Acute Toxicity Test GB15193.3-94).

III. The difference between PSP and PSK

B. Long-term toxicity

The best know commercial polysaccharopeptide preparations of C. versicolor are PSK and PSP. Both products are obtained from extraction of C. versicolor mycelia (Figure 1). PSK is a Japanese product, while PSP is Chinese product which was first isolated in 1986 (Yang and Van, 1986). Both products have similar physiological activities but are structurally different. PSK is produced from CM-101 strain of C. versicolor, the extraction is done by salting out with ammonium sulfate from the hot water extract. PSP is produced from Cov-1 strain of C. versicolor (Figure 2), the extraction is done by using alcoholic precipitation from the hot water extract.

Subchronic and chronic toxicity studies were done by Jian et al who continuously administrated 4 oral doses (0, 1.5, 3.0, and 6.0 mg/kg) to 80 rats for 62 days. The results showed no toxic symptoms or death. Neither were there any obvious toxic changes in blood and serum biochemistry (Jian, 1999). Rats and monkeys were administrated with PSP by oral at a dose of higher than 200 and 100 times of human dose separately daily for 6 months, no abnormal changes in development, hematology, blood chemistry, and electrocardiography were observed (Zou et al, 2003).

Figure 1. Trametes (Coriolus) versicolor (http://www.alohamedicinals.com/chapt3_c.pdf).

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Cancer Therapy Vol 6, page 119

Figure 2. Typical partial structures of polysaccharide portions of the polysaccharide peptide (PSP) of COV-1 strain of Coriolus versicolor (Zhou and Yang, 1999).

Table 1. The differences of PSP and PSK

Source Produced in Appeared on the market in Extract method

Physicochemical properties

Chemical composition

Biological properties

References

PSP Mycelia of Coriolus versicolor Cov-1 strain China 1987 Recovered by alcoholic precipitation from hot water extract Brown in color; soluble in water; insoluble in organic solvents; stable to heat; mean MW=100kDa (1!3) !-glucan branched at 4’ and 6’ positions

PSK Mycelia of Coriolus versicolor CM-101 strain Japan 1977 Recovered from hot water extracts of the biomass by salting out with ammonium sulfate Brown in color; soluble in water; insoluble in organic solvents; stable to heat; mean MW=100kDa 18%--38% w/w protein (1!3) !-glucan branched at 4’ and 6’ positions rhamnose, arabinose fucose In vitro and in vivo In vitro and in vivo immunorestorative and antiimmunorestorative and antitumor activities tumor activities Sakagami and Takeda, 1993; Ng et al, 1999; Kidd, 2000; Cui and Yusuf, 2003

Accumulating evidence suggested that the polysaccharopeptides were nontoxic even when administered at several times the therapeutically effective dosage and over extended periods. Extended use of PSP at 100-fold the normal clinical dose had not induced acute and chronic toxicity in animals (Ng et al, 1997).

The results of chromosomal aberration tests and cytogenetic lesions in mice showed that the number of chromosomes had not changed in PSP treated groups even at the high dose rate 126 mg/kg.

D. Reproductive test The possible effects on male and female reproductive physiology and embryonic development were also examined. Results from these studies suggested that PSP could not cause sperm aberration at a dosage 100 times higher that the usual clinical dose (Qian et al, 1993). The lack of deleterious effects on ovarian follicular development, ovulation, pregnancy and embryo development in mice was also demonstrated (Ng et al, 1997). Polysaccharopeptides appear to be safe during pregnancy. No adverse effects of PSP had been observed in female reproductive and embryonic development in mice (Ng et al, 1997).

C. Genetic toxicity (Zhong et al, 1999) Mutagenicity of PSP was assessed with the Ames test and with the chromosomal aberration test of bone marrow cells in mice. It was concluded that PSP showed no evidence of mutagenic or cytogenetic activity.

Cytotoxicity tests of PSP with V79 Chinese hamster cells in vitro also showed no toxic effects against the V79 cell line.

In vivo micronucleus tests to assess the cytogenotoxicity on mammalian somatic cells, the results indicated that PSP showed no evidence of mutagenic potential.

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Cheng and Leung: General review of polysaccharopeptides (PSP) from C. versicolor Researches demonstrated that PSP can antagonize the immunosuppression caused by such chemotherapeutic agents (Qian et al, 1997; Li, 1999). The administration of PSP (at a dosage of 2 grams/kg day) on cyclophosphamide-induced immunosupressed rats demonstrated that the mushroom extract was effective in restoring their immune system. It did so by stimulating lymphocytes proliferation, NK cell functions, and the growth of spleen and thymus where lymphocytes mature and transit (Qian et al, 1997).

V. Pharmacological actions A. Immunomodulatory effects The immunological activities of PSP and PSK have been extensively investigated both in vitro and in vivo.

PSP strengthening the immunological functions was studied. Its anti-tumor effect seemed to be mediated more through immunomodulatory regulation rather than by direct cytotoxicity as was the case for most anticancer drugs currently used. Numerous reports had demonstrated the ability of PSK and PSP to active cellular and humoral components of the host immune system. In addition, these polysaccharides had been shown to inhibit the growth of tumor cell lines and to have in vivo anti-tumor activity (Tzianabos, 2000).

The effect of PSP on the phagocytic functions had been tested in normal ICR mice. It was determined that the carbon clearance rate of the groups given oral doses of 0.5-1.5g PSP/kg or intraperitoneal (i.p.) injections of 100, 200, 400mg/kg was similar to that of groups treated with acanthopanax (300mg/kg). Regardless of the route of administration, PSP increased the carbon clearance rate in mice and it suggested that PSP could increase the phagocytic function of normal animals (Yang et al, 1993).

It was reported that PSP in different concentrations promoted the proliferation of T-lymphocytes both in human peripheral blood and mouse splenocytes (Li, 1999).

PSP augmented T-helper cell (CD4+) activation, and also increased the ratio of CD4+/T suppressor (CD8+) production (Li, 1999). It appeared that the basic mechanisms for PSP to inhibit tumor cells included the activation of 1) macrophages, 2) natural killer cells and 3) T-helper cells (CD4+) which induce T-killer cells, antibody production, and interleukins (Li, 1999). Studies were conducted in vitro with numerous cell lines to investigate the immunomodulatory effects of PSP. It was recognized that Interleukine-2 (IL-2) plays a critical role in immune defense against tumors, because it is a potent inducer of activation of NK cells. In a study designed to evaluate the anti-tumor potential of IL-2 and PSP, it was demonstrated that the combination of the two agents had the most dramatic anti-tumor effect (Mao et al, 1996).

Moreover, PSP could effectively stimulate the generation of Interferon-" (IFN-") and markedly improve the production of IFN-# (Yang et al, 1999). A study demonstrated that PSP did not exert a direct cytotoxic effect on tumor cell lines but rather stimulated macrophages, thus strengthening the hypothesis that C. versicolor anti-tumor effects were mediated by an immunomodulatory mechanism (Liu et al, 1999). In vivo studies had revealed that PSP usually had no significant immunological effects on a normal host, but could restore a depressed immunological responsiveness as seen in cancer or with chemotherapy (Chu et al, 2002).

PSP can also counteract the depressive effect of cyclophosphamide (CPA) on the white blood cell count and interleukin-2 production. CPA has become the leading drug in the clinical treatment of cancer, particularly for lymphomas, leukemia and solid tumors. This drug is cytotoxic, kills rapidly dividing neoplasic and normal cells, but has deleterious effect on the immune system.

B. Anti-tumor effects in vivo Many studies have been done since 1980â&#x20AC;&#x2122;s to demonstrate the effectiveness of PSP, and its counterpart PSK (Table 2). The anti-tumor actions are predominantly considered to be host-mediated. The preliminary determination of antitumor activity is usually assessed by a bioassay system normally using Sarcoma 180 in mice and B16 melanomabearing mice through transplantable animal tumor (Yang et al, 2007). Several hundreds of polysaccharides or polysaccharide-protein complexes have been screened for their anti-tumor activity, and three of them, namely schizophyllan, lentinan and protein-bound polysaccharides (PSK and PSP), have been used clinically (Kobayashi et al, 1993). PSK has been successful in postoperative treatment of respectable cancer in humans, increasing survival rates (Ito et al, 2004). Protein-bound polysaccharide (PSK) prepared from the cultured mycelia of Coriolus versicolor in Japan demonstrated a significant anti-tumor effect against allogeneic tumors such as Sarcoma 180 and Ehrlich carcinoma of experimental animals by both intraperitoneal and oral administration (Taniguchi et al, 1984; Kobayashi et al, 1993). Researches indicated that PSK and PSP can suppress pulmonary metastasis from induced sarcomas, induced prostate cancer, lymphatic metastasis of mouse leukemia P388, and that both could prolong the survival period in spontaneous metastasis model (Xu, 1999).

Polysaccharopeptides from C. versicolor influence cancer metastasis in a number of ways: 1) by suppression of intravasation through the inhibition of tumor cells infiltration, 2) by suppression of tumor cell attachment to endothelial cells through the inhibition of tumor cellinduced platelet aggregation, 3) by suppression of tumor cell migration after extravasation through the inhibition of tumor cell mobility, and 4) by suppression of tumor growth after extravasation through the inhabitation of angiogenesis, the modulation of cytokine production and the augmentation of effector cell function (Liu et al, 2004).

In addition to anti-cancer effect, animal study also demonstrated that PSP had central analgesic effect (Yin et al, 2002).

In vitro antitumour study, the C. versicolor extract was also found to tumour-selectively and dosedependently inhibit the proliferation of lymphoma and leukemic cells possibly via an apoptosis-dependent pathway (Lau et al, 2004; Zhou et al, 2007). However, both immune property and anticancer potency of polysaccharopeptide-Coriolus versicolor were affected by the fermentation duration of the fungi (Lee et al, 2006).

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Cancer Therapy Vol 6, page 121 Table 2. Some animal anti-tumor studies.

1 2

Animal Mice

Test article PSP

Administration By oral

Dosage 1-2g/kg/day

Duration 15-20 days

Nude mice

PSP

Intraperitoneal

50mg/kg/day 3 weeks

Mice

PSP

Intraperitoneal

2 weeks

Rats

PSK

oral

150mg/kg 3 weeks twice a week

Mice

PSP

Oral

2, 5 g/kg daily

4 weeks

Mice

CVP1

Intraperitoneal

5-20mg/kg

3-15 days

Rats

PSP

Oral

1.2g/day

21 days

Results Inhibited growth of human lung adenocarcinoma by 50-70% Inhibited the growth of Lewis lung cancer by nearly 45% Decreased the incidence of tumor growth, tumor size in control group about 35 times bigger than the PSP group Prolonged the survival period of mammary tumor-bearing rats Tumor inhibition rate of 77 and 63% in treated groups Exerted inhibitory effects on experimental and clinical tumors Oral PSP did not prevent CTX2-induced cytopenia in rats

Reference Zeng et al, 1993

Wang et al, 1993

Dong et al, 1996

Fujii et al, 1995

Zeng et al, 1999

Wei et al, 1996

Kanoh et al, 1994

Coriolus versicolor polysaccharides Cyclophosphamide

When PSK, obtained from cultured mycelia of Coriolus versicolor, was administered in mice, in vivo tumor-induced angiogenesis was suppressed (Mao et al, 2001).

However, some animal experiments could not demonstrate a specific effect of polysaccharopeptides extracted from the mushroom C. versicolor. For example, for a long-term control of brain tumors, intraperitoneal injection of 2mg of PSP with radiotherapy did not increase radiation efficacy (Mao et al, 1996). Another study investigated the effect of low-dose administration of IL-2 or PSP alone in a herpes virus type-2 transformed murine tumor in mice. The results indicated that IL-2 or PSP alone could slow down tumor progression, but the combination of the two modalities had no synergistic effects on tumor growth (Liu, 2001). These results warranted further investigation to determine if PSP could be effectively used for all types of tumors, or cancers, in which immunosuppression was a prominent feature.

In general, it seemed that oral administration of PSP reduced the incidence of tumor or prolonged the survival period, following chemical carcinogen-induced, radiationinduced and spontaneously developed animal cancer models. Coriolus versicolor (CV) regulated cytokine production and possessed both anti-tumor and immunopotentiating activities (Ho and Lau, 2004). The

main mechanism might be an anti-teratogenic effect attributed to free radical trapping and prevention of chromosome injury, coupled to an immunomodulating effect linked to the modulation of cytokines production and effect cell function. Table 3 summaries the possible mechanisms of anticancer effects of PSP (Hobbs, 2004).

C. Antimicrobial effects Besides its documented anti-cancer effects, polysaccharopeptides from C. versicolor could be useful for other conditions as well.

PSK has been demonstrated to have antiviral activities against ectromelia virus (Taniguchi et al, 1984) and cytomegalovirus infections (90) and human immunodeficiency virus (HIV) (Zou and Zhu, 2003).

In China, C. versicolor is also considered useful in the treatment of hepatitis. Preliminary studies had indicated that PSP was effective in protecting liver from hepatotoxins in laboratory animals (Song and Liang, 2000; Zou et al, 2003). As with antiviral action, the multivalent manner in which PSP acts to protect liver cells and detoxification mechanisms, demonstrates the potential usefulness of C. versicolor extracts to prevent damages from reactive compounds which could be carcinogenic agents (Jong and Yang, 1999; Yeung, 1999).

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Cheng and Leung: General review of polysaccharopeptides (PSP) from C. versicolor Table 3. Mechanisms of anticancer effects of extracts of C. versicolor.

• Inhibition of DNA of tumour cells • Enhancement of cytokine production • Antitumour activity in wide range of animal systems • Tumour cell killing effect • Inhibition of carcinogen-induced cancers in rats • Antioxidant effects in tumour-bearing rats • Induction of apoptosis • Antiproliferative effect on many cancer cell lines • Anti-invasion effects • Angiogenesis effects • Tumouricidal and cytotxicity effects • Antimetastic activity • Immunoprotective effects during radiation and chemotherapy

have an impact on the survival rate of different types of cancer. PSK used in Japanese trials significantly extended the survival rate at five years for stomach, colorectal, esophagus, nasopharynx, breast and lung cancers. Study also showed that PSP has effect of cancer prevention and development (Zhou et al, 2001). The following were the clinical trial results selected from research papers conducted in Japan (Table 4, 5).

D. Anti-nociceptive effects In an animal study, two different mice pain models were used to investigate the anti-nociceptive effects of PSP. The results demonstrated that PSP could induce hyperalgesia. PSP-induced hyperalgesia was related the activation of peritoneal macrophages and mast cells and, hence, increased the release of inflammatory mediators (Chan and Yeung, 2006).

A. Breast cancer

VI. Clinical studies

As early as 1970, breast cancer patients received long term combination chemotherapy along with C. versicolor extract immunotherapy. Addition of the extract to the regimen significantly extended the survival rate. In a large trial done in 1995 in Japan, the survival rate at 10 years was 81% for the PSK plus chemotherapy group which the rate fell to 64% for the group that used chemotherapy alone. The study concluded that immuno-chemotherapy with mushroom extract could improve the prognosis of patients with resectable breast cancer with vascular invasion. Mild and well tolerated side effects such as leukopenia and nausea were observed in 5 out 227 patients (Iino et al, 1995).

The therapeutic use of PSP or PSK as an adjuvant therapy in cancer treatment has been substantiated by numerous clinical trials. Table 6 summarizes the methodological parameters and the results of some these trials. As an adjuvant in the treatment of many types of cancers, Yun Zhi (PSP) was subjected to Phase I, II and III clinical trials in Shanghai, China. The results showed that addition of PSP to radiotherapeutic or chemotherapeutic protocols can greatly improve the quality of life of cancer patients and reduce chemotherapy-induced side effects (Zhong et al, 2001), because PSP alleviated weakness, anorexia, vomiting, dryness of throat, spontaneous sweat and pain symptoms. In addition to symptoms improvement, polysaccharopeptides from Yun Zhi also Table 4. Randomized controlled trials for breast cancer.

Patients 914 cases Standard or Radical mastectomy

Stage IIA, IIB, III

227 cases operable breast cancer with v+ and/or n+ involvement 134 cases Typed as HLAA, HLA-B and HLA-C

Treatment 1.Patients(ER+tumours) chemo +/- tamoxifen 2.Patients (ER- tumour) Chemo +/- PSK Chemo (n=77) Chemo +LMS (n=76) Chemo +, PSK (n=74)

Operable with v+ and/or nv+

Previously randomised into two groups(ref 23): 1. Chemo 2. Chemo +PSK Each group stratified by HLA type B40+ or B40-.

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Outcome Longer overall survival for patients in Stage IIA T2N1 cancer ER- and node-negative treated with chemo + PSK compared with other ERsubgroups without PSK. Risk ratio lower in the chemo+ PSK group. Overall and diseasefree survival rates not significant for all groups.

Refs Toi et al, 1992

Years for chemo + PSK group: HLA-B40+ : 100%; HLA-B40- : 76% and 55%, respectively.

Significant difference at p =0.05.

Yokoe et al, 1997

Iino et al, 1995; Yokoe et al, 1997

Cancer Therapy Vol 6, page 123 Table 5. Selected randomized controlled trials for colorectal cancer.

Patients 55 cases 56 controls

Multicentre 221 cases 227 controls Total 207 134 cases 67 controls 6 withdrew

Stage Advance (II/III)

Primary (II/III)

Total 205 137 cases 68 controls

Primary (II/III)

Colon cancer with lymph node metastasis Total 441 220 cases 221 controls

Dukes A:7% B:45.5% C:47.3%

202 primary colon cancer patients 5-FU + PSK:99 5-FU alone:103

Primary colon cancer

Treatment 1. Surgery + placebo 2. Surgery + PSK (3gm/day for 2 months; 2g/day for 24 months; 1 gm/day thereafter) 1.Chemo 2.Chemo+ PSK (3g/day for 3 years) 1. Chemo 2.Chemo+ PSK (3g per day for >2 yrs)

All patients received Mitomycin-C postsurgery.

1. Chemo 2. Chemo + PSK (3g/ day) Both treatments for 2 yrs All patients received chemo after surgery for 3-4 weeks, then 10 courses of treatment.

1. PSK 4 weeks then 4 weeks chemo.

2. 4 weeks rest then 4 weeks chemo.

99 underwent adjuvant treatment with PSK and 5-FU (PSK group), 103 were treated with 5FU alone (5-FU group).

Outcome 8-yrs survival rate significant in the PSK group( p<0.05); Disease-free interval (p<0.05)

Refs Torisu et al, 1990

Disease-free interval and survival significantly better for PSK in the colon group (p<0.05 in both) Overall survival rate higher in the PSK group but not significant (p=0.21).

3-year disease-free survival rate significantly higher in the PSK group (p=0.02).

Stage III. Patients 3-year overall and disease-free survival rates in the PSK significant (p=0.02; p =0.01) 5-year overall survival rate significantly higher in the PSK group (p<0.016, p <0.056 respectively).

Stage III patients: Overall and 5-year disease-free survival in PSK group (p <0.003; p<0.002).

Seven- year survival rate Significantly higher in the PSK group (p=0.019).

Overall survival or disease-free rates not significant.

Mitomi et al, 1992

The presence of diffuse nuclear accumulation-type !-catenin activation identifies patients with colon cancer who respond better to immunotherapy with polysaccharide K.

Yamashita et al, 2007

Ohwada et al, 2003

Ohwada et al, 2004

Ito et al, 2004

5-FU = 5-fluorouracil

patients in three clinical trials. The aim of the metaanalysis was to evaluate the effect of PSK as adjuvant immunochemotherapy for patients with curatively resectal colorectal cancer. The results suggested that adjuvant immunochemotherapy with PSK can improve both survival and disease-free survival of patients with curatively resectal colorectal cancer.

B. Colorectal cancer C. versicolor extract was assessed for its potential anticancer activity in patients with advanced colorectal cancer (stages III and IV) (Torisu et al, 1990). PSK was given at 3 grams/day for two months after surgery, followed by 2 grams/day until the end of the second year and 1 gram/day thereafter. This study found that the leukocyte activity of the PSK group was remarkably enhanced. Notably, polymorphonuclear leukocytes from PSK-treated patients showed enhancement in their activities, such as random and/or chemotactic locomotion, and phagocytic activity, when compared with those of the control group. The survival rate of the PSK group reached 40%, a net improvement over the 25% rate registered for the placebo group. From this study, it was concluded that PSK could be useful as a maintenance therapy for patients after their curative surgical operations for colorectal cancer.

Sakamoto and colleagues performed in 2006 a metaanalysis of colorectal cancer, which involved 1094

C. Gastric and esophageal cancer Stomach cancer is a major cause of mortality in Japan and China and, for that reason, has been the object of many clinical trials with polysaccharopeptides from C. versicolor. Trials done in the 1970s and 80s had evidenced a better survival rate at two or three years. More recent clinical studies, done in the 1980s and 90s, established that PSK could improve the survival rate at five years and beyond in stomach cancer patients, including some patients with advanced Stage III and IV cancer with metastasis (Kidd, 2000).

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Cheng and Leung: General review of polysaccharopeptides (PSP) from C. versicolor Table 6. Assessment of methodological parameters on clinical trials of PSP or PSK. Reference

Mitomi et al, 1993

Jadad Study design Score (max = 5) 2 Randomized control, followup study

Nakazato et al, 3 1989

Ichihashi et al, 3 1987

Sample size

Inclusion/Exclusion criteria

Patients younger than 75 years of age with stage III or IV colorectal cancer and consented form obtained were included Patients with WBC<4000/mm3, PLT<100,000/mm3, TP<6.0g/dl, Alb<3.0g/dl, A/G<1, SGOT/SGPT>100U, urine protein (+), Crea>1.5mg/dl were excluded Randomized 262 gastric Patients with age<75 control, follow- cancer patients years, PPD(+), diagnose up trial with radical confirmed by pathology surgery were included.

Patients who underwent any radiotherapy, chemotherapy, or immunotherapy or having multiple cancers, or any abnormal hematological findings were excluded Randomized 168 patients with Inclusions included: age control follow- stomach cancer <75 years, without up study multiple cancers, normal hematological findings and diagnosis confirmed by post-operation pathology

Guo, 2000

3

Double-blind placebocontrolled randomized study

Ze et al, 2003

3

Randomized controlled trial

Ebihara and 2 Minamishima, 1984

Randomized controlled trial

448 colorectal cancer patients treated with chemotherapy

34 patients with Completed conventional non-small cell treatment for advanced lung cancer NSCLC

Treatment schedule

Results

227/221 patients were randomly assigned to control (chemotherapy for 6 months) and treatment (chemotherapy 6 months plus PSK 3g/day for 3 years)

The disease-free survival and the survival of the PSK group were better than those of the control group (Disease-free survival: p=0.0214, Survival: p=0.0272)

129/124 were randomly assigned to control (chemotherapy) and treatment (chemotherapy plus PSK 3g/day for 4 weeks)

The disease-free survival curves and overall survival curves of PSK treatment group were significant (p=0.018 and p=0.045) better than those of control group.

49/47/28 patients were randomly assigned to receive chemotherapy (CQ), PSK (3g/50kg) plus CQ for 13 months and no CQ and PSK treatment (as control).

Patients received 28-day administration of PSP

Overall 7 year survival rate in PSK group higher than chemotherapy group but no significant difference.

After 28-day treatment, there was a significant improvement in blood leukocyte and neutrophil counts, serum IgG and IgM, and percent of body fat among the PSP, but not the control, patients (p<0.05) 201 patients with Age < 75 year and 137/68 patients The three-year, stage II or III historical confirmed treated with 3g PSK disease-free survival colorectal cancer colorectal cancer. Exclude: plus 300mg tegafur rate was 80.6% in underwent any /uracil or 300mg PSK group (p=0.02) radiotherapy, tegafur/uracil alone compared with 68.7% chemotherapy or for 2 years in the control group. immunotherapy.

25 advanced Advanced malignant Treatment group Quality of life and malignant cancer cancer patients without orally taken PSP 5g symptoms were patients immunotherapy each time 3 times a improved in PSPday for 2 months treated group plus symptoms compared with control treatment control group (p<0.01 Control group only and p< 0.05) gave symptoms control treatment

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Cancer Therapy Vol 6, page 125 In a randomized clinical trial including 579 patients with gastric cancer receiving chemotherapy, C. versicolor extract was administrated orally as an adjuvant to surgery in a combination therapy to part of the group, at a daily dose of 3 grams for 1 year. Results from this study showed a significant increase in the 5-year survival rate for the PSK-treated group when compared with the other groups (Niimoto et al, 1988).

In an additional study involving more than 260 patients who underwent surgery for stomach cancer at 46 hospitals in Japan, those who received PSK along with chemotherapy experienced a higher 5-year disease-free rate and a better 5-year survival rate than subjects who underwent chemotherapy alone (73% vs. 60%). The two regimens had slight toxic effects, consisting of nausea, leucopenia, and liver function impairment but no characteristic toxic effects were linked to PSK administration (Nakazato et al, 1994).

Trials with PSP indicated that C. versicolor extract has the potential to alleviate the side effects normally associated with chemotherapy (lassitude, inappetence, spontaneous perspiration, etc.) in patients with stomach cancer classified as stage I to IV (Zhang et al, 1999).

Moreover, an increase in the immunological functions and a concomitant decrease of the adverse hematological side effects of chemotherapeutical drugs was demonstrated for stomach cancer patients following the administration of PSP (1 gram three times a day for 8 weeks) (Wu et al, 1999).

Results from a prospective multi-centre study including 158 esophageal cancer patients, indicated that those who received PSK (3 grams/day for three months after surgery) had a significantly better survival rate at five years (55% and 58%) compared with those without PSK supplementation (26% and 31%) (Ogoshi et al, 1995a).

Another study reported the results of 174 patients who underwent esophagectomy and were then assigned to receive radiotherapy or chemotherapy with or without PSK. There was a tendency for longer survival on PSK, but statistical significance was not reached. However, regression analysis indicated that C. versicolor extract might have a beneficial effect on esophageal carcinoma when combined with radiotherapy and chemotherapy (Ogoshi et al, 1995b).

Better survival rates were also achieved with PSP. A hundred patients with esophageal carcinoma were randomly divided into two groups: one group was treated with radiotherapy alone while other one received radiotherapy plus PSP (3 grams daily for a total dose of 190 grams during the period of radiation time). The results demonstrated that patients treated with radiotherapy plus PSP had higher one, three and five survival rates (67%, 38%, and 19% respectively) versus the control group (47%, 21% and 14%) (Yao, 1999). Addition of PSP to the regimen improved the relief of major symptoms commonly associated with esophageal cancer, such as change of weight, alteration in the hemogram profile and in immunological functions. The relief of these symptoms was quantified to reach 61% in the PSP-treated group, while it was 31% in the control group (Wu and Wang, 1999).

A Meta-analysis study was performed to evaluate the effect of immunochemotherapy on survival in patients with curative resections of gastric cancer. The metaanalysis included 8,009 patients from eight randomized controlled trials after central randomization. The results suggest that adjuvant immunochemotherapy with PSK improves the survival of patients after curative gastric cancer resection (Oba et al, 2007).

D. Leukemia A study with PSK as an adjuvant to chemotherapy done in the early 1980â&#x20AC;&#x2122;s (with 28 patients) found that remission and survival were significantly prolonged for patients who received PSK plus chemotherapy over those who received chemotherapy alone (Nagao et al, 1981). In another multi-center trial including 67 patients in remission of acute non-lymphocytic leukemia (ANLL) in Japan, patients who received a maintenance chemotherapy plus immunotherapy with PSK tended to have longer survival over the group that received chemotherapy alone but without significance. However, analysis of the data of patients who had maintained complete remission for more than 270 days revealed that immunotherapy had a suggestive beneficial effect (p=0.105), prolonging the 50% remission period by 418 days (885 vs. 467 days). It was concluded that PSK may help in the treatment of adult ANLL when used for maintenance therapy in combination with chemotherapy, especially in patients with a good prognosis.

E. Lung cancer A clinical trial conducted in Japan was done with patients having different lung cancers at stages I-III; a group was selected to receive 3 grams of PSK daily after cessation of radiation therapy. PSK was given in repeating cycles of two weeks on and two weeks off. After 5 years, 27% of the patients treated with PSK were alive compared to 7% for those not given the mushroom extract (Hayakawa et al, 1993). The study also demonstrated that patients with Stage III disease who received PSK had a better prognosis than those with stages I and II without PSK. A study investigated the effects of PSK as an accessory treatment for lung cancer (Ke et al, 1999), 30 patients were administered the mushroom extract while they received chemotherapy. The symptoms (side effects) improvement for PSP-treated patients was over 87%, while it was 47% for the control group.

Thirty-four patients, with no significant difference in their baseline demographic, clinical or tumor characteristics, or previous treatment regimes (p>0.05), were recruited into each of the PSP and control arms.

After 28-day treatment, there was a significant improvement in blood leukocyte and neutrophil counts, serum IgG and IgM, and percent of body fat among the PSP, but not the control patients (p<0.05) (Tsang et al, 2003).

VII. Discussion and Conclusion Since 1970s numerous mushroom fungi have been increasingly used as a source of medicinal compounds and

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therapeutic adjutants or health food supplements. PSP has been previously shown to have immuno-stimulatory, antitumour and analgesic effects (Zhong et al, 2001) in animal models. When used as an adjunct in cancer chemotherapy in clinical trials carried out in China, PSP improved the quality of life in the patients by improving appetite and alleviating symptoms associated with cancer chemotherapy. Cancer chemotherapy and radiotherapy are standard treatments of cancer in the past 30 years, often associated with side effects such as immuno-suppression, poor appetite, and vomiting, which seriously affected the therapy. Studies in Japan and China have suggested mushroom proteoglycans may provide a possible solution, with Polysaccharide Krestin and PSP being systemically studied as adjunct to cancer chemotherapy (Kidd, 2000).

Nowadays the biological activities of PSP and PSK have received much attention in biomedical sciences. One of the most important functions of PSP and PSK is their immunomodulation and anti-cancer actions. Various experimental evidences demonstrated that the anti-tumor action of mushroom polysaccharides is due to the enhancement and potentiation of cell-mediated immune system through the regulation of immunomodulatory cytokines and activation of the complement system and Natural Killer Cells (NK cells) (Ohwada et al, 2006).

However the mechanism of anti-tumor actions of PSP and PSK from most fungi is still not clear. It is accepted that anti-tumor polysaccharides enhance various immune responses, and act as biological response modifiers (Ohwada et al, 2006). PSK/PSP are nonspecific immunopotentiators and exert immunomodulatory actions by promoting the proliferation of T-lymphocytes, the activation of macrophages, natural killer cells, and Thelper cells, thereby inducing the production of antibody and interleukins (Mao et al, 1996; Li, 1999). PSK also has favorable effect on the activation of leucocyte chemotactic locomotion and phagocytic activity (Torisu et al, 1990).

However further studies on the mechanisms behind anticancer, immunostimulatory, and biological response modifying effects of PSK or PSP are needed.

Acknowledgments This project was made possible by Grant Number 1 P50 AT002779-01 from the National Center for Complementary and Alternative Medicine (NCCAM) and the Office of Dietary Supplements (ODS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCCAM, ODS or the National Institute of Health.

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From left to right: King-Fai Cheng, Ping-Chung Leung

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Therapeutic modalities for intraocular lymphoma Review Article

Sapna Gangaputra, Robert Nussenblatt, Grace Levy-Clarke* National Eye Institute, National Institutes of Health

__________________________________________________________________________________ *Correspondence: Grace Levy Clarke, MD, Uveitis Specialist, St. Luke’s Cataract and Laser Institute, 9400 9th St N (MLK), St. Petersburg, Fl 33702, USA; Tel: 727 328 7700; Fax:727 321 2301; E-mail: gclarke@stlukeseye.com Key words: Immunotoxin HA22 – B, T cell murine models, Clinical presentation, Diagnosis, High dose MTX, Local Chemotherapy, Radiotherapy (RT), Rituximab, Treatment options, Trofosfamide, Ifosfamide Abbreviations: blood-brain barrier, (BBB); central nervous system, (CNS); fluorescein angiography, (FA); Non Hodgkin’s Lymphoma, (NHL); primary central nervous system lymphoma, (PCNSL); Primary intraocular lymphoma, (PIOL); Radiotherapy, (RT); retinal pigment epithelium, (RPE) Received: 1 July 2007; Revised: 31 August 2007 Accepted: 18 February 2008; electronically published: February 2008

Summary PIOL is a rare tumor that primarily affects intraocular tissues. It is a subset of PCNSL. It usually presents as unremitting uveitis that is refractory to corticosteroid therapy. A work-up is warranted in every patient presenting with a picture clinically compatible with PIOL. The diagnostic algorithm followed at NEI outlines the critical steps to rule out a lymphoma. This paper also reviews the current therapeutic modalities available for the treatment of PIOL. The treatment algorithm developed at NEI, offers a comprehensive treatment plan based on the clinical presentation of the PIOL. A consortium of physicians including neurologists, oncologists and ophthalmologists working together will achieve improved tumor remission and survival. More studies are needed to better understand the pathophysiology of PIOL and develop treatment targeting the lymphoma cells at a molecular level.

and overall patient survival. Prompt and accurate diagnosis together with improving treatment plans can lead to better visual and systemic outcomes (Choi et al, 2006).

I. Introduction Primary intraocular lymphoma (PIOL) is a form of non-Hodgkin’s lymphoma that involves primarily intraocular structures. It was first described in 1951 by Cooper and Riker as “reticulum cell sarcoma” (Cooper and Riker, 1951). PIOL refers to a type of primary central nervous system lymphoma (PCNSL), which presents in the eye with or without CNS involvement. PIOL is a rare malignancy, but the exact incidence is unknown. The frequency of this rare condition has increased over the past years in immunosuppressed as well as immunocompetent patients. It has been shown that chronic antigenic stimulation may result in the development of PIOL (Gunduz et al, 2006). Histologically, PIOL is usually a diffuse large-cell B-cell lymphoma. Intraocular lymphoma of T-cell type is rare, and most cases represent a primary cutaneous T-cell lymphoma, most commonly Mycosis Fungoides or secondary manifestations of a systemic Tcell lymphoma in conjunction with systemic leukemia, such as Adult T cell leukemia (Levy-Clarke et al, 2002; Coupland et al, 2005). PIOL presents a diagnostic and therapeutic challenge as it is a rare and lethal malignancy.

It often masquerades as uveitis, and delay in prompt and accurate diagnosis can affect treatment, ocular outcome

II. Clinical presentation The most common presentation of Non Hodgkin’s Lymphoma (NHL) of the central nervous system (CNS) is an older patient with chronic uveitis that is not responsive to corticosteroids. These patients may complain of painless loss of vision with floaters. Patients may also rarely complain of red eye, photophobia, or ocular pain, or even be clinically silent (Gill and Jampol, 2001). The vitreous cavity usually contains a cellular infiltrate composed of neoplastic and reactive inflammatory cells by cytology. Clinical exam reveals vitreous cells and vitreous haze. The infiltrate often forms clumps and sheets in the vitreous and may obscure visualization of the retina.

Retinal findings commonly seen in patients with PIOL include scattered punctate, deep retinal lesions and yellowish subretinal infiltrates that may enlarge and coalesce (Buggage et al, 2001). Atypical findings on ophthalmic examination may include the presence of keratic precipitates, and mild cellular reaction in the

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Gangaputra et al: Therapeutic modalities for intraocular lymphoma anterior chamber. Noninvasive ancillary tests such as fluorescein angiography (FA) can play an important role in the early diagnosis of PIOL. Fluorescein angiography is a technique for examining the blood circulation of the choroid and retina. A bolus of Fluorescein is injected intravenously and after a few minutes is visible in the retinal vessels, when visualized using blue light. Serial photographs of the filling and emptying of dye from the retinal and choroidal circulation are used to study the vascular tree and retinal perfusion. The most common angiographic characteristics include disturbances at the level of the retinal pigment epithelium (RPE), such as granularity, blockage and late staining. These changes correlate to histopathologic findings of lymphoma cells between the RPE and Bruchâ&#x20AC;&#x2122;s membrane. Perivascular staining or leakage and cystoid macular edema are not frequent findings (Velez et al, 2002).

be done (Levy-Clarke et al, 2001). When a definite diagnosis is obtained, a neuro-oncologist should participate in the treatment and follow up of the patient (Levy-Clarke et al, 2005).

IV. Treatment options At National Eye Institute, we have formulated a treatment algorithm based on disease presentation (LevyClarke et al, 2005). At initial presentation, systemic chemotherapy is offered for PIOL without parenchymal or leptomeningeal involvement. Adjunct local chemotherapy is typically added when there is high tumor burden in the eye or systemic therapy is contraindicated. If there is PIOL with intraparenchymal or leptomeningeal involvement, then systemic and intrathecal chemotherapy should be offered with management by oncologist and ophthalmologist. When there is refractory or recurrent intraocular disease, then additional systemic chemotherapy with adjunctive intravitreal methotrexate maybe administered, or radiotherapy can be used. If intravitreal methotrexate is used, then a baseline electroretinogram to assess pre-treatment retinal function and to assess for subsequent treatment toxicity is recommended. In addition, rescue therapy for limbal stem cells with topical leucovorin should be attempted. Topical leucovorin should be formulated by the local pharmacist and administered as 0.003% eyedrops, four times a day or as needed. A diagnosis of keratoconjunctivitis sicca is treated as a relative contraindication for intravitreal MTX due to the high incidence of corneal epitheliopathy (Smith et al, 2002). A thorough corneal evaluation with Schirmer testing is recommended prior to institution of this therapy.

Monitoring for recurrence of disease during disease free intervals should include neuroimaging and cytoanalysis of the CSF. Vitreous specimen for cytopathology and cytokine and molecular analyses should be included when clinically indicated.

III. Diagnosis Cytological examination of vitreous is the best test to exclude lymphoma in patients with persistent idiopathic uveitis. Chorioretinal biopsies increase the chances of diagnosing or excluding a PIOL. Biopsies also allow for exact subtyping of the malignant lymphoma (Levy-Clarke et al, 2001; Coupland et al, 2003; Gonzales and Chan, 2007). Recommendations to maximize utility of cytologic evaluation for PIOL include discontinuation of systemic corticosteroids before vitrectomy, obtaining cells from the subretinal pigment epithelium space when possible, and to process the cells immediately for cytologic evaluation.

Corticosteroids have a cytotoxic effect on lymphoma cells and consequently will decrease the availability of malignant cells at the time of biopsy.

Immunohistochemistry and flow cytometric immunophenotyping may help to support the diagnosis (Zaldivar et al, 2004). Judicial handling of the vitreal biopsy and evaluation of the slides by an experienced cytopathologist are also key factors in the diagnostic process (Karma et al, 2007). Molecular analysis using microdissection and PCR in the examination of vitreous specimens in patients with PIOL have shown diagnostic utility. Clonal rearrangements of the immunoglobin heavy chain or the T-cell receptor genes and are well reported adjunctive studies utilized in the assessment of PIOL patients (Shen et al, 1998; Chan, 2003; Merle-BĂŠral et al, 2004; Baehring et al, 2005; Coupland et al, 2005). Chan and colleagues have published extensively on the unique molecular patterns of PIOL compared with other systemic lymphomas (Wallace et al, 2006). At the National Eye Institute we follow a diagnostic algorithm. Every patient suspicious for PIOL undergoes neuroradiologic imaging and CSF examination. No further ocular diagnostic tests are required in patients with positive CSF findings by cytology and/or flow cytometry. In patients with a negative CSF study, a vitrectomy or vitreous tap should be performed in the eye with more severe vitritis or worse visual acuity. This sample should be sent for immediate cytolopathologic analysis. Adjunctive studies may include immunophenotyping/ flow cytometry, cytokine analysis, microdissection and PCR (Chan and Wallace, 2004). If indicated, chorioretinal biopsy or subretinal aspirate may

V. High dose MTX Advances in PCNSL treatment has shown evidence that high-dose methotrexate-based chemotherapy regimens improve survival compared to those treated with radiotherapy alone. However, there is no optimal treatment and therapy can be associated with long-term neurotoxicity. Gavrilovic and colleagues reported on their cohort of PCNSL who were treated with high dose MTX chemotherapy (Gavrilovic et al, 2006). Whole brain radiotherapy was used when necessary. The 10 year follow up period showed remission in almost half of the enrolled patients with just chemotherapy. They observed that the rate of death due to neurotoxicity was equivalent to the rate of death due to progression of the tumor. Batchellor and colleagues studied the effects of high dose methotrexate in patients with concurrent PIOL and PCNSL. They had satisfactory rates of remission.

Refractory cases were treated with radiation. The concentration of methotrexate in the vitreous and aqueous four hours post infusion, was high enough to be cytotoxic to the lymphoma cells (Batchelor et al, 2003). In another study, patients with recurrent or refractory lymphoma were treated with methotrexate and hematopoietic stem 132

Cancer Therapy Vol 6, page 133 cell rescue. They showed improved survival with the regimen (Soussain et al, 2001).

VIII. Newer therapies A. Trofosfamide and Ifosfamide Trofosfamide and Ifosfamide are alkylating oxazaphosphorine derivatives. They are prodrugs which require hydroxylation at the cyclic carbon-4 position by hepatic cytochrome P-450 isoenzymes. IFO and TRO penetrate through the blood-brain barrier (BBB) due to their lipid solubility, small molecular size, and minimal binding to plasma and tissue proteins. Jahnke and colleagues published in 2004 their experience using oral trofosfamide. Two patients, who were not good candidates for radiation therapy or systemic chemotherapy, were seen to have complete remission on this regimen (Jahnke et al, 2004). One patient carried a diagnosis of PIOL while the other was diagnosed with oculocerebral lymphoma. The same investigators later evaluated the efficacy and aqueous penetration of intravenous ifosfamide and oral trofosfamide on 10 patients with PIOL. All patients responded and showed evidence of aqueous penetration of the active metabolite (Jahnke et al, 2005).

VI. Local chemotherapy In an attempt to provide more focused drug delivery, Smith and colleagues report in 2002 treating patients with intravitreal methotrexate according to a standard induction-consolidation-maintenance regimen.

The induction phase consisted of twice weekly intravitreal MTX injections for one month. A dose of 400µg in 0.1ml was injected at the level of pars plana using a 30G needle.

After induction, weekly consolidation doses were given for a month. The maintenance phase involved monthly MTX injections for a year. They achieved a 100% remission, defined as clinical absence of tumor cells and resolution of retinal and optic nerve infiltration. The side effects commonly observed were cataract, corneal epitheliopathy, and maculopathy. All patients were also on systemic chemotherapy at the same time (Smith et al, 2002). Intrathecal MTX and Ara-C delivered by means of an Ommaya reservoir was also tried. Patients showed complete remission and good visual outcome (Valluri et al, 1995; Mason and Fischer, 2003). Rabbit eye studies showed that methotrexate when delivered intravitreally, remained at therapeutic levels for about 48 hours in the vitreous. It was proven to be safe and efficacious when given with a single injection of fluorouracil and dexamethasone (Velez et al, 2001). Based on their results, the optimal dosing schedule for intravitreal methotrexate is every 48-72 hours. There have been other case reports showing success in inducing complete remission in patients with PIOL, using intravitreal MTX as an adjunct to systemic chemotherapy (Fishburne et al, 1997; de Smet et al, 1999; Velez et al, 2002).

B. Rituximab It is a monoclonal antibody against the B cell specific CD20 antigen. Though proven useful to treat CNS B Lymphomas, the CSF levels of rituximab after infusion are not sufficiently high and it does not appear to cross the blood brain barrier (Harjunpää et al, 2001). Investigations of the pharmacokinetics following intravitreal administration showed drug levels in aqueous and vitreous chambers with a half life of 4.7 days (Kim et al, 2006). An investigation was conducted to look at the efficacy of intrathecal monotherapy using a Phase I dose escalation study, enrolling patients with recurrent CNS non Hodgkin's lymphoma. The results suggested that an intrathecal dose of 10-25 mg would be an effective dose to use in patients with PCNSL (Rubenstein et al, 2007). A recent case series found rituximab to be histologically non toxic to rabbit and human eyes, at the dosage of 1.0mg/01ml. The effectiveness of the drug to induce regression of the lymphoma was not confirmed and more studies are needed to prove its efficacy (Kitzmann et al, 2007).

VII. Radiotherapy (RT) Studies published in 1980s indicated that RT was the first choice of treatment as lymphoma cells are highly sensitive to radiation. Complications as a result of radiotherapy were common. The most frequently reported was cataract. Dry eye was also relatively common, while serious complications of radiation retinopathy and optic atrophy were less frequent. However, it should be noted that these complications occur late and survival of the patients may compromise reporting (Hoffman et al, 2003).

Ocular external beam radiotherapy is proven to be highly effective in controlling PIOL and is associated with tolerable ocular complications. One reported regimen in a retrospective, interventional case series used 35-40 Gy given in 15 fractions to both globes to minimize normal tissue toxicity (Berenbom et al, 2006). A multiinstitutional survey in Japan summarized the experience of 17 institutions performing radiotherapy for PIOL. The conclusive recommendation was to deliver 40 Gy of ocular Radiotherapy, in conjunction with prophylactic cranial irradiation at doses 30 Gy and high-dose MTX to control PIOL (Isobe et al, 2006).

IX. Immunotoxin HA22 - B and T cell murine models Researchers at NEI developed a murine model of PIOL by direct inoculation of adult mouse vitreous with immunogenic variants of mouse T cell lymphomas.

Although this model was not a B-cell lymphoma, there were many features of human PIOL, such as clinical presentation, histologic findings, and cytokine expression pattern (Chan et al, 2005).

To mimic the human PIOL, a B cell murine model was developed by intravitreally injecting human B-cell lymphoma cells into severe combined immunodeficient mice. Results showed that the murine model resembled human PIOL closely. Pathologic examination revealed that the tumor cells initially colonized on the retinal surface, later infiltrated through the retinal layers and eventually penetrated through the retinal pigment epithelium into the 133

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choroid. Several putative molecular markers for human PIOL were expressed in vivo in this model. Tumor metastasis into the central nervous system was also observed. Having developed a closely resembling model, the next step was to use the model to test therapeutic strategies. A recently developed immunotoxin combining a monoclonal antibody against CD22 and a Pseudomonas exotoxin (BL22) has been successfully used in a phase I clinical trial for treating hairy cell leukemia. Immunotoxin HA22 is a mutant of BL22 with mutations in heavy-chain CDR3 resulting in increased cytotoxic activity. The therapeutic effectiveness of immunotoxin HA22 was tested by injecting the drug intravitreally into the B cell murine model. A single intravitreal injection of immunotoxin HA22 resulted in complete regression of the tumor (Li et al, 2006).

PIOL is a difficult disease to diagnose and treat and the best therapeutic options have not yet been formalized.

Earlier publications centered on radiotherapy, but approaches over the last 2 decades have focused on systemic and intrathecal chemotherapy. Within the new realm, high dose MTX still remains the first option for many oncologists. Our experience at NEI has shown that as a first line therapy, it is very effective at treating PIOL (a subset of PCNSL) especially in patients with large subretinal tumor bulk. Patients with recurrent disease have been treated with local intravitreal MTX and have shown good initial response but we have seen a high rate of recurrence, with the need for multiple courses of therapy.

For patients with refractory disease, radiotherapy still remains a good therapeutic option. Radiation is also effective at treating leptomeningeal involvement with associated optic nerve infiltration, which is an ophthalmologic emergency. The patient can have rapidly progressive vision loss and leading to blindness.

In conclusion, PIOL continues to be a diagnostic and therapeutic challenge. The International CNS and Ocular Lymphoma workshop group (Nussenblatt et al, 2006) recommend new approaches to diagnose PIOL with better accuracy and sensitivity. In this regard, an animal model for the rare disease will help in understanding the biology of the disease. Other methods for disease detection should be explored so that accurate diagnosis, staging and treatment regimens can be formulated. In order for such studies to have greatest impact, national and international collaboration should be coordinated.

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Furthermore, some nutritional flavonoids (i.e., quercetin, naringenin, and daidzein) that bind to ER! with higher affinity than ER", act as E2-mimetic in the presence of ER! rapidly activating p38/MAPK (Totta et al, 2004, 2005). Because of their potential to transactivate ER! more than ER", phytoestrogens may be of benefit in tissues in which ER!-mediating signaling plays a significant role (Koheler et al, 2005; Ascenzi et al, 2006; Moutsatsou, 2007).

In conclusion, the discovery of ER! has deeply changed our understanding about the biological effects of E2 and the mechanism of ER action. This offers a new prospective for the development of ER! selective drug s for the treatment of diverse clinical conditions.

Acknowledgements The authors wish to thank past and present members of their laboratories who contributed to the ideas presented here through data and discussions. The editorial assistance of Peter DeMuro is also acknowledged. This work was supported by grants from the Ministry of University and Research of Italy (PRIN-COFIN 2006 to M.M.).

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Bandera CA, Takahashi H, Behbakht K, Liu PC, LiVolsi VA, Benjamin I, Morgan MA, King SA, Rubin SC, Boyd J (1997) Deletion mapping of two potential chromosome 14 tumor suppressor gene loci in ovarian carcinoma. Cancer Res 57, 513-515.

Barchiesi F, Jackson EK, Imthurn B, Fingerle J, Gillespie DG, Dubey RK (2004) Differential regulation of estrogen receptor subtypes " and ! in human aortic smooth muscle cells by oligonucleotides and estradiol. J Clin Endocrinol Metab 89, 2373-2381.

Bardin A, Boulle N, Lazennec G, Vignon F, Pujol P (2004a) Loss of ER! expression as a common step in estrogendependent tumor progression. Endocr-Relat Cancer 11, 537-551.

Bardin A, Hoffmann P, Boulle N, Katsaros D, Vignon F, Pujol P, Lazennec G (2004b) Involvement of estrogen receptor ! in ovarian carcinogenesis. Cancer Res 64, 5861-5869.

Barlaam B, Bernstein P, Dantzman C, Warwick P (2002) Preparation of benzoxazoles and benzothiazoles as selective

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Cancer Therapy Vol 6, page 151 status of ERs (Bunone et al, 1996; Weigel and Zhang, 1998; Tremblay et al, 1999). AF-2 is present at the Cterminus and shows a ligand-dependent activation (Wrenn and Katzenellenbogen, 1993; Weihua et al, 2003; Galluzzo and Marino, 2006).

Besides full-length ERs, numerous mRNA splice variants exist for both ERs and these have been found in a number of different normal and diseased tissues frequently co-expressed with their wild-type counterparts. The exact function and potential role of ER! and ER! splice variants in physiology and human disease remain to be elucidated (see Ascenzi et al, 2006; Herynk and Fuqua, 2004), but several experiments indicate that ER! isoforms can differentially modulate estrogen signaling and, as a consequence, impact upon target gene regulation. At least five splice variant isoforms of the ER! gene product (ER!1-ER!5) have been described (Moore et al, 1998; Wong et al, 2005) (Figure 2): the 530-amino acid human ER! isoform is currently regarded as the wild-type ER!;

ER!2 (also called ER!cx) (Ogawa et al, 1998b) is identical to the ER! long form, except that 26 unique amino acid residues replaces the C-terminal of LBD. Additionally, two truncated isoforms have been identified and named ER!4 and ER!5. Several additional ER! isoforms have been reported, although full-length sequences have not been determined (Ascenzi et al, 2006; Matthews and Gustaffson, 2003; Heldring et al, 2007).

III. ER mechanism of action The mechanisms of ER! and ER! action are complex pathways that involve two distinct types of signaling which lead to protein kinase activation (rapid non-genomic mechanism) and direct or indirect transcription of target genes (genomic mechanism) (Figure 3). All these pathways synergize to determine the over all effects of E2.

Figure 2: ER! splicing variants. The striped fill patterns of the 3â&#x20AC;&#x2122; end of hER!2 (also named hER!cx), hER!4, and hER!5 represent the differing C-terminal regions of these isoforms. For details, see text.

Figure 3: Schematic model illustrating the localization at and maintenance to the plasma membrane of ER!. In the first panel (a) is depicted the classical interaction of the activated receptor with ERE on DNA. In panels b and c are representations of the indirect effects of ERs on transcription interactions. This occurs through protein-protein interactions with the Sp1 (b), AP-1 (c). The panel d represents the E2-non-genomic mechanism. For details, see text. AP-1, activating factor-1; Sp-1, stimulating factor-1. For details, see text.

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Marino and Galluzzo: ER! and colon cancer promoter resulted in attenuation of promoter responsiveness to E2 (Marino et al, 2002, 2003). Unlike ER", E2-bound ER! represses cyclin D1 expression (Acconcia et al, 2005) and blocks ER"-E2-mediated induction when both receptor isoforms are present (Matthew and Gustafsson, 2003). Consequently, these differences in transcriptional activity between the ER" and ER! may account for the major differences in their tissuespecific biological actions. This complexity is further enhanced by the presence of different ER! splice variants, through the ability of the ER isoforms to form homodimers and hetero-dimers, and by their capacity to interact with different co-regulators (Bardin et al, 2004a; Marino et al, 2006b). ER!1 is essential for ER!-induced transcription initiation at ERE, whereas the other ER! isoforms have no innate transcriptional activity but play an enhancement role when dimerized with ER!1. ER!1 is the only full-functioning ER!, which preferentially heterodimerize with other ER! isoforms, particularly ER!4 and ER!5 forming “variable dimer partners” under the stimulation of estrogens (Leung et al, 2006). Furthermore, ER!2 (ER!cx), which is unable to bind ligands or coactivators and has no transcriptional activity in reporter assays, shows preferential hetero-dimerization with ER" rather than with ER!. ER!2 inhibits ER" DNA binding and has a dominant-negative effect on ligand-dependent ER! reporter gene activity (Ogawa et al, 1998b). These data suggest that the ER! isoforms could differentially modulate E2 action (Ascenzi et al, 2006) and make elucidating the physiological role of this receptor more difficult.

A. ER! genomic mechanism In the “classical” mechanism of action, estrogens diffuse into the cell and bind to the ERs. The nuclear ER"or ER!-E2 complex directly binds DNA through the ERE sequences or indirectly through protein-protein interactions with activator protein-1 (AP-1) or stimulating protein (Sp-1), resulting in recruitment of coregulatory proteins (coactivators or corepressors) to the promoter, increased or decreased mRNA levels, protein production, and physiological responses (Ascenzi et al, 2006; Deroo and Korach, 2006). A large subset of coregulatory proteins (e.g., steroid receptor coactivator-1, 2, and 3) help to recruit histone acetyltransferases and methyltransferases which, in turn, possess chromatin-remodeling ability and tether activated receptors to the basal transcriptional machinery (Smith and O’Malley, 2004). Both ER" and ER! are capable of regulating gene transcription through this classical mechanism involving ERE, but ER! seems to be a weaker transactivator (Cowley and Parker, 1999).

AF-1 activity of ER! is weak compared with that of ER" on ERE, whereas their AF-2 activities are similar (Cowley and Parker, 1999). In turn, when both AF-1 and AF-2 functions are active in a particular cell and/or on a particular promoter, the activity of ER" greatly exceeds that of ER!, whereas ER" and ER! activities are similar when only AF-2 is required (McInerney et al, 1998; Cowley and Parker, 1999; Ascenzi et al, 2006). It has been postulated that differences in the ER! and ER! activities are due to differences in the ability of the receptors to interact with coregulatory proteins, because of the low amino acid identity in A/B domain of ERs (Figure 1) (Smith and O’Malley, 2004; Ascenzi et al, 2006).

Another category of gene promoters, lacking any ERE-like sequences, requires a second DNA-binding transcription factor (e.g. Sp-1 and AP-1) to mediate ER association with the DNA (O’Lone et al, 2004). Although ER" and ER! have similar effects on ERE-mediated gene transcription, the receptors show opposite effects on promoters containing AP-1 (Paech et al, 1997). E2 activates AP-1-mediated gene transcription when bound to ER" but inhibits promoter activity when bound to ER! (Paech et al, 1997). The converse is true for anti-estrogens, such as tamoxifen, raloxifene, and ICI 164384, which are AP-1 transcriptional suppressors via ER" and activators via ER! (Paech et al, 1997; Weyant, et al, 2001).

Similar to AP-1, E2 binding to ER" induces transcriptional activation when associated with Sp-1 in GC-rich regions. However, E2 binding to ER! does not result in the formation of a transcriptionally active complex at a promoter containing Sp-1 elements (Saville et al, 2000). As an example ER" and ER!, in the presence of E2, oppose each other’s function in the regulation of the cyclin D1 promoter (Liu et al, 2002). There is considerable evidence that cyclin D1, important for the progression of cells through the G1 phase of the cell cycle, is a welldefined target for ER"-E2 action in mammary carcinoma cells (Altucci et al, 1996; Foster and Wimalasena, 1996; Prall et al, 1997), although no detectable “perfect” or ERE-like sequence in the cyclin D1 gene promoter has been reported (Herber et al, 1994). Deletion of AP-1 and Sp-1 responsive element motifs in the cyclin D1 gene

B. ER! non-genomic mechanism The “classical” genomic mechanism of ER" and ER! action typically occurs over the course of hours. In contrast, E2 can act more quickly (within seconds or minutes) via “non-genomic” mechanisms that require the presence of ER" at the plasma membrane and resulting in such cellular responses as increased levels of Ca2+ or NO, and activation of kinases, such as phospholipase C (PLC)/protein kinase C (PKCs); Ras/Raf/mitogen activated protein kinase (MAPK), phosphatidyl inositol 3 kinase (PI3K)/AKT, c-src/MAPK, and cyclic AMP (cAMP)/ protein kinase A (PKA) (Castoria et al, 2001; Levin, 2005; Marino et al, 2006b and literature cited therein).

Only limited information is available on the role played by the ER!-E2 complex in the activation of rapid non-genomic mechanisms, whereas a considerable volume of evidence (Ansonoff and Etgen, 1998; Improta-Brears et al, 1999; Kahlert et al, 2000; Marino et al, 2001, 2005, 2006b; Chambliss and Shaul, 2002; Dos Santos et al, 2002; Chambliss et al, 2005; Kim and Bender, 2005; Kupzig et al, 2005) points to ER" as the primary endogenous mediator of rapid E2-induced signalling, which contributes to the proliferative effects of the hormone. Data from cell culture, gene expression, and knockout mice indicate that E2-activated ER! can function as a dominant negative suppressor of the proliferative activity of ER" (Couse and Korach, 1999; Paruthiyil et al, 2004; Strom et al, 2004; Weihua et al, 152

Cancer Therapy Vol 6, page 153 2003). These studies support a functional antagonism between ER" and ER! with respect to the E2-induced cell proliferation, but do not clarify either the putative role of ER! in E2-induced apoptosis or the signal transduction pathways involved. The ability of the ER!-E2 complex to activate rapid non-genomic mechanisms has been reported, however these data are limited and conflicting. A sub-population of ER! transfected into Chinese Hamster ovary cells is capable of stimulating IP3 production, ERK/MAPK activation, and c-JNK phosphorylation (Razandi et al, 1999). Geraldes and coworkers reported that E2 reduces ERK activity through ER! stimulation in porcine smooth muscle cells (Geraldes et al, 2003). In ER!-transfected HeLa cell, we have recently reported ER! rapidly induces a persistent membrane-initiated activation of p38/MAPK which in turn is involved in caspase-3 activation and cleavage of poly(ADP-ribose) polymerase (PARP), driving cells to the apoptosis.

Consequently, besides its role as a negative modulator of ER" activities, our findings indicate that ER! directs the anti-proliferative effects of E2 sustaining the tumor suppressor functions of ER! (Acconcia et al, 2005).

Several labs have shown that kinase signaling cascades promote gene expression through the phosphorylation of coactivators. In particular, p38/MAPK phosphorylates and potentiates the SRC-2 coactivator (Frigo et al, 2006). How this result impacts on E2-induced protective effects on colon cancer growth is still unknown.

However, these data support the idea that E2-induced rapid signals synergize with genomic events to maintain the pleiotropic hormone effects.

expression of the differentiation markers (Wada-Hiraike et al, 2006b). As a whole, the loss of ER! leads to hyperproliferation, loss of differentiation, and decreased apoptosis in the cells of the colonic epithelium suggesting a pivotal role for ER! in the organization and architectural maintenance of the epithelial barrier (Wada-Hiraike et al, 2006a).

V. ER! and colon cancer Epidemiological studies have ascertained that colorectal cancer (CRC) is the second to fourth most common fatal malignancy in industrialized countries (Potter, 1999; Slattery et al, 2001). The prognosis for patients with this disease is heavily dependent on the stage of the malignancy and on time of diagnosis and almost all patients will require surgical intervention. Therefore early diagnosis and prevention is extremely important. CRC is thought to develop as a consequence of aberrant crypt proliferation or progression of benign hyperplasia to benign adenoma and then in most cases to adenocarcinoma (Vogelstein et al, 1988; Wada-Hiraike et al, 2006). CRC is a common malignancy in both sexes (DeCosse et al, 1993). However, several sex-related differences in incidence, molecular characteristics and response to chemotherapy have been reported. It has therefore been suggested that exposure to E2 and/or estrogenic compounds may underlie these differences.

CRC is more common in men than women, the difference being more striking amongst premenopausal women and age-matched men (DeCosse et al, 1993; Wong et al, 2005). In the early 1970s, a transient decrease in colon cancer incidence occurred among women aged 35-44 years old, but not among men (McMichael and Potter, 1980). This observation correlated with a peak in fertility and the use of high dose oral contraceptives during the preceding decade. The authors concluded that either high fertility or exposure to exogenous steroid hormones protected women from colon cancer. Based on metaanalysis of 18 epidemiological studies, the use of hormone replacement therapy by postmenopausal women was associated with a 20% decrease in colon cancer risk (Bhat et al, 2003; Guo et al, 2004). Other studies also demonstrated that women with a history of current or past hormone replacement therapy had a significantly decreased risk of colon cancer and showed that there are gender differences regarding cancer location and type within the colorectum (Cho et al, 2007).

These findings have led many investigators to search for the ER isoform involved in E2 protection against colorectal cancer. Since ER" is reported to be minimally expressed in normal colon mucosa and colon cancer cells (Campbell-Thompson et al, 2001; Waliszewski et al, 1997), the effects of E2 on colon cancer susceptibility could be mediated by ER! (Bardin et al, 2004a). ER!1, ER!2 and ER!5 have been demonstrated in normal colorectal mucosa and at much higher levels than ER" (Foley et al, 2000; Campbell-Thompson et al, 2001). As described above, only the full-length ER! protein, equivalent to the ER!1 isoform, can activate ERE in reporter assays (Peng et al, 2003; Wong et al, 2005). On the other hand, the presence of different ER!-isoforms

IV. ER! and colon differentiation Although, mouse physiology is clearly different from human, knockout experiments targeting ER! genes in mice have been useful in understanding the role played by ER" and ER! in human physiology. These are valuable experimental models which provide a basic insight into the normal functions of genes during development and maturity. Indeed, targeted disruption of ER! in mice (Kuiper et al, 1996) has revealed roles for ER! in many tissues and organs, including the ovary, uterus, mammary gland, ventral prostate, salivary gland, immune system, and the central nervous system (Nilsson et al, 2001; Forster et al, 2002; Rossouw et al, 2002; Shim et al, 2003; Imanov et al, 2004). In particular, several studies have revealed that ER! is the predominant ER expressed in colonic tissues (Campbell-Thompson et al, 2001; Konstantinopoulos et al, 2003), its expression being selectively lost in human malignant colon tissue (Foley et al, 2000; Issa et al, 1994; Wada-Hiraike et al, 2006a).

In a recent study, to better understand the physiological role of ER! in colonic tissue, Wada-Hiraike and coworkers compared in 2006 morphology, proliferation, and differentiation of colonic epithelium in ER!-/- mice and wild-type (WT) littermates. BrdUrd labeling revealed that the number of proliferating cells was higher in ER!-/- mice than in WT and that the migration of labeled cells toward the luminal surface was faster in ER!/mice than in WT littermates. Additionally, in the absence of ER!, there was a decrease in apoptosis and in the 153

Marino and Galluzzo: ER! and colon cancer (Galluzzo et al, 2007). Upon E2 stimulation, ER" undergoes de-palmitoylation that is paralleled by an increased association of the receptor with caveolin-1 and to p38. The physical association ER"-caveolin-1 and p38 increases the abundance of ER" at the plasma membrane, impairing its association to other signaling proteins which characterize E2-induced ER!-mediated cell survival and proliferation (e.g., Src, ERK/MAPK and PI3K/AKT) (Galluzzo et al, 2007). On the other hand, the E2-induced ER" association with p38 impacts greatly on DLD-1 colon cancer cells. Since p38 activation is required for the establishment of a downstream pro-apoptotic cascade involving caspase-3 and PARP cleavage. E2-induced p38/MAPK is also fundamental both for the rapid increase of ER" mRNA translation and for the slow ER" gene transcription (Caiazza et al, 2007). The mRNAs encoding hormone receptors are commonly regulated by their own hormones to create auto-regulatory feedback loops.

Moreover, different hormones, including steroid hormones, regulate concentrations of various gene products primarily by altering mRNA translation and stability (Ing, 2005). The final consequence is an increased level of ER" in DLD-1 cells which, in the presence of E2, will further increase the hormone protective effect against tumor growth (Figure 4).

The signalling cascade initiated through ER! at the plasma membrane seems to be mainly involved in the protective effects of E2 against colon cancer. In fact, the treatment of these cells with the palmitoylation inhibitor 2Bromopalmitate (2Br) completely removed ER! from the plasma membrane impairing p38 activation. This condition prevents the activation of the pro-apoptotic cascade without interfering with ER! transcriptional activity, which is still able to promote ERE-dependent gene transcription.

Experimental studies with nitric oxide (NO) support the hypothesis that E2-induced rapid signaling through ER! is involved in the protective effects of E2 in colon cancer. NO is a diatomic molecule whose presence, induced by several hormones, E2 included, is important for gastrointestinal motility. NO mainly acts through Snitrosylation of Cys residues in target proteins modulating their activity (Beckman and Koppenol, 1996; Jaffrey et al, 2001; Stamler et al, 2001; Nathan, 2004; Marino et al, 2006a). Modulation of ER activity by NO has been demonstrated. NO is able to link to ERâ&#x20AC;&#x2122;s zinc finger impairing the transcriptional activity of the receptors without interfering with rapid signal pathways. Snitrosylation seems to selectively modulate the biological activity of ERs, shifting the receptor from its role as a transcription factor toward rapid functions. For instance, in DLD-1 colon cancer cells, in the occurrence of NO concentration in micromolar range, normally present during peristalsis, transcriptional activity of ER! is inhibited, but ER! maintains its capability to mediate the pro-apoptotic effects of E2 inducing caspase-3 activation and PARP cleavage. When over produced (e.g., during inflammatory processes) NO worsens the effects.

Although the ER!-dependent phosphorylation of p38/MAPK is still present, NO inhibits the caspase-3

could differentially modulate E2 action as previous reported (see section II.B. ER! genomic mechanism).

Using semi-quantitative RT-PCR, Campbell-Thompson and colleagues showed 2001 that ER! is the predominant ER subtype in the human colon, and that decreased ER!1 (ER!wt) and ER!2 (ER!cx) mRNA levels are associated with colonic tumorigenesis in women. In accordance, Foley and co-workers in 2000 and Konstantinopoulos and co-workers in 2003 showed that ER! expression was significantly lower in colon cancer cells than in normal colonic epithelium, and that there was a progressive decline in ER! expression, which paralleled the loss of malignant colon cell de-differentiation. A mouse model bearing germ line mutations in the Apc (adenomatosis polyposis coli) gene developed multiple intestinal tumors.

In this model, the prevention of Apc-associated tumor formation by estrogen correlated with an increase in ER! expression and a decrease in ER" expression (Weyant et al, 2001; Bardin et al, 2004a). In addition to these experimental models, isolated colon cancer cells have also been found to express primarily ER! (Fiorelli et al, 1999; Qiu et al, 2002), where E2 stimulation (10-1000 nmol/L) consistently induced apoptosis in a dose-dependent manner (Qiu et al, 2002; Guo et al, 2004; Acconcia et al, 2005; Caiazza et al, 2007; Galluzzo et al, 2007).

Altogether, these results strongly suggest that the ER":ER! ratio is a possible determinant of the susceptibility of colon to E2-induced carcinogenesis, sustaining the theory that binding of E2 to ER" induces a cancer promoting response, whereas binding to ER! exert a protective action (Weyant et al, 2001).

A. ER! mechanism of action in colon cancer The first mechanism for the anti-proliferative action of ER! was proposed by Paruthiyil and co-workers in 2004 and Strom and co-workers in 2004. They showed that introducing ER! into breast cancer cell lines (MCF-7 and T47D), which also expresses ER", caused an inhibition of proliferation in vitro and prevented tumor formation in a mouse xenograft model in response to E2.

ER! inhibited proliferation by repressing components of the cell cycle which are associated with proliferation, such as c-myc, cyclin D1, and cyclin A gene transcription, and by increasing the expression of Cdk inhibitor p21Cip1 and p27Kip1, which leads to a G2 cell cycle arrest. These findings suggested a possible role for ER! as tumor suppressor in breast cancer, impairing ER"-mediated proliferative effects of E2 (Paruthiyil et al, 2004; Strom et al, 2004). But in colonic mucosa and colon cancer cells only ER! is expressed (Campbell-Thompson et al, 2001; Waliszewski et al, 1997), so the protective effects of estrogen on this tissue should be mediated by specific ER!-activated signal transduction pathways.

To test this hypothesis, we used DLD-1 colon cancer cells in which only the ER"1 isoform is present. In these cells ER" undergoes palmitoyl acyl transferase (PAT)dependent S-palmitoylation which allows to a small ER" pool to localize at the plasma membrane and associate with caveolin-1 and the p38 member of MAPK family 154

Cancer Therapy Vol 6, page 155 catalytic activity by nitrosylation of the enzymeâ&#x20AC;&#x2122;s cysteine residues (Marino et al, 2006a).

In addition to its role as negative modulator of ER" activity as elsewhere reported these novel findings indicate that ER! is able to mediate specific rapid signaling cascades mainly involved in the protective effect of E2 in colon cancer.

peripheral (Bennet et al, 2003) nervous systems, and the immune system (Shim et al, 2003; Koehler et al, 2005).

In breast tissues, which express both ER" and ER!, several studies have indicated an increase in ER"/ER! mRNA and protein ratios in cancer as compared with benign tumors and normal tissues. In immunochemical analyses, Roger and colleagues found in a higher percentage of ER!-positive cells in normal mammary glands than carcinoma in situ. In contrast, an increase in ER" protein expression was noted during tumor progression. Moreover, ER! was inversely correlated with Ki67 expression, a cell proliferation marker. Zhao and colleagues also concluded in 2003 that decreased ER! mRNA expression could be associated with breast tumorigenesis and that DNA methylation is an important mechanism for ER! gene silencing in breast cancer.

