Monoclonal gammopathy of clinical signifi cance with osteosclerotic lesions - a case report and a literature review.

INTRODUCTION: Multiple myeloma is a common plasma cell neoplasia usually accompanied by the formation of osteolytic foci, whereas osteosclerotic myeloma is a very rare form of plasma cell dyscrasia. When osteosclerotic myeloma is detected, osteosclerotic foci are usually part of the POEMS syndrome. Osteosclerotic myeloma without other manifestations of the POEMS syndrome is an unusual finding. CASE DESCRIPTION: In a 46-year-old woman, osteosclerotic changes of the temporoparietal region caused soft tissue induration over this lesion, which initiated further investigation. Imaging studies subsequently showed multiple osteosclerotic foci in the skull. Examination of blood proteins revealed 8 g/L of IgG-lambda monoclonal immunoglobulin, subclass IgG1. In search of the cause of the osteosclerotic changes, FDG-PET/CT was performed, which revealed no FDG accumulation, i.e., no other tumor (breast or stomach cancer). Low-dose CT showed irregular bone structure, but not significant osteolytic or osteosclerotic foci. To map the extent of osteosclerotic changes, NaF-PET/CT imagination followed, which revealed multiple spots with high fluoride accumulation. A parietal bone biopsy showed osteosclerosis with minor clonal plasma cell infiltration. Trepanobioptic bone marrow sampling revealed an infiltration of bone marrow with atypical plasma cells in 8%. Flow-cytometric examination of bone marrow showed 0,37% of plasma cells, however predominantly (91%) clonal with lambda expression. MRI of the brain identified asymptomatic meningeal thickening. There was no evidence of POEMS syndrome in the patient; thus, we concluded the diagnosis as monoclonal gammopathy of clinical significance with osteosclerosis which was previously termed osteosclerotic multiple myeloma. CONCLUSION: Monoclonal gammopathy of clinical significance (MGCS) with osteosclerotic skeletal changes, documented on CT and multiple foci with intensive osteoneogenesis, documented on NaF-PET/CT without evidence of POEMS syndrome, is an extremely rare form of plasma cell dyscrasia. This publication documents the unique clinical manifestations of IgG-lambda type plasma cell proliferation without signs of POEMS syndrome and the role of NaF-PET/CT imaging. Classification of this disease as MGSC with osteosclerotic manifestations is more consistent with the indolent nature of the disease with a significantly better prognosis, compared with multiple myeloma.

Modified Glasgow prognostic score (mGPS) is correlated with sarcopenia and dominates the prognostic role of baseline body composition parameters in advanced gastric and esophagogastric junction cancer patients undergoing first-line treatment from the phase III EXPAND trial.

BACKGROUND: Sarcopenia represents an established adverse prognostic factor in cancer patients. Consequently, different means to counteract sarcopenia have been proposed to improve cancer treatment. Computed tomography (CT)-based measurements, also labor intensive, are well validated for the analysis of sarcopenia. As inflammation plays a key role in the development of sarcopenia, we here studied the role of the modified Glasgow prognostic score (mGPS), consisting of inflammation parameters plasma C-reactive protein (CRP) and albumin, to predicting sarcopenia and adipose tissue-related body composition (BC) parameters at baseline and their changes during treatment and to analyze its prognostic role in conjunction with BC parameters. PATIENTS AND METHODS: CT measurements of BC parameters were carried out at baseline and week 12 in patients with advanced gastric or esophagogastric junction cancer from the phase III EXPAND trial, undergoing first-line platinum-fluoropyrimidine chemotherapy. mGPS was calculated from baseline CRP and albumin plasma levels. Pearson correlation and Cox regression analyses were carried out. RESULTS: mGPS is strongly prognostic for overall survival (OS). Baseline mGPS is significantly correlated with baseline mean muscle attenuation (MA; P < 0.0001). Baseline mGPS did not predict a decline in muscle or adipose tissue parameters during 12 weeks of treatment and a decline in muscle or adipose tissue parameters was not prognostic for OS. MA lost its prognostic role for OS when mGPS or CRP was entered into the Cox models. Eastern Cooperative Oncology Group performance status together with CRP or mGPS remained the sole baseline prognostic factors for OS. CONCLUSIONS: Our findings support a model where tumor-mediated inflammatory response represents a strong prognostic factor, which is causally related to sarcopenia, but with no direct causal path from sarcopenia to survival. Therefore, therapeutic targeting of systemic inflammation should be further explored as a promising strategy to improve both sarcopenia and the efficacy and tolerability of cancer treatment.

