[Recurrent depressive disorder associated with an atypical CADASIL syndrome]. / Recidiverende depressieve stoornis bij een atypisch CADASIL-syndroom.

A 55-year-old man with recurrent depressive episodes, with onset at age 45, was admitted to hospital after a suicide attempt. Due to a recent stroke as well as a family history of stroke and depression, CADASIL (prevalence of 2-5 per 100.000) was considered as a possible diagnosis. Although depression is common in CADASIL, the initial presentation is not typically comprised of recurrent depressions. Brain MRI, however, did not show the characteristic white matter lesions in the anterior temporal lobe. Genetic analysis revealed a cysteine-sparing mutation (Arg61Trp) in the NOTCH3 gene. Recently, several such mutations have been associated with CADASIL presenting with an atypical phenotype including a lower prevalence of recurrent stroke. This suggests that the prevalence of CADASIL may be higher than estimated in depressed patients. This case demonstrates the importance of considering CADASIL as a possible etiology of depression as this has consequences for prognosis, treatment and genetic counseling.

Personalized biomarker-based treatment strategy for patients with squamous cell carcinoma of the head and neck: EORTC position and approach.

The molecular landscape of squamous cell carcinoma of the head and the neck (SCCHN) has been characterized and actionable or targetable genomic alterations have been identified. However, targeted therapies have very limited activity in unselected SCCHN, and the current treatment strategy is still based on tumor location and disease stage and not on tumor biology. Trying to select upfront the patients who will benefit from a specific treatment might be a way to improve patients' outcome. With the objective of optimizing the activity of targeted therapies and immunotherapy, we have designed an umbrella biomarker-driven study dedicated to recurrent and/or metastatic SCCHN patients (EORTC-1559-HNCG, NCT03088059). In this article, we review not only the different trial designs for biomarker-driven studies with their respective advantages and opportunities but also the potential pitfalls that led to the design of the EORTC-1559-HNCG protocol. We also discuss the scientific and logistic challenges of biomarker-driven trials.

An EORTC phase I study of Bortezomib in combination with oxaliplatin, leucovorin and 5-fluorouracil in patients with advanced colorectal cancer.

The combination of oxaliplatin, leucovorin and 5-fluorouracil (FOLFOX-4) is still a reference regimen in advanced colorectal cancer; however, the addition of new biologic compounds represents a significant way forward. Bortezomib is an inhibitor of proteasome, a multicatalytic enzyme complex that degrades several intracellular proteins. In this study, escalating doses of Bortezomib were administered along with the standard FOLFOX-4 doses, in order to evaluate the dose-limiting toxicity (DLT), toxicity profile and activity of the combination. Patients with advanced colorectal cancer, unpretreated for metastatic disease, were enroled in the study. Bortezomib starting dose was 1.3mg/m(2), which was to be escalated in the subsequent steps according to the toxicities observed after first cycle. Exploratory pharmacogenetics research was conducted by analysing the association between clinical outcomes and polymorphisms in candidate genes for response to each of the used drugs. Correlation between tumour marker changes and response was also investigated. One mg/m(2) (DL-1) was defined as being the maximum tolerated dose since only 1 DLT was observed in 6 patients. The main toxicities were haematologic, neuropathy, diarrhoea and fatigue. Amongst 13 evaluable patients, five had a partial response, five had a stable disease and three patients progressed. Two patients are long-term survivors after a combined chemosurgical approach. Further trials of the current combination may be justified.

A phase I and pharmacokinetic study of OSI-7904L, a liposomal thymidylate synthase inhibitor in combination with oxaliplatin in patients with advanced colorectal cancer.

PURPOSE: OSI-7904L is a liposomal formulation of a potent thymidylate synthase (TS) inhibitor. This phase I study evaluated the safety, tolerability and pharmacokinetics (PK) of OSI-7904L administered in combination with oxaliplatin every 21 days in patients with advanced colorectal carcinoma. METHOD: A 3+3 study design was utilized at predefined dose levels. Polymorphisms in the TS enhancer region and XPD enzyme were investigated as potential predictors of efficacy and toxicity. RESULTS: Fourteen patients received 76 cycles of treatment. At the highest dose level (OSI-7904L 9 mg/m(2), oxaliplatin 130 mg/m(2)) investigated, one of nine patients experienced dose-limiting toxicity of grade 3 oral mucositis with cycle 1 and five further patients required dose reductions. The toxicity profile of stomatitis, diarrhea, nausea, fatigue, sensory neuropathy and skin rash was consistent with that expected for a TS inhibitor/oxaliplatin combination regimen. PK analysis showed high interpatient variability with no detectable interaction between OSI-7904L and oxaliplatin. Partial radiological responses were documented in two patients. CONCLUSIONS: The recommended regimen for further investigation is OSI-7904L 9 mg/m(2) and oxaliplatin 130 mg/m(2).