VI. ER! and other cancers In addition to its presence in colonic tissue, ER! is expressed at high levels in other E2-target tissues, such as prostate (Weihua et al, 2001), salivary glands (Valimaa et al, 2004), testis (Makinen et al, 2001), ovary (Cheng et al, 2002), vascular endothelium (Lindner et al, 1998), smooth muscle (Barchiesi et al, 2004), certain neurons in the central (Shughrue et al, 2000; Mitra et al, 2003) and

Figure 4: Model representing the various modes through which estrogen receptors (ER) can modulate cell functions. Under steady state condition ER! is palmitoylated (black triangle) and localized at the plasma membrane associated to caveolin-1 (cav1) and p38. Upon E2 stimulation ER! undergoes de-palmitoylation, this increases ER! association to cav1, p38, and membrane. This association impairs the ER! re-allocation at the plasma membrane and its association with other signaling proteins. However, ER! association to p38 increases the kinase activity triggering cell functions. ERK, extracellular regulated kinase; MNAR, modulator of nongenomic activity of ER. For details, see text.

155

Marino and Galluzzo: ER! and colon cancer In 1998 Pujol and coworkers reported an increase in the ER"/ER! mRNA ratio in ovarian carcinomas as compared with normal ovaries and cysts, suggesting that the overexpression of ER" mRNA with respect to ER! mRNA could be considered a marker of ovarian carcinogenesis.

Thus the balance between ER" and ER! expression levels seem to be essential for maintaining normal growth function. As the ER! level decreases, this results in the uncontrolled cellular proliferation that leads to a metastatic state (Rutherford et al, 2000). Thus, decreasing levels of ER! expression seem to be a common denominator between breast and ovarian carcinogenesis.

The change in the ER"/ER! ratio in prostate cancer seems to be correlated with malignancy, where ER! mRNA level was decreased in most of the tumor samples as compared with normal prostate (Latil et al, 2001), suggesting that ER" and ER! expression status could be used to identify advanced prostate tumor patients.

Most studies have shown decreased ER! expression in cancer as compared with benign tumors or normal tissues, whereas ER" expression persists. The loss of ER! expression in cancer cells could reflect tumor cell dedifferentiation but may also represent a critical stage in E2-dependent tumor progression. Consequently, the modulation of the expression of target genes by ER" or ER! sustains that ER! has a differential effect on proliferation as compared with ER". ER! exerts a protective effect and thus constitutes a new target for hormone therapy, based on ligand specific activation (Bardin et al, 2004a,b).

membrane-initiated signaling pathways. Different splicing variants of the ER isoforms may also be important in modulating the cellular response (Leung et al, 2006).

Since ER! is the dominant ER isoform in normal colonic mucosa, ER! could represent a target in preventing the malignant transformation of colonic epithelial cells. Results obtained from cellular or animal models, in which ER! was exogenously expressed, show that this receptor is definitely an interesting target for cancer therapy. Strategies that are able to restore or to increase ER! expression or activity, in addition to the selective ER! agonists under development, could definitely be of great interest (Lazennec, 2006). For instance, Schering AG (Berlin, Germany) described two ER isoform selective ligands, which are modified estradiol derivatives (i.e. estradiol 16"-lactone and 8!-vinyl estradiol, for ER" and ER! respectively) (Hillisch et al, 2004). A number of additional subtype-selective ligands have also been described (Koelher et al, 2005): the ER!selective agonists diarylpropionitrile (DPN) (Meyers et al, 2001); indole (Kato et al, 2003), benzoxazole (Barlaam et al, 2002), indenoquinoline (Veeneman et al, 2001), cyclopentachromene (Dodge et al, 2003), cyclopentaindene (Parker et al, 2004), and WAY-358 and ERB-041 (Malamas et al, 2004; Manas et al, 2004).

At present, extremely encouraging data for ER!specific agonist action have been reported, for instance in treatment of rodent models of rheumatoid arthritis and endometriosis or atherosclerosis, hypertension, cardiac dysfunction or stroke, and inflammatory bowel disease (IBD). In particular, Harris and co-workers (Harris et al, 2003) have developed and characterized the biological profile of a highly selective ER! agonist, ERB-041. This compound is inactive on traditional target tissues such as the uterus and mammary gland and does not affect bone wasting, inhibit ovulation, or prevent ovariectomy-induced weight gain in clinically predictive rat models. In addition, ERB-041 is not uterotrophic and mammotrophic.

However, ERB-041 has a dramatic beneficial effect in the HLA-B27 transgenic rat model of inflammatory bowel disease and the Lewis rat adjuvant-induced arthritis model.

Daily oral doses as low as 1 mg/kg reverse the chronic diarrhea of HLA-B27 transgenic rats and dramatically improve histological disease scores in the colon. Thus, other ER!-selective ligands may be therapeutically effective in the treatment of inflammatory bowel disease and/or arthritis (Gustafsson, 2006). The future will be extremely exciting, when results from clinical trials testing the clinical utility of ER! targeted drugs begin to follow.

Finally, diet, lifestyle, and other non-genetic factors, such as gut flora, are thought to have a strong impact on CRC risk (Wada-Hiraike et al, 2006a). Diet is known to influence the development of CRC, with high consumption of fruits and vegetables conferring a protective effect. These food categories contain a variety of phytoestrogens capable of modulating ER" and ER! activity (Weyant et al, 2001). Phytoestrogens are believed to play a role as oncoprotective agents and to lower the risk of CRC in rodent models and it has been reported that lignans, plant precursors of the phytoestrogens enterolactone and enterodiol, or lignan-rich food can

VII. Conclusions Epidemiological, clinical, and experimental evidence reported in this review shows that E2 confers protection against colon cell proliferation and malignant transformation, reducing the incidence of colon adenoma and carcinoma by about 20% (Guo et al, 2004). The molecular mechanisms underlying these effects are starting to be clarified. Among others (e.g. epigenetic mechanisms) (Qiu et al, 2002), the specific tissue distribution and the intracellular-generated signals of ERs have opened new avenues for understanding the protective effects of E2 (Acconcia et al. 2005; Weihua et al, 2003; Marino et al, 2006a; Caiazza et al, 2007; Galluzzo et al, 2007). ER! expression in this tissue, especially in the basal region of the colonic crypts, suggests that it has an important role in the growth and regeneration of normal colonic mucosa (Xie et al, 2004). Therefore, an important variable which regulates E2 action on colon tissue is expression and function of ERs (Fiorelli et al, 1999).

Numerous clinical and in vitro studies suggest that imbalanced ER"/ER! expression and selective loss of ER! protein is a common feature and could be a critical step in estrogen-dependent tumor progression. ER! seems to play a key role in the mitogenic action of estrogens by providing protection against ER"-induced hyperproliferation and the stimulation of apoptosis. A number of molecular mechanisms could explain the differential roles of ER" and ER!, including differences in ligand affinity and transactivation, distinct cofactor interactions and putative hetero-dimerization, and the activation of distinct 156

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Cancer Therapy Vol 6, page 149 Cancer Therapy Vol 6, 149-162, 2008

Estrogen receptor ! mediates the protective effects of estrogen in colon cancer Review Article

Maria Marino*, Paola Galluzzo Department of Biology, University Roma Tre, Viale G. Marconi 446, I-00146 Roma, Italy.

__________________________________________________________________________________ *Correspondence: Maria Marino, Department of Biology, University Roma Tre, Viale G. Marconi, 446, I-00146 Roma, Italy; Fax: +39-06-55176321; E-mail: m.marino@uniroma3.it Key words: 17!-Estradiol, Estrogen receptor !, Estrogen receptor palmitoylation, Colon cancer cell, Apoptosis, Membrane association of estrogen receptors, Estrogen receptor signal transduction Abbreviations: 2-Bromopalmitate, (2Br); activating factor-1, (AP-1); colorectal cancer, (CRC); cyclic AMP, (cAMP); diarylpropionitrile, (DPN); DNA binding domain, (DBD); estrogen receptor, (ER); estrogen response element, (ERE); inflammatory bowel disease, (IBD); ligand binding domain, (LBD); mitogen activated protein kinase, (MAPK); nitric oxide, (NO); palmitoyl acyl transferase, (PAT); phosphatidyl inositol 3 kinase, (PI3K), phospholipase C, (PLC); poly(ADP-ribose) polymerase, (PARP); protein kinase C, (PKCs); stimulating factor-1 (Sp-1); wild-type, (WT) Received: 4 January 2008; Revised: 22 February 2008 Accepted: 26 February 2008; electronically published: March 2008

Summary Epidemiological studies indicate that colorectal cancer is more common in men than in women, the difference being more striking amongst pre-menopausal women and age-matched men. These differences suggest that the sex steroid hormone estrogens could elicit protective effects against this disease. Estrogen receptors (ER" and ER!) are differently expressed in colon. In particular, ER" is minimally expressed in normal colon mucosa and colon cancer cells, whereas ER! is the predominant subtype expressed in human colon. Thus, the protective effects of estrogen on colon cancer should be mediated by specific signal transduction pathways activated by ER!. ER! is significantly decreased in colonic tumors compared with normal mucosa. The loss of ER! leads to hyperproliferation, loss of differentiation, and decreased apoptosis in the epithelium of the colon, suggesting a pivotal role for ER! in the organization and architectural maintenance of the colon, and its potential role in the regulation of colon tumor growth. The mechanisms underlying estrogen effects against colon cancer are starting to be elucidated. Here, the epidemiological and experimental evidence as well as the molecular mechanisms sustaining the ER! role as a tumor-suppressor in colon cancer will be reviewed.

hypothesized to reflect full length ER! (Enmark et al, 1997). The following year, Ogawa and co-workers reported the cloning of an additional ER!, consisting of 530 amino acids, which is now considered to represent the full length ER! (Ogawa et al, 1998a). A few months later, Moore and co-workers also identified the same 530 amino acid sequence as the full length ER!, as well as various other isoforms (Moore et al, 1998). It would not be an overstatement to say that this discovery electrified the field of estrogen biology, causing a re-examination of all our understanding and assumptions about the mechanism of estrogen action. Early studies, naturally, focused on cloning ER! from additional species (Mosselman et al, 1996; Tremblay et al, 1997), describing ER! ligand specificity (Kuiper et al, 1997; Kuiper et al, 1998b; Harris et al, 2002) and tissue distribution (Couse et al, 1997;

I. Introduction Estrogens, in particular 17!-estradiol (E2) the most potent and dominant estrogen in humans, elicit a myriad of biological responses directed towards profoundly changing female physiology. Since the early 1960s it has been accepted that these actions are receptor mediated.

When an estrogen receptor (ER) was cloned in 1986 (Green et al, 1986a,b) and its ablation in mice had the typical E2-deficiency phenotype in many organs (Lubahn et al, 1993), it seemed a plausible conclusion that only one ER existed. It was, thus, an enormous surprise when the second ER, ER!, was cloned from a prostate cDNA library (Kuiper et al, 1996). At first, a human ER! with 477 amino acids was reported (Mosselman et al, 1996). A few months later, Enmark and co-workers reported the identification of an ER! with 485 amino acids, and it was

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Marino and Galluzzo: ER! and colon cancer Shughrue et al, 1997; Kuiper et al, 1998a; Shughure et al, 1998; Harris, 2007). Presently, the research is focused on the comprehension of the role played by the receptor isoform in the E2 effects (Imanov et al, 2005; Koehler et al, 2005; Harris, 2007).

Indeed, the discovery of ER! changed the concept of estrogen signaling, opening a new chapter in E2 effects and in the design of estrogenic pharmaceuticals. This widened the role of E2 in human physiology (Ascenzi et al, 2006; Deroo and Korach, 2006; Hewitt et al, 2000), which at the present is not only limited to reproductive female functions, but has been also found in the modulation of the growth of different tissues, bone integrity, cardiovascular apparatus, immune system, and nervous system physiology as well as in the regulation of male physiology (Ascenzi et al, 2006). Given this widespread role of E2 in human physiology, it is not surprising that estrogens are also implicated in the development or progression of diseases, which include various types of cancer (breast, ovarian, and endometrial), osteoporosis, neurodegenerative and cardiovascular diseases, insulin resistance, lupus erythematosus, endometriosis, and obesity (Ascenzi et al, 2006; Deroo and Korach, 2006). However, recent epidemiological, clinical, and experimental evidence shows that E2 also confers protection against cell proliferation and malignant transformation (e.g., prostate and colon cancer) (Horvath et al, 2001; Konstantinopoulos et al, 2003; Bardin et al, 2004a; Acconcia et al, 2005; Koehler et al, 2005; Caiazza et al, 2007; Galluzzo et al, 2007). The role of each ER isoform and the E2-dependent signal transduction mechanisms have recently started to be clarified. ER" seems to mediate proliferative effects of E2 (Castoria et al, 1999, 2001; Lobenhofer et al, 2000; Marino et al, 2002; Fernando and Wimalasena, 2004); on the contrary, recent evidence (Acconcia et al, 2005; Marino et al, 2006a; Caiazza et al, 2007; Galluzzo et al, 2007) indicates that ER! directs the anti-proliferative effects of E2. This hypothesis needs to be confirmed, but could make sense in view of the location of ER! on chromosome 14q (Enmark et al, 1997). A loss of 14q has been detected by comparative genomic hybridization in some breast cancers (Burki et al, 2000; Loveday et al, 2000). Interestingly, in

ovarian cancer, two potential tumor-suppressor gene loci have been mapped to 14q (Bandera et al, 1997). 14q deletions are also observed in colon carcinoma (Young et al, 1993) and prostate cancer (Kasahara et al, 2002). These overall findings suggest a potential tumor-suppressive function for ER!.

In this review the epidemiological and experimental evidence as well as the molecular mechanism(s) supporting the role of ER! as a tumor-suppressor will be discussed with particular attention to colon cancer.

II. ER! structure Human ER!, like ER", is a modular protein sharing common regions, named A/B, C, D, E/F, with all the members of the nuclear receptor super-family. These regions participate in the formation of structurally independent but functionally interacting domains: the Nterminal transactivation domain, the DNA binding domain (DBD), the dimerization domain(s), the nuclear localization sequence, and the ligand binding domain (LBD) (Figure 1) (Ribeiro et al, 1995; Mosselman et al, 1996; Kumar and Thompson, 1999; Nillson et al, 2001; Claessens and Gewirth, 2004; Kumar et al, 2004; Ascenzi et al, 2006).

The N-terminal domain (A/B region) is involved in both inter-molecular and intra-molecular interactions as well as in the activation of gene transcription. The DBD (C region) allows ERs to dimerize and to bind to the specific estrogen responsive element (ERE) sequence on DNA through its two â&#x20AC;&#x153;zinc fingerâ&#x20AC;? structures. The hinge domain (D region) has a role in receptor dimerization and in binding to chaperone heat-shock proteins (Hsp). The LBD (E/F region, C-terminal) comprises the E2-binding domain and acts, synergistically with the N-terminal domain in the regulation of gene transcription (Mosselman et al, 1996; Nilsson et al, 2001; Claessens and Gewirth, 2004; Kumar et al, 2004). The two regions present in ERs that contribute to transcriptional activity are called activation functions (AFs). AF-1 is located in the Nterminal region and could be activated even in a ligandindependent manner depending on the phosphorylation

Figure 1. A schematic structural comparison of human ER" and ER! functional domains. Receptor domains are illustrated with different colored boxes, and the approximate size of each domain is indicated. The A/B domain contains the ligand-independent transcriptional-activation function AF-1, the C domain represents the DNA-binding-domain (DBD), the D domain corresponds to the hinge region, and the E domain contains the hormone-binding domain (LBD) and the hormone-dependent transcriptional-activation function AF-2. The number inside each box of ER! refers to the percentage of amino acid identity. For details, see text.

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Prediction of very short survival in patients with brain metastases from non-small cell lung cancer Research Article

Carsten Nieder1,2,*, Reinhard Thamm3, Sabrina T. Astner3, Michael Molls3 1

Radiation Oncology Unit, Nordlandssykehuset HF, 8092 Bodø, Norway Institute of Clinical Medicine, Faculty of Medicine, University of Tromsø, Tromsø, Norway 3 Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675 Munich, Germany 2

__________________________________________________________________________________ *Correspondence: Carsten Nieder, M.D. Ph.D., Radiation Oncology Unit, Medical Department – Oncology, Nordlandssykehuset HF, 8092 Bodø, Norway; Tel: +47 755 78449; Fax: +47 755 34975; e-mail carsten.nieder@nlsh.no Key words: radiotherapy, brain metastases, lung cancer, whole brain radiotherapy, prognosis Abbreviations: non-small cell lung cancer, (NSCLC); recursive partitioning analysis, (RPA); whole brain radiotherapy, (WBRT) Received: 17 January 2008; Revised: 22 February 2008 Accepted: 28 February 2008; electronically published: March 2008

Summary Current prognostic models are not accurate enough to identify brain metastases patients with non-small cell lung cancer who have very short survival, i.e. <2 months, and therefore are unlikely to derive major benefit from the addition of whole brain radiotherapy (WBRT) to steroid treatment and general supportive measures. Our aim was to develop a more reliable model. A retrospective analysis of patients with squamous cell or adenocarcinoma histology treated with immediate WBRT to 30 Gy was performed. The patients were randomly divided into two groups, i.e. a test and a validation group. The groups included 37 patients each. After analysis of factors predictive for short survival, a risk score based on 5 statistically significant parameters was developed (age, gender, primary tumor histology, extracranial metastases and number of brain metastases). The score performed well with regard to prediction of survival >2 months, but remained unsatisfactory (low positive predictive value) with regard to prediction of survival <2 months even after various optimisation attempts. In conclusion, the prognostic factors for overall survival that form the basis for the recursive partitioning analysis (RPA) classes (age, extracranial metastases, primary tumor control, performance status) do not predict for very short survival. However, we were not able to develop another model that performed accurate enough for clinical decision making.

brain metastases (Gaspar et al, 1997; Nieder et al, 2000; Kepka et al, 2005), including those with primary NSCLC (Rodrigus et al, 2000; Gülbas et al, 2006). However, survival in the most unfavourable class III (defined by Karnofsky performance status, KPS, <70%) is quite variable, with 40-50% of patients dying within 2 months, but 15-20% surviving for more than 6 months (Gaspar et al, 1997; Nieder et al, 2000). Therefore, we aimed at developing a model that is based on readily available clinical parameters and predicts a survival time <2 months in patients with brain metastases from NSCLC better than RPA class and other previous scores.

I. Introduction Whole brain radiotherapy (WBRT) continues to represent an important palliative treatment option for patients with brain metastases from non-small cell lung cancer (NSCLC). The fact that a certain percentage of these patients have very short survival times after WBRT suggests that accurate survival prediction models might help to avoid overtreatment (Lock et al, 2004). Even in brain metastases trials with restrictive inclusion criteria, more than 10% of the patients died within 8 weeks (Mehta et al, 2003; Andrews et al, 2004). It has been reported that survival after corticosteroids alone is in the order of 6-8 weeks (overview in (Khuntia et al, 2006)). In groups with such short survival time, the role of added WBRT is questionable. Prognostic scores such as the recursive partitioning analysis (RPA) classes can support decision making and treatment recommendations in patients with

II. Materials and methods We used a database at the Klinikum rechts der Isar, Munich, Germany, which includes patients with brain metastases treated with 10x3 Gy WBRT and identified all patients with

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Then, we randomly generated two equally-sized groups (37 patients each) for development and validation of a prognostic score. Patient assignment to these groups was based on year of treatment, where the patients treated in the last year were assigned to the first group, the patients treated in the year before to the second group, and so on in the same alternating fashion (in order to avoid a major bias in treatment period). All patients had received immediate WBRT plus steroids after the diagnosis of brain metastases. No other simultaneous treatments or surgical resection were provided. Treatment decisions were made by a multidisciplinary tumor board. Patients with limited brain disease and favourable prognostic factors were treated during the same time period with either surgery or radiosurgery, but were excluded from this analysis to avoid treatment bias.

Chemotherapy after WBRT was given as indicated for extracranial disease. Prognostic factors for overall survival and factors predicting a survival <2 months (60 days) were evaluated by univariate tests in the test group. RPA class, initial KPS, age, presence of extracranial metastases, status of the primary tumor, number of brain metastases, histology, interval from first NSCLC diagnosis to development of brain metastases, gender and dexamethasone dose at the start of WBRT were evaluated. These factors were recorded in all patients. Information on T- and Nstage, tumor grade, tumor markers or other haematology or blood chemistry values was not available. Survival was calculated from the first day of WBRT. Typically, WBRT started within 2 weeks from diagnosis. None of the patients were initially treated with chemotherapy for their brain metastases. We used the KaplanMeier method to generate actuarial survival curves. These were compared with the log rank test to obtain univariate prognostic factors (all performed with the SPSS software). A p-value <0.05 was considered statistically significant. A multivariate analysis of prognostic factors was not performed, as the test group included only 37 patients.

metastases, controlled primary tumor, age less than 65 years) that survived for less than 2 months. In addition, 35% of the patients in class III survived for 3-6 months.

Thus, the authors attempted to develop a score based on the 5 significant predictive factors identified in this group.

We assigned one point each for male gender, adenocarcinoma, multiple brain metastases, presence of extracranial metastases and age >65 years. When applying this score to the test group, 8 patients were assigned 1 point, 13 patients 2 points, 7 patients 3 points, 6 patients 4 points and 3 patients 5 points. Out of 30 patients with survival >2 months, 29 had 4 or less points while one had 5 points. Out of 7 patients with survival <2 months, 2 had 5 points while 5 had 2-3 points. It was not possible to modify the score in a way that would improve its performance. No single parameter or combination of parameters allowed for reliable prediction of survival <2 months.

When looking at the validation group of 37 patients, 9 survived for less than 2 months. These 9 patients scored 1-4 points. Out of 28 patients with survival >2 months, 27 had 4 or less points while one had 5 points. These results confirmed the high specificity (96%) and negative predictive value (75%), however the positive predictive value of 5 score points was 0%.

Looking at all 74 patients, there was no pattern identifying the 16 patients that died within 2 months reliably. Whatever prediction model one attempts to use, the risk of withholding WBRT because of suspected poor survival remains higher than 20%. In the present data set, survival <2 months was not observed in patients with initial KPS 90-100%.

III. Results

IV. Discussion

Table 1 shows the patients’ characteristics for the test group. Statistically significant univariate prognostic factors for overall survival included lower RPA class, younger age, higher KPS, absence of extracranial metastases, controlled primary tumor and solitary brain metastasis. However, other factors were important with regard to prediction of survival <2 months, e.g., gender and histology (Table 1). RPA class did not predict survival <2 months reliably. There were, e.g., 2 patients with RPA class I (KPS at least 70%, no extracranial

Outside of prospective clinical trials that include selected patients only, a considerable number of patients with brain metastases from NSCLC die within 2 months, e.g., 22% in this series. The authors tried to develop and validate a clinical risk score that could help to avoid overtreatment in such patients, if one assumes that patients dying within 8 weeks can be managed adequately by best supportive care focused on corticosteroid treatment.

Table 1. Patients’ characteristics in the test group, n=37.

Parameter Median age, range Median KPS, range¤ Median time interval*¤ Median dose**¤ % with controlled primary¤ % without extracranial metastases % with solitary brain met. % males % squamous cell cancer

Survival <2 months, n=7 64 yrs., 54-69 80%, 60-80 6 mo., 0-15 12 mg, 8-32 43 43 29 100 29

Survival >2 months, n=30 56 yrs., 44-77 80%, 60-100 7 mo., 0-35 12 mg, 0-32 31 60 46 81 53

KPS: Karnofsky performance status, ¤ not predictive for short survival, i.e. p>0.05, * from lung cancer diagnosis to brain metastases, ** dexamethasone per day at the start of radiotherapy

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metastases from non-small-cell lung cancer. Jpn J Clin Oncol 36, 193-196.

Jacot W, Quantin X, Boher JM, Andre F, Moreau L, Gainet M, Depierre A, Quoix E, Chevalier TL, Pujol JL; Association d'Enseignement et de Recherche des Internes en Oncologie (2001) Brain metastases at the time of presentation ogf nonsmall cell lung cancer: a multi-centric AERIO analysis of prognostic factors. Br J Cancer 84, 903-909.

Kepka L, Cieslak E, Bujko K, Fijuth J, Wierzchowski M (2005) Results of the whole-brain radiotherapy for patients with brain metastases from lung cancer: the RTOG RPA intraclasses analysis. Acta Oncol 44, 389-398.

Khuntia D, Brown P, Li J, Mehta MP (2006) Whole-brain radiotherapy in the management of brain metastasis. J Clin Oncol 24, 1295-1304.

Lock M, Chow E, Pond GR, Do V, Danjoux C, Dinniwell R, Lea J, Bezjak A (2004) Prognostic factors in brain metastases: can we determine patients who do not benefit from wholebrain radiotherapy? Clin Oncol (R Coll Radiol) 16, 332338.

Mehta MP, Rodrigus P, Terhaard CH, Rao A, Suh J, Roa W, Souhami L, Bezjak A, Leibenhaut M, Komaki R, Schultz C, Timmerman R, Curran W, Smith J, Phan SC, Miller RA, Renschler MF (2003) Survival and neurologic outcomes in a randomized trial of motexafin gadolinium and whole-brain radiation therapy in brain metastases. J Clin Oncol 21, 25292536.

Nieder C, Nestle U, Motaref B, Walter K, Niewald M, Schnabel K (2000) Prognostic factors in brain metastases: should patients be selected for aggressive treatment according to recursive partitioning analysis (RPA) classes? Int J Radiat Oncol Biol Phys 46, 297-302.

Rades D, Schild SE, Lohynska R, Veninga T, Stalpers LJ, Dunst J (2007) Two radiation regimens and prognostic factors for brain metastases in nonsmall cell lung cancer patients.

Cancer 110, 1077-1082.

Rodrigus P, de Brouwer P, Raaymakers E (2000) Brain metastases and non-small cell lung cancer. Prognostic factors and correlation with survival after irradiation. Lung Cancer 32, 129-136.

The analysis was limited to a narrowly defined group of patients, i.e. those with squamous cell or adenocarcinoma NSCLC, treated with a well defined WBRT regimen, to avoid confounding factors. It was first examined whether RPA class predicts for survival <2 months in the present patient cohort. As this was not the case, attempts to identify other factors were made. From 5 statistically significant parameters, a final score was developed. The majority of these 5 parameters were previously described by other groups, e.g., age and extracranial metastases (Rades et al, 2007) or male gender (Jacot et al, 2001).

However, previous analyses were not focussed on short survival. KPS showed a significant impact on overall survival in the present data set, but was not predictive for survival <2 months. This might be explained by the fact that none of our patients had KPS <60%. Usually, patients with very low KPS were not treated with WBRT at our institution. Among those with KPS 90 or 100, all survived for more than 2 months.

Eventually, despite of score optimisation attempts, an unacceptable number of patients were not correctly predicted. Lock and colleagues previously evaluated the same endpoint in a larger group of patients, but with different primary tumors (Lock et al, 2004). They found ECOG performance status and number of metastatic sites as important parameters. However, their model classified only 68% of patients correctly, while 55% would have been incorrectly predicted to die early. Thus, all attempts to predict survival <2 months have failed so far. One of the reasons might be that early death in patients with brain metastases might result from different events such as failure to control the intracranial disease, progressive extracranial disease, infectious complications, thromboembolic events etc. Different factors might predict the likelihood of these underlying causes of death, possibly including certain blood count and chemistry abnormalities that were not available for retrospective analysis (leukocyte count, haemoglobin, c-reactive protein etc.). Thus, continuous research is necessary to identify those patients that safely can be managed and palliated without WBRT.

References Andrews DW, Scott CB, Sperduto PW, Flanders AE, Gaspar LE, Schell MC, Werner-Wasik M, Demas W, Ryu J, Bahary JP, Souhami L, Rotman M, Mehta MP, Curran WJ Jr (2004) Whole brain radiation therapy with and without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomized trial. Lancet 363, 1665-1672.

Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, McKenna WG, Byhardt R (1997) Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials.

Int J Radiat Oncol Biol Phys 37, 745-751.

G端lbas H, Erkal HS, Serin M (2006) The use of recursive partitioning analysis grouping in patients with brain

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Veterinary radiation oncology: technology, imaging, intervention and future applications Review Article

Ira K. Gordon, Michael S. Kent* Department of Surgical and Radiological Sciences, UC Davis School of Veterinary Medicine, Davis, CA 95616

__________________________________________________________________________________ *Correspondence: Michael S. Kent, Assistant Professor, Department of Surgical and Radiological Sciences, 2112 Tupper Hall, 1 Shields Ave, Davis, CA 95616, USA; Tel: 530-752-1393; Fax: 530-752-9620; E-mail: mskent@ucdavis.edu Key words: Radiation therapy, Oncology, Cancer, Tumor, Veterinary Abbreviations: adaptive and image guided radiation therapy (IGRT); board cone beam computed tomography (CBCT); clinical tumor volume (CTV); computed tomography (CT); functional magnetic resonance imaging (fMRI); Gray (Gy); gross tumor volume (GTV); intensity modulated radiation therapy (IMRT); kilovoltage (kV); magnetic resonance imaging (MRI); magnetic resonance spectroscopic imaging (MRSI); multileaf collimators (MLC); planning target volume (PTV); single-positron emission computed tomography (SPECT); stereotactic radiosurgery (SRS); ultrasound (U/S) Received: 1 February 2008; electronically published: June 2008

Presented at the Theilen Tribute Symposium at UC Davis 31st May- 1st June 2008.

Summary Radiation therapy has become an important modality in treating the veterinary cancer patient. Recent advances in technology such as advanced imaging, electron therapy, custom blocking, computerized treatment planning and advanced treatment techniques such as 3D conformal therapy and intensity modulated radiotherapy have advanced the field. On the near horizon are particle therapy, stereotactic radiosurgery and functional imaging. All these advances allow better targeting and treatment of tumors with the possibility of decreased side effects. This paper reviews the current state of the art of veterinary radiation oncology and looks toward the near future to see where the specialty is going.

versus tumor tissues can be accentuated with dose fractionation.

Keeping these principles in mind, most of the recent advances made in radiation therapy have been to spare normal tissue by better targeting of the tumor with external beam radiotherapy techniques and equipment. This allows greater doses of radiation to be delivered to the tumor without increasing the side effects of irradiation. As these are technology driven, they can be expensive to implement but the benefits to the patient can be great.

I. Introduction In simplest terms, the primary goal of the oncologist is to kill cancer cells while sparing normal cells and tissues. In medical oncology, this is usually accomplished by the use of agents that are given systemically but have preferential toxicity to neoplastic cells. Only occasionally is chemotherapy given by a route that targets the desired site (intratumoral, intrathecal, intracavitary). In surgical oncology, the goal is to surgically remove the tumor with the dose of surgery limited by the resulting functional or cosmetic defects.

In contrast, the radiation oncologist primarily accomplishes this fundamental goal by maximizing radiation dose to a defined tumor target while minimizing the dose received by surrounding normal tissues. This can be accomplished through the use of various radiation techniques including brachytherapy, external beam radiotherapy, and systemic targeted radiotherapy. In addition, differences in radiation response of normal

II. History and progress in radiation therapy Radiation oncology is a medical science that has existed for just over 100 years. The discovery of X-ray photons is considered the birth of radiation oncology which occurred in Wilhelm Roentgenâ&#x20AC;&#x2122;s lab on November 8, 1895 (Smith et al, 2006). Within months, the first cancer patients were treated with radiotherapy. Shortly thereafter, radioactivity and radium were discovered by

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Gordon and Kent: Veterinary radiation oncology Henri Becquerel and Pierre and Marie Curie (Hall and Giaccia, 2006). By 1902, over 100 different conditions were listed that could be treated with X-rays.

Brachytherapy was first described and performed in 1904.

Many of the early radiation researchers suffered serious injuries or death due to a lack of understanding of radiation biology and dose measurement. The first major advance in radiation technology was the invention of the Coolidge tube in 1912-13 which delivered a more reliable beam in terms of beam energy and penetration and was the precursor to orthovoltage radiotherapy machines (Bernier et al, 2004). In the 1920s and 1930s, in addition to continued improvement of radiation delivery technology, the major advances were the development of dose measurement techniques, central axis treatment planning, and understanding of the benefits of dose fractionation.

In 1955, the first patient was treated using the first linear accelerator at Stanford (Hall and Giaccia, 2006).

Over the next 30-40 years, significant improvements were made to radiation therapy equipment with higher energy and multiple energy machines being developed. Machines were also made that produce other types of radiation including electrons, neutrons, and protons. Additionally, advances in computer technology allowed for faster and more complex treatment planning software. Despite these advances, the basic process of radiation planning and delivery remained relatively unchanged for most of the 20th century.

In the past 10-15 years, while equipment and technology have continued to improve, the most significant clinical improvements in radiation treatments have come from fundamental changes to the basic approach to radiation planning, setup, and treatment delivery. The development and advances of novel imaging techniques, intensity modulated radiation therapy (IMRT), adaptive and image guided radiation therapy (IGRT), and stereotactic radiosurgery (SRS) represent new frontiers for advancement toward the cure of diseases that were previously considered untreatable or uncurable.

deliver a variety of energies and many of the newer machines allow treatment with either photons or electrons (see below for a more detailed explanation). They also allow the use of smaller field sizes, allow for a more homogenous dose to be delivered to deep-seated tumors and can take advantage of newer treatment techniques.

The use of advanced treatment planning software allows dosimetric calculations and three-dimensional treatment planning to deliver accurate doses to deep-seated tumors.

Systemic radiotherapy using radionucleotides and brachytherapy are also used in treating veterinary patients but are not covered in this review.

IV. Electron therapy Linear accelerators deliver radiation through photons and in newer machines either photons or electrons.

Photons provide better deep penetration and often a more homogenous dose distribution in tissue than electrons but there are times that this might pose a problem (Figure 1).

If the tumor is located over critical normal structures that you do not want to irradiate such as the spinal cord, intestines or lungs, electrons may be more advantageous.

Electrons deliver their dose through a certain depth and then fall off very quickly. By setting the energy of the electrons you can control the depth of penetration. A rule of thumb is penetration in cm is about 1/2 of the energy of electron selected, while the useful beam penetrates to a maximum of about 1/3 of the energy of the electron you choose in cm. For example, treating with 6 MeV electrons corresponds to about 2 cm of tissue effectively treated and using 20 MeV electrons results in approximately 6 cm of tissue being effectively treated. Many of the tumors that we treat in veterinary medicine are located in the skin or subcutaneous tissues allowing electrons to be used effectively.

V. How radiation is dosed The SI unit of absorbed dose used in radiation oncology is the Gray (Gy). The older unit is the rad. 1 Gy is equal to 100 cGy or 100 rads. When considering the total dose to be given, several things need to be taken into account; Specifically: The radiosensitivity of the tumor, the dose delivered in each fraction, the time between fractions, the total number of fractions, the goal of therapy (palliative vs. definitive) and often most importantly, the tolerance of the surrounding normal tissues.

III. Machines used to deliver radiation therapy There are three different types of machines used to deliver external beam radiation therapy in veterinary radiation oncology (McEntee, 2004). Orthovoltage machines, cobalt-60 machines and linear accelerators are used for teletherapy. Orthovoltage machines are no longer widely used and have the disadvantages of increased skin reactions, no computerized treatment planning systems, high bone absorption of dose and the lack of isocentric machines. Cobalt-60 machines are still in use in veterinary medicine but also have some disadvantages compared to linear accelerators, which include increased penumbra at the field edge (leading to larger treatment fields), lower energy (leading to increased skin dosing), lower dose rate, and less penetration of dose.

Linear accelerators are becoming more widely available in veterinary radiation oncology and are the standard of care in treating humans. They are able to

VI. Target therapy

volumes

in radiation

It is useful to define several â&#x20AC;&#x153;tumor volumesâ&#x20AC;? when prescribing a radiation dose to a given area. The simplest target to define is the gross tumor volume (GTV). This volume incorporates all palpably or visually abnormal disease that is evident on physical examination or routine diagnostic imaging studies. In animals that present for radiotherapy after marginal surgical resection of the primary mass, there is no GTV.

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Figure 1. CT image of a dog’s thoracic cavity with an incompletely resected soft tissue sarcoma showing the dose distribution for electrons.

The clinical tumor volume (CTV) represents the gross tumor volume plus all regions that are suspected to contain microscopic disease. In some cases, this may be several centimeters around the gross disease in all directions. In other instances, it may represent the area defined by surgical hemoclips with a several centimeter additional margin. When a tumor is contained by a bony structure or is not felt to contain significant microscopic extension, the CTV may not be much larger than the GTV. A major challenge with delineating the CTV exists as it is unknown how far microscopic disease extends. This decision is therefore based on the biologic behavior of the tumor and the clinical situation of the particular patient and has the risk of missing disease. More commonly, a radiation oncologist will try to overestimate the extent of disease to prevent “geographic miss”. The consequence of these overestimates is increasing the volume of normal tissue that full dose is prescribed to. With advances in physiologic and functional imaging such as PET/CT and fMRI, one goal is to better define the CTV rather than simply adding a margin to the GTV. The planning target volume (PTV) is the CTV plus an additional margin to account for uncertainties associated with radiation delivery (Figure 2) (Purdy, 2004). The PTV is the volume that you ultimately plan to treat with your treatment setup or treatment planning system. The extent of this additional margin is completely

dependant upon your ability to minimize setup uncertainty and patient positioning relative to the radiation field and commonly range from at least 3-5 millimeters up to 1-2 centimeters. These uncertainties include tolerances for the radiation equipment as well as setup inaccuracies and both interfraction and intrafraction patient motion (Purdy, 2004). Each of the following parameters can introduce at least 1-2 mm of uncertainty about the precision of the radiation field relative to the patient although not all are relevant for every patient: 1) Collimator position – The size the collimator is set for versus the actual size of the radiation field 2) Collimator drift- Movement in the collimator during treatment or when the gantry is at different positions 3) Isocenter uncertainty- Movement of the isocenter when the gantry is at different positions 4) Light field uncertainty- Deviation between the radiation field and the light field displayed on the patient 5) Portal imaging uncertainty- The edges and field center as defined by portal image (whether film or digital) 6) Diagnostic imaging uncertainty- This can be from limitations of spatial accuracy with MRI or constraints based on the slice thickness of your diagnostic CT scan 7) Image registration uncertainty- If you merge 2 diagnostic studies such as an MRI and CT scan, there is uncertainty in the precision of that match.

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Figure 2. CT image of a cat with an injection site sarcoma showing the GTV (yellow line) CTV (red line) and the PTV (green shading).

8) Positioning and movement uncertainties before and during each treatment 9) Movement of fiducial markers or skin marks relative to the tumor target 10) Penumbra of field- The penumbra of the field is the region at the field edge where dose falloff occurs. This depends on the type and energy of radiation you are using and can be greater than 10 millimeters for Co-60 ! rays or for electron beams. Penumbras for linear accelerators are much smaller. If this is taken into account with your treatment planning system, it may not need to be considered twice by adding a margin into your PTV. However, if not or if you are planning a treatment by hand, the uncertainty of the penumbra region should be incorporated into the PTV. Once again, the tradeoff between a small and large PTV margin is the risk of geographic miss versus increased normal tissue radiation exposure. In stereotactic radiosurgery, which is discussed later, the use of external fiduciary markers with precise positioning devices and lasers minimize setup uncertainty while finely collimated cones reduce penumbra and collimator uncertainties so that a tight PTV can be drawn around the CTV to even further minimize dose to normal tissue.

can be used. Custom blocks can be made for shaping both electron and photon beams (Figure 3). Blocking can be used with both hand and computer plans. A custom electron block can be made in less than 10 minutes. When the patient has finished their treatment course, the block can then be melted and the alloy reused.

VIII. Patient reproducibility

positioning

for

It is essential not to decrease the PTV beyond patient positioning and movement limitations or the tumor may not receive the planned dose. Using a 3-D conformal or IMRT plan that targets the tumor precisely on a patient that cannot be accurately positioned will not deliver the desired dose and does not make sense. Fortunately, imaging techniques to check patient positioning have also improved which allows checking the accuracy of patient positioning on each treatment if needed.

A major question that must be answered is how precisely can a patient be setup each day. All of the precision and detail that goes into advanced treatment planning is useless if the patient is unable to be positioned precisely, reliably and reproducibly. The importance of this cannot be overstated, especially as technology allows for finer tumor targeting it can often be just millimeters separating a full dose from a region far below therapeutic doses.

Many devices have been developed to help with this over the last few years. These include vacuum bags, bite blocks, headframes, masks and calibrated treatment couches (Figure 4) (Kippenes et al, 2000; Lester et al, 2001; Green et al, 2003). Port films, which are radiographs taken using the treatment machine to check patient positioning are key in determining the accuracy of positioning (Rohrer Bley et al, 2003). They are particularly important for deep seated tumors such as nasal tumors and brain tumors where you cannot directly see the

VII. Custom blocking While the standard collimator on a cobalt-60 machine or linear accelerator can make only squares or rectangles, planned radiation fields are often more complex in shape. There are several different ways that the beam can be shaped to conform to the planned field. The simplest but crudest way is to have pre-cast blocks which can be hand positioned onto plastic trays fitted into the machine. For increased accuracy, either a multileaf collimator, which most commonly have between 80 and 120 leaves, or a custom made block made from a low temperature melting lead alloy to shield part of the field 170

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Figure 3. Images of a (a) photon block and a (b) electron block.

Figure 4. Image of a dog set-up for a radiotherapy treatment using both a vacuum bag and a head mask.

area you are treating. They should be done at least weekly and with particularly difficult fields should even be done on a daily basis for quality assurance (McEntee, 2008).

Taking two orthogonal port films allows accurate positioning of a patient to within several millimeters, ensuring that the plan can be accurately carried out regardless of how many beams are used or at what angle they enter.

Traditionally, port films have been made using specialized cassettes and film and processed like a regular

piece of radiograph film. Newer techniques such as digital on board portal imaging equipment allow imaging of the patient right before treatment and image registration to compare actual patient positioning with what was planned (Figure 5) (McEntee, 2006, 2008). One limitation of this technique is that imaging with the high energy megavoltage (MV) beam of a linear accelerator yields poor soft tissue contrast. One solution has been to equip a linear accelerator with an on-board kilovoltage (kV) imaging system for diagnostic quality radiographs.

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Figure 5. A digitally reconstructed radiograph created from the initial CT scan of a dog with a solitary plasma cell tumor of the maxilla used for treatment planning (a) and a port film taken using an electronic portal imaging device (b).

On board cone beam computed tomography (CBCT) imaging is a technique of producing volumetric CT images at the time of treatment and is now becoming available on newer linear accelerators for even more precise positioning.

The use of real-time imaging to adjust patient positioning immediately before and even during treatment is called IGRT (Xing et al, 2006). The power of this technology may reach the point that as the patient or tumor shape changes during the course of treatment, adaptive treatment planning can adjust for positioning changes during a single treatment and shape changes within the patient and/or target over the course of radiotherapy as well.

With the increased precision of radiation equipment, the importance of 4-D treatment planning and positioning is now being realized. The â&#x20AC;&#x153;4th dimensionâ&#x20AC;? this refers to is subtle movement over time during and between radiation treatments (intrafraction and interfraction motion).

Respiratory motion can result in several centimeters of movement of a tumor target and critical normal tissues including heart and lung. Gastrointestinal peristalsis during radiation is now recognized as a major cause of both geographic miss and colonic overdosage in human prostate cancer patients undergoing radiation therapy.

Through the use of fiducial markers or infrared sensors, there are now techniques that can actually adjust the radiation field to match patient motion. While organ

motion was once difficult to study, 4-dimensional CT can provide extensive information about the dynamic nature of tumors and internal organs (Webb, 2006).

Linear accelerators are now available with integrated imaging devices to provide target identification, real time monitoring for motion and delivery modification, verification, dose reconstruction, and adaptive therapy.

Imaging devices that allow for respiratory gating, breathing control, and adapt therapy to account for motion will allow further sparing of normal tissue and finer tumor targeting (Giraud et al, 2006). These techniques will become extremely important for techniques such as IMRT with extremely conformal dose distributions and gradients at the boundary of target volumes and organs at risk (Keall et al, 2006). Refining these techniques will likely allow for dose escalations resulting in higher rates of local tumor control and survival.

IX. Treatment planning A. Hand planning When treating an area surrounding a scar from an incompletely excised soft tissue sarcoma or mast cell tumor for example, a hand calculated plan is often sufficient and saves cost to the owner This is done by placing an appropriate margin around the scar and then calculating an appropriate dose to the desired depth, taking into account the skin and exit doses. This becomes rapidly impractical if multiple beams, complex blocking or beam 172

Cancer Therapy Vol 6, page 173 modifying devices are used. The dose delivered also may not match the dose calculated across the radiation field, particularly if the patient’s body contour in the radiation field is not flat.

X. 3-D conformal radiation therapy and IMRT 3-D conformal radiation therapy is similar to conventional 3-D planning except that multiple beam angles and conformal blocks are used to shape the dose closely to the target volume and simultaneously allow sparing of normal tissues. These beam angles and blocks are selected using reconstructed imaging data and treatment planning software capable of performing thousands of calculations in a short amount of time.

IMRT is a technique that takes advantage of exact patient positioning, multileaf collimators (MLC) and treatment planning software to shape and modify the intensity of the beam so that the delivered dose conforms to the tumor (Purdy, 2007). There are two fundamental differences between IMRT and 3-D conformal radiation therapy.

The first fundamental difference is the use of the computer driven small mobile tungsten leaves of the MLC to various positions around the patient. The “step and shoot” technique of IMRT involves moving the leaves to multiple fixed positions around the patient. What is more common and useful is dynamic treatment in which the leaves of the MLC move while the linear accelerator beam is on, modulating the fluence of the beam and effectively treating thousands of “beamlets” per field. The calculation algorithms for dynamic IMRT are so complex that they cannot be planned by conventional methods (Bortfeld, 2006).

The second fundamental difference between IMRT and conformal radiotherapy is the use of “inverse planning.” Recall that in conventional and conformal treatment planning, the radiation oncologist or dosimetrist creates the beam orientation, weight, shape, field size and modifiers. The treatment planning system then calculates the resulting dose. The parameters can then be adjusted by modifying beam weighting, adding or removing beams,

B. Computer planning With the advent of computer planning, radiation plans with multiple beams can be easily made using images from a CT or MRI. Most treatment planning systems use CT scans for treatment planning since it provides density information for dose calculation and because it provides better geometric accuracy than MRI. However many of these programs allow fusing an MRI to a CT scan, taking advantage of the superior soft tissue detail seen with MRI. This is particularly useful when planning brain tumors, which are much better visualized on MRI than CT. For most other tumor types usually a CT alone is sufficient.

For treatment planning, the patient is scanned in the position that they will be treated in using any patient positioning devices that will be used. This allows for the most accurate dose calculation and delivery. The CT is then imported into the treatment planning software program. The area to be irradiated is then identified and marked and the CTV is drawn. The margin for the CTV is based on the tumor’s type, location, and biological behavior. The PTV is then drawn around the CTV. The radiation oncologist then adds beams onto the tumor and calculates the dose. 3-D treatment planning systems let you visualize dose on a 3-D image and also allow creation of dose volume histograms, which are graphs that show what volume of tissue is receiving what dose of radiation (Figure 6). This is useful in ensuring that the tumor is receiving the desired dose and that normal structures (such as lung, spinal cord or eyes) are getting the minimal possible dose. Individual plans can then be compared and the best one chosen.

Figure 6. (a) A plan from a dog with a pituitary tumor and (b) the dose volume histogram from the same plan showing dose to the CTV (purple), PTV (red) and to the brain (blue) and eyes (green).

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Gordon and Kent: Veterinary radiation oncology and adjusting other dose modifiers in a trial and error process. In inverse planning, the process starts by prescribing a dose to the defined target volume and setting constraints for the tolerable doses to normal tissues. The treatment planning system is responsible for optimizing beam weights, field sizes, and beam fluence to meet those constraints (Bortfeld, 2006). When those constraints cannot be met, inverse planning becomes an interactive process whereby the radiation oncologist or dosimetrist must adjust or prioritize the dose constraints until the most ideal treatment plan is created. Because frequently the ratio of the dose delivered to normal tissues compared to the tumor is reduced to a minimum with IMRT, dose escalation to more effective radiation doses can safely be performed with fewer side effects compared with conventional radiotherapy techniques (Smith et al, 2006).

There are several limitations to IMRT. First, not all treatment locations can be improved to a significant extent compared to more conventional techniques. It is much more time consuming to verify radiation dose with IMRT than conventional and conformal techniques. The problems of organ motion (see section on image guided radiation therapy) may also interfere with the ability to accurately carry out an IMRT plan (Purdy, 2004). Of unknown clinical importance at this time is the effect of adding more beams to treatment. In addition to daily treatment time increasing, the volume of normal tissue that receives some dose of radiation increases and the total body radiation dose increases as well. Because these techniques are still relatively new, it is not yet known whether or to what extent those increases may lead to increased rates of carcinogenesis or other adverse effects (Hall, 2006).

use these benefits without losing the benefit of the information provided by a CT scan by overlaying the data.

Historically, U/S has found limited application for external beam radiation due to a lack of a well-defined method for using a three dimensional coordinate system.

As image quality has improved, U/S is now able to verify patient setup and identify organs at risk in a radiation field (Smith et al, 2006). It also has wide applications in humans for image guided placement of seed implants.

While radioactive implants may not be a viable option for many veterinary patients, the placement of fiducial markers into internal sites for daily treatment localization can be readily accomplished (Smith et al, 2006).

Techniques such as fMRI are not yet widely available in veterinary medicine but can provide information about local oxygen concentrations, oxygen consumption, and perfusion which may give information about areas within a tumor that may be hypoxic or more resistant to radiation. MRSI has the ability to detect molecules that may reflect different disease states to differentiate normal and malignant tissues (Smith et al, 2006).

For 50 years, radiation oncologists have tried to improve the homogeneity of dose throughout a tumor. It is well known that tumors are very heterogeneous. As advances in imaging permit detection of these tumor heterogeneities, it may be found that the best treatment is not one of homogeneous dose throughout the tumor but one of planned heterogeneous dosing with higher risk portions of the tumor boosted to a much increased dose.

IMRT techniques can accomplish these dose profiles more readily than traditional methods of radiation therapy.

B. Particle radiotherapy

XI. Moving toward the future in veterinary radiotherapy

1. Neutron therapy The main potential advantage for neutron therapy is the radiobiologic advantage they confer. Due to the characteristics of their dose deposition, they cause less sublethal damage to cells that can be repaired.

Additionally, the extent of cell killing by neutrons is not cell cycle dependant and is not decreased by the presence of hypoxia. As neutrons are not charged particles they do not cause direct ionization and are also likely to pass through tissue without interacting. One approach is the use of boronated compounds to capture neutrons in the tumor itself. The concept of â&#x20AC;&#x153;boron-neutron capture therapyâ&#x20AC;? is also an area where significant advances may still be made.

There are very few facilities capable of treating veterinary patients with a neutron beam although there is a recent report of boron neutron capture therapy for feline nasal squamous cell carcinoma (Trivillin et al, 2007).

A. Advanced imaging The future of radiation therapy is intimately tied to technology driven and image guided techniques inside and outside of the linear accelerator vault. The ability to accurately delineate target volumes based on physiologic imaging tests represents an area where significant advancement can be made. The ability to register and fuse multiple imaging modalities in combination with immobilization devices reduces both the CTV and PTV by reducing geometric uncertainties. These improvements will incorporate computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (U/S), positron emission tomography and PET/CT, single-positron emission computed tomography (SPECT), functional magnetic resonance imaging (fMRI) and magnetic resonance spectroscopic imaging (MRSI)A. For 30 years, CT has been the most commonly used imaging technique for radiation treatment planning due to its spatial fidelity and the ability to reconstruct images into a three-dimensional model (Smith et al, 2006). Alternative imaging techniques including MRI and PET may provide superior visualization of tumor and normal structures.

Fusion of CT and MRI images is common in veterinary medicine in treatment of brain, spinal and nasal tumors to

2. Proton therapy The main potential advantage for protons is that as a proton passes through tissue, the dose deposited increases slowly with depth until it reaches a sharp peak at its maximum depth of penetration, known as the Bragg peak.

No dose is delivered beyond this peak. The depth of the peak can be adjusted by varying the energy of the beam or through the use of compensating material and specialized filters. This property makes it possible to create a dose 174

Cancer Therapy Vol 6, page 175 profile that is precisely confined to a tumor volume with extremely sharp dose fall off deep to the tumor in normal tissue. There are only scattered reports of proton therapy in veterinary medicine, including the treatment of brain tumors. The technique and dose distributions have also been evaluated for canine nasal tumors and may have some dosimetric advantages to photons (Kaser-Hotz et al, 2002; Bley et al, 2005).

tumors (Lester et al, 2001; Farese et al, 2004). Many other potential applications exist and there are anecdotal reports of effective SRS treatments for urinary bladder and urethral transitional cell carcinoma, pituitary dependant Cushingâ&#x20AC;&#x2122;s disease, and spinal tumors.

XII. Radiation training and expertise As radiation therapy becomes more complex and technology driven, the role of the medical physicist and board certified radiation oncologist has become far more important. Because the specialty of veterinary radiation oncology is still relatively new and small, there are many facilities that rely on radiologists, medical oncologists, general practitioners, and human radiotherapists to perform radiation. Implementation of more complex techniques with appropriate care requires more advanced training and better knowledge of radiation equipment, radiation safety, radiation physics, and radiobiology.

The role of the medical physicist includes calibration of the machine, collection of dosing data, assuring radiation safety and assisting in treatment planning and assuring that dose delivered is the dose planned. The law only requires yearly testing of the equipment in California for veterinary facilities. In human facilities the requirements are much more strict, with a physicist on-site or on call at all times. As veterinary facilities begin to implement treatments that have similar complexity, regular quality assurance evaluations by a medical physicist are needed to prevent serious errors.

Similarly, as target margins become smaller with the goals of decreasing toxicity and dose escalation, the risks associated with subtle errors in calculation and treatment become much greater. Having an on-site radiation oncologist to evaluate patients and treatment sites to develop an integrative plan for imaging and therapy is important. Even more critically, the radiation oncologist is responsible for verifying accurate positioning and port films before a treatment is administered. Because the consequences of even small errors are markedly increased with finely conformal therapy, the importance of such verification is greatly amplified.

C. Tomotherapy Tomotherapy represents a specific type of advanced IMRT with IGRT. It is a helical machine employing a linear accelerator mounted into a CT style gantry that rotates as a fan beam modulated by an MLC and rotating around the patient as the couch moves the patient into the gantry. Tomotherapy represents an integrated system for treatment planning, patient positioning, and treatment delivery utilizing an inverse planning system. Using this type of image registration for patient positioning provides more detail for not only the 3 translational degrees of freedom but also the 3 rotational degrees of freedom (pitch, roll, and yaw) (Forrest et al, 2004; Hong et al, 2007). The tomotherapy unit is also capable of verifying treatment delivery using a detector to compute the energy fluence delivered with any error outside of the specified tolerance range triggering treatment shutdown. This information can also be used for dose reconstruction to compare the planned dose delivery to the actual delivery for quality assurance and adaptive radiation therapy (Lawrence and Forrest, 2007; Tome et al, 2007).

D. Stereotactic radiosurgery SRS was originally designed by a neurosurgeon with the intent to treat functional disorders of the brain. It is now recognized as a treatment with many indications including tumors, vascular lesions, and pain syndromes, including but not exclusive to the brain and spine (Smith et al, 2006). There are three basic techniques currently available for stereotactic radiosurgery. The underlying principle is the use of many finely collimated beams focused on a specific (and usually small) target to deliver a very high dose to the small target with much lower doses to all surrounding tissue. Initially, all stereotactic radiosurgical treatments were performed with a single or very few fractions. Fractionated SRS is now preferred for many conditions (Smith et al, 2006).

Linear accelerator based SRS uses stereotactic cones to modify and collimate the beam of a standard linear accelerator. The gantry rotates similar to 3-D conformal therapy or IMRT to multiple positions. Gamma knife based radiosurgery utilizes up to 201 small Cobalt-60 sources in a heavily shielded apparatus. The third technique is robotically controlled radiosurgery (Cyberknife) which employs a small linear accelerator mounted on a robotic arm to deliver multiple beams.

Currently, the few veterinary facilities performing SRS are using primarily linear accelerator based treatments although there is currently one veterinary facility with a Cyberknife. Published veterinary applications for SRS include an alternative to surgery for appendicular osteosarcoma and treatment of intracranial

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Hall EJ, Giaccia AJ, (2006) Radiobiology for the radiologist.

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From left to right: Ira K. Gordon, Michael S. Kent

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Cancer Therapy Vol 6, page 187 Cancer Therapy Vol 6, 187-192, 2008

The association of hematologic changes and histological responses to preoperative chemoradiotherapy in oral cancer patients Research Article

Kenji Yamagata*, Kojiro Onizawa, Toru Yanagawa, Hiroshi Yoshida Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan

__________________________________________________________________________________ *Correspondence: Kenji Yamagata, Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan; Tel: +81-29-853-3052; fax: +81-29-853-3039; E-mail address: ykenji@md.tsukuba.ac.jp Key Words: Oral cancer, Preoperative chemoradiotherapy, Histological response, Hematologic side effect, Leucopenia Abbreviations: 5-fluorouracil and cisplatin or nedaplatin, (FP group); C-reactive protein, (CRP); Granulocyte-colony stimulating factor, (G-CSF); International Union Against Cancer, (UICC); Oral squamous cell carcinomas, (OSCCs); Tegaful uracil, (UFT group); White blood cell, (WBC) Received: 5 January 2008; Revised: 11 March 2008 Accepted: 15 March 2008; electronically published: March 2008

Summary Advanced oral cancers are commonly treated with a combination of surgery and chemoradiotherapy; however, chemoradiotherapy has adverse hematologic effects. This study was conducted to assess the association between the hematologic side effects and the histological responses of the tumor to preoperative chemoradiotherapy for oral squamous cell carcinoma. Forty-five patients who received preoperative chemoradiotherapy and radical surgery were retrospectively enrolled. The hematologic laboratory results were obtained from patient medical records, the histological response of the tumor was determined by examining the resected specimen. On the basis of the histological assessment, the 43 patients were classified as “good responders” (24 patients) or “poor responders” (19 patients). Hematologic toxicity was assessed according to the NCI-CTCAE v 3.0 scale, the percentage of peripheral blood cell reduction was calculated from the difference between the pre- and post-chemoradiotherapy cell counts.

The major forms of hematologic toxicity were leucopenia and granulocytopenia, which occurred in 69.8% and 46.5% of the patients, respectively. There was a significant correlation between the reduction of white blood cell (WBC) and a good histological response: a reduction of 50% or more was significantly more frequent in good responders than poor ones. These results suggest that the magnitude of hematologic changes following preoperative chemoradiotherapy was associated with the histologic response of oral cancer tumors to the treatment.

Non-laboratory toxicity (presenting as oral mucositis, dermatitis, nausea, vomiting) and hematologic toxicity (leukopenia, anemia, thrombocytopenia) are adverse effects of chemoradiotherapy treatment for head and neck cancers (Kirita et al, 1999). Interestingly, several reports indicate that there is a positive correlation between the severity of these adverse side effects and the tumor response to chemoradiotherapy. For example, Ikebe et al. reported that patients with severe mucositis responded well to the presurgical therapy (Ikebe et al, 2005), Poikonen et al. reported a relationship between a low leucocyte count following chemotherapy and longer survival (Poikonen et al, 1999).

Given the above observations, hematological toxicity, which is caused by most cytotoxic drugs, might

I. Introduction Oral squamous cell carcinomas (OSCCs), when treated early with surgery or radiotherapy, can be cured, but therapy for locally advanced lesions usually involves multiple treatment modalities. Chemoradiotherapy in combination with radical surgery constitutes a more effective approach for treating advanced OSCCs than the use of either therapy alone, this combined treatment results in relatively good locoregional control of the cancer and high survival rates (Kirita et al, 1999). We previously reported that patients whose advanced oral cancer responded well to preoperative chemoradiotherapy generally show better tumor control and survival rates over the long term than patients whose cancer responds poorly to this treatment (Onizawa et al, 2006).

187

Yamagata et al: Hematologic changes and histological responses in oral cancer patients IIb, III, IV) categories, according to commonly used classification established on basis of an amount of remaining viable tumor cells (Yusa et al, 2000; Onizawa et al, 2006). Based on this histologic response, the patients were then classified as poor or good responders.

The patients’ hematologic laboratory data were investigated retrospectively by reviewing their medical records.

In particular, the total white blood cell (WBC) counts, the individual counts of neutrophils, lymphocytes, monocytes were determined pre-treatment, at the post-chemoradiotherapy nadir state (samples were taken repeatedly to identify nadiar), immediately before surgery. The C-reactive protein (CRP) was assessed as an infection marker. Hematologic toxicity was evaluated using the NCI-CTCAE v 3.0, included the values for hemoglobin, WBCs, platelets before and after chemoradiotherapy.

The hematologic effect of the chemoradiotherapy was defined numerically as the difference between the values before and at the nadir, the percentage of the reduction was calculated as: {(pretreatment value - value at the nadir) / pre-treatment value} x 100.

Statistical analyses were performed using the Stat View 5.0 J (SAS Institute Inc., U.S.A.) software package. The MannWhitney U-test and Chi square test were used in statistical comparisons between the poor and good responders. A p-value of less than 0.05 was considered significant.

be a useful biological measure of drug activity that could also predict treatment efficacy (Kvinnsland, 1999). In fact, a similar association was reported for non-small-cell lung cancer, in which neutropenia during chemotherapy was associated with increased patient survival (Di Maio et al, 2005). A low leucocyte nadir caused by adjuvant chemotherapy has been correlated with improved survival in breast cancer patients, in whom the drop in leucocytes is used as an effective biological marker for chemotherapeutic effect (Poikonen et al, 1999). However, the predictive role of chemotherapy-induced leukocytopenia in advanced OSCC remains unknown. The good response to preoperative chemotherapy might make it possible to reduce resected regions with subsequent ablative surgery, leading to the preservation of patients’ oral function. This study was carried out to assess whether adverse hematologic effects were associated with histologic tumor response to preoperative chemoradiotherapy in OSCC patients.

II. Patients and Methods Forty-three patients, 24 men and 19 women, who underwent radical surgery after preoperative chemoradiotherapy for OSCC at the Division of Oral and Maxillofacial Surgery, Tsukuba University Hospital, between 1991 and 2005, were retrospectively enrolled as subjects. Their ages ranged from 33 to 83 years, with a median of 65.0 years. The primary tumor sites were 22 of the tongue, 11 of the gingiva, 3 of the floor of mouth, 2 each of the oropharynx, maxillary sinus, buccal mucosa, and 1 of the mandibular bone. The histologic differentiation of the tumor was well for 27 cases, moderate for 13 cases and poor for 3 cases. We followed the 1997 International Union Against Cancer (UICC) categories for staging, the tumors were classified as stage II for 5 cases, stage III for 10 cases, stage IV for 28 cases. The antitumor agents used in the preoperative chemotherapy were a combination of 5-fluorouracil and cisplatin or nedaplatin (FP group) in 26 cases and tegaful uracil (UFT group) in 17. In the FP group, 5-fluorouracil at 350 mg/m2 was administered intravenously every 24 hours for 6 days, cisplatin or nedaplatin at 80 mg/m2 was infused on the 7th day only. The FP therapy was performed for one cycle for 20 patients in whom oral intake was difficult by sever stomatitis, and two cycles for 6 patients in whom oral intake was possible with mild oral mucositis. UFT at 400 mg or 600 mg was administered orally concomitant with the radiotherapy, with the dose determined by the patient’s general condition. The patients also received preoperative radiotherapy at 1.8 or 2.0 Gy per fraction, 5 fractions per week, using 6 MV x-rays. Consequently, the total radiation dose ranged from 45 to 54 Gy, with a median dose of 50.0 Gy (Table 1). All patients underwent radical surgery within 4 weeks of completing the chemoradiotherapy, upon the clinical healing of treatment-induced stomatitis or dermatitis.

The histological response of OSCC to preoperative chemoradiotherapy was evaluated by examining the surgically resected specimen of the primary tumor. The response was classified according to the qualitative, 4-stage grading system of Shimosato et al, using semi-serial sections of the entire surgical specimen as follows: Grade I, tumor structures were still visible; Grade IIa, viable tumor cells were frequently observed; Grade IIb, viable tumor cells were few; Grade III, viable tumor cells were rare; Grade IV, no tumor cells were visible in any section (Shimosato et al, 1971). These grading was performed by an abundantly experienced pathologist who was not informed about antitumor agents used. The histologic response was then dichotomized into “poor” (Grades I and IIa) or “good” (Grades

III. Results The histologic grades were Grade I for 2 cases, Grade IIa for 17, Grade IIb for 7, Grade III for 2, Grade IV for 15. Of the 43 patients, 24 (55.8%) were classified as good responders and 19 (44.2%) as poor responders. The mean duration from the initiation of chemotherapy to the nadir after chemotherapy was 23.6 days for the FP group Table 1. Patient characteristics Characteristics Sex Male /Female Age (years) Median (range) Primary tumor site Tongue Gingiva Floor of mouth Oropharynx Maxillary sinus Buccal mucosa Mandibular bone Pathological differentiation Well Moderate Poor Stage II III IV Preoperative chemotherapy FP group One cycle Two cycle UFT group Total radiation doses (Gy) Median (range) 188

No. of patients (n=43) 24/ 19 65.0 (33-83) 22 11 3 2 2 2 1 27 13 3 5 10 28 26 20 6 17 50.0 (45-54)

Cancer Therapy Vol 6, page 189 and 33.8 days for the UFT group. Of the 26 patients treated with FP therapy, 17 were good responders and 9 were poor responders. Six patients received 2 cycles of FP therapy showed severe hematologic toxicity and effective histologic response compared with 20 patients treated with 1 cycle of FP therapy. Of the 17 patients treated with UFT therapy, 7 were good responders and 10 were poor responders. The frequency of good responder is greater in the FP group than the UFT group, but there was no statistical difference between FP and UFT groups.

The hematologic examinations showed leucopenia in 30 patients (69.8 %) and neutrocytopenia in 20 (46.5 %).

The severity of the leucopenia was Grade 1 in 14 patients, Grade 2 in 11, Grade 3 in 5. The severity of the neutrocytopenia was Grade 1 in 6 patients, Grade 2 in 9, Grade 3 in 5. Anemia was found in 29 patients, thrombocytopenia in only 2 patients (Table 2). The hematologic toxicity was severer in patients with 2 cycle of TP therapy than those with 1 cycle. Granulocyte-colony stimulating factor (G-CSF) was administered to the 5 patients with Grade 3 leucopenia. There was no significant difference in the pre-chemoradiotherapy between good and poor responders (Table 3).

A comparison of the preand postchemotradiotherapy laboratory data between the two histologic response groups showed that the median reduction in the total WBC and neutrophil values was, respectively, 51.4% and 59.3% in the good responders, 32.8% and 42.9% in the poor responders. The numerical reduction in the total WBC and neutrophil counts were significantly greater in the good responders than in the poor ones. The reduction in lymphocytes, monocytes, hemoglobin, platelets was not statistically different for the two response groups (Table 4). Of the 24 good responders, 8 (33.3%) showed a reduction in the WBC

count of less than 50%, 16 (66.7%) showed a reduction of more than 50%. Of the 19 poor responders, the WBC reduction was less than 50% in 16 (84.2%) and more than 50% in 3 (15.8%) of them. The reduction of the WBC by more than 50% was significantly more frequent in the good responders than in the poor responders (Table 5).

Classification by the type of chemotherapy used showed that in the FP group, good responders had statistically greater percent reduction in their total WBC and monocyte counts than did poor responders. However, the UFT group did not show a significant difference in the percent reduction of these counts between the two response groups (Table 6).

IV. Discussion Survival is the most important endpoint in cancer treatment, and has been frequently used as the indicator of effectiveness of antitumor agents. However, survival is dependent on many factors. One of the purpose of antitumor chemotherapy is eradication of tumors which is evaluated with histologic findings. The current study used not survival but histologic response as an indicator of the effectiveness of the agents, because the response is a more direct measure of the efficacy. Several findings lend support to the idea that leucopenia or neutropenia, which is the most frequent hematologic toxicity in cancer patients treated with chemoradiotherapy and which occurs in about 50% of patients treated with platinum-based chemotherapy regimens (Kirita et al, 1996), might be a surrogate indicator for the biological activity of the drugs (Saarto et al, 1997; Kvinnsland, 1999; Poikonen et al, 1999; Di Maio et al, 2005). Accordingly, association of histologic response and hematologic changes to chemotherapy in OSCC was interested.

Table 2. Grading of hematologic toxicity after preoperative chemoradiotherapy.

Grade Toxicity Leukopenia Neutrocytopenia Anemia Thrombocytopenia

1 14 6 21 2

2 11 9 8 0

3 5 5 0 0

4 0 0 0 0

Table 3. Association between hematologic data and histological response in pre-treatment stage.

Good responder 3

3

WBC (x10 /mm ) Neutrophil Lymphocyte Monocyte Hemoglobin (g/dl) Platelets (x103 /mm3) CRP (ug/dl)

6.15 (3.30~10.70) 4.12 (2.03~7.61) 1.52 (0.34~4.28) 0.47 (0~1.64) 12.6 (8.8~15.7) 248.5 (130.0~355.0) 0.29 (0~5.83)

n.s.: no significant difference

189

Median (min~max) Poor responder 5.80 (3.80~9.90) 3.23 (1.41~7.05) 1.70 (0.84~3.38) 0.46 (0.13~1.09) 12.0 (10.1~14.9) 217.0 (141.0~394.0) 0.11 (0~1.08)

p value n.s. n.s. n.s. n.s. n.s. n.s. n.s.

Yamagata et al: Hematologic changes and histological responses in oral cancer patients

Table 4. Association between WBC reduction (%) and histologic response.