Uncommon EGFR Mutations in Non-Small Cell Lung Cancer and Their Impact on the Treatment.

BACKGROUND: Epidermal growth factor receptor (EGFR) mutations play an important role in the pathogenesis of non-small cell lung cancer. Because these alterations are so-called targetable mutations, their identification is important in daily clinical practice. The diagnostic standard of EGFR mutations is currently based on polymerase chain reaction methods, particularly the quantitative real-time polymerase chain reaction. In recent years, new generation sequencing has become increasingly important. In patients with EGFR mutations, a significant improvement in therapeutic outcomes was achieved with the administration of targeted therapy using tyrosine kinase inhibitors. EGFR is composed of four domains: extracellular with a ligand binding site, a transmembrane domain, a cytoplasmic tyrosine kinase catalytic domain, and a C-terminal domain. The key structures of the tyrosine kinase domain responsible for signal activation and transmission are encoded within exons 18-21 on chromosome 7. EGFR mutations are highly heterogeneous. About 90% of EGFR mutations are deletions of exon 19 and point mutation L858R in exon 21. These are referred to as classic mutations. Approximately 10% of the total number of EGFR mutations is attributable to less frequent alterations in the EGFR gene. Due to the low incidence of non-small cell lung cancer with less frequent EGFR mutations, information on their predictive significance is still incomplete. Most of the data for the treatment of cases with uncommon mutations were gathered from retrospective analyses and evaluations of small cohorts. PURPOSE: The aim of this review is to summarise the current options for diagnosing and treating non-small cell lung cancer patients with uncommon EGFR mutations. This work was supported by the MEYS - NPS I - LO1413 and MH CR - DRO (MMCI, 00209805). The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 2. 6. 2019 Accepted: 26. 8. 2019.

[Can we Observe Ethnic Difference in Basic Blood Tests? Single-institution Data from Cancer Prevention Programme in the Czech Republic]. / Je mozné pozorovat etnickou diferenci v základních krevních testech? Údaje z programu onkologické prevence v komplexním onkologickém centru v Ceské republice.

BACKGROUND: Laboratory tests are standard part of a routine check-up of current medical status and an important tool in diagnostic workup, in planning or evaluation of treatment, and disease monitoring. To reduce misdiagnosis, accurate reference intervals reflecting age, sex, ethnicity and other relevant clinical parameters must be established. We aimed to explore ethnic difference in basic blood parameters relevant for the Czech Republic. PATIENTS AND METHODS: The study was performed analyzing blood tests from 13,126 individuals in cancer prevention program. Individuals were divided into two subgroups - 1. Czech, 2. Vietnamese, and laboratory parameters were compared. RESULTS: Statistically significant differences were observed in majority of basic blood tests. These could be explained either by ethnical differences in basic biological parameters (weight, body mass) or dietary habits, such as in case of lower blood cholesterol levels and lower creatinine levels respectively in individuals of Vietnamese origin. Observed differences in erythrocyte-related parameters likely reflect higher incidence of haematogical disorders such as hemoglobinopathies. CONCLUSION: We observed statistically significant difference in basic blood tests between individuals of Czech and Vietnamese origin. Taking into consideration routinely used creatinine-based estimation of glomerular function, the most clinically relevant ethnic-based difference is substantially lower creatinine plasma level in individuals of Vietnamese origin.Key words: lab tests - reference range - ethnic specificity The work was supported by Czech Ministry of Health via DRO 00209805 and by MEYS via NPS I (LO1413). The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 13. 3. 2017Accepted: 26. 3. 2017.

[Molecular Pathology of Colorectal Cancer, Microsatellite Instability - the Detection, the Relationship to the Pathophysiology and Prognosis]. / Molekulární patologie kolorektálního karcinomu, mikrosatelitová nestabilita - zpusob detekce, vztah k patofyziologii a prognóze.