Retroviral-mediated transfer of genes encoding interleukin-2 and interleukin-12 into fibroblasts increases host antitumor responsiveness.

The transfer of genes encoding cytokines into tumor cells has emerged as a new strategy to increase in vivo host reactivity to a variety of tumors. Because gene transfer into tumor cells cannot be easily applied in the clinical setting, we have developed an experimental model of gene transfer into fibroblasts and examined the capacity of these engineered cells to elicit an antitumor immune response. Interleukin-12 (IL-12) is a heterodimeric cytokine with pleiotropic activities presenting strong antitumor and antimetastatic effects in murine models. A bicistronic retroviral vector was constructed that contained the cDNAs encoding both chains (p40 and p35) of murine IL-12 separated by an internal ribosomal entry site sequence. Syngeneic cutaneous fibroblasts obtained from newborn mice and transduced to secrete either IL-12 or IL-2 were injected subcutaneously with B16F0 or B16F1 melanoma cells. The time of tumor occurrence and overall survival of mice were significantly prolonged when B16F1 cells were coinjected with cytokine-producing fibroblasts compared with B16F1 alone or B16F1 together with unmanipulated fibroblasts. Systemic effects were seen in the mice injected with either IL-2- or IL-12-secreting fibroblasts, with the highest proliferation capability and interferon-gamma production observed in vitro from splenocytes from recipients of IL-2-secreting fibroblasts. Injection of IL-2-secreting fibroblasts or coinjection of IL-2- and IL-12-producing fibroblasts resulted in a significant increase of survival in the B16F0 model; in some cases, complete disease eradication was observed. These results suggest that cutaneous fibroblasts represent a target of choice for gene transfer and would be useful in the treatment of minimal residual disease in humans.

Retrovirus-mediated gene transfer of the human multidrug resistance-associated protein into hematopoietic cells protects mice from chemotherapy-induced leukopenia.

Utilization of chemotherapy for the treatment of tumors is mainly limited by its hematological toxicity. Because of the low-level expression of drug resistance genes, transduction of hematopoietic progenitors with multidrug resistance 1 (MDR1) or multidrug resistance-associated protein (MRP) genes should provide protection from chemotherapeutic agent toxicity. Successful transfer of drug resistance genes into hematopoietic cells may allow the administration of higher doses of chemotherapy and, thus, increase regression of chemosensitive tumors. The interest in the use of MRP as an alternative to MDR1 for bone marrow protection lies in its different modulation. This would allow, in the same patient, the use of MDR1 reversal agents to decrease MDR1 tumor resistance without reversing bone marrow (BM) protection of the MRP-transduced hematopoietic cells, since MRP expression is not reversed by these agents. We have constructed MRP-containing retroviral vectors using the phosphoglycerate kinase promoter and generated ecotropic producer cells. Lethally irradiated mice were engrafted with BM cells transduced by coculture with MRP producer cells. Evidence of long-term (9 months) gene transfer was provided by PCR of peripheral blood from MRP-transduced mice. Southern blot analysis confirmed the integrity of the provirus in the MRP-transduced mice. Long-term MRP expression (>5 months) was detected by RT-PCR and fluorescence-activated cell sorting of blood from living mice. High-level expression of MRP in murine hematopoietic cells reduces doxorubicin-induced leukopenia and mortality. Furthermore, we show in vivo selection of MRP-transduced cells following doxorubicin administration, with better and more significant chemoprotection after the second chemotherapy cycle. These data indicate that MRP retroviral gene transfer may be useful for chemoprotection and selection.

[Integration of carcinogenic viruses in the genome of in-vitro cultured human fibroblasts]. / Intégration de virus cancérigènes dans le génome de fibrolastes humains cultivés in vitro.

Avian sarcoma viruses are known for inducing no transformation of human diploid fibroblasts. Nevertheless, we show that the Rous sarcoma virus can infect and transform some human fibroblastic cell lines, replicate and express viral proteins, integrate into the host genome and prevent expression of MHC class I antigens on cell membranes. Cell transformation happens together with important and significant abnormalities of the cell karyotype and proviral integration is most often close to the c-src oncogene on chromosomes 1 and 20.

[HLA and multiple sclerosis]. / HLA et sclérose en plaques.

Etiology of and pathogenetic mechanisms in multiple sclerosis are still badly known; therapy is thus uncertain and poorly active. Many recent studies have nevertheless shown a weak but clear association with HLA-DR2, as the possible role of a HTLV-related virus. Infection of genetically sensitive (DR2 positive) children would induce an auto-immune disease with a cellular and humoral reactivity against myelin antigens. A rather active and certainly harmless treatment consists in administration of immunoglobulins.

HLA and multiple sclerosis: population and families study.

Association between HLA and multiple sclerosis (MS) was investigated at the population level on 100 MS patients genotyped for HLA-A, B, C, DR and Bf, Glo, and on 155 patients phenotyped for the same HLA antigens. Association between MS and DR2 was clearly confirmed, although its strength is rather weak. No other genetic marker could be related to the disease, no haplotype nor any allelic combination could be recognized as MS specific, and antigen genotype frequencies among the diseased could not ascertain the mode of inheritance, although dominance is very likely. Computer analysis between HLA, Bf, Glo and age of the patient, sex, age of onset and evolution of MS, impairment indexes, titres of anti-DNA and anti-measles antibodies in CSF did not show any interaction. Twenty sib pairs and two trios of MS were also studied; they showed no significant distortion with the random distribution of haplotypes. DR2 gene frequency, however, was significantly higher in sib pairs showing one or two haplotypes than in HLA different affected siblings. Three crossing-overs were identified which suggest where the HLA-linked MS susceptibility (MSS) gene could be located within the HLA segment, while other epistatic MSS genes or environmental factors are likely to be important.

HLA-DR-dependent variation of intrathecal IgG1 (Gm) allotype synthesis in multiple sclerosis.

Genetic susceptibility to multiple sclerosis (MS) in Caucasians was previously shown to be correlated to the presence of given alleles at the HLA-DR and Gm loci. We now demonstrate that the humoral immune response in MS central nervous system (CNS) is modulated by both loci: the levels of IgG1 subclass and IgG1 allotypes in cerebrospinal fluid of MS patients depend on both their Gm genotype and their HLA-DR2 or HLA-DR7 phenotype. That HLA-DR molecules may either participate in a preferential recruitment of IgG1 allotype-producing B cells in MS CNS or act after such a selective homing is discussed. These results demonstrate that both HLA and Gm loci are synergistically involved in the modulation of the humoral immune response.

HLA and susceptibility to multiple sclerosis.

The study of the joint segregation of multiple sclerosis and HLA, using affected sib pairs as well as whole pedigrees, shows that these two traits are not independently transmitted. The hypothesis of a single susceptibility locus inside HLA region could explain all the observed data, only if a high gene frequency, a very low penetrance, and some environmental correlation between relatives are assumed. Linkage analysis performed on the basis of this hypothesis for 58 multiple sclerosis families concludes to a strict linkage. We obtained a maximum score of 3.11 at theta = 0.00 for a dominant gene of frequency 0.18 and penetrance of 0.02. This result contrasts with the large recombination fraction obtained by other authors and the discrepancy is explained by the very low gene frequency used in their analysis. Some environmental correlation, in addition to the genetic determinant in HLA region, may explain the overall familial aggregation, but an alternative is the existence of additional genetic determinants.

Recent developments in the clinical use of blood derivatives.

New trends of the clinical use of blood derivatives are mainly: The extensive use of concentrated RBC (Haematocrit 72 +/- 2%) prepared from blood collected in CPD-adenin bags and stored at 4 degrees C up to 35 days. The selective use of packed RBC resuspended in SAG-mannitol solutions, providing long conservation of plasma-free RBC. The increasing use of platelets transferred into gas permeable plastic bags, allowing a 22 degrees C storage of at least 5 days, with an excellent viability. The coming back of fresh frozen plasma (FEP) and cryoprecipitates which reduce the potential risk of AIDS, bound to the use of large pools of plasma. In connection with this, a brief updating of the AIDS spread and etiology is presented and discussed.

First results of immunotherapy with immunoglobulin G in multiple sclerosis patients.

31 patients with multiple sclerosis were treated for an mean period of 4 years with high doses of human immunoglobulin. Overall, one third improved, one third showed no change and one third deteriorated. The effect of treatment was not related to any clinical or biological variable except perhaps the immunogenetic profile (HLA). The potential role of this symptomatic treatment is discussed.