WBC Neutrophil Lymphocyte Monocyte Hemoglobin Platelets

Reduction (%) Good responder Poor responder 51.4 (13.2 ~ 88.7) 32.8 (16.7 ~ 61.5) 59.3 (-25.4 ~ 92.0) 42.9 (-36.6 ~ 72.1) 57.3 (-161.6 ~ 85.1) 31.1 (-13.9 ~ 79.2) 22.2 (-105.4 ~ 73.4) 1.8 (-210.3 ~ 70.9) 9.1 (-0.8 ~ 23.6) 6.4 (-0.9 ~ 30.8) 20.4 (-55.7 ~ 59.4) 11.9 (-41.3 ~32.2)

Median (min~max) p value <0.01 <0.05 n.s. n.s. n.s. n.s.

n.s.: no significant difference

Table 5. Association between the severity of WBC reduction and histological response

WBC reduction (%) 10~30

Histological response Good responder Poor responder (n=24) (n=19) 4 7

30~50

4

9

50~70

13

3

70~

3

0

*

*p <0.01

Table 6. Association between WBC reduction and histological response in FP and UFT groups Median (min~max) (%)

WBC Neutrophil Lymphocyte Monocyte

Good responder (n=17) 52.4 (24.5~88.7) 62.1 (-25.4~92.0) 63.1 (17.2~85.1) 23.9 (-105.4~73.4)

FP (n=26) Poor responder (n=9) 45.2 (16.7~61.5) 52.5 (4.7~72.1) 34.5 (-3.6~79.2) -2.0 (-210.3~17.4)

p value <0.05 n.s. n.s. <0.05

Good responder (n=7) 42.9 (13.2~57.0) 45.8 (-20.9~70.0) 52.0 (-161.6~73.1) 5.8 (-39.3~63.1)

UFT (n=17) Poor responder (n=10) 31.3 (20.8~55.2) 35.7 (-36.6~61.2) 30.6 (-13.9~64.4) 6.9 (-180.5~70.9)

p value n.s. n.s. n.s. n.s.

n.s.: no significant difference

As the pretreatment laboratory data differed widely among individual patients, the differences in the peripheral blood cell counts during treatment were considered useful for assessing the hematologic change, therefore the percent reduction was used as a quantitative parameter in the current study. A change in WBC counts commonly results from an infection, a malignancy, anticancer drug use, a drug allergy, or a hematological disease. The severe stomatitis that frequently occurs during chemoradiotherapy may subsequently induce an oral infection. The patients presented here showed no significant change in their CRP value, which was determined at the same time points as the other laboratory data. Consequently, the WBC and neutrophil counts were considered to represent the effects of chemoradiotherapy.

The response of cancer cells to chemotherapy depends on the amount of active drug reaching the target and on

whether the target is sensitive to the effect of the drug.

These factors also affect healthy cells, particularly hematopoietic cells. The access of active drug to the tumor or healthy cells is affected by the pharmacokinetics of the drug, which produce a similar effect in tumor cells and healthy ones. Leucopenia and neutropenia are the most frequent adverse effects on healthy cells caused by chemotherapy. The present study showed that the percent reduction in the total WBC and neutrophil counts was significantly greater in the good responders than in the poor responders, that a reduction in WBCs of greater than 50% was significantly more frequent in good responders than poor ones. The results suggest that preoperative chemoradiotherapy was effective in oral cancer patients who experienced severe hematologic toxicity, even though their healthy cells suffered from serious, albeit reversible, damage.

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Cancer Therapy Vol 6, page 191 Di Maio M, Gridelli C, Gallo C, Shepherd F, Piantedosi FV, Cigolari S, Manzione L, Illiano A, Barbera S, Robbiati SF, Frontini L, Piazza E, Ianniello GP, Veltri E, Castiglione F, Rosetti F, Gebbia V, Seymour L, Chiodini P, Perrone F (2005) Chemotherapy-induced neutropenia and treatment efficacy in advanced non-small-cell lung cancer: a pooled analysis of three randomised trials. Lancet Oncol 6, 669677.

Cancerous tissue is almost always infiltrated by inflammatory cells, including lymphocytes, this tissue infiltration may represent an immunological defense against the cancer (Marshall and Dayan, 1964). The role of the lymphocytes in cancer is still controversial, however.

One report found that the mean peripheral lymphocyte count was significantly lower in short-term than long-term survivors (Yamaguchi et al, 2000). Another report describes a close relationship among the absolute number of lymphocytes, tumor curability, immunocompetence, found that immunological activity of peripheral lymphocytes was favorable for surviving cancer (Riesco, 1970). The present study showed a numerical reduction of lymphocytes during chemoradiotherapy, no association between the histologic response and the absolute number of lymphocytes. The reduction in lymphocytes may in fact negatively impact the immune systemâ&#x20AC;&#x2122;s ability to resist oral cancer. However, the immunosuppression lasted for only a few weeks following the chemotherapy, so the relationship between patient prognosis and the chronic reduction of lymphocytes is unknown.

The use of platinum compounds and the continuous infusion of 5-FU are the standard induction regimen for advanced cancer (Pignon et al, 2000), and 26 patients received the combination. The frequency of histologically good responder was greater in the FP group, but no significant difference was observed between FP and UFT, as the sample size was small in the present study. The FP group showed a significantly greater reduction in WBCs in the good responders than in the poor responders, but the UFT group did not show this effect. Severe hamatologic toxicity and effective response were observed in the patients with 2 cycles FP therapy compared with those received 1 cycle FP therapy. The adverse effects of UFT were commonly mild compared with those of FP. Since the radiation dose was identical in the FP and UFT treatment groups, the results obtained almost certainly reflected the simply effects of the antitumor agents, suggesting that the stronger antitumor drugs are more effective.

The results of this study suggest that the hematologic side effects, especially a reduction in the WBC count, were associated with the histologic response of OSCC to preoperative chemoradiotherapy, and might be positive useful indicator of increased delivery and sensitivity of antitumor agents to tumors. However, further study with a larger sample is essential to verify this relationship.

Moreover, the field of pharmacokinetics is growing in how individual genetic variation plays a role in drug metabolism and transport. In the field of small-cell lung cancer, patientsâ&#x20AC;&#x2122; genetic variation in the form of single nucleotide polymorphisms in genes responsible for drug metabolism and transport was analyzed (Lara et al, 2007).

In the future, genetic approach will be necessary to investigate the effectiveness of antitumor agents to OSCC.

Ikebe T, Seki K, Nakamura S, Takenoshita Y, Nakayama H, Shinohara M, Shirasuna K (2005) Severity of oral mucositis correlates with the response of oral cancer to preoperative radiochemotherapy. Int J Oral Maxillofac Surg.34, 642645.

Kirita T, Ohgi K, Shimooka H, Yamanaka Y, Tatebayashi S, Yamamoto K, Mishima K, Sugimura M (1999) Preoperative concurrent chemoradiotherapy plus radical surgery for advanced squamous cell carcinoma of the oral cavity: an analysis of long-term results. Oral Oncol 35, 597-606.

Kirita T, Ohgi K, Tsuyuki M, Kamikaido N, Yamamoto K, Sugimura M (1996) Preoperative simultaneous cisplatin- or carboplatin-based chemotherapy and radiotherapy for squamous cell carcinoma of the oral cavity. J Surg Oncol.63, 240-248.

Kvinnsland S (1999) The leucocyte nadir, a predictor of chemotherapy efficacy? Br J Cancer 80, 1681.

Lara P, Redman M, Lenz H, Gordon M, Shibata T, Fukuda H, Tamura T, Saijo N, Natale R, Gandara D (2007) Cisplatin (Cis)/etoposide (VP16) compared to cis/irinotecan (CPT11) in extensive-stage small cell lung cancer (E-SCLC): Pharmacogenomic (PG) and comparative toxicity analysis of JCOG 9511 and SWOG 0124. ASCO Abstract 7524.

Marshall AH, Dayan AD (1964) An Immune Reaction In Man Against Seminomas, Dysgerminomas, Pinealomas, The Mediastinal Tumours Of Similar Histological Appearance?

Lancet 13, 1102-1104.

Onizawa K, Yoshida H, Ohara K, Noguchi M (2006) Predictive factors for the histologic response to preoperative radiotherapy in advanced oral cancer. J Oral Maxillofac Surg 64, 81-86.

Pignon JP, Bourhis J, Domenge C, Designe L (2000) Chemotherapy added to locoregional treatment for head and neck squamous-cell carcinoma: three meta-analyses of updated individual data. MACH-NC Collaborative Group.

Meta-Analysis of Chemotherapy on Head and Neck Cancer.

Lancet 355, 949-955.

Poikonen P, Saarto T, Lundin J, Joensuu H, Blomqvist C (1999) Leucocyte nadir as a marker for chemotherapy efficacy in node-positive breast cancer treated with adjuvant CMF. Br J Cancer 80, 1763-1766.

Riesco A (1970) Five-year cancer cure: relation to total amount of peripheral lymphocytes and neutrophils. Cancer.25, 135140.

Saarto T, Blomqvist C, Rissanen P, Auvinen A, Elomaa I (1997) Haematological toxicity: a marker of adjuvant chemotherapy efficacy in stage II and III breast cancer. Br J Cancer 75, 301-305.

Shimosato Y, Oboshi S, Baba K (1971) Histological evaluation of effects of radiotherapy and chemotherapy for carcinomas.

Jpn J Clin Oncol 1, 19-35.

References

Yamaguchi K, Noshiro H, Shimizu S, Morisaki T, Chijiiwa K, Tanaka M (2000) Long-term and short-term survivors after pancreatectomy for pancreatic cancer. Int Surg 85, 71-76.

Cancer Therapy Evaluation Program, Common Terminology Criteria for Adverse Events, Version 3.0, (2006) (http://ctep.cancer.gov).

Yusa H, Yoshida H, Iwasa S, Ueno E, Tohno E, Onizawa K,

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Kenji Yamagata

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Cancer Therapy Vol 6, page 193 Cancer Therapy Vol 6, 193-212, 2008

Targeting critical disease pathways in male breast cancer: a pharmacogenomics approach Research Article

Debmalya Barh*, Kaberi Das Unit of Cancer Genomics, Department of Applied Genetics, AIS, 51.CIL lay out, RT Nagar, Bangalore-560032, Karnataka, India.

__________________________________________________________________________________ *Correspondence: Debmalya Barh Ph.D., Unit of Cancer Genomics, Department of Applied Genetics, AIS, 51.CIL lay out, RT Nagar, Bangalore-560032, Karnataka, India.

Key words: male breast cancer, critical disease path, drug targets, phytochemicals, apoptosis, network regulators and targets Abbreviations: avian myelocytomatosis viral oncogene homolog, (MYC); breast cancer 2, (BRCA2); breast cancer, (BC); cyclin D1, (CCND1); epidermal growth factor receptor, (EGFR); epidermal growth factor, (EGF); estrogen receptor-1, (ER/ESR1); female breast cancer, (FBC); ingenuity systems pathways analysis, (IPA); Luteinising-hormone releasing hormone, (LHRH); male breast cancer, (MBC); matrix metalloprotease, (MMP); nuclear factor-kappa B, (NF-!B); pathway architect, (PA); progesterone receptor, (PR); selective estrogen-receptor modulators, (SERMs); transpath public, (TP); tumor necrosis factor, (TNF); tumor protein p53, (p53); vascular endothelial growth factor, (VEGF); v-erb-b2 erythroblastic leukemia viral oncogene homolog 2, (HER-2/ERBB2) Received: 15 February 2008; Revised: 11 March 2008 Accepted: 18 March 2008; electronically published: March 2008

Summary Male Breast Cancer (MBC) is rare that accounts for less than 1% of all cancers in men and exhibits highest cancer specific death rate (Jemal et al, 2002). The incidence ranges from 0.06 to 4.06% in India compared to the 0.08 to 6.4% in western countries and the incidence is increasing over years (Giordano et al, 2004). The occurrence of MBC is most common in men between the ages of 60 to 70 and the most common form is invasive ductal carcinoma (Joshi et al, 1996). Though the clinical outcomes of MBC apparently look similar to FBC (Giordano, 2002), they differ in several aspects (Heller et al, 1978; Frangou et al, 2005; Saudade et al, 2007). Due to the rare occurrence and late diagnosis of this disease, biology and molecular events behind the MBC pathogenesis are not yet clear (Petrocca et al, 2005), so the usual treatments for FBC are not generally applicable in MBC (Scott-Conner et al, 1999; Mahmoud et al, 2004). Due to severe side effects of conventional FBC drugs (Partridge et al, 2001; Harkins and Geyer, 2007) and due to the impact of comorbidities and secondary neoplasm, the mortality rate is increasing (Cutuli, 2007).

There is a dire need to prevent this. Using several approaches from bioinformatics we have identified 25 genes and 3 critical or shortest pathways in MBC pathogenesis. Pathways may crosstalk with each other and in adverse cases more than one pathway can be involved. 30 possible drug targets were identified and at least 13 dietary chemopreventive phytochemicals those can inhibit cell cycle, growth, and metastasis of both ER (+) and ER (-) FBC were found to have potentiality to act on those identified targets. 5, out of these 13 phytochemicals simultaneously can induce apoptosis by activating different apoptotic pathways in FBC. Hypothetically, these phytochemicals will also act on those same targets as an alternative source of conventional drugs for MBC. Literature mining reveals that an individual or a particular group of population shows different types of molecular alterations for MBC development. So a pharmecogenomics approach with individual or in a combination and doses of these phytochemicals may be effective to treat or prevent specific MBC cases depending on their molecular profile. This approach may help in developing a multi-targeting MBC drug using natural dietary phytochemical with minimal or no side effects. in USA (El-Gazayerli and Adbel-Aziz, 1963; Bhagwandin, 1972). The range of incidence varies from 0.08 to 6.4% of total breast cancers in the western countries and 0.06 to 4.06% in India (Dubey and Aggarwal, 1971; Dutta et al, 1975). MBC accounts for less than 1% of all cancers in men, yet shows higher cancer specific death rate (Jemal et al, 2002) and the number of incidences are increasing over years (Giordano et al, 2004).

I. Introduction A. MBC-Epidemiology MBC is rare and its incidence varies with geographic locations. It shows higher occurrences in USA and UK, where even the FBC incidences are reported high, and shows lower occurrences in Japan, where the FBC incidences are also low (Schotterfield and Lilienfeld,1963). Zambia and Egypt show respectively 15 and 12 times higher incidence than the incidences reported

193

Barh and Das: Targeting critical disease pathways in male breast cancer pharmacogenomics point of view. 2) Identification of molecular cross-talk, critical/shortest disease pathways, and disease biomarkers or drug targets, and 3) Identification of potential dietary phytochemicals to target those markers and their probable use as effective alternative of chemo and hormone therapy thus minimizing the side effects of those existing treatments.

B. Risk factors The risk of MBC peaks around 60 years of age and risk factors include family history (Anderson, 1992), gynaecomastia (Goss et al, 1999), marital status, relative hyperoestrogeny (Sasco, 1993), aneuploidy (Pich et al, 1996), paraneoplastic syndromes (Wirtz et al, 2002), and prostate cancer (Karamanakos et al, 2004). Other factors are Klinefelter syndrome (Hultborn et al, 1997), excess weight, radiation exposure, exposure to estrogen, and excessive use of alcohol.

II. Materials and Methods A broad bioinformatics approach was taken to answer these questions. Several key words related to MBC were used to retrieve related literatures from PubMed, Medline, and Elsevier literature databases and subsequent data mining was performed to identify genes associated with MBC. General MBC pathways were constructed by mining 57 different pathways from Invitrogen, KEGG, BioCarta, Ambion, and Cell Signaling pathway databases using identified genes from literature mining. BRB ArrayTools- version 3.6.0 (http://linus.nci.nih.gov/BRBArrayTools.html) was used to find correlation of gene expression profiles between FBC and MBC in respect to BRCA1 and BRCA2 using available microarray data for FBC. Using identified genes of literature search and BRB Array result, genetic interaction net works, network regulators and targets, key nodes analysis, shortest or critical pathways, and key regulator of critical pathways those are likely to be drug targets were identified using Pathway Architect -version 3.0.1 (PA) (www.stratagene.com), Ingenuity Systems Pathways Analysis (IPA)-version 5.5 (www.ingenuity.com), and Transpath System Public version-6.0 (TP) (www.generegulation.com).

Osprey-Version 1.0.1 (http://biodata.mshri.on.ca/osprey/servlet/ Index) powered by human GRID was used for duel purposes i.e, to build the final molecular interaction network and to draw critical diseases paths. Extensive literature mining was taken into consideration to identify potential phytochemicals and their molecular targets in FBC those may have possibilities to target MBC critical paths, their regulators, and targets.

C. Clinical features 96% MBCs are carcinoma and most common is invasive ductal cancer (Joshi et al, 1996) and more than 75% cases are likely to be hormone receptor positive (Giordano, 2003). MBC apparently looks similar to FBC in biology and pathogenesis (Borgen et al, 1992; Anelli et al, 1995), and the clinical outcomes (Bland et al, 1998; Scott-Conner et al, 1999; Giordano, 2002), however, they are quite distinct and unique in nature. The fixed treatments for FBC may not work properly in MBC and the treatment depends on specific grade, stage, age, and genetic makeup of the cancer.

D. Therapy Drugs used in MBC treatment mainly consist of SERMs (Tamoxifen), Aromatase Inhibitors those inhibit estrogen synthesis inhibitor (Femara), Anthracyclines (DNA replication inhibitor), and microtubule dynamics modulator (Taxol) etc. As more than 75% MBC is ER or PR positive, SERMs and anti-estrogen drug tamoxifen (Nolvadex) are most commonly used (Eucker et al, 2007).

Doxorubicin is generally used in ER (-) MBC (Agrawal et al, 2007). Aromatase inhibitors along with LHRH analogs such as Leuprolide and Goserelin are in trial now. Some targeted therapeutics such as Herceptin (Trastuzumab) and Tykerb (Lapatinib) are also in use to treat ERBB2/HER2positive MBCs. Avastin (Bevacizumab) used to check breast cancer angiogenesis and metastasis in combination with Taxol (paclitaxel) and to target VEGF. Adjuvant and combinational chemotherapy are practiced for many cases.

All these treatments evoke severe deadly side effects (Sipples, 2006; Moore, 2007) and frequently affect cognitive abilities.

III. Results A. Literature survey and data mining for MBC molecular pathogenesis Due to rarity of the disease, sufficient relevant data and gene expression profile are not available. So we depend on literature mining which reveals that, there are around 25 genes involved in the MBC pathogenesis. These genes are BRCA1 (Frank et al, 2002; Sun et al, 2002; Karamanakos et al, 2004), BRCA2 (Couch et al, 1996; Haraldsson et al, 1998; Csokay et al, 1998; Ford et al, 1998; De la Hoya et al, 2002; Frank et al, 2002; Gudmundsdottir et al, 2003; Kirsi et al, 2004), HER2/ERBB2 (Joshi et al, 1996; Pich et al, 2000; Shpitz et al, 2000; Mourão et al, 2001; Ottini et al, 2003; Bärlund et al, 2004; Rudlowski et al, 2004; Fonseca et al, 2006; Dakin et al, 2007), P21/Waf1 and P53 (Anelli et al, 1995; Dawson et al, 1996; Pich et al, 2000; Chiusa et al, 2000; Shpitz et al, 2000; Mourão et al, 2001), MYC (Pich et al, 2000; Mourão et al, 2001; Bärlund et al, 2004), AR (Lobaccaro

E. Objective Due to rarity of the disease and improper characterization and prognosis, subsequent effective treatment is yet to be standardized to prevent and cure the disease and to reduce mortality rate. Similarly, to minimize side effects of conventional therapeutic drugs, potential new drugs and targets are to be identified and evaluated, where the dietary phytochemicals having antioxidant, immuno-stimulatory, and anti-tumorogenic properties may be alternatives of currently used drugs. Till the date, no report is available about the use of dietary phytochemicals in prevention or treatment or even in vitro experiments with MBC. Keeping in mind these facts, objectives of the current research are 1) Characterization of MBC at molecular and

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Cancer Therapy Vol 6, page 195 et al, 1993; Poujol et al, 1997; Munoz de Toro et al, 1998; Pich et al, 1999; Young et al, 2000), CYP19A1 (Dakin et al, 2007), ESR1 (Loman et al, 1998; Dakin et al, 2007), PGR (Munoz de Toro et al, 1998; Dakin et al, 2007), PPM1D (B채rlund et al, 2004), ZNF217 (B채rlund et al, 2004), CCND1 (B채rlund et al, 2004), KRAS (Dawson et al, 1996), CHEK2 (Meijers-Heijboer et al, 2002), MMP2 and MMP9 (Giannelli et al, 2002), CYP17A1 (Young et al, 1999; Gudmundsdottir et al, 2003), and PCNA (Pich et al, 1994). According to the recent review by Leinung and colleagues in 2007, PTEN, HFE, MSH2, MLH1, PMS1, and PMS2 are also associated in MBC. All genes are not involved as a whole at a time in MBC pathogenesis instead, single or a small groups of them are involved in specific cases. Mutations have been found in BRCA1, BRCA2, CHEK2, P53, PTEN, CYP17A1, HFE, MSH2, MLH1, PMS1, PMS2, AR, KRAS, and CYP17A1.

Whereas, BRCA2, HER-2/neu or ERBB2, ESR1, PGR, MYC, PPM1D, ZNF217, CCND1, P53, CYP19A1, MMP2, MMP9, P21/Waf1, and PCNA are upregulated in many cases individually or in a small groups, AR and BRCA1 found to be downregulated in few cases.

In general, BRCA2 mutation is predominant and overexpression of HER2/ERBB2, P53, MYC, ESR1, and MMP9 are common in several cases. Also it has been observed that molecular profile of MBC pathogenesis can vary depending on a particular group of population.

Though downregulation of BRCA1 has been noticed, the expression level of BRCA2 is not reported any where.

2001 for hereditary FBC. The idea of this analysis was to find correlation at expression level of different genes between FBC and MBC with respect to BRCA2 as in both cases BRCA2 is involved. Setting BRCA2 vs non-BRCA2 upregulated genes (fold differences-2.0) we were able to find expression correlation only with MYC (data not shown).

C. Construction of MBC disease path way based on pathway databases To construct MBC pathway, we grouped those identified 25 genes in different class and tried to match with different pathway they involved. 57 different pathways including cell cycle regulation, cell proliferation, various cancers, metastasis, inflammation, apoptosis, and DNA repair were selected from Invitrogen, KEGG, BioCarta, Ambion, and Cell Signaling pathway databases where these genes are involved. By mining all these pathways, we constructed a general MBC pathway using Osprey (Vs-1.0.1) with its integrated Human-GRID database. The constructed MBC disease pathway is represented in Figure 1.

D. Modeling of interaction net works and identification network regulators and targets These analyses were done using PA powered by Avadis. A set of upregulated genes (ERBB2, P53, MMP9, MYC, ESR1, and PGR) identified from literature review were used for construction of network and their subsequent analysis. Combining all models generated by interaction networks, relevance interactions, and advanced

B. Microarray data and analysis As there is no such available microarray data for MBC, we used data from Hedenfalk and colleagues in

Figure 1. The General MBC disease pathway developed by pathway database mining.

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Barh and Das: Targeting critical disease pathways in male breast cancer analysis modules for network regulators, network targets, and transcription regulation, it can be concluded that at gene or protein level, different growth factors and hormones mainly TGF, TNF, EGF, and estrogen induce expression of ERBB2 , MYC and MMPs .MYC is the common target of the network. JUN regulates ESR1 and MMPs, FOS regulates MMP2 and MYC, and P53 and BRCA1 regulates MYC (Figure 2). Overexpression of MMP9 induces NF-!B thus upregulates P53 in advanced stages when the cancer cells exhibits maximum genomic instability (Figure 3).

Using the unique advantage of PA i.e, protein-small molecule interactions to find the involvement of small molecules in regulating the network, it was observed that estrogen is the main regulator of this network that also can

directly induce MYC, JUN, FOS, MMPs, ESR1, PGR, MAPK, and IGF thus induces cell proliferation through several pathways (Figure 4). Another small molecule cAMP was found to induce transcription of MYC and estrogen by inducing CYP19A1 (Figure 5), thus cAMP can induce growth factor and ER signaling to induce cell proliferation in MBC. Critical or shortest pathways of the network created

by PA were identified using PAâ&#x20AC;&#x2122;s shortest path module between paths ERBB2-P53, ESR1-MYC, ERBB2-FOS, ERBB2-ESR1, CYP19A1-MYC, ESR1-BRCA1, ESR1FOS, ERBB2-MMP9, and ESR1-P53 (data not shown).

Figure 3. Estrogen regulates ER critical path and directly induces MYC. MMP9 regulates NF-!B.

Figure 2. MBC disease pathway network regulators and targets developed by PA.

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Figure 4. Estrogen is key transcription regulator in MBC genetic network.

Identified key molecules bridging shortest paths are ERBB2, EGFR, JUN, and estrogen. Identified key network regulators and probable drug targets of this network are ERBB2, EGFR, ESR1, NF-!B, and MYC (Figure 2, 3, and 4). These results also support the findings of network models using mutant genes (BRCA1, BRCA2, CHEK2, P53, PTEN, CYP17A1, HFE, MSH2, MLH1, PMS1, PMS2, AR, KRAS, and CYP17A1) (data not shown). Mutant gene net work identifies three additional regulators TNF, TGF, MMP9, and IL6 and two network targets PCNA and CCND1 (Figure 6).

IPA systemâ&#x20AC;&#x2122;s pathway explorer module was also used to make genetic interactions and shortest pathway among mutated genes involved in MBC pathogenesis.

Results showed that P53 is in centre of this network and also plays a key role in maximum shortest paths. Key genes identified are CCND1, MYC, and ERBB2 (Figure 7). CYP17A1, MIB1, ZNF217, and HFE did not follow any pathway in this model.

Figure 5. cAMP can induce ER signaling through CYP19A1 and directly activates MYC.

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Barh and Das: Targeting critical disease pathways in male breast cancer

Figure 6. Network targets and regulators of mutant genes network in MBC using PA.

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Figure 7. Shortest/critical path interactions among mutated genes in MBC developed by IPA.

E. Analysis of key nodes in network

F. Drug targets in critical pathways

Key molecules identified through PA and IPA system were used for key nodes analysis of the network to identify up and down stream reactions and key terminal factors using TP. Combined results of PA, IPA, TP, and other pathway databases for upstream and downstream or terminal reactions are represented in Table 1. Figure 8 shows the graphical representation of the constructed network using Osprey. The network was built to identify key nodes, terminal regulators, and key transcription factors.

From this key nodes analysis (Table 1 and Figure 8), it is evident that, maximum number of genes those are involved in MBC pathogenesis are upstream of various growth and transcription factors and cell cycle regulators.

So mutation or overexpression or any aberrant expression of these upstream genes directly affects the activity of their corresponding downstream transcription or growth factors. Identified key nodes for potential drug targets are EGF, ESR1, JUN, MMP2, FOS, MYC, BRCA2, CHK2, PCNA, PPM1D, KRAS, and ERBB2

Combining results of all previous experiments, an overlapping pathway was constructed for identification of critical paths. The overlapping network derived from PA, IPA, TP, and Human GRID interactions is represented in (Figure 9). Final critical pathways were made using PA and the represented diagram of the same (Figure 10) was drawn using Osprey.

It has been found that, there are three pathways namely ER signaling pathway, EGFR signaling pathway, and DNA repair pathway involved in MBC. As represented in Figure 10, critical paths for ER signaling pathway are ER-JUN-NF-!B-FOS and ER-MMP2MMP9-NF-!B-MYC/FOS. JUN can also induce expression of MMP9. CYP19A1, ESR1 and NF-!B are found to be key regulator thus probably are good drug targets of this critical path. EGF-FOS and EGFERBB2/EGFR-MAPK9-JUN are critical paths in EGFR signaling pathway, where JUN can activate MM2, MMP9, NF-!B and their downstream target genes (MYC and FOS) for cell proliferation. Upregulation of ERBB2 can also activate AKT and subsequently upregulates !-catenin and its downstream genes (CCND1, MYC, and FOS) for

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Barh and Das: Targeting critical disease pathways in male breast cancer progression through cell cycle, cellular growth, and tumorogenesis. In this pathway main drug targets will be ERBB2, EGFR, AKT, and !-catenin. In DNA repair pathway, the critical path consists of BRCA1, BRCA2, P53, PCNA, RB, and RAD51. It has been found from the existing evidences that one or more genes of this pathway is/are mutated in MBC pathogenesis. And in several cases

the central mutation is found in one or more than one tumor suppressor genes (BRCA1, BRCA2, P53, PCNA etc.). So restoration of those case specific genes functions or targeting their downstream molecules for regulation of cell cycle or DNA repair will be a strategy of MBC prevention or therapy.

Table 1. Key nodes and their upstream and downstream reactions based on TP, PA, and other pathway databases. “+” denotes binding reaction and “-” represents inhibition.

Key nodes MMP2 MMP9 MSH2

Up stream AP-2 ", P53, KRAS, HER2, ESR1 SDF1, MMP2, TGF, HER2 JUN, P53

PCNA PMS2 /MLH1

E2F-4, P53, IKK-"

PPM1D CYP19A1 BRCA1

P53 USF1, USF2, EGF, IL6 ESR1, FRA2, GABPA, TP53BP1, EGF, SP1 USF1, USF2, SLUG

BRCA2

CHK2/RAD53 MYC

K-RAS HER2/neu

AP1/JUN, AP2, STAT, EGF, SP1, MAK, TCF4 JUN, FOS, AP1, NF1, PAX5, PTEN P53, CTF, SP1 , HER2 GABPA, MYC, SPI1, AR, EGF

AR

SIRT1

PGR ESR1

ER1, ADA3 FOXO3a, RUNX2/AML3 MYC

P53

CDK4 E2F4 FOS MAPK9 PCNA

SIRT1,

EGF, AP1/JUN, ESR1, IFNG, STAT, IL22, SRC EGFR NF!B, E2F4, P53, ESR1, AP1

RAD51 VEGF JUN PTEN TNF

SP1, ERK, TGF, SMAD, AP1, BRCA1 EGF, TGF, CNK, IKK, SENP1 P53, HER2

Down stream MMP9

Inhibitor MDM2

+TSP1. +TSP2, NF-!B +ESR1, +PCNA, +MLH1/PMS2, +RAD51, +BML+RAD50+ ATM+BRCA1+RFC1 POL-D, DNA Ligase-1, RFC +MSH2,+PCNA, +GTBP, +ATM, +RAD50, BARD1+BRCA1+ MLH1 + Tubulin, TOPBP1+BRCA1 ATM, CHK2, +CHK1+PP2C delta ESR1, PGR, P53 CDKN1B, +CTLP, +MYC, +ZBRK1, - Angioprotein-1, TERT, VEGF BRCC, RAD53/CHK2, + RAD51, +BARD1+BRCA1+ MLH1+Tubulin, +SKP2, +PALB2 P53, BRCA1, CDC25B, MDM4, CyclinB (CCNB1)-Cdk1 CDC25A, CDK4, eIF-4E, neu, TERT

IL7

PCNA, MSH2, K-RAS, PPM1D MMP2, MMP9, -CCND1 PTEN, KRAS, CyclinD1, ESR1, MMP2, MMP9, MYC ESR1, ESR2, FIX, indirectly regulates through ER, P53, FOS, BRCA1, PGR CSF, IGFBP AR, P53, TGF, FOS, PGR, BRCA1, CYP1B1, FIX, MMP2, -IL6 +CyclinD1, +BRCA1 PCNA, CDK1, +RB, +CDK2 +Cyclin A + CDK2, +BRCA1 FRA1, IL2, IL8, ET1, MMP1, FLG, P53 JUN, RARA +RFCs, +Ligase, +MSH3, +GTBP, +POL-D and- E, +PMS2, +RARA BRCC, +ATM, +BRCA2, +GTBP, +P53, +BRCA1 VEGF-A, VEGF-165, VEGF-145 MSH2, ESR1 NF-!B MYC, MMP2, MMP9

200

JUN ELF1

P53

Cancer Therapy Vol 6, page 201

Figure 8. Key nodes of MBC disease network. A molecule (gene or protein) placed relatively upper side regulates its corresponding lower placed molecule except a few. (A B) means A is upstream of B and ( indicates binding reaction.

represent lists of respectively FBC specific antitumorogenic and apoptotic phytochemicals those might be effective in MBC provided similar molecular pathogenesis.

G. Key regulators and targets of all critical pathways Using Array analyzer and PA, additional key regulators and targets of these critical pathways were identified those will probably be good drug targets.

Identified such targets are AKT, EGF, PKAc, TNF, PI3K, JNK1, PTEN, ERBB2, MAPK, CyclinD-CDK4, VEGF, MMP2, BRCA1. Thus combining all results possible total 30 drug targets are EGF, EGFR, ERBB2, JUN, FOS, AKT, !-catenin CYP19A1, ESR1, NF-!B, MYC, TNF, IL6, VEGF, MMP2, MMP9, BRCA1, BRCA2, P53, CHK2, PCNA, PPM1D, PKAc, PI3K, MAPK, JNK1, PTEN, KRAS, and CyclinD-CDK4.

IV. Discussion MBC is uncommon but accounts for highest cancer specific death and the incidences are increasing. Lack of proper disease characterization at molecular level due to the rarity of the disease is responsible for poor treatment and severe side effects of conventional treatments results in a high mortality rate. Thus understanding of MBC biology at molecular point of view and subsequent targeted therapy with alternative drugs is essential. Using several bioinformatics approaches we tried to answer those questions by finding MBC critical disease paths, their key regulators and network targets of those critical paths to identify potential drug targets. Finally we tried to identify potential dietary antioxidant, anti-cancer, and immuniostimulatory phytochemicals as an alternative of conventional drugs those can target our identified critical paths.

H. Targets of chemoprevention in BC Several dietary phytochemicals of various groups including flavonoid, tannins, triterpene, saponins, alkaloids, and anthraquinone compounds have been found to bring cell cycle arrest and apoptosis by various mechanisms involving various pathways in malignant cells with out affecting normal cells. Literature mining identified such phytochemicals those are effective in FBC and can target our identified molecules. Table 2 and 3

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Barh and Das: Targeting critical disease pathways in male breast cancer

Figure 9. Overlapping networks. Arrows in Black, Violet, Red, Green, and Blue indicate respectively interactions of Osprey Human GRID, common interactions between Osprey and PA, common interactions between PA and TP, TP interactions, and common interactions between GRID and TP.

Figure 10. Critical paths for DNA repair (gray), ER (green), and EGF (blue) signalling in MBC. Pink colour net works indicates common downstream network for both ER and EGFR signalling. Orange network is common for DNA repair and EGF signalling. Bottle green represents TGF and TNF signaling.

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Cancer Therapy Vol 6, page 203 Table 2. Molecular targets of dietary phytochemicals in FBC. Drug Targets

ESR1

Phytochemicals Resveratrol (Red grape skin) Indole-3-carbinol (I3C) (Cruciferous vegetables)

Glyceollins (soy derived) Kaempferide, Apigenin, and Flavone Rretinoic acid Genistein (soy derived) Resveratrol BRCA1 BRCA2

and

BRCA1

I3C and genistein (Red grape skin) Lycopene (Tomato) Indole-3-carbinol (I3C)

PTEN

Indole-3-carbinol (I3C)

BRCA1, PTEN, E-cadherin, !-catenin, E-cadherin and !-catenin

Indole-3-carbinol

Aromatase (CYP19A1)

Tangeretin (Citrus Fruits) Procyanidin B from red wine Grape seed extract

IGF-I

Lycopene

VEGF TGFb1 VEGF

and

Genistein Resveratrol

TGF-#

EGCG (Green tea)

IkkB, VEGF, MMP-9, and ICAM-1 pS2, TGF-#, MMP2, TIMP1 COX-2, MMP9, NF-!B NF-!B, COX2, MMP-9

Curcumin (Curcuma longa)

NF-!B, MMP-

Resvertrol

Curcumin

Resveratrol Curcumin

Mode of action With 17#-estradiol, functions as an antiestrogen (Bhat et al, 2001), inhibits ER-" expression (Bhat and Pezzuto, 2002).

Anti-estrogenic (Chen et al, 2004), upregulates CYP enzymes responsible for 2-hydroxylation of estrogen (Yuan et al, 1999), synergistic effect of I3C and genistein induces growth arrest in response to DNA damage and increases apoptosis (Auborn eta la, 2003).

Antiestrogenic and an antagonist to ER", inhibits ESR1 signaling (Burow et al, 2001).

Antagonist to ER" but may not bind to ESR1 (Collins-Burow et al, 2000).

Down-regulates expression of the estrogen-responsive genes PR and pS2 (Rubin et al, 2004).

Potent estrogen agonist, binds to ER, dose dependent growthinhibition, similar effect as of tamoxifen (Zava and Duwe, 1997).

Upregulates BRCA1 and BRCA2 mRNAs (Fustier et al, 2003).

Both I3C and genistein upregulates BRCA1 and BRCA2 (Fan et al, 2006).

Upregulates BRCA1 and BRCA2 mRNA in ER positive breast cancer (Chalabi et al, 2004).

Induces BRCA1 expression and both I3C and BRCA1 inhibit oestrogen (E2)-stimulated oestrogen receptor (ER-") activity (Fan et al, 2006).

Upregulates PTEN and inhibits cell adhesion, spreading, and invasion (Qi et al, 2005).

Inhibits the cell adhesion, spreading and invasion of BC by upregulation of PTEN BRCA1, E-cadherin and downregulates !-catenin and inhibits adhesion, migration and invasion of BC (Meng et al, 2000).

Upregulates E-cadherin and downregulats !-catenin, inhibits adhesion, migration and invasion in BC (Brack et al,2002).

Reduces androgen-dependent tumor growth by inhibiting estrogen formation (Eng et al, 2003).

Suppresses aromatase expression in estrogen-dependent BC (Kijima et al, 2006).

Downregulates IGF-I in ER positive BC and brings growth inhibition (Karas et al, 2000).

Inhibits angiogenesis by downregulating VEGF and TGFb1 in ER negative BC (Shao et al, 1998).

Downregulates VEGF and inhibits angiogenesis in ER negative BC (Garvin et al, 2006).

Upregulated p21/WAF1 and p27, inhibits TGF-# induced EGFR auto-phosphorylation in ER negative BC (Masuda et al, 2002).

Inhibition and degradation of IkappaB, and downregulation of metastatic proteins VEGF, MMP-9, and ICAM-1 (Ramachandran et al, 2005).

Inhibits ER downstream genes, pS2 and TGF #, MMP2 and upregulates TIMP1 in estrogen-dependent BC (Shao et al, 2002).

Inhibits COX-2, MMP-9, and NF-!B expression and brings S-G2-M arrest in ER positive BC (Banerjee et al, 2002).

Inhibits breast cancer metastasis to the lung by downregulating NF-!B, COX-2, and MMP-9 (Aggarwal et al, 2005).

Downregulates NF-!B, Cox-2 and MMP-9 and inhibits 203

Barh and Das: Targeting critical disease pathways in male breast cancer 9 NF-!B, AKT MMP-9 MMP2, MMP9 MMP-9, TIMP-1

Genistein Sulforaphane (Broccoli) Genistein Genistein

EGFR, PKC "

Ratinoic Acid

EGFR, HER2, ESR1

Genistein+ tamoxifen

Src, EGFR, STAT-1, STAT-3 ERK1/2, p38

Indole-3-carbinol

MAPK

Asiatic acid (Centella asiatica) EGCG

Irs-1 and AKT

Ratinoic Acid

AKT and ERK

EGCG

Wnt signaling

EGCG

AP1, ERK, FOS AP1/JUN

Genistein

MET, ERG-1, FOS, JUN, SP1

Cleavage products of #carotene Genistein

Cyclin B1 and tubulin

Sulforaphane (Cruciferous vegetables)

Cyclin Dl Cyclin D1, Cdk4 and 6 Cyclin E

Lycopene Curcumin

CDK2

I3C+tamoxifen

P53, CHK2, and ATM p21/WAF1 and p27 hTERT

Genistein

hTERT, Bcl-2 c-MYC, Ras EROD and TPA

Dibenzoylmethane (Glycyrrhiza inflata) Genistein

Curcumin

EGCG (Green tea) Curcumin

metastasis in rat model (Banerjee et al, 2002).

Inactivates NF-!B and downregulates AKT in BC (Gong et al, 2003).

Inhibits MMP-9 activity and invasiveness in ER negative BC (Rose et al, 2005).

Downregulates transcription of MMPs and inhibits metastasis in both ER positive and negative BC (Kousidou et al, 2005).

Inhibits metastasis by downregulation of MMP-9 and upregulation of TIMP-1 in in both ER positive and negative BC (Shao et al, 1998).

Inactivates EGFR and inhibites PKC " in hormone dependent BC, arrests cell cycle, prevent growth factor signaling (Tighe and Talmage, 2004).

Inhibits growth of HER2 overexpressing BC by downregulating survivin, EGFR, HER2, and ER (Mai et al, 2007).

Sequential activation of Src, EGFR, STAT-1 and STAT-3, followed by EGFR degradation, induces apoptosis and cell cycle arrest in BC (Moiseeva et al, 2007).

Induces S-G2-M arrest and apoptosis through ERK1/2 and p38 in BC (Hsu et al, 2005).

Blocks ER-dependent transcription and MAPK activation (Sartippour et al, 2006).

Downregulates Irs-1 and AKT and inhibits proliferation in ER positive BC (Del Rincon et al, 2003).

Inhibits HGF-induced Met phosphorylation and subsequent AKT and ERK activation (Bigelow Cardelli, 2006).

Suppress Wnt signaling in invasive breast cancer (Kim et al, 2006).

Inactivates AP1 and ERK and downregulates c-Fos in BC (Dampier et al, 2001).

Inhibits activator protein-1-mediated transcriptional activation and inhibit BC growth (Tibaduiza et al, 2002).

Inhibits BC proliferation, downregulates MET protooncogene, upregulates breast tumor suppressor EGR-1; inhibits FOS, JUN, and Egr-1 binding to Sp1 transcription factor 9 (Singletary and Ellington, 2006).

Inhibits proliferation by elevating Cyclin B1 and tubulin polymerization and arrest G2-M in ER positive BC (Jackson et al, 2004).

Attenutes cyclin Dl (Nahum et al, 2006).

Downregulates Cyclin-D1 expression and blocks its association with cdk4 and 6 (Choudhuri et al, 2005).

Downregulates cyclin E and inhibits proliferation (Aggarwal et al, 2007).

Downregulates CDK2 in estrogen-dependent BC (Cover et al, 1999).

ATM dependent upregulation and activation of P53 and CHK2 (Ye et al, 2001).

Upregulated p21/WAF1 and p27 proteins in estrogendependent BC (Liang et al, 1999).

Downregulates hTERT in estrogen-dependent BC (Ramachandran et al, 2002).

Inhibits all four E2-ERE-dependent oncogenes (Lin et al, 2006).

Inhibits CYP1A1-mediated EROD and TPA-induced COX-2 activities in BC (Shon et al, 2006).

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Cancer Therapy Vol 6, page 205 Table 3. Apoptotic targets of dietary phytochemicals in FBC. Targets P53, Bax MAPK CYP19A1 P53 FasL Cyclin D/ CDK 4, p53, p21, Casp-9, Bax, Bcl-2 and Bcl-XL Bcl2 Bax, Casp -9 and Casp-7 Bak, Bcl-x

Phytochemicals Curcumin (Turmeric) Curcumin Resvertrol (red grape skin) Resvertrol Resvertrol Resvertrol

Ratinoic Acid (ATRA) Styrylpyrone derivatives (Goniothalamus sp) Genistein (soy derived)

Bax, Casp-3

EGCG (Green tea)

XIAP, IAP1, IAP-2, Bcl-2, and Bcl-xL PTEN

Curcumin

Aktcaspase-9 pathway PI3K, Bcl2, NF-!B hTERT

Resveratrol

Genistein

Resveratrol Resveratrol

Mode of action Upregulates p53 followed by Bax in ER positive BC (Choudhuri et al, 2002).

Induction of apoptosis by downregulating MAPK activation (Squires et al, 2003).

Acts as an aromatase inhibitor and suppress estrogen biosynthesis (Eng et al, 2003).

Downregulates p53 (Gehm et al, 1997; Hsieh et al, 1999; Bhat et al, 2001).

Fas/Fas ligand-mediated apoptosisis (Clement et al, 1998).

Inhibits Cyclin D/CDK 4, p53, and p21 and activates Caspase-9 and Bax and downregulating Bcl-2 and Bcl-XL in ER positive BC (Kim et al, 2004).

Downregulates Bcl2 and induces apoptosis in metastasis ER positive BC (Hayashi et al, 2003; Danforth, 2004). increases Bax level and induces apoptosis through Caspase -9 and Caspase-7 in BC (Alvin et al, 2003).

Bak and Bcl-x mediated apoptosis (Po et al, 2002), synergistic effect of I3C and genistein induces GADD expression and increases apoptosis in ER positive BC (Auborn et al, 2003).

Upregulates Bax/Bcl2 ratio activates caspase-3 in metastatic mouse BC (Baliga et al, 2005).

Downregulates anti-apoptotic XIAP, IAP-1, IAP-2, Bcl-2, and BclxL (Ramachandran et al, 2005).

Induces apoptosis in ER positive BC by upregulating PTEN (Dave et al, 2005).

Brings growth-inhibition and apoptosis in ER positive BC through Akt-caspase-9 pathway (Li et al, 2006).

Induces caspase-independent apoptosis by inhibiting PI3K signaling, Bcl2, and NF-!B in ER positive BC (Pozo-Guisado et al, 2005).

Brings apoptosis by downregulating telomerase activity in ER positive BC (Lanzilli et al, 2006).

Total 25 genes involving three critical disease pathways namely ER signaling pathway, EGFR signaling pathway, and DNA repair pathway are found to be involved in MBC pathogenesis (Figure 10). It has been noticed that MYC is downstream target of all pathways and is regulated by TNF, EGF, TGF, and estrogen through ERBB2 (Figure 2). MMP9 acts through NF-!B and estrogen is the major regulator of all MBC pathways and in some extent cAMP (Figure 4) which is partially supported by findings of Bernard-Gallon and colleagues in 2003 that estrogen upregulates BRCA1 and BRCA2.

Our key nodes analysis and critical path models (Figure 8 and 10) can explain the role of any gene associated with MBC. For example reports of lack of expression (Pich et al, 1999), loss of function and decreased transcriptional activator activity (Poujol et al, 1997), G2185A point mutation (Lobaccaro et al, 1993) and CAG repeat mutation (Young et al, 2000), or downregulation (Munoz de Toro et al, 1998) of Androgen

receptor (AR) in MBC can be supported by our key nodes analysis (Figure 8) where AR is upstream regulator of ESR1, BRCA1, P53, and FOS. Thus any abnormal AR expression must affect all three critical pathways. This key nodes analysis will also work for other mutated or overexpressed genes.

Maximum shortest paths are found to be mediated by EGFR, ERBB2, JUN, NF-!B and estrogen those can serve as good drug targets. Identified key nodes of MBC pathways are EGF, ESR1, ERBB2, JUN, MMP2, FOS, MYC, BRCA1 and 2, CHK2, PCNA, AKT, TNF, VEGF, CyclinD-CDK4, KRAS, and PPM1D those manly regulate cell cycle, cellular growth, and DNA repair machinery.

According to figure (Figure 10), ESR1 and NF-!B are main drug targets in ER signaling pathway, ERBB2/EGFR, AKT, and !-catenin in EGFR signaling pathway, and in DNA repair pathway, downstream of tumor suppressor genes may be considered as drug targets.

ESR1, AKT, EGF, JNK, TNF, PTEN, and ERBB2 seem to

205

Barh and Das: Targeting critical disease pathways in male breast cancer be broad spectrum targets. MBC due to PTEN mutation can be treated by targeting AKT or !-catenin.

Population based studies show various percentages of MBC incidences due to mutation in BRCA1 and BRCA2 accompanied with ERBB2 overexpression (Kirsi et al, 2004), overexpression of P53, ERBB2, and ESR1 (Mour찾o et al, 2001), upregulation of ERBB2, MYC, PPM1D , ZNF217, ESR1, and CCND1 (B채rlund et al, 2004), ERBB2 gene amplification (Rudlowski et al, 2004; Fonseca et al, 2006), and overexpression of ESR1, ERBB2 and CYP19A1 (Dakin et al, 2007). Thus genetic makeup of MBC varies from person to person and also varies depending on particular group of population. These facts indicate that our identified all three critical paths are involved in many MBC cases thus an appropriate pharmacogenomics approach of treatment rather than conventional one will be more effective to fight with MBC. Targeting option will depend on the molecular makeup of particular cases of MBC as all identified genes are not at a time involved in a single case. Strategy of induced apoptosis (Fan et al, 1998) and cell cycle arrest in the neoplastic cells without affecting the normal cells of the body by chemopreventive dietary and safer phytochemicals (Jang et al, 1997; Chattopadhyay et al, 2004), those are showing promising results is now-a-days interest of research. Based on literature mining it has been found that, several dietary phytochemicals act on our identified targets (Table 2 and 3).

At least thirteen phytochemicals (Resveratrol, Indole-3-carbinol, Glyceollins, Genistein, Lycopene, Tangeretin, EGCG, Curcumin, Sulforaphane, Ratinoic

Acid, #-carotene, Grape seed extract, and Dibenzoylmethane are found effective in targeting several identified key molecules (ESR1, BRCA1, BRCA2, PTEN, !-catenin, Aromatase (estrogen), VEGF, TGF, MMP-2, MMP-9, NF-!B, AKT, EGFR, PKC, HER2, ERK, FOS, JUN, Cyclins and CDKs, CHK2, and MYC, RAS) to inhibit cell cycle, growth, and metastasis in both ER (+) and ER (-) FBCs (Table 4). Five, out of these thirteen phytochemicals namely Curcumin, Resvertrol, ATRA, Genistein, and EGCG simultaneously can induce apoptosis by activating different apoptotic pathways without affecting normal cells (Table 5). As these five phytochemicals are effective on both ER (+), ER (-), and even on metastatic FBCs and can act on all most all targets of our identified three shortest paths in MBC, hypothetically, these phytochemicals can be potential alternative source of conventional drugs for MBCs. Individual phytochemicals may be effective to treat or prevent specific MBC cases depending on their molecular profile. As these five phytochemicals are able to act on maximum drug targets covering all critical paths in MBC, a proper combination and doses of these phytochemicals may be applicable to all MBCs irrespective of their molecular profile. In vitro experiments using these identified phytochemicals and understanding of their mode of action and specificity to MBC will help to develop a multi-targeting anticancer drug using single or a combination of these natural dietary phytochemical with minimal or no side effects.

Table 4. Phytochemicals and their mode of actions on targets.

Phytochemicals Curcumin

Upregulates/ activates TIMP1, P53, Bax, XIAP, IAP-1, IAP-2, Bcl-2, and Bcl-xL

Resvertrol

BRCA1, BRCA2, Casp-9, Bax

Ratinoic Acid

N/A

Genistein

BRCA2, P53, CHK2, TIMP-1, EGR-1, PTEN

EGCG Indole-3-carbinol Glyceollins Lycopene Tangeretin Sulforaphane

p21/WAF1, p27, Bax, Casp-3 BRCA1, PTEN, E-cadherin N/A BRCA1, BRCA2 E-cadherin Cyclin B1, tubulin

Downregulates/inhibits MAPK, IkkB, VEGF, ICAM-1, pS2, TGF-#, MMP2, MMP-9, NF-!B, COX-2, Cyclin D and E, Cdk4 and 6, hTERT ESR1, Akt, PI3K, VEGF, NF-!B, COX-2, MMP-9, Cyclin D/CDK4, p53, p21, Bcl-2, BclXL, hTERT ESR1, PGR, pS2, EGFR, PKC ", Irs-1, AKT, Bcl2 ESR1, VEGF, TGFb1, NF-!B AKT, ERK, MMP2, MMP9, EGFR, HER2, MET, AP1, FOS TGF-#, EGFR, MAPK, AKT, ERK, Wnt signaling ESR1, EGFR, !-catenin, CDK2 ESR1 IGF-I, Cyclin Dl !-catenin MMP-9

Grape seed extract Dibenzoylmethane #-carotene

N/A Bcl2 N/A

CYP19A1 hTERT, c-MYC, Ras AP1/JUN 206

BC type ER (+) ER (-) Metastatic

ER (+) ER (-) Metastatic

ER (+) Metastatic ER (+) ER (-) Metastatic ER (+) ER (-) Metastatic ER (+) ER (+) ER (+) ER (+) ER (-) ER (+) ER (+)

Cancer Therapy Vol 6, page 207 Table 5. Phytochemicals those can target both growth factor signaling and Apoptosis.

Phytochemicals Curcumin (Turmeric) Resvertrol (Red grape skin) Ratinoic Acid Genistein (Soy derivatives)

EGCG (Green Tea)

Cell cycle/ growth/ metastatic inhibitory targets VEGF, MMP-2, MMP-9, TGF #, NF-!B, Cyclin D1, Cyclin E , Cdk-4 and -6, MAPK, BRCA1, BRCA2, ESR1, VEGF, NF-!B and MMP-9, CYP19A1, Cyclin D/CDK 4, p53, and p21 ESR1, EGFR and PKC, Irs-1 and AKT BRCA1, BRCA2, ESR1, VEGF and TGFb1, NF-!B and AKT, MMP2 and MMP9, EGFR, HER2, AP1, ERK, FOS, P53, CHK2, and ATM TGF-#, MAPK, AKT and ERK, p21/WAF1 and p27

Apoptotic targets

BC type

P53, Bax, XIAP, IAP-1, IAP-2, Bcl-2, and Bcl-xL

ER (+) ER(-) Metastatic

FasL, P53, Akt-caspase-9 pathway, PI3K, NF-!B, hTERT

ER (+) ER(-) Metastatic

Bcl2

ER (+) Metastatic ER (+) ER (-) Metastatic

Bak, Bcl-x, PTEN

Bax, Casp-3

ER (+) ER (-) Metastatic

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Bhagwandin SS (1972) Carcinoma of the male breast in Zambia.

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Bhat KP, Lantvit D, Christov K, Mehta RG, Moon RC, Pezzuto JM (2001) Estrogenic and antiestrogenic properties of resveratrol in mammary tumor models. Cancer Res 61, 7456-7463.

Bhat KP, Pezzuto JM (2001) Resveratrol exhibits cytostatic and antiestrogenic properties with human endometrial adenocarcinoma (Ishikawa) cells. Cancer Res 61, 61376144.

Bigelow RL, Cardelli JA (2006) The green tea catechins, (-)epigallocatechin-3-gallate (EGCG) and (-)-picatechin (ECG), inhibit HGF/Met signaling in immortalized and tumorigenic breast epithelial cells. Oncogene 25, 1922-1930.

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Burow ME, Boue SM, Collins-Burow BM, Melnik LI, Duong BN, Carter-Wientjes CH, Li S, Wiese TE, Cleveland TE, McLachlan JA (2001) Phytochemical glyceollins, isolated from soy, mediate antihormonal effects through estrogen receptor " and #. J Clin Endocrinol Metab 86, 1750-1758.

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Acknowledgements We thank to those Bioinformatics software providers, whose tools were used in this research and we highly appreciate them for their offers of academic and free licensing and limited trial options. We also express gratitude to all database providers for their rich and up-todate information frequently used in this research.

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Cancer Therapy Vol 6, page 213 Cancer Therapy Vol 6, 213-220, 2008

Hypoxic abdominal perfusion for recurrent platin refractory ovarian cancer Research Article

Karl R. Aigner!,*, Sabine Gailhofer!, Monika Schwarz!, Norbert Hilger" !Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstrasse 1, 84489 Burghausen, Germany "Center for Evaluation and Methods, University of Bonn, Oxfordstrasse 15, 53111 Bonn, Germany

__________________________________________________________________________________ *Correspondence: Prof. Dr. Karl R Aigner, Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstrasse 1, 84489 Burghausen, Germany; Tel: +49-(0)-8677-91600; Fax: +49-(0)-8677-9160120; e-mail: info@prof-aigner.de Key words: ovarian cancer, platin refractory, regional chemotherapy, isolated perfusion, chemofiltration, chemoresistance Abbreviations: Complete response, (CR); progression free survival, (PFS); Vascular Endothelial Growth Factor, (VEGF) Received: 18 March 2008; Accepted: 21 March 2008; electronically published: April 2008

Summary In platin-refractory recurrent ovarian cancer the evidence available does not support firm conclusion about the preferred chemotherapy regimen. An increase of local exposure, however, by means of isolation perfusion techniques may have a greater impact on the cancer cells by a breakthrough in drug resistance and prolong symptom-free survival and overall survival. In a study on 79 patients, 61 of which were platin-resistant and in progression after first and second line platin combination chemotherapies, isolated hypoxic abdominal perfusion was performed. 20 complete responses and 31 partial responses were registered for an overall response rate of 64 %. Complete resolution of ascites after two isolated perfusions was noted in 43 %, a reduction of the ascites by > 50 % was observed in 19 %. Bone marrow toxicity was usually mild and did not exceed grade 1 â&#x20AC;&#x201C; 2. Grade 3 leucopenia and thrombocytopenia was observed only in cases with intensive prior systemic chemotherapy. The median survival time was 14 months, the median progression free survival was 8 months and the 25 % survival was 30 months with predominantly good quality of life. 8/79 patients (10 %) survived six years and more (75, 89, 91, 110, 172, 180, 187, 218 months). 4/79 patients have been living disease free for 110, 180, 187 and 218 months. Three of them had G3 tumors.

without any improvement in overall survival. The reason for this phenomenon might be that a much higher local drug exposure is required in order to definitely affect residual disease and as a consequence improve overall survival. This was the rationale to investigate whether a further, substantial increase of the administered drug concentration, as can be achieved by isolated perfusion with an extracorporeal circuit, may generate a drugexposure, strong enough to eradicate the entire or at least a significant part of the residual drug-resistant tumor burden.

I. Introduction Platinum refractory recurrent ovarian cancer remains a challenge. Currently the treatment of choice for advanced disease involves thorough cytoreductive surgery in combination with platinum containing chemotherapy plus paclitaxel. In case of relapse the prognosis is closely correlated with the interval from completion of initial therapy to recurrence (Gore et al, 1990), such that, the longer the interval between primary treatment to relapse, the greater the chance to have response rates to retreatment approaching those achieved with primary therapy.

Therapeutic options, however, are poor in those patients who relapse within six months following completion of primary therapy, because their tumors are most unlikely to respond to any kind of therapy. These patients are considered non curable (Ozols, 1997).

In studies on long-term maintenance therapy (Markman et al, 2003) or enhanced dose chemotherapy (Dark et al, 2005) a prolonged remission was noted, but

II. Material and Methods A. Patient characteristics 79 patients in clinical stage FIGO IIIC/IV were enrolled in this phase II clinical trial. 61 were in progression after first and second line chemotherapy with cisplatin combination therapies (anthracyclines, cyclophosphamide, taxanes). Six patients had had third 213

Aigner et al: Hypoxic abdominal perfusion for recurrent platin refractory ovarian cancer ligament and secured with tourniquets. Through a longitudinal incision a venous stopflow-catheter is inserted into the femoral vein and fixed with a prolene purse string suture. The femoral artery is cannulated through a transverse incision. Both stopflowcatheters (Pfm Cologne, Dispomedica Hamburg) are proceeded with the balloon tips to the level of the diaphragm, the venous catheter just above the venous drainage of the liver veins into the vena cava. After correct positioning both catheters are deflated again in order to avoid too early hypoxia. Two pneumatic cuffs around the upper thighs are then blocked. After starting the extracorporeal circuit at a flowrate of maximally 500 ml/min, the chemotherapeutics are administered as a one minute bolus infusion into the arterial line. Immediately after injection both stopflow-catheters are blocked and the extracorporeal circuit maintained for fifteen minutes of hypoxic perfusion (Figure 1).

Thereafter both stopflow-catheters are deblocked simultaneously and chemofiltration through the same catheters is switched on (Figure 2) for substitution of approximately four liters. After the procedure the catheters are removed and the vessels repaired with running sutures.

line, one fourth line pre-treatment. One patient had prior radiotherapy of the pelvis (Table 1). Median age was 55 years (30 – 83 years). Three patients were stage FIGO III B (4 %), 56 patients were FIGO III C (71 %) and 20 patients (25 %) were stage FIGO IV disease. 62 patients (78.5 %) had a four-quadrant peritoneal carcinosis and 17 patients (21.5 %) a two-quadrant dissemination. Tumor grading was noted grade G3 in 39 % of the patients (Table 2). Pre-treatment data are listed in Tab. 2. 62/79 patients had been pre-treated. 54 of those pre-treated patients had prior systemic chemotherapy (87 %), four had radiochemotherapy (6.5 %) and the remainder had radionuclidinstallation and systemic chemotherapy (5 %) and radiotherapy of the pelvis (1.5 %).

B. Technique chemofiltration

of

perfusion

and

Isolated abdominal perfusion is performed under in general anesthesia. Through a small longitudinal incision in the groin the femoral or ilio-femoral vessels are exposed beneath the inguinal

Table 1. Patient characteristics I. Pretreatment Systemic chemotherapy Radiochemotherapy Radionuclid install. + SCT: Radiotherapy pelvis:

n = 62/79 (79 %) n = 54/62 (87 %) n = 4/62 (6,5 %) n = 3/62 (5 %) n = 1/62 (1,5 %)

Table 2. Patients characteristics II. Age: Stage:

Grading:

55 years (range: 30 – 83) FIGO III B: FIGO III C: FIGO IV: 4 – quadrant peritoneal carcinosis: 2 – quadrant peritoneal carcinosis: G3: 39 %

3 patients 56 patients 20 patients 62 patients 17 patients

Figure 2. Chemofiltration.

Figure 1. Scheme of perfusion.

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(4 %) (71 %) (25 %) (78,5 %) (21,5 %)

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III. Treatment

IV. Results

Four cycles of isolated hypoxic abdominal perfusion were performed at in four weeks intervals. The doses administered into the arterial line of the perfusion circuit were cisplatinum 1 mg/kg, adriamycin 0.7 mg/kg and mitomycin 0.43 mg/kg bodyweight. After each treatment cycle complete blood count and platelet count were carried out on a weekly basis. CA 12-5 levels were tested on day one of each cycle, directly before starting the isolated perfusion and on day 5 before discharging the patient. A CT-scan was performed after the second and the fourth cycle. 23/79 patients underwent explorative second look laparotomy for re-staging and determination of histological response. Clinical response was evaluated after the second and the fourth treatment cycle. Complete response (CR) was defined as the disappearance of all target lesions in CT-scan, normalization of the tumor marker CA 12-5 lasting at least four weeks and improvement of quality of life to “symptom free survival”.

Partial response was defined a 30 % or greater reduction of the longest diameter of target lesions, if accessible, and a more than 50 % reduction of the tumor marker CA 12-5.

Exclusion criteria were severe concurrent malignancies or other health problems such as cardiovascular insufficiency from coronary heart disease or absolute arrhythmia or uncontrolled diabetes or severe infection. White blood count should not be below 2.500/nl and not in a decrease, platelets lower than 150.000/nl.

Choice of drugs in combination with hypoxia was according to Beverly in 1981 classification of antineoplastic agents by their selective toxicities toward oxygenated and hypoxic tumor cells. Herein mitomycin C and adriamycin were preferentially toxic under hypoxic conditions (Figures 3, 4), whilst cisplatinum did not show any major preferential toxicity to cells under the condition of oxygenation or hypoxia.

Figure 3. Kaplan Meier survival estimate.

Histological response as an objective criterion was evaluated in 23 patients who underwent second-look laparotomy for restaging.

Clinical response was estimated according to the course of the tumor marker CA 12 – 5, the CT-scan, and the performance and quality of life, especially in terms of decrease or resolution of ascites, pain and discomfort.

Special attention was given to symptom free survival.

The rate of complete remissions, comparing clinical versus histological response was 25% vs. 13 %. The rate of partial remissions was 39 % vs. 35 %, respectively.

In the overall series 51 clinically complete and partial remissions (64 %) were noted, whereas overall histological CR's and PR's were 48 % (Table 3).

Complete resolution of ascites was observed in 43% of the patients after two therapies, and a marked reduction by estimated more than 50 % of the prior volume was noted in a further 19%. This translates into a clinical response in terms of ascites in 62 % of all patients (Table 4). Approximately three out of four patients (74 %) reported a substantial relief of pain and abdominal discomfort.

Median survival time of all 79 patients was 14 months, whilst the 25 % survival amounted to 30 months.

Median progression free survival was 8 months (Table 5).

Eight patients survived six years and more (79, 89, 91, 110, 180, 187, 218 months), in other words, 10% of all patients survived between six years and seven months up to eighteen years and two months.

The remaining four survivors have been living disease and symptom free for 110, 180, 187 and 218 months. Three of them initially had G3 tumors.

Comparing pretreated vs. non-pretreated patients, survival curves are almost identical and there is no significant difference in median survival (Figure 5).

Figure 4. Progression-free survival.

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Aigner et al: Hypoxic abdominal perfusion for recurrent platin refractory ovarian cancer Table 3. Response rates clinical-histological.

1. Clinical Response CR: 20/79 Pat. = 25%

2. Histological Response CR: 3/23 Pat. = 13% 64%

48 %

PR: 31/79 Pat. = 39%

PR: 8/23 Pat. = 35%

Table 4. Response ascites.

Results Resolution of Ascites

43 %

Reduction > 50 %:

19 %

62 %

Table 5. Progression-free survival.

25 % 50 % 75 %

PFS (months) 12 8 4

Survival (months) 30 14 8

V. Discussion A number of randomized studies in the past have failed to prove a clear superiority of any one chemotherapeutic regimen, neither in survival, nor in response rate or quality of life (Fung Kee Fung, 2002) only relapses occurring after a progression free survival of more than one year were successfully treated and responded to docetaxel and oxaliplatin (Ferrandina et al, 2007). Just as little, surgical debulking in advanced disease prolongs progression free survival. This is limited to early stages where curative surgery is feasible (Crawford et al, 2005).

In an attempt to break through drug resistance, a number of trials with dose intensification were conducted (Omura et al, 2003; Dark et al, 2005). Despite increased response rates they did not translate into prolonged survival but exhibited more toxicity. In context with recent studies toxicity was the limiting factor for dose escalation.

Continuing dose escalation by means of maintenance therapy with paclitaxel for an extended time period in women with advanced ovarian cancer who had achieved a clinically defined complete response to initial platinum/paclitaxel- based chemotherapy significantly prolonged progression free survival but did not establish clinical benefit in terms of prolonged survival nor quality adjusted survival due to severe neuropathy which again, forced to reduce dosages (Markman et al, 2003). After dose escalation turned out to be a dead end street other therapeutic modalities like Vascular Endothelial Growth Factor (VEGF) inhibitors with our without accompanying chemotherapy were considered to be promising treatment options.

Monk and colleagues reported in 2006 good results with Bevacizumab in a study on 32 patients who had multiple prior chemotherapies. The median survival time of 6.9 months at a median progression free survival (PFS) of 5.5 months, however, was far less than beyond those after isolated abdominal perfusion with a median survival

Figure 5. Survival estimate: pretreated vs. non-pretreated.

A. Toxicity and side-effects The most common side-effects are lymphfistulas (> 30 %) in the groin, such as a daily secretion between 30 ml to 70 ml or more, lasting between two days or two weeks until they dry up. Bone marrow toxicity was usually mild and did not exceed grade 1 â&#x20AC;&#x201C; 2, except in patients with intensive prior third or fourth line chemotherapy. In these patients grade 3 leucopenia and thrombocytopenia was observed. Grade 4 toxicity never occurred. Fatigue was observed in coincidence with posttherapeutic peak increase of the LDH and CA 12 â&#x20AC;&#x201C; 5, lasting two to three days and was considered a sign of tumor destruction or tumor lysis syndrom. Those patients (15 â&#x20AC;&#x201C; 20 %) usually develop fever in the afternoon during the first postoperative week.

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Cancer Therapy Vol 6, page 217 time of 14 months and a PFS of 8 months. In a phase II study to assess the efficacy and tolerability of Bevacizumab Burger and colleagues reported in 2007 a median PFS and overall survival of 4.7 months and 17 months respectively in patients with progressive ovarian cancer. Toxicity and adverse events were noted grade 3 (hypertension) and grade 4 in terms of pulmonary embolism, vomiting, constipation and proteinurea.

Although data seem promising, toxicity and side-effects are higher than after isolated perfusion and chemofiltration. Garcia and colleagues reported in 2008 similar results with a somewhat longer PFS (7.2 months) and about the same overall survival (16.9 months).

Toxicity included gastrointestinal bleeding, perforation and pulmonary hypertension.

It has to be pointed out, however, that due to nonhomogeneous patient selection phase II studies cannot be compared. Therefore it seems mandatory to initiate a randomized phase III trial comparing the isolation perfusion access with other modalities.

The remaining option, high dose chemotherapy, was investigated by Moebus and colleagues in 2007 in a phase III study, comparing high dose chemotherapy with peripheral blood stem cell support with standard intravenous chemotherapy for first line treatment of advanced ovarian cancer. In this study toxicity was much higher in the high dose chemotherapy arm, yet it failed to improve survival. Although disappointing at the first glance, these data are important (Ozols, 2007) because they make favourable results from prior phase II studies on substantial benefit from high-dose chemotherapy appear questionable. There seems to have been an overinterpretation of positive results which possibly to a great extent depend on patient selection criteria (Levin and Hrynink, 1987; Jodrell et al, 1992; Thigpen et al, 1997; Markman et al, 2003; Omura et al, 2003; Dark et al, 2005).

Another crucial point in the interpretation of doseresponse behaviour is the absolute drug-concentration required to overcome drug-resistance. In this aspect isolation perfusion techniques are a much more flexible tool, because required concentrations and AUCâ&#x20AC;&#x2122;s can be adjusted more or less on demand. The upper dose- or concentration limit is not systemic toxicity, but local tissue tolerance in the isolated circuit.

In this study with regional chemotherapy the starting point and the treatment modality differ from other studies.

First, patient selection included all patients in whom chemotherapy had been abandoned due to non responsiveness or patients who refused further chemotherapy due to intolerable toxicity. Second isolation perfusion is different from high-dose chemotherapy insofar as higher exposures (AUCâ&#x20AC;&#x2122;s) are feasible because of segmental treatment and subsequent chemofiltration which cuts off peak concentrations of the systemic drug exposure after deblocking the balloon catheters and cuffs.

Furtheron the administration of the total drug into the arterial line of the perfusion system can generate a much higher arterial drug concentration than can be achieved with sequential intravenous high-dose chemotherapy and thus establish a first pass tissue extraction able to

overcome drug resistance. An important parameter was the administration of adriamycin and mitomycin which develop increased cytotoxicity under hypoxia (Teicher et al, 1981) whereas cisplatinum shows no preferential toxicity under either conditions.

Interestingly in our study there was no difference in survival whether patients were pretreated or not, as shown in Figure 3a. This might indicate that the isolation perfusion procedure may overcome drug resistance.