BACKGROUND: Colorectal carcinoma (CRC) is third most common cancer worldwide with very heterogenous character. In most cases, it is caused by sporadic events leading to disruption of epithelial cells of the colon. The minority evolves from germline mutations associated with hereditary cancer syndromes. Mechanisms leading to mutations of oncogenes, tumour suppressors and genes of DNA repair mechanisms include: 1. chromosomal instability, 2. microsatellite instability and 3. CpG island methylator phenotype. Microsatellite instability (MSI) usually arises from a germline mutation of the component of mismatch repair machinery (MMR) or somatic hypermethylation of the MLH1 promoter. The diagnostic approaches include PCR methods and immunohistochemistry for the detection of the loss of MMR part. The aim of our study was to characterise the cohort of ongoing study of gut microbiome in CRC patients considering MSI. MATERIAL AND METHODS: The consecutive study group consisted of 103 patients diagnosed with CRC. The cohort consisted of 45 women (43.7%) and 58 men (56.3%). Patient age at the time of diagnosis was within the range of 31-83 years (median 66 years). The expression of MLH1, MSH2, MSH6 and PMS2 proteins was detected by immunohistochemical method and the positivity was correlated with the stage and the localization of the primary tumour. RESULTS: The MMR status was determined by immunohistochemical method in 43 (41.7%) from the existing total of 103 patients. MSI was detected in 11 (25.6%) cases while 32 (74.4%) were microsatellite stabile. With the respect to cancer clasification the most cases of MSI was detected in stage II (8 cases; 22.2%). In regard to localization of primary tumour, MSI rather correlates to right site CRC, while microsatellite stable tumours do not show any site preferences. CONCLUSION: Considering low number of MMR status determination in study group, statistic evaluation is inaccurate so far. However there is a trend in our cohort in relation to determination of the portion of MSI in CRC population and also in localization of primary tumour according to literature.Key words: colorectal carcinoma - microsatellite instability - Lynch syndrome The work was supported by the project MEYS - NPS I - LO1413 and AZV 16-31966A. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 13. 3. 2017Accepted: 26. 3. 2017.

[Lactate Dehydrogenase - Old Tumour Marker in the Light of Current Knowledge and Preanalytic Conditions]. / Laktátdehydrogenáza - starý nádorový marker ve svetle soucasných poznatku a v preanalytických souvislostech.

With the development and subsequent clinical applications of anticancer immuno-and angiomodulatory therapies and expanded knowledge on significance of tumor microenvironment for disease prognosis and treatment outcome, a classical blood analyte, lactate dehydrogenase (LDH), gains in importance as a tumor marker reflecting to some extent immunosupressive and angiogenic tumour milieu. Physical extravascular hemolysis due to complicated or inaccurate blood sampling interferes strongly with quantification of LDH in serum/plasma samples. Upon correlating circulating hemoglobin level with LDH catalytic activities in 99,937 plasma samples we quantified hemolysis interference with LDH plasma levels. An increment of LDH (µkat/l) caused by hemolysis is equal to 0.002 times circulating hemoglobin level (mg/l). Thus, hemolysis interference can be mathematically subtracted from measured LDH using a formula: [LDH (measured) (µkat/l) - 0.002 × circulating hemoglobin (mg/l) ]. In other words, each increment of hemolysis equal to 100mg/l of circulating hemoglobin will result to LDH increase equal to 0.2 µkat/l. As one of the emerging predictors of treatment outcome, a cancer prognostic biomarker and dynamic tumor marker, serum/plasma LDH concentration needs to be interpreted with respect to reported hemolysis level. Also, for these purposes, quantitative determination of serum/plasma levels of free circulating hemoglobin has to be routinely performed.Key words: lactate dehydrogenase - hemolysis - preanalytical error This work was supported by MEYS via NPS I for RECAMO2020 (LO1413). The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 13. 3. 2017Accepted: 26. 3. 2017.

[Circulating Myeloid Suppressor Cells and Their Role in Tumour Immunology]. / Cirkulující myeloidní supresorové bunky a jejich úloha v nádorové imunologii.

BACKGROUND: Myeloid-derived suppressor cells (MDSCs) are heterogenic population of multipotent progenitors of myeloid lineage. For their immunosuppressive effect, MDSC are responsible for tumour escape from the host immune surveillance. Furthermore, MDSCs support tumour by promotion of angiogenesis and metastasis. Membrane markers of human MDSCs are myeloid markers CD11b and CD13, these cells are HLA-Drlow/- and expression of CD15 or CD14 differentiate them into granulocytic (Gr-MDSCs) and monocytic (Mo-MDSCs), resp. PATIENTS AND METHODS: Using flow cytometry, we investigated Mo-MDSC counts in peripheral blood of non-cancer individuals - control group (n = 61), breast (n = 39) and colorectal (n = 52) cancer patients. These cells were detected as CD45+CD11b+CD33+CD14+HLA-Drlow/- and quantified as percentage of total white blood cells and as absolute count. RESULTS: In control group, circulating Mo-MDSCs was gender-and age-independent and the average value was 1.09% and 0.073 × 109/l. Breast cancer patients had higher circulating Mo-MDSCs compared to control group with average values: 3.57% and 0.229 × 109/l (p < 0.001) and we also observed increase in Mo-MDSC number after granulopoietic growth factors administration (p = 0.043). Colorectal cancer patients had higher average number of circulating Mo-MDSCs compared to control group: 1.71% a 0.125 × 109/l (p = 0.003) and its number did not correlate with tumour clinicopathological stage, localization of primary tumour (colon vs. rectum), site (left vs. right) and microsatellite instability. CONCLUSION: Increased number of MDSCs in circulation and within tumour microenvironment has been associated with immune suppression and tumour progression. Colorectal cancer patients at diagnosis showed higher circulating Mo-MDSCs possibly reflecting immunosuppressive effect of tumour microenvironment. Change of Mo-MDSC number from baseline level need to be evaluated in the context of CRC patients outcome. Recombinant granulopoietic growth factors increase number of circulating Mo-MDSCs and the effect of this phenomenon on cancer prognosis remains to be elucidated.Key words: myeloid-derived suppressor cells - colorectal cancer - breast cancer - immunology - immunosuppression - G-CSF This work was supported by MEYS by NPU I (LO1413), grant AZV 16-31966A and MH DRO 00209805. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 11. 3. 2017Accepted: 26. 3. 2017.

The safety of therapeutic monoclonal antibodies: implications for cancer therapy including immuno-checkpoint inhibitors.

Monoclonal antibody-based treatment of cancer has been established as one of the most successful therapeutic strategies for both hematologic malignancies and solid tumors. In addition to targeting cancer antigens antibodies can also modulate immunological pathways that are critical to immune surveillance. Antibody therapy directed against several negative immunologic regulators (checkpoints) is demonstrating significant success in the past few years. Immune checkpoint inhibitors, ipilimumab, pembrolizumab and nivolumab, have shown significant clinical benefit in several malignancies and are already approved for advanced melanoma and squamous NSCLC. Based on their mechanism of action, these agents can exert toxicities that are unlike conventional cytotoxic chemotherapy, whose nature is close to autoimmune diseases - immune related adverse events (irAEs). In this review we focus on the spectrum of irAEs associated with immune checkpoint antibodies, discussing the pharmacological treatment strategy and possible clinical impact.

[Non-Small Cell Lung Cancer - from Immunobiology to Immunotherapy]. / Nemalobunecný karcinom plic - od imunobiologie k imunoterapii.

BACKGROUND: The treatment of early or locally advanced stages of non-small cell lung cancer (NSCLC) is based on surgical resection or radiotherapy. Metastatic disease is always incurable, treatment is palliative, systemic based on chemotherapy or target therapy. NSCLC is the most common cause of cancer-related death worldwide, and new therapeutic approaches are needed. Based on the emerging data on the role of immune system in shaping of tumor outbreak and outcome, immunotherapy is currently in the center of interest of cancer research and therapy of solid cancers including NSCLC. Various anti-cancer vaccination approaches and antigen-independent immunomodulatory drugs are being developed and trialed. The most advanced in terms of approaching clinical practice are the so-called checkpoint inhibitors blocking cytotoxic T-lymphocyte antigen-4 (CTLA-4) or programmed cell death of the protein and its ligand (PD-1, PD-L1). Beside innovative drug development, the field of cancer immunotherapy focuses on the identification and clinical application of effective biomarkers of clinical efficacy and on the evaluation of combinations of immunotherapeutic drugs or with classical anti-cancer approaches, such as chemotherapy, radiotherapy or with targeted therapy. AIM: In this review, we summarize basic principles of immnobiology of NSCLC in the context of innovative immunotherapeutics, strategy and phase III results of anti-cancer vaccines in NSCLC, results of NSCLC treatment with checkpoint inhibitors, and current challenges in immunotherapy of lung cancers.Key words: non-small cell lung cancