Non-cytotoxic Agents Research Articles

Electrochemotherapy and Calcium Electroporation on Hepatocellular Carcinoma Cells: An In-Vitro Investigation

PurposeElectrochemotherapy, clinically established for treating (sub)cutaneous tumors, has been standardized in the framework of the European Standard Operating Procedure on Electrochemotherapy (ESOPE). Due to common side effects of chemotherapeutic drugs, recent advances focus on non-cytotoxic agents, like calcium, to induce cell death (calcium electroporation). Therefore, this study aims to determine the efficacy of electrochemotherapy with bleomycin or cisplatin, or calcium electroporation on human hepatocellular carcinoma cells (HepG2) in vitro using the ESOPE protocol.MethodsHepG2 cell viability was measured with a MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay after electrochemotherapy with the chemotherapeutic drugs bleomycin or cisplatin (0–20 µM), or after calcium electroporation (0–20 mM), to determine its efficacy on HepG2 cells in vitro using the ESOPE protocol (8 rectangular pulses, 1000 V/cm, 100 µs) compared to non-electroporated drug treatment.ResultsCell viability was significantly lower in electroporated samples, compared to their non-electroporated controls (27–75% difference). Electrochemotherapy with bleomycin and calcium electroporation, reached (almost) complete cell death (− 1 ± 3% and 2.5 ± 2%), in the lowest concentration of 2.5 µM and 2.5 mM, respectively. Electrochemotherapy with 2.5 µM cisplatin, significantly decreased cell viability to only 68% (± 7%).ConclusionElectrochemotherapy with bleomycin or cisplatin, or calcium electroporation were more effective in reducing the HepG2 cell viability in vitro using the ESOPE protocol compared to the non-electroporated drug treatments alone. When comparing electrochemotherapy, HepG2 cells are more sensitive to bleomycin than cisplatin, in similar concentrations. Calcium electroporation has the same effectiveness as electrochemotherapy with bleomycin, but calcium potentially has a better safety profile and several treatment advantages.Graphical

The 3 + 3 design in dose-finding studies with small sample sizes: Pitfalls and possible remedies.

In the last few years, numerous novel designs have been proposed to improve the efficiency and accuracy of phase I trials to identify the maximum-tolerated dose (MTD) or the optimal biological dose (OBD) for noncytotoxic agents. However, the conventional 3+3 approach, known for its and poor performance, continues to be an attractive choice for many trials despite these alternative suggestions. The article seeks to underscore the importance of moving beyond the 3+3 design by highlighting a different key element in trial design: the estimation of sample size and its crucial role in predicting toxicity and determining the MTD. We use simulation studies to compare the performance of the most used phase I approaches: 3+3, Continual Reassessment Method (CRM), Keyboard and Bayesian Optimal Interval (BOIN) designs regarding three key operating characteristics: the percentage of correct selection of the true MTD, the average number of patients allocated per dose level, and the average total sample size. The simulation results consistently show that the 3+3 algorithm underperforms in comparison to model-based and model-assisted designs across all scenarios and metrics. The 3+3 method yields significantly lower (up to three times) probabilities in identifying the correct MTD, often selecting doses one or even two levels below the actual MTD. The 3+3 design allocates significantly fewer patients at the true MTD, assigns higher numbers to lower dose levels, and rarely explores doses above the target dose-limiting toxicity (DLT) rate. The overall performance of the 3+3 method is suboptimal, with a high level of unexplained uncertainty and significant implications for accurately determining the MTD. While the primary focus of the article is to demonstrate the limitations of the 3+3 algorithm, the question remains about the preferred alternative approach. The intention is not to definitively recommend one model-based or model-assisted method over others, as their performance can vary based on parameters and model specifications. However, the presented results indicate that the CRM, Keyboard, and BOIN designs consistently outperform the 3+3 and offer improved efficiency and precision in determining the MTD, which is crucial in early-phase clinical trials.

Extravasation of Non-Cytotoxic Drugs in Older People.

Objective To describe the risk factors of extravasation, its impact on the pharmacokinetics of non-cytotoxic drugs, and management of extravasation in older individuals. Extravasation occurs when vesicants leak from blood vessels into surrounding tissue causing severe injury such as tissue necrosis while infiltration is caused by leakage of an irritant that causes injury but does not lead to tissue necrosis. Extravasation occurs in approximately 0.01% to 6% of patients, particularly with cytotoxic agents. However, there is limited documentation about extravasation of non-cytotoxic agents, particularly in older people. Data Sources A literature search of Pubmed and Medline was performed using the following search items: "extravasation," "infiltration," "elderly," and "non-cytotoxic drugs," as well as a combination of these terms. Conclusion It is important to recognize, identify, and manage extravasation early since it can have deleterious consequences for older people. It is more important to prevent extravasation than manage it using standardized evidence-based protocols, and this can be implemented in the nursing facility and acute care setting.

Long-lasting complete remission in a patient with systemic metastases of recurrent breast cancer treated with cyclin-dependent kinases 4/6 inhibitors: a case report

BackgroundThe prognosis for recurrence cases of hormone receptor-positive HER2-negative breast cancer remains poor, and treatment strategies that emphasize quality of life have often been chosen, with few physicians aiming for a cure. Our objective is to assess the validity of such current treatment strategies.Case presentationA 74-year-old Asian woman with multiple lung and liver metastases after local recurrence of breast cancer was treated with two different cyclin-dependent kinases 4/6 inhibitors sequentially in combination with endocrine therapy. Flow cytometric analysis of the patient’s peripheral blood mononuclear cells was also performed to evaluate the host’s immune status. Complete remission was achieved without cytotoxic agents and the patient remains disease free to this day, 6 years after the initial relapse. Additionally, no increase in the population of the immunosenescent T cells with a phenotype of CD8+CD28− was observed in the patient’s peripheral blood mononuclear cells, suggesting that the immune system was well maintained.ConclusionsWe present this case study to develop new treatment strategies for recurrent breast cancer that is not only bound to misinterpretations of the Hortobagyi algorithm, but also aim for a cure with noncytotoxic agents to maintain the host’s immune system and early detection of recurrence.

Controlled amplification in oncology dose-finding trials

In oncology clinical trials the guiding principle of model-based dose-finding designs for cytotoxic agents is to progress as fast as possible towards, and identify, the dose level most likely to be the MTD. Recent developments with non-cytotoxic agents have broadened the scope of early phase trials to include multiple objectives. The ultimate goal of dose-finding designs in our modern era is to collect the relevant information in the study for final RP2D determination. While some information is collected on dose levels below and in the vicinity of the MTD during the escalation (using conventional tools such as the Continual Reassessment Method for example), designs that include expansion cohorts or backfill patients effectively amplify the information collected on the lower dose levels. This is achieved by allocating patients to dose levels slightly differently during the study in order to take into account the possibility that “less (dose) might be more”. The objective of this paper is to study the concept of amplification. Under the heading of controlled amplification we can include dose expansion cohorts and backfill patients among others. We make some general observations by defining these concepts more precisely and study a specific design that exploits the concept of controlled amplification.

Clinical Laboratory Mutation Analysis Performed on Tumor Biopsies from Patients with First Relapsed/Refractory Aggressive B Cell Lymphoma Treated with Curative-Intent Immunochemotherapy

Background Comprehensive genomic analysis has identified subgroups of diffuse large B cell and high grade B cell lymphoma (DLBCL/HGBL) patients (pts) who experience inferior survival outcomes following receipt of first-line treatment (1Ltx) with immunochemotherapy (PMID: 29713087, 29641966). However, this type of analysis has not been performed for pts with R/R DLBCL/HGBL treated with curative-intent IC in the 2L, although descriptive analyses of mutations (mut) present at the time of first R/R DLBCL/HGBL have been reported (PMID: 26647218, ICML 2017 #294). Here we report mut identified by clinical laboratory mutation analysis (CLMA) in tumor biopsies (bx) obtained at the time of first R/R DLBCL/HGBL in patients subsequently receiving 2Ltx with curative-intent IC with analysis of response and survival outcomes. Methods Pts diagnosed with first R/R DLBCL/HGBL after receipt of 1Ltx who underwent tumor bx at that time with diagnostic CLMA performed at the University of Pennsylvania from 2015-21 with one of three lymphoma sequencing panels who were treated with RICE or RDHAP/C as 2Ltx were retrospectively analyzed. Immunohistochemical staining (IHC) for MYC and BCL2 expression as well as fluorescence in situ hybridization (FISH) for MYC, BCL2 and BCL6 rearrangements were performed as per institutional standard. 2Ltx was given at the discretion of the treating physician. Disease free survival (DFS) was defined as the interval between diagnosis of first R/R DLBCL/HGBL to next occurrence of R/R DLBCL/HGBL or last follow-up in remission. Overall survival (OS) was defined as the interval between diagnosis and time of death or last follow-up while alive. Data were censored on 7/1/22. Results CLMA was performed on 28 pt tumor bx with 25 successful assays (89% success rate) and a median result turnaround time (TAT) of 17 days. Baseline clinicopathologic and tx characteristics are listed in the Table and mutations detected by frequency with n≥1 in the Figure. 2Ltx was RICE in 18 (72%) and R-DHAP/C in 7 (28%) pts. With a median follow-up of 32.4 months from the time of first R/R disease, the Kaplan Meier estimate of 2 year (y) DFS was 12% (95% confidence interval [CI] 2-31%) and 2y OS 59% (95% CI 33-78%). Response to 2Ltx was achieved by 18 pts (72%). Additional analysis was performed to determine factors predictive of response to 2Ltx and 2y DFS using the characteristics in Table 1, 2Ltx received as well as mutation detected in ≥5 cases (CREBBP, TP53, SOCS1 and MYD88). Those predictive of response to 2Ltx with P<0.10 on univariate logistic regression were receipt of R-DHAP/DHAC vs RICE (odds ratio [OR] 0.15, 95% CI 0.02-1.0, P=0.06) and CREBBP mutation vs not (OR 0.07, 95% CI 0.01-0.83, P=0.04). Those predictive of disease relapse by 2y with P<0.10 on univariate Cox regression were HGBL vs DLBCL histology (hazard ratio [HR] 4.8, 95% CI 1.4-16.4, P=0.01), receipt of R-DHAP/DHAC vs RICE (HR 4.7, 95% CI 1.6-13.8, P=0.005), GCB vs non-GCB cell of origin (HR 1.9, 95% CI 0.94-4.0, P=0.07), MYC rearrangement vs not (HR 4.5, 95% CI 1.3-15.4, P=0.02) and double hit lymphoma vs not (HR 3.8, 95% CI 1.0-14.5, P=0.046). Meaningful multivariate analyses for response to 2Ltx or disease relapse at 2y could not be carried out due to small sample size. Conclusion In this cohort of pts with DLBCL/HGBL whose tumor bx obtained at the time of first R/R disease underwent CLMA and were treated with RICE or RDHAP/C as 2Ltx, few patients achieved long-term DFS in spite of a high rate of chemosensitivity to 2Ltx. Mut in CREBBP predicted for a lower response rate to 2Ltx but not disease progression at 2y, and no other mut analyzed predicted for either outcome. Given the low rate of 2y DFS as well as a shift in practice to the use of chimeric antigen receptor-modified T cells (CART) as 2Ltx for pts with early R/R DLBCL/HGBL, these data do not support further investigation of CLMA performed on a larger sample of tumor bx from all pts at the time of first R/R disease who are candidates for CART. However, performance of CLMA could further explored in the subset of DLBCL/HGBL pts with late first R/R disease for whom the standard of care 2Ltx remains curative-intent IC, as the presence of absence of mut predicting for disease response/DFS in this pt population may inform tx decisions given the availability of non-cytotoxic agents as 2L tx as well as CART at the time of subsequent R/R disease. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Classification of Skin Injury Risk Caused by Extravasation of Electrolyte Solutions or Infusions in a Rat Model.

Cytotoxic agents are classified according to the severity of skin injury after extravasation. However, injuries caused by extravasation of noncytotoxic agents have not been sufficiently investigated, although the risk of extravasation is mentioned in medical safety information published by the Japan Council for Quality Health Care. Therefore, in this study, we focused on noncytotoxic electrolyte solutions and infusions and evaluated skin injuries during leakage using extravasation model rats. Rats were anesthetized and intradermally injected with 100 µL of an electrolyte solution or infusion. Injection lesions were macroscopically and histopathologically evaluated for extravasation injuries. Each electrolyte solution and infusion were classified into three categories (vesicants, irritants, and non-tissue-damaging agents) depending on the degree of skin injury. Similar to saline, 0.3% potassium chloride and 0.6% magnesium sulfate showed almost no injury, and 3% sodium chloride and BFLUID® caused erythema and induration. Erythema, induration, and ulceration were observed with the following: 10% sodium chloride, 2% calcium chloride, 8.5% calcium gluconate, 12.3% magnesium sulfate, MAGSENT®, FESIN®, and Intralipos®. The duration of damage with these agents was markedly prolonged. Electrolyte solutions and infusions can be classified into vesicants (10% sodium chloride, 2% calcium chloride, 8.5% calcium gluconate, 12.3% magnesium sulfate, MAGSENT®, FESIN®, and Intralipos®), irritants (3% sodium chloride and BFLUID®), and non-tissue-damaging agents (0.3% potassium chloride and 0.6% magnesium sulfate) according to their composition. The characteristic symptoms and severity of each drug extravasation revealed in this study will provide basic information for preparation of guidelines for treatment of extravasation.

Calcium Electroporation Reduces Viability and Proliferation Capacity of Four Uveal Melanoma Cell Lines in 2D and 3D Cultures.

Simple SummaryCalcium electroporation (CaEP) is an innovative anti-tumor treatment modality that induces cell death by introducing supraphysiological concentrations of calcium into cells with a limited effect on normal cells. The objective of the present study is to assess the effect of CaEP in uveal melanoma (UM) cell lines in comparison to electrochemotherapy (ECT) with bleomycin using 2D monolayer cell cultures as well as 3D tumor spheroid models in four different UM cell lines. The morphological changes of the spheroids, the cell viability, growth rate as well as the cytotoxic effect of electroporation (EP) with calcium chloride and bleomycin were evaluated with various drug concentrations. The results of CaEP and ECT both suggest a comparable dose-dependent reduction in cell viability and proliferation rate in all tested 2D cell lines and 3D tumor spheroids. These data point out that CaEP is an established anticancer treatment causing cell death by ATP depletion in in vitro and in vivo, representing an efficient alternative therapy with a lower cytotoxic potency for the local UM tumor control.Electrochemotherapy (ECT) is the combination of transient pore formation following electric pulse application with the administration of cytotoxic drugs, which enhances the cytotoxic effect of the applied agent due to membrane changes and permeabilization. Although EP represents an established therapeutic option for solid malignancies, recent advances shift to the investigation of non-cytotoxic agents, such as calcium, which can also induce cell death. The present study aims to evaluate the cytotoxic effect, the morphological changes in tumor spheroids, the effect on the cell viability, and the cell-specific growth rate following calcium electroporation (CaEP) in uveal melanoma (UM) 2D monolayer cell cultures as well as in 3D tumor spheroid models. The experiments were conducted in four cell lines, UM92.1, Mel270, and two primary UM cell lines, UPMD2 and UPMM3 (UPM). The 2D and 3D UM cell cultures were electroporated with eight rectangular pulses (100 µs pulse duration, 5 Hz repetition frequency) of a 1000 V/cm pulse strength alone or in combination with 0.11 mg/mL, 0.28 mg/mL, 0.55 mg/mL or 1.11 mg/mL calcium chloride or 1.0 µg/mL or 2.5 µg/mL bleomycin. The application of calcium chloride alone induced an ATP reduction only in the UM92.1 2D cell cultures. Calcium alone had no significant effect on ATP levels in all four UM spheroids. A significant decrease in the intracellular adenosine triphosphate (ATP) level was documented in all four 2D and 3D cell cultures for both CaEP as well as ECT with bleomycin. The results suggest a dose-dependent ATP depletion with a wide range of sensitivity among the tested UM cell lines, control groups, and the applied settings in both 2D monolayer cell cultures and 3D tumor spheroid models. The colony formation capacity of the cell lines after two weeks reduced significantly after CaEP only with 0.5 mg/mL and 1.1 mg/mL, whereas the same effect could be achieved with both applied bleomycin concentrations, 1.0 µg/mL and 2.5 µg/mL, for the ECT group. The specific growth rate on day 7 following CaEP was significantly reduced in UM92.1 cell lines with 0.5 and 1.1 mg/mL calcium chloride, while Mel270 showed a similar effect only after administration of 1.1 mg/mL. UM92.1 and Mel270 spheroids exhibited lower adhesion and density after CaEP on day three in comparison to UPM spheroids showing detachment after day 7 following treatment. CaEP and bleomycin electroporation significantly reduce cell viability at similar applied voltage settings. CaEP may be a feasible and inexpensive therapeutic option for the local tumor control with fewer side effects, in comparison to other chemotherapeutic agents, for the treatment of uveal melanoma. The limited effect on normal cells and the surrounding tissue has already been investigated, but further research is necessary to clarify the effect on the surrounding tissue and to facilitate its application in a clinical setting for the eye.

Beware clonal haematopoiesis following chronic lymphocytic leukaemia treatment

Clonal myeloid haematopoiesis co-existing with chronic lymphocytic leukaemia (CLL) is not rare and is associated with high risks for development of therapy-related myeloid neoplasms (t-MNs) after cytotoxic chemotherapy. This has serious implications for the use of these therapies in newly diagnosed CLL patients. Therapy-related myeloid neoplasms are devastating conditions. Their development following cytotoxic chemotherapy for various neoplasms often ultimately leads to treatment-refractory acute myeloid leukaemia and is usually lethal for afflicted patients. These neoplasms often develop following exposure to alkylating agents or anthracyclines,1 but they have been reported following single-agent fludarabine.2 T-MNs typically present after prior cytotoxic therapy given in an adjuvant context or for relatively indolent neoplasms, and thus their development is particularly distressing for many otherwise cancer-free or cancer-controlled patients. Effective long-term control of t-MNs is difficult to achieve, and at present always requires allogeneic haematopoietic transplant. The paper by Voso et al.3 regarding clonal haematopoiesis of indeterminant potential (CHIP) as a risk factor for t-MNs following chemotherapy for CLL is thus timely and worthy of attention from all physicians who manage CLL. CHIP has (unsurprisingly) been associated with increased risks of t-MN. The current report is, however, the first reported study of t-MN following therapy for CLL. It is worth noting that this experience is based upon 15 patients who were selected only for the availability of pretreatment genomic material. Amongst the relevant 13 patients whose t-MN followed the use of cytotoxic therapy, a prior mutation consistent with myeloid CHIP was present in 10, or 77%. Mutations compatible with CHIP were found in 34 of 285 cases of CLL not developing t-MN. The authors thus appropriately conclude that CHIP seems to be a significant risk factor for the development of t-MN following cytotoxic therapy for CLL. This work presents a detailed description of the mutations found in prechemotherapy haematopoietic material. The authors are conservative in terms of attributing these mutations to the CLL or the myeloid elements found in the available pretreatment cells. They correctly observe that mutations of TP53 and SF3B1 could in principle arise either from clonal CLL cells or from a myeloid CHIP clone, and thus cannot be firmly identified as having driven the development of the t-MN. Data found in their table S4, however, show that in two patients (#6 and #8), mutations in TP53 (two cases) and in SF3B1 (one case), were identical in pretreatment samples of CLL containing cells and in the t-MN material. The same mutated sequences were found in these two paired samples in both cases and for both genes. Thus, although we cannot be completely certain, it seems very likely that in fact the pretreatment mutation was found in myeloid cells that were subsequently transformed in response to the exposure to cytotoxic agents, leading to the t-MN. These findings have important implications for the management of CLL and other neoplasms. First, CHIP is reasonably common in patients who are candidates to receive cytotoxic agents. Pre-existing CHIP clearly poses very significant risks for the development of t-MN and most of these secondary neoplasms will prove to be lethal for affected patients. Thus, particularly in older patients with higher risks of CHIP, it seems reasonable to consider screening patients for myeloid clonal states prior to offering cytotoxic therapy for management. Notably, there are now alternative systemic therapies available for CLL (and many other neoplasms) which do not involve cytotoxic therapy and thus should not pose the same risk of potential secondary neoplasm. Another and potentially provocative conclusion is that mutations of TP53 or SF3B1 found in pretreatment blood or other tissues from CLL patients may not necessarily represent changes in the CLL clone but may be situated in associated myeloid cells. This issue in it itself may affect decisions concerning CLL management, as TP53 mutations are associated with poor prognosis and as this finding in a CLL patient may potentially increase the desire for aggressive therapy. Finally, in such patients the use of cytotoxic chemotherapy in disease management might have disastrous downstream consequences, leading to a lethal t-MN. The development of effective systemic targeted therapies for CLL not employing cytotoxic or mutagenic agents has revolutionized the therapy of CLL. The application of these agents has already greatly reduced the use of potentially leukaemogenic therapies. Recently, however, it has been asserted that “In fit patients with immunoglobulin heavy chain mutation, it is still acceptable to use the chemotherapy regimen with fludarabine, cyclophosphamide, and rituximab (FCR) and, in those who [are] not fit or are not IgVH-mutated, bendamustine-rituximab regimen”.4 Given the availability of effective non-cytotoxic agents for management of essentially all CLL patients, haematologists and oncologists managing this group of highly treatable but fragile patients should take pause, and note the findings described by Voso et al.

Emerging Targeted Therapy for Specific Genomic Abnormalities in Acute Myeloid Leukemia.

We describe recent updates of existing molecular-targeting agents and emerging novel gene-specific strategies. FLT3 and IDH inhibitors are being tested in combination with conventional chemotherapy for both medically fit patients and patients who are ineligible for intensive therapy. FLT3 inhibitors combined with non-cytotoxic agents, such as BCL-2 inhibitors, have potential therapeutic applicability. The menin-MLL complex pathway is an emerging therapeutic target. The pathway accounts for the leukemogenesis in AML with MLL-rearrangement, NPM1 mutation, and NUP98 fusion genes. Potent menin-MLL inhibitors have demonstrated promising anti-leukemic effects in preclinical studies. The downstream signaling molecule SYK represents an additional target. However, the TP53 mutation continues to remain a challenge. While the p53 stabilizer APR-246 in combination with azacitidine failed to show superiority compared to azacitidine monotherapy in a phase 3 trial, next-generation p53 stabilizers are now under development. Among a number of non-canonical approaches to TP53-mutated AML, the anti-CD47 antibody magrolimab in combination with azacitidine showed promising results in a phase 1b trial. Further, the efficacy was somewhat better in patients with the TP53 mutation. Although clinical evidence has not been accumulated sufficiently, targeting activating KIT mutations and RAS pathway-related molecules can be a future therapeutic strategy.

Phase Ib trial of lenalidomide as post-remission therapy for older adults with acute myeloid leukemia: Safety and longitudinal assessment of geriatric functional domains

Background and ObjectivesNovel, non-cytotoxic agents are driving a paradigm shift for treatment of older adults with acute myeloid leukemia (AML). Older patients who initially receive intensive cytotoxic induction may choose to not proceed with cytotoxic consolidation therapy. Lenalidomide is an orally-administered immunomodulatory small molecule with activity in AML and a favorable safety profile in older adults with active leukemia. We conducted a phase Ib study of lenalidomide as post-remission therapy in older adults and assessed its impact on geriatric functional domains. Materials and MethodsParticipants were patients with AML over age 60 years who had undergone induction therapy and were poor candidates for cytotoxic consolidation. Lenalidomide was administered for 28 days in three dose cohorts. A Bayesian dose-escalation method determined cohort assignment and maximum tolerated dose (MTD). Geriatric assessment (GA) was performed before and after the cycle of lenalidomide. ResultsNineteen patients with median age 68 were treated with at least one 28-day course of lenalidomide. Dose-limiting toxicities were observed in three participants at 25 mg, zero participants at 35 mg, and one participant at 50 mg. MTD was 35 mg. Median relapse-free survival was 4.3 months. GA was completed before and after treatment in fifteen patients, demonstrating improved cognitive function and no changes in physical, psychological, or social function after lenalidomide. ConclusionLenalidomide can be safely administered to older adults with AML with preservation of functional domains important to older patients. Serial GA can be performed in a novel drug study as a tool to characterize treatment tolerability.

Innovative Therapeutic Strategies for Primary CNS Lymphoma

Primary central nervous system (CNS) lymphoma (PCNSL) represents 4% of all CNS malignancies and 4–6% of all extranodal lymphomas. Its low incidence is the main reason why it has been difficult to develop guidelines on the treatment and management of PCNSL patients. The lack of consensus around standard therapy and best diagnostic approach, inevitably, affected the outcome of these patients for many years. Current efforts are focusing on: (1) defining the optimal induction and consolidation therapies in fit and frail patients, (2) establishing when and how to use the new non-cytotoxic agents, (3) investigating innovative radiotherapy to mitigate treatment-related neurotoxicity, (4) limiting delays in diagnosis, and (5) improving response assessment with new biological markers and radiological tools. Finally, the complexity of the management of PCNSL patients compels clinicians to provide timely and efficient social, neuropsychological, and physiotherapy support, which is feasible only when there is effective collaboration between the multiple specialists involved in the care of these patients. In the last decade, thanks to multicenter collaborations, important gains have been made, particularly in the front line therapy and in the biological understanding of this disease. The progressive knowledge on molecular profile of PCNSL has justified the recent use of targeted therapy also in these settings of patients. In this review, we discuss important advances in the management of PCNSL and we highlight unresolved questions that should be addressed in the future.

Searching for Small Molecules as Antibacterials: Non-Cytotoxic Diarylureas Analogues of Triclocarban.

Triclocarban (TCC), a broad-spectrum lipophilic antimicrobial agent, is a diarylurea derivative that has been used for more than 60 years as a major ingredient of toys, clothing, food packaging materials, food industry floors, medical supplies and especially of personal care products, such as soaps, toothpaste and shampoo. In September 2016, the U.S. FDA banned nineteen antimicrobial ingredients, including TCC, in over-the-counter consumer antiseptic wash products, due to their toxicity. Withdrawal of TCC has prompted efforts to search for new antimicrobial compounds. In this paper, we present the synthesis and biological evaluation, as antibiotic and non-cytotoxic agents, of a series of diarylureas, analogues of TCC. These compounds are characterized by an intriguingly simple chemistry and can be easily synthesized. Among the synthesized compounds, 1ab and 1bc emerge as the most interesting compounds as they show the same activity of TCC (MIC = 16 µg/mL) against Staphylococcus aureus, and a higher activity than TCC against Enterococcus faecalis (MIC = 32 µg/mL versus MIC = 64 µg/mL). Moreover, 1ab and 1bc show no cytotoxicity towards the human mammary epithelial cells MCF-10A and embryonic kidney epithelial cells Hek-293, in opposition to TCC, which exhibits a marked cytotoxicity on the same cell lines and shows a good antitumor activity on a panel of cell lines tested.

Polatuzumab vedotin: an investigational anti-CD79b antibody drug conjugate for the treatment of diffuse large B-cell lymphoma

ABSTRACT Introduction New agents for managing B-cell non-Hodgkin lymphomas (NHLs) are needed, particularly for high-risk and relapsed or refractory patients. Antibody–drug conjugates (ADCs) provide targeted drug delivery to tumors with a broaden therapeutic index of cytotoxic agent, reducing their systemic toxicity while increasing intracellular concentrations. Polatuzumab vedotin, an anti-CD79b conjugated to the microtubule inhibitor monomethyl auristatin E (MMAE) raises particular interest. Areas covered We discuss here polatuzumab vedotin development, challenges of designing a successful ADC, preclinical studies and recent trials, leading to FDA approval and the ongoing phase III POLARIX trial. Expert opinion Clinical data from early studies hold promises for polatuzumab vedotin in association with rituximab-bendamustine in relapsed or refractory (R/R) DLBCL and other combinations are investigated in this setting. In first line, with rituximab, cyclophosphamide, doxorubicin and prednisone (R-CHP), promising results lead to develop the phase III POLARIX trial that may represent a new advance for untreated patients. If dosing and scheduling are adequately managed to avoid peripheral neuropathy risk, polatuzumab vedotin might become a key component of DLBCL therapeutic management. This antibody drug conjugate also offers new opportunities of combination with non-cytotoxic agents or immunological interventions that might reshape the treatment of DLBCL in the future.

Design, synthesis, in vitro and in silico investigation of aldose reductase inhibitory effects of new thiazole-based compounds

Aldose reductase (AR) catalyzes the NADPH-dependent reduction of glucose to sorbitol in the polyol pathway, which plays an important role in the development of diabetic complications including cataract, retinopathy, nephropathy, and neuropathy. AR has been considered as an important target to heal these long-term diabetic complications and for this reason the development of new AR inhibitors is an important approach in modern medicinal chemistry. In the current study, new 4-aryl-2-[2-((3,4-dihydro-2H-1,5-benzodioxepine-7-yl)methylene)hydrazinyl]thiazole derivatives (1–12) were synthesized and screened for their inhibitory effects on AR which was purified by diverse chromatographic methods with a yield of 1.40% and a specific activity of 2.00 EU/mg. All compounds were determined as promising AR inhibitors with the Ki values in the range of 0.018 ± 0.005 μM-3.746 ± 1.321 μM compared to the quercetin (Ki = 7.025 ± 1.780 μM). In particular, 4-(4-cyanophenyl)-2-[2-((3,4-dihydro-2H-1,5-benzodioxepin-7-yl)methylene)hydrazinyl]thiazole (3) was detected as the most potential AR inhibitor in this series with the Ki value of 0.018 ± 0.005 µM and the compound showed competitive AR inhibition. The cytotoxic effects of compounds 1–12 were investigated on L929 mouse fibroblast (healthy) cells using MTT assay and all these compounds were defined as non-cytotoxic agents against L929 cells. Molecular docking studies, which were employed to determine the affinity of compounds 1–12 into the active site of AR, highlighted that the thiazole scaffold of all these compounds presented π-π stacking interactions with Trp20 and Phe122. According to both in vitro and in silico assays, these potential AR inhibitors may have great importance in the prevention of diabetic microvascular conditions.

Emerging carrier-free nanosystems based on molecular self-assembly of pure drugs for cancer therapy.

The potential toxicity of nanocarrier excipients and complicated preparation technologies have impeded the clinical application of nanomedicine. Recently, pure drug-assembled nanosystems (PDANS) have been widely investigated, due to the unique self-assembly characteristics of pure drug molecules. PDANS provides a facile nanoplatform for developing carrier-free nanomedicine. Herein, the recent trends in PDANS for cancer therapy are outlined. First, the emerging strategies to develop single pure drug-based nanoassemblies are discussed. Second, co-assembly of two or more pure drugs for efficient combination therapy is overviewed. Then, the functional self-assembly of non-cytotoxic agents in tumor sites is presented. Finally, the rational design and self-assembly mechanisms of these unique nanoplatforms are highlighted.

Efficacy and safety of anticancer drug combinations: a meta-analysis of randomized trials with a focus on immunotherapeutics and gene-targeted compounds

ABSTRACT Hundreds of trials are being conducted to evaluate combination of newer targeted drugs as well as immunotherapy. Our aim was to compare efficacy and safety of combination versus single non-cytotoxic anticancer agents. We searched PubMed (01/01/2001 to 03/06/2018) (and, for immunotherapy, ASCO and ESMO abstracts (2016 through March 2018)) for randomized clinical trials that compared a single non-cytotoxic agent (targeted, hormonal, or immunotherapy) versus a combination with another non-cytotoxic partner. Efficacy and safety endpoints were evaluated in a meta-analysis using a linear mixed-effects model (guidelines per PRISMA Report).We included 95 randomized comparisons (single vs. combination non-cytotoxic therapies) (59.4%, phase II; 41.6%, phase III trials) (29,175 patients (solid tumors)). Combinations most frequently included a hormonal agent and a targeted small molecule (23%). Compared to single non-cytotoxic agents, adding another non-cytotoxic drug increased response rate (odds ratio [OR]=1.61, 95%CI 1.40-1.84)and prolonged progression-free survival (hazard ratio [HR]=0.75, 95%CI 0.69-0.81)and overall survival (HR=0.87, 95%CI 0.81-0.94) (all p<0.001), which was most pronounced for the association between immunotherapy combinations and longer survival. Combinations also significantlyincreased the risk of high-grade toxicities (OR=2.42, 95%CI 1.98-2.97) (most notably for immunotherapy and small molecule inhibitors) and mortality at least possibly therapy related (OR: 1.33, 95%CI 1.15-1.53) (both p<0.001) (absolute mortality = 0.90% (single agent) versus 1.31% (combinations)) compared to single agents. In conclusion, combinations of non-cytotoxic drugs versus monotherapy in randomized cancer clinical trials attenuated safety, but increased efficacy, with the balance tilting in favor of combination therapy, based on the prolongation in survival.

Real-world practice patterns in veterans with metastatic castration-resistant prostate cancer

BackgroundMetastatic castration-resistant prostate cancer (mCRPC) is incurable, with most patients surviving less than 3 years. However, many treatments that extend survival have been approved in the past decade. ObjectiveTo describe the patient demographics, disease characteristics, treatment patterns, and outcomes in a cohort of Veterans diagnosed with mCRPC in the Veterans Health Administration. DesignWe identified 3,637 Veterans diagnosed with prostate cancer between January 2006 and August 2015 with evidence of mCRPC through December 2016. We described the most commonly used systemic mCRPC treatments according to mCRPC diagnosis era: Epoch 1 (2006–2010) or Epoch 2 (2011–2016). Patient demographics, disease characteristics, and treatment patterns were examined using descriptive statistics. An unadjusted Kaplan–Meier method was used to estimate the median time to biochemical progression and overall survival (OS) with 95% confidence intervals. ResultsThe median age at initial prostate cancer diagnosis was 68 years. Approximately 67% of patients were non-Hispanic white, 29% were black, and 4% were other/unknown. A high-risk Gleason score (8–10) was reported in 748 (67%) of patients in Epoch 1 and 1578 (63%) of patients in Epoch 2, and the median prostate-specific antigen level at initial prostate cancer diagnosis was higher in Epoch 1 patients than in Epoch 2 patients (68 vs. 35 ng/ml). Following mCRPC diagnosis, the most common first-line therapies in Epoch 1 patients were docetaxel (83%) and abiraterone (9%), whereas Epoch 2 patients mainly received abiraterone (47%), docetaxel (36%), and enzalutamide (15%). In Epoch 1 and Epoch 2 patients, the median time to biochemical progression (unadjusted) was 9 and 13 months, respectively, and the median OS (unadjusted) was 15 and 23 months, respectively. ConclusionsThe introduction of new therapies has resulted in increased use of the noncytotoxic agents abiraterone and enzalutamide as first-line treatment in lieu of docetaxel. Our results suggest that more recently diagnosed patients (Epoch 2) have a delayed time to biochemical progression and longer OS (unadjusted) compared with patients diagnosed earlier (Epoch 1).

Follicular lymphomas in vulnerable/older patients.

Unlike for diffuse large-cell lymphoma, both the management of elderly patients with follicular lymphoma and the role of comprehensive geriatric evaluation to optimize treatment choices have been rarely addressed. This review analyses available evidence on follicular lymphoma occurring in aged persons. Most retrospective studies and expert recommendations agree that the diagnostic approach and the treatment algorithm in elderly follicular lymphoma should not differ from younger patients up to the age of 80. However, slowly progressing follicular lymphoma low-tumor burden should start treatment even though asymptomatic. Prospective identification of those unfit patients is needed where a treatment deintensification may not be detrimental. Octogenarians have more aggressive disease and do not benefit from chemoimmunotherapy more than from single-agent rituximab. An activity of daily living loss significantly impact on their outcome and specific prognostic scores may help in the better manage these oldest patients. Given the lack of prospective studies there is an urgent need to investigate if geriatric assessment including comorbidities, geriatric parameters, patient's reported outcomes and quality of life issues, may help selecting those frail elderly follicular lymphoma patients less suitable for full-dose treatments. In addition, the potential usefulness of the new noncytotoxic agents of proven efficacy in follicular lymphoma warrants specific investigations in older patients.

Evaluation of Risk of Injury by Extravasation of Hyperosmolar and Vasopressor Agents in a Rat Model

Inadvertent leakage of noncytotoxic agents causes severe tissue injury. In this study, we macroscopically and histopathologically evaluated the extent of skin injury caused by extravasation of hyperosmolar or vasopressor agents in rats. Rats were intradermally administered saline (100 µL), the hyperosmolar agents mannitol (5-20 mg/100 µL) and glucose (5-50 mg/100 µL), or the vasopressors dopamine (2 mg/100 µL), adrenaline (0.1 mg/100 µL), and noradrenaline (0.1 mg/100 µL). Lesion size (erythema, induration, ulceration, and necrosis) was monitored after agent injection. Skin tissue biopsies were evaluated at 24 h after agent injection. Mannitol and glucose induced severe lesions in a concentration (and osmolarity)-dependent manner. Mannitol and glucose at 10-20% (w/v) induced inflammation, and lesions healed within 3-6 d. In contrast, ≥25% (w/v) glucose elicited severe skin lesions with ulceration and necrosis within 24 h, which healed gradually 16-22 d after injection. The severity of extravasation injury caused by vasopressors varied. Adrenaline and noradrenaline induced severe injury with ulceration and necrosis, which healed over 23.3 and 18.3 d, respectively. In contrast, dopamine induced erythema and induration, and damage duration was only 5.7 d. In conclusion, mannitol and glucose at osmolarities of 549-1098 and 833-1110 mOsm/L, respectively, can be classified as "irritants," while ≥1388 mOsm/L glucose can be classified as a "vesicant." As for vasopressors, adrenaline and noradrenaline can be classified as "vesicants" whereas dopamine can be classified as an "irritant."