The most important moment while performing a hypoxic isolated perfusion, is time of administration of the chemotherapeutics into the arterial line. It is a crucial error to wait with the application until the perfusion system is in a stable balance and then infuse the drug over a longer time interval (van Jiken et al, 2005). In a hypoxic system at a low pH drugs are most unlikely to pass cell membranes. This may be the reason for unfavourable results (Meyer et al, 2006).

The criticisms made of use of these techniques are largely based on outdated information from their initial inappropriate use on the one hand and inability and inexperience with their use on the other hand. There is no doubt that special skills and experience need to be learned for the safe and effective use of regional chemotherapy (Stephens, 1995) In a recent phase II study, Pohlen and colleagues reported in 2007 positive results with hypoxic abdominal perfusion in 59 patients with intraabdominal tumors like colorectal-, stomach-, gallbladder- and pancreatic cancer â&#x20AC;&#x201C; all of them more chemoresistant than ovarian cancer.

Nevertheless with 22 partial responders a good result was obtained.

If chemotherapeutics are applied in the given doses, the risk of bone marrow toxicity is very low, even if there is a systemic leakage and systemic drug exposure after opening the isolated circuit. Peak drug concentrations are eliminated by means of subsequent chemofiltration. Thus toxicity acceptable and quality of life is not impaired, but improved (Aigner, 1983, 1985, 1988; Muchmore et al, 1995; Tonn, 1985). Hypoxic perfusion, although performed as a routine for 17 years has definitely one weak point. This is the short time interval, available for injection of drugs at an acceptable pH, which is only a few minutes. Advantage of increased cytotoxicity under hypoxia can only be taken after the drug has entered the tumor tissue- and this requires initial oxygenation. Isolated abdominal perfusion with chemofiltration is also feasible using a heartlungmachine. Although technically more sophisticated, with sufficient routine and experience it is performed with the same manpower and with 1 # - 2 hours not more time consuming than hypoxic perfusion.

Expanding the interval of oxygenation by a few minutes might improve the outcome.

However, only phase III trials can give a clear answer about the real value of a method. Since even in G3 tumors continuing survivals over many years have been achieved, a phase III trial comparing regional chemotherapy in terms of isolation perfusion with current conventional treatments is recommended.

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Aigner et al: Hypoxic abdominal perfusion for recurrent platin refractory ovarian cancer Paclitaxel in Patients With Advanced Ovarian Cancer After Complete Response to Platinum and Paclitaxel-Based Chemotherapy: A Southwest Oncology Group and Gynecologic Oncology Group Trial. J Clin Oncol 21, 24602465.

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Aigner KR, Müller H, Walter H, Link KH (1988) Drug filtration in high-dose regional chemotherapy. Contrib Oncol 29, 261-280.

Meyer F, Gebauer T, Grote R, Martens-Lobenhoffer J, Ridwelski K, Lippert H (2006) Results of regional chemotherapy using the aortic stopflow technique in advanced pancreatic carcinoma. Surg Today 36, 155-61.

Aigner KR, Tonn JC, Hechtel R, Seuffer R (1983) Die intraarterielle Zytostatikatherapie mit venöser Filtration im halboffenen System. Onkologie 6, 2-4.

Burger RA, Sill MW, Monk BJ, Greer BE, Sorosky JI (2007) Phase II Trial of Bevacizumab in Persistent or Recurrent Epithelial Ovarian Cancer or Primary Peritoneal Cancer: A Gynecologic Oncology Group Study. J Clin Oncol 25, 51655171.

Möbus V, Wandt H, Frickhofen N, Bengala C, Champion K, Kimmig R, Ostermann H, Hinke A, Ledermann JA (2007) Phase III Trial of High-Dose Sequential Chemotherapy With Peripheral Blood Stem Cell Support Compared With Standard Dose Chemotherapy for First-Line Treatment of Advanced Ovarian Cancer: Intergroup Trial of the AGOOvar/AIO and EBMT. J Clin Oncol 25, 4187-4193.

Crawford SC, Vasey PA, Paul J, Hay A, Davis JA, Kaye SB (2005) Does Aggressive Surgery Only Benefit Patients With Less Advanced Ovarian Cancer? Results From an International Comparison Within the SCOTROC-1 Trial. J Clin Oncol 23, 8802-8811.

Monk BJ, Han E, Joseph-Cowen CA, Pugmire G, Burger RA (2006) Salvage bevacizumab-(rhuMABVEGF)-based therapy after multiple prior cytotoxic regimens in advanced refractory epithelial ovarian cancer. Gynecol Oncol 102, 140-4.

Dark GG, Calvert AH, Grimshaw R, Poole C, Swenerton K, Kaye S, Coleman R, Jayson G, Le T, Ellard S, Trudeau M, Vasey P, Hamilton M, Cameron T, Barrett E, Walsh W, McIntosh L, Eisenhauer EA (2005) Randomized Trial of Two Intravenous Schedules of the Topoisomerase I Inhibitor Liposomal Lurtotecan in Women With Relapsed Epithelial Ovarian Cancer: A Trial of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 23, 1859-1866.

Muchmore JH, Aigner KR, Beg MH (1995) Regional Chemotherapy for Advanced Intraabdominal and Pelvic Cancer in: Cancer of the Colon, Rectum and Anus. Eds: Cohen AM, Winawer SJ, Friedman MA, Günderson LL., 881-889.

Omura GA, Brady MF, Look KY, Averette HE, Delmore JE, Long HJ, Wadler S, Spiegel G, Arbuck SG (2003) Phase III Trial of Paclitaxel at Two Dose Levels, the Higher Dose Accompanied by Filgrastim at Two Dose Levels in PlatinumPretreated Epithelial Ovarian Cancer: An Intergroup Study. J Clin Oncol 21, 2843-2848.

Ferrandina G, Ludovisi M, De Vincenzo R (2007) et al.

Docetaxel and Oxaliplatin in the Second-line Treatment of Platinum-sensitive Recurrent Ovarian Cancer: A Phase II Study. Ann Oncol 18, 1348-1353.

Ozols RF (1997) Treatment of recurrent ovarian cancer: Increasing options - "recurrent" results (editorial). J Clin Oncol 15, 2177-80.

Garcia AA, Hirte H, Fleming G, Yang D, Tsao-Wei DD, Roman L, Groshen S, Swenson S, Markland F, Gandara D, Scudder S, Morgan R, Chen H, Lenz HJ, Oza AM (2008) Phase II Clinical Trial of Bevacizumab and Low-Dose Metronomic Oral Cyclophosphamide in Recurrent Ovarian Cancer: A Trial of the California, Chicago, and Princess Margaret Hospital Phase II Consortia. J Clin Oncol 26, 76-82.

Ozols RF (2007) Ovarian Cancer: Is Dose Intensity Dead? J Clin Oncol 25, 4157-4158.

Pohlen U, Rieger H, Kunick-Pohlen S, Berger G, Buhr HJ (2007) Phase II study of regional chemotherapy using the hypoxic abdominal perfusion technique in advanced abdominal carcinoma. 5-FU pharmacokinetics, complications and outcome. Anticancer Res 27, 667-74.

Gore ME, Fryatt I, Wiltshaw E, Dawson T (1990) Treatment of relapsed carcinoma of the ovary with cisplatin or carboplatin following initial treatment with these compounds. Gynecol Oncol 36, 207-11

Stephens FO (1995) Induction (Neoadjuvant) Chemotherapy by Intra-arterial Infusion or Perfusion Analysis of Criticism Raised and Difficulties Encountered-Valid and Invalid. Reg Cancer Treat 8, 109-114.

Jodrell DI, Egorin MJ, Canetta RM, Langenberg P, Goldbloom EP, Burroughs JN, Goodlow JL, Tan S, Wiltshaw E (1992) Relationships between carboplatin exposure and tumor response and toxicity in patients with ovarian cancer. J Clin Oncol 10, 520-528.

Teicher BA, Lazo JS, Sartorelli AC (1981) Classification of Antineoplastic Agents by their Selective Toxicities toward Oxygenated and Hypoxic Tumor Cells. Cancer Res 41, 7381.

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Thigpen JT (1997) Dose-intensity in ovarian carcinoma: Hold, enough? J Clin Oncol 15, 1291-1293.

Fung MF, Johnston ME, Eisenhauer EA, Elit L, Hirte HW, Rosen B; Cancer Care Ontario Practice Guidelines Initiative Gynecology Disease Site Group (2002) Chemotherapy for recurrent epithelial ovarian cancer previously treated with platinum - a systematic review of the evidence from randomized trials. Eur J Gynaec Oncol 23, 104-10

Tonn JC (1985) Die portocavale Hämofiltration bei der isolierten Perfusion der Leber. In: Hrg. Aigner KR. Beitr Onkol 21, 108-116. van Ijken MGA, van Etten B, Guetens G, de Bruijn EA, ten Hagen TLM, Wiggers Th, Eggermont AMM (2005) Balloon catheter hypoxic pelvic perfusion with mitomycin C and melphalan for locally advanced tumours in the pelvic region: A phase I-II trial. EJSO 31, 897-904.

Markman M, Liu PY, Wilczynski S, Monk B, Copeland LJ, Alvarez RD, Jiang C, Alberts D; Southwest Oncology Group; Gynecologic Oncology Group (2003) Phase III Randomized Trial of 12 Versus 3 Months of Maintenance

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Cancer Therapy Vol 6, page 219

From left to right: Karl R. Aigner, Sabine Gailhofer, Monika Schwarz, Norbert Hilger

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Aigner et al: Hypoxic abdominal perfusion for recurrent platin refractory ovarian cancer

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Cancer Therapy Vol 6, page 221 Cancer Therapy Vol 6, 221-226, 2008

Veterinary pathologists achieve 80% agreement in application of WHO diagnoses to canine lymphoma Research Article

Victor E. O Valli Veterinary Lymphoma Study Group

__________________________________________________________________________________ *Correspondence: Victor E. O Valli, DVM Professor Department of Pathobiology College of Veterinary Medicine University of Illinois, MC 004, Rm 284 SAC, 1008 W Hazelwood Drive Urbana IL 61821, USA; Tel: 217 265 5415; Fax 217 333 5496; email vevalli@uiuc.edu Key words: canine lymphoma, WHO diagnoses, Case assembly, Histopathology, microscopic review, pathologists, statistical methods, Case derivation, Diagnostic pitfalls Abbreviations: American Kennel Club, (AKC); Anaplastic Large Cell Lymphoma, (ALCL); Burkitt-Like Lymphoma, (BKL); Diffuse Large cell B-cell Lymphoma, (DLBCL); Follicular Lymphoma, (FL); Histiocytic Sarcoma, (HS); not otherwise specified, (NOS); Peripheral T-cell Lymphoma, (PTCL); T-Lymphoblastic Lymphoma, (T-LBL) Received: 27 March 2008; electronically published: June 2008

Presented in the Theilen Tribute Symposium at UC Davis 31 st May- 1st June 2008.

Summary To assist the accuracy and impact of lymphoma diagnosis in animals a blinded study was carried out to test the accuracy and reproducibility of veterinary pathologists, not specialists in hematopathology in applying the World Health Organization (WHO) classification system for human lymphomas. Twenty pathologists reviewed 300 cases of canine lymphoma with a consensus diagnosis derived for each case by three pathologists specializing in hematopathology. The 17 Reviewing pathologists were given the signalment for each animal and required to render a diagnosis on biopsy tissue after reviewing an oversight stain of hematoxylin and eosin, followed by the same tissues stained by immunohistochemical methods for B and T-cell lineage. The diagnostic process required the reviewers to fill out a bubble sheet having 43 types of lymphoma as choices. The overall accuracy of the 17 reviewing pathologists on the 300 cases was 83.1%. In a review of accuracy on the 6 most common diagnoses that contained 79.5% of total cases their accuracy rose to 86.6%. In a test of reproducibility made by recutting 5% of the cases that were re-entered under a different number the overall agreement between the first and second diagnosis on the same tissue varied from 40-86.7%. Statistically there were 43,000 data points for each of the 17 reviewers.

(Harris et al, 1994, 2000; [No authors listed], 1997).

Currently, lymphomas in dogs are treated as if they are all of the same type, but we now find that like those in humans, the canine lymphomas are of many types that also benefit from specific identification and treatment. The goal of this international standardization project is to demonstrate that veterinary diagnosticians can effectively apply the human criteria to the canine tumors and thus permit much more effective treatment by veterinary oncologists. The WHO system of disease classification is based on diagnosis of diseases rather than on cell types and requires complete patient data plus immunophenotyping 5,6. In an international review by human medical pathologists, their overall accuracy and reproducibility in testing the WHO system exceeded 85%,

I. Introduction Lymphoma is the most common canine cancer treated by chemotherapy and a most common neoplasm that afflicts dogs of all breeds and ages. The disease is recognized internationally and treated by veterinarians in both first opinion and referral practice. The completion of sequencing of the canine genome has shown the remarkable similarities between the genetic make-up of dogs and humans. Similarly, many of the malignancies that occur in dogs are also like their human counterparts especially the tumors of the lymphoid system. The World Health Organization has devised a new system of recognizing and categorizing the many subtypes of human lymphoid tumors with very different characteristics that must be considered in providing effective treatments 221

Valli: Veterinary pathologists in agreement of WHO diagnoses to canine lymphoma through the 300 cases using a dual viewing microscope and compared their interpretations with that derived by Dr Valli.

About 10% of diagnoses were changed on the basis of their review with a full consensus required and reached for each case.

That consensus diagnosis became the official interpretation against which all of the 17 additional reviewers were compared.

The second group of 6 pathologists (Aug. 18-25), and the third group of 4 from Europe (Nov 18-24), all followed the same routine. Dr Scott Moroff was not able to attend for all of the first week and completed the half of the study by subsequent shipment of the slides. Dr. Tony Ross was the only participant who labored entirely alone on the study while on a working visit to Illinois. Each group began with a Monday morning review of cases in contention; the cases in question were projected and the diagnostic reasoning behind the interpretation was discussed.

Throughout, reviewers would bring cases they were unsure of to one of the three principal pathologists for consultation, utilizing a 4 headed microscope.

Lunch was provided on site and most days the pathologists worked till 7-8:00PM, depending on their rate of progress, and then all would break for dinner. The final review period was conducted during the Thanksgiving week for European pathologists while students were absent and facilities available.

Plans to conduct the final review in Bristol University UK were changed to Illinois with the decline in the dollar against the Euro making the change essential.

rendering other systems obsolete ([No authors listed], 1997). The WHO system defines human lymphoid neoplasms as 16 disease subtypes of B- and of T-cell tumors that differ greatly in presentation, normal biology, rate of progression and response to therapy. Consequently, these neoplasms are very specifically identified and treated. Remarkably, canine, like human lymphomas, differ greatly in natural rate of progression and response to therapy. Canine lymphomas have been described in the WHO format and there is now very strong evidence that when specifically identified, they closely mimic the human counterparts in gaining remission and projected survival patterns (Valli et al, 2002, 2006; Jubb et al, 2006).

II. Materials and Methods A. Case assembly 1. Collection of cases Excellent and essential collaboration was requested from National Diagnostic Laboratories to provide histology slides to the ACVP study. Animal owners paid for the cost of biopsy and interpretation, including immunophenotyping. Veterinary oncologists were requested to submit cases for interpretation through cooperation of the Veterinary Cancer Society with the ACVP study. All cases processed at Illinois were sectioned cut at a thickness of 3 microns to facilitate recognition of cellular detail. Bubble sheet forms, derived from the medical pathologists Non-Hodgkin’s Lymphoma study were printed and used for each case reviewed by veterinary pathologists. Accession of cases began in January of 2006 with 670 received prior to beginning the review, and increased to 950 at the time of this writing. A target goal of 1000 cases is within reach and will allow determination of the value of specific diagnosis on response to treatment and survival.

C. The lymphoma review pathologists

2. Histopathology The slides were given a unique ACVP serial number in addition to the pathology number of the processing laboratory and the case reports were archived. A period of one week was projected for the pathology slide review. The number of cases to be evaluated by each pathologist was limited to 300 to permit completion of the entire slide set during that period. The signalment for each case was extracted from the case reports and assembled into an electronic file numbered 1-300. The 300 cases were divided into 8 separate groups of <38 cases in each group to allow the 8 pathologists to review cases simultaneously. An overview powerpoint program of diagnoses was prepared. CD’s, with over 250 images of the different diagnostic categories, were sent to pathologists potentially interested in participating in a blinded review. A shorter CD was prepared of major diagnostic types and teamed with a 4 page algorithm that provided a logical pathway for diagnostic decision points based on architecture (nodular or diffuse), cell size (small, intermediate or large), nuclear shape (round or indented), nuclear chromatin (dispersed or with parachromatin clearing), nucleoli number and placement (single central, immunoblastic or multiple peripheral, centroblastic), and mitotic rate (0-5 low, 6-10 medium, >10 high).

Name Barthel*A. Bienzle* D. Caswell* J. Colbatzky F.

Residence USA Canada Canada Germany

Training TAMU OVC OVC Hanover

Durham A.

USA

U Penn

Ehrhart* E. Jones* C. Kiupel* M. LaBelle* P. Lester*S. Miller*M. Moore*P. Moroff* S. Ramos-vara J. Roccabianca*** P.

USA USA USA USA Canada USA USA USA USA Italy

CSU Tufts Utrecht UCD UCD WSU UCD

Ross A.

Australia

Scase* T. Tvedten** H. Valli** V. Vernau* W

UK Sweden USA USA

Spain UCD & UNIMI U Sydney U FL MSU OVC OVC

Employment Antech University University BoehringerIngelheim Senior Resident University IDEXX University Antech Private Lab University University Antech University University Private lab University University University University

*Indicates diplomate ACVP, ** indicates diplomate ACVP AP and CP. ***indicates diplomate ECVP.

1. The problem

B. The microscopic review of cases

Lymphoid tumors in animals are often given a generic diagnosis of “lymphoma” by veterinary pathologists. Oncologists determining treatment thus receive a non-specific interpretation despite the marked variation in clinical behavior of animal lymphomas, as seen in human patients.

Strategic solution: Demonstrate that veterinary pathologists who are not specialists in hematopathology can accurately and

In June/July of 2007, DVM pathologists were contacted largely by email to determine availability for a week in Illinois to participate in the review process. The Review program paid for air fare and hotel in Champaign IL and all meals.

The first group of 8 pathologists (Aug 11-18) included Drs Peter Moore and William Vernau of UC Davis CA. They worked

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Cancer Therapy Vol 6, page 223 consistently apply an upgraded system of lymphoma classification in a blinded study. If veterinary diagnostic efficacy is proven then pathologists can accept that more specific diagnosis of lymphoma is achievable.

Hodgkinâ&#x20AC;&#x2122;s Lymphoma Study Group, who found that immunophenotyping is essential for correct recognition of all human lymphomas except those with a follicular architecture. Since follicular lymphoma constituted less than 1% of total cases in this study, it is apparent that immunophenotyping is essential for all cases of animal lymphoma.

Intraobserver reproducibility was tested by re-cutting 5% of the cases, including examples from the most common entities. These recuts were reentered into the study with a similar signalment but different pathology accession numbers and ACVP serial numbers. The mean overall agreement between the first and second diagnosis on the same tissue for the 20 test observers was 65.5% with a range of 40-86.7%.

The answer to the final question (clinical presentation and survival by diagnosis) will be derived from analysis of the presenting signs recorded in the final group of 1,000 cases as part of the review of survival by diagnosis. Initial evaluation of clinical data has been tallied for the 300 case study. It is apparent that dogs with indolent lymphoma retain normal appetite and activity, two very key determinants of well being, with advanced stages of lymphoma. The specific lymphomas with these characteristics include: nodal and splenic Marginal Zone lymphoma, the follicular lymphomas, small cell lymphoma of B and T-cell types, T-Cell Rich Large BCell lymphoma and T-Zone lymphoma. An important conclusion to be derived from this study is that the current paradigm of a diagnosis of B-cell lymphoma is more favorable to the outcome than one of T-cell lymphoma is no longer valid. We are now in the era of understanding that there are very aggressive lymphomas like lymphoblastic lymphoma of B or T-cell type and very indolent lymphomas of both B and T-cell type. The latter include Mantle and Marginal Zone lymphoma of B-cell type and the most indolent of all T-Zone lymphoma.

2. The plan Duplicate the plan as carried out by medical pathologists for The Non-Hodgkinâ&#x20AC;&#x2122;s Lymphoma Classification Project (Blood 89: 3909-3918, 1997) ([No authors listed], 1997).

Specific Study Goals: 1. Determine the ability of veterinary pathologists to apply the WHO system of lymphoma classification on a retrospective group of cases of canine lymphoma derived nationwide.

2. Determine the need for immunophenotyping and clinical history in the diagnostic process.

3. Determine the intraobserver and interobserver reproducibility in the diagnosis of the more common diagnostic entities.

4. Determine the presenting clinical signs for the various types of lymphoma and the survival by diagnosis.

3. The funding In association with case collections fund raising efforts resulted in donations of $35,000.00. Idexx Labs, Ft. Dodge Animal Health and the ACVP Council each provided $10,000.00, and an additional $5000.00 was received from Dr Sally Lester. Funding of $42,000.00 was received in 2007 from the American Kennel Club (AKC). Substantial support from Antech was provided by covering both travel and hotel expenses for participating Antech personnel, and on occasion, graciously paying for food for the whole group attending the first week of review. Antech also provided funding for related research to determine the clonality of cells in a subset of reviewed cases.

Boehringer-Ingelheim paid the travel expenses of Dr. Florian Colbatzky from Germany to Illinois.

III. Results A. The statistical methods and data The data were subjected to a 2x2 tabular analysis that measured both sensitivity based on the number of times the consensus diagnosis was chosen and specificity that measured the rate of rejection of incorrect diagnoses. The first analysis compared all of the 17 reviewers with the consensus diagnoses for each case. The overall level of agreement was 83.1% which included all 43 diagnostic categories; the percentages ranged from 46.4 to 100%.

Upon analyzing data from the 6 most common diagnostic entities, which constituted 79.5% of total cases, the overall agreement was 86.6%. These six subtypes of lymphoma included; marginal zone spleen, diffuse large B-cell, Tlymphoblastic, nodal T zone, peripheral T-cell not otherwise specified (NOS) and disease other than lymphoma. Remarkably, there are 43,000 data points for each reviewer, which indicates the complexity of the analysis.

Clearly these are most gratifying results and the most clinically significant to be derived from this data.

These results positively and emphatically answer the first two stated goals of this study. The first is that veterinary pathologists who are not specialists in hematopathology can achieve a high degree of accuracy in applying the WHO classification system for lymphomas. The second is that immunophenotyping is essential for diagnosis of canine lymphoma. This is in agreement with the Non-

B. Case derivation by state As of this writing 950 cases have been received with 911 derived from 34 American States and 3 other countries including Canada 14, Austria 13 and The Netherlands for 6 cases. The major States on the basis of cases submitted in alphabetical order are: Arizona California Colorado Connecticut Florida Illinois Massachusetts New Jersey New York

134 314 23 33 36 118 18 20 109

Other States submitting 16 or less cases include: Alaska, Alabama, Arkansas, Georgia, Iowa, Indiana, Louisiana, Maryland, Minnesota, Missouri, Montana, North Carolina, Nebraska, New Hampshire, Nevada, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Texas, Washington State, Wisconsin.

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Valli: Veterinary pathologists in agreement of WHO diagnoses to canine lymphoma

C. Case distribution by diagnosis: (950 cases) B-CELL LYMPHOMAS

T-CELL LYMPHOMAS

NOT LYMPHOMA

B-CLL

2

CUTANEOUS T-CELL

14

ANGIOSARCOMA

1

B-LBC

3

MYCOSIS FUNGOIDES

4

CANINE HISTIOCYTOMA

B-SLL

8

PERIPHERAL T-CELL

118

HISTIOCYTIC SARCOMA

8 1 0

BURKITT-LIKE

86

T ANGIOIMMUNOBLASTIC

1

MAST CELL TUMOR

1

CENTROCYTIC DIBCL

4

ENTEROPATHY TYPE T

1

MYCOTIC ADENITIS

1

DLBCL

370

T-ANAPLASTIC LARGE CELL

5

SOFT TISSUE SARCOMA

1

FL II&III

3

T-CLL

1

THYMOMA

1

LYMPHOPLASMACYTOID

2

T-LBC

14

MANTLE CELL

15

T-LBL

16

MARGINAL ZONE

54

T-NK

3

PLASMACYTOMA

16

T-SLL

1

PLASMABLASTOMA T-CELL RICH LARGE BCELL

6

T-ZONE

104

10

6. Marginal zone lymphoma can be difficult to distinguish from early DLBCL. Distinction involves assessment of mitotic rate. Additionally, although rare, the blastoid variant of mantle cell lymphoma is also difficult to recognize.

D. Diagnostic pitfalls In the course of reaching consensus on all diagnostic entities and in going over cases with pathology reviewers it is apparent that there are a number of diagnoses that are “look-alikes” and must be carefully interpreted to reach a correct conclusion.

1. Diffuse Large cell B-cell Lymphoma (DLBCL), the most common diagnostic entity in the dog, and Peripheral T-cell Lymphoma (NOS) (PTCL) are indistinguishable without immunophenotyping.

2. PTCL with most cells of intermediate size can be mistaken for T-Lymphoblastic Lymphoma (T-LBL). The distinction is important since T-LBL is the most aggressive lymphoma and is characterized by the shortest survival time despite intensive therapy.

3. DLBCL may be confused with Burkitt-Like Lymphoma (BKL). The standard criteria are if there are large cells with nuclei 2.0 or more red cells in diameter in every field, then the diagnosis is Large Cell type despite 90% of the cells being of intermediate size (nuclei are 1.5 times the diameter of RBC).

4. Follicular Lymphoma and Benign or Atypical Follicular Hyperplasia are frequently confused with consequent overdiagnosis of follicular lymphoma. True Follicular Lymphoma (FL) has no mantle cell cuffs and few or no tingible body macrophages. In FL the same cell types are present in the same proportion in each neoplastic follicle as might be expected with a clonal neoplasm.

5. Anaplastic Large Cell Lymphoma (ALCL) of T cell and B cell lineage, and canine Histiocytic Sarcoma (HS) may be confused. It is essential to note that the large atypical neoplastic cells of T-ALCL have variable CD3 expression (often reduced). Both neoplasms are characterized by marked variation in nuclear size and both have unusually abundant cytoplasmic volume.

IV. Discussion The most important findings of this study are that veterinary pathologists can accurately apply the criteria of the WHO classification for the diagnosis of canine lymphomas. If the degree of diagnostic accuracy achieved in this study was generally applied to animal lymphomas, it would provide the basis for more specific therapy and result in longer survival of many animals. Equally important is the hope that this characterization will facilitate more effective research on those entities that are currently virtually untreatable, like lymphoblastic lymphoma. Confidence in the significance of these findings is based on feedback from oncologists who find they can now tailor their treatments to specific diagnostic entities such as TZL (indolent lymphoma). The first step in proving the application of the WHO classification is done. The second step is to prove the value of its application by determining survival as a function of specific diagnosis and stratified by therapeutic protocol.

The selection of pathologists for the review was not random, but largely based on their availability to attend during the times requested. Input received from medical colleagues central to the operations of the Non-Hodgkin’s Lymphoma Study Group suggested that an international approach was vitally important, so that US pathologists did not dominate the overall review. With that in mind, 7 of the 20 pathologists currently reside outside of the US (Bienzle, Caswell, Colbatzky, Roccabianca, Ross, Scase and Tvedten). In addition Barthel, Kiupel, LaBelle, and

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Cancer Therapy Vol 6, page 225 Ramos-Vara are originally from outside of the US, giving us more than a 50% international presence.

In a previous smaller blinded microscopic review, it was found that a first year resident scored higher in applying the study criteria than a pathologist with many years of experience. On that basis, one participant - now a senior resident - was invited to participate. That confidence was rewarded with an overall mean accuracy in the upper half of the entire review group. The very relevant point to be gained from this participation is that a pathologist need not have a long period of experience in order to successfully apply the WHO criteria. In fact, it might be argued that a lack of background bias based in application of previous diagnostic systems may be a distinct advantage.

The case material for the study brought up several important issues. First, at our current level of understanding, it is not possible to provide a specific diagnosis of many of the lymphoma subtypes based on cytologic assessment. There are fine points of recognition in interpretation of lymphoma on Wrights-stained cytologic preparations, but these need verification that can only be gained by having access to cytology and histology on the same tissues. Secondly, there is a minimum size of biopsy required for a firm histologic interpretation. Nodal excision is always preferable and a wide bore cutting needle biopsy may be preferable to a shallow incisional biopsy. It can be firmly stated that an 18 gauge tru-cut biopsy may be adequate for renal biopsy but not for lymphoma. In general a nodal biopsy should be near 2mm in width to provide sufficient architecture for diagnosis on lymphoid tissue. Additionally, specimen thickness is critical with optimal assessment requiring sections 4u or thinner. With respect to immunophenotyping, there appears to be significant variation in the quality of CD79 a immunohistochemical staining achieved between laboratories, with poor quality staining significantly complicating interpretation.

Consequently, CD20 assessment can be an extremely useful adjunctive (but not replacement) stain.

To mount the study we needed access to new cases as retrospective studies could not routinely provide the immune stained slides felt to be essential. The Veterinary Cancer Society not only printed a request for case submissions in their newsletter but the membership responded and has continued to do so with the target of 1000 cases likely achieved at this presentation. In the formative stages of the study the members repeatedly gave input on the content of the clinical history format. The input of oncologists was essential and is gratefully recognized.

An accurate assessment of hematopoietic tissue requires superb histological preparations with those processed at Illinois thinly cut and well stained both for routine and immune preparations. Further to mount the study is was essential to gain continuing access to the slides for the pathology review and for the ability to reexamine these further on the basis of survival data yet to be derived. All contributing laboratories have our thanks.

Finally the next step is also dependent on our clinical colleagues as we determine the outcome of cases for impact of the nature of tumor subtype on response to therapy. We thank them in advance as well as their animal owning clients.

References [No authors listed] (1997) A clinical evaluation of the International Lymphoma Study Group classification of nonHodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project. Blood 89, 3909-3918.

Harris NL, Jaffe ES, Diebold J, Flandrin G, Muller-Hermelink HK, Vardiman J, Lister TA, Bloomfield CD (2000) The World Health Organization classification of neoplastic diseases of the haematopoietic and lymphoid tissues: Report of the Clinical Advisory Committee Meeting, Airlie House, Virginia, November 1997. Histopathology 36, 69-89.

Harris NL, Jaffe ES, Stein H, Banks PM, Chan JK, Cleary ML, Delsol G, De Wolf-Peeters C, Falini B, Gatter KC, et al (1994) A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 84, 1361-1392.

Jubb KVF, Kennedy PC, Palmer N (2006) Pathology of Domestic Animals. Fifth Edition, Vol 3. Chapter 3, the Hematopoietic System, VE Valli.

Valli VE, Jacobs RM, Parodi AL, Vernau W, Moore PF (2002) Histological Classification of Hematopoietic Tumors of Domestic Animals. WHO, Second Series, Vol VIII. Armed Forces Institute of Pathology Washington DC. Valli VE, Vernau W, de Lorimier LP, Graham PS, Moore PF (2006) Canine Indolent Nodular Lymphoma. Vet Pathol 43, 241-56.

Acknowledgements This document would not be complete without recognition of the assistance gained and essential to the study. The initial financial support gave the impetus to get the project underway and provided the credibility for the American Kennel Club proposal for which many pathologists and oncologists offered supporting statements. Thanks to all.

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Cancer Therapy Vol 6, page 227 Cancer Therapy Vol 6, 227-238, 2008

Waldenström’s Macroglobulinemia: new therapeutic options Review Article

Aldo M. Roccaro1,2,3, Xavier Leleu1,4, Simona Blotta1, Nicholas Burwik1, Angelo Vacca3, Domenico Russo2, Irene M. Ghobrial1,* 1

Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA Unit of Blood Diseases and Cell Therapies, University of Brescia Medical School, Brescia, Italy 3 Department of Internal Medicine and Oncology, University of Bari Medical School, Bari, Italy 4 Service des Maladies du Sang, Hopital Huriez, CHRU, Lille, France 2

__________________________________________________________________________________ *Correspondence: Irene M. Ghobrial, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA; Tel: (617) 632-4198; Fax: (617) 632-6624; E-mail. Irene_ghobrial@dfci.harvard.edu Key words: Waldenstrom Macroglobulinemia Abbreviations: 2-cyano-3,12-dioxoolean-1,9-dien-28-oic acid, (CDDO); CDDO imidazolide derivative, (CDDO-Im); CDDO methyl ester, (CDDO-Me); B-lymphocyte stimulator, (BLyS); chronic lymphocytic leukemia, (CLL); computed tomography, (CT); dexamethasone, (DRC); Fludarabine, Cyclophosphamide and Rituximab, (FCR); German Low Grade Lymphoma Study Group, (GLSG); IgM-monoclonal gammopathy of undetermined significance, (IgM-MGUS); immunoglobulin M, (IgM); Immunomodulatory drugs, (IMiDs); Magnetic resonance imaging, (MRI); marginal cell lymhpoma, (MZL); multiple myeloma, (MM); Revised European American Lymhoma, (REAL); stromal derived factor, (SDF-1); Waldenström’s Macroglobulinemia, (WM); World Health Organization, (WHO)

Supported in part by International Waldenstrom Macroglobulinemia Foundation (IWMF) grant Received: 14 January 2007; Revised: 28 January 2007 Accepted: 2 February 2008; electronically published: April 2008

Summary Waldenström’s Macroglobulinemia (WM) represents a distinct clinicopathological entity resulting from the proliferation of B lymphocytes that show maturation to plasma cells; infiltration in bone marrow; and secretion of a monoclonal IgM detectable in the serum. The disease was first reported by Jan Waldenström who described two patients with a high level of a pentameric immunoglobulin IgM, elevated serum hyperviscosity accompanied by typical funduscopic features, and a lymphocytoid bone marrow infiltration. To date, WM remains incurable, with a median overall survival of 5 years. There is no standard treatment for this disease; the current therapeutic modalities available include alkylating agents, rituximab and purine nucleoside analogues. Recently, several new molecules have been tested in vitro and in vivo in WM (proteasome inhibitors, perifosine, enzastaurin and others), providing the framework for clinical trials in this disease.

symptoms because of the hyperviscosity which was attributed to the presence of an abnormally elevated high molecular weight serum protein, which subsequently was demonstrated to be a monoclonal pentameric IgM (Waldenström, 1944). WM has an overall incidence of approximately 3 per million persons per year, with almost 1500 new cases diagnosed per year in US (Herrinton and Weiss, 1993; Jemal et al, 2005), with a median overall survival of 5-6 years. However, recent data report a median disease specific survival of 11.2 years among the 337 patients evaluated (Ghobrial et al, 2003). It appears to be more common in Caucasian than in African Americans, representing only 5% of all patients (Jemal et al, 2005).

I. Introduction Waldenström’s Macroglobulinemia (WM) represents a rare lymphoplasmo-proliferative disorder characterized by accumulation of lymphoplasmacytic cells in the bone marrow or, rarely, in lymph nodes, accompanied by secretion of monoclonal immunoglobulin M (IgM) protein in the serum (Owen et al, 2003). It was described for the first time in 1944 by Jan Gosta Waldenström in two patients with lymphoadenopaty, oronasal bleeding, anemia, thrombocytopenia, elevated erythrocyte sedimentation rate, high serum viscosity, in absence of bone lesions, and with infiltration of bone marrow by lymphoid cells. Dr. Waldenström interpreted the

227

Roccaro et al: Waldenström’s Macroglobulinemia: new therapeutic options WM represents a sporadic disease and its cause remains unknown; however, various reports indicate a high familial incidence, with 18.7% of the patients having at least one first-degree relative with a familial history of WM or any other B-cell clonal disorder (Treon et al, 2006a). The main risk factor for the development of WM is the pre-existing IgM-monoclonal gammopathy of undetermined significance IgM-MGUS) which confers a 46 fold higher relative risk to develop WM than for the general population (Kyle et al, 2003a). WM is currently considered a lymphoplasmacytic lymphoma, according to the Revised European American Lymphoma (REAL) and World Health Organization (WHO) classification systems (Remstein et al, 2003).

subset of genes identified in WM patients, which included the MAPK pathway and IL-6 (Chng et al, 2006). These data were confirmed in another study where 4 genes were able to discriminate WM cells from chronic lymphocytic leukemia (CLL) cells (LEF1, MARCKS, ATXN1 and FMOD). To further determine the molecular signatures of WM at the protein levels, recent data have identified multiple novel proteins that are dysregulated in WM, which both enhance our understanding the pathogenesis of the disease and represent targets for novel specific inhibitors (Hatjiharissi et al, 2007). These include upregulated polypetides involved in signaling pathways such as those regulating Ras-related proteins (Rab4, p62DOK); Rho-related proteins (CDC42GAP, ROK!); and other proteins such as SNX-1, and Roaz.

II. Biology

III. Diagnosis

A. Origin of clonal cell

Diagnostic criteria for WM have been defined by Owen and colleagues in 2003 and they include the presence of a serum IgM component, accompanied by intra-trabecular bone marrow infiltration of small lymphocytes (with plasmacytoid or plasma cell differentiation).

Specifically, high-resolution electrophoresis and immunofixation of serum and urine are necessary to identify and characterize the IgM monoclonal protein. Densitometry should be used to determine IgM levels, whose measurement may be affected by the presence of cold agglutinin or cryoglobulins. For this reason, testing for cold agglutinin and cryoglobulins should be performed at diagnosis and, if present, serum samples should be analyzed under warm conditions. Despite the fact that Bence-Jones proteinuria is frequently present in WM patients, it rarely exceeds 1 g/24 hours (only 3% of cases). In addition, serum viscosity should be determined in patient who presents with signs or symptoms of hyperviscosity syndrome. A fundoscopic exam is recommended in these patients as it appears to be an excellent indicator for hyperviscosity, showing dot, blot and flame shaped hemorrages in the macular area, accompanied by markedly dilatated and tortuous veins with focal constrictions, resulting in the so-called “venous sausaging”.

As reported above, bone marrow biopsy represents a cornerstone of disease diagnosis. The intra-trabecular pattern of bone marrow infiltration (may be diffuse, interstitial, nodular) is commonly found in WM patients, while a solely para-trabecular pattern is rare and should raise the possibility of follicular lymphoma. An increased number of mast cells, close to lymphoid aggregates is commonly found in WM. The bone marrow infiltration should routinely be confirmed by immunophenotypic studies showing the following profile: sIgM+, CD19+, CD20+, CD22+, CD79+. Usually CD5, CD10 and CD23 are negative but a positivity for these markers may be observed up to 20% of cases, (surface IgM+, CD5/CD23/CD10/103/138-, CD19/20/25/27+, FMC7+) Magnetic resonance imaging (MRI) of the spine in conjunction with computed tomography (CT) of the abdomen and pelvis are useful in evaluating the disease status in WM. Bone marrow involvement can be documented by MRI studies of the spine in over 90% of

The origin of the malignant clone is thought to be a B-cell arrested after somatic hypermutation in the germinal center and before terminal differentiation to plasma cells (Sahota et al, 2002; Kriangkum et al, 2004).

This indication has been confirmed by the results of the analysis of the nature and distribution of somatic mutation in Ig heavy- and light-chain variable regions obtained from patients with WM (Wagner et al, 1994; Aoki et al, 1995), indicating that WM may originate from a IgM+ and/or IgM+IgD+ memory B cell, with a deficiency in the initiation of the switching process.

B. Cytogenetic findings Several studies have been conducted in order to investigate and define the possible role of genetic abnormalities in the pathogenesis of WM. The most common cytogenetic abnormalities identified by FISH analysis is the deletion of the long arm of chromosome 6, which was reported in up to 55% of patients with WM in one study (Schop et al, 2002a). Other studies demonstrated the presence of other cytogenetic abnormalities including trisomy 4, trisomy 5, monosomy 8 and deletion of the long arm of chromosome 20 (Schop et al, 2002b; Liu et al, 2006; Terre et al, 2006). Among the genes that are dysregulated in WM, BLIMP-1 is one of the candidate tumor suppressor genes in 6q21 that is under study: it regulates the transition of mature B-cells to terminally differentiated plasma cells (Turner et al, 1994). Other genes whose abnormal expression has been reported as a possible pathogenetic factor in WM include HAS1 and XBP-1 (Wu et al, 2000; Adamia et al, 2003). Recently, it has been shown that WM is characterized by upregulation of cytokines and chemokines that induce proliferation and survival of the clonal cells, such as B-lymphocyte stimulator (BLyS), IL-6, CD40 ligand, BAFF, APRIL and stromal derived factor (SDF-1) (Hatzimichael et al, 2001; MacKay et al, 2003; Chng et al, 2006; Elsawa et al, 2006a; Tournilhac et al, 2006).

Gene expression analysis has allowed us to better understand the underlying molecular aberration in WM. Gene expression data obtained from 23 WM patients, showed that WM presents a homogeneous expression profile similar to that of patients with CLL, with a unique

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Cancer Therapy Vol 6, page 229 patients, while CT of the abdomen and pelvis demonstrates enlarged nodes in 20% of WM patients.

Lymph node biopsy may show preserved architecture or replacement by infiltration of neoplastic cells with lymphoplasmacytoid, lymphoplasmacytic, or polymorphous cytological patterns.

of the patients, and some patients may present with B symptoms including night sweats, fever, and weight loss.

Other presentation features include peripheral neuropathy, cryoglobulinemia, skin rash (Shnitzlerâ&#x20AC;&#x2122;s syndrome is the term for IgM monoclonal gammopathy associated with urticarial skin lesions, fever, and arthralgia), coldagglutinin hemolytic anemia and amyloidosis. Antiâ&#x20AC;&#x201C; myelin-associated glycoprotein (MAG) antibody has been implicated in the demyelinating neuropathy found in WM. (Marmont and Merlini, 1991; Gertz et al, 1993; Gertz and Kyle, 2005; Ghobrial et al, 2003)

IV. Differential diagnosis It is possible to find an IgM monoclonal component accompanied by a bone marrow infiltration of lymphoplasmacityc cells in other B-cell lymphoproliferative disorders including B-cell CLL, multiple myeloma (MM), mantle cell lymphoma, marginal cell lymhpoma (MZL) and follicular lymphoma. B-CLL is mostly characterized by clinical features that overlaps with WM, nevertheless B-CLL patients often present lymphoadenopathies which are less common in WM. In addition, clonal cells in CLL are typically small to mature lymphocytes that are CD5 and CD23 positive, which are markers that are usually negative in WM. WM may be in differential diagnosis with IgM-MM, but the bone marrow infiltration by plasma cells, the presence of osteolytic lesions, as well as renal failure are more common in MM rather than in WM. In addition IgH translocations are more common in IgM-MM. Mantle cell lymphoma may be differentiated from WM because of the bone marrow infiltration by monomorphous small-medium lymphoid cells, with irregular nuclei; moreover, besides bone marrow, it usually involves lymph nodes, and extranodal sites such as gastro-intestinal tract and spleen. In addition in almost all cases of mantel cell lymphoma there is t(11;14) (q13;q32).

MZL, both nodal and splenic-MZL are in differential with WM. The nodal-MZL is characterized by variable bone marrow infiltration and a typical localized or generalized peripheral adenopathy with marginal zone and interfollicular areas with marginal zone, monocytoid, small B cells, and sometimes a plasma cell differentiation may be observed. On the other hand, splenic-MZL mostly involves spleen with small round lymphocytes that replace germinal centers and infiltration of red pulp.

Splenomegaly is very common with rare involvement of adenophathies or extranodal sites.

Finally, follicular lymphoma differs from WM for the bone marrow infiltration of small, cleaved cells, which is usually para-trabecular. In addition, cytogenetic analysis shows rearrangement of Bcl-2 in 70-90% of the cases.

VI. Prognosis Although WM represents an indolent disease, a wide variability in prognosis can be observed, therefore it is important to define prognostic factors. Factors associated with poor prognosis include advanced age (>60-70 years), which is often impacted by unrelated morbidities, high "2microglobulin, cytopenias, low serum albumin levels, high serum IgM monoclonal protein, and organomegaly (Dhodapkar et al, 2001; Dimopoulos et al, 2004; Ghobrial et al, 2006). The International Prognostic Staging System for WM, proposed by Morel et al, describe age >65 years, elevated unrelated morbidities, high2-microglobulin at 3 mg/L, serum IgM monoclonal protein > 70g/L, and hemoglobin <11.5g/dL as factors that confer poor prognosis in WM patients (Morel et al, 2006).

VII. Treatment options The Third International Workshop on WM confirmed the original recommendations of consensus panels on WM that patients should receive therapy only if they have symptoms or signs related to the disease, or specific laboratory abnormalities, and not based only on the serum monoclonal protein level (Treon et al, 2006b).

The most common reason for initiation therapy is represented by anemia, as well as hyperviscosity symptoms, cytopenias, evidence for disease transformation, and significant neuropathy, adenopathy or hepatosplenomegaly (Kyle et al, 2003b; Ghobrial IM et al, 2004a; Treon et al, 2006b; Vijay and Gertz, 2007).

There is no standard of therapy for the treatment of WM. In addition, to date there are no FDA approved therapeutic agents for the specific treatment of WM. Most treatment options were originally derived from other lymphoproliferative disease including multiple myeloma and CLL (Vijay and Gertz, 2007). The Third International Workshop on MM updated the treatment recommendations for frontline and salvage therapy of WM (Treon et al, 2006b). The panel emphasized that many factors should be considered in making the decision: the age of the patient, presence of cytopenias, and the rate of disease progression. The recommendations for upfront therapy included alkylating agents, nucleoside analogs, and the monoclonal antibody rituximab. For patients with relapsed disease, the use of alternate first-line agents, reuse of a first-line agent, use of combination myelotoxic chemotherapy, and the use of thalidomide as a single agent or in combination therapy were recommended. High-dose chemotherapy with autologous stem cell rescue in primary refractory or relapsed disease should be considered for

V. Clinical features The majority of the patients with WM present with signs and symptoms related to the monoclonal serum protein, tumor infiltration, tissue deposition of IgM, and to autoantibody activity of IgM. The most common clinical presentations are related to cytopenias, specifically anemia related to replacement of the bone marrow with tumor cells. Fatigue is a very common presentation of WM that is multifactorial, due at least in part to the underlying degree of cytopenias. Patients may also present with symptoms of hyperviscosity related to elevate IgM levels including headache, blurring of vision, and epistaxis.

Hepatosplenomegaly and lymphadenopathy occur in 20% 229

Roccaro et al: Waldenström’s Macroglobulinemia: new therapeutic options eligible patients.

However, allogeneic and “nonmyeloablative allogeneic” transplantations should be cautiously approached, given the associated high mortality and/or morbidity risks, and should be undertaken only in context of a clinical trial.

in WM has been recently examined in a large series of WM patients (Leleu et al, 2007). A 7-fold increase in transformation to an aggressive lymphoma/myelodysplasia was observed among patients who received a nucleoside analogue versus other therapies for WM.

B. Monoclonal anti-CD20 antibody

A. Standard therapies used in WM

Rituximab has become one of the main treatment options of patients with WM. Standard rituximab (4 weekly infusions of 375 mg/m2) has demonstrated at least a minor response in 52% of patients (Gertz, 2004).

Polymorphisms in the Fc!RIIIA (CD16) receptor gene may affect response to rituximab in WM (Treon et al, 2005). Authors showed that response to rituximab is delayed in most patients with a median time to partial response of 4 months and a median time to best response of 17 months (Treon et al, 2005). In addition, the IgM level may initially increase in response to rituximab, a phenomenon termed IgM flare that occurs in about in 54% of patients (Ghobrial et al, 2004b; Treon et al, 2004a).

These levels may persist for up to 4 months and do not indicate treatment failure, but may necessitate plasmapheresis to reduce hyperviscosity. Some patients receive maintenance therapy with rituximab. Although the impact of this regimen on the time to progression has not been determined specifically in WM, it has prolonged time to progression in patients with other low-grade lymphomas who received rituximab maintenance compared to those who did not (van Oers et al, 2006). Rituximab may also be useful in treating patients with IgM autoantibody-related neuropathies (Renaud et al, 2006). The use of radioimmunotherapy such as iodine 131I-tositumomab radioimmunotherapy in WM has been limited since the high level of bone marrow involvement precludes their use. However, case reports have shown that these therapies may be effective in patients with WM who have <25% bone marrow involvement (Tsai et al, 2004).

1. Alkylating agents Chlormabucil was the first agent used in clinical trials in WM. In a prospective randomized study by Kyle et al, there was no significant difference in the overall response rate between daily (0.1 mg/kg/day) or intermittent chlormabucil (0.3 mg/kg for 7 days, every 6 weeks). Overall responses to single agent chlorambucil varied between 31 and 92% (Kyle et al, 2000; Treon et al, 2006b). Reasons for these variations include small sample size, as well as different inclusion and response criteria.

The main complication of chlorambucil is the risk of developing myelodysplasia and acute myelogenous leukemia. In addition, stem cell damage due to therapy may prevent collection of stem cells. The use of steroids in combination with alkylator therapy resulted in a partial response in 72% of patients (Treon et al, 2006b).

The combination of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) together with rituximab (CHOP-R) has been tested in patients with WM. The German Low Grade Lymphoma Study Group (GLSG) performed a randomized upfront study of CHOP-R versus CHOP in 72 patients with low-grade lymphoma (71% of who had lymphoplasmacytic lymphoma) (Buske et al, 2004). The response rate in the CHOP-R arm was 94% compared to 69% in the CHOP arm. A prospective study of CHOP-R in newly diagnosed patients with WM is ongoing in the Eastern Cooperative Oncology Group.

2. Purine nucleoside analogues Cladribine and fludarabine have been extensively studied in WM and induced durable responses. Cladribine administered as intravenous infusion or by subcutaneous bolus injections has resulted in major responses in 40%90% of newly diagnosed patients, versus 38% to 54% in the salvage setting (Dimopoulos et al, 1993a, 1994; Treon et al, 2006b; Vijay et al, 2007). The overall response rate with daily infusional fludarabine therapy administered mainly on 5-day schedules in previously untreated and treated WM patients has ranged from 38% to 100% and 30% to 40%, respectively (Dimopoulos et al, 1993a,b; Treon et al, 2006b). The main complications of these agents are myelosuppression and immunosupression, especially of T cells leading to an increased risk of infections and a treatment-related mortality of up to 5% in some series (Vijay et al, 2007). In addition, stem cell collection may also be problematic after prolonged exposure to purine nucleoside analogues. There is limited experience in the use of an alternate nucleoside analogue to salvage patients whose disease relapsed after cladribine or fludarabine therapy: three of four patients (75%) responded to cladribine following relapse to fludarabine therapy, whereas only 1 of 10 (10%) with disease resistant to fludarabine responded to cladribine (Treon et al, 2006b; Vijay et al, 2007). The long safety of nucleoside analogues

C. Combinations of alkylating nucleoside analogs and rituximab

agents,

The addition of alkylating agents to nucleoside analogs is active against WM. For example, the combination of oral cyclophosphamide with subcutaneous cladribine in 37 newly diagnosed patients achieved 84% PR or more, with a median duration of response of 36 months (Weber et al, 2003) The combination of fludarabine and intravenous cyclophosphamide in 11 previously treated patients resulted in 55% overall response. In another study of 49 patients, the combination of fludarabine plus cyclophosphamide induced 78% overall response, with median time to treatment failure was 27 months (Tamburini et al, 2005; Treon et al, 2006b). Hematologic toxicity was commonly observed, and 3 patients died of treatment-related toxicities. A phase II clinical trial of 60 patients with WM treated with Cyclophosphamide, rituximab and dexamethasone (DRC) demonstrated an overall response rate of 70%, with 7% complete remission (Dimopoulos et al, 2006). Treatment was well tolerated and the main toxicity observed was grade 3-4 neutropenia in 20% of the patients. The combination of rituximab, cladribine and 230

Cancer Therapy Vol 6, page 231 cyclophosphamide was tested in 17 previously untreated patients with WM and achieved at least a partial response in 94% of the patients, with complete response in 18% (Weber et al, 2003; Treon et al, 2006b). The combination of Fludarabine, Cyclophosphamide and Rituximab (FCR) was tested in 21 patients with WM who had at least 1-2 prior regimens of therapy; overall response rate was 52%, with 5% complete remissions (Treon et al, 2006b).

Table 1 summarizes standard therapies used in WM.

4 patients. Despite reduction of initiation doses to 5mg daily, anemia continued to be problematic without evidence of hemolysis or more general myelosuppression.

Therefore, the mechanism for pronounced anemia in WM patients receiving lenalidomide remains to be determined and the use of this agent among WM patients remains investigational.

2. The proteasome inhibitor bortezomib The prototype 26S proteasome inhibitor bortezomib (Velcade, PS-341) selectively binds to the catalytic domain of the proteasome and prevents its activity (Hideshima et al, 2001). Based on its activity in MM, single agent bortezomib was tested in WM in phase II trials and achieved 40-80% responses (Chen et al, 2007; Dimopoulos et al, 2005). The combination of bortezomib, dexamethasone and rituximab was recently evaluated in untreated patients with WM. Each cycle of therapy consisted of IV bortezomib at 1.3 mg/m2 and IV dexamethasone 40 mg on days (1,4,8, and 11), and Rituximab at 375 mg/m2 (day 11). Patients received four consecutive cycles, followed by a three-month pause, and then 4 more cycles, each given three months apart. The interim analysis of the first 10 patients who received the first 4 cycles of therapy showed partial response in 50% and minor response in the other 50%, with 2 patients (20%) achieving an unconfirmed complete response (Treon et al, 2006c). The main complications of this trial were Herpes Zoster reactivation in 40% (Treon et al, 2006c). Another phase II trial of weekly bortezomib at 1.6 mg/m2 in combination with rituximab is currently ongoing in patients with relapsed or relapsed/refractory WM. The preliminary results of this study demonstrated an 81% response rate in the first 17 evaluable patients (Ghobrial et al, 2007).

D. Novel therapeutic agents 1. Immunomodulatory drugs (IMiDs) In view of their success in the treatment of patients with Multiple Myeloma, IMIDs thalidomide and lenalidomide were tested in patients with WM. A study to evaluate thalidomide alone or in combination with clarithromycin and dexamethasone showed partial response in 25% of previously untreated and treated patients who received single-agent thalidomide. Adverse effects were common and prevented dose escalation of thalidomide in 75% of patients. Thalidomide (50 mg daily) in combination with dexamethasone (40 mg orally once a week) and clarithromycin (250 mg orally twice a day) induced partial response in 83% of previously treated patients (Dimopoulos et al, 2003). However, a follow up study of 10 patients with higher doses of thalidomide (200 mg daily) showed only 20% overall response rate (Treon et al, 2006b).

Based on the potent activity of lenalidomide in MM and the lack of neuropathy with this agent, a phase II study of lenalidomide 25 mg daily in combination with rituximab is ongoing in patients with relapsed or relapsed/refractory WM. Acute decreases in hematocrit were observed during first 2 weeks of lenalidomide therapy in 81% of patients with a median hematocrit decrease of 4.4% (1.7-7.2%), resulting in hospitalization in Table 1. Treatment regimens active in WM. Treatment regimens CHOP vs CHOP-R Cladribine

Response Rates ORR: 94% vs 69% ORR: 38-90%

Toxicity Myelosuppression Myelosuppression; immunosuppression

Fluda

ORR: 30-100%

CTX/Cladribine CTX/Fluda

ORR: 84% ORR: 55-78%

Myelosuppression; immunosuppression Myelosuppression Myelosuppression

CTX/R/Dex Cladribine/CTX/R Fluda/CTX/R Thal vs Thal/Clarithromycin/ Dex Bortezomib

ORR: 70% ORR: 94% ORR 52% 25% vs 83% (PR)

Myelosuppression Myelosuppression Myelosuppression Thrombotic effect/myelosuppression

ORR: 40-80%

Neuropathy

ORR: overall response rate; PR: partial response R: rituximab; Fluda: fludarabine; CTX: cyclophosphamide; Thal: thalidomide; Dex: dexamethasone

231

References Buske, 2004 Dimopoulos, 1993a,1994; Treon 2006b; Vijay, 2007 Dimopoulos, 1993a,b; Treon, 2006b Weber, 2003 Tamburini, 2005; Treon, 2006b Dimopoulos, 2006 Weber, 2003 Treon, 2006b Dimopoulos, 2003

Dimopoulos, 2005; Chen, 2007

Roccaro et al: WaldenstrĂśmâ&#x20AC;&#x2122;s Macroglobulinemia: new therapeutic options and cessation of therapy in 23% patients (Treon et al, 2006d).

3. Anti-CD52 alemtuzumab-1H (Campath) CD52 is highly expressed on WM cells in the bone marrow, and alemtuzumab induces cytotoxicity of WM cells in vitro. A phase II study of alemtuzumab in 25 patients with relapsed WM or newly diagnosed untreated WM showed an overall response rate of 76%, including 8 (32%) partial responses and 11 (44%) minor responses (Hunter et al, 2006). Hematological toxicities were common among previously treated (but not untreated) patients and included G3/4 neutropenia (39%); thrombocytopenia (18%); anemia (7%). G3/4 nonhematological toxicity for all patients included dermatitis (11%); fatigue (7%); and infection (7%). CMV reactivation and infection was commonly seen among previously treated patients. Three patients died due to therapy-related complications (Hunter et al, 2006).

7. TACI-Ig Atacicept (ZymoGenetics) contains the soluble TACI receptor that binds to the cytokines BLyS and APRIL, members of the tumor necrosis factor family that promote B-cell survival. An open-label, dose-escalation Phase 1b study enrolled 16 patients with refractory or relapsed MM or active progressive WM. Sequential cohorts received one cycle of 5 weekly subcutaneous injections of atacicept at 2, 4, 7or 10 mg/kg (Rossi et al, 2006). Treatment with atacicept was well tolerated, and no dose limiting toxicity was observed. A biological response was observed in this heavily treated refractory population, with disease stabilization in 75% of the patients with WM (Rossi et al, 2006).

4. Bcl-2 inhibitor, G3139 (Oblimersen sodium; Genasense, Genta Inc, Berkeley Heights, NJ)

8. Perifosine KRX-0401 (Keryx Biopharmaceuticals, NY).

Perifosine is a novel Akt inhibitor that belongs to a class of lipid-related compounds called alkylphospholipids. It has shown activity in phase II trials in MM (Hideshima et al, 2006). Previous studies have demonstrated that the activity of the survival protein Akt is upregulated in patients with WM compared to normal B cells, and that downregulation of Akt leads to significant inhibition of proliferation and induction of apoptosis in WM cells in vitro (Leleu et al, 2007). In vivo studies of perifosine have shown significant cytotoxicity and inhibition of tumor growth in a xenograft mouse model (Leleu et al, 2007).

Subsequently, perifosine was shown to induce synergistic cytotoxicity with rituximab and bortezomib as well as with other conventional agents including fludarabine and cyclophosphamide (Leleu et al, 2007). Based on this preclinical activity, a phase II trial of single agent perifosine in patients with relapsed or relapsed/refractory disease using 150 mg oral daily dosing was initiated. The response rate in the first 27 evaluable patients was 32%, with over 90% of the patients showing no progression on this trial. The treatment was well tolerated with minimal side effects. These results indicate that perifosine is a promising agent to be used in combination in future studies in WM.

Bcl-2 regulates apoptosis and resistance to chemotherapeutic agents; it has therefore become an attractive target for anticancer therapy in a number of malignancies including WM (Frankel, 2003). In vitro studies have shown that Bcl-2 is expressed in WM cells, and that downregulation of Bcl-2 and increased cytotoxicity in WM cells may be achieved with G3139 (Nichols and Stein, 2003). A Phase I/II clinical trial of G3139 was conducted in patients with relapsed or relapsed/refractory WM showed favorable tolerability but little activity (Gertz et al, 2005).

5. Sildenafil citrate Based on the clinical observation that patients receiving sildenafil citrate had a decrease in their IgM (Treon et al, 2004c), a phase II trial of single agent sildenafil citrate in patients with slowly progressing WM, who did not meet consensus eligibility for active therapy, was initiated. The purpose of the study was to delay time to progression in these patients. Thirty patients were treated on this study, and disease progression was suppressed in more than 50% of the patients. After 3 months of therapy, 17% showed a minor response.

However, disease progression at 6 months of follow occurred in almost all the patients (Patterson et al, 2006).

9. RAD001 Based on the preclinical data showing increased activity of the PI3K/mTOR pathway in WM, rapamycin (mTOR inhibitor) has been studied in vitro in WM and showed significant cytotoxicity in WM cells lines, specifically when combined with bortezomib (unpublished data). A phase II trial of single agent RAD001 (orally at 10 mg daily) was initiated in aggressive, low grade lymphomas, and rare lymphomas including WM. Over 17 patients are enrolled on this study with over 40% response rate in the first 11 evaluable patients.

Table 2 shows on going clinical trials using novel agents in WM.

6. Imatinib mesylate (Gleevec) Imatinib targets the microenvironment of WM through inhibition of stem cell factor signaling through CD117, which is expressed on WM and mast cells. A phase II trial of single agent imatinib is ongoing in patients with relapsed or refractory WM (Treon et al, 2006d).

Imatinib is given at 400 mg daily, with dose escalation to 600 mg after one month of therapy. After 3 months of therapy, 6/13 (46.2%) of patients achieved MR. The main toxicities observed included cytopenias, edema, and hyperglycemia, leading to dose reductions in 31% patients

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Cancer Therapy Vol 6, page 233 Table 2. On going clinical trials using new drugs in WM. (Source: www.clinicaltrials.gov) Treatment regimen Thal Thal+Rituximab Len+Rituximab Bortezomib Bortezomib+Rituximab (relapsed/refractory disease) Bortezomib+Rituximab (newly diagnosed) RAD001 Perifosine

Phase II II II II II

Endpoints Tumor response, OS, PFS RR, time to treatment failure, toxicity RR, TTP, safety RR, safety, tolerability RR, safety, TTP

II

RR, ORR, TTP, toxicity, ability to collect stem cells

II II

ORR, OS, PFS, duration of response ORR, toxicity, TTP, PFS, duration of response

Thal: thalidomide; Len: lenalidomide OS: overall survival; PFS: progression free survival; RR: response rate; TTP: time to progression; ORR: overall response rate

E. Future therapeutic options: agents in preclinical studies

3. The new proteasome inhibitor, NPI-0052 (Nereus Pharmaceuticals, CA)

1. PKC inhibitor, Enzastaurin (LY 317615; Eli Lilly, Indianapolis, IN)

Based on the activity of bortezomib in patients with WM, NPI-0052 was tested in WM cell lines and patient samples (Roccaro et al, 2008a). NPI-0052 induced apoptosis, cytotoxicity and inhibition of DNA synthesis, with an IC50 of 15-30nM in all cell lines tested at 48 hours. Similar effects were demonstrated in primary CD19+ WM cells. Importantly, the combination of NPI0052 and bortezomib induced significant inhibition of proliferation compared to each agent alone (Roccaro et al, 2008a).

Proteomic studies in WM demonstrated upregulation of PKC" in malignant cells compared to normal B cells.

Based on this, Enzastaurin a novel PKC inhibitor was used to block PKC activity in WM cells. Enzastaurin induced a significant decrease of proliferation and induced apoptosis in WM cell lines and primary patient samples, without cytotoxicity on peripheral blood mononuclear cells (Moreau et al, 2007). In addition, enzastaurin overcame tumor cell growth induced by co-culture of WM cells with bone marrow stromal cells. Enzastaurin inhibited Akt phosphorylation and Akt kinase activity, as well as downstream p-MARCKS and ribosomal p-S6 (Moreau et al, 2007). Furthermore, Enzastaurin demonstrated additive cytotoxicity in combination with bortezomib, and synergistic cytotoxicity in combination with fludarabine.

Finally, in an in vivo xenograft model of human WM, significant inhibition of tumor growth was observed in the Enzastaurin treated mice, providing the framework for clinical trials of this agent in WM (Moreau et al, 2007).

4. AMD3100 (Genzyme, MA) WM is characterized by widespread involvement of the bone marrow (BM), and lymphadenopathy in 20% of the patients, implying continuous trafficking of WM cells into and out of the BM and lymph nodes. The normal process of B-cell homing is regulated by cytokines, chemokines, and adhesion molecules (Lapidot et al, 2005).

One of the most extensively studied chemokines in migration is stromal derived factor SDF-1 and its receptor CXCR4. WM cells and patient samples highly express CXCR4; and that SDF-1 induces migration of WM cells, with rapid activation of signaling pathways downstream of CXCR4 including pERK1/2, pAKT, and pPKC (Ngo et al, 2006). The CXCR4 inhibitor AMD3100 inhibited migration of WM cells, as well as their adhesion to fibronectin (Ngo et al, 2006). Adhesion of WM cells to stromal cells confers resistance to apoptosis and induces proliferation. The combination of AMD3100 with bortezomib significantly enhances the cytotoxic effect of bortezomib in the presence of stromal cells, possibly by interfering with adhesion of WM to stromal cells and thereby overcoming their protective effect (Ngo et al, 2006). These studies provide the preclinical framework to study CXCR4 inhibitors in the regulation of homing and adhesion in WM.

2. Anti-CD70 antibody, SGN-70 (Seattle Genetics, Inc., Bothell WA) Lymphoplasmacytic cells stimulate cell surface expression of TNF-family ligands through release of sCD27, which induces CD70 on mast cells. WM cells and cell lines highly express CD70 (Hatjiharissi et al, 2006).

Therefore, directly targeting CD70 using the fully humanized monoclonal antibody SGN-70 may represent a therapeutic option in WM. SGN-70 mediated significant dose-dependent ADCC against WM cell and mast cells at concentrations of 0.1-20Âľg/ml (Hatjiharissi et al, 2006).

SCID-hu mice bearing WM cells were treated with SGN70, and serum IgM and sCD27 levels were measured to monitor for disease progression. SGN-70 initiated 6 weeks following tumor engraftment blocked tumor growth in all the treated mice, whereas all 5 untreated mice demonstrated disease progression (Hatjiharissi et al, 2006).

233

Roccaro et al: Waldenström’s Macroglobulinemia: new therapeutic options against WM cells in order to carry out clinical trials that achieve high remission rates and prolonged survival in patients with WM. Together, these therapies should lead to higher response rates, more durable duration of response, less toxicity and prolonged survival for patients, making WM an increasingly chronic and treatable disease.

5. Triterpenoids CDDO and CDDO-Im. 2-cyano-3,12-dioxoolean1,9-dien-28-oic acid (CDDO) and its methyl ester derivative (CDDO-Me) and imidazolide derivative (CDDO-Im) are synthetic triterpenoids derived from oleanolic acid. In vitro studies in primary WM samples showed that CDDO-Im inhibited cell proliferation and induced apoptosis in WM cells compared to normal B cells (Elsawa et al, 2006b). There was evidence of PARP cleavage in a dose-dependent manner, suggesting that CDDO-Im induced malignant cell death occurs through a caspase-dependent mechanism, and may have potential efficacy in WM patients (Elsawa et al, 2006b).

Acknowledgement The authors want to thank the researchers in the laboratory whose work is the cornerstone of the progress made in the understanding of Waldenstrom Macroglobulinemia and in the development of targeted therapeutics: Abdel kareem Azab, Ph D, Judith Runnels, PhD, Antonio Sacco, Feda Azab, Xiaoying Jia, Hai T. Ngo, Molly R Melhem.

6. Other agents It has been reported the anti-neoplastic activity of simvastatin (Moreau et al, 2007) and resveratrol (Roccaro et al, 2008b) in WM. In a cohort of 110 WM patients, we observed that WM patients receiving statin cholesterol-lowering drugs had significantly lower IgM levels versus patients not on a statin drug (Treon et al, unpublished). We therefore investigated the activity of statin drugs on WM cell growth and survival (Moreau et al, submitted). Simvastatin, an HMG-CoA reductase inhibitor, induced dose-dependent inhibition of proliferation, cytotoxic effect and apoptosis in IgM secreting cell lines as well as in primary WM cells at 72 hours. Interestingly, those effects were reversed by addition of mevalonate and geranylgeranylpyrophosphate, but not of squalene or farnesylpyrophosphate, suggesting an important role of geranylgeranylated proteins in WM cell growth and survival. Furthermore, simvastatin enhanced the cytotoxicity induced by bortezomib, fludarabine and dexamethasone.

Resveratrol is a polyphenolic natural product synthesized by a wide variety of plant species including grapes. Resveratrol has gained considerable attention because of its anti-cancer properties as demonstrated in solid and hematological malignancies, including multiple myeloma. We therefore examined resveratrol for its antitumor activity in WM and observed induction of significant cytotoxicity and inhibition proliferation of BCWM.1 WM cells and primary tumor cells from WM patients at doses which spared peripheral blood mononuclear cells isolated from healthy donors (Roccaro et al, 2008b). Importantly, Resveratrol induced apoptosis in BCWM.1 and primary WM cells. These data demonstrated that both simvastatin and resveratrol have significant antitumor activity in WM, providing the framework for clinical trials in WM patients.

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Schop RF, Jalal SM, Van Wier SA, Ahmann GJ, Bailey RJ, Kyle RA, Greipp PR, Rajkumar SV, Gertz MA, Lust JA, Lacy MQ, Dispenzieri A, Witzig TE, Fonseca R (2002b) Deletions of 17p13.1 and 13q14 are uncommon in Waldenström macroglobulinemia clonal cells and mostly seen at the time of disease progression. Cancer Genet Cytogenet 132, 5560.

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Tamburini J, Levy V, Chaleteix C, Fermand JP, Delmer A, Stalniewicz L, Morel P, Dreyfus F, Grange MJ, Christian B, Choquet S, Leblond V (2005) Treatment of Waldenström's macroglobulinemia with the combination of fludarabine and cyclophosphamide, results in 49 patients. Leukemia 19, 1831-1834.

Terre C, Nguyen-Khac F, Barin C, Mozziconacci MJ, Eclache V, Leonard C, Chapiro E, Farhat H, Bouyon A, Rousselot P, Choquet S, Spentchian M, Dubreuil P, Leblond V, Castaigne S (2006) Trisomy 4, a new chromosomal abnormality in Waldenström’s macroglobulinemia, a study of 39 cases.

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From left to right upper row: Abdel Kareem Azab, Xiaoying Jia, Nicholas Burwick, Irene Ghobrial, Aldo Roccaro, Judith Runnels, Xavier Leleu From left to right lower row: Antonio Sacco, Feda Azab, Molly Melhem, Hai Ngo

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Cancer Therapy Vol 6, page 247 Cancer Therapy Vol 6, 247-256, 2008

Radioimmunotherapy of B-cell non-Hodgkin’s lymphoma Review Article

Caroline Bodet-Milin1, Michel Chérel1, Alain Faivre-Chauvet1, Manuel Bardiès1, Steven Le Gouill2, Thomas Gastinne2, Jean-François Chatal1, David M. Goldenberg3, Françoise Kraeber-Bodéré1* 1

INSERM U601, Institut de biologie, 9 quai Moncousu, 44093 Nantes cedex 1, France Hematology Department, Hotel Dieu, 1 place Alexis Ricordeau, 44093 Nantes cedex 1, France 3 Garden State Cancer Center, Center for Molecular Medicine and Immunology, Belleville, New Jersey, USA 2

__________________________________________________________________________________ *Correspondence: Françoise Kraeber-Bodéré, Cancerology Research Department, Inserm U601, Institut de Biologie, 9 quai Moncousu, 44093 Nantes Cedex 1, France; Tel: (33) 2 40 08 47 47; Fax: (33) 2 40 35 66 97; E-mail: francoise.bodere@chu-nantes.fr Key words: Radioimmunotherapy, lymphoma, monoclonal antibody, CD20, CD22, mimimal residual disease, dosimetry, yttrium-90, iodine-131, bone marrow transplantation, FDG PET Abbreviations: antigen, (Ag); autologous stem-cell transplantation, (ASCT); complete remission, (CR); diffuse large B cells NHL, (DLBCL); dose-limiting toxicity, (DLT); duration of response, (DR); event-free survival, (EFS); follicular lymphoma, (FL); high dose, (HD); mantle cell lymphoma, (MCL); maximum tolerated dose, (MTD); minimal residual disease, (MRD); monoclonal antibodies, (MAb); myelodysplastic syndrom, (MDS); non-Hodgkin’s lymphoma, (NHL); objective response, (OR); overall survival, (OS); partial responses, (PR); positron emission tomography with 18F-fluorodeoxyglucose, (FDG-PET); progression-free survival, (PFS); radioimmunotherapy, (RIT); time to progression, (TTP) Received: 12 June 2007; Revised: 08 October 2007 Accepted: 10 December 2007; electronically published: May 2008

Summary This article reviews current advances in the radioimmunotherapy of B-cell non-Hodgkin’s lymphoma. We present the use of anti-CD20 RIT using Bexxar® and Zevalin® in the routine treatment of relapsed indolent lymphoma. We discuss clinical perspectives of RIT with myeloablative activities, as consolidation after chemotherapy, in frontline treatment and using other antigen targets, such as CD22. Finally, we present our experience of RIT efficacy assessment using FDG/ computed tomography imaging.

present even if such a relationship could be masked by any anti-tumor effects of cold MAb. Indeed, MAbs, particularly rituximab, have cytotoxic effects mediated by apoptosis, CDC and ADCC (Coiffier, 2004). This efficacy is improved when MAbs are radiolabeled, because of combination of immunological and radiobiological mechanisms, and irradiation of non-MAb targeted cells by the cross-fire effect of the radionuclide. The choice of appropriate antibodies and radionuclides is critical. The range of radioactive emission should match the size of the targeted tumor, since different radionuclides vary in their path-length of penetration.

It has been clearly established that RIT is more efficient in patients with small tumor masses, ideally at the stage of minimal residual disease (MRD) (Sharkey et al, 2005). MRD could be considered in a patient at an early stage of recurrence or in macroscopic complete remission (CR) after an induction treatment. In this clinical setting,

I. Introduction A. Principle of RIT Radioimmunotherapy (RIT) is a new modality of targeted therapy in which irradiation from radionuclides is delivered to tumor targets using monoclonal antibodies (MAb) directed to tumor-associated antigen (Ag) (Chatal et al, 1998). RIT has been developed for more than 20 years and significantly progressed with the development of new stable chelates, humanization of MAbs, and pretargeting techniques (Sharkey et al, 2005). Today, RIT efficacy has been documented in hematology, in particular in B-cell non-Hodgkin’s lymphoma (NHL), but needs to be demonstrated in more radioresistant solid tumor (Goldenberg et al, 2006). Effects of RIT result from both radiobiological and immunological mechanisms (Juweid, 2002). Radiolabeled MAbs deliver a heterogenous lowdose-rate irradiation. Although a dose-effect relationship has not yet been clearly demonstrated, it is likely to be 247

Bodet-Milin et al: Radioimmunotherapy of B-cell non-hodgkinâ&#x20AC;&#x2122;s lymphoma biodistribution and tumor dosimetry are more favorable, tumor cells are less hypoxic and more radiosensitive (Brown et al, 1998), and immunotherapy is more efficient (Collins-Burow et al, 2007).

therapeutic activity required to deliver a whole-body dose of 65 to 75 cGy. It has been demonstrated that if all patients had been injected with a standard dose of 40.7 MBq/kg, half of them would have been under or overdosed according to the whole-body clearance studies (Zelenetz et al, 2001).

B. B-cell non-Hodgkin lymphomas (NHL) B-cell NHL consists in more than 25 histological subtypes according to World Health Organization (WHO) classification, and can be separated in aggressive (65% of NHL) and indolent forms (35%) (Harris et al, 1999). The Ann Arbor classification is used for the staging, with 1 to 4 stages. Diffuse large B-cell NHL (DLBCL) is the most common type of aggressive NHL (31%) and follicular lymphoma (FL) is the most common type of indolent NLH (22%). FL generally shows indolent progression with response to chemotherapy, but always relapses. Survival ranges from 5 to 15 years, depending on the FLIPI (Follicular Lymphoma International Prognostic Index) or GELF prognosis score. Prognosis of DLBCL is different, with cures in 50-60% of patients. Treatments of NHL include chemotherapy, high-dose (HD) chemotherapy with bone marrow transplantation in young people (< 60 years), combination with rituximab (anti-CD20 chimeric MAb), and external radiotherapy for residual masses (Coiffier, 2004, 2005). Patients with FL and DLBCL are potential candidates for RIT. In 1988, DeNardo and collaborators reported the first RIT clinical trial in resistant NHL, using anti-HLA-DR 131I-Lym-1 MAb (DeNardo et al, 1988).

B. Response rate In a study of 143 patients with relapsed or refractory FL or transformed B-cell NHL, Zevalin! appeared more efficient than rituximab, with the objective response (OR) and CR rate significant higher with Zevalin! (80% vs.

56%, p = 0.002, and 30% vs. 16%, respectively, p = 0.04) (Witzig et al, 2002). Patients refractory to rituximab had a 74% OR and those with thrombocytopenia a 83% OR (Witzig et al, 2002; Wiseman et al, 2003). Mean time to progression (TTP) and duration of response (DR) in responders were 12.6 months and 11.7 months, respectively. OR was observed in 50% of patients with bulky lymphoma. Chemotherapy, administered in patients treated with RIT, was not associated with higher toxicity (Ansell et al, 2002).

Data on patients with relapsed NHL treated with Zevalin! in 4 clinical trials were reviewed to identify those with a long-term response (TTP > 12 months) (Witzig el al, 2007). Long-term responses were seen in 37% of patients. At a median follow-up time of 53.5 months, the median DR was 28.1 months and the median TTP was 29.3 months. A third of these patients had been treated with at least 3 previous therapies, and 37% of them had not responded to their last therapy. The estimated OS at 5 years was 53% for all patients treated with Zevalin! and 81% for long-term responders.

Fischer and colleagues showed in a meta-analysis of 250 patients treated by Bexxar! in 5 clinical trials (median of 4 prior courses of therapy and 50% of nonresponders at the last therapy) that OR and CR rates were, respectively, 56% and 30%, and median duration of response 1.1 years (Fisher et al, 2005).

The efficacy of RIT appeared lower in non-FL, with large tumor masses, Ann Arbor stage IV, elevated LDH, age > 65 years, non-responders to last chemotherapy and heavily treated patients. Earlier injection of Zevalin! lead to better outcomes (Emmanouilides et al, 2003). As compared to patients treated at least at second relapse, patients treated at first relapse had a higher OR rate (86% vs. 72%, p = 0.051) and CR rate (49% vs. 28%, p = 0.004) and longer TTP (12.6 vs. 7.9 months, p = 0.038).

Similarly, higher OR and CR rates were observed in patients treated by Bexxar! at first or second relapse (Davis et al, 2004).

II. RIT of NHL in clinical practice A. Administration schemes Today, RIT can be integrated in clinical practice using non-ablative activity of murine anti-CD20 131Itositumomab, Bexxar! (approved in The United States), and 90Y-ibritumomab tiuxetan, Zevalin! (approved in the United States and Europe) for treatment of patients with relapsed or refractory FL. Bexxar! and Zevalin! are administered after a pre-dose of cold MAb to improve biodistribution and tumor targeting, respectively 2 x 450 mg of tositumomab for Bexxar! and 2 x 250 mg of rituximab for Zevalin! administered 6-8 days apart. The first dose of cold MAb is given with dosimetry and the second dose with therapy.

Except in research protocols, no dosimetry study is required for Zevalin! RIT. When a dosimetry study is performed, the first dose of cold MAb is injected with 5 mCi of 111In-ibritumomab tiuxetan. The injected activity depends of the body weight and the platelet count. The therapeutic dose is 0.4 mCi/kg (14.8 MBq/kg) (0.3 mCi/kg, 11.1 MBq/kg, in patient with a platelet count of 100,000 to 149,000/mm3) to a maximum total activity of 32 mCi (1,184 MBq) (Witzig et al, 1999).

RIT using Bexxar! is delivered after a dosimetry study to identify patients whose biodistribution profiles preclude administration of the therapeutic step, and to adapt therapeutic activity to whole-body clearance of the radiolabeled MAb. Whole-body clearance is determined by a series of 3 scans recorded after infusion of 35 mg of tositumomab labeled with 5 mCi of iodine-131. This dosimetry study allows determination of the injected

C. Efficacy assessment RIT efficacy can be assessed by conventional exams (computed tomography, bone marrow biopsy, MRI), but we clearly showed the additional benefit of positron emission tomography with 18F-fluorodeoxyglucose (FDGPET) (Bodet-Milin et al, 2004). FDG-PET appeared superior to CT for evaluation of RIT responders,

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Figure 1. RIT efficacy assessed by FDG-PET. (A) Pre-treatment FDG PET imaging showed diffuse lymph node involvement (right axillary, lumbar, right and left iliac and right inguinal on slices). (B) FDG-PET performed 6 weeks after RIT showed a metabolic complete response.

agent rather than the RIT itself (Bennett et al, 2005).

Moreover, prior RIT has not posed a limitation to subsequent stem-cell collection and transplant. (Ansell et al, 2002; Dosik et al, 2006). A cytological and genetic analysis of bone marrow could be proposed in heavily pretreated patients before beginning RIT.

especially for patients with unconfirmed CR, as early as 6 weeks after treatment (Figure 1). PET performed 6 weeks after RIT could predict later relapse in the event of remaining hot spots.

D. RIT Toxicity Dose-limiting toxicity (DLT) of RIT is hematological toxicity, depending of bone marrow involvement and prior treatment (Witzig et al, 2003, Horning et al, 2005). Nadir after Zevalin! occurred 7 to 9 weeks after injection, and after Bexxar! 4 to 6 weeks after injection. Using Bexxar!, grade 4 neutropenia, thrombopenia and anemia were observed in 17%, 3% and 2%, respectively. Infusion reactions could be observed, in particular after first rituximab injection before Zevalin!. Non-hematological toxicity was generally low, grade 1 or 2, including asthenia, anorexia, fever, nausea, headache, chills, arthralgia and myalgia. Immunogenicity with human antimouse and human anti-chimeric antibody production was observed, ranging from 1 to 63% between studies. The immunogenicity risk was significantly higher in previously untreated patients (Kaminski et al, 2005).

Finally, secondary myelodysplastic syndrom (MDS) or acute myelogenous leukemia was reported in 1 to 3% of cases (Bennett et al, 2005, Horning et al, 2005). The risk could be increased in patients previously treated by several lines of chemotherapy or radiotherapy. However, no causal relationship between RIT and subsequent MDS has been established, and there is ongoing debate about the role of prior therapy (i.e., fludarabine) as the causative

III. Perspectives Today, different approaches are explored to improve efficacy of RIT in NHL: myeloablative RIT or HD treatment, RIT as consolidation after chemotherapy to target MRD, RIT in first-line treatment, fractionated RIT, RIT using other Ag targets, other MAbs, in particular humanized MAbs, other radionuclides, and immunoPET to optimize personalized dosimetry.

A. Myeloablative RIT This approach requires autologous stem-cell transplantation (ASCT) and consists of injecting myeloablative activity or association of nonmyeloablative activity with HD chemotherapy. The rationale of HD approaches is to deliver curative radiation doses to tumor sites while limiting exposure to normal organs. The rationale of RIT combined with chemotherapy is to obtain a synergistic effect between radiosensitiziting chemotherapy and radiation, or to deliver RIT after chemotherapy to target MRD.

1. HD RIT Administration of HD RIT without chemotherapy could be interesting in aggressive NHL, which probably 249

Bodet-Milin et al: Radioimmunotherapy of B-cell non-hodgkinâ&#x20AC;&#x2122;s lymphoma requires higher absorbed doses than indolent NHL, and in patients older than 60 years, which are often denied potentially curative HD therapy because of the risk of excessive treatment-related morbidity and mortality.

Liu and coworkers reported results of RIT using activities of 10.4 to 29.0 GBq (280 to 785 mCi) of 131Itositumomab in 29 patients with relapsed B-cell NHL (Liu et al, 1998). The OR was 86%, with 79% CR. With a median follow-up of 42 months, the estimated overall survival (OS) and progression-free survival (PFS) rates were 68% and 42%, respectively. The non-hematopoietic DLT was reversible cardiopulmonary insufficiency, which occurred in 2 patients at doses ! 27 Gy to the lungs. Late effects were renal insufficiency in 1 patient and functional cardiac impairment in 1 patient. Two patients developed second malignancies, but none have developed MDS. Gopal and coworkers reported, in 2007, their experience with HD 131I-tositumomab activity in 24 patients older than 60 years with relapsed B-cell NHL (Gopal et al, 2007). Twelve to 42.7 GBq (328 to 1,154 mCi) were injected to deliver 25 to 27 Gy to the critical normal organ receiving the highest radiation dose. ASCT was performed approximately 2 weeks after therapy. The estimated 3-year OS and PFS rates were 59% and 51%, respectively, with a median follow-up of 2.9 years (range, 1 to 6 years). There were no treatment-related deaths, and only two patients experienced grade-4 non-hematological toxicity.

Vanazzi and coworkers reported at the ASH congress in 2006 the results of toxicity and efficacy of HD ZevalinÂŽ! (0.8 to 1.5 mCi/kg, 57 to 150 mCi, 2.1 to 5.55 GBq) delivered after a dosimetry study in 18 refractory NHL patients (11 diffuse, 4 MCL, 2 FL, 1 Richter) (Vanazzi et al, 2006). Median age was 66.5 yrs (21 to 75), with a median of 3 prior therapy courses including HD chemotherapy (1 to 6). Dosimetry showed acceptable calculated absorbed-doses to normal organs in all cases.

Infections and liver toxicity were observed, but no pulmonary, cardiac or renal toxicity. Seven CRs, 4 partial responses (PRs), 1 stable disease, and 6 progressions were observed. The authors concluded that HD Zevalin! was feasible with ASCT and suggested an activity of 1.5 mCi/kg for patients with a normal platelet count, while 1.2 mCi/kg could be considered for patients with platelet counts < 150. 109/L.

2. HD treatment chemotherapy

combining

RIT

during the same period (OS of 53% and PFS of 36% at 2 years), even after adjustment for confounding variables in a multivariant analysis. Interestingly, survival was improved in aggressive and indolent NHL. This approach was validated in 16 patients with relapsed or refractory mantle cell lymphoma (MCL) (Gopal et al, 2002). The enrolled patients had received a median of 3 prior treatments, and 7 had chemotherapyresistant disease. The median activity of iodine-131 was 510 mCi (18.87 GBq). There were no therapy-related deaths. Among the 11 patients with conventionally measurable disease at the time of treatment, the respective CR and OR were 91% and 100%. Fifteen patients remained alive, and 12 had no progression at 6 to 57 months from transplantation. OS at 3 years from transplantation was estimated at 93%, and PFS at 61%.

Today, a standard HD schedule before transplantation includes carmustine, etoposide, cytarabine, and melphalan (BEAM). Vose et al. determined, in a phase I trial, the maximum outpatient dose of 131Itositumomab (up to 0.75 Gy total-body dose) combined with BEAM followed by ASCT for the treatment of chemotherapy-resistant relapsed or refractory NHL (Vose et al, 2005). Twenty-three patients received 0.30 to 0.75 Gy total-body dose of RIT. The CR rate was 57% and the OR rate 65%. Short-term and long-term toxicities were similar to historical control patients treated with BEAM alone. With a median follow-up of 38 months (range, 27 to 60 months), OS was 55%, and event-free survival (EFS) 39%.

Zevalin! can be combined with BEAM. Shimoni et al reported the safety and outcome following standarddose Zevalin! (0.4 mCi/kg) followed by HD BEAM and ASCT in 23 patients, median age 55 years (range, 35-66) with chemo-refractory NHL (15 DLBCL, 7 Richter, 1 MCL), either primary refractory or in refractory relapse (Shimoni et al, 2007). Rituximab followed by Zevalin! were given on day-14 and HD BEAM started on day-6.

Twenty-one patients were evaluable for response; 11 achieved CR, 9 achieved PR, 5 of whom converted to CR with additional radiation therapy (overall CR rate 76%).

The estimated 2-year OS and PFS were 67% and 52%, respectively. The day-100 rate of treatment-related mortality was 9% (95% CI, 2-33%), and the 2-year cumulative incidence of relapse was 31% (95% CI, 1757%). Extensive prior therapy (>3 lines), high LDH and IPI score at ASCT, bulky disease, and progression during last chemotherapy were risk factors for reduced survival.

Khouri et al. reported, at ASH 2006, the results of toxicity and efficacy of the same therapeutic protocol in 26 patients with chemo-refractory NHL (16 DLBCL, 2 MCL, 8 FL). The estimated 2-year OS and PFS were higher (92% and 83%, respectively), but the number of assessed FL was higher. Adverse events were similar to BEAM alone.

Winter el al. assessed a Z-BEAM regimen using escalated doses of Zevalin! (900 to 1700 cGy to critical organs, 0.3 to 1.2 mCi/kg) in 44 patients with chemorefractory NHL (55% DLBCL, 16% Richter, 16% MCL, 11% low grade) (Winter et al, 2006). Two DLTs occurred at the 1700-cGy dose level. One heavily pretreated patient

and

Press and coworkers conducted a phase I/II trial to estimate the maximum tolerated dose (MTD) of 131Itositumomab that could be combined with etoposide and cyclophosphamide, followed by ASCT, in 52 patients with relapsed B-cell NHL (Press et al, 1995). The MTD of 131Itositumomab that could be safely combined with 60 mg/kg etoposide and 100 mg/kg cyclophosphamide was calculated to deliver 25 Gy to critical normal organs. The estimated OS and PFS at 2 years was 83% and 68%, respectively. These findings compare favorably with those in a non-randomized control group of patients who underwent transplantation, external-beam total-body irradiation, and etoposide and cyclophosphamide therapy 250

Cancer Therapy Vol 6, page 251 developed MDS on D+291. The 3 years OS and PFS were 52% and 37%, respectively. For dosimetry-based trials, 1500 cGy to the critical organ was the recommended dose (arround 0.8 mCi/kg of Zevalin速). Outcomes were encouraging given the high-risk patient population.

A conditioning regimen using Z-BEAM was retrospectively compared with conventional HD BEAM in 2 groups of elderly patients (> 50 yrs), well-matched for most demographics and disease status (Krishnan et al, 2006). Two-year OS in the Z-BEAM group was 88% versus 65% in the group treated by BEAM. Analysis of histology showed that there was a significant difference in OS and PFS of Z-BEAM versus BEAM in patients with DLBCL. The toxicity profiles and transplant-related mortality were similar in both regimens.

Clinical studies, in particular randomized phase-III, should be done to better assess survival in a homogenous group of NHL: FL, MCL or DLBCL. In France, a phase-II study assessing Z-BEAM in second-line treatment of FL has just been finished.

5-year estimated PFS rate was 60%. Baseline FLIPI was significantly associated (P = 0.003) with PFS. Five of six patients with more than 25% bone marrow involvement at baseline achieved adequate bone marrow cytoreduction to receive standard-dose iodine-131 tositumomab. Ten of 13 patients (77%) with baseline bone marrow Bcl-2 positivity demonstrated molecular remissions at 12 months.

Toxicities were manageable and mainly hematological.

Two of 35 patients (6%) developed human anti-murine antibodies (HAMA) after RIT. The authors concluded that this sequential treatment regimen was highly effective as a front-line therapy for FL, particularly for low- or intermediate-risk FLIPI patients.

Prospective studies should be done to confirm these results, particularly to demonstrate benefits of RIT after initial treatment including rituximab, such as CHOP-R regimen. It is possible that anti-CD20 RIT is less efficient in patients previously treated by anti-CD20 cold MAb (Morschhauser et al, 2007). However, Shipley reported, in the 2005 ASCO congress, preliminary results of treatment including CHOP-R followed by Zevalin! (Shipley et al, 2005). Forty-two patients were included between April 2002 and March 2004 (Median age 57 years, Stage IV 60%). After R-CHOP, the OR rate was 100% and the CR rate 28%. After Zevalin!, the CR rate was 67%. After a 24-month median follow-up, actuarial 2-year PFS was 85%. Unexpected toxicity was not observed. We are awaiting results of the phase-III randomized studies comparing the efficacy of the promising CHOP + RIT regimen with the efficacy of CHOP + rituximab.

Moreover, in low-risk FL, RIT could be applied as consolidation after rituximab induction therapy.

B. Use of RIT as consolidation after chemotherapy Another perspective is the use of RIT as consolidation after chemotherapy in a non-myeloblative regimen (targeting of MRD). This approach appears interesting in > 60-year-old patients who are not candidates for bone marrow transplantation. Press et al. reported in 2006 the results of a phase-II trial of CHOP chemotherapy followed by tositumomab/131I-tositumomab for previously untreated FL (Press et al, 2006). From 1999 to 2000, the Southwest Oncology Group (SWOG) conducted a phase-II trial (S9911) to test a novel regimen consisting of six cycles of CHOP chemotherapy, followed 4 to 8 weeks later by tositumomab/131I-tositumomab in 90 eligible patients with previously untreated, advancedstage, FL. The OR was 91%, including 69% CR. After a median follow-up of 5.1 years, the estimated 5-year OS rate was 87%, and the PFS rate was 67%. The 5-year estimates of OS and PFS were each 23% better (absolute difference) than the corresponding figures for patients treated on previous SWOG protocols with CHOP alone.

An analysis according to the FLIPI showed that 21% of patients had high-risk features, 44% had intermediate-risk features, and 34% had low-risk features. High-risk patients had worse OS than lower risk patients (p = 0.05), but differences in PFS were not statistically significant (p = 0.21). Serial monitoring of the t(14;18) translocation demonstrated that 32 of 38 patients obtained molecular CRs, including seven patients (18%) after CHOP and 24 additional patients (63%) after tositumomab/131Itositumomab.

Leonard and colleagues evaluated in 2005, in 35 previously untreated FL patients, the efficacy of abbreviated 3 courses of fludarabine followed, 6 to 8 weeks later, by tositumomab and 131I-tositumomab (Leonard et al, 2005). After fludarabine, 31 (89%) of 35 patients responded, with three (9%) of 31 patients achieving a CR. After the full regimen of fludarabine and 131 I-tositumomab, all 35 patients responded; 30 (86%) of 35 patients achieved CR, and five (14%) achieved PR. The

C. RIT in first-line treatment As shown by Emmanouilides et al, an injection of Zevalin! earlier in the course of the disease lead to better outcomes (Emmanouilides et al, 2003). Indeed, the best results of non-myeloablative RIT administered alone (without chemotherapy) had been obtained as first-line treatment of FL (Kaminski et al, 2005). A single one-week course of 131I-tositumomab therapy, as initial treatment, can induce prolonged clinical and molecular remissions.

Seventy-six patients with stage III or IV FL received as initial therapy a single course of 131I-tositumomab therapy.

Ninety-five % of the patients responded, including 75% with a CR. The use of PCR to detect rearrangement of the bcl2 gene showed molecular responses in 80% of assessable patients who had a clinical CR. After a median follow-up of 5.1 years, the actuarial 5-year progressionfree survival for all patients was 59 percent, with a median progression-free survival of 6.1 years. Of 57 patients who had a complete response, 40 remained in remission for 4.3 to 7.7 years. Hematological toxicity was moderate, with no patient requiring transfusions or growth factors. No case of MDS syndrome has been observed. Hagenbeek and colleagues reported, in the 2007 ASH congress, the first results of the phase 3 FIT study assessing Zevalin! as consolidation of first remission in advanced stage FL (Hagenbeek et al, 2007). From 8/2001 to 1/2005, 414 patients were enrolled at 77 study centers in 12 European countries and Canada. After completing induction therapy, 251

Bodet-Milin et al: Radioimmunotherapy of B-cell non-hodgkin’s lymphoma patients were randomized to receive either Zevalin! (250 mg/m2 rituximab on day -7 and on day 0 followed on day 0 by Zevalin! 0.4 mCi/kg; maximal dose: 32 mCi;[n=208]) or no further treatment [n=206]). Induction therapies included: CVP n=106, CHOP (-like) n=188, fludarabine combinations n=22, chlorambucil n=39 and rituximab-chemotherapy combinations n=59. With a median follow-up of 2.9 yrs, the median PFS increased from 13.5 (controls) to 37 mo (Zevalin!; p<0.0001; HR 0.463). For patient subgroups in PR or CR after induction, median PFS was 6.3 vs 29.7 mo (p<0.0001; HR 0.304) and 29.9 vs 54.6 mo (p=0.01; HR 0.609), respectively.

After Zevalin! consolidation, 77% of patients in PR after induction therapy converted to CR. Toxicity was primarily hematologic. Grade 3/4 infections occurred in 16 (8%) patients after Zevalin! vs 5 (2%) in the control arm.

Moreover, in low-risk FL, RIT could be applied as consolidation after rituximab induction therapy.

external imaging. These observations should not been interpreted that there was a minor effect of targeting, but probably could be explained by the role of immunological status of patients and immunological mechanisms in tumor response after RIT. Moreover, in this series of heavily pretreated patients, disease became resistant to all therapies, in particular RIT, independently of the targeting. In this study, an anti-antibody response was detected in only 2 of 16 patients.

We have designed a phase II study assessing fractionated RIT using 90Y-hLL2 as consolidation after CHOP-rituximab in first-line treatment of patients > 60 years of age with aggressive NHL.

E. Fractionated RIT and pretargeting RIT The advantages of fractionated delivery of external radiation therapy may also apply to RIT. Fractionated RIT may provide a safe and effective treatment with lower hematological toxicity, allowing administration of higher doses. A phase I/II, multi-center, dose-escalation trial is ongoing, assessing 90Y- hLL2 administered once weekly for 2 or 3 weeks (Chatal et al, 2005). Therapy was well tolerated, and other than hematological DLT, no serious adverse events were considered treatment-related. Of 38 patients with evaluated treatment responses, 21 (55%) had an objective response (OR) by International Working Group (IWG) criteria, across all histologies [FL, 10/16 (63%); DLBCL, 4/10 (40%); MCL, 4/9 (44%), marginal zone, 3/3 (100%)], and including patients after prior BMT (7/17, 41%), or pts not responding to prior rituximab.

Most ORs were complete responses (CR/CRu, 17/21, 81%). CRs appear durable. OR rates increased at a higher cumulative dose (at 30 mCi/m2, 5/6 (83%). Fractionated RIT with epratuzumab appears feasible and safe, achieving high response rates at cumulative 90Y doses several-fold higher than the 32-mCi limit approved for a single dose of Zevalin!.

Other approaches to decrease toxicity and improve injected activity are the pretargeting techniques (Goldenberg et al, 2006; Meredith et al, 2006). In a phase I study assessing an anti-CD20/streptavidin fusion protein in a pretargeted approach and clearing with the biotin-poly N-acetyl-galactosamine compound, excellent tumor targeting was noted, with nodes <1 cm detected within 3 h after radiolabeled biotin administration and the mean tumor-to-whole-body radiation dose ratio being 49 (Meredith et al, 2006). Based on the dose estimates from this phase I study, escalation of high-administered activities would be tolerated by the bone marrow without need for stem cell rescue or growth factor support.

D. Other MAbs and other antigen targets than CD20 Targeting of antigens other than CD20 appears particularly interesting, with the possibility of targeting populations of lymphoma cells not expressing CD20 or having lost expression as a result of treatment. Several antigens have been tested: CD21, CD22, CD37 and HLA DR (Juweid, 2002). Both radiolabeled anti-CD22 (epratuzumab, hLL2) and anti-HLA-DR (Lym-1) MAb have shown efficacy in patients who have failed chemotherapy, either with low-grade or aggressive forms of NHL (DeNardo et al, 1998; O’Donnel et al, 2000, Goldenberg, 2006). CD22 is a B-cell-restricted transmembrane glycoprotein expressed on mature B cells but not expressed on stem cells and plasma cells, and acting in B-cell regulation/activation. CD22 is highly expressed across malignant B-cell histologies. hLL2 MAb, epratuzumab, has good features for RIT because it is humanized, internalized by target cells, stably labeled using DOTA, and administered without a loading dose of cold antibody, at variance with Zevalin! or Bexxar!.

Results of a phase I/II trial assessingDOTAconjugated 111In- and 90Y-hLL2 in patients with NHL have been reported (Sharkey et al, 2003). Patients had a pretherapy imaging study with 111In- hLL2, followed about 1 week later with 90Y- hLL2 RIT, starting at a dose level of 0.185 GBq/m2 in patients who had prior HD chemotherapy (Group 2), and at 0.370 GBq/m2 in patients who did not have a prior transplant (Group 1), with escalation by 0.185-GBq/m2 increments. Radiation absorbed doses to liver, lungs, and kidneys averaged 0.55 ± 0.13, 0.28 ± 0.06, and 0.38 ± 0.07 mGy/MBq, respectively, with 0.14 ± 0.02 and 0.23 ± 0.04 mGy/MBq delivered to the wholebody and red marrow, respectively. Tumor doses ranged from 1.0 to 83 mGy/MBq for a 0.5-g lesion (median = 7.15 mGy/MBq). Anti-tumor effects were seen in both indolent and aggressive NHL. The data also suggest that anti-tumor responses of potentially equal magnitude can occur irrespective of tumor targeting and tumor size.

Hence, tumor response did not correlate with the radiation dose delivered or with the tumor being visualized by

F. Optimization of injected activity with dosimetry study Pre-RIT dosimetry studies should allow adapting injected activity to pharmacokinetics in each patient.

Dosimetry studies performed before Bexxar® injection showed large variability between patients, requiring injection of around 50 to 150 mCi of Bexxar® to deliver a 75-cGy whole-body dose. Indeed, a lot of patients are

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Cancer Therapy Vol 6, page 253 probably under-treated with the 0.4 mCi/kg of Zevalin®.

No dose-effect relationship has been clearly demonstrated in clinical studies, but patients have been heavily pretreated. Dosimetry of RIT in first- line treatment should allow to better analysis of a dose-effect relationship.

Moreover, immuno-PET using iodine-124 or yttrium-86 could improve quantitative imaging and biodistribution analysis of Bexxar® and Zevalin®, respectively. Preclinical studies in mice showed that 89Zrand 88Y-Zevalin® had a very similar biodistribution, implying that 89Zr-Zevalin®-PET might be well-suited for prediction of 90Y-Zevalin® biodistribution in a myeloablative setting (Perk et al, 2006).

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G. Other radionuclides Patients with > 25% bone marrow involvement are not good candidates for RIT using iodine-131 and yttrium90 due to increased risk of hematological toxicity. This problem may be overcome by the use of short-range radionuclides, such as alpha- or Auger-emitters. However, because of their low energy, a high number of Augerelectrons must be delivered to kill cells. Alpha particles have a linear energy transfer (LET) much greater than electrons. This characteristic makes it possible to perform very localized irradiation while preserving the surrounding tissues, and also obtaining cell toxicity with only a few radioactive atoms at the cell surface (Cherel et al, 2006).

More specific strategies for using alpha particles have been developed for the treatment of hematological diseases. The targeting of IL-2 receptors using specific CD25 antibodies coupled with 213Bi has proved to be more efficient than the use of 90Y in the treatment of T-cell leukemia (Zhang et al, 1999). This advantage also applies to the targeting of CD33 antigen in chronic myeloblastic leukemia, which was selected for the first clinical alphaimmunotherapy trial. We have also demonstrated that multiple myeloma can be a good indication for alphaimmunotherapy using an anti-CD138 MAb (Supiot et al, 2002).

IV. Conclusion Preclinical and pilot clinical studies will provide a better understanding of the cytotoxic effects, and for selecting new targets and immunoconjugates for further development. Today, the clinical results show that RIT has significant efficacy but moderate response duration as a monotherapy in rituximab-refractory recurrence of NHL, but a higher therapeutic impact may be achieved using RIT in HD myeloablative treatment, as consolidation after chemotherapy-immunotherapy, or as a first-line treatment.

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Cancer Therapy Vol 6, page 257 Cancer Therapy Vol 6, 257-262, 2008

Single split-course Cycle of CHOP Chemotherapy resulting in long-term disease-free Survival in a Patient with advanced and aggressive T-cell NonHodgkin´s Lymphoma Case Report

Sebastian Fetscher1,*, Jan Schmielau1, Annette Schmitt-Gräff2 1 2

Division of Hematology and Oncology, Department of Internal Medicine, Sana Hospital Lübeck, Lübeck, Germany Institute of Pathology, Freiburg University Medical Centre, Freiburg im Breisgau, Germany

__________________________________________________________________________________ *Correspondence: Sebastian Fetscher M.D., Division of Hematology and Oncology, Department of Internal Medicine, Sana Hospital Lübeck, Kronsforder Allee 72-74, D-23560 Lübeck, Germany; Tel: 0451-585-1402; Fax: 0451-585-1407; e-mail: s.fetscher@sanaluebeck.de Key words: Central nervous system, chemotherapy, T-cell Non-Hodgkin!s lymphoma Abbreviations: Central nervous system lymphoma can occur as primary, (PCNSL); Central nervous system lymphoma, (CNSL); diffuse large B-cell lymphoma, (DLBCL); Eastern Cooperative Oncology Group performance status, (ECOG); International NHL Prognostic Index, (IPI); mycosis fungoides, (MF); overall survival, (OS); whole-brain radiation therapy, (WBRT) Received: 16 November 2007; Revised: 15 April 2008 Accepted: 16 April 2008; electronically published: May 2008

Summary We describe the successful chemotherapy of a patient with high-grade, high-risk T-cell-Non-Hodgkin´s lymphoma with only one standard-dose CHOP-chemotherapy given in a split-course fashion at a seven-day interval. The atypical and incomplete chemotherapy in this patient was mandated by extraneous circumstances, the patient being in septic multiorgan failure at initial therapy. Due to the slow physical recuperation of the patient, timely continuation of the planned chemotherapy protocol was impossible. Staging examinations during the recovery process then surprisingly showed a complete pathological remission of all lymphoma manifestations. Therefore, no further therapy was given. The patient has now been in complete remission for more than ten years. We attempt an interpretation of this counter-intuitive course of disease by taking the unique constellation of medical and haematological features into account that were present at the beginning of therapy. The case history vividly documents the wide variability in the clinical course of patients with Non-Hodgkin´s lymphoma dependent on coexisting medical conditions, histological and molecular characteristics, and form of chemotherapy chosen. The truly fortuitous clinical observation made in this case may serve as reminder of the necessity to develop a better understanding of inter-individual differences in lymphoma biology before anti-lymphoma is instituted.

Regardless of the histopathological definition of ALCL, the clinical course of this NHL is heterogeneous, with marked inter-individual differences in histology, phenotype, cytogenetics, and clinical characteristics at initial diagnosis being cited as the most common causes for this phenomenon (Coiffier et al, 1990; Filippa et al, 1996).

While most cases of ALCL express antigens of T- or B-cell lineage, some may lack lymphoid antigens, and rare cases may express both T- and B-cell markers (Coiffer et al, 1989; Tashiro et al, 1989). The Revised EuropeanAmerican Lymphoma (REAL) classification of lymphoid

I. Introduction Anaplastic large cell lymphoma (ALCL), also called Ki-1 lymphoma, is a morphologically and immunologically distinct subset of non-Hodgkin's lymphoma (NHL), accounting for 2% to 8% of all NHL. The disease is characterized by the proliferation of pleomorphic large neoplastic lymphoid cells, which strongly express the CD30 antigen (Ki-1 antigen), and preferentially spread in lymph node sinuses (Chott et al 1990; Greer et al, 1991; Clavio et al 1996; Stansfeld et al, 1988; Agnarsson et al, 1988; Weisenburger et al, 2001; Batchelor et al, 2006).

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Fetscher et al: Single split-course Cycle of CHOP Chemotherapy resulting in long-term disease neoplasms includes the B-cell type of ALCL among the variants of diffuse large B-cell lymphoma, limiting the term of anaplastic large cell lymphoma to the T- and nullcell type (Harris et al, 1994).

ALCL can occur in patients with prior malignancies, and in particular in patients successfully treated for Hodgkin´s disease. Nonetheless, most cases occur spontaneously. The clinical presentation of primary ALCL may be cutaneous and systemic (Clavio et al, 1996).

Cutaneous ALCL is difficult to distinguish from lymphomatoid papulomatosis and regressing atypical histiocytosis and, like these, can occasionally undergo spontaneous regression (Greer et al, 1991; Mori et al, 1999; Fujiwara et al, 2001; Tamura et al, 1999; Pena et al, 2003).

Systemic ALCL, however, typically takes an aggressive course, often presenting with B- symptoms, advanced-stage, and extranodal disease (Coifffier et al, 1990; Harris et al, 1994). While treatment results in children with ALCL are quite good (Reiter et al, 1994; Seidemann et al, 2001; Williams et al, 2002), the prognosis of this type of NHL in adults is no better than that of other advanced diffuse large cell lymphomas (DLCL); some experts believe, that the prognosis of ALCL is worse when compared with classic DLCL (Nakamura et al, 1991; Penny et al, 1991; Shulman et al, 1993; Harris et al, 1994; Kadin et al, 1994; Pileri et al, 1994; Karakas et al, 1996; Maes et al, 2001).

ALCL mostly affects young men, with the male predominance being most apparent in the T-cell type.

Bone marrow involvement is seen as frequently in ALCL as in other lymphomas. Interestingly, the occurrence of digestive tract involvement is quite unusual, another rare and distinguishing feature of patients with ALCL (Maes et al, 2001).

Response of ALCL to conventional chemotherapy is comparable to that of DLCL, with CR rates ranging from 60% to 90% (Shipp et al, 1990; Shulman et al, 1993). The overall survival of localized disease is good, especially in children (Reiter et al, 1994; Seidemann et al, 2001; Williams et al, 2002). Advanced stages are characterized by frequent relapse and a much poorer prognosis. While some investigators have treated advanced-stage ALCL with intensified primary therapy including high-dose chemotherapy and autologous stem cell transplantation (Coiffier et al 1989; Fanin et al, 1996), others believe that the clinical behaviour of ALCL - stage for stage - is not fundamentally different from other high grade NHL (Karakas et al, 1996). In one study, conversely, ALCL was associated with a longer event-free and overall survival than non-ALCL lymphomas (Coiffier et al, 1990).

In multivariate analyses, however, anaplastic histology was identified as independent negative prognostic factor outweighing other variables such as bone marrow involvement or number of extranodal sites or risk groups as defined by the International Prognostic Index (IPI) (The NHL IPI Projekt, 1993). Lastly, current treatment options for T-cell NHL include the monoclonal anti-CD52-antibody MabCampath that was, however, not available, at the time of the treatment of our patient.

II. Case history On September 1st 1997 a 21-year old German military recruit suffered minor injuries to his left arm due to a tank accident during a NATO manoeuver. While being treated for his laceration in the local Hospital, the patient developed fever, night-sweats, left axillary lymphadenopathy and general malaise, resulting in a significant weight loss over a period of three weeks (15%). Excisional biopsy of the left axillary lymph node was performed. Histology was interpreted as reactive inflammatory tissue.

Despite aggressive local and systemic antimicrobial treatment, the soldiers condition rapidly deteriorated. By midSeptember mechanical ventilation was required due to a severe ARDS, considered to be “septic-toxic” in origin. When ventilation parameters deteriorated despite 100% O2-support, the patient was transferred by military airplane to a tertiary care hospital (Freiburg University Medical Center) for extracorporeal membrane oxygenation (ECMO). In addition, renal failure had developed, requiring hemofiltration for volume and electrolyte control.

Repeat CT-scan after transfer of the patient demonstrated advanced ARDS and significant axillary and mediastinal lymphadenopathy. Repeat axillary lymph-node biopsy in midSeptember now showed a highly proliferative, blastoid T-cell Non-Hodgkin´s lymphoma expressing CD30, ALK1 and CD43, resulting in the diagnosis of common-type T-cell ALCL. The axillary lymph-node biopsy from the local hospital was now re-examined by a lymphoma pathologist, also revealing ALCL. Lymphoma involvement was furthermore documented in biopsies of stomach, bronchus and liver. Other than age of <60 years, all high-risk-features of the IPI-system were fulfilled (high LDH, stage IV, ECOG 3-4, extranodal disease in three sites).

Given the marginal clinical condition of the patient, chemotherapy was implemented in a split-course fashion as two 50%-dose CHOP-chemotherapies, given on September 27th and October 3d 1997. The total dose given equalled one 100% cycle of conventional CHOP chemotherapy (Cyclophosphamide 750 mg m2/, Doxorubicin 50 mg/m 2 , Vincristine 2 mg, 5 days of Prednisone 50 mg/ m2 ).

The original treatment plan for this patient with an IPIhigh-risk T-NHL had included three additional cycles of 100%dose CHOP for induction therapy, followed by stem-cell mobilization chemotherapy with intermediate-dose Ifosfamide and VP16, and intensive consolidation in first remission with high-dose BEAM-chemotherapy plus autologous peripheral blood stem cell transplantation. However, due to the catastrophic clinical course of the patient during October and November 1997, this treatment plan was never carried out and no further anti-lymphoma measures were taken after October 3 d 1997.

Briefly, the following problems developed during the stay in the intensive care unit after the application of CHOPchemotherapy one week after the transfer from the local hospital: protracted respiratory insufficiency (8 weeks on mechanical ventilation), pseudomonal sepsis with circulatory failure requiring catecholamines, renal failure requiring hemofiltration, toxic cardiomyopathy with a left ventricular ejection fraction nadir at 30%, pansinusitis, HSV-blepharitis, and WHO III-IV toxic polyneuropathy related to medications given during longterm ventilation and to Vinca-alkaloid therapy on September 27th and October 3d 1997.

When the patient returned to the hematology unit on November 24th 1997, his neuromotor function was largely obliterated. Starting from functional tetraparesis with physical inability to push the alarm-button at his bedside, he went through a prolonged recovery that has resulted, as of April 2008, in complete physical, neuromotor and social rehabilitation.

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Cancer Therapy Vol 6, page 259 During the initial months of this long recuperation, the patients condition remained so poor that continuation of the planned chemotherapy at an adequate dose-level was deemed medically impossible. In the following months, a continuation of chemotherapy was then felt to be not required given the unexpectedly negative results of all ensueing staging examinations which failed to show evidence of active lymphoma ever since December 1997. The examinations included repeatbiopsies in all initially affected sites, MR, PET and endoscopy.

Due to the documentation of a complete remission after two 50%-CHOP cycles, priority was given to the process of rehabilitation. Treatment was then planned to be reinstituted at the first sign of lymphoma relapse. Signs of relapse, however, have never appeared since. The patient was last examined in April 2008, with no signs of symptoms of residual or relapsed Tcell Non-Hodgkin’s lymphoma.

D Interaction between infectious disease and lymphomagenesis While the etiology of gastric MALT-NHL has been linked to a defined infectious agent, no such infectious link has as of yet been described in ALCL (Honkop et al, 1993; Shulman et al, 1993; Tirelli et al, 1995). Moreover, the repeated, polymicrobial and at times life-threatening infectious events occurring between September 1997 and January 1998 in our patient are best viewed as a result of the severe immunosuppression associated with a rapidly progressive T-cell NHL involving critical organs such as liver, gastrointestinal system and lung as well as the lymphatic system. The minor injury that led to left axillary lymphadenopathy at the beginning of the illness can be interpreted as a sentinel event that uncovered a much more serious underlying illness that otherwise would have become manifest by “pure” B-symptoms or other signs of systemic or local lymphoma activity. Remarkably, the patient hat not experienced significant infectious episodes since March 1998.

III. Discussion The clinical history of this patient with ALCL is counterintuitive in that it contradicts the conventional conviction that full-dose and timely application of six to eight courses of CHOP-like chemotherapy is the minimal regimen to cure in disseminated, IPI-high-risk, aggressive T-cell NHL. The well-documented long-term disease-free survival of this patient more than ten years after two splitcourse 50%-CHOP chemotherapies therefore demands an explanation.

The following possibilities should be considered when analysing the unexpected outcome of this case history:

A. Error classification

in

E. Higher-than-expected efficacy of splitcourse CHOP-chemotherapy The reason to apply two 50%-CHOP cycles as induction therapy in our patient was his critical medical condition at the time when being treated for multiorgan failure. By ascertaining the immediate response of the lymphoma to, and the treatment toxicity of 50%-doseCHOP we wanted to achieve a tolerable risk-benefit relation. After an acceptable tolerance of 50%-CHOP cyle#1, the chemotherapy was “completed” with another 50%-cycle#2 six days later.

However, a number of factors may have led to a higher than expected treatment toxicity and efficacy of this approach: by using a split-course application, the second dose of cyclophosphamide and doxorubicin was applied at the beginning of the neutropenic nadir, thus leading to prolonged cytopenia (ANC <500 11 days - as opposed to the usual duration of neutropenia after standard CHOP of 3 days).

At the same time, ALCL cell kinetics may have led to an increased vulnerability of the NHL cells that had survived to first 50%-CHOP therapy; in addition, impaired renal, cardiac, hepatic, and circulatory function probably led to impaired metabolism, clearance and excretion of cytotoxic metabolites, thus enhancing toxicity and efficacy of CHOP-chemotherapy.

histopathological

This possibility was first considered early in 1998.

However, repeated and independent review of the slides, and repeat immunhistochemistry of the biopsies consistently confirmed the diagnosis of T-cell ALCL.

B. Occurrence of spontaneous remission While spontaneous remissions have been described in follicular, mantle-cell and diffuse large-cell NonHodgkin´s lymphoma (Tamura et al, 1993; Kumar et al, 2004), the phenomenon has, to our knowledge, not yet been observed in ALCL and in particular not in a stage IV, IPI high-risk T-cell NHL. The aggressive and progressive course of the lymphoma prior to, and the rapid resolution of B-symptoms and nodal manifestations after the institution of CHOP-chemotherapy, also clearly argue against the assumption of a self-defined disease course due to spontaneous remission.

F. Altered and enhanced immunological self-repair mechanism during, and after intensive-care therapy for multiorgan failure

C Transformation into secondary lowgrade T-NHL Cases of high-grade aggressive ALCL have been observed that - after implementation of appropriate chemotherapy - later recurred or transformed into an indolent peripheral T-cell or B-cell NHL (Madero et al, 2001). However, this observation has so far been limited to pediatric cases with limited disease volume at initial diagnosis. Furthermore, signs of a secondary low-grade Tcell-NHL were never observed in our patient.

Undoubtedly, the patient went through a process of profound immunosuppression and protracted immunological reconstitution. The immune recovery required 6-12 months and was accompanied, and prepared for by, the patient´s slow physical recuperation. It is tempting to assume, that the recovery of the patients immune system enhanced not only standard immunological functions, but also immune surveillance of “internal errors” such as lymphomagenesis. The 259

Fetscher et al: Single split-course Cycle of CHOP Chemotherapy resulting in long-term disease stupendous general recovery of the patient at least hints at a complete, or even “more than complete” immunological reconstitution after the double catastrophe of ALCL and multi-organ failure triggered by polymicrobial infections.

Therefore, an “autologous graft-versus-lymphoma effect” may have occurred contributing to the excellent short-term and long-term outcome.

et al, 2006). Pharmacological examinations may show the “in-vivo-doses” achieved under such circumstances. In our case, the “true” pharmacological dose applied may have been the equivalent of 2-4 full cycles of CHOP. However, since the metabolism of cytotoxic agents was not be examined in our patient, this remains an assumption.

3) Thirdly, the decision to institute CHOPchemotherapy in two 50%-cycles in split-course fashion separated by a seven days interval likely contributed decisively to the outcome. In the treatment of acute myeloid leukemia, this principle has been applied in the SHAM salvage protocol. The NHL kinetics of our patient were highly proliferative, as evidenced by rapid clinical deterioration, pronounced B-symptoms, rapid growth of affected lymph nodes, high serum LDH-levels, and high mitotic activity with blastoid morphology in the histology specimens. It is therefore conceivable that one split-course CHOP-chemotherapy destroyed the entire population of actively replicating lymphoma cells in our patient. In combination with an impaired drug metabolism this may have been the clue to the unexpectedly positive outcome.

Although current research focuses of treatment intensification in DLCL utilizing CHOP-14-protocols with or without rituximab (Coiffier et al, 2002; Pfreundschuh et al, 2004), the principle of repeating 50%-CHOP in 7-dayintervals has not yet been explored to our knowledge.

Given the risks of this approach, even in patients with excellent performance score, this can only be envisaged in study protocols. The reason CHOP was historically given in a 21-day interval, and is currently examined in 14-dayintervals (Pfreundschuh et al, 2004), has been the tolerance of CHOP by the human organism. However, we do not know what would be the best treatment interval for CHOP, once treatment toxicity would cease to be, and lymphoma biology would be the only issue relevant for therapy scheduling.

4) Lastly, this case of ALCL demonstrates that despite all attemps at refining lymphoma classification, individual patients may present to the hematologist with unique disease features that decisively influence the tolerance and outcome of antilymphoma therapy. Many attempts to individualized therapy have been made by using classification techniques, cytogenetics and the IPIscore system (The NHL IPI Projekt, 1993; Pileri et al, 1994; Romaguera et al, 1994; Sarris et al, 1996; Zinzani et al, 1996). But despite these increasingly useful prognostic instruments, individual patients with NHL may still take a completely unexpected course.

In our patient, treatment individualization meant deferring a minimum of five further cycles of like polychemotherapy that would have - as we now know resulted in significant short- and long-term toxicity without adding to disease control. Hopefully, the future refinement of cancer diagnostics by methods such as gene mapping may enable us to predict “standard” and exceptional “non-standard” patient careers such as the one described here, thus tailoring therapy from the start to the patients true genetic risk profile and not to surrogate pathological or serological classifications that may miss as much as they describe.

IV. Conclusions The following conclusions may be derived this particular case history: 1) The case may serve as a reminder for clinicians who are confronted with the necessity of prematurely terminating anti-lymphoma therapy due to extraneous circumstances such as prohibitive treatment toxicity. This case history demonstrates that, regardless how of many cycles have been completed, successful outcomes can be observed even with “highly incomplete” chemotherapies.

Further conclusions, as to the necessity of applying four cycles of CHOP in earlier stage, or six to eight cycles of CHOP in advanced NHL, cannot be drawn from this case.

Nonetheless, the conventional conviction that a fixed, and usually even, number of chemotherapy cycles is the inexorable precondition for cure, must be viewed not as a dogma but rather as an useful rule applicable to most, but not all patients with aggressive NHL. 2) A second pertinent observation relates to the individual, and poorly predictable effects of cytotoxic chemotherapy in severely ill patients. This applies in particular to patients with multiorgan failure dependent on intensive care support during initiation of anti-lymphoma chemotherapy. While there are standard recommendations regarding the use of chemotherapy agents in the presence of different degrees of cardiac, hepatic or renal dysfunction, the decision to implement therapy at all, or at reduced intensity still depends heavily on the personal judgement, experience, and intrepidity of the responsible clinician. Balancing possibly life-threatening treatment side-effects against the predictably lethal course of an untreated, or insufficiently treated, malignancy requires the acknowledgment of standard dose-adjustment rules and contraindications; however, it also requires the ability to break these rules when they may not, or may not fully, apply.

Another factor in this decision process is the fact, that much of the organ damage present at initial diagnosis may be the direct or indirect result of the underlying malignancy such as immunosupression leading to atypical infections or parenchymal NHL involvement leading to organ dysfunction (liver, lung, intestinal tract, kidneys).

Initiation of therapy regardless of “prohibitive” organ dysfunction is therefore often preferable in aggressive lymphomas, especially when organ dysfunction and disease activity are closely intertwined.

In applying this principle, unexpected or pronounced side-effects need to be prepared for. At the same time, unexpected and pronounced therapeutic effects of cytostatic agents given in this context may also occur. This phenomenon has been described in the treatment of central nervous system NHL, were high-dose MTX leads to better responses in the presence of renal insufficiency (Batchelor 260

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Cancer Therapy Vol 6, page 263 Cancer Therapy Vol 6, 263-270, 2008

Immunological concepts applied to pathologic diagnosis of proliferative diseases of the immune system Review Article

Peter F. Moore Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis CA 95616, USA

__________________________________________________________________________________ *Correspondence:Peter F. Moore, Professor, Department of Pathology, Microbiology and Immunology 3315 Vet Med 3A, School of Veterinary Medicine, University of California, Davis, CA 95616, USA; Tel: 530 752 5204; Fax: 530 752 3349; e-mail: pfmoore@ucdavis.edu Key words: functional significance, immune system, Lymphocyte antigen receptor, lymphoma, diagnosis, Cell lineage Abbreviations: antigen presenting cells (APC); Canine cutaneous histiocytoma (CCH); chronic lymphocytic leukemia of T cell, (TCLL); Cluster of differentiation (CD); Cluster of differentiation (CD); complementarity determining region 3 (CDR3); dendritic cells (DC); heavy chain Ig genes (VHDJ); histiocytic sarcomas (HS); immunoglobulin (Ig); immunoglobulin heavy chain locus (IGH); intestinal epithelial compartment (IEC); intra-epithelial lymphocytes (IEL); large granular lymphocyte (LGL); light chain Ig genes (VLJ); major histocompatibility complex, (MHC); mucosal addressin cell adhesion molecule (MadCAM); natural killer (NK); polymerase chain reaction (PCR); T cell receptor molecules (TCR) Received: 21 February 2008; electronically published: June 2008

Presented in the Theilen Tribute Symposium at UC Davis 31 st May- 1st June 2008.

Summary Investigation of immunopathological diseases often entails precise identification of lineages of infiltrative cells and the nature of the disease process â&#x20AC;&#x201C; inflammatory or neoplastic. The development of the Cluster of differentiation (CD) antigen system and the associated monoclonal antibodies specific for CD molecules has facilitated immunostaining for the detection of the lineages of cells in hemopoietic neoplasia of animals (immunophenotyping). This has been important in the classification of lymphomas and proliferative histiocytic diseases in dogs and cats. The distinction of lymphocyte dominant inflammation from lymphoma has been facilitated by the development of methods to readily assess lymphocyte antigen receptor gene rearrangements. These assessments are almost exclusively performed by polymerase chain reaction (PCR) methodology with primers designed to amplify the T cell receptor ! locus (TCRG) for T cell clonality assessment, and the immunoglobulin heavy chain locus (IGH) for B cell clonality assessment. It is important to recognize that cell lineage is best determined by immunophenotypic analysis, and that molecular clonality assessment should be performed in the light of a full appreciation of the clinical and morphological features of the disease process.

rearrangement by polymerase chain reaction (PCR) provides valuable information pertaining to antigen receptor diversity in the lesion. Specifically, the detection of lymphocyte clones in lymphoproliferative disease, in the appropriate clinical and morphological context, is consistent with lymphoma. Detection of clonality in nonlymphoid proliferative diseases such as histiocytic proliferative disease is more challenging and has not been routinely applied in diagnosis in animals.

The nomenclature and complexity pertaining to the biology of leukocyte surface molecules is intimidating.

I. Introduction The crux of investigation of immunopathological diseases involves identification of the cells involved and the process, inflammatory (reactive) or neoplastic. Cell lineage determination in the immune system has advanced since the inception of the â&#x20AC;&#x153;cluster of differentiationâ&#x20AC;? (CD) antigen system. Precise cell identification can be achieved by the application of monoclonal antibodies (mAb) specific for leukocyte antigens to isolated cells, cell smears and tissue sections. In the case of lymphoid proliferation, assessment of B or T cell antigen receptor 263

Moore: Immunological concepts applied to pathologic diagnosis There are currently 350 CDs assigned in the human immune system, as well as many other defined molecules that have not yet been assigned to clusters of differentiation (Zola et al 2005, 2007). Comprehensive reports of recent leukocyte antigen workshops have been published for ruminants (Naessens et al, 1997), swine (Haverson et al, 2001), and horses (Lunn et al, 1998). A single workshop was convened to identify canine leukocyte antigens (Cobbold and Metcalfe, 1994) and none has been conducted for cats. Despite the large number of CD molecules identified, not all are useful or available for use in immunodiagnostics. In most instances, CD molecules are detectable by mAb, which react only with native antigen in unfixed cells, which can include unfixed air dried cytological preparations, anti-coagulated blood or bone marrow, and fresh tissue which has been carefully snap frozen and sectioned. In some instances, antibodies that detect epitopes resistant to the deleterious effects of formalin fixation have been developed; these are valuable reagents for the study of archived tissue in paraffin blocks and routinely processed pathological material (Moore et al, 1998).

they assist B cell activation, affinity maturation and immunoglobulin class switching in response to antigen (Janeway et al, 2001). CD8 T cells interact with MHC class I peptide complexes on almost any cell including APC. Hence, CD8 cytotoxic T cells are well suited to the task of clearing virally infected cells and cancer cells via detection of virally encoded peptides or peptides derived from mutated self proteins presented in the peptide binding groove of MHC class I (Janeway et al, 2001).

The identification of histiocytes in tissue sections also relies on the identification of functionally important molecules on these cells. Histiocytes include macrophages and dendritic cells (DC). Dendritic cells are the most potent APC. Nomenclature of DC populations is based on the differentiation pathway followed by the cell (the cell lineage), and by the location in tissue. There are 3 DC lineages: interstitial DC, epithelial localized DC (Langerhans cells or LC) and plasmacytoid DC. MHC class I and class II, together with CD1, are the molecules responsible for presentation of peptides, lipids and glycolipids to T cells. Hence, DC in humans and dogs are best defined by their abundant expression of molecules essential to their function as antigen presenting cells. Of these, the family of CD1 proteins is more or less restricted to DC and other APC such as subsets of B cells and monocytes; while MHC class I and II are more broadly expressed. Based on CD1 expression, DC of canine skin occur in 2 major locations: within the epidermis (LC), and within the dermis especially adjacent to postcapillary venules (dermal interstitial DC) (Moore and Mariassy, 1986; Moore et al, 1996). The expression of #2 integrins is differentially regulated in normal canine macrophages and DC; CD11c is frequently expressed by DC; while macrophages predominately express CD11b (or CD11d in the splenic red pulp and bone marrow (Danilenko et al, 1992, 1995). Langerhans cells and dermal DC are distinguishable by their Thy-1 (CD90) expression; epidermal LC lack Thy-1 and dermal DC express abundant Thy-1 (Moore et al, 1996). Epidermal LC also express E-cadherin, which assists in their localization in the epidermis via a homotypic adhesive interaction with Ecadherin expressed by keratinocytes (Borkowski et al, 1994; Blauvelt et al, 1995).

Regardless, it is important to realize that DC arise in bone marrow and migrate through blood to a variety of epithelial sites (cutaneous and mucosal), where they take up residence either within epithelia or in dermis and lamina propria. In these sites they function as antigen processing and ultimately antigen presenting cells, which interact with T cells. Migration of cutaneous DC (as veiled cells) via lymphatics to the paracortex of lymph nodes occurs following contact with antigen. Dendritic cells alter their chemokine receptor expression profile (upregulate CCR7) and are attracted to chemokine ligands displayed on the surface of lymphatic endothelial cells (CCL21) and on stromal cells in the paracortex of lymph nodes(Cyster, 1999; Kellermann et al, 1999). Dendritic cells differentiate into potent APC during this migration and change their surface phenotype accordingly (see below). The interdigitating dendritic APC of lymph node paracortex are partially derived from such migration. Another major

II. Cell lineages revealed by markers of functional significance Very few leukocyte antigens are expressed only by a single lineage of cells. For example, T cell receptor molecules (TCR) are only expressed by T cells, but the associated signaling molecule, CD3 epsilon, is expressed on the surface of T cells, and in the cytoplasm of activated natural killer (NK) cells (Lanier et al, 1992). CD3 expression has also been observed in human NK lymphoma (Suzumiya et al, 1994). For many other CD molecules, the cellular expression patterns are promiscuous. Pathologists wishing to use utilize leukocyte antigen expression patterns in diseased tissues for cell lineage determination, must utilize a combinatorial logic based on the examination of a diagnostically relevant region in multiple sections stained with members of a panel of mAb specific for leukocyte antigens. This is distinct and opposite of the logic applied to the application of special histochemical stains to tissue sections. Simply stated, â&#x20AC;&#x153;the one stain - one cellâ&#x20AC;? paradigm must be abandoned in the former context.

Cell lineage is best determined by evaluation of the expression pattern of leukocyte antigens that are functionally important for a particular cell. The use of arcane markers with unknown functional significance is usually less valuable. In this context, identification of T cells and important T cell subsets is best achieved by demonstration of components of the TCR/CD3 complex on the surface of the cell, in association with other functionally important TCR/CD3 co-receptor molecules such as CD4 (helper T cells) or CD8" (cytotoxic T cells) (Janeway et al, 2001). These co-receptor molecules are involved in interaction of T cells with antigen presenting cells (APC). CD4 T cells interact with major histocompatibility complex (MHC) class II peptide complexes on the surface of APC. CD4 helper T cells are critically involved in humoral immune responses in which

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Cancer Therapy Vol 6, page 265 population of DC occurs in lymph nodes; these cells do not arrive after migration from tissues. Instead they enter lymph nodes from blood as immature DC precursors, which differ from other DC in their surface phenotype.

These DC do not express many of the lineage determining molecules of tissue DC, rather, they are relatively undifferentiated upon arrival in lymph nodes. They express abundant CD4, CD45RA and CD123, the IL-3 receptor " subunit, indicating that these cells differentiate under a different cytokine/growth factor milieu than tissue DC (Olweus et al, 1997). Accordingly, these DC have been named plasmacytoid DC (Rothenfusser et al, 2002).

Plasmacytoid DC have not been identified in the canine due to lack of available reagents specific for key identifying surface molecules (esp. CD123).

Successful interaction of DC and T cells in response to antigenic challenge also involves the orderly appearance of co-stimulatory molecules (B7 family) on DC, and their ligands (CD28 and CTLA-4) on T cells (Sethna et al, 1994; Walunas et al, 1994; Tivol et al, 1995). Defective interaction of DC and T cells appears to contribute to the development of reactive histiocytic proliferative diseases (cutaneous and systemic histiocytosis), which are related diseases arising out of disordered immune regulation.

Recognition of this has led to the development of effective treatments for reactive histiocytic proliferative diseases; these treatments rely on potent immunosuppression, which may need to be lifelong in severe cases. Much research is currently directed at the molecular events associated with maturation and migration of DC, and the co-stimulatory function of DC. To some extent this research should be of future benefit to understanding the pathogenesis of reactive proliferative disorders of DC in both human and dog.

Aspects of the developmental and migratory program of cutaneous DC are recapitulated in the DC proliferative disorders of canine skin. Canine cutaneous histiocytoma (CCH) is a LC disorder, in which tumor histiocytes express CD1, CD11c, MHC II and E-cadherin. Migration (metastasis) of CCH to lymph nodes is observed, although rarely. Tumor histiocytes in these instances are likely following the migratory route of normal LC after contact with antigen (Moore et al, 1996, 1998). Accordingly, CCR7 transcripts have been demonstrated in CCH (Moore unpublished data). Tumor LC obliterate affected lymph nodes. In some instances, spontaneous regression occurs; this is the usual outcome in cutaneous tumors and the time course of regression in lymph nodes is similar. In other instances tumor LC persist in lymph nodes, but do not usually extend beyond them. Regression does not occur in these cases and many of these dogs are euthanized.

Normal DC do not recirculate following migration to lymph nodes; efferent lymph lacks significant numbers of DC, and most migratory DC undergo apoptosis following interaction with paracortical T cells in the process of antigen presentation. The distinctive surface antigen phenotype of canine LC has also enabled recognition of more aggressive LC proliferative disorders in dogs similar to aggressive forms of Langerhans cell histiocytosis in humans. In canine LCH, widespread cutaneous lesions are present initially; this phase is followed by a phase of rapid

dissemination to lymph nodes and internal organs (especially lung). Canine LCH has a poor prognosis; all afflicted dogs have been euthanized (Moore and Affolter, unpublished data).

Most canine histiocytic sarcomas (HS) involve infiltration and expansion of cells of DC lineage (Affolter and Moore, 2002). These include localized and disseminated HS; the latter is often equated with malignant hisiocytosis. However, proliferative disorders of macrophage lineage have also been recognized. The best example is the hemophagocytic HS (hemophagocytic malignant histiocytosis) of dogs (Moore et al, 2006). In most instances this disorder is associated with expansion of splenic red pulp macrophages, often coincident with expansion of bone marrow macrophages, both of which manifest prominent erythrophagocytosis. Application of #2 integrin markers to frozen or even formalin fixed tissue sections is of value in recognizing the lineage and origin of the histiocytic population (Danilenko et al, 1992).

While macrophages in hemophagocytic HS do not express abundant CD1 as expected of DC, they do prominently express CD11d and CD18, which are diffusely expressed by normal resident macrophages of splenic red pulp and bone marrow (Danilenko et al, 1995; Moore et al, 1998).

Immunostaining of tissue sections with CD11d can reveal early intravascular spread of hemophagocytic histocytic sarcoma to liver and lung, which has proven to be frequently overlooked by pathologists who examine only routine HE sections (Moore et al, 2006).

The exquisite expression pattern of CD11d is also of value in identification of hepatosplenic T cell lymphoma.

Peripheral lymphadenopathy is not a feature of this disease. Neoplastic T cells arise in splenic red pulp and invade liver and bone marrow sinuses. These T cells are often of !$ lineage, possess large granular lymphocyte (LGL) morphology and express CD11d (Farcet et al, 1990; Weidmann, 2000; Fry et al, 2003). An examination of normal splenic T cell populations in dogs revealed that !$ T cells are most abundant in splenic red pulp and express CD11d at a frequency 4 fold higher than !$ T cells of peripheral blood (McDonough and Moore, unpublished).

To further underscore the usefulness of evaluation of CD11d in hematopoietic neoplasia, evaluation of canine chronic lymphocytic leukemia of T cell origin (T-CLL) revealed that more than 70% of the cases were of LGL type. Clinical evaluation of these cases revealed that TCLL of LGL type was usually an indolent disease in which splenic red pulp infiltration and splenomegaly were well developed prior to bone marrow infiltration (Vernau and Moore, 1999; McDonough and Moore, 2000). In fact, bone marrow infiltration was inconsistent, and was only seen late in the clinical course. Immunophenotypic analysis of the cases revealed that both "# T cells (69%) and !$ T cells (31%) were involved in this disease. CD11d and CD8 were expressed in 90% of cases of LGL T-CLL (McDonough and Moore, 2000); this is an unusual phenotype in peripheral blood and bone marrow, but not in the splenic red pulp. Accordingly, it is highly likely that LGL T-CLL originates as a proliferation of splenic red pulp T cells, which populate the blood and cause significant splenomegaly. The defining concept of 265

Moore: Immunological concepts applied to pathologic diagnosis leukemia as a primary bone marrow disorder is changing, and the modern definition of leukemia is best defined as hemopoietic neoplasia with predominant blood involvement. These few examples serve to highlight the multi-lineage expression of many leukocyte antigens.

The dominant expression of CD11d by LGL T-CLL, coupled with the observation that T cell lymphomas and perhaps NK cell lymphomas in dogs also frequently express CD11d in diverse sites (skin, nervous system and others), clearly associates the granulated lymphocyte phenotype with CD11d expression. However, in cats we have documented a series of cases of LGL lymphocytosis, in which CD11d expression was not as prevalent (24%).

These cats had intestinal LGL lymphomas most frequently of T cell lineage (90% CD3+). In many instances these LGL expressed the unusual phenotype CD3CD8" (60%), which is commonly observed in intra-epithelial lymphocytes (IEL) extracted from the small intestinal epithelial compartment (IEC). Normally these IEL contain about 30% LGL, and express the #-7 integrin CD103 ("E) (Roccabianca et al, 2000; Woo et al, 2002). We observed CD103 expression in about 60% of the LGL lymphocytosis cases tested, consistent with their intestinal origin (Roccabianca et al, 2006). CD103 expression by lymphocytes is rare in peripheral blood (about 1%) due to the nature of lymphocyte trafficking to the gut (Woo et al, 2002).

Lymphocytes that traffic to small intestine express the integrin "4#7. These cells transmigrate across endothelial cells of the post-capillary venules which express the "4#7 ligand, mucosal addressin cell adhesion molecule (MadCAM) (Cheroutre, 2004; Cheroutre and Madakamutil, 2004). The chemokine receptor CCR9 and its ligand, thymus expressed chemokine (TECK or CCL25), which is produced by crypt epithelium of the small intestine are also involved in this process (Kunkel et al, 2000; Marsal et al, 2002; Mora et al, 2003). Once lymphocytes enter the lamina propria (LPL) they begin to down-regulate the "-4 subunit and up-regulate the "-E subunit and now express "E#7. The frequency of expression of "E#7 is greater in the IEL population than in the LPL population. The ligand for "E #7 in the IEC is the homotypic epithelial adhesion molecule E-cadherin (Cepek et al, 1994; Higgins et al, 1998). Expression of "E #-7 on mucosal lymphocytes is influenced by TGF-# secreted by the IEC. IEL are largely comprised by T cells, and lymphocyte trafficking to the small intestinal lamina propria and IEC has been mostly studied in this cell type.

Evidence for broader application of the rules of intestinal lymphocyte trafficking to plasma cells has been published (Pabst et al, 2004). IgA producing plasma cells also use CCR9/CCL25 interaction to enter the mucosa of the small intestine and cluster around the epithelial crypts, which produce CCL25, and the polyIg receptor, which transports dimeric IgA to the intestinal lumen (Phalipon and Corthesy, 2003; Pabst et al, 2004). Morphologic evaluation of intestinal biopsies is impacted by lymphocyte trafficking patterns, which impart the normal segregation of lymphocytes and plasma cells within the lamina propria of the small intestine.

Understanding of these small intestinal lymphocyte trafficking principles, coupled with the development of PCR primer sets capable of detecting clonal expansion of B and T cells (see below), has led to the discovery of the high prevalence of mucosal-confined small T cell lymphoma in cats (Moore et al, 2005; Werner et al, 2005).

III. Lymphocyte antigen receptor gene rearrangement â&#x20AC;&#x201C; an aid to diagnosis of lymphoma During T cell development in the thymus, T cells rearrange their antigen receptor genes TCRA, TCRB, TCRG and TCRD, and in the process create 2 lineages of T cells, "# and !$ T cells. The majority of "# T cells rearrange TCRG prior to the rearrangement of TCRA and TCRB. Hence, TCRG gene rearrangement occurs in the majority of T cells regardless of surface the type of TCR expressed (Theodorou et al, 1994). The protein product of TCRG is TCR !, which contains a variable (V) domain and a constant (C) domain. The V domain is encoded by 2 segments of DNA, the variable and joining (J) segments. Although multiple V and J segments exist for TCRG, they are relatively limited in number and diversity by comparison with TCRA and TCRB. Gene rearrangement during T cell development in the thymus leads to random joining of a V segment to a J segment, leading to the formation of the complete V domain exon.

The diversification of the TCRG repertoire is enhanced by the creation of P nucleotides, and the random insertion of N nucleotides by terminal transferase between the V and J segments. This creates the highly diverse third hypervariable region of the V domain, also known as the complementarity determining region 3 (CDR3). The CDR3 region is at the center of the antigen binding site and hence is the major contributor to antigen specificity (Janeway et al, 2001). In the rearrangement of TCRB and TCRD, a diversity (D) segment is interposed between V and J segments to create the CDR3 region, which is longer and more diverse due to the presence of 2 regions of N nucleotide addition (V-N-D-N-J). The TCRD locus is contained within the TCRA locus such that rearrangement of TCRA results in deletion of TCRD from the genome (Janeway et al, 2001). In consideration of the above, the preferred target for determination of clonality in T lymphocyte populations of both "# and !$ lineages is PCR amplification of the CDR3 region of TCRG. B cells rearrange their antigen receptor genes in the bone marrow during B cell development. B cells rearrange multiple V, J and D immunoglobulin (Ig) gene segments, initially in their heavy chain Ig genes (VHDJ), and later in either % or & light chain Ig genes (VLJ). This process of somatic recombination was first described for Ig genes and resembles the description of the process already outlined for T cells. A further property of Ig genes is their propensity to undergo V region somatic hypermutation, particularly during secondary antibody responses in germinal centers of follicles in peripheral lymphoid organs (Janeway et al, 2001). In addition, secondary V(D)J re-arrangement has also been described in germinal centers of mice through reactivation of 266

Cancer Therapy Vol 6, page 267 recombinase genes, which were previously thought to be active only in central lymphoid organs (Han et al, 1997).

By these mechanisms, antibodies of high affinity are produced in secondary lymphoid responses (affinity maturation). The most commonly used target for determination of clonality in B lymphocyte populations is the IGH locus due to the extensive diversity of the CDR3 region and the conservation of IGH V and J segments, which facilitate PCR primer design. One pitfall of using IGH for molecular clonality determination is the extensive V segment gene mutation that occurs in post germinal center B cells can modify primer binding sites in the V segment. This can lead to false negative PCR results and reduced sensitivity of IGH as a molecular target for clonality determination in B cells (van Dongen et al, 2003).

Lymphocyte antigen receptor clonality determination is a valuable adjunct to morphologic and immunophenotypic assessment of lymphoproliferative disorders in dogs and cats (Vernau and Moore, 1999; Burnett et al 2003; Moore et al 2005; Werner et al, 2005).

It is not a primary diagnostic assay, and it cannot replace morphologic and immunophenotypic assessment.

Lymphocye antigen receptor gene rearrangement can be promiscuous; both TCRG and IGH rearrangement can be observed in lymphomas of a single immunophenotype (B or T cell). Also, lymphocyte antigen receptor gene rearrangement has been observed in non-lymphoid leukocytic malignancy, such as acute myeloid leukemia (van Dongen et al, 2003).

Molecular clonality determination is not needed to establish a diagnosis in most lymphoid proliferations in which architectural effacement of organized lymphoid tissue, cytological features of lymphocytes, and immunophenotyping are sufficient. Molecular clonality determination is indicated when morphological features of lymphocytes and immunophenotyping are inconclusive.

These conditions are most often met in some lymphoid proliferations in gut and skin, or in organized lymphoid tissue when architecture is largely intact (for example: early marginal zone and T-zone lymphoid proliferations) (Moore et al, 2005; Valli et al, 2006). The relatively recent recognition of marginal zone lymphomas in dogs has complicated the interpretation of complex splenic lymphoid nodular lesions.

Molecular clonality determination has become a decisive tool to unravel these complex lesions (Benak and Moore, unpublished data).

Molecular clonality determination is also valuable in the assessment of the clonal relationship of lymphoid proliferations in separate sites. In this instance, it is possible to distinguish relapse from a second malignancy.

The use of clonotypic primers (specific for a particular CDR3 sequence) can facilitate this investigation.

However, development of clonotypic primers is expensive and not always possible based on the CDR3 sequence.

cells in diseased tissues. This coupled with the analysis of lymphocyte antigen receptor gene rearrangement in lymphoproliferative diseases, has greatly expanded our abilities to diagnose proliferative diseases of the immune system. However, the interrogative techniques of immunohistochemistry and molecular clonality determination, while powerful, should only be used as adjunctive aids coupled with careful clinical assessment of the patient and morphologic assessment of lesional tissue.

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Moore: Immunological concepts applied to pathologic diagnosis

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Cancer Therapy Vol 6, page 271 Cancer Therapy Vol 6, 271-274, 2008

Toxic epidermal necrolysis, an unusual adverse effect of Capecitabine Case report

Nelson Matos-Fernández*, Yelitza Ruiz, Jorge Rodríguez, Luís Báez, William Cáceres, Víctor López-Pinto, Glenda González Department of Hematology and Medical Oncology, Veteran Affairs Caribbean Healthcare System, San Juan, Puerto Rico

__________________________________________________________________________________ *Correspondence: Matos-Fernandez, Nelson, MD, Department of Hematology and Medical Oncology, Veteran Affairs Caribbean Healthcare System, 10 Casia Street, San Juan, Puerto Rico, 00921; Tel: (787) 641-3693; E-mail: matosfdz@hotmail.com Key words: Toxic Epidermal Necrolysis, Acral erythema, Capecitabine, Colon cancer Abbreviations: 5-fluorouracil, (5-FU); blood urea nitrogen, (BUN); immunoglobulin, (Ig); score for toxic epidermal necrolysis, (SCORTEN); thymidine phosphorylase, (TP); Toxic epidermal necrolysis, (TEN)

Conflict-of-interest disclosure: No potential conflict of interest with any of the pharmaceuticals companies exist.

Received: 9 October 2007; Revised: 30 April 2008 Accepted: 6 May 2008; electronically published: May 2008

Summary We describe the case of a 59-year-old African American man with metastatic colon cancer who received treatment with capecitabine, irinotecan, and oxaliplatin as part of a phase II clinical trial. Following administration of capecitabine, he developed dry scale lesions that later became generalized, with desquamation and skin necrosis, spreading all over his body. A punch biopsy showed changes suggestive of toxic epidermal necrolysis. The patient received therapy with intravenous immunoglobulins, antibiotics, fluid hydration, and topical skin care, resulting in resolution of lesions. His treatment for colon cancer was discontinued. Capecitabine is a commonly used therapy for metastatic colorectal and breast cancer, and it is generally associated with mucositis, diarrhea, and hand-foot syndrome. To our knowledge, this is the fist case of toxic epidermal necrolysis secondary to the use of capecitabine.

capecitabine in adenocarcinoma.

I. Introduction Capecitabine is an orally administered fluoropyridine carbamate with proven efficacy against colon and breast adenocarcinoma. It is converted, in a three step process, to the active moiety 5-fluorouracil (5-FU) by thymidine phosphorylase (TP) found predominantly on malignant cells. This mechanism results in high concentration of 5FU within the tumor, and a low systemic exposure potentially reducing its systemic toxicity. 5-FU is then metabolized into active nucleotides, resulting in disruption of DNA synthesis. The major dose limiting toxicities are diarrhea, and palmar-plantar erythrodysesthesia also known as chemotherapy-induce acral erythema or handfoot syndrome (Dooley and Goa, 1999; Budman, 2000; Ishitsuka, 2000; Schilsky, 2000; McGavin and Goa, 2001; Johnston and Kaye, 2002). Toxic epidermal necrolysis is a medication-induced skin disease with a high mortality rate despite appropriate supportive therapy. We report a unique case of toxic epidermal necrolysis which developed after

a

patient

with

metastatic

colon

II. Case Report A 59-year-old African American man with metastatic adenocarcinoma of colon with liver involvement underwent proximal and distal colectomy with primary anastomosis secondary to intestinal obstruction. The patient has a medical history significant for hypertension. He has been suffering of cancer related pain for which he has been prescribed long acting morphine sulfate 15 mg orally every 12 hours, and oxycodone HCl controlled-release 5 mg orally every 4 hours for breakthough pain. He received treatment consisting of capecitabine (825 mg/m2 orally twice a day on days 1-14 and 2135) in combination with irinotecan (180 mg/m2 on day ) and oxaliplatin (130 mg/m2 IV on day 1) as part of a phase II clinical trial; duration of 42 days/cycle. After completion of his third cycle of therapy, he developed generalized painful macules with some areas of crust which manifested during the time he was receiving capecitabine. The lesions involved the gluteus area, lower and upper extremities but no mucosal involvement at that

271

Matos-Fernรกndez et al: Toxic epidermal necrolysis, an unusual adverse effect of Capecitabine evaluation. Patient denies prior skin rashes, reactions to medications or insect bites.

The patient was admitted under with a diagnosis of possible disseminated herpes zoster infection and was started on intravenous acyclovir 800 mg every eight hours. In addition, was prescribed empirically cefepime 1 gm every 12 hours and vancomycin 1 gm every 12 hours. Laboratory results consisting of a CBC, and a comprehensive metabolic panel were nonrevealing. Skin lesions became more generalized, and painful, within the next 24 hours involving the chest, abdominal area, upper back, lower back lower, upper and lower extremities (Figure 1) and oral mucosa with blistered and eroded areas with a body surface area of 63%. In addition, the lesions coalesce into large skin blisters that separate with slight pressure leaving red

denuded lesions. Tzanck smear was negative for herpes infection.

Dermatology service diagnosed with a drug with eruption of the erythema multiforme-toxic epidermal necrolysis spectrum. The patient has 3 risk factors of severity of illness score for toxic epidermal necrolysis (SCORTEN) that place him with a mortality rate of 35%. He was treated with aggressive hydration, local care and 25 mg of intravenous immunoglobulin (Ig) daily for 4 days. Punch biopsy showed changes consistent with toxic epidermal necrolysis (Figure 2). Skin culture revealed normal skin flora, and no fungal elements on KOH as well on culture.

Skin lesions improved and patient was discharged home after 12 days of hospitalization with resolution of mucosal lesions and healing of skin lesions.

Figure 1. Red denuded lesions with erythema on back (A), and lower extremities (B-D).

Figure 2. Skin biopsy that shows changes of toxic epidermal necrolysis. Subepidermal blister formation (arrow), necrotic keratinocytes (double arrow), and sparse lymphohistiocytic infiltrate around the dilated blood (block arrow).

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Cancer Therapy Vol 6, page 273 associated to capecitabine is lichenoid photosensitive eruption. Only two cases have been reported so far in two patients that were treated for metastatic breast cancer (Baack and Burgdorf, 1991; Weiss and Baker, 1987; Willey, 2002; Lassere and Hoff, 2004; Prod Info XelodaR, 2007; Hague and Ilchyshyn, 2007).

Felodipine is a dihydropyridine calcium channel blocker that is used for hypertension. Reported cutaneous reaction includes erythema, eczema, and leukocytoclastic vasculitis but no toxic epidermal necrolysis has been reported. Our patient was using the felodipine for at least two years before and treatment was continued during and after this episode. Patient was using oxycodone for cancer associated pain for one year prior to this episode. Reported cutaneous reactions associated to this medication are dry skin, exfoliative dermatitis, and urticaria. These reactions commonly occurred with initiation of therapy. Another drug that was used for at least a year before this episode is morphine. The reported cutaneous reactions associated to this medication are rash and sweating. No toxic epidermal necrolysis has been reported for either oxycodone or morphine (Stern and Khalsa, 1989; Prod Info PlendilR, 2003; Prod Info AvinzaR, 2005; Prod Info OxycontinR, 2007).

As part of the study oxaliplatin and irinotecan was administered at once doses on day 1 for oxaliplatin and day 21 for irinotecan. The oxaliplatin reported cutaneous reactions are alopecia, and flushing. In combination with 5-FU and leucovorin the incidence of acral erythema is 11% secondary to the use of the 5-FU. Rash is been reported as irinotecan associated cutaneous reaction. No toxic epidermal necrolysis has been reported for either oxaliplatin alone or irinotecan (Prod Info CamptosarR, 2007; Prod Info EloxatinTM, 2007).

Capecitabine is well known to produce acral erythema but no toxic epidermal necrolysis has been reported. It is well known that capecitabine can cause cutaneous reactions with a time onset between 10 hours and 10 months. In addition the TEN started during the time that capecitabine was administered. Felodipine, oxycodone, and morphine were not the underlying cause because his administration continued through the episode.

In addition irinotecan and oxaliplatin is not assicated with TEN. This is complelling evidence that the capecitabine was the underlying cause. We reported a case of toxic epidermal necrolysis secondary to the use of capecitabine in the treatment of metastatic colon cancer. Although this is a rare reaction associated to the use of capecitabine one has to be aware for the rapid identification, and treatment to decrease mortality.

III. Discussion Toxic epidermal necrolysis (TEN) is a medicationinduced dermatological disorder with an overall mortality rate approximately of 30%. The most common drugs associated with TEN are (in descending order): Sulfonamides, anti-gout agents such as allopurinol, antipsychotic and anti-epileptics such as carbamazepine and phenobarbital, and analgesics such as piroxicam, among others. It is characterized by a sudden onset epidermal necrosis that involves 30% or more of the total body surface area. Mucosal involvement is not uncommon. The mechanism is unknown, and several studies suggest that cytotoxic T lymphocytes may be the responsible for the disease. Clinical manifestations usually occur hours to days after the first exposure. Importantly, patients developing TEN are more vulnerable to bacterial and fungal superinfections due to the epithelial damage. Also, patients can develop severe hypovolemia and shock, due to vextravascular volume loss, and may eventually develop multiorgan failure, hence the high mortality rate.

Bastuji-Garin S, et al developed a score capable of prediciting mortality rate in these patients by evaluating seven variables: age more than 40 years, heart rate more than 120 beats per minute, presence of cancer or hematological malignancy, more than 10% of sureface area involvement, blood urea nitrogen level (BUN) greater than 28mg/dL, serum bicarbonate level less than 20 mEq/L and blood glucose level above 252 mg/dL. Patients with only 0 or 1 factor(s) have a mortality rate of 3%; those with 2 factors have a mortality rate 12%; when three factors are present, the mortality rate is 35%; with 4 factors the mortality rate is 58%; and with 5 or more factors the mortality rate is 90%. Treatment requires discontinuation of the offending drug, aggressive fluid and electrolyte replacement, and local skin care as necessary.

Bacterial colonization should be prevented with contact precautions and intravenous antibiotics are often necessary if an infection is suspected. Intravenous immunoglobulin has been reported to be beneficial in the treatment of TEN (Schopf et al, 1991; Bastuji-Garin et al, 2000; Paquet et al, 2000; Schulz et al, 2000; Prins et al, 2003; Pereira et al, 2007).

Capecitabine is a third generation fluoropyrimidine carbamate that is an oral chemotherapy for the treatment of metastatic breast and colorectal cancers. The dose limiting toxicities are diarrhea and chemotherapy-induce acral erythema (Dooley and Goa, 1999; Budman, 2000; Schilsky, 2000; Ishitsuka, 2000; McGavin and Goa, 2001; Johnston and Kaye, 2002; Prod Info XelodaR, 2007). Apart from capecitabine, acral erythema is also seen with other chemotherapy agents like doxorubicin, 5-FU, and cytosine arabinose and appears to be dose dependent. Usually the time of onset varies from 10 hours to 10 months. The cause is unknown and is limited to the palms and soles been more common on palms. The patient can present with paresis that can be followed by painful symmetric erythema, swelling and desquamation. The diagnosis is made on the basis of the clinical setting and usually the course is self-limited. The treatment is supportive with local care, and dose modification of the causative agent is advised. Another recently reported cutaneous reaction

Acknowledgment The authors are grateful for the useful suggestions in editing this article of Viviana Chavez-Sauto, BS, MBA/HCM.

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Pereira FA, Mudgil AV, Rosmarin DM (2007) Toxic epidermal necrolysis. J Am Acad Dermatol 56, 181-200.

Prins C, Kerdel FA, Padilla RS, Hunziker T, Climenti S, Virad I, Mauri DN, Flynn K, Trent J, Margolis DJ, Saurat JH, French LE (2003) Treatment of toxic epidermal necrolysis with high-dose intravenous immunoglobulins: multicenter retrospective analysis of 48 consecutive cases. Arch Dermatol 139, 26.

Product Information: Avinza (R) extended-release oral capsules, morphine sulfate extended-release oral capsules. Ligand Pharmaceuticals Incorporated, San Diego, CA, 2005.

Product Information: Camptosar (R) injection, irinotecan hydrochloride injection. Pfizer Inc, New York, NY, 2007.

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Cancer Therapy Vol 6, page 285 Cancer Therapy Vol 6, 285-302, 2008

Search for oncogenic retroviruses in wild mice and man: Historical reflections Review Article

Murray Gardner Center for Comparative Medicine, University of California at Davis

__________________________________________________________________________________ *Correspondence: Murray B. Gardner, MD, University of California School of Medicine, Department of Medical Pathology, One Shields Avenue, Davis, CA 95616, USA; Tel: 530 752 1245; fax: 530 752 7914; e-mail: mbgardner@ucdavis.edu Key words: viral oncogene, provirus hypotheses, Epidemiology, Virus properties, Exogenous transmission, Pathology, pathogenesis, Lymphoma, Paralysis, Control measures, Genetic resistance, gene therapy, oncogenic retrovirus antigens/antibodies Abbreviations: baboon endogenous virus, (BaEV); bovine leukemia virus, (BoLV); complement fixation, (CF); electron microscopy, (EM); feline leukemia virus, (FeLV); human t-cell leukemia virus, (HTLV); interleukin 2, (IL-2) murine leukemia virus, (MuLV); murine mammary tumor virus, (MMTV); National Cancer Institute, (NCI); polymerase chain reaction, (PCR); radioimmunoassay, (RIA); reverse transcriptase, (RT); Rous sarcoma virus (RSV); simian t-cell leukemia virus, (STLV); Virus Cancer Program, (VCP) Received: 14 March 2008; electronically published: June 2008

Presented in the Theilen Tribute Symposium at UC Davis 31 st May- 1st June 2008.

Summary In 1968, the National Cancer Institute inaugurated the Virus Cancer Program to search for oncogenic retroviruses in humans and their domestic pets. I was recruited to help with this effort by building an interdisciplinary research team and, in particular, to search for such viruses in wild mice, the progenitor of laboratory mice which served as the major animal model for retroviral-induced cancer. Summarized here is the result of a 12 year effort of this team towards fulfilling these goals. We uncovered a new biology of oncogenic retroviruses in wild mice but failed to find any retrovirus in humans. Retroviruses in the wild mouse provided a more accurate model than retroviruses in the inbred laboratory mouse in predicting the natural history of the first human oncogenic retrovirus discovered elsewhere a decade later.

was predicated primarily on the belief that viruses of this type might cause cancer in humans as they were known to do naturally in chickens, lab mice, and domestic cats. By contrast, most of the known DNA tumor viruses, such as polyoma and adenovirus were considered to be lab artifacts and not tumorigenic in nature. When Ludwig Gross first isolated murine leukemia virus (MuLV) from AKR mouse embryos in 1951, he was convinced that the virus was transmitted vertically only as an infectious agent (Gross, 1951). However, in 1968, the emphasis was not on finding RNA tumor viruses in the conventional infectious disease sense; consensus opinion was that you did not “catch” cancer, and cancer in lab mice did not behave like a horizontally transmitted infectious disease. The favored expectation was that cancer was a genetic disease: i.e. “genes gone wild”. Therefore, the concept that potentially infectious RNA tumor viruses might be inherited as cellular, i.e. endogenous, virogenes in humans and other mammals, as had been found in chickens and inbred mice, had great intellectual appeal. Activation of such latent virogenes, under control by other host genes, by factors

I. Introduction Background: viral oncogene and provirus hypotheses Forty years ago, 1968, I was given the grand opportunity to embark on a new and exciting scientific adventure. I was recruited by Robert Huebner of the National Cancer Institute (NCI) to build an interdisciplinary research team at the USC School of Medicine in Los Angeles in order to investigate the possible role of oncogenic retroviruses in naturally occurring cancer in humans and their domestic house pets, including the common house mouse. From a medical background in general practice and academic pathology, but without any research training, I transformed overnight, at the age of 39, into a “virus hunter”. The chairman of my department, Hugh Edmondson, and his wife donated money for a building to house the research group and the NCI funded construction of the lab facilities.

At that time, oncogenic retroviruses were called RNA tumor viruses and the NCI’s Virus Cancer Program (VCP), part of Nixon’s “War on Cancer” (Rettig, 1977), 285

Gardner: Search for oncogenic retroviruses in wild mice and man such as aging, x-irradiation, chemical carcinogens, sex hormones, DNA tumor viruses or other mutagens could theoretically produce infectious virus whose cell to cell spread would amplify the oncogenic signal and lead to cancer. This idea was analogous to the activation of integrated lysogenic bacteriophages described in the 1950s (Lwoff, 1960). In the late 1960s, the mammary tumor and leukemia RNA tumor viruses (MMTV and MuLV, respectively), derived from mammary tumor and lymphoma prone inbred lab mice, were, indeed, shown to be transmitted genetically as integrated viral genomes (Bentvelzen and Daams, 1969; Rowe, 1973). Of course, MMTV had earlier been shown to be spread also by milk but this was not considered typical of MuLV transmission.

Endogenous inherited virogenes were considered the evolutionary relic of ancient RNA tumor virus infections and, surprisingly, several examples of cross-species spread with such viruses had apparently occurred in the distant past (Weiss, 2006). We discovered one such example with the isolation of the cat endogenous virus, RD114, which had apparently infected the ancestors of modern day cats from the baboon several million years ago (McAllister et al, 1972). The “rescue” of defective sarcoma viral genomes by “helper” leukemia viruses in chickens and mice, together with the knowledge of endogenous virogenes, led to the Viral Oncogene Hypothesis (Huebner and Todaro, 1969), which predicted that endogenous virogenes might include specific “oncogenes” that could trigger cancer, not only in animals, but possibly in man.

Later on, the oncogenes were shown to be of cellular, not viral origin. Confirmation of the endogenous virogene concept in chickens and mice occurred in the 1970s, as summarized in Table 1.

Howard Temin’s pioneering cell culture studies in the early 1960s suggested the presence of an inheritable DNA “provirus” determining the cell phenotype in the replication cycle of the Rous sarcoma RNA tumor virus of chickens (RSV). Temin’s Proviral Hypothesis (Temin, 1964) was not generally accepted at first. He also considered the possibility that an ongoing transfer of DNA to RNA to DNA, in normal cells, like what is now called retrotransposon activity, might generate RNA tumor viruses de novo and that secondary mutations in the cell genome might trigger cancer. The discovery of the

enzyme, reverse transcriptase (RT), in 1970, (Baltimore, 1970; Temin and Mizutani, 1970), whose existence had been inferred by the Viral Oncogene and Provirus Hypotheses, explained the ability of the RNA tumor virus genome to be completely copied as DNA provirus and inserted into chromosomal DNA. Temin’s proviral hypothesis was correct. The name of RNA tumor viruses was then changed to “retroviruses”. The RT enzyme became an indisputable reagent for detection of retroviruses and for modern day molecular biology.

In 1976, the oncogene (src) present in RSV was demonstrated to be a cellular gene that had been transduced i.e. captured, by the helper avian leukemia virus (Stehelin et al, 1976). Subsequently, other sarcoma or acute leukemia viruses of chickens, lab mice, domestic cats, a turkey and a wooly monkey were shown to contain specific oncogenes transduced by the helper leukemia viruses. Such oncogene-containing viruses were defective because the envelope was deleted to accommodate the cellular oncogene. In 1981, it was first shown that the slowly acting avian leukosis virus induced cancer through activation of the cellular myc oncogene by nearby insertion of the proviral DNA (Hayward et al, 1981). Soon thereafter, myc and other retroviral transduced or activated oncogenes were shown to be involved in normal cell growth, each oncogene functioning at a certain level of cell signaling, either cell surface receptor, cytoplasmic second messenger, or regulatory gene in the nucleus (Bishop, 1987). Activation and mutation of cellular oncogenes by the control elements in the proviral long terminal repeats (LTR) enhanced the growth promoting properties of these normal cellular genes and is now recognized as the common mechanism by which oncogenic retroviruses trigger hematopoietic tumors in animals. Approximately 60 retroviruses containing oncogenes are now known along with over 100 known oncogenes targeted by provirus insertional mutagenesis (Rosenberg and Jolicoeur, 1997). In lab mice over 3000 retroviral integration sites have been cloned from retroviral induced hemotopoietic tumors (Davé et al, 2004). Many of these sites undoubtedly represent oncogenes yet to be defined. In humans, however, the only known oncogenic retrovirus (HTLV) does not contain or activate any known oncogenes.

Table 1. Evidence of endogenous virogenes in chickens and lab rodents (1968-1980)*.

Detection of core antigen in uninfected embryos, under genetic control.

Immunological tolerance to core antigen in adult animals.

Spontaneous release of viral particles from aging or exogenously mutated cells in vitro.

Activation of virus production from single cell clones of virus-free embryo cells.

Rescue of endogenous virus by complementation of defective sarcoma virus.

Homology between viral RNA and uninfected cellular DNA. Identification of specific genetic loci representing complete viral genomes.

Transfection of infections virus from cellular DNA. Cloning and sequencing of endogenous virogenes. *For review see Weiss, 2006.

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Cancer Therapy Vol 6, page 287 Transduction of cellular oncogenes by leukemia viruses is a rare event in animals that leads to the creation of highly oncogenic sarcoma or acute leukemia viruses.

The sarcoma viruses are not infectious in nature and have not been found in humans. Nevertheless, the unique animal sarcoma viruses first pointed the way to cellular oncogenes in the 1960s and 1970s and opened the door to our understanding of their function in controlling cell growth. In human cancer, the cellular oncogenes are activated, not by any retrovirus, but by other mutagenic events, such as chromosomal translocation or point mutations (Croce, 2008). Several oncogenes first discovered after transduction by retroviruses in chickens, lab mice and cats and several other non-retroviral oncogenes that are targets of present day cancer therapy are shown in Table 2.

Although the VCP emphasized endogenous virogenes, which may now seem an unrealistic expectation, it became readily apparent during the 1970s that the oncogenic Type C retroviruses found in other animals (chicken, turkey, mouse, cat, cow, gibbon ape) are transmitted only exogenously (for review see Gardner, 1980a). Horizontal transmission also accounts for spread of the recently discovered Type C leukemia virus of koala bears in Australia; interestingly this virus appears to be undergoing endogination (Tarlinton et al, 2006). We also learned in the 1970s that the exogenous Type C viruses of animals can cause non-oncogenic disorders such as wasting, immunosuppression, anemia, and neurological disease.

In 1968, most of this story was yet to unfold. The major goal of the VCP was to look for activation of endogenous retrovirogenes and oncogenes in human cancer, as well as domestic pets. The possibility that

exogeneous retroviruses might be acquired horizontally, even perhaps transmitted from domestic animals to humans in close contact, could not be ignored. Because the Viral Oncogene Hypothesis was based primarily on inbred mice prone to mammary tumors and leukemia it was obviously critical to determine to what extent this concept applied to feral outbred mice, the progenitors of lab mice.

This effort seemed all the more appropriate in so far as the domestic house mouse – Mus musculus domesticus - had been man’s inadvertent house pet since antiquity and had served as the major animal model for cancer research for well over a century.

Therefore, our “marching orders” were to search for oncogenic retroviruses in wild mice, other domestic pets and in humans, and if found, to explore the natural history and ways to control these agents, including vaccination.

We were starting, of course, with a rich background of retrovirus knowledge gained from lab mice (Sarma and Gazdar, 1974). Remember that this effort was undertaken about a decade before the onset of modern-day molecular biology. We relied on standard techniques such as complement fixation (CF) and later, radioimmunoassay (RIA), for detection of viral antigens and antibodies in blood or tissue extracts, tissue culture, with neutralization and interference tests, for viral isolation and classification, and electron microscopy (EM) for detection of Type C (MuLV) or Type B (MMTV) virus particles. Assays for reverse transcriptase activity as a virus marker were very useful (Roy-Burman et al, 1976). Viral proteins were analyzed by tryptic-peptide mapping. By the mid 1970s, oligonucleotide fingerprinting, restriction enzyme analysis and molecular hybridization for analysis of viral and cellular RNA and DNA had become available.

Table 2. Cancer therapies that target oncogenic proteins. Reproduced from Croce, 2008 with kind permission from The New England Journal of Medicine.

Anticancer Drug Monoclonal antibodies Trastuzmab (Herceptin, Genentech) Cetuximab (Erbitux, ImClone) Bevacizumab (Avastin, Genentech) Small molecules

Target

Retrovirus Source

Disease

ERBB2

!ALV

Breast Cancer

EGFR

None

VEGF

None

Colorectal Cancer Colorectal Cancer, non-smallcell lung cancer

Imatinib (Gleevem Novartis)

ABL KIT

! MuLV ! FeLV

Gefitinib (Iressa, AstraZeneca) Erlontinib (Tarceva, Genentech)

EGFR EGFR

Sorafenib (Nexavar, Bayer/Onyx)

VEGFR, PDGFR, FLT3

Sunitinib (Sutent, Pfizer)

VEGFR, PDGFR, FLT3

None None None None ! FeLV None None ! FeLV

Chronic myelogenous leukemia, gastrointestinal stromal tumors, chordoma Non-small-cell lung cancer Non-small-cell lung cancer Renal-cell carcinoma Gastrointestinal stromal tumors, renal-cell carcinoma

EGF-epidermal growth receptor, VEGF-vascular endothelial growth factor, PDGFR-platelet-derived growth factor receptor, FLT3-FMSlike tyrosine kinase 3, ALV-avian leukemia virus.

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Gardner: Search for oncogenic retroviruses in wild mice and man Immunofluorescense and immunoperoxidase staining techniques and monoclonal antibodies were now on hand.

Enzyme linked immunoassays (ELISA), and cloning and sequencing of viral DNA came much later. Nevertheless, using the available biological and relatively primitive molecular techniques of that era, we made, in my admittedly biased opinion, considerable headway towards our goals, the results of a magnificent collaborative effort, which I will now summarize.

County (Figure 1) and an egg farm in La Puente were high MuLV expressors and lymphoma prone (Gardner et al, 1973a).

Our first MuLV isolate was in 1971, after 3 years of searching, from two embryo cultures and their mother trapped at La Puente (Gardner et al, 1976a,d). Finally, we could begin to do some interesting virology. LC wild mice provided our most bountiful resource for studying the natural history of MuLV in a highly infected population (Gardner et al, 1976c). About 80% of the mice from here were laden with MuLV when trapped and were persistently infected throughout life. The animals were immune tolerant to their MuLV because of its acquisition at birth, primarily via milk. The 20% uninfected LC mice had no anti MuLV antibodies so, presumably, had not resisted infection because of an antiviral immune response. We realized later that these uninfected mice were the progeny of uninfected mothers and had escaped congenital infection. Followed over their life span, about 20% of the MuLV infected LC mice developed lymphoma but only after 1-2 years of observation. The lymphoma rate in LC mice was about 10-fold greater than in the low MuLV expressor wild mice. Also after 1-2 years, about 12% of MuLV-infected LC mice developed a fatal neurological disease featuring hind limb paralysis (Gardner et al, 1973b). This observation was totally unanticipated, and we were soon able to prove that the neurological disease was caused by the LC-MuLV. Some mice had both lymphoma and paralysis but the diseases could occur independently of each other. The LC mice were not immunosuppressed, and isoenzyme analysis showed that they were fully outbred (Rice et al, 1980).

Polyoma virus infection was not present in the LC mice.

Wild mice at another squab farm (Bouquet Canyon) were infected with polyoma virus which had no oncogenic effect (Gardner et al, 1974b). The squabs (baby pigeons) were not infected with MuLV or avian leukosis viruses.

Incidentally, the squabs were raised for food in LA Chinatown. Because of human consumption, the LC squab farm was inspected regularly and had to be certified as “rodent free”. Therefore, our trapping operation was carried out in secret.

II. MuLV in wild mice A. Epidemiology How to find and trap wild mice was our initial challenge. The best locations were, not surprisingly, at places with ample grain such as an egg farm, race track, bird seed plant and several squab farms. At first we used single open ended traps but later found that we could capture the mice, several at a time, with gloved hand by stunning them with a bright light from a miner’s helmet while they were feeding at night. We eventually trapped mice from 15 different locations in LA County and environs and returned them to the lab where we set up separate “Leisure World” communities for each trapping area. The mice were allowed to live out their full life span housed individually in mason jars while we observed them daily. When moribund or recently dead, the mice were necropsied, studied histopathologically and assayed for MuLV. We also screened against a battery of other mouse pathogens. In later years, breeding colonies were established in the lab from several of the representative mouse populations.

After several years of observing over 500 wild mice grow old, we concluded that these were hardy animals indeed. Most of them lived for 2-3 years in the lab after capture and fewer than 10% developed cancer only in old age (Gardner et al, 1973c). Lymphomas were the most common tumor. We could see Type C virus particles by EM and detect MuLV core antigen by CF test in a few lymphomas examined but not in any of the other tumors.

Type C particles and antigen were also detected in a small percentage of sarcomas that were induced by 3methylcholanthrene in old wild mice (Gardner et al, 1971b). However, we could never isolate or transmit infectious MuLV from these animals or their tumors. At this point, about 1970, we could conclude that MuLV certainly was not prevalent or ubiquitous in wild mice, in marked contrast to the lymphoma prone inbred mouse stains (e.g. AKR). The MuLV that we detected in a few “old timers” seemed to be strongly repressed but we suspected that it was probably responsible for the few lymphomas observed. We surmised, based on our “mind set” at that time, that the virus we detected was activated endogenous virus. Several years later, after developing better techniques for virus isolation and characterization, we found how wrong we were. Had we stopped our study then we would have concluded that most wild mice are cancer resistant, low MuLV expressors and quite free of infectious MuLV. But, luckily, we discovered several populations of wild mice that were quite the opposite. Mice habitating a squab farm near Lake Casitas (LC) in southern Ventura

Figure 1. Bucolic smog-free location of the LC squab farm. Wild mice trapped here were laden with MuLV and prone to lymphoma and neurodegenerative disease.

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Cancer Therapy Vol 6, page 289 lymphoma. Later, others showed that molecularly cloned LC ecotropic MuLV could induce both lymphoma and CNS disease in lab mice (Jolicoeur, et al 1983). Passage of amphotropic or ecotropic MuLV from wild mice into susceptible lab mice sometimes gave rise to recombinant viruses with enhanced virulence and altered cell tropism (Lai et al, 1982; Rasheed et al, 1982), just as happened in AKR mice when ecotropic MuLV recombined with endogenous virogenes to create highly virulent viral variants called mink cell focus (MCF), because they transformed mink cells (Hartley et al, 1977). But this type of recombination event was never observed in nature. We did not recover a sarcoma virus from the few wild mouse spontaneous or chemically induced sarcomas including several infected with MuLV. We concluded that recombination between exogenous MuLV and endogenous virogenes or oncogenes, a step required to generate highly leukemogenic or sarcomagenic viruses in lab mice, chickens and cats, does not occur in wild mice and therefore must represent, to some extent, an artifact of inbreeding and selection for cancer.

B. Virus properties The wild mice MuLV is related to, but distinct from MuLV in lab mice. Together with other oncogenic type C retroviruses of animals (e.g. chicken, turkey, cat, gibbon ape, koala), MuLV is classified as a simple retrovirus in the newly designated gamma retrovirus genus. The viral genome structure is LTR-Gag-Pol-Env-LTR, without accessory genes. Gag is the group specific core antigen.

Pol is the RNA dependent DNA polymerase (i.e. RT). Env is the envelope and LTR is the long terminal repeat. By end point dilution we identified two different neutralization or interference classes of MuLV that occurred separately or together in MuLV infected mice from LC and several other widely separated trapping areas (Rasheed et al, 1977; Gardner and Rasheed, 1982). The most prevalent virus was an entirely new class of MuLV, never found in lab mice. It was called “amphotropic” because of its wide in vitro host range including human cells, a surprising finding (Hartley and Rowe, 1976; Rasheed et al, 1976). Less common was “ecotropic” MuLV which, as in lab mice, grows only in rodent cells.

“Xenotropic” virus which grows only in non-murine cells (Levy, 1976), and is isolated frequently from lab mice, was rarely detected in wild mice. The lack of xenotropic virus isolates was explained a decade later when it was found that many of our southern California wild mice were free of any xenotropic proviral DNA (Kozak and O’Neill, 1986). Molecular hybridization with lab mouse MuLV probes and, much later, cloning, sequencing and phylogentic analysis of the wild mouse MuLVs revealed that both amphotropic and ecotropic MuLV have a unique origin from the same ancestor, quite distinct from the MuLV of lab mice (Barbacid et al, 1979, Howard et al, 2006). These viruses have apparently been maintained as infectious agents among indigenous feral mouse populations of Southern California for a long time and they never changed their cell tropism, virulence or disease phenotype over the decade that we studied them. Although showing microheterogenity in envelope proteins by tryptic peptide mapping (Bryant et al, 1978), the retroviruses in wild mice were remarkably stable. Amphotropic and ecotropic MuLV did not recombine with each other or with endogenous virogenes in the wild mouse genome (Gardner and Rasheed, 1982). Whereas amphotropic and ecotropic MuLV were found in both healthy and lymphomatous wild mice, ecotropic MuLV seemed uniquely associated with the spontaneous paralytic disease of LC mice. In nature, the more prevalent amphotropic virus had rather low virulence because over 50% of infected mice lived a healthy long life without developing lymphoma.

Experimental transmission of end point cloned wild mouse MuLV in virus-free newborn NIH Swiss lab mice showed that amphotropic virus induced lymphoma, but not paralysis, in about 20% of recipients after 1 year, whereas ecotropic MuLV induced both lymphoma and paralysis, with higher incidence and shorter incubation. By inoculating susceptible newborn lab mice with high titered LC ecotropic MuLV, the incubation period for inducing paralysis was shortened to just 1-2 months with 100% incidence; longer surviving recipients also developed

C. Exogenous transmission We found, contrary to our expectations, that MuLV in wild mice was transmitted exogenously, primarily by milk and to a lesser extent by the venereal route (Gardner et al, 1979). Exogenous transmission via milk apparently occurred in both low and high MuLV expressor populations of wild mice. But we only confirmed this by foster nursing experiments in the virus-laden LC mice.

Numerous type C virus particles were visible in the breast tissue and milk of the infected LC mice (Figure 2a and b). By foster nursing newborn LC mice from MuLV infected mothers on uninfected lab mice, most of the infectious MuLV could be eliminated in the progeny. We were eventually able to derive by foster nursing a subpopulation of LC mice totally free of infectious MuLV. These mice remained uninfected over their entire lifespan and were as resistant to cancer of all types as were the low MuLV expressor populations of wild mice. Extensive attempts over a decade to activate endogenous MuLV in vitro from uninfected cells of wild mice, using techniques successful in activating endogenous MuLV from inbred mice, were universally unsuccessful (Gardner and Rasheed, 1982). We were able to transmit amphotropic and ecotropic MuLV to uninfected and highly susceptible C57L inbred mice by foster nursing on infected LC mothers. Virus could also be transmitted sexually from infected LC males to C57L females. Once infected the C57L mice transmitted the virus to their progeny through milk, generation after generation, just as occurred naturally in LC mice.

The milk transmission of MuLV in wild mice resembled milk transmission of MMTV in high breast cancer strains of lab mice. In retrospect, some lab strains of MuLV (FMR) were previously found to be transmitted exclusively by mother’s milk (or doctor’s needles) (Law and Moloney, 1961). But these FMR viruses, carried for many years in transplant tumors (e.g. Erlich ascites), were considered lab artifacts or “passenger viruses”. Ironically, the exogenous transmission via milk of the FMR viruses in 289

Gardner: Search for oncogenic retroviruses in wild mice and man lab mice proved more like MuLV transmission in wild mice than the endogenous MuLV transmission in the AKR and related lab mouse models. The “passenger” lab mouse viruses were like the “real world”, whereas the AKR mouse virus was the artifact.

analog of Fli-1 and surrounding genes have been mapped to chromosome 11 in a conserved arrangement: this region of the human genome is associated with various leukemias. Other common integration sites, at EVI-1 and MYB loci, were also detected in different leukemia cell types induced in lab mice by LC ecotropic MuLV after recombination with endogenous virogenes. Tumor suppressor genes are not common targets of retroviral transduction or insertional mutagenesis but mutation of the p53 gene occurs in some LC ecotropic MuLV induced lymphomas in lab mice (Bergeron et al, 1993). This technology was not available in the 1970s, so we never examined proviral integration sites in the spontaneous LC lymphomas.

D. Pathology and pathogenesis 1. Lymphoma Most of the spontaneous lymphomas in old, low MuLV expressor wild mice were of histiocytic cell origin, then called reticulum cell sarcoma. By contrast, the LC lymphomas, occurring naturally or experimentally induced by amphotropic or ecotropic MuLV, were of lymphocytic origin and had remarkably similar gross, microscopic (Figure 3a-e) and functional characteristics. In contrast to the AKR mouse, the tumors spared the thymus, arose primarily in the splenic red pulp, became leukemic and were comprised of stem or null cells lacking T and B cell markers (Bryant et al, 1981). Numerous Type C virus particles were seen budding from and lying between the tumor cells. Several lymphoma clonal cell lines were of diploid karyotype and positive for surface antigens of lymphoid stem cells or pre-B-cells. The MuLV lymphomas in LC mice thus provided a useful model for childhood leukemia and for study of the early steps of B cell differentiation. As mentioned, on passage through lab mice, the LC MuLV sometimes recombined with endogenous virogenes which changed its cell tropism, virulence and type of leukemia induced. Interestingly, the CBL (“Casitas B. Lymphoma”) oncogene was derived from an ecotropic LC MuLV after several passages through lab mice (Langdon et al, 1989).

As eventually found with the other slowly acting animal leukemia retroviruses, the mechanism for leukemogenesis by the LC MuLV is that of proviral insertional mutagenesis. In 1990, a common site of proviral integration was found in many of the clonal null cell lymphomas induced by the LC ecotropic MuLV in NIH Swiss mice (Bergeron et al, 1992). This site, called Fli-1, is localized on chromosome 9, near several other previously described proto-oncogenes and other common retroviral integration sites, including CBL. The human

2. Paralysis This disease, caused by LC ecotropic MuLV (Gardner et al, 1973b), has been studied in many labs over the past 30 years (Wiley and Gardner, 1993). It is the first example of a naturally occurring degenerative neurological or motor neuron disease caused by an oncogenic retrovirus (Officer et al, 1973). At first, it was considered a model for amyotrophic lateral sclerosis (ALS) in humans, but we were never able to find a retrovirus in ALS patients (Gardner and Henderson, 1974a). Subsequently, several lab mouse MuLV strains have induced a similar CNS disease (Zachary et al, 1986; Portis, 1990). The natural and experimental CNS disease is characterized histopathologically by a non-inflammatory spongiform change with reactive gliosis and loss of anterior horn motor neurons in the lower spinal cord (Figure 4a-g) (Gardner, 1985). Numerous Type C particles are present in the extra-cellular space. In some of the experimental models, the same changes occur also in the brain stem and cerebellum. Because of the loss of anterior horn neurons and motor nerve denervation, the lower limbs suffer severe muscle atrophy with tremors and eventual total paralysis. Pathogenesis clearly involves an early viremic spread of virus to the CNS, a productive infection of CNS endothelial cells and a non-immune mediated pathology related to virus level in the CNS.

Figure 2. (A) (left) MuLV in milk from a pregnant LC mouse: sucrose density gradient. (B) MuLV Type-C particles located extracellularly in breast tissue of a pregnant LC mouse.

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Cancer Therapy Vol 6, page 291 The pathogenesis of the spongiform change and neuronal loss is still not understood. Viral recombination or prions are not involved. Disagreements among the different models center on whether glial cells and motor neurons become infected and whether direct or indirect effects of the virus cause the spongiform degeneration and loss of motor neurons. Infection of motor neurons was our initial suspicion based on EM detection of aberrant budding of virus particles into cytoplasmic vacuoles or the endoplasmic reticulum of anterior horn neurons of naturally diseased LC mice (Andrews and Gardner, 1974).

However, we could not distinguish whether these aberrant particles were the result of aborted exogenous infection or activated endogenous virogenes. Infection of microglial

cells and not neurons has been a prominent feature of some versions of the disease in lab mice. Neurotoxicity of the viral envelope glycoprotein is suspected in some models, including a mild form of the disease induced in transgenic mice expressing only the Env gene of the LC ecotropic MuLV under control of its own LTR (Kay et al, 1993). Equally plausible is the neurotoxic effect of cytokines released by infected glial or endothelial cells.

Such cytokines could damage cell membranes and lead to the spongiform change. Better understanding of the molecular pathogenesis of this retrovirus induced neurologic disease, discovered in the early 1970s, could reveal mechanisms shared in common with AIDS encephalopathy and prion diseases.

Figure 3. (A) Enlarged spleen and cervical lymph nodes of a LC wild mouse with spontaneous lymphoma. (B) Poorly differentiated lymphoid tumor cells invading wall of bronchiole. (C) Poorly differentiated lymphoid tumor cells invading wall of bronchiole. (D) Lymphoid tumor cells circulating in blood. (E) Extracellular Type-C virus particles lie between lymphoid cells of LC wild mouse lymphoma. Insert shows typical Type-C particle budding from lymphoid cell X84000.

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Gardner: Search for oncogenic retroviruses in wild mice and man

Figure 4. (A) Paralyzed LC wild mouse: Note severe hind limb atrophy. (B) Spongiform degeneration of lower spinal cord. (C) (left) Degenerating motor neurons (arrows) in anterior horn of lower spinal cord. (right) Gliosis (arrows) in same location. (D) Spongiform degeneration of anterior horn motor neuron in lower spinal cord. One micron section of tissue fixed before death to avoid post-mortem shrinkage artifact.

(E) Neurogenic muscle atrophy of hind limb. (F) Aberrant virus particles budding into cisterns of the endoplasmic reticulum of anterior horn motor neuron. (G) Extracellular Type-C virus particles in lower spinal cord.

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Cancer Therapy Vol 6, page 293 population of LC mice accounts for why the ecotropic MuLV is less prevalent than amphotropic MuLV. Only about 20% of LC mice fail to inherit one or both Fv-4 resistance alleles and therefore are susceptible to congenital infection with the LC ecotopic virus and subsequent disease. The other 80% of LC mice carry one or two Fv-4 alleles and are therefore resistant to LC ecotropic virus. Accordingly, the CNS disease occurs in only a few aging, ecotropic MuLV infected LC mice that survive long enough in nature. Because amphotropic virus is not restricted, it is much more prevalent in LC mice.

The Fv-4 gene is not found in North America lab mice because of the narrow genetic base from which these mice were derived. Based on the signature of endogenous virogene DNA, including xenotropic, MCF and Fv-4 sequences, it was later shown that wild mice from southeast Asia (Mus castaneous) were the source of the Fv-4 resistance gene (Gardner et al, 1991). The Asian wild mouse had passed this gene to both Japanese wild mice and LC wild mice. LC mice are thus a hybrid between feral mice (M.m. domesticus), which crossed the Atlantic Ocean from western Europe to the eastern USA and feral mice (M.m. castaneous) which crossed the Pacific Ocean from Asia to Southern California. Fv-4 represents a fascinating example of a useful endogenous defective, but functional, provirus that is still segregating in a freeranging population of wild mice to regulate a serious infectious disease. Similar defective endogenous proviral genes that protect against exogenous retrovirus infection were also found in chickens, (Robinson et al, 1981) and, later in Asian wild mice (Mus castaneus) (Wu et al, 2005), and in DBA/2 lab mice (Jung et al, 2002). Since HTLV-1 or HIV-1 were not endogenous in humans, this type of genetic resistance probably does not apply to these retroviruses. However, genetic resistance to HIV-1 infection does similarly occur at the cell surface level; this is attributed to mutations in the CCR chemokine coreceptors.

E. Control measures Contrary to expectations based on the AKR mouse model, control of MuLV and prevention of lymphoma and paralytic disease in the high MuLV expressor LC mice was dramatically accomplished, as mentioned above, by foster nursing on virus-free NIH Swiss mothers (Gardner et al, 1979). Surgical removal of the spleen, the â&#x20AC;&#x153;virus factoryâ&#x20AC;? early in life, lowered the virus burden sufficiently to prevent the CNS disease completely and markedly reduced the incidence of lymphoma. Passive immunization of newborn LC mice with goat immunoglobulin, having a high neutralization titer to ecotropic virus and a low titer to amphotropic virus, completely prevented the paralytic diseases but only slightly lowered the incidence of lymphoma (Gardner et al, 1980b). Active immunization with inactivated LC MuLV had no effect, of course, in already infected immune tolerant LC mice, although they responded well to a heterologous MuLV vaccine and other foreign antigens (Klement, 1976). A decade later, the beneficial effect of transplacental anti-retroviral therapy with azidothymidine was shown in lab mice that were protected against the CNS disease after inoculation with LC ecotropic MuLV during mid-gestation or at birth (Sharpe et al, 1987). This is the first example of successful antiviral therapy for congenitally transmitted retrovirus.

Finally, selective breeding could strongly suppress LCMuLV. Because the MuLV of LC and other wild mice is N-tropic, i.e. grows preferentially in NIH Swiss mouse cells, and not in BALB-C mouse cells (B-tropic), introduction of the FV-1B virus resistance gene from C57 BL-10 inbred mice completely blocked LC MuLV expression in the F-1 hybrids (Gardner et al, 1976b). More dramatic, however, was the discovery of a natural virus resistance gene in LC mice, described next.

F. Genetic resistance The exciting discovery of a naturally segregating MuLV-resistance gene in LC wild mice was serendipitous.

I was curious as to what would happen to MuLV expression in the progeny of genetic crosses between LC and AKR mice. Analysis of AKR ecotopic virus in the FI progeny revealed a pattern of virus expression and leukemia consistent with a dominant AKR MuLV resistance gene in the LC mouse population (Gardner et al, 1980c). Back crosses of virus-free FI progeny to AKR proved that a single dominant gene was responsible for the virus restriction. A similar gene called Fv-4, because it restricted the Friend strain of MuLV, had been described in Japanese wild mice (Mus molossinus) (Odaka, et al, 1981). In crosses with Japanese wild mice, this restriction gene, initially called Akvr-1, was found allelic on chromosome 12 with the Fv-4 restriction gene (Oâ&#x20AC;&#x2122;Brien et al, 1983). The Akvr-1 and Fv-4 resistance genes proved to be sequence identical, including flanking DNA, and to represent a defective, truncated endogenous provirus encoding an envelope glycoprotein (gp70) closely related to ecotropic MuLV of both AKR and LC mice (Dandekar et al, 1987; Ikeda and Sugimura, 1989). Expression of this envelope protein on the cell surface blocks the receptor for the ecotropic class of MuLV. Segregation of this dominant polymorphous gene, now called Fv-4, in the natural

G. Reagents for gene therapy Because of their wide cell tropism, including human cells, the amphotropic MuLV from wild mice and the cat endogenous virus RD114 have provided the envelope glycoprotein for recombinant retroviruses employed in experimental gene therapy (Cosset et al, 1995). One of the tumor cell lines, HT-1080 (Rasheed et al, 1974), which we derived, is a favorite packaging cell because of its ability to release high-titered viruses that are resistant to inactivation by human serum. Such vectors are quite capable of gene transfer to human cord blood CD34+ cells, which can then be transplanted into an immunosuppresed host (Kelly et al, 2000, Relander et al, 2005). Progress in this direction depended on first defining, in the 1980s, the cell surface receptors for different retroviruses. The ecotropic MuLV receptor is a cationic amino acid transporter, whose gene is mapped to chromosome 5 in the mouse and a highly related, but non permissive gene, mapped to chromosome 13 in humans (Albritton et al, 1989). The receptor for amphotropic MuLV and for FeLV-B and GALV are phosphate transporters that map to mouse chromosome 8 and human 293

Gardner: Search for oncogenic retroviruses in wild mice and man chromosome 8 (Miller et al, 1994). The receptor for cat endogenous RD114, BaEV and avian reticuloendotheliosis virus is a neutral amino acid transporter mapped to human chromosome 19 (Tailor et al, 1999). All of these receptors have many membrane spanning domains and an external envelope binding domain. In the 1970s, we had no idea that our newly discovered viruses and cell lines would have a practical purpose for therapy. However, their clinical application is still “on hold” because of safety concerns i.e. insertional activation of oncogenes, a disasterous event which has occurred on several occasions (Davé et al, 2004).

EM in milk from about 50% of our wild mice (Rongey et al, 1973), (Figure 2c and d) and MMTV antigen was detected by immunoperoxidase staining of lactating mammary gland in about 20% of all wild mice (Fine et al, 1978); about 50% of the spontaneous breast tumors contained MMTV antigen (Gardner et al, 1980c), yet, less then 1% of these animals developed breast tumors and only after 1 year of age. Therefore, the virus may not be essential for breast tumors to develop in wild mice. Under natural conditions, then, the highly prevalent MMTV is only weakly carcinogenic, and it is also only weakly tumorigenic when transmitted by foster nursing to susceptible lab mice. Lab mouse derived MMTV was also of low pathogenicity in uninfected wild mice, probably because of strong genetic resistance. We could conclude that MMTV infected breast cancer prone strains of lab mice, like MuLV infected lymphoma prone lab mice, are an artifact of “inbreeding” and selection for this cancer.

Interestingly, unlike lab mice, we found some LC wild mice totally lacking any endogenous MMTV proviral DNA. A wild mouse line was derived that had no MMTV DNA (Cohen et al, 1982), yet had normal mammary gland development and was susceptible to mammary hyperplasia and neoplasia (Faulkin et al, 1984). Thus, endogenous MMTV has no role in normal mammary gland development or function, as had been suggested, and is not required for breast tumorigenesis. When present in lab

H. Conclusion In its natural history features, the wild mice MuLV model was more accurate than the laboratory mouse MuLV model for predicting the natural history of HTLV1, which was discovered a decade later. The similarities and differences between the wild mouse MuLV model and HTLV-1 are listed in Table 3A and B. The inbreeding of mice and selection for cancer clearly created an artificial biology not accurately reflective of the real world, but, nevertheless, useful for experimental biology.

III. MMTV in wild mice A. Natural history In contrast to the regional, familial clustering of MuLV in wild mice, MMTV was equally prevalent in all of the populations examined. MMTV was detectable by Table 3 A. Similarities between MuLV in wild mice and HTLV1 in humans Viruses are not ubiquitous; they occur in regional and familial clusters associated with specific types of leukemia.

Viruses are of low pathogenicity and long latency.

Viruses are exogenous and transmitted mainly by milk.

Sexual transmission can also occur.

Viruses are stable, replication competent and do not undergo recombination with endogenous virogenes or oncogenes.

Viruses integrate monoclonally in leukemia cells.

Viruses are neuropathogenic as well as lymphomagenic.

Viruses and disease can be controlled by foster nursing or avoidance of breast feeding (Tsuji et al, 1990).

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B. Differences between MuLV in wild mice and HTLV-1 humans HTLV-1 is more T-cell restricted and induces T-cell leukemia. Wild mouse MuLV is more B-cell tropic and induces a null or pre-B-cell leukemia.

HTLV-1 is more latent and cell associated without viremia.

HTLV-1 induces an immune response whereas wild mice are immunologically tolerant to their congenitally acquired virus.

HTLV-1 can transform T-cells in vitro; MuLV does not transform T or B-cells.

HTLV-1 does not induce leukemia by insertional activation of cellular oncogenes as does wild mouse MuLV. HTLV-1 has a more complex genetic composition than MuLV. It contains accessory genes not present in MuLV. One of these accessory genes called TAT transactivates several transcription factors which indirectly promote T-cell immortalization. HTLV-1, STLV-1 and BoLV have a similar pathogenesis (and genetic structure) in humans, monkeys and cows, respectively; these viruses are now classified in the deltaretrovirus genus.

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Figure 2. (C) MMTV in milk from a pregnant LC mouse: sucrose density gradient. (B) MMTV Type-B particles in breast tissue of pregnant LC mouse.

mice bred for susceptibility to breast tumors, MMTV behaves as a strong carcinogen, initiating early mammary hyperplasia (Cardiff, 1984). Interestingly, the oncogenes that are activated by insertion of MMTV proviral DNA (Peters et al, 1983) are not activated in human breast cancer. Probably the most important contribution of our MMTV work was to give credibility to our negative results in searching for a similar virus in human milk (Roy-Burman et al, 1973). Reports were appearing at that time of MMTV like virus particles and reverse transcriptase activity in human milk and of MMTV related antigens in human breast tumors. None of these reports could be confirmed. We could easily detect MuLV and MMTV in a drop of wild mouse milk, but could detect no virus in â&#x20AC;&#x153;gallonsâ&#x20AC;? of human milk. No convincing evidence exist today of MMTV or related retroviruses in human milk or breast cancer despite a few reports to the contrary.

Figure 5. A smoggy day in LA-Mid 1960s.

IV. Search for oncogenic retroviruses in humans

were performed on fresh samples which were also frozen or shipped to collaborators. Cell cultures were established when possible and tumor and control samples were shipped weekly to the Naval Biological Lab in Alameda, CA, where they were cultured and karyotyped. Animal tumors and other tissues were obtained from local veterinarians and pet owners. We received the complete cooperation of the LA Health Department and LA County Veterinarians. Nonhuman primate and other animal tissues were provided by veterinarians at the LA and San Diego Zoos and the Alamogordo, NM chimpanzee colony.

Thankfully, the 1970s were not as litigious or encumbered by paper-work and legal permissions as nowadays and, there was no proprietary interest involved. All resources were available to all VCP investigators and new discoveries, such as viruses and tumor cell lines, were distributed freely after initial publication. I will now summarize our negative efforts to find an oncogenic human retrovirus.

A. Methods used and negative results Despite our success in finding oncogenic retroviruses in wild mice, wild rats (Rasheed et al, 1978a) and domestic cats (Gardner et al, 1971c) we could not find any such viruses in humans, dogs, parakeets (Gardner et al, 1981) and a few captive non-human primates (Rasheed and Gardner, 1979). The effort made in humans was truly exhaustive, many man-years of time over a 12 year period (1968-1980) (Gardner et al, 1977). For tracking the ongoing occurrence of specific types of human cancer by geographic location and smog exposure in LA (Figure 5), we developed a Tumor Registry of all 264 hospitals in LA County and pinpointed the cases on detailed maps of LA County and its freeways. Smog particulate matter was collected on giant filters in mobile trailers, analyzed for chemical content and tested for activation of endogenous virogenes in rodent tissue cultures and for mutagenicity by AMES assays. We collected fresh human tumors and normal tissues, blood, bone marrow, milk, aborted embryos and placentas from 16 major hospitals in LA county. Virologic, immunologic and biochemical assays

1. Epidemiology No geographical or familial cluster of lymphoma, sarcoma or other cancers were spotted in LA County that

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Gardner: Search for oncogenic retroviruses in wild mice and man might suggest the presence of an activated endogenous or exogenous retrovirus. In particular, no cases of adult T cell leukemia, the eventual source of HTLV-1, were recognized in our tumor surveys. No evidence for an association of cancer in humans and household pets was found (Hanes et al, 1970; Gardner, 1971a). Specifically, no seroepidemiologic or virologic evidence was found to suggest the cross-species spread of FeLV or MuLV to humans in close contact. No evidence was obtained to indicate that the concentration, content, or in vitro cell transforming activity of LA smog particulate matter (Rhim et al, 1972) was related to the distribution of human or household pet cancers. Five years of prior research had found no lung tumorigenic effect in lab mice after lifelong exposure to ambient LA smog (Gardner et al, 1970), and expression levels of MuLV in wild mice were not correlated with levels of smog exposure.

including wild mice, rats and domestic cats. It is important to note that we had eight known occasions on which, despite good lab conditions, contamination of human or dog cell cultures inadvertently occurred. Efforts to isolate viruses from cultured nonhuman primate tissues were also negative, with the exception of two baboon embryo cell cultures which spontaneously released the endogenous baboon virus (BaEV). Although infection of virus-free rat cells in vitro by helper rat leukemia virus could rescue an endogenous SRC gene (Rasheed et al, 1978b), this result could never be duplicated in human or other mammalian cells. Interestingly, skin fibroblasts from individuals with a familial high risk to colorectal cancer, who we know now have mutations in tumor suppressor genes, were supersusceptible to transformation by animal sarcoma viruses (Rasheed and Gardner, 1981).

4. Attempts to identify oncogenic retrovirus antigens or antibodies in human materials

2. EM search for Type C or Type B virus particles

By using radioimmunoassay (RIA) for speciesspecific or interspecies viral core determinants, we sought evidence in humans for known mammalian oncogenic retrovirus antigens from cats, gibbon apes and mice or antibodies to these viruses. As a positive control we were able to detect MuLV core and envelope antibodies in terminal cancer patients experimentally immunized with formalin inactivated Rauscher MuLV (Hersh et al, 1974).

No evidence of reactivity against such viruses was found in 100 human cancer and control sera. We were also unable to detect virus-specific antigens and antibodies by complement fixation or, later immunofluoresence tests. No reactivity by RIA was found in individuals with amyotropic lateral sclerosis (31), cat scratch disease (11) or systemic lupus erythematosis (26). Household contacts (71) of FeLV infected cats were all negative by RIA. No antibody to FeLV reverse transcriptase was found in 15 humans exposed to FeLV-positive cats, although antibody to this FeLV enzyme was detected in most cats naturally or experimentally infected with FeLV (Roy-Burman et al, 1972). Nor was any evidence found for infection in humans with known household or laboratory exposure to oncogenic retroviruses from mice and gibbon apes or in veterinarians and zoo primate handlers. The absence of antibodies to these viral antigens in many hundreds of human sera is strong evidence against the horizontal infection of humans with any of the known mammalian Type C oncogenic retroviruses, including those that could grow well in human cells in vitro.

These exhaustive and fruitless efforts to find an oncogenic retrovirus in humans indicated that humans (like most wild mice) do not harbor such viruses. Most importantly, the activation of replication competent or infectious endogenous virogenes does not seem involved in human (or wild mouse) cancer.

More than 200 primary tumors including 102 sarcomas, 20 lymphomas and 86 carcinomas were examined. Tissues from 52 primary embryos at 10-20 weeks gestation and milk from 27 lactating women, one with breast cancer, were examined. No virus particles were seen in any fresh or cultured human tissue except when purposely or accidentally introduced. The closest resemblance was the budding Type C virus-like structures seen in 14 of 50 placentas examined. These structures, initially reported in baboon placentas from which the baboon endogenous type C virus was isolated (Benveniste et al, 1974), were located solely along the base of the syncytiotrophoblast layer. No mature or extracellular Type C virus particles were seen in the human placentas, and no virus was ever isolated. In recent years, these structures have been associated with the expression of a human endogenous retrovirus whose envelope protein may be involved in formation of this placental layer (Blond et al, 1999). EM search for virus particles in bone marrow, peripheral blood leukocytes or tumor cell lines from about 20 children with leukemia or sarcomas was also negative.

No virus particles were seen, in human milk despite our ability, mentioned above, to readily detect MMTV and MuLV particles in wild mouse milk.

3. Attempt to isolate infectious oncogenic retrovirus from human tissues No virus was isolated from hundreds of fresh tumors and short-term tumor cell cultures and fewer established cell lines. No virus was isolated from blood cells, lymphoid tissues or cell lines from more than 30 children with acute leukemia or lymphoma. We grew many B-cell lines immortalized by the latent Ebstein-Barr herpes virus (EBV). We could not grow T-cells because T-cell growth factor (IL-2) had not yet been discovered. Placental and embryo tissues were also free of detectable infectious virus. Assays of different tumor cell cultures included cocultivation with numerous different human and nonhuman indicator cells and treatment of the cultures with various chemical and physical agents capable of inducing Type C viruses in our animal model systems,

V. Summary A. Importance of real world biology and animal models My 40 year adventure in oncogenic retrovirus research taught me the importance of keeping an eye on

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Cancer Therapy Vol 6, page 297 natural history and the value of comparative or “one medicine” using animal models. Natural biology often seems eclipsed nowadays by the ascent of molecular biology and genomics. This is certainly true of genetically engineered mice (GEM) which, although genetic artifacts, have rightfully taken the place of conventional inbred mice in cancer research. Oncogenic retroviruses have become museum exhibits, no longer in fashion. However, integration sites of endogenous retrovirogenes continue to have an impact upon the phenotype of GEM (Barthold, 2002). Worth reemphasizing is the not surprising realization that the proviral insertional activation of cellular oncogenes discovered in naturally occurring oncogenic retrovirus animal models also potentially occurs in humans following gene therapy with vectors using these viruses.

Positive results win in scientific research. Negative results seldom get published, except in the context of positive results. Yet, looking back 40 years later, I would say that the significance of the negative results (Table 4) of our research outweighed, by far, the positive results.

Our inability to find an oncogenic retrovirus in humans or in most wild mice, seems far more important now than the finding of such viruses in a small minority of wild mice, no matter how interesting it was back then. The absence of human infection with animal oncogenic retroviruses is a significant negative result. There was much public health concern in the 1970s that FeLV might pose a risk to humans in contact with infected cats. Finding no retroviruses in household dogs or parakeets is reassuring.

Our negative results in humans have stood the test of time.

Over the years numerous “sightings” and even isolations of putative human oncogenic retrovirus have been reported in high-profile scientific journals. All of the isolated viruses were contaminations with extant animal retroviruses. Inability to confirm false claims usually remained unpublished.

retrotransposons that may represent either the relics or predecessors of retroviruses (Griffiths, 2001). In contrast, the lab mouse genome contains 37% endogenous retroviral DNA and retrotransposon activity is far greater in mice than humans. Many families of human endogenous retroviruses (HERVs) have been mapped to chromosomal loci and used to create primate phylogenies (Johnson and Coffin, 1999). Most of these HERVs contain sequences closely related to animal oncogenic retroviruses, but not to HTLV or HIV. As mentioned above, during evolution some animal and human endogenous viruses were apparently acquired by cross species infection.

Importantly, all of the HERVs are defective in that they contain mutations that prevent the production and release of complete virus particles (Löwer et al, 1995). Most of the HERVs have undergone recombinational deletion (Belshaw et al, 2007). Therefore, all that effort made during the 1970s to discover infectious or replication competent HERV was destined to fail; we now know almost for certain that there exists no infectious endogenous human oncogenic retrovirus. However, we also have to recognize that, since the human genome sequence is based on a single individual, it remains a remote possibility that genomes of other individuals might reveal “islands” of replication competent HERV. The absence of replication competent virus does not preclude the possibility that expression of HERV genes might have some biologic function. HERV-RNA and proteins, including envelope and incomplete budding particles, have been detected in some germ cell tumors, and as mentioned above, in the placental syncytial trophoblast layer (Blond et al, 1999, Frendo et al, 2003). HERV gene expression has been incriminated in several non-infectious diseases of humans such as insulin-dependent diabetes mellitus (Medstrand and Mager, 1998) but, as yet, without convincing evidence of a pathogenic role. Rarely, an endogenous retroviral insertion site has caused a recessive gene disorder in humans (Hughes and Coffin, 2001; Villesen et al, 2004).

C. Significance retroviruses in humans

endogenous

D. New claims of oncogenic retroviruses in humans

With the human genome now sequenced, we see that about 8% consists of endogenous retroviral DNA sequences and even a greater percentage consists of

New claims of putative oncogenic retroviruses in human tissues continue to appear. These reports rely mainly on PCR-based amplification of retroviral-related DNA sequences and are not accompanied by EM detection of typical virus particles, immunological or biochemical markers, or of virus isolated in tissue cultures. Report of MMTV related ENV-gene DNA in human breast cancer (Wang et al, 1995) has not been confirmed (Mant et al, 2004). A recent report of mouse xenotropic MuLV-related DNA in human prostate cancer (Urisman et al, 2006) remains a mystery. In the 1970s, a putative oncogenic retrovirus had to be isolated in vitro, its ultrastructure visualized, its antigenicity determined, and it had to survive shipment to other labs for confirmation. Clearly, retrovirus hunters of the past have transformed into modern day molecular geneticists.

B. Importance of negative results

of

Table 4. Important negative results.

Lack of any replication competent endogenous or exogenous retrovirus in humans.

Lack of any replication competent retroviruses in dogs and parakeets.

Lack of any evidence of human infection with animal ongenic retroviruses.

Lack of replication competent endogenous retrovirus in wild mice.

Lack of any detectable oncogenic effect of LA smog on wild mice or humans Lack of rescueable oncogene by helper leukemia virus in vitro in any species other then rat.

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Gardner: Search for oncogenic retroviruses in wild mice and man multiple membrane-spanning protein and confers susceptibility to virus infection. Cell 57, 659-666.

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Barthold SW (2002) “Muromics”: genomics from perspective of the laboratory mouse. Comp Med 52, 206-223 Belshaw R, Watson J, Katzourakis, Howe A, Wooven-Allen J, Burt A, Tristem M (2007) Rate of recombinational deletion among human endogenous retroviruses. J Virol 81, 94379442.

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Bergeron D, Poliquin L, Houde J, Barbeau B, Rassart E (1992) Analysis of provirus integrated in Fli-1 and Evi-1 regions in Cas-Br-E MuLV-induced Non-T-Non-B-cell leukemias.

Virology 191, 272-282.

Bergeron D, Houde J, Poliquin L, Barbeau B, Rassart E (1993) Expression and DNA rearrangement of proto-oncogenes in Cas-Br-E-induced non-T, non-B leukemias. Leukemia 7, 954-962.

Bishop JM (1987) The molecular genetics of cancer. Science 235, 305-311.

Blond JL, Besème F, Duret L, Bouton O, Bedin F, Perron H, Mandrand O, Mallet F (1999) Molecular characterization and placental expression of HERV-W, a new human endogenous retrovirus family. J Virol 73, 1175-1185.

Bryant ML, Pal BK, Gardner MB, Elder JH, Jensen FC, Lerner RA (1978) Structural analysis of the major envelope glycoprotein (gp70) of the amphotropic virus and ecotropic type C viruses of wild mice. Virology 84, 348-358.

Bryant ML, Scott JL, Pal BK, Estes JD, Gardner MB (1981) Immunopathology of Natural and Experimental Lymphomas Induced by Wild Mouse Leukemia Virus. Am J Pathol 104, 272-282.

Cardiff RD (1984) Protoneoplasia: the molecular biology of murine mammary hyperplasia. Adv Cancer Res 42, 167190.

Cohen JC, Traina VL, Breznik T, Gardner MB (1982) Development of a mouse mammary tumor virus-negative mouse strain: a new system for the study of mammary carcinogeneis. J Virol 44, 882-885.

Cosset FL, Takeuchi Y, Battini JL, Weiss RA, Collins MKL (1995) High-Titer packaging cells producing recombinant retroviruses resistant to human serum. J Virol 69, 74307436.

Croce CM (2008) Molecular Origins of Cancer Oncogenes and Cancer. N Engl J Med 358, 502-511.

Dandekar S, Rossitto P, Picket S, Mockli G, Bradshaw H, Cardiff R, Gardner MB (1987) Molecular characterization of Akvr-1 restriction gene: A defective endogenous retrovirus identical to Fv-4R. J Virol 61, 308-314.

Davé UP, Jenkins NA, Copeland NG (2004) Gene Therapy Insertional Mutagenesis Insight. Science 303, 333.

Fine DL, Arthur LO, Gardner MB (1978) Prevalence of murine mammary tumor virus antibody and antigens in normal and tumor-bearing feral mice. J Natl Cancer Inst 61, 485-491.

E. Other infectious causes of human cancer Hepatitis B and C viruses (HBV/HCV), Human Papilloma Virus (HPV), Ebstein-Barr Virus (EBV), Kaposi’s Herpes Sarcoma Virus (KSHV), Heliocobacter pylori and Schistosomiasis mansoni, have all been established, mostly after 1980, as important infectious causes of cancer. It is estimated that infections may be responsible for over 15% of all malignancies worldwide (Kuper et al, 2000). HBV vaccination has markedly reduced the incidence of liver cancer, and the new HPV vaccine promises to protect against cervical cancer. Thus, the 1968 idea of a possible human Type C virus vaccine never came to fruition, but vaccination works against other cancer viruses. Tumor suppressor genes, important “players” in cell behavior, were identified in the mid 1980s by their inactivation by DNA tumor viruses (e.g. polyoma, SV40, adenovirus), which had been less emphasized by the VCP. The initial recognition of AIDS in humans in 1981 was totally unexpected as was the discovery that HIV-1, the causative retrovirus, was in the lentivirus genus, members of which were not known to induce cancer in animals and were, therefore, rather neglected during the 1970s. Needless to say, the VCP did prepare investigators like myself and others to suspect that a retrovirus might be responsible for AIDS in humans and for a similar disease that was recognized soon thereafter in captive macaques. After coming to UC Davis Medical School in 1981, I was able to study new animal lentivirus models of AIDS in macaques (Gardner et al, 2004) and cats (Gardner, 1992), but that is another story). In the late 1980s our efforts to find a lentivirus in wild mice from the Lake Casitas squab farm and elsewhere around the world was another important negative and unpublished study. .

This long scientific journey was only possible because of the opportunity given me 40 years ago to enter the world of retroviruses and learn on the job and because of the support provided to me by colleagues at the USC School of Medicine and at the UC Davis Veterinary School, Primate Center and Center for Comparative Medicine.

Foremost among these colleagues at UC Davis was Gordon Theilen who helped to recruit me there and whose pioneering research on animal retroviruses was my inspiration.

Acknowledgements The following investigators at the USC School of Medicine participated in the research summarized in this review: Robert McAllister, Earle Officer, Suraiya Rasheed, Vaclov Klement, Marty Bryant, Howard Charman, P Roy Burman, B.K. Pal, Michael Lai, Bob Rongey, Robert Bryan, John Estes, Brian Henderson, Malcolm Pike, John Cassagrande, Ron Ross, and John Hisserick. Support was primarily from NCI contracts. For their critical review of this manuscript I thank Suraiya Rasheed, Peter Barry, Paul Luciw and Steve Barthold.

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Histopathological pattern of Non-melanoma skin cancer at King Fahd Hospital of the University in the Eastern Region of Saudi Arabia during the years 1983 to 2002 Research Article

Omar M. Alakloby1,*, Iqbal A. Bukhari1, Mohamed A. Shawarby2 1

Dermatology Department Pathology Department, College of Medicine, King Faisal University and King Fahd hospital of the University, Dammam, Saudi Arabia.

2

__________________________________________________________________________________ *Correspondence: Dr. Omar M. Alakloby, King Fahd Hospital of the University, P.O. Box 40130, Al-Khobar 31952, Saudi Arabia; Tel: 00966-3-8580793; Mobile: 00966-504814962; e-mail: oakloby1@yahoo.com Key words: Histopathological pattern, Non-melanoma skin cancer, Saudi Arabia, Squamous cell carcinoma, Basal cell carcinoma Abbreviations: Basal cell carcinoma, (BCC); Non-melanoma skin cancer, (NMSC); Squamous cell carcinoma, (SCC) Received: 13 March 2008; Revised: 8 April 2008 Accepted: 17 April 2008; electronically published: May 2008

Summary We have reviewed the pathology records of all patients who were diagnosed to have either basal cell carcinoma or squamous cell carcinoma at King Fahd Hospital of the University during the years 1983-2002. To our knowledge, this is the first analysis of its type in this part of Saudi Arabia. A total of 82 cases of BCC and SCC were diagnosed between the years 1983 and 2002. The male to female ratio was 1.4:1. The mean age was 67.2 years with an age range of 35-98 years. Most of the patients were over the age of 50 years. BCC was more common (62.2%) with the solid (nodular) pattern being the most frequent pattern (84.3%) fibroepithelioma of Pinkus (5.9%), superficial (3.9%), keratotic (3.9%) and infiltrative (2%). SCC comprised 37.8% of the total with the well differentiated pattern being the most frequent pattern (45%), followed by poorly differentiated (32.3%) and moderately differentiated (22.6%). The occurrence of Non-melanoma skin cancer in the Eastern Region of Saudi Arabia is quite low and BCC is more frequent than SCC.

defined clinically and as a result it may recur locally because of incomplete excision (Murphy and Elder, 1991).

The eastern part of Saudi Arabia is situated along lines of latitude 26 째N and longitude 50째. The climate is mainly sunny and humid during the twelve months of the year.

The region has a population of about 3.0 million, mostly of Arab origin, with Fitzpatrick skin phenotype mainly IVV. Most of them are working in indoor civil well serviced buildings. There are areas were people are working as farmers in remote villages but they are of small proportion. This study aimed to investigate the histopathological pattern of BCC and SCC in the Eastern Region of Saudi Arabia and to compare our results to those from other areas of Saudi Arabia and the rest of the world.

I. Introduction Non-melanoma skin cancer (NMSC) generally refers to cutaneous SCC and BCC (Thomas et al, 1999; Hensin 2001); together with malignant melanoma (MM) are sunrelated skin cancers. They are considered as the commonest cancers in Caucasians, with incidences sometimes reaching epidemic proportions (Diegen and Mahler, 2002). There are considerable geographic and racial variations (Harris et al, 2001). The incidence of NMSC is highest in Australia (Marks, 1997), United States of America (Martinez and Otley, 2001), and in Finland BCC is the second most common type of cancer (Cancer Society of Finland, 1997). In Jordan which is a Middle Eastern country, it is the sixth most common type of cancer in males and the fourth most common type in females (Omari et al, 2006). There are a number of histologic variants of BCC, but the two most important are the superficial type and the sclerosing type. These are important because most of the time the lesions are ill

II. Materials and Methods The histopathology slides of all newly diagnosed cases of BCC and SCC at King Fahd Hospital of the

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Alakloby et al: Analysis of histopathological pattern of Non-melanoma skin cancer University over a 20 years period starting January 1983 through December 2002 were retrieved, reviewed and reevaluated. Age and sex were documented. Despite the presence of different histopathological variants of BCC, with different degrees of differentiation, we categorized it into superficial, solid (nodular), fibroepithelioma of Pinkus, keratotic and infiltrative, while SCC was categorized as well differentiated, moderately differentiated and poorly differentiated (Elder et al, 2004).

of cases and females 34 (41.5%) with a male to female ratio of 1.4:1. The mean age was 67.2 years with an age range of 35-98 years. Most of the patients were above the age of 50 years; 65 patients (79.2%). No case was detected below the age of 30 years.

Amongst the BCC cases mentioned above There were 33 (64.7%) males and 18 (35.3%) females with a male to female ratio of 1.8:1. The maximum number of cases were reported in the year 1988 during the 20 years period. The histopathological pattern for BCC was as follows: solid (nodular) (84.3%), fibroepithelioma of Pinkus (5.9%), keratotic (3.9%), superficial (3.9%) and infiltrative (2%) (Table 1 & Figure 1-5).

III. Results A total of 82 new cases of NMSC were recorded during the 20 years period. 51 cases (62.2%) were BCC and 31 cases (37.8%) SCC. Males comprised 48 (58.5%) Table 1. Histopathological patterns in patients with BCC. Histopathological pattern Solid (Nodular) Fibroepithelioma of Pinkus Superficial Keratotic Infiltrative Total

Number of cases and their percentage 43 (84.3%) 3(5.9%) 2(3.9%) 2(3.9%) 1(2%) 51(100%)

Figure 1. Infiltrative BCC, 67 years old female (x40).

Figure 2. Solid (nodular) BCC, 52 years old male (x40).

Figure 3. Superficial BCC, 55 years old male (x40).

Figure 4: Keratotic BCC, 52 years old male (x40).

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Cancer Therapy Vol 6, page 305 in different regions of Saudi Arabia and Qatar, which is a neighboring country (Bahamdan and Morad, 1993; Mahmoud and Azadeh, 1996; El Hag et al, 2002; Al Aboud et al, 2003; AlMaghrabi et al, 2004). The only exception was in Asir region (southern region of Saudi Arabia) where SCC was found to be the most common skin cancer (Bahamdan and Morad, 1993). Our results correspond to those of National Cancer Registry of Saudi Arabia, reporting BCC more prevalent (51.1%) than SCC (27.6%) (National Cancer Registry, Kingdom of Saudi Arabia, 2004).

In the case of BCC the male to female ratio was 1.8:1 and the maximum number of reported cases was in the age group of 50-59 years which is a younger age as compared to that reported by others (Marks, 1997; Cancer Society of Finland, 1997; Martinez and Otley, 2001; AlMaghrabi et al, 2004; Omari et al, 2006). The most frequent histopathological pattern was the solid (nodular) pattern but we were unable to compare this with other studies because other studies focused mainly on the clinical pattern of BCC. In the case of SCC the male to female ratio was 0.9:1 which is different than that for BCC, and the maximum number was found in the age group 50-59 years, less than what was reported from other regions (Mahmoud and Azadeh, 1996; Omari et al, 2006). The most frequent histopathological pattern was the â&#x20AC;&#x2DC;well differentiatedâ&#x20AC;&#x2122; pattern. As in case of BCC, we were not able to compare this finding with any other study.

Figure 5: Fibroepithleioma of Pinkus 52 years old male (x40).

A total of 31 (37.8%) cases were diagnosed as SCC with the maximum number of cases reported in the year 1985 during the 20 years period. There were 15 (48.4%) males and 16 (51.6%) females with a male to female ratio of 1:0.94. The histopathological pattern for SCC was as follows: well differentiated (45.1%), poorly differentiated (32.3%) and moderately differentiated (22.6%) (Table 2 & Figure 6-8).

IV. Discussion In our study we found BCC to be more common than SCC, which is similar to the findings in other studies done

Table 2. Histopathological patterns in patients with SCC. Histopathological pattern Well differentiated Poorly differentiated Moderately differentiated Total

Number of cases and their percentage 14 (45.1%) 10 (32.3%) 7 (22.6%) 31(100%)

Figure 6. Poorly differentiated SCC, 68 years old female (x40).

Figure 7. Moderately differentiated SCC, 55 years old male (x40).

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Alakloby et al: Analysis of histopathological pattern of Non-melanoma skin cancer clothing, which properly covers the body, might have contributed to the lower occurrence of NMSC.

References Al Aboud KM, Al Hawsawi KA, Baht MA, Ramesh V, Ali SM (2003) Skin cancers in Western Saudi Arabia. Saudi Med J 24, 1382-1387.

Al Ghamdi SA, Malatani T, Kameswaran M, Khurban P (1994) Head and neck cancer in referral center in Asir region. Ann Saudi Med 14, 383-386.

AlMaghrabi JA, Al Ghamdi AS, Elhakeem HA (2004) Pattern of skin cancers in Southern Saudi Arabia. Saudi Med J 25, 776-779.

Bahamdan KA, Morad NA (1993) Pattern of malignant skin tumors in Asir region, Saudi Arabia. Ann Saudi Med J 13, 402-406.

Cancer incidence in Finland 1995 (1997) Cancer Statistics of the National Research and Development Center for Welfare and Health, Publication 58. Helsinki: Cancer Society of Finland.

Diepgen TL, Mahler V (2002) The epidemiology of skin cancer.

Br J Dermatol 146, 1–6.

Elder DE, Elenitsas R, Jaworsky C, Johnson B (1997) Lever's Histopathology of the Skin, 8th ed. Lippincott & Raven, Philadelphia. 685-746.

El Hag IA, Katchabswaran R, Chiedozi LC, Kollur SM (2002) Pattern and incidence of cancer in Northern Saudi Arabia.

Saudi Med J 23, 1210-1213.

Harris RB, Griffith K, Moon TE (2001) Trends in the incidence of nonmelanoma skin cancers in southeastern Arizona, 1985– 96. J Am Acad Dermatol 45, 528–536.

Hensin T (2001) Genetics of non-melanoma skin cancer. Arch Dermatol 137, 1486-1492.

Khan AR, Hussain NK, Al Saigh A, Malatani T, Sheikh AA (1991) Pattern of cancer at Asir Central Hospital, Abha, Saudi Arabia. Ann Saudi Med 11, 285-288.

Mahmoud SF, Azadeh B (1996) Basal cell carcinoma in Qatar.

Int J Dermatol 35, 704-706.

Marks R (1997) Epidemiology of non-melanoma skin cancer and solar keratosis in Australia: a tale of self-immolation in Elysian Fields. Australas J Dermatol 38, S26–S29.

Martinez JC, Otley CC (2001) The management of melanoma and nonmelanoma skin cancer: a review for the primary care physician. Mayo Clinic Proc 76, 1253–1265.

Murphy GF, Elder DE (1991) Atlas of Tumor Pathology: Non_melanocytic Tumors of the Skin. 3rd series. Armed Forces Institute of Pathology, Washington D.C. 11-60.

National Cancer Registry, Kingdom of Saudi Arabia (2004) Omari A, Khammash M, Matalka I (2006) Skin Cancer trends in northern Jordan. Int J Dermatol 45, 384-388.

Stirling G, Khalil Am, Nada GN, Saad AA, Rahem MA (1979) Malignant neoplasms in Saudi Arabia. Cancer 44, 15431548.

Thomas JR, Leonard JS, Antoinette FH (1999) Premalignant and malignant tumors of the skin. J Am Acad Dermatol 28, 2228.

Figure 8. Well differentiated SCC, 63 years old female (x40).

The knowledge of the frequency of histopathological patterns can help in viewing the prognostic outlook for patients and planning an effective management. During the past 13 years the National Tumor Registry started to collect information from all over the Kingdom of Saudi Arabia (KSA). Studies have shown variable data of skin cancer in KSA ranging from lowest frequencies in the northern part of the kingdom to higher frequencies in other areas (Stirling et al, 1979; Khan et al, 1991; Al Ghamdi et al, 1994; El Hag et al, 2002). In general, the incidences of both BCC and SCC seem surprisingly low in a country with almost twelve sunny months during the year. This could be attributable to many different factors including geographical and environmental factors, skin color, genetic background, lifestyle, attitude and traditional clothing, which usually consist of a head covering (Gutra) and a long white shirt (Thobe) worn by the males and long dresses and veils (Hijab) worn by the females, which decrease the sun-exposed areas of the body. In fact, the true incidence of skin cancer in Arabian countries is difficult to measure because it is a disease of elderly people who may never seek medical advice and who may not bother to have a nodule on the skin. In addition, some cases may have been treated using ablative procedures, without being submitted to histopathological examination.

V. Conclusion This study investigated the histopathological pattern of BCC and SCC in the Eastern Region of Saudi Arabia.

The 20-years period of study revealed a low frequency and stable trend in BCC and SCC, similar to most other areas of Saudi Arabia. BCC was more common than SCC as reported in many international studies. Traditional

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Acute tumoral bleeding in recurrent falx meningioma after stereotactic radiosurgery: a case report Case Report

Feng-Wen Su1, Tao-Chen Lee1,*, Yu-Ling Ting4, Yu-Jie Huang2, Hsiu-Yu Huang3, Hung-Chen Wang1, Yu-Jun Lin1 1

Department of Neurosurgery, Radiation Oncology, 3 Pathology, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan 4 Department of Nursing, Chang Jung Christian University 2

__________________________________________________________________________________ *Correspondence: Tao-Chen Lee, M.D., Department of Neurosurgery, Chang Gung Memorial Hospital, 123 Ta Pei Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan; Tel.: +886 7 7317123 X 8011; Fax: +886 7 7318762; e-mail: leetc@adm.cgmh.org.tw Key words: Acute tumoral bleeding, falx meningioma, stereotactic radiosurgery Abbreviations: Computed Tomography, (CT); Gamma Knife Radiosurgery, (!KR); Hematoxylin-Eosin, (HE); Magnetic Resonance Imaging, (MRI); Stereotactic radiosurgery, (SRS) Received: 12 July 2007; Revised: 30 August 2007 Accepted: 5 May 2008; electronically published: May 2008

Summary We report a 39-year-old man who underwent stereotactic radiosurgery for recurrent right frontal falx meningioma.

Severe headache with transient loss of consciousness occurred 3 hours after the procedure. Emergent image study revealed tumor bleeding with rupture into the ventricles. Conservative treatment was administered and six-month follow-up revealed no complications. Although SRS has proven to be a safe therapeutical option for intracranial tumors, acute tumoral bleeding may occur in a benign intracranial tumor after SRS.

bleeding after SRS for benign intracranial tumors has not been reported.

I. Introduction Stereotactic radiosurgy (SRS) for brain tumors is generally believed to have no significant acute complications. Iwai and colleagues in their series of gamma knife radiosurgery (!KR) treatments for forty-three meningioma patients, observed in 2003 no neurological deficits after radiosurgery.

Kondziolka and colleagues noted in 2000 that neurological symptoms after !KR for vestibular schwannomas were usually mild and transient. Harris and colleagues reported in 2003 delayed visual field defect in only one of thirty meningioma patients having undergone SRS. A Pittsburgh study of fifty meningioma patients treated with GKR revealed no immediate postoperative complications (Kondziolka et al, 1991).

Acute tumoral bleeding after SRS is particularly rare.

A review of the English medical literature reveals only one case of tumoral hemorrhage immediately after SRS for a metastatic brain tumor (Izawa et al, 2006). Acute tumor

II. Case A 39-year-old male had undergone removal of a right frontal falx meningioma 7 years earlier (Figure 1). Since then, his condition was uneventful until the day before admission when he suffered a generalized seizure attack. Emergent CT scan indicated local recurrence with a tumor volume of 12.26 ml contoured by MRI-CT fusion images. The average diameter of this tumor was less than 3 cm (range, 2.14-3.20 cm) (Figure 2).

Throughout the course of treatment, the patient exhibited only transient loss of consciousness and had no focal motor weakness.

The selected treatment option was SRS, which has been recommended for residual meningiomas after surgical resection and has a low complication rate (Torres et al, 2003).

The prescribed dose was 15 Gy to margin. A five-arc treatment plan was designed by Novalis treatment planning v5.31 (BrainLab, Germany). The tumor was covered by 100% isodose line with a maxium dose of 16.95 Gy. The course of SRS was

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Su et al: Acute tumoral bleeding in recurrent falx meningioma uneventful. However, the patient suffered a generalized seizure attack 3 hours after the radiosurgical procedure. Fortunately, he quickly regained consciousness and showed no neurological deficit. Emergent CT scan without enhancement showed focal hematoma in the meningioma and rupture of blood into the ventricles (Figure 3).

The patient was treated conservatively with short term intravenous administration of steroids. One week later, follow-up CT scan without enhancement showed clearance of blood in the ventricles and marked decrease in intratumoral blood (Figure 4).

He was discharged in good condition 10 days after the bleeding episode. At 3-month follow-up, the condition of the patient was good and showed no neurological deficits.

Magnetic resonance imaging at that time showed no intracranial blood and a slight decrease in the volume (9.22ml) of the treated tumor (Figure 5). The condition of the patient was again stable at 6-month follow-up.

Figure 1. Microphotoscopic image of the falx meningioma revealing sheets of meningothelial cells with oval nuclei arranged in short fascicles (H&E stain, 100X).

Figure 2. Magnetic resonance image of the falx meningioma immediately before SRS showing a tumor volume of 12.26 ml with average diameter of less than 3 cm. A: axial view showing a maximum and minimum diameter of 3.15 and 2.33 cm, respectively. B: saggital view showing a maximum and minimum diameter of 3.20 cm and 2.14cm, respectively.

Figure 4. Reduced blood in the tumor and clearance of intraventricular blood revealed by CT scan 7 days after SRS.

Figure 3. Tumoral hemorrhage and rupture of blood into ventricles revealed by CT scan 3 hours after SRS.

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Cancer Therapy Vol 6, page 309 marginal dose, corresponding to a 50% isodose line, was 20 Gy for nine metastatic lesions. The patient expired 4 days later (Izawa et al, 2006).

Five cases of delayed (1 to 8 years after GKR) tumoral hemorrhage that had undergone GKR for intracranial tumors have also been reported (Kwon et al, 2002; Kim et al, 2004). However, any correlation between the hemorrhage and the radiosurgical procedure was speculative as bleeding occurred long after SRS and may have been the natural course of a tumor.

This case presented a meningioma originating from the falx. Patients with tumors in this area are vulnerable to injury by SRS (Kalapurakal et al, 1997), and this injury was believed to have been cause by occlusion of superior sagittal sinus and bridging veins after SRS (Gotoh et al, 1993). However, previously reported cases involved brain edema instead of tumoral bleeding (Kalapurakal et al, 1997).

In conclusion, this is the first reported case of immediate tumoral hemorrhage in a benign tumor (falx meningioma) after SRS. Any case of intracranial tumor must be closely examined for tumoral bleeding when undergoing SRS.

Figure 5. Clearance of intracranial blood and slight decrease in tumor volume revealed by MR image 3 months after SRS.

IV. Discussion

References

Although SRS at sufficient doses has proven to be a safe therapeutical option for intracranial tumors (Bertalanffy et al, 2001), temporary volume increases observed in some tumors after SRS demonstrate the vigorous effect of radiosurgery on treated targets (El Shehaby et al, 2005). In a study of forty-three meningioma patients who received SRS or radiotherapy, Kalapurakal and colleagues reported in 1997 that five patients with large tumors developed life-threatening panhemispheric edema.

A multicenter review of 203 patients who underwent radiosurgery for parasagittal meningiomas showed no clinical failures in patients with smaller tumors (<7.5 ml).

The authors advocated radiosurgery for patients with small (<3 cm in average diameter) tumors (Kondziolka et al, 1998). Although tumor volume in the current case was 12.26 ml, its average diameter of less than 3 cm was safe for radiosurgery according to the multicenter review (Kondziolka et al, 1998).

A strong correlation has been demonstrated between the occurrence of post-SRS complications and higher irradiation dosages (Kalapurakal et al, 1997). However, these dosages are necessary for tumor volume reduction (Ganz et al, 1993). An irradiation dosage of 15 Gy to margin was prescribed in the current case. This dosage was based on a study by Kondziolka and colleagues who reported in 1999 an average margin dose of 16 Gy for patients undergoing radiosurgery for meningiomas.

Tumor bleeding induced by SRS is extremely rare. In a large series study of 380 meningioma patients who underwent SRS, none presented tumoral bleeding complications (Kondziolka et al, 1999). A literature review further reveals only one case of acute tumoral hemorrhage after SRS for intracranial tumors. This case involved a 46-year-old female with lung cancer complicated by multiple brain metastases. The prescribed

Bertalanffy A, Dietrich W, Aichholzer M, Brix R, Ertl A, Heimberger K, Kitz K (2001) Gamma knife radiosurgery of acoustic neurinomas. Acta Neurochir (Wien) 143, 689-95.

El Shehaby A, Ganz JC, Reda WA, Hafez A (2005) Temporary symptomatic swelling of meningiomas following gamma knife surgery. Report of two cases. J Neurosurg 102, (Special Suppl), 293-6.

Ganz JC, Backlund EO, and Thorsen FA (1993) The results of Gamma Knife surgery of meningiomas, related to size of tumor and dose. Stereotact Funct Neurosurg 61, (Suppl 1), 23-9.

Gotoh M, Ohmoto T, and Kuyama H (1993) Experimental study of venous circulatory disturbance by dural sinus occlusion.

Acta Neurochir (Wien) 124, 120-6.

Harris AE, Lee JY, Omalu B, Flickinger JC, Kondziolka D, Lunsford LD (2003) The effect of radiosurgery during management of aggressive meningiomas. Surg Neurol 60, 298-305; discussion 305.

Iwai Y, Yamanaka K, Ishiguro T (2003) Gamma knife radiosurgery for the treatment of cavernous sinus meningiomas. Neurosurgery 52, 517-24; discussion 523-4.

Izawa M, Chernov M, Hayashi M, Kubota Y, Kasuya H, Hori T (2006) Fatal intratumoral hemorrhage immediately after gamma knife radiosurgery for brain metastases: case report.

Minim Invasive Neurosurg 49, 251-4.

Kalapurakal JA, Silverman CL, Akhtar N, Laske DW, Braitman LE, Boyko OB, Thomas PR (b) Intracranial meningiomas: factors that influence the development of cerebral edema after stereotactic radiosurgery and radiation therapy.

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Kim CH, Kim DG, Paek SH, Chung HT, Choi YL, Chi JG (2004) Delayed bleeding after gamma knife surgery for meningioma. Acta Neurochir (Wien) 146, 741-2.

Kondziolka D, Flickinger JC, Perez B (1998) Judicious resection and/or radiosurgery for parasagittal meningiomas: outcomes from a multicenter review. Gamma Knife Meningioma Study Group. Neurosurgery 43, 405-13; discussion 413-4.

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Su et al: Acute tumoral bleeding in recurrent falx meningioma Kondziolka D, Levy EI, Niranjan A, Flickinger JC, Lunsford LD (1999) Long-term outcomes after meningioma radiosurgery: physician and patient perspectives. J Neurosurg 91, 44-50.

Kondziolka D, Lunsford LD, Coffey RJ, Flickinger JC (1991) Stereotactic radiosurgery of meningiomas. J Neurosurg 74, 552-9.

Kondziolka D, Lunsford LD, Flickinger JC (2000) Gamma knife radiosurgery for vestibular schwannomas. Neurosurg Clin N Am 11, 651-8.

Kondziolka D, Niranjan A, Lunsford LD, Flickinger JC (1999) Stereotactic radiosurgery for meningiomas. Neurosurg Clin N Am 10, 317-25.

Kwon Y, Ahn JS, Jeon SR, Kim JH, Kim CJ, Lee JK, Kwun BD, Lee DH, Kim SY (2000) Intratumoral bleeding in meningioma after gamma knife radiosurgery. J Neurosurg 97, 657-62.

Torres RC, Frighetto L, De Salles AA, Goss B, Medin P, Solberg T, Ford JM, Selch M (2003) Radiosurgery and stereotactic radiotherapy for intracranial meningiomas. Neurosurg Focus 15, 14(5):e5.

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Immunotherapy and radioimmunotherapy for nonHodgkin's Lymphoma Review Article

Chrissa Sioka*, Andreas Fotopoulos Department of Nuclear Medicine, University Hospital of Ioannina, Ioannina, Greece

__________________________________________________________________________________ *Correspondence: Chrissa Sioka, M.D., 10 Patriarhou N. Evangelidou, Ioannina, 454 44 Greece; Tel: 0030-2651097514; Fax: 00302651097011; E-mail: csioka@yahoo.com Key words: Non-Hodgkin lymphoma, immunotherapy, radioimmunotherapy, anti-CD 20, Bexxar, Zevalin, 131I, 90Y Abbreviations: autologous stem cell transplantation, (ASCT); high-dose chemotherapy, (HDC); iodine-131, (131I); monoclonal antibody, (MAb); non-Hodgkin's lymphoma, (NHL); radioimmunotherapy, (RIT); yttrium-90, (90Y) Received: 11 March 2008; Revised: 17 April 2008 Accepted: 16 May 2008; electronically published: May 2008

Summary Until recently, the standard treatment options for advanced non-Hodgkin's lymphoma (NHL) included chemotherapy with or without external beam radiation. However, administration of chemotherapy may not be well tolerated in the elderly. In addition, the majority of patients with NHL who respond to conventional chemotherapy will relapse and eventually become refractory to chemotherapy. Molecular targeting therapy has become an increasingly important therapeutic strategy for NHL. One such therapy includes use of unconjugated monoclonal antibodies which are cytotoxic by several mechanisms, including complement-dependent cytotoxicity, antibodydependent cell-mediated cytotoxicity, and apoptosis. Radioimmunotherapy (RIT) is a form of targeted radiation therapy that may be a viable therapeutic option for patients whose NHL has failed prior treatment with chemotherapy and unconjugated monoclonal antibodies. Thus, RIT with radio-labelled anti-CD20 antibodies (iodine -131 tositumomab and yttrium-90 ibritumomab tiuxetan), has demonstrated both efficacy and acceptable toxicity profiles. The purpose of this review was to evaluate the effectiveness of immunotherapy and RIT for NHL through controlled trials and to discuss the role of the nuclear medicine oncologist in administering this important new form of biologically targeted radiotherapy.

may prolong survival in a subset of patients with indolent (Mounier et al, 2002) or aggressive (Zinzani et al, 2004) NHL. Adding rituximab (a chimeric monoclonal antibody against the CD20 B-cell antigen) to the CHOP regimen may improve outcome of aggressive NHL and has clearly become the standard therapy. Overall, rituximab has therapeutic activity in refractory diffuse large-B-cell lymphoma and indolent lymphomas (Maloney et al, 1997; Coiffier et al, 1998; McLaughlin et al, 1998; Foran et al, 2000; Coiffier et al, 2002).

Radioimmunotherapy (RIT) is a form of targeted radiation therapy that may add to our therapeutic options for patients who failed prior treatment with chemotherapy and rituximab (Cheson, 2003). Thus, RIT with radiolabeled anti-CD20 antibodies has become a viable therapeutic option for relapsed or refractory follicular/lowgrade, transformed NHL and indolent NHL. The two agents currently approved by the US Food and Drug Administration, iodine -131 tositumomab (Bexxar) and

I. Introduction Lymphomas represent the fifth most common malignancies. Each year, 54,370 to 55,400 new cases are diagnosed with non-Hodgkin lymphomas (NHL) (Jemal et al, 2004). Among them, 30%-40% of patients have diffuse large-B-cell lymphoma (Coiffier, 1997) and over 50% of them are older than 60 years (The International NonHodgkin's Lymphoma Prognostic Factors Project, 1993; The Non-Hodgkin's Lymphoma Classification Project, 1997).

Until recently, the standard treatment options for advanced disease included chemotherapy with or without external beam radiation. However, CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) may be too toxic for elderly patients (Zinzani et al, 1999) and in addition, it is associated with increased risk of osteoporosis and fracture especially in elderly patients with NHL (Cabanillas et al, 2007). Nevertheless, high-dose chemotherapy with stem-cell transplantation 311

Sioka and Fotopoulos: Immunotherapy and radioimmunotherapy for non-Hodgkin's Lymphoma yttrium-90 ibritumomab tiuxetan (Zevalin), have demonstrated both efficacy and acceptable toxicity profiles (Press et al, 1993; Witzig et al, 1999; Kaminski et al, 2000; Vose et al, 2000; Witzig et al, 2002; Cheson, 2003; Davies et al, 2004; Ghobrial and Witzig, 2004; Horning et al, 2005). Both compounds exhibit 20%-40% complete response rates and 60%-80% overall response rates for patients with indolent B-cell NHL) (Kaminski et al, 1996; Macklis, 2004, 2007). Although RIT is indicated in selected patients with disease refractory to chemotherapy or rituximab, its role as initial therapy for NHL is less well defined, even though sometimes high response rate and prolonged survival may be noted (Kaminski et al, 2005).

active in patients with advanced-stage follicular grade 1 NHL and could be administered with minimal toxicity (Witzig et al, 2005).

Since rituximab is a chimeric antibody, development of human antibodies, such as IMMU-106 (hA20), would minimize infusion reactions and development of human antibodies against the therapeutic antibody. Development of new antibodies include antibodies against CD22, CD23, CD80, CD52, CD2, CD30, and CD40.

CHOP combined with rituximab (R-CHOP) is regarded as an effective treatment for indolent B-cell NHL and has become the standard form of therapy. A study compared survival in patients with primary refractory NHL who underwent either chemotherapy with CHOP regimen, standard intensive chemotherapy regimens (BEAM) and combination of CHOP plus rituximab and found that CHOP plus rituximab regimen increased overall survival from 7.4 months to 17 months (Tsartsidze et al, 2007).

In a randomized phase II study, 69 patients received either six courses of CHOP concurrently with rituximab (Arm C), or six courses of CHOP followed by six courses of weekly rituximab (Arm S). The overall response rate (ORR) in Arm C was 94%, including a 66% CR compared with 97% including a 68% CR in Arm S. Patients in Arm C experienced more grade 4 neutropenia (85% vs 70%) and experienced more grade 3 or greater nonhematological toxicities (21% vs 12%). Thus, R-CHOP was effective in untreated indolent B-NHL, either concurrent or in a sequential combination (Ogura et al, 2006). A retrospective study of 45 patients with follicular grade 3 lymphoma treated with rituximab and CHOP showed CR rate of 96%. The 3-year FFS rate was 80% in low, 81% in low intermediate, and 50% in highintermediate/high-risk patient group. The addition of rituximab to CHOP improved both 5-year FFS, 71% compared with 44%, and 5-year OS, 98% compared with 75%, suggesting that the addition of rituximab to CHOP provided a high response rate and excellent early survival (Overman et al, 2007). Similar data supporting the use of rituximab-based immune-chemotherapy as a standard firstline therapy for patients with diffuse large B cell lymphoma (DLBCL) were obtained by other studies (Belada et al, 2007; Li et al, 2007; Rueda et al, 2007).

Using the combination of R-CHOP resulted in significant improvement of outcome in 399 previously untreated elderly patients, age 60 to 80 years with DLBCL suggesting that this combination should become the standard treatment for the elderly patients as well (Feugier et al, 2005).

Another study was undertaken to compare the efficacy (survival) and direct medical costs of two chemotherapy regimens, R-CHOP and CHOP, in the treatment of DLBCL in young patients with a good prognosis. It was found that when taking into account the cost of rescue therapy, the overall mean treatment cost per patient was lower with the R-CHOP regimen than with the CHOP regimen. This result was mainly due to the fact that the higher costs associated with rituximab were offset by the significantly lower rescue therapy costs (Ferrara and Ravasio, 2008). In a recent report, 24 untreated patients 60

II. Standard forms of therapy for NHL The CHOP regimen used to be the standard of care for younger and elderly patients with diffuse large-B-cell lymphoma (Fisher et al, 1993), but it induced complete responses in only 40-50% of elderly patients, with threeyear event-free and overall survival rates of 30% and 3540%, respectively (Sonneveld et al, 1995). Patients with refractory/relapsing lymphoma were rarely cured by chemotherapy alone. The chemotherapeutic options for relapsed/refractory NHL include high-dose chemotherapy (HDC) followed by autologous stem cell transplantation (ASCT). A retrospective analysis of 2 such regimens, combination of BCNU, etoposide, cytarabine, and cyclophosphamide (BEAC, N = 56) and combination of BCNU, etoposide, cytarabine, and melphalan (BEAM, N = 28), showed similar incidence of significant side-effects but BEAM appeared to be superior to BEAC for survival (Jo et al, 2008). In addition, high-dose chemotherapy followed by ASCT might extend survival in some groups of patients with lymphoma regardless of bone marrow involvement at initial diagnosis (Yano et al, 2007). An eight-year experience in high risk NHL patients, demonstrated that HDC and ASCT should be done early after first complete remission to avoid chemo-resistance (Chang et al, 2006).

Molecular targeting therapy has become an increasingly important therapeutic strategy for cancer.

There are several monoclonal antibodies (MAbs) used for treatment of various malignancies. Unconjugated MAbs are cytotoxic by several mechanisms, including complement-dependent cytotoxicity, antibody-dependent cell-mediated cytotoxicity, and apoptosis.

To evaluate the efficacy and feasibility of rituximab monotherapy in patients with relapsed or refractory aggressive B-cell lymphoma, patients were treated with rituximab at 375 mg/m2 by eight consecutive weekly infusions. The overall response rate (ORR) of 68 enrolled patients and 57 eligible patients were 35% and 37%, respectively. Median progression-free survival (PFS) of 53 evaluable patients was 52 days, whereas time to progression of 21 responders was 245 days, indicating that this therapy has significant activity for relapsed aggressive B-cell lymphoma (Tobinai et al, 2004). Similar results were obtained by other studies (Walewski et al, 2001; Rothe et al, 2004). Furthermore, rituximab was highly 312

Cancer Therapy Vol 6, page 313 years and older with DLBCL were treated with a combination therapy including cyclophosphamide, mitoxantrone, vincristine, etoposide, bleomycin, and prednisone (VNCOP-B) plus four rituximab administrations. Nineteen of the 24 patients (80%) obtained a CR, four had a PR, and the rest had progressive disease. This regimen was effective in inducing a good remission rate with moderate toxic effects in elderly DLBCL patients (Fina et al, 2007).

BCL-2 protein expression correlates with shorter survival in patients with DLBCL who are treated with CHOP chemotherapy. A recent study demonstrated that the addition of rituximab to CHOP chemotherapy reversed the adverse prognostic influence of BCL-2 protein expression on progression free and overall survival in DLBCL (Wilson et al, 2007). In addition, rituximab plus CHOP (R-CHOP) overcame PRDM1-associated resistance to chemotherapy in patients with DLBCL (Liu et al 2007).

Thus, the above mechanisms contribute to our understanding of the additive benefit of combination of HDC with rituximab.

increasing ratios of tumor to whole-body activity due to specific antibody binding. Because of the variation of whole-body and organ dose factors, it was suggested that individual dosimetry is essential for RIT with 131I-labeled rituximab (Scheidhauer et al, 2002).

Phase I/II data have determined the dose of 0.4 mCi/kg of ibritumomab tiuxetan to be the maximum tolerated dose for patients with NHL and platelet counts > 150,000 and < 25% bone marrow involvement. In patients with platelet counts between 100,000-149,000 the maximum tolerated dose has been 0.3 mCi/kg. Toxicity was primarily hematologic, transient, and reversible (Krasner and Joyce, 2001). Prior to administration of 131I tositumomab or 90Y- ibritumomab tiuxetan an infusion of 375 mg/m2 (450 mg) unlabelled anti-CD20 antibody is required to clear peripheral B cells and improve biodistribution. For diagnostic purposes, a dose of 185 to 370 Mbq (5 to 10 mCi) 131I tositumomab or 111In- ibritumomab tiuxetan is administered. Patients that received myeloablative radioimmunotherapy with a mean activity of 21 GBq of 131I tositumomab for therapy estimated to absorb 25 Gy to the normal organ receiving the highest radiation dose (Rajendran et al, 2004). Unlike chemotherapy, after which nadir counts occur in about 1 to 2 weeks, the nadir with 90Y occurs at about 7 to 9 weeks following therapy.

Several clinical trials of RIT in relapsed low grade or transformed NHL are shown in Table 1. In an integrated efficacy analysis of five clinical trials in 250 heavily pretreated patients with low-grade and transformed NHL, further therapy after relapse with 131I tositumomab resulted in 20% to 38% complete response rates and 5-year progression-free survival of 17% (Fisher et al, 2005). In a multicenter phase II clinical study of 131I-rituximab RIT in relapsed or refractory indolent NHL the CR rate was 53% and objective overall response rate was 76%. The median progression-free survival for the entire group was 13 months, with 14% remaining relapse free further than 4 years (Leahy et al, 2006). Long-term CR after 131Itositumomab therapy for relapsed or refractory indolent NHL were reported in 18 patients (12 chemotherapy relapsed indolent and 6 transformed lymphoma patients).

Two patients were not treated secondary to disease progression during dosimetry. The overall response rate was 81% in the 16 patients treated (50% CR and 31% PR), with median progression free survival of the 22.5 months (Buchegger et al, 2006). Another study using 131Irituximab in 9 previously heavily treated patients with relapsed, refractory or transformed B-NHL showed one CR ongoing at 14 months and two PR progressing at 12 and 13 months after treatment. One partial responder was re-treated with RIT and achieved an additional progression-free interval of 7 months (Bienert et al, 2005).

Patients with NHL previously received 90Yibritumomab tiuxetan RIT can be given external beam radiation therapy (EBRT) safely with good efficacy (Justice et al, 2006). In a report of 135 patients with relapsed B-cell NHL who had received prior RIT with 90Yibritumomab tiuxetan, received median EBRT dose of 28.5 Gy and overall response rate of 90% (26/29) with 12 CR (41%), 7 complete clinical responses (24%), 7 PR

III. Radioimmunotherapy RIT has yielded promising results in relapsed and refractory NHL patients. Radioimmunoconjugates are combinations of antibodies and radionuclides that exhibit a additive effect of radiation and immune-mediated cellular toxicity. Successful RIT for lymphomas is linked to the rapid and efficient binding of the targeted MAb to lymphoma cells. The exact mechanism of the RIT effect in B-cell malignant lymphoma is still unclear, but it may be related to additional effect of the continuous low-dose radiation and the concurrent anti-CD20 antibody effect (Macklis, 2004).

In addition, use of radioimmunoconjugates to boost the effectiveness of unlabeled antibodies may have a bystander effect, killing also antigen-negative tumor cells adjacent to those expressing the target antigen.

Because 90Y (yttrium-90) is a pure beta-emitter and there are no penetrating gamma-emissions associated with the therapy, 90Y-ibritumomab tiuxetan is routinely administered on an outpatient basis. Furthermore, the risk of radiation exposure to patients' family members is minimal even without restrictions on contact. There is therefore no need to establish dose rate limits prior to releasing patients treated with 90Y RIT. Thus, only standard precautions for handling body fluids are recommended for health care workers and patientsâ&#x20AC;&#x2122; family members after 90Y-ibritumomab tiuxetan therapy (Wagner et al, 2002). On the contrary, patients who receive 131Itositumomab therapy are usually hospitalized in radioprotection wards, and the administration of RIT requires a dedicated team approach, involving nuclear medicine, oncology, and radiation safety personnel (Bischof Delaloye, 2003).

The distribution and pharmacokinetics of 131I labeled rituximab for RIT of relapsed CD20-positive NHL was evaluated in 35 patients and found that activity was excreted mainly through the kidneys; the normal organs showed decreasing ratios of organ to whole-body activity over time, whereas the tumor tissue demonstrated 313

Sioka and Fotopoulos: Immunotherapy and radioimmunotherapy for non-Hodgkin's Lymphoma Table 1. RIT in relapsed low grade or transformed NHL No patients - type of trials 250 pts in 5 clinical trials

Prior treatment

90 patients Phase II

Yes

18 patients Phase II

Yes

Yes

RIT type 131

I tositumomab

131

I tositumomab

131

Results

I tositumomab

90

143 patients Phase III

Yes

211 patients 4 clinical trials Phase III

Yes

23 patients Phase I

Yes

90 patients Phase II

No

35 patients Phase I - II

No

23 patients Phase II

Yes

Y iritumomab vs rituximab

90

Y iritumomab

131

I tositumomab + BEAM + ASCT 131

I tositumomab + CHOP

131

I tositumomab + Fludarabine 90

Y iritumomab + high dose BEAM + ASCT

CR: 20%-38% 5 years PFS 17% CR: 53% Median PFS:13 months CR: 50% Median PFS:22.5 months CR: 34% 90 Y iritumomab vs 20% for rituximab TTP:15 vs 10.2 months Median TTP 29.3 months. Median duration of response 28.1 months CR: 57% OS: 55% with median follow up of 38 months CR: 69% 5 years OS: 87% PFS :67% CR: 86% 5 years OS: estimated PFS :60% 2 years OS:67% 2 years PFS : 52%

Reference Fisher et al, 2005 Leahy et al, 2006 Buchegger et al, 2006

Witzig et al, 2002 Gordon et al, 2004

Witzig et al, 2007

Vose et al, 2005

Press et al, 2006

Leonard et al, 2005 Shimoni et al, 2007

RIT, radioimmunotherapy; NHL, Non-Hodgkin lymphoma; PFS, progression-free survival; CR, complete response; TTP, time to progression; OS, overall survival; BEAM, combination of BCNU, etoposide, cytarabine, and melphalan; ASCT, autologous stem cell transplantation; CHOP, combination of cyclophosphamide, doxorubicin, vincristine, and prednisone.

(24%), and 3 stable (10%) (Justice et al, 2006). A report of an updated time-to-event variables of a phase III randomized study (Witzig et a, 2002) compared 90Y labeled ibritumomab to rituximab standard therapy in 143 rituximab-naive patients with relapsed or refractory lowgrade, follicular, or transformed CD20+ NHL. The overall response rate was 80% versus 56% and CR rates were 34% for 90Y ibritumomab tiuxetan versus 20% for rituximab. The results of this trial showed trends toward longer median TTP (15 vs. 10.2 months) in patients treated with 90Y ibritumomab tiuxetan compared with the rituximab control arm (Gordon et al, 2004). In order to identify long-term responses in 211 previously relapsed NHL patients treated with 90Y ibritumomab, data of 4 clinical trials were analyzed. Long-term responses were seen in 37% of patients with median duration of responses of 28.1 months and median time to progression of 29.3 months. These findings suggest that a single dose of 90Y ibritumomab tiuxetan can produce durable responses and prolonged overall survival in a large number of patients who failed previous therapies (Witzig et al, 2007).

Comparison on the efficacy and safety of 90Y ibritumomab tiuxetan when it was used after the first

relapse of NHL or after two or more prior therapies showed that 90Y ibritumomab tiuxetan had substantial clinical benefits as a second-line therapy, especially in patients with follicular NHL. The quality of disease remissions with the 90Y ibritumomab tiuxetan after first relapse appeared to be comparable with that observed with most chemotherapy regimens in first-relapse patients (Emmanouilides et al, 2006). A prospective, nonrandomized phase II trial in 104 elderly patients at first relapse or with primary refractory diffuse large B-cell lymphoma (DLBCL) ineligible for stem-cell transplantation using a single dose of 90Y ibritumomab tiuxetan was conducted. Patients had been previously treated with either chemotherapy (group A), or chemotherapy plus rituximab (group B). Patients in group A were further divided into patients in whom induction therapy had failed (AI) and patients who had relapsed after achieving complete response (AII). Median overall survival was 21.4, 22.4, and 4.6 months in stratum AI, stratum AII, and group B, respectively, suggestive that 90 Y-ibritumomab was active in patients with relapsed and refractory DLBCL (Morschhauser et al, 2007).

314

Cancer Therapy Vol 6, page 315 The site-specific patterns of recurrence after 90Y ibritumomab tiuxetan RIT for CD20+ B-cell NHL seem to depend on the pre-treatment target volumes. Thus, a collective analysis of disease sites from 20 patients found that 83% sites of "bulky" disease displayed evidence of progression vs. 28% of "non-bulky" disease sites. These results suggest that one could use this pattern to direct use of additional EBRT to augment treatment and avoid relapses (Gokhale et al, 2005).

Fractionated RIT may improve therapeutic outcome by decreasing heterogeneity of the dose delivered to the tumor and by decreasing hematologic toxicity. Thus, RIT with weekly 185 MBq/m2 90Y epratuzumab achieved a high objective response rate (62%) across lymphoma subtypes, including durable CR (LindĂŠn et al, 2005).

Analysis of patients treated with two courses of ibritumomab tiuxetan revealed that the second treatment was well tolerated and with a safety profile similar to the first course suggesting that patients benefited from the first course can be benefited from a second course without additional toxicity (Shah et al, 2007). Moreover, retreatment with 131I tositumomab following a previous response could produce second durable responses (Kaminski et al, 2005).

reported in five patients (1%) 8 to 34 months after treatment (Witzig et al, 2003). Data on safety and efficacy of 90Y-ibritumomab tiuxetan found that patients > or =70 years had a similar incidence of grade 3 or 4 neutropenia (68% vs. 66%), thrombocytopenia (68% vs. 70%), anemia (8% vs. 22%), and non-hematologic adverse events (23% vs 19%) as that observed in patients <60 years. Response rates (range, 71%-80%) and the durations of response were similar suggesting that 90Y ibritumomab tiuxetan produced high rates of clinical response (up to 80%) and durable remissions in patients with NHL, and could be given at standard doses in older patients (Emmanouilides et al, 2007). In a feasibility and toxicity pilot study in 13 patients with resistant/refractory B-cell NHL using three different doses of 90Y-ibritumomab tiuxetan -30 MBq/kg (0.8 mCi/kg), 45 MBq/kg (1.2 mCi/kg) and 56 MBq/kg (1.5 mCi/kg) followed by ASCT, there were no significant differences in haematological toxicities among the three levels, except from delayed platelet recovery in heavily pre-treated patients receiving 56 MBq/kg. From this study it was concluded that high-activity ibritumomab tiuxetan with ASCT could be safely administered in elderly patients, as well as patients who had previously HDC and ASCT (Ferruci et al, 2007). In another study 24 patients older than 60 years with relapsed B-cell NHL received individualized therapeutic infusions of 131I tositumomab (median, 19.4 Gbq [525 mCi]; range, 12.1 to 42.7 Gbq [328 to 1,154 mCi]) followed by ASCT 2 weeks after therapy. The estimated 3-year overall and progression-free survival rates were 59% and 51%, respectively, and there were no treatment-related deaths, and only two patients experienced grade 4 non-hematologic toxicity. Thus, myeloablative RIT was safe and effective therapeutic option for older adults with relapsed B-NHL (Gopal et al, 2007). Radiopharmaceutical data from 12 NHL patients showed no accurate correlation of marrow dose estimates based on serial pre-treatment radiopharmaceutical imaging and blood data with actual marrow toxicity in anti-CD20 90 Y monoclonal antibody treated patients. It has been suggested that caution must be exercised when relying on these methods to predict hematologic toxicity (Erwin et al, 2001).

The most common non-hematologic toxicities of ibritumomab tiuxetan RIT included mild fatigue, nausea, infection, chills, fever, and abdominal pain. Less often, grades 1 and 2 nausea, vomiting, and abdominal pain can occur. However, these non-hematologic toxicities were transient and easily managed with supportive care.

Significant toxicity to the thyroid gland from potential uptake of free 131I can be avoided with administration of saturated solution of potassium iodine. Human antimouse antibodies (HAMA) can develop in approximately 17% of patients and their presence can affect the subsequent repeat of RIT. It is important to note that subsequent chemotherapy regimens can be well tolerated after RIT with 90Y ibritumomab tiuxetan (Ansell et al, 2002). A less frequent but important potential toxicity of ibritumomab tiuxetan RIT is the development of secondary malignancies, such as acute myelogenous leukemia (AML) and treatment-related myelodysplastic syndrome (MDS). Since the frequency of secondary malignancies

IV. Toxicity studies of RIT Patients with >25% bone marrow involvement are usually excluded from RIT because of risk of excessive hematologic toxicity. However, a dose-escalation study of tositumomab and 131I tositumomab in 11 patients with baseline bone marrow involvement of >25% and platelet count of >or=150,000/mm3 showed that RIT with attenuated dose 131I tositumomab had acceptable bone marrow toxicity and could result in lymphoma responses (Mones et al, 2007). The bio-distribution and tissue kinetics of 131I-rituximab, while specific to each patient, remained constant during unlabeled antibody therapy, indicating that RIT radiation doses could be reliably extrapolated from a preceding dosimetry study (Antonescu et al, 2005).

Toxicity of 90Y -ibritumomab tiuxetan RIT after combining data from 4 clinical trials for relapsed or refractory B-cell NHL showed median radiation absorbed doses of 7.42 Gy to spleen, 4.50 Gy to liver, 2.11 Gy to lung, 0.23 Gy to kidney, 0.62 Gy (blood-derived method) and 0.97 Gy (sacral image-derived method) to red marrow, and 0.57 Gy to total body (Wiseman et al, 2003a). A phase II trial of reduced-dose 90Y ibritumomab tiuxetan RIT in 30 patients with low-grade, follicular, or transformed Bcell NHL and mild thrombocytopenia showed median radiation absorbed doses were 0,48 Gy to red marrow, 3,93 Gy to liver, 5,22 Gy to spleen, 1,62 Gy to lungs, and 0,14 Gy to kidneys (Wiseman et al, 2003b).

Safety data from 349 patients in five studies of outpatient treatment with 90Y ibritumomab tiuxetan showed that infusion-related toxicities were grade 1 or 2 and primarily hematologic lasting 1-4 weeks but no significant organ toxicity was noted. Seven percent of patients were hospitalized with infection (3% with neutropenia) and 2% had grade 3 or 4 bleeding events.

Myelodysplasia or acute myelogenous leukemia was 315

Sioka and Fotopoulos: Immunotherapy and radioimmunotherapy for non-Hodgkin's Lymphoma refractory NHL employing rituximab 250 mg/m2 followed by ibritumomab tiuxetan 0.4 mCi/kg and high-dose BEAM chemotherapy with ASCT resulted in an improved outcome and estimated 2-year overall and progression-free survival of 67% and 52%, respectively (Shimoni et al, 2007). High-dose 90Y-ibritumomab tiuxetan could be combined safely with high-dose etoposide and cyclophosphamide without an increase in transplantrelated toxicity or delayed engraftment (Nademanee et al, 2005).

may increase with longer follow-up it is necessary to elucidate if they are due to 90Y ibritumomab tiuxetan or to the pretreatment with alkylating agents with or without external beam irradiation that these patients had received.

A dose of 0.2 mCi/kg ibritumomab tiuxetan appears to be safe and effective for patients with progressive disease after HDC and ASCT (Vose et al, 2007). The incidence of treatment-related MDS and AML after tositumomab and iodine 131I tositumomab administration to previously treated and untreated patients with NHL was similar to that expected on the basis of patients' prior chemotherapy for NHL (Bennett et al, 2005). In addition, there were no reported cases of either MDS or leukemia in the upfront study performed by Kaminski and colleagues suggesting that they may be related to prior therapies and not RIT (Kaminski et al, 2005). However, cytogenetic analysis before treatment with RIT should identify existing chromosomal aberrations in previously treated patients that would be at higher risk for MDS or AML (Czuczman et al, 2007).

VI. Conclusions NHL is a frequent tumor that occurs predominantly in the elderly. Prior to the introduction of the monoclonal antibodies, the standard treatment options for advanced disease included chemotherapy with or without external beam radiation. However, most chemotherapies may be too toxic for elderly patients and associated with increased risk of osteoporosis and fractures. Adding rituximab to the standard chemotherapies can improve outcome of aggressive NHL. RIT is a form of targeted radiation therapy that may add to our therapeutic options for patients whose NHL has failed prior treatment with chemotherapy and rituximab. Thus, RIT with radiolabeled anti-CD20 antibodies has become an important therapeutic option for relapsed or refractory follicular/low-grade, transformed and indolent NHL. The two agents currently approved by the US Food and Drug Administration, 131I tositumomab and 90Y ibritumomab tiuxetan, have demonstrated both efficacy and acceptable toxicity profiles. RIT can be used alone or in combination with chemotherapy in selected patient groups with relapsed NHL.

V. Radioimmunotherapy and chemotherapy 90 The anti-CD20 radioimmunoconjugates, Y 131 ibritumomab tiuxetan and I tositumomab can induce high durable response rates with limited toxicity, making them ideal candidates for use in autotransplantation. Thus, these agents can be combined with HDC prior to ASCT. The radioimmunoconjugates can either replace total body irradiation or augment standard chemotherapy regimens. A phase I trial of 131I tositumomab (up to 0.75 Gy) with HDC (carmustine, etoposide, cytarabine, and melphalan) and ASCT for relapsed NHL resulted in 57% CR rate and 65% overall response rate. With a median follow-up of 38 months the OS rate was 55%, and the event-free survival (EFS) rate was 39% (Vose et al, 2005). In a phase I/II trial of 131I-tositumomab followed by etoposide and cyclophosphamide and ASCT had estimated OS at 2 years of 83% and progression-free survival (PFS) of 68%, results which compared favorably with those in a nonrandomized control group of patients who underwent transplantation, external-beam total-body irradiation, and etoposide and cyclophosphamide therapy during the same period (Press et al, 2000). Similarly, a phase II trial of of CHOP chemotherapy followed by 131I tositumomab in 90 previously untreated patients with follicular non-Hodgkin's lymphoma was conducted by the Southwest Oncology Group, and the 2,3-year and five-year follow-up were reported to show superior results compared to previous treatment with CHOP alone (Press et al, 2003, 2006).

Specifically, in the 5-year follow-up study the overall response rate was 91%, including a 69% complete remission (CR) rate, and the estimated 5-year overall survival rate was 87%, and the progression-free survival rate was 67% (Press et al, 2006). An abbreviated chemotherapy with fludarabine followed by 131I tositumomab in 35 patients with untreated follicular lymphoma showed a 5-year estimated progression-free survival rate of 60% suggesting this regimen was effective as front-line therapy for follicular lymphoma (Leonard et al, 2005). Another study in 23 patients with chemotherapy

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Chrissa Sioka

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and

I

42

50.4

Gemcitabine weekly 250mg/m2

21

9.5

infusion 5-FU (200-300 mg/m2/day) with radiation (30 Gy delivered in 10 fractions), and 53 patients received gemcitabine (250-300 mg/m2) weekly over 7 weeks with the same radiation. There was no statistically significant improvement in median survival observed with short follow-up and there was significantly more toxicity encountered for the patients who received gemcitabine as compared to those receiving 5-FU (23% and 2%, respectively p=0.0001) (Crane et al, 2002).

and were associated with acceptable toxicity. A study from Ikeda and colleagues established the MTD for concurrent weekly gemcitabine to be 250 mg/m2, (Ikeda et al, 2002) and a subsequent phase II study using this chemoradiation dosing schedule, followed by maintenance gemcitabine demonstrated an encouraging median survival at 9.5 months (Okusaka et al, 2004), A similar experience utilized a 7 week gemcitabine induction therapy, followed by weekly gemcitabine delivered at a dose of 400 mg/m2 (3 out of every 4 weeks) concurrent with conventional radiation. The results were encouraging as 3 of the 10 patients were able to undergo pancreatectomy, and only fibrosis was found at the time of surgery in 1 patient (Epelbaum et al, 2002).

An ECOG phase I trial evaluated the safety of 7-day continuous infusion 5-FU and weekly gemcitabine delivered with conventional radiation therapy to a total dose of 59.4 Gy. Significant toxicity resulted in the trial being closed before accrual, and authors concluded that this regimen was not feasible (Talamonti et al, 2000). A similar phase I/II study using a 5-day continuous infusion 5-FU regimen given with weekly gemcitabine and external beam radiation (50.4 Gy), was tolerable at the MTD gemcitabine dose of 200 mg/m2 (Willett et al, 2005).

Discrepancies in toxicity between these two studies are thought to be related to the lower dose of radiation delivered, smaller radiation portals and that the continuous infusion 5-FU was delivered 5 days per week, not 7 days per week. Further evaluation of the safety of a 5-FUgemcitabine-radiation regimen for the treatment of locally advanced pancreatic cancer was demonstrated in a phase II CALGB and resulted in an encouraging median survival of over 12 months (personal communication H. Mamon).

To date there have been no randomized studies comparing 5-FU-based chemoradiation regimens with gemcitabine-based regimens for definitive treatment of locally advanced pancreatic cancer patients. Radiation Therapy Oncology Group (RTOG) 9704 compared 5-FUbased chemoradiation with a gemcitabine chemoradiation regimen in the post-operative setting, with a statistically significant improvement in survival demonstrated for the gemcitabine cohort (Regine et al, 2006). Although a large cooperative group study has not been performed in patients with locally advanced pancreatic cancer, one small phase III study compared gemcitabine-based chemoradiation to 5-FU-based chemoradiation by randomizing 34 patients to weekly concurrent gemcitabine (600 mg/m2) versus concurrent bolus 5-FU for 3 consecutive days delivered every 2 weeks with conventional radiotherapy followed by maintenance gemcitabine (all patients). A statistically significant improvement in median survival was observed in favor of the gemcitabine-based regimen (14.5 months versus 6.7 months) (Li et al, 2003). Conversely, a retrospective review of 114 patients with locally advanced pancreatic cancer at MD Anderson compared the relative benefit of using 5-FU versus gemcitabine concurrently with radiotherapy. Sixty-one patients received continuous

F. Radiation and the targeted therapies The use of specific targeted molecular and biologic therapies also may provide a synergistic or additive effect when combined with radiation in preclinical models.

Crane and colleagues at MD Anderson have established the feasibility of integrating the anti-vascular endothelial growth factor (VEGF) antibody, bevacizumab, into current chemoradiation strategies (Crane et al, 2006). Currently, an intergroup trial, lead by ECOG is pursuing an adjuvant trial of radiation plus bevacizumab and capecitabine, based upon the findings from the MD Anderson trial.

Sorafenib is a small molecule inhibitor of Raf kinase, platelet derived growth factor receptor kinase, and VEGF receptor kinase, which targets signal transduction and angiogenic pathways. This novel targeted therapy has been studied in a phase II study in combination with gemcitabine as first line therapy for patients with advanced pancreatic cancer and ECOG performance status 0-1. Gemcitabine was administered at 1000 mg/m2 on days 1, 8, and 15 on a 28 day schedule with sorafinib given 400 mg given twice daily on days 1 through 28. The regimen was tolerable, but, unfortunately, no objective responses were observed (Wallace et al, 2007).

Epidermal growth factor receptor inhibitors also demonstrate promising preclinical results when combined with radiation (Buchsbaum et al, 2002). A recent phase I trial combining erlotinib and chemoradiation utilized twice-weekly gemcitabine with conventional radiation followed by maintenance erlotinib (150 mg daily) in patients with locally advanced pancreatic cancer, and found the MTD for erlotinib to be 100 mg daily. Of the 8 patients treated using this regimen, 7 demonstrated stable disease, and 1 subsequently underwent resection (Kormansky et al, 2005). Another phase I study combined erlotinib with weekly gemcitabine (75 mg/m2), paclitaxel (40 mg/m2), and radiation followed by maintenance erlotinib (150 mg daily). The MTD of erlotinib using this regimen was reported to be 50 mg daily, and the median survival was an encouraging 15 months; 46% of patients demonstrated a partial response (Iannitti et al, 2005).

Given the disappointing results with targeted agents in advanced pancreatic cancer, it is not clear how these compounds will move forward, with or with radiation, in patients with earlier stage disease.

VI. Conclusions The treatment of patients with pancreatic cancer remains a challenge. Historically, the treatment for 349

Russo et al: The multidisciplinary treatment of non-metastatic pancreatic cancer Cohen L, Woodruff KH, Hendrickson FR, Kurup PD, Mansell J, Awschalom M, Rosenberg I, Ten Haken RK (1985) Response of pancreatic cancer to local irradiation with highenergy neutrons. Cancer 56, 1235-1241.

Colucci G, Giuliani F, Gebbia V, Biglietto M, Rabitti P, Uomo G, Cigolari S, Testa A, Maiello E, Lopez M (2002) Gemcitabine alone or with cisplatin for the treatment of patients with locally advanced and/or metastatic pancreatic carcinoma: a prospective, randomized phase III study of the Gruppo Oncologia dell'Italia Meridionale. Cancer 94, 902â&#x20AC;&#x201C; 910 Crane C, Ellis L, Abbruzzese J, Amos Z, Xiong HQ, Ho L, Evans DB, Tamm EP, NG C, Pisters PW, Charnsengavej C, Delclos ME, OReilly M, Lee JE, Wolff RA (2006) Phase I trial of bevucizumab (BV) with concurrent radiotherapy (RT) and capecitabine (CAP) in locally advanced pancreatic adenocarcinoma (PA). J Clin Oncol 24, 1145-1151.

Crane CH, Abbruzzese JL, Evans DB, Wolff RA, Ballo MT, Delclos M, Milas L, Mason K, Charnsangavej C, Pisters P, Lee J, Lenzi R, Vauthey J, Wong AB, Phan T, Nguyen Q, Janjan NA (2002) Is the therapeutic index better with gemcitabine-based chemoradiation than with 5-fluorouracilbased chemoradiation in locally advanced pancreatic cancer?

Int J Radiat Oncol 52, 1293-302.

Crane CH, Antolak JA, Rosen II, Forster KM, Evans DB, Janjan NA, Charnsangavej C, Pisters PW, Lenzi R, Papagikos MA, Wolff RA (2001) Phase I study of concomitant gemcitabine and IMRT for patients with unresectable adenocarcinoma of the pancreatic head. Int J Gastrointest Cancer 30, 123-132.

Crane CH, Janjan NA, Evans DB, Wolff R, Ballo M, Milas L, Mason K, Charnsangavej C, Pisters P, Lee J, Lenzi R, Vauthey J, Wong A, Phan T, Nguyen Q, Abbruzzese J (2001) Toxicity and efficacy of concurrent gemcitabine and radiotherapy for locally advanced pancreatic cancer. Int J Pancreatol 29, 9-18.

Cunningham D, Chau I, Stocken D, Davies C, Dunn J, Valle D, Snith D, Steward W, Harper P, Neoptolemos J (2005) Phase III Randomized comparison of gemcitabine versus gemcitabine plus capecitabine in patients with advanced pancreatic cancer. European J Cancer 3 (4), 4 (abstract).

Dobelbower RR Jr, Merrick HW 3rd, Ahuja RK, Skeel RT (1986) 125I interstitial implant, precision high-dose external beam therapy, and 5-FU for unresectable adenocarcinoma of pancreas and extrahepatic biliary tree. Cancer 58, 21852195.

Douglass HO (1987) Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Gastrointestinal Tumor Study Group. Cancer 59, 2006-2010.

Epelbaum R, Rosenblatt E, Nasrallah S, Faraggi D, Gaitini D, Misrahi S, Kuten A (2002) Phase II study of gemcitabine combined with radiation therapy in patients with localized, unresectable pancreatic cancer. J Surg Oncol 81, 138-143.

Evans D, Abbruzzese J, Willett C (2001) Cancer of the Pancreas.

Philadelphia, Lippincott Williams and Wilkins.

Fields MT, Eisbruch A, Normolle D, Orfali A, Davis MA, Pu AT, Lawrence TS (2000) Radiosensitization produced in vivo by once- vs. twice-weekly 2'2'-difluoro-2'deoxycytidine (gemcitabine) .Int J Radiat Oncol Biol Phys 47, 785-791.

Garton GR, Gunderson LL, Nagorney DM, Donohue JH, Martin JK, McIlrath DC, Cha SS (1993) High-dose preoperative external beam and intraoperative irradiation for locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys 27, 1153-1157.

Gastrointestinal Tumor Study Group (1998) Treatment of locally unresectable carcinoma of the pancreas: A comparison of combined modality therapy (chemotherapy plus

resected and locally advanced disease usually consists of 5-fluorouracil (5-FU, either bolus or continuous infusion) and external beam radiation. Recent studies now demonstrate that gemcitabine either used alone or in combination with other agents such as oxaliplatin, or erlotinib and/or external beam radiation may improve outcomes in objective response rates but with only a modest improvement in survival. Future clinical trial strategies in pancreatic cancer may require a paradigm shift, given the modest progress observed to date with conventional approaches.

References Al-Abdulla AS, Hussey DH, Olson MH, Wright AE (1981) Experience with fast neutron therapy for unresectable carcinoma of the pancreas. Int J Radiat Oncol Biol Phys 7, 165-1672.

American Cancer Society Cancer Facts and Figures (2007) American Cancer Society 2007. http://www.cancer.org/downloads.

Ben-Josef E, Shields AF, Vaishampayan U, Vaitkevicius V, ElRayes BF, McDermott P, Burmeister J, Bossenberger T, Philip PA (2004) Intensity-modulated radiotherapy (IMRT) and concurrent capecitabine for pancreatic cancer. Int J Radiat Oncol Biol Phys 59, 454-459.

Berlin JD, Catalano P, Thomas JP, Kugler JW, Haller DG,Benson AB (2002) Phase III study of gemcitabine in combination with fluorouracil versus gemcitabine alone in patients with advanced pancreatic carcinoma: Eastern Cooperative Oncology Group trial E2297. J Clin Oncol 20, 3270-3275 Blackstock AW, Bernard SA, Richards F, Eagle KS, Case LD Poole ME, Savage PO, Tepper, JE (1999) Phase I trial of twice-weekly gemcitabine and concurrent radiation in patients with advanced pancreatic cancer. J Clin Oncol 17, 2208-2212.

Blackstock AW, Mornex F, Partensky C, Descos L, Case LD, Melin SA, Levine EA, Mishra G, Limentani SA, Kachnic LA, Tepper JE (2006) Adjuvant gemcitabine and concurrent radiation for patients with resected pancreatic cancer: a phase II study. Br J Cancer 95, 260-265.

Blackstock AW, Tepper JE, Niedwiecki D, Hollis DR, Mayer RJ, Tempero MA (2003) Cancer and leukemia group B (CALGB) 89805: phase II chemoradiation trial using gemcitabine in patients with locoregional adenocarcinoma of the pancreas. Int J Gastrointest Cancer 34, 107-116.

Buchsbaum DJ, Bonner JA, Grizzle WE, Stackhouse MA, Carpenter M, Hicklin DJ, Bohlen P, Raisch KP (2002) Treatment of pancreatic cancer xenografts with Erbitux (IMC-C225) anti-EGFR antibody, gemcitabine, and radiation. Int J Radiat Oncol Biol Phys 54, 1180-1193.

Burris HA 3rd, Moore MJ, Andersen J, Green MR, Rothenberg ML, Modiano MR, Cripps MC, Portenoy RK, Storniolo AM, Tarassoff P, Nelson R, Dorr FA, Stephens CD, Von Hoff DD (1997) Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. J Clin Oncol 15, 24032413.

Chauffert B Mornex F, Bonnetain F, Triboulet JB, Bouche O, Rougier P (2006) Phase III trial comparing chemoradiotherapy (intermittent cisplatin and infusional 5FU) followed by gemcitabine vs. gemcitabine alone in patients with locally advanced non metastatic pancreatic cancer: A FFCD-SFRO study (Abst 4008. presented at 2006 ASCO annual meeting). J Clin Oncol 24(18S part 1)

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Cancer Therapy Vol 6, page 341 Cancer Therapy Vol 6, 341-354, 2008

The multidisciplinary treatment of non-metastatic pancreatic cancer: a review Review Article

Suzanne Russo1, Roger Ove1, A. William Blackstock2,* 1 2

East Carolina University Brody School of Medicine, Greenville NC Wake Forest University School of Medicine, Winston-Salem, NC

__________________________________________________________________________________ *Correspondence: A. William Blackstock MD, Professor - Department of Radiation Oncology, Wake Forest University Comprehensive Cancer Center, Winston-Salem, NC US 27157, USA; Tel: 336-713-6560; Fax: 336-713-6565; e-mail: ablackst@wfubmc.edu Key words: Pancreatic Cancer, Locally-Advanced, Chemotherapy, Radiation, Targeted Therapies Abbreviations: 5-Fluorouractil, (5-FU); American Joint Committee on Cancer, (AJCC); American Society for Clinical Oncology, (ASCO); Cahrite Onkologie Clinical Studies in GI Cancers, (CONKO); computed tomography, (CT); Endoscopic ultrasound, (EUS); Epidemiology and End Result, (SEER); European Study Group of Pancreatic Cancer, (ESPAC); Federation Francophone de Cancerologie Digestive and Societe Francaise de Radiotherapie Oncologique, (FFCD-SFRO); fine needle aspiration, (FNA); Gastrointestinal Tumor Study Group, (GITSG); Group dâ&#x20AC;&#x2122;Etude et de Recherche en Cancerologie Onco-radiotherapie, (GERCOR); intensity-modulated radiation therapy, (IMRT); intraoperative electrons, (IOERT); Italian Group for the Study of GastroIntestinal Tract Cancers, (GISCHAD); magnetic resonance imaging, (MRI); Positron Emission Tomography, (PET); Protracted venous infusion, (PVI); Radiation Therapy Oncology Group, (RTOG); Southwest Oncology Group, (SWOG); vascular endothelial growth factor, (VEGF) Received: 8 June 2007; Revised: 11 September 2007 Accepted: 15 December 2007; electronically published: June 2008

Summary The treatment of pancreatic cancer remains a clinical challenge despite advances in the understanding of the molecular and genetic basis of this deadly disease. Mortality remains high, as it is anticipated that there will be 33,730 new cases of pancreatic cancer diagnosed in the U.S. in this year, resulting in approximately 32,300 deaths.

At the time of diagnosis, most patients are found to have distant metastases. Less than 20% are found to have tumors amenable to resection, and approximately 40% of patients will present with locally advanced, nonmetastatic disease. For resectable tumors, surgery followed by chemotherapy with or without radiation is considered standard of care, although there is substantial controversy surrounding the appropriate adjuvant treatment modalities. Chemotherapy alone or concurrent chemoradiation are currently the recommended treatments for those patients with non-metastatic unresectable pancreatic cancer. Unfortunately, in most cases patients ultimately succumb to distant metastases. Gemcitabine has emerged as the standard chemotherapy for pancreatic cancer. Recent studies have evaluated new approaches usually in combination with gemcitabine. In an attempt to improve standard chemoradiation treatment regimens, clinical studies have been designed to evaluate whether incorporating cytotoxic chemotherapeutic agents with radiation sensitizing properties, and/or integration of novel therapies that utilize targeted molecular therapies into standard treatment regimens, have the potential to improve patient outcome. This review summarizes the current status, and future directions of treatment of nonmetastatic pancreatic cancer.

cancer, and there has been little improvement in survival observed in the past 20 years (Evans et al, 2001; American Cancer Society Cancer Facts and Figures 2007) for all stages combined, the 1-year relative survival rate is 20%, and the 5-year relative survival rate is only 4%.

Only treatment regimens that include surgery are considered curative for patients with pancreatic cancer, and less than 20% have tumors that are considered resectable at the time of diagnosis. Approximately 60% of all pancreatic cancer patients will have clinically or

I. Introduction Adenocarcinoma of the pancreas is the fourth leading cause of cancer death in the United States with the lowest five-year survival rate of any cancer. In 2007, it is projected that an estimated 37,170 new cases of pancreatic cancer will be diagnosed in the U.S., resulting in approximately 33,370 deaths from the disease (American Cancer Society Cancer Facts and Figures 2007. American Cancer Society 2007). Mortality rates closely follow incidence rates because of the poor prognosis of pancreatic 341

Russo et al: The multidisciplinary treatment of non-metastatic pancreatic cancer radiographically detectable metastatic disease at the time of diagnosis, while the majority of the remaining patients will have locally advanced unresectable disease.

while 20% of patients had no lymph nodes examined. Of patients who had lymph nodes reported in the pathology report, 41% demonstrated no metastases, and 51% were found to have N1 disease. Median survival was 12 and 5 months, respectively for patients with N0 versus patients with N1 disease. A multivariate analysis identified prognostic factors (p=0.01) for poor survival including advanced tumor stage, grade and size > 2 cm, number of lymph nodes examined and N1 disease. Patients with N0 disease could be further stratified based on the number of lymph nodes examined. If less than 12 lymph nodes were examined, 5 year overall survival was found to be 15% compared to 30% for 12 or more lymph nodes (Pawlik et al, 2007).

Local failure has also been reported to be significant (Tepper et al, 1976; Whittington et al, 1991). Due to anatomic constraints to wide posterior margins, pathologic examination of the posterior pancreatic soft tissue margin demonstrates microscopic residual tumor in approximately 38% of patients undergoing curative resection (Willett et al, 1993). Survival with surgical resection is reported to be 48% at 1-year), 24% at 2-years, and 17% at 3-years using a multimodality approach, compared to 23% (1-year), 9% (2-year), 6% (3-year) without resection (Lillemoe, 1995).

Effect of margin status has been shown to effect patient outcome. Data published from Massachusetts General Hospital reported that 37 of 72 patients (51%) had margins involved with tumor after surgery; 38% in peripancreatic soft tissue, 19% at the pancreatic transection line, and 6% at the bile duct margin. The 2-year overall survival and local control for those patients with positive margins were reported to be 18% and 44%, respectively, compared to 37% and 60%, for those with uninvolved margins (Willett et al, 1993).

II. Resectable pancreatic cancers A. Surgery Surgical resection is part of the multimodality treatment approach for patients with non-metastatic, locally advanced adenocarcinoma of the pancreas, and currently represents the only curative treatment strategy.

“Resectability” has no universally accepted criteria, however it is generally believed that there is no role for surgery in patients with visceral, distant nodal, or peritoneal metastases (M1). In most cases, resectability depends on whether the tumor has invaded major vascular structures +/- presence of extrapancreatic tumor. Usually, direct extension into the superior mesenteric artery (SMA), celiac axis, hepatic arteries, or mesenteric vein, preclude resection. Most surgeons require a patent superior mesenteric vein (SMV), portal vein, and less than 50% circumferential encasement of major vessels.

A pylorus-sparing pancreaticoduodenectomy (Whipple procedure) is considered the standard surgical procedure for patients with resectable pancreatic cancers.

The procedure incorporates removal of the head of pancreas and adjacent lymph nodes, removal of distal stomach, duodenum, proximal jejunum, gall bladder, and common bile duct, with inspection of the liver and peritoneum with biopsy, if appropriate, and a Roux en Y anastamosis with choledochojejunostomy, pancreaticojejunostomy and gastrojejunostomy. The surgical literature would suggest that this procedure is associated with a 3% operative mortality and 40% operative morbidity (Yeo et al, 1997).

Institutions differ in their approach to patients with regional nodal (N1) disease. Patients with regional lymph node involvement are suitable for resection (if technically feasible) and some long-term survivors have been reported (Yeo et al, 1999). Another study randomized 81 patients who underwent definitive surgery without adjuvant therapy to pancreaticoduodenectomy with “standard” lymph node dissection (removal of the anterior and posterior pancreatoduodenal, pyloric, and biliary duct, superior and inferior pancreatic head, and body lymph node stations) versus “extended” lymph node dissection (hepatic hilum and along the aorta from the diaphragmatic hiatus to the inferior mesenteric artery and laterally to both renal hila, with circumferential clearance of the origin of the celiac trunk and superior mesenteric artery). Although there was no significant benefit to the extended dissection for the entire group, an unplanned subgroup analysis showed that node-positive patients undergoing extended resection had outcome similar to node-negative patients (Pedrazzoli et al, 1998).

More recently, Pawlik and collegaues reported that the number of lymph nodes examined was also predictive of survival in an analysis of 3306 patients from the Surveillance, Epidemiology and End Result (SEER) database. Of the 2629 patients who had lymph nodes examined, the median number of lymph nodes was 6,

B. Adjuvant chemotherapy Because both local and distant failures are common after curative resection, may clinical trials have addressed the utility of adjuvant treatments to improve patient outcome. Survival and quality of life are the most objective endpoints for evaluating efficacy of treatment.

Only 2 chemotherapeutic agents (5-fluorouracil and gemcitabine), and 1 targeted therapy (erlotinib) have produced survival benefits in advanced pancreatic adenocarcinoma patients, and have been, or are being investigated in the adjuvant setting, with or without other agents or adjuvant radiation.

A recent study performed by Cahrite Onkologie Clinical Studies in GI Cancers (CONKO 001) randomized patients after resection (R0 or R1) to gemcitabine versus observation. With a median follow-up of 53 months, the overall survival was reported to be 22.1% for the gemcitabine arm compared to 20.2% in the observation arm, which was not statistically significant. The median disease free survival was 13.4 months for gemcitabine versus 6.9 months for observation (p < 0.001). The recurrence rate was 74% for gemcitabine, and 92% for observation, and the estimated disease free survival at 3 and 5 years was 23.5% and 7.5% respectively, for gemcitabine, and 16.5% and 5.5% respectively for observation arm (Oettle et al, 2007). Other similar trials 342

Cancer Therapy Vol 6, page 343 evaluating newer chemotherapeutic and targeted drugs are currently being investigated in patients who have undergone curative resection, however, the potential benefits of this strategy have yet to be defined in the adjuvant setting.

chemoradiotherapy is not warranted, although favorable results were observed for patients with periampullary tumors, who demonstrated a median survival of 40 months, and a 5-year overall survival of 37%. However, a statically significant improvement in median survival (17.1 months versus 12.6 months), 2-year overall survival (37% versus 23%), and 5-year overall survival (20% versus 10%) was demonstrated for those patients with pancreatic head tumors receiving adjuvant therapy (p=0.09) (Klinkenbijl JH et al, 1999). The criticisms of this study are that the use of maintenance chemotherapy was not incorporated, of 104 patients randomized to adjuvant therapy and eligible for analysis, 10 refused treatment, 11 did not receive treatment for other reasons (only 83 of 104 patients, 80%, received the prescribed therapy), and the benefit of adjuvant treatment was diluted by including large numbers of periampullary cancers.

Similarly, another randomized trial performed by the European Study Group of Pancreatic Cancer (ESPAC) demonstrated no benefit for the use of radiation therapy in the postoperative setting. In this study, 541 patients with pancreatic adenocarcinoma only, who underwent gross total resection, were stratified by treatment center and margin status. Nineteen percent of patients were documented to have positive margins in 19%; and 53% had involved lymph nodes. The randomization scheme included a 2-by-2 factorial design to address the separate questions of treatment with and without chemotherapy and with and without radiotherapy. However, to be pragmatic they expanded the trial to allow additional randomizations for chemoradiotherapy and for chemotherapy only.

Chemoradiotherapy consisted of 40 Gy with 2 week break after 20 Gy, with 5-FU bolus (500 mg/m2) x 3 days, repeated for a second course during radiotherapy, or bolus 5-FU (425 mg/m2) / leucovorin x 5 days; repeated every 28 days for 6 cycles if given without radiation. To make the study even more pragmatic the clinicians were allowed to choose the randomization options, and were able to give additional â&#x20AC;&#x153;backgroundâ&#x20AC;? treatment (patients randomized to no chemoradiotherapy could get background chemotherapy and patients randomized to chemotherapy only could get background radiotherapy). Background therapy was given in 47% of those randomized to chemoradiation, 45% of those randomized to no chemoradiation, 38% of those randomized to chemotherapy, and 40% of those randomized to no chemotherapy. Despite the allowance of background therapy 51 patients (9%) had protocol violations, 25 patients refused their randomized treatment and 25 patients withdrew after beginning treatment. The first analysis of results with a median follow-up of 10 months revealed 314 deaths (58%), and no benefit for the chemoradiation arm with a median survival of 15.5 months with treatment versus 16.1 months without (hazard ratio 1.18, p=0.24), and a benefit for chemotherapy with a median survival of 19.7 months with treatment versus 14 months without (hazard ratio 0.66, p=0.0005). For the two-by-two factorial analysis, the chemoradiation arm similarly showed no benefit with a median survival of 15.8 months with treatment versus 17.8 months without (hazard ratio 1.30, p=0.09), and a trend in favor of chemotherapy

C. Adjuvant chemoradiation The justification for the use of adjuvant radiation after definitive surgery is based on the published patterns of failure data demonstrating a substantial local failure rate. Early studies investigated the use of adjuvant radiation with or without concurrent chemotherapy but interpretation of these data are limited by the small patient numbers, split-course fractionation schedule, and radiation treatment portals based on bony anatomy in the pre-CT radiation treatment planning era. Despite these limitations, Gastrointestinal Tumor Study Group (GITSG) trials randomizing patients to adjuvant therapy demonstrated significant improvement in survival for those patients receiving chemoradiation postoperatively. Forty-three resected patients with negative margins, and no peritoneal metastases found at the time of surgery were randomized to external beam radiotherapy (EBRT; 40 Gy split course with 2 week break after 20 Gy) and 5-fluorouracil (5-FU; FU (500 mg/m2) bolus on days 1-3 of each cycle; then weekly x 2 yrs beginning 1 month after XRT) versus no adjuvant treatment. The median survival, overall survival and rate of distant metastases for the adjuvant therapy arm was 20 months, 43% (2-year), 19% (5-year), and 40%, respectively, compared to 11 months, 15% (2-year), 5% (5-year), and 52% for the surgery alone arm (Kalser and Ellenberg, 1985). A nonrandomized confirmatory GITSG study was performed on an additional 30 patients, receiving the same adjuvant therapy after surgery as the initial study. The median survival for these patients was reported to be 18 months, the 2-year overall survival was 43%, and the 5-year overall survival was 17%, similar to the previous randomized data (Douglass, 1987). In the randomized study, 4 of 21 patients receiving adjuvant therapy survived greater than 5 years (5.1, 9.0, 10.2, and 11.2 years), but all of the 22 patients randomized to no adjuvant treatment, had died of pancreatic cancer at 5 years.

More recently, an European Organization of Research and Treatment of Cancer (EORTC) adjuvant pancreatic cancer trial randomized 218 pts (55% T1-2 N01a pancreas; 45% T1-3 N0-1a periampullary) to receive chemoradiation (40 Gy with 2 wk break after 20 Gy, and 5-FU (25 mg/kg) 24-hr continuous infusion with each course of XRT for up to 5 days, without maintenance chemotherapy) versus no adjuvant treatment. Twenty-one percent of the patients were found to have positive margins and 50% had lymph nodes involved with tumor.

The median progression free survival was reported to be 17.4 months with adjuvant treatment compared to 16 months without (NS). The median survival was 24.5 months with treatment versus 19 months without, and the 2 and 5 year overall survival were 51% and 28% for the patients receiving postoperative chemoradiation versus 41%, and 22% for those who did not (NS). The conclusion of this trial was that routine use of adjuvant 343

Russo et al: The multidisciplinary treatment of non-metastatic pancreatic cancer with a median survival of 17.4 months with therapy versus 15.9 months without (hazard ratio 0.82, p=0.19) (Neoptolemos et al, 2001).

The final analysis of this study was based on the 289 patients randomized only by the two-by-two factorial design plus 4 new patients since the last report. The median follow-up of living patients was 47 months with 237 deaths (82%). Chemoradiation was determined to be detrimental with a median survival of 15.9 months with treatment compared to 17.9 months without. The 2-year overall survival was reported to be 29% with chemoradiation versus 41% without and the 5-year overall survival was 10% with chemoradiation versus 20% without (hazard ratio 1.28, p=0.05). Once again, chemotherapy was thought to be beneficial in the adjuvant setting with median survival at 20.1 months with versus 15.5 months without, 2-year overall survival at 40% with treatment versus 30% without, and 5-year overall survival at 21% with treatment versus 8% without (hazard ratio 0.71, p=0.009). Median survival was reported for observation, chemoradiation, chemotherapy alone and combined treatment at 16.9, 13.9, 21.6, and 19.9 months respectively, and 5-year overall survival was 11%, 7%, 29%, and 13% respectively (Neoptolemos et al, 2004).

Criticisms of this trial included the complicated design that did not attempt to compare combined modality treatment against observation but looked at the singular effects of chemotherapy and chemoradiation separately, protocol violations with many patients receiving therapy other than that assigned, the median time from resection to start of treatment was lengthy (on average 46 days for chemotherapy and 61 days for chemoradiation), and chemoradiation may have interfered with subsequent chemotherapy as 33% did not complete the protocol and 17% received no chemotherapy at all. A subsequent ESPAC-3 trial is currently randomizing patients following resection to 5-FU with folinic acid and gemcitabine or observation. No radiotherapy is included in this trial.

As a result, data evaluating the routine use of adjuvant chemoradiation is controversial due to the problems in statistical interpretation, the lack of quality control, and high rate of non-adherence to the randomized treatment. Further studies are needed to clarify the optimum adjuvant treatment. A population-based study has recently been reported to help clarify whether the addition of radiation in the adjuvant setting improves overall survival. SEER registry data was utilized, and patients with stage I or II pancreatic cancer who received perioperative or intraoperative radiation as a component of treatment between 1973 and 2003 were evaluated. 1124 patients received adjuvant radiation and 1513 did not.

Kaplan-Meier methods and the log-rank test were used for survival data. Cox regression model was tested for gender, race, grade, age over 60, and stage. With a median followup of 19 months, the data demonstrated that patients who received radiation had a statistically significant increase in median survival compared to those who did not; 18 months compared to 11 months, p<0.01). Additionally the Cox regression analysis demonstrated that patients receiving radiation had an increase in overall survival compared to those who did not (HR 0.57, 95% CI: 0.52-

0.63, p<0.01). Significant (p<0.01) prognostic factors for decreased survival included race, black compared to white, moderately and poorly differentiated tumors, increased stage, and age >60 years (Greco et al, 2007). One must acknowledge the inherent limitations of a SEER analysis and interpret these data cautiously.

Despite the controversy surrounding the benefit of routine incorporation of radiation therapy in the postoperative setting, recent clinical trials based in the United States continue to include radiotherapy as part of the adjuvant treatment regimen (Blackstock et al, 2006).

The Radiation Therapy Oncology Group (RTOG) recently reported the results of the RTOG-9704 phase III study at the 2006 American Society for Clinical Oncology (ASCO) meeting, in which 442 pancreatic cancer patients received sandwich therapy (3 weeks chemotherapy followed by continuous infusion 5-FU and concurrent radiation, then 12 weeks further chemotherapy) after curative resection.

Patients with T1-4, N0-1, M0 adenocarcinomas (381 pancreatic head cancers) were randomized to either 5-FU or gemcitabine before and after concurrent chemoradiation. More T3/4 tumors were treated in the gemcitabine arm. The ability to complete prescribed therapy and the non-hematologic toxicities were similar between the two treatment arms. The hematologic toxicity was greater in the gemcitabine arm (14% versus 2%). The median and 3-year survival for the 5-FU group were 10.6 months and 21%, respectively, versus 36.9 months and 32% for the gemcitabine group (p=0.0047). No statistically significant difference was reported for body and tail tumors. The conclusions of this trial were that gemcitabine improves survival for pancreatic head tumors, with an increase in manageable hematologic toxicity, and that gemcitabine should be considered a new standard treatment in the adjuvant setting (Regine et al, 2006).

III. Potentially resectable pancreatic cancer It is proposed that borderline-resectable pancreatic cancer whose tumors exhibit encasement of a short segment of the hepatic artery, short-segment occlusion of the superior mesenteric vein, portal vein, or their confluence, without evidence of tumor extension to the celiac axis with <180 degrees of the circumference of the superior mesenteric artery may be amenable to resection because normal tissue planes exist above and below the area of tumor involvement, and vascular reconstruction may be a suitable option (Varadhachary et al, 2006). With currently available surgical techniques, these patients are at high risk for a margin-positive resection, therefore, a treatment strategy utilizing preoperative chemoradiation designed to address the potential for systemic disease and maximize the potential for an R0 resection is promising.

Single institution studies demonstrate the feasibility of this approach with promising results, however, there have been no randomized studies evaluating the use of neoadjuvant chemoradiation for this subset of patients to date. This treatment strategy, therefore, should be offered in a clinical trial setting as it is not currently considered standard of care. Theoretically, the potential benefits of this approach include no delay in treatment (unlike 344

Cancer Therapy Vol 6, page 345 adjuvant therapy), selection of a subset of patients who do not have occult metastases at diagnosis and/or biologically aggressive tumors that do not respond to therapy, radiation treatment in a more adequately oxygenated environment, and the possibility of allowing for more patients to undergo resection depending on treatment response. In general, tumor response rates using this approach are low.

However, in one study, the resection of a borderline resectable tumor was successfully accomplished in onethird of cases. Chemoradiotherapy did not increase the operative risk, but the surgery proved more technically difficult and required a longer postoperative stay. Patients resected after chemoradiation for locally advanced disease had at least the same survival as those patients resected for localized cancer, and only R0 resections in both groups provided the opportunity for a disease-free survival longer than 24 months (Massucco et al, 2006).

IV. cancer

Locally

advanced

gastric or small bowel obstruction, intra-abdominal abscess, and deep vein thrombosis/pulmonary embolism were also reported as complications associated with radiation dose escalation using interstitial brachytherapy containing treatment regimens (Dobelbower et al, 1986; Peretz et al, 1989; Mohiuddin et al, 1995).

Fast neutron particle beam therapy with or without external beam radiation and 5-FU has also been evaluated to determine whether local control can be improved in patients with locally advanced pancreatic cancer (AlAbdulla et al, 1981; Smith et al, 1981; Cohen L et al, 1985). The RTOG performed a randomized trial in 49 patients, who received either 64 Gy standard radiation (photons) versus an equivalent dose with neutron therapy, or combined photons and neutrons. No significant difference in median survival or local control was observed between the groups, however, life-threatening gastrointestinal or hepatic toxicity was observed for patients receiving neutron therapy (Thomas et al, 1989).

Another trial randomized locally advanced pancreatic cancer patients to either helium ion radiation therapy (60 to 70 Gy equivalent dose) or split-course standard photon radiation (60 Gy), with or without 5-FU. A slight improvement in median survival was observed for the patients receiving helium ions (7.8 months versus 6.5 months) but the results did not warrant further investigation (Linstadt et al, 1988).

Modern radiation technologies are now routinely used in an attempt to improve the outcome for patients with pancreatic cancer. Three-dimensional conformal radiotherapy, using CT-based treatment planning to optimize tumor targeting, beam orientation and weighting, to reduce the dose to surrounding normal tissues, and intensity-modulated radiation therapy (IMRT) further refines this approach using â&#x20AC;&#x153;inverse treatment planningâ&#x20AC;?, permitting computerized optimization of a radiation treatment plan. IMRT is currently being investigated in clinical trials for the treatment of a variety of intraabdominal malignancies, including pancreatic cancer (Crane et al, 2001; Landry et al, 2002; Milano et al, 2004).

Stereotactic radiosurgery (SRS) is another method of precisely delivering radiation to a targeted area, which incorporates the use of a body frame for immobilization and a linear accelerator that delivers a single large fraction of external beam radiation, often in conjunction with IMRT. Two phase II trials have evaluated the use of SRS as a boost (Koong et al, 2005) or hypofractionated radiotherapy (Hoyer et al, 2005) following conventionally fractionated EBRT in patients with locally advanced pancreatic cancer. SRS used as a boost was found to result in local control in 15 of 16 patients, with only 2 patients experiencing significant toxicity, but survival was not impacted (Koong et al, 2005). SRS used as hypofractionated treatment (45 Gy delivered in 3 fractions over 5 to 10 days) resulted in a 9% partial radiographic response rate, but unacceptable toxicity was observed putting into question this strategy in this clinical setting (Hoyer et al, 2005). In summary, while improvements in delivery of local radiation therapy are important, the impact on outcome for patients with locally advanced pancreatic cancer is unclear.

pancreatic

Traditionally chemotherapy alone, external beam irradiation alone, radiation in combination with chemotherapy, intraoperative radiation therapy (IORT) or radioactive seed implantation have been used for the treatment of locally advanced, unresectable pancreatic cancer.

A. Radiation therapy alone External Beam Radiation Therapy (EBRT) alone is sometimes used to palliate obstructive symptoms and pain caused by pancreatic cancer (Minsky et al, 1988).

However, EBRT (40 to 60 Gy) used alone results in a local failure rate exceeding 70% (Roldan et al, 1988) and is inadequate therapy for tumor control. Because local failure remains a problem with conventional external beam radiotherapy used with or without chemotherapy, radiation techniques that increase the radiation dose to only the tumor volume have been explored in attempt to improve local control without increasing normal tissue toxicity.

Permanent Iodine-125 radioactive seed implantations (Shipley et al, 1980; Syed et al, 1983) and intraoperative electrons (IOERT) (Wood et al, 1982; Shipley et al, 1984) have been used as a dose-escalation technique in combination with chemotherapy and external beam radiation. These techniques allow for direct visualization and delivery of radiation to the tumor, while defining the target volume. Data from single institution studies indicate that IOERT used at appropriate doses can be used safely and results in an improvement in local control when compared to conventional external beam techniques (Wood et al, 1982; Shipley et al, 1984; Tepper et al, 1987, 1991; Garton et al, 1993; Sindelar et al, 1999; Willett et al, 2005a,b). Interstitial brachytherapy using Iodine-125 or Palladium-103 has been used for the treatment of unresectable pancreatic cancer alone or in combination with external beam radiation with and without 5-FU. Two of three studies evaluating the use of brachytherapy in this setting reported palliation of pain in approximately 60% of patients, and one study reported an 84% local control rate.

Unfortunately, gastrointestinal bleeding, fistula formation,

345

Russo et al: The multidisciplinary treatment of non-metastatic pancreatic cancer demonstrated clinical benefit for patients with advanced metastatic disease and is the first drug approved by the FDA based on quality of life indicators (Burris HA 3rd et al, 1997). It offers improvement of tumor-related symptoms and marginal survival advantage for patients with advanced pancreatic cancer, resulting in improved overall quality of life.

Recent studies have evaluated novel agents a in combination with gemcitabine. ECOG 6201 compared overall survival of standard gemcitabine delivered at 1000mg/m2/30 minute infusion weekly for 7 of 8 weeks, with fixed dose rate infusion (FDR) at 1500 mg/m2/150min weekly for 3 of 4 weeks, or gemcitabine delivered at 1000mg/m2/100 minutes on day 1 plus oxaliplatin at 100mg/m2 on day 2 delivered every 14 days (GemOx). In this study, 833 patients with advanced pancreatic cancer (88% with distant metastatic disease) with a median follow-up of 5.7 months were stratified by ECOG performance status 0-1 versus 2, and locally advanced versus metastatic disease. Prior 5-FU and radiation therapy were allowed. Grade 3 and 4 toxicity was increased in the FDR (heme) and GemOx (neuro) groups. Both FDR and GemOX result in 1 month longer median survival than 30 min infusion gemcitabine (6.0 months, 6.5 months, and 5.0 months, respectively).

However, median survival was slightly lower than other gemcitabine trials. In addition, survival was lower for patients with metastatic disease (5.4 mo) than locally advanced disease (9.1 mo), indicating the need to study these patient groups separately in future clinical trials (Poplin et al, 2006).

A pooled analysis of 2 randomized trials was performed by Group dâ&#x20AC;&#x2122;Etude et de Recherche en Cancerologie Onco-radiotherapie (GERCOR) and Italian Group for the Study of GastroIntestinal Tract Cancers (GISCHAD) in which 252 patients received gemcitabine plus oxaliplatin or cisplatin, and 251 patients received gemcitabine alone. There was a similar distribution of ECOG performance status 0, grade 3 histology, and stage 4 disease between the 2 groups. The meta-analysis results demonstrate a statistically significant improvement in progression free survival, and a non-significant trend for improvement in overall survival for the combination chemotherapy arm. Upon subset analysis, ECOG performance status 0 patients achieve a greater benefit for both progression free and overall survival with gemcitabine and a platinum compound compared to gemcitabine alone, and stage of disease and performance status were identified as important prognostic factors (Louvet et al, 2005). In addition to the aforementioned study, a recently reported phase III study compared the efficacy of gemcitabine plus capecitabine versus gemcitabine alone in advanced pancreatic cancer showing an improvement in overall survival for patients in good performance status (Herrmann et al, 2007). Cunningham and colleagues reported in 2005 a similar improvement in overall survival for all patients treated with gemcitabine plus capecitabine versus gemcitibaine alone, however this study has only been reported as an interim analysis in abstract form.

B. Chemotherapy alone Many patients with locally advanced pancreatic cancer are medically unable to tolerate the side effects of combined modality therapy. Clinical studies evaluating the utility of chemotherapy alone for the treatment of locally advanced pancreatic cancer have been reported. The first of these studies was a GITSG trial that randomized fortythree patients with locally advanced disease to receive either streptozotocin, mitomycin and 5-fluoruracil (SMF) chemotherapy alone or radiation (54 Gy) with concurrent bolus 5-FU followed by adjuvant SMF, demonstrated a significant survival advantage for the combined modality arm at 1 year (41% versus 19%, respectively) (Gastrointestinal Tumor Study Group, 1988). Conversely, another study failed to demonstrate improvement in median survival (8.3 versus 8.2 months) with the addition of radiation (40 Gy) to concurrent bolus 5-FU followed by weekly maintenance 5-FU over the use of 5-FU alone (Klaassen et al, 1985).

Alternative approaches to combination 5-FU based chemoradiation regimens have developed as the mechanism of 5-FU radiosensitization has been studied.

Protracted venous infusion (PVI) 5-FU dosing schedules have replaced the traditional bolus administration. The protracted drug exposure potentially optimizes the 5-FU radiation sensitization by increasing cumulative drug dose without increased toxicity. A retrospective study demonstrated PVI-5-FU chemoradiation resulted in less toxicity and greater chemotherapy and radiation dose intensity compared to bolus 5-FU, however there have been no randomized trials comparing these two strategies (Poen et al, 1998). Capecitabine is an orally available 5fluorouracil pro-drug, which has been used in combination with radiation with or without the addition of other agents in the treatment of locally advanced pancreatic cancer, and appears to be comparable to 5-FU (Ben-Josef et al, 2004; Saif et al, 2005; Schneider et al, 2005). To date, there have been no randomized trials comparing PVI-5-FU or capecitabine and radiation to bolus for the treatment of pancreatic cancer.

S-1 is another new oral formulation consisting of tegafur, gimeracil and oteracil potassium that potentiates the antitumor activity of 5-FU and reduces gastrointestinal toxicity. Phase I studies demonstrate feasibility (Ueno et al, 2005) and a multicenter phase II trial incorporating S-1 in a gemcitabine-containing regimen for patients with advanced pancreatic cancer has now been reported. The overall response rate was a promising 44%, the median progression-free survival was 5.9 months, the median overall survival was 10.1 months and the 1 year survival was 33% (Ueno et al, 2007). S-1 has also been evaluated in conjunction with radiotherapy for locally advanced pancreatic cancer patients. A phase I trial determined that the MTD of twice-daily S-1 with concurrent radiation was 80 mg/m2 and the dose-limiting toxicities were grade 3 nausea and vomiting, and hemorrhagic gastritis (Ikeda et al, 2007). A multicenter phase II trial is now underway.

Gemcitabine has emerged as the standard chemotherapy for pancreatic cancer. Initially gemcitabine 346

Cancer Therapy Vol 6, page 347 Taxanes have also been incorporated into gemcitabine-containing chemoradiation schemas in the clinical setting. Taxanes are known to be radiosensitizing agents with systemic activity in pancreatic cancer. A phase I study demonstrated the safety of combining weekly gemcitabine (75 mg/m2) with paclitaxel (40 mg/m2), and concurrent conventional radiotherapy (Safran et al, 2002).

A subsequent RTOG trial adopted this treatment strategy in a phase II study, resulting in a 26% partial response rate, and 7% complete response rate. The 1- and 2-year survival rates were 43% and 13%, respectively and the median survival was 11.2 months for the 109 evaluable patients. Patients unfortunately encountered unexpected toxicity, with 4 grade 4 toxicities and 1 grade 5 treatmentrelated complication (Rich et al, 2004). Unexpected toxicity has been encountered with other taxanecontaining chemoradiation regimens. One dose-escalating study of weekly docetaxel and concurrent radiation was closed at the 35 mg/m2 dose-level. While the investigators indicate this dose was well tolerated with concurrent radiation, 28% of the patients entered in to the study had to be hospitalized (Viret et al, 2003).

As reflected in Table 1, other gemcitabine containing combination regimens have been explored in the metastatic setting with, in general, disappointing results.

been studied in the phase III cooperative group setting and was recently presented at the 2007 ASCO Gastrointestinal Cancer Symposium. Unfortunately, the preliminary results of Cancer and Leukemia Group B (CALGB) 80303 failed to demonstrate a survival benefit from adding bevacizumab to gemcitabine, despite the encouraging results of the phase II study. Patients were randomized to receive either gemcitabine (1000 mg/m2 over 30 minutes on days 1, 8 and 15 every 28 days with bevacizumab 10 mg/kg or placebo on the same schedule. The median follow-up was 8.4 and 8.1 months for the bevacizumab and placebo arm, respectively. The treatment was tolerable; hematologic toxicity was similar for both arms, however hypertension and proteinuria were more common in the bevacizumab arm (Kindler et al, 2007).

Inhibitors of the ErbB family of receptors also demonstrate promising preclinical results (Xiong and Abbruzzese, 2002). Cetuximab, a humanized monoclonal antibody to the epidermal growth factor receptor (EGFr), and trastuzumab, an antibody to ErbB2 have been combined with gemcitabine in patients with advanced pancreatic cancer (Safron et al, 2004; Xiong et al, 2004).

In a recent multicenter phase II trial, the combination of gemcitabine and cetuximab has demonstrated a promising 1 year survival rate of 32% (Xiong et al, 2004). Erlotinib has also recently demonstrated a small, but significant survival advantage for patients with metastatic pancreatic cancer when used in combination with gemcitabine versus gemcitabine used alone (Moore et al, 2005).

Unfortunately, the addition of cetuximab with gemcitabine failed to show a survival benefit in a recent phase III Southwest Oncology Group (SWOG) when randomized against gemcitabine alone for patients with advanced pancreatic cancer (Philip, 2007). With the exception of the Moore et al trial, the experience of adding a targeted agent to gemcitabine for patients with advanced disease has not shown to provide a significant survival benefit.

C. Chemotherapy and targeted therapies As the pathogenesis of pancreatic cancer becomes better understood, the use of specific targeted molecular and biologic therapies are being investigated. Many of these approaches may provide a synergistic or additive effect when combined with conventional chemotherapy in preclinical models. A cooperative group study has investigated the combination of gemcitabine and bevacizumab in a phase II trial demonstrating a median survival of 8.8 months (Kindler et al, 2005). Gemcitabine and bevacizumab versus gemcitabine alone has recently

Table 1. Selected randomized trials of gemcitabine versus a gemcitabine doublet Investigator Abou-Alfa and colleagues Berlin and colleagues Colucci and colleagues Herrmann and colleagues Louvet and colleagues Roche Lima and colleagues Moore and colleagues Phillip and colleagues Kindler

Agents Gemcitabine Gemcitabine/Exactecan Gemcitabine Gemcitabine/5-Fluorouracil Gemcitabine Gemcitabine/Cisplatin Gemcitabine Gemcitabine/Capecitabine Gemcitabine Gemcitabine/Oxaliplatin Gemcitabine Gemcitabine/Irinotecan Gemcitabine Gemcitabine/Erlotinib Gemcitabine Gemcitabine/Cetuximab Gemcitabine Gemcitabine/Bevacizumab

347

Median Survival 6.2 6.7 5.4 6.7 5.4 7.0 7.2 8.4 7.0 9.0 6.6 6.3 5.9 6.2 5.9 6.4 6.1 5.8

P- value 0.52 0.09 0.43 0.23 0.13 NS NS 0.14 0.78

Russo et al: The multidisciplinary treatment of non-metastatic pancreatic cancer

D. Radiation Fluorouractil (5-FU)

combined

with

pancreatic cancer at the 2006 ASCO meeting. Patients with locally advanced non-metastatic pancreatic cancer stratified for performance status, treatment center, exploratory surgery, were randomized to induction (5-FU, cisplatin, and conventional radiation) followed by maintenance gemcitabine until progression or limiting toxicity, or induction gemcitabine followed by maintenance gemcitabine. The combined modality arm resulted in a significant increase in hematologic toxicity.

The median survival for the combined modality arm was 8.4 months compared to 14.3 months for the gemcitabine arm (p=0.014), while the 6 month and 12 month overall survival were 78% and 24% for chemoradiation followed by gemcitabine, and 82% and 51.4% for gemcitabine alone. The study was stopped before planned accrual due to lower survival in CMT arm. The conclusion of this trial is that gemcitabine alone results in a statistically significant improvement in overall survival for locally advanced non-metastatic pancreatic cancer. Increased toxicity encountered in the combined modality arm, resulting in decreased maintenance gemcitabine may explain this difference (Chauffert et al, 2006).

Phase I studies have determined the MTD of concurrent gemcitabine and conventional radiation dose.

The MTD for twice-weekly gemcitabine and conventionally fractionated radiation was 40 mg/m2, determined by Blackstock et al. in a study emphasizing the radiosensitizing effects of gemcitabine (Blackstock et al, 1999). A similar phase I study was done evaluating twiceweekly gemcitabine in which the MTD determined to be 50 mg/m2 (Pipas et al, 2001). Unfortunately, several subsequent phase II studies of twice-weekly gemcitabine provided mix results (Table 2) (Pipas et al, 2001; Blackstock et al, 2003). Studies evaluating once-weekly gemcitabine with concurrent radiation have also been pursued. Short-course radiation (30 to 33 Gy delivered over 2 weeks) with concurrent gemcitabine (200 to 500 mg/m2), unfortunately resulted in unacceptable acute severe treatment-related toxicity (Crane et al, 2001; Wolff et al, 2001). Studies investigating conventionally fractionated radiation therapy (45-50 Gy) with escalating doses of weekly gemcitabine are also outlined in Table 2

5-

The first study to evaluate combined modality treatment randomized unresectable gastrointestinal cancers to receive external beam radiation (35 to 40 Gy) with or without 5-FU and demonstrated a significant improvement in median survival with the addition of 5-FU (10.4 months versus 6.3 months) in 32 patients (Moertel et al, 1969).

The subsequent Gastrointestinal Tumor Study Group (GITSG) trial confirmed these results by randomizing patients to receive high dose EBRT (60 Gy) alone, versus the same radiation with 5-FU chemotherapy, followed by maintenance 5-FU, versus moderate dose EBRT (40 Gy) with 5-FU followed by maintenance 5-FU. Both the high dose and moderate dose radiation groups receiving combined modality therapy resulted in an improved median survival over the EBRT alone group (9.2, 9.6, and 5.2 months, respectively) (Moertel et al, 1981). The addition of 5-FU to radiation was the only advancement in the treatment of locally advanced pancreatic cancer for many years and has defined the standard of care until recently.

Further attempts to improve outcome for these patients by adding other systemic agents to the 5-FUbased chemoradiation treatment regimen proved unsuccessful. An additional GITSG trial failed to demonstrate further improvement in survival the addition of doxorubicin to EBRT with concurrent and maintenance 5-FU, or 40 Gy with concurrent weekly doxorubicin, followed by maintenance 5-FU and doxorubicin (GITSG, 1985).

E. Radiation combined with gemcitabine Gemcitabine has demonstrated radiation sensitizing properties in vitro and in vivo, (Lawrence et al, 1996; Milas et al, 1999; Fields et al, 2000) and has been investigated in combination/conjunction with radiotherapy in patients with pancreatic cancer. The Federation Francophone de Cancerologie Digestive and Societe Francaise de Radiotherapie Oncologique (FFCD-SFRO) recently reported the results of a phase III trial comparing chemoradiation followed by gemcitabine versus gemcitabine alone in patients with locally advanced

Table 2. Selected phase I/II trials of gemcitabine based chemoradiation.

Study

Phase

Number

Radiation (Gy)

Chemotherapy

Response (%)

II

38

50.4

44

Crane and colleagues

I/II

51

30-33

Pipas and colleagues

I

21

50.4

Gemcitabine 40mg/m2 twice weekly then weekly x 5 Gemcitabine weekly 200500mg/m2 then weekly x 7 Gemcitabine 10-60 mg/m2 twice weekly

CALGB

348

Median Survival months 8.2

11 33

9.5

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The study on relation of Human Papillomavirus with bladder transitional cell carcinoma Research Article

Gita Eslami1,*, Maryam Golshani1, Mohammad Rakhsh!n2, Fatemeh Fallah1, Hossein Goudarzi1 1 2

Department of Microbiology, School of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.

Department of Pathology, School of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.

__________________________________________________________________________________ *Correspondence: Eslami Gita, PhD, Department of Microbiology, School of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, Iran; Tel: ++98-21-23872556; E-mail:g_eslami@yahoo.com Key words: Human papillomavirus, Clinical specimens, DNA extraction, HPV detection, HPV high risk typing, Statistical analysis Abbreviations: Double Distilled Waterm (DDW); Human papillomavirusm (HPV); Transitional Cell Carcinomam (TCC) Received: 30 October 2007; Revised: 9 November 2007 Accepted: 14 April 2008; electronically published: June 2008

Summary Carcinoma of bladder is one of the most common types of cancer in the world. Different factors have been known to act as risk factors in progression of the cancer. However the role of Human Papillomavirus in bladder carcinoma development is still controversial. Thus, the aim of this study was to investigate the possible correlation between genital Human Papillomavirus (HPV) infection and Transitional Cell Carcinoma (TCC). formalin- fixed, paraffin embedded tissue samples of 147 patients with TCC and 39 non- neoplastic cases as a control group were tested for the presence of HPV DNA. In addition, HPV high risk typing was performed to all positive patients. The ratio of male to female was the same in both case and control groups and it was about 6.4. Investigation on age classification showed that the highest number of case group patients aged 51-60 years old. The positive rates of HPV DNA were 34.7% and 7.6% in case and control groups, respectively. HPV18 was the most common type detected from HPV positives (47.1%). We could not find any significant relation between tumor grade/stage and HPV- positivity (P>0.05, P=0.1). Genital HPV infection, in particular HPV 18, increases the risk of bladder cancer in Iranian population.

cancer development in different body sites such as the upper alimentary and respiratory tracts, esophagus, anus, vulva and cervix. However, the possible role of HPV in bladder cancer is still controversial (Furihata et al, 1993; De Gaetani et al, 1999; Barghi et al, 2005; Helal et al, 2006).

HPV infection is the most frequent sexually transmitted disease worldwide and among over 100 HPV genotypes isolated to date, more than 40 have shown specific tropism for the male and female genitourinary tract (De Gaetani et al, 1999; Mayrand,etal et al, 2000; Lukaszuk et al, 2003). The oncogenic potential of highrisk HPV types lies in the oncoproteins E6 and E7 targeting p53 proteins and the retinoblastoma gene product, respectively. The binding of E6 oncoprotein results in rapid degradation of p53 via the ubiquitindirected pathway. Furthermore, the role of E6 and E7 oncoproteins are to eliminate or inactivate p53 and P105Rb as tumor suppressors. These interactions lead to a

I. Introduction Carcinoma of bladder is the most common type of urogenital cancer in the world, particularly in some parts of the world like Africa. Bladder cancer is the fourth most common type of cancer in men and the eighth most common type in women and it is 2 to 3 times more frequent in men. In the United States, approximately 38,000 men and 15,000 women are diagnosed with the disease each year (www.NationalCancerInstitute.com; Malwla and Kholaed, 2001; Kufe et al, 2003; Helal et al, 2006). There are different kinds of carcinogenic and cocarcinogenic factors associated with bladder cancer ; age, sex, smoking, alcohol abuse, long time taking of analgesic and anti- neoplastic drugs, Contact with carcinogenic chemicals, Schistosomiasis and HPV genital infections (www.NationalCancerInstitute.com; LaRue and Simoneau, 1995; Chan et al, 1997; Sur and Allard, 2001; Kufe et al, 2003; Karagas et al, 2005; Helal et al, 2006).

Human papillomavirus (HPV) is a major risk factor for 355

Eslami et al: Relation of Human Papillomavirus with bladder transitional cell carcinoma run for 42 cycles, under the following condition: 15min at 95ºC, 30 sec at 95ºC, 30 sec at 63ºC and 30 sec at 72ºC. The final elongation step of 1 min at 72ºC was performed to complete the elongation. Amplification products were visualized and photographed under UV light after electrophoresis for 45 min through a 2% agarose gel containing ethidium bromide.

disturbance of cell cycle control and a deficiency in DNA repair, resulting in genomic instability and an increased risk of malignant transformation (Werness et al, 1990; Zur Hausen and de Villiers, 1994; Kim and Kim 1995; Murray et al, 2001).

In regard to the significant role of HPV in some genital malignancies, numerous studies have been performed in recent years on a possible association between HPV and human bladder cancer, but contradictory results have been reported. It is believed that different technical factors and geographical conditions may affect the studies results (LaRue and Simoneau, 1995; Barghi et al, 2005).

The purpose of the present study was to compare the prevalence of HPV high risk types in formalin-fixed, paraffin embedded tissue samples of patients with TCC (Transitional Cell Carcinoma) and control group in order to find any meaningful relation between HPV and TCC.

D. HPV high risk typing HPV high risk Typing was performed using HPV High Risk Typing PCR Kit (Sacace Company, Italy, Catalog No. V25-50R). HPV High Risk Typing was an in vitro nucleic acid amplification test for qualitative detection and genotyping of HPV types 16, 18, 31, 33, 35, 39, 45, 52, 56, 58, 59, 66 in the urogenital swabs and biopsies. Each PCR-mix-1 tube contained primers directed against regions of four HPV types and !-globine gene used as Internal Control. Multiplex amplification reaction was performed in a volume of 40.5 µl and contained: 5"l of PCR-mix-1, 10 "l of 2.5X buffer-red, 0.5 "l of Hot Start Polymerase, 15 "l of Reaction Mix, 1 drop (25 "l) of Mineral Oil and 10 "l of DNA sample. Reaction was run for 42 cycles, under the following condition: 15min at 95ºC, 30 sec at 95ºC, 30 sec at 63ºC and 40 sec at 72ºC. The final elongation step of 1 min at 72ºC was performed to complete the elongation. Amplification products were visualized and photographed under UV light after electrophoresis for 45min through a 3% agarose gel containing ethidium bromide (Figure 1).

II. Methods and Materials A. Clinical specimens The medical records and formalin- fixed paraffin embedded tissue samples of 147 patients with TCC and 39 nonneoplastic cases as a control group stored in pathology laboratory of Modares Hospital, Tehran, Iran have been purchased. The pathology slides were reviewed and the original diagnoses were confirmed. Examination details of tissue specimens of control group are listed in Table 1.

Table 1. Examination histology of tissue specimens from control group.

B. DNA extraction

Finding Cystitis Inflammation Fibrosis Normal

Tissue sections were deparafinized with xylene and rehydrated by decreasing concentrations of ethanol and Double Distilled Water (DDW). Then DNA extraction was performed according to the following steps, using DNA Extraction Kit (DNP Kit, CinnaGen Company, Iran, Catalog No. DN8115C).

100 µl Protease buffer and 10 µl Protease were added to 25 mg of the tissue sample. After incubation at 37ºC for over night, 10 µl Protease was added again and the sample was incubated at 55ºC till the tissue was digested completely. After incubation at 72ºC for 10 min, the solution was mixed with 400 µl Lysis Solution and vortexed for 15-20 sec. Then DNA was precipitated with 300 µl Precipitation Solution at -20ºC for 20 min and centrifuging at 12000X for 10 min. After drying the tubes for 2-3 sec, 1 ml Wash buffer was added to the pellet and then the solution was centrifuged at 12000X for 5 min and the tube was decanted. This step was repeated once more. Eventually DNA was suspended in 50 µl Solvent Buffer .The entire extracted DNA was stored at -20º C until PCR.

Frequency 17 11 6 5

C. HPV detection HPV detection was performed using HPV Screening PCR Kit (Sacace Company, Italy, Catalog No.V-26-50R). HPV High Risk Screen was an in vitro nucleic acid amplification test for qualitative detection of HPV types 16, 18, 31, 33, 35, 39, 45, 52, 53, 56, 58, 59, 66, 70 in the urogenital swabs and biopsies. This test was based on multiplex amplification of DNA using specific HPV primers (specific amplified DNA fragments length was 267-325 bp for HPV and 723 bp for Internal Control). PCR-mix1 tube contained primers directed against regions of HPV A6, A7, A9 groups (HPV types 16, 18, 31, 33, 35, 39, 45, 52, 53, 56, 58, 59, 66, 70) and !-globine gene used as Internal Control.

Multiplex amplification reaction was performed in a volume of 40.5µl and contained: 5"l of PCR-mix-1, 10 "l of 2.5X bufferred, 0.5 "l of Hot Start Polymerase, 15 "l of Reaction Mix, 1 drop (25 "l) of Mineral Oil, 10 "l of DNA sample. Reaction was

Figure 1. Detection of HPV high risk types from HPV positive tissues samples. Lane 1 100bp DNA ladder, Lane 2, 3, 4, 5, 7 HPV positive clinical samples: Lane 2 HPV16 (325bp), Lane 3 HPV31 (520bp), Lane 4 HPV33 (227bp), Lane 5 HPV 18 (425bp) and Lane 7 HPV52 (360bp). Lane 8 negative clinical sample (723bp). Lane 9 HPV16, 31, 33, 35 positive controls, Lane 10 HPV18, 39, 45, 59 positive controls, Lane 11 HPV 52, 56, 58 positive controls and Lane 6 negative control.

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Cancer Therapy Vol 6, page 357 the HPV positivity showed that the highest number of cases belonged to patients aged 51-60 years old (Table 2).

In present study, 34.7% (51/147) of cases and 7.6% (3/39) of control group were positive for HPV (P<0.008) (Table 3). The prevalence of HPV high risk types 18, 16, 33, 31 and 52 detected from HPV positive cases was 47.1%, 37.2%, 11.7%, 2% and 2%, respectively. In control group, 2 cases were HPV18 positive and 1 case was HPV16 positive (Table 4).

The histopathological grade and stage of tumor specimens considering the sex and HPV positivity are shown in (Table 5). We could not find any meaningful relation between the tumor grade/stage and presence of HPV (P>0.05, P=0.1). However, the grade and stage of tumor were higher in men (47.2% Grade II, 57.5% Stage T2-T4) (Table 6).

E. Statistical analysis Statistical analysis was performed by SPSS statistical software package version 11, using Chi-square test, MannWhitney U test. Statistical significance was assumed at the P<0.05 level.

III. Results The population of 147 cases and 39 controls were analyzed for the presence of HPV. The ratio of male to female was the same in both case (127 males, 20 females) and control groups (34 males, 5 females) and it was about 6.4. The mean age was 62 years (range 18 to 87) and 63 years (range 41 to 89) in the case and control groups, respectively. Investigation on age classification according

Table 2. Classification of Case and control groups according to their age.

Groups Control 1.4(2/147) 3.4(5/147) 13.6(20/147) 29.9(44/147) 23(34/147) >70

Age (yr.) a <20 21-30 31-40 41-50 51-60 61-70 28.5(42/147) a

Case 15.3 (6/39) 33.3(13/39) 23(9/39) 28(11/39)

Values are percentages per group (with the number of patients/ total number of patients per group in parentheses)

Table 3. HPV PCR results from case and control groups.

PCR result Case group n (%) Positive 51 (34.7) Negative 96 (65.3) Total 147 (100)

Control group n (%) 3 (7.6) 36 (92.4) 39 (100)

Table 4. HPV high risk typing results of HPV positive specimens.

HPV type/Group Case Control

HPV18 n (%) 24(47.1) 2 (66.7)

HPV16 n (%) 19(37.2) 1(33.3)

HPV33 n (%) 6(11.7) -

HPV31 n (%) 1(2) -

HPV52 n (%) 1(2) -

Table 5. Relation between HPV infection and stage/grade of tumor

HPV DNA Positive Negative Total

Grade I

II

III

Stage Ta-T1

T2-T4

11 (21)* 28 (29) 39 (26)

27 (53) 39 (41) 66 (45)

13 (26) 29 (30) 42 (29)

20 (39) 55 (57) 74 (50.4)

31 (61) 41 (43) 73 (49.6)

*n (percentage)

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Eslami et al: Relation of Human Papillomavirus with bladder transitional cell carcinoma Table 6. The distribution of patients' sex according to tumor's grade and stage.

Sex Male Female

Grade I

II

III

Stage Ta-T1

T2-T4

Total

25(19.7)* 14(70)

60(47.2) 6(30)

42(33.1) -

54(42.5) 20(100)

73(57.5) -

127 20

*n (percentage)

Although HPV is known as a risk factor for tumor development, we could not find any significant relation between the stage of tumor and HPV-positivity (P=0.1). In addition, there was no meaningful difference between HPV positive and HPV negative groups with regard to the grade of tumor (P> 0.05). On the other hand, the grade and stage of the tumor were higher in men (47.2% Grade II, 57.5% Stage T2-T4) in comparison to women (70% Grade I, 100% Stage Ta-T1). We think that it is because of the more care of Iranian women for their health and early examination and diagnosis of malignancies in women.

Investigation on the age classification shows that the rate of bladder cancer is the most in age-group 51-60. This is in consistent with the results of some other authors (Furihata et al, 1993; Barghi et al, 2005).

IV. Discussion The role of genital Human Papillomavirus in carcinoma of bladder is still a controversial issue. While the relation between the HPV infection and cancer development in different genital parts has been confirmed, contradictory results have been reported by different authors about the association of genital HPV with bladder cancer (Furihata et al, 1993; De Gaetani et al, 1999). It has been reported a high prevalence of HPV in patients with TCC. In our study, we could find a significant difference between case and control groups for HPV positivity (34.7% of cases and 7.6% of control group were positive for HPV, P<0.008) (Agliano et al, 1994; LaRue and Simoneau, 1995; Chen et al, 2000; Soulitzis et al, 2002; Fioriti et al, 2003; Barghi et al, 2005; Wiwanitkit, 2005).

The higher prevalence of HPV in patients with TCC reported in these studies demonstrates the possible relation between HPV and bladder carcinoma. However, some authors such as Boucher and colleagues in 1996; Ludwig and colleagues in 1996; Tekin and colleagues in1999; Sur and Allard, 2001; Youshya and colleagues in 2005, could not find any meaningful relation between HPV and bladder carcinoma.

In our study, HPV high risk types 18, 16, 33, 31 and 51 were detected from case group and HPV18 was the most common type detected from patients with TCC. Results of previous studies show that HPV18, 16 and 33 are the most common HPV types detected from patients with bladder carcinoma (Anwar et al, 1992; Furihata et al, 1993; Yu et al, 1993; Lopez Beltran and Munoz, 1995; Tenti et al, 1996; De Gaetani et al, 1999; Chen et al, 2000; Barghi et al, 2005). Additionally, considering the oncogenic potential of HPV proteins E6 and E7 in targeting cell growth mechanism, Kamel and colleagues in 1995 and Chan and colleagues in 1997 could find a correlation between abnormal accumulation of P53 and HPV18/16 infection. With regard to these facts, we can come to this conclusion that HPV18/16 may correlate with carcinoma of bladder.

Moreover to HPV types 18/16/33, types 11, 6 and 35 have been found (Anwar et al, 1992; Shibutani et al, 1992; Lopez Beltran and Munoz, 1995; De Gaetani et al, 1999; Chen et al, 2000; Barghi et al, 2005). In present study, we could find 1 case of HPV52 which had not been found in previous studies. In summary, this variety in reports may be explained by differentiation in a. type of specimen (fresh or fixed tissue) b. examination methods (different series of primers, sensitivity) c. geographical distribution of HPV types existed between countries (LaRue and Simoneau, 1995; Chan et al, 1997).

V. Conclusion Higher prevalence of genital HPV in patients with TCC demonstrates the possible role of HPV infection, particularly HPV18, in carcinoma of bladder among Iranians. Therefore, informing people, especially men, about genital HPV infections and screening of patients with high risk for developing of bladder carcinoma seems to be necessary.

Acknowledgments The authors of this article would like to thank the staff of Pathology Laboratory, Modares Hospital, especially Dr. Javadzadeh and Mrs. Bahadorani who assisted with collecting of tissue specimens and medical records. This study was supported by a grant from School of Medicine, Shaheed Beheshti University of Medical Sciences.

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PCR detection and high risk typing of human papillomavirus DNA in cervical cancer in Iranian women Research Article

Gita Eslami1,*, Maryam Golshani1, Mohammad Rakhshan2, Fatemeh Fallah1, Hossein Goudarzi1, Afsoun Taghavi2 1

Infectious Disease and Tropical Medicine Research Center, School of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.

2 Department of Pathology, School of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.

__________________________________________________________________________________ *Correspondence: Eslami Gita, PhD, Department of Microbiology, School of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, Iran; Tel: ++98-21-23872556; E-mail:g_eslami@yahoo.com Key words: HPV, cervical cancer, PCR, biopsy Abbreviations: Double Distilled Water, (DDW); human Papilloma virus, (HPV); sexually transmitted diseases, (STDs); Squamous Cell Carcinoma, (SCC) Received: 30 October 2007 Revised: 4 December 2007 Accepted: 21 December 2007; electronically published: June 2008

Summary Cervical cancer is the second common type of cancer among women, worldwide and it is the second cancerous cause of death, particularly in women aged 25-65. In order to progress a cancer from dysplasia to invasive carcinoma, a series of cellular changes should occur. Since genital HPV carries oncogenes involving in these essential changes, today HPV has been considered as the most significant risk factor of cervical cancer. It is believed that HPV can increase the rate of cancer progression when associating with other risk factors such as smoking, taking contraceptive drugs, immunosuppression and etc. Paraffin embedded cervical tissue of 70 patients with cervical cancer was analyzed by PCR method for presence of HPV. In addition, high risk typing of HPV positive samples was performed using HPV high risk typing PCR kit. Among total patients 49% were positive for HPV. HPV16 was the most common HPV type detected from HPV positive cases. Investigation of age classification showed that the highest number of HPV positive cases belonged to age-group 35-44.We could not find any meaningful relation between HPV infection and neither educational status nor sort of job (P> 0.05).

infection is the most frequent sexually transmitted disease worldwide, and up to 60% of sexually active women will become infected by HPV in the genital tract (Mayrand et al, 2000; Lukaszuk et al, 2003). Over 100 HPV genotypes have been isolated to date. Among these more than 40 have been shown to infect the genital tract, and 15 of them (genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82) have been found to be associated with cervical cancer or high-grade cervical intraepithelial neoplasia and therefore classified as high-risk types (Munoz et al, 2003; Kraus et al, 2006; Fontaine et al, 2007). The most frequent HPV types found in cervical intraepithelial neoplasia and Squamous Cell Carcinoma (SCC) (in more than 99% of cervical cancer biopsies) are HPV type 16 (HPV-16) and HPV-18, which in 1995 were classified as human carcinogens by the International Agency for Research on Cancer (7, 9, 3 ). Worldwide

I. Introduction Cervical cancer is the second common type of cancer among women, worldwide (Murray et al, 2001; Bethesda, 2003). With about 400,000 new cases and nearly 250,000 deaths each year, it contributes significantly to worldwide cancer-related morbidity and mortality, especially in developing countries (Vizcaino et al, 2000; Kufe et al, 2003; Arias- Pulido et al, 2006). The risk of cervical cancer is more in women aging 40 years of age or older and those who smoke, take contraceptive drugs for more than 5 years, have the history of multiple sex partners or immunosuppression (Kenneth and Ryan, 1999; Bethesda, 2003; Kufe et al, 2003). However, infection by certain types of human Papilloma virus (HPV) has been considered as the most significant risk factor for the development of cervical cancer (Kjaer et al, 1996; Lanham et al, 2001; Moberg et al, 2003; Kraus et al, 2006). HPV

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Eslami et al: PCR detection and high risk typing of HPV DNA in cervical cancer Iranian patients Screening PCR Kit is an in vitro nucleic amplification test for detection of HPV in clinical specimens. This kit contains primers directed against regions of HPV A6, A7 and A9 groups and !Globin gene as an internal control. Amplification products were visualized and photographed under UV light after electrophoresis for 45min through a 2% agarose gel containing ethidium bromide.

studies show that HPV types 16, 18, 31, 33, and 45 are the most prevalent types associated with cervical carcinomas (Bosch et al, 1995; Klaes et al, 1999; Lukaszuk et al, 2003; Moberg et al, 2003; Kraus et al, 2006; Fontaine et al, 2007). The oncogenic potential of these high-risk HPV types lies in the oncoproteins E6 and E7, which bind to and modulate a number of different gene products, in particular, the tumor suppressors p53 and pRb. These interactions lead to a disturbance of cell cycle control and a deficiency in DNA repair, resulting in genomic instability and an increased risk of malignant transformation (Zur and de Viliers, 1994; Murray et al, 2001; Bethesda, 2003; Kraus et al, 2006).

Genital infections of oncogenic types of HPV are common, especially in sexually active women and they disappear spontaneously without clinical lesion. Only persistent high-risk HPV infection induces higher risk for the development of a high-grade precancerous lesion or cervical cancer (Franco et al, 1999; Walboomers et al, 1999; Vizcaino et al, 2000; Fontaine et al, 2007). Since the lifelong risk of HPV infection is 80%, and only a small proportion of women infected with HPV will develop high-grade cervical neoplasia, it is important to identify those HPV-positive women with an increased risk of developing cervical carcinoma by methods that reveal persistent HPV infection or detect viral oncogene expression and investigation of additional human markers for cervical carcinogenesis (Sotlar et al, 1998; Syrjanen and Syrjanen, 2000; Von Knebel, 2002; Moberg et al, 2003).

With regard to these facts, the purpose of this study was to detect HPV from paraffin embedded tissue samples of patients with cervical cancer. Since, in previous similar Iranian studies, only the prevalence of HPV types 16, 18 and 33 have been considered, in order to investigate the most common HPV types among Iranian women, we used HPV High Risk Typing Kit (Mortazavi et al, 2002; Farjadian et al, 2003).

D. HPV high risk Typing HPV high risk Typing was performed using HPV High Risk Typing PCR Kit (Sacace Company, Italy, Catalog No. V25-50R). HPV high risk Typing PCR Kit is a multiplex in vitro nucleic amplification test for genotyping of HPV types 16, 18, 31, 33, 35, 39, 45, 52, 56, 58, 59 and 66 in clinical specimens. It contains three PCR-mix tubes; in each of them primers directed against regions of four HPV types and !-Globin gene as an internal control are prepared. Amplification products were visualized and photographed under UV light after electrophoresis for 45min through a 3% agarose gel containing ethidium bromide.

E. Statistical analysis Statistical analysis was performed by SPSS statistical software package version 12, using Student's t test for calculating means and standard deviations, logistic regression test for comparing age and positive results, The x2 test and Chi-square test for comparing and finding any relations between HPV positivity and other variations. Statistical significance was assumed at the P< 0.05 level.

III. Results In this study, formalin- fixed paraffin embedded tissue sample of 70 patients with SCC of cervix was tested for detection and typing of Human Papillomavirus. The mean age of patients was 46.5 years (ranging from 25 to 68 years) and the highest number of HPV positive cases belonged to patients aged 35-44 years old (Table 1).

Among 70 patients 49% (34/70) were positive for HPV (Table 2). Results of HPV high risk typing showed that HPV types 16, 18, 33, 45, 31 and 52 (arranging by decreasing rate) were detected from HPV positive cases.HPV16 was the most common type detected from HPV positive cases(Table 3).

We could not find any meaningful relation between HPV infection and neither educational status nor sort of job.

II. Methods and Materials A. Clinical specimens In this retrospective study, formalin- fixed paraffin embedded tissue of 70 patients with SCC of cervix stored in pathology laboratory of Taleghani Hospital, Tehran, Iran was purchased. The pathology slides were reviewed and the original histological diagnoses of cancer were confirmed by our pathologists. In addition, medical documents of all patients were reviewed in order to access to their clinical and personal information.

IV. Discussion In present study, among 70 patients, HPV was found in 49% of cases. In comparison to our study, previous studies performed by other countries like Sri Lanka 100% (De Silva et al, 2006) Brazil 96% (Eleuterio et al, 2006), India 95% (Peedicayil et al, 2006), Norway 92% (Kraus et al, 2006), Lithuania 92% (Gudleviciene et al, 2005), Australia 90% (Liu et al, 2004), Korea 90% (An et al, 2005), Japan 87% (Asato et al, 2004), Italy 85% (Tornesello et al, 2006), Greece 74% (Konidaris et al, 2007) and China 75-83% (Qiu et al, 2007) have shown higher HPV prevalence. This may be explained by the difference in the number of samples, the type of case group (high risk or low risk groups) or cultural limitations.

B. DNA extraction Tissue sections were deparafinized with xylene and rehydrated by decreasing concentrations of ethanol and Double Distilled Water (DDW). Then DNA extraction was performed using DNA Extraction Kit (DNP Kit, CinnaGen Company, Iran, Catalog No. DN8115C). The entire extracted DNA was stored at -20ยบ C until PCR.

C. HPV detection HPV detection was performed using HPV Screening PCR Kit (Sacace Company, Italy, Catalog No.V-26-50R). HPV

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Cancer Therapy Vol 6, page 363 Table 1. Classification of PCR positive and negative patients according to their age.

Age (yr.) a 33.33(12/36) 50(18/36) 8.33(3/36) 8.33(3/36) a

HPV PCR Results Negative

Positive

14.71(5/34) 73.5(25/34) 3(1/34) 8.8(3/34)

25-34 35-44 45-54 >55

Values are percentages per group (with the number of patients/ total number of patients per group in parentheses)

Table 2. HPV PCR results from patients with cervical cancer.

PCR result

Patients n (%) 34 (49) 36 (51) 70 (100)

Positive Negative Total Table 3. HPV high risk typing results of HPV positive specimens HPV type

Patients n (%) 21 (62) 4 (12) 9 (26) 34 (100)

HPV 16 HPV 18 Others(31,33,45,52) Total

As our experience shows because of the establishment of special religious and cultural bans in countries like Iran that prevents people from involving risky sexual contacts, the prevalence of sexually transmitted diseases (STDs) is lower, especially in women (Farid et al, 1978; Badami and Salari, 2001; Badami et al, 2004; Kajbaf and Akhbarian, 2004; Shobeiri and Nazari, 2006; Zaeimi et al, 2006; Bakhtiari and Firoozjahi, 2007; Golshani et al, 2007).

With regard to this fact, the prevalence of HPV infection as a kind of sexually transmitted disease in which the risk of persistent infection increases by having multiple sex partners from young ages, is lower in Iranian women (Kenneth and Ryan, 1999; Bethesda, 2003; Kufe et al, 2003). On the other hand, because of the lack of knowledge toward STDs prevention ways and their longtime negative effects, Lack of consideration to ones health and not undergoing regular cervical cytological screening, the risk of persistent genital infections (like HPV infection, in present study) with broad destructive potential is somewhat noticeable in Iran. Therefore, investigation of women with an increased risk of developing cervical carcinoma seems to be necessary (CMP, 2005; Simbar et al, 2005). However, as our results show 51% of patients are HPV negative. We think that other risk factors of cervical cancer may play a possible role in cervical cancer among Iranian women.

Results obtained from HPV high risk typing show that HPV16 is the most common type detected from our patients. This is in consistent with the results of other authors who have mentioned HPV16 as the main

oncogenic type of HPV associated with cervical cancer (Asato et al, 2004; Ma et al, 2004; Masumoto et al, 2004; Silins et al, 2004). Other HPV types detected from our patients are HPV18, 31, 33, 45 and 52. Previously, HPV types 16, 18 and 33 have been reported by other Iranian studies (Mortazavi et al, 2002; Farjadian et al, 2003), but because of the investigation of broader HPV types, more HPV types are reported by our study. Moreover to these HPV types, other worldwide authors could find types 6, 35, 58, 71, 90 and 91 which have been not reported in Iran (Liu et al, 2004; Wall et al, 2005; Fontaine et al, 2007).

This may be explained by differences in geographical distribution of HPV types existed between countries (Clifford et al, 2005; Fontaine et al, 2007).

Investigation of the age classification dedicates that age-group 35-44 has been allocated the highest number of HPV positive cases. Similar results have been reported in other Studies (Liu et al, 2004; Wall et al, 2005).

Conclusively, frequent Pap screening of all women 25 years of age and older, HPV testing of women with abnormal cervical cytology, educating of women about HPV genital infection and persuading them to perform routine Pap smear seem to be necessary.

Acknowledgments The authors of this article would like to thank the staff of Pathology Laboratory, Taleghani Hospital who assisted with collecting of tissue specimens. This study was supported by a grant from Infectious Disease and Tropical Medicine, School of Medicine Research Center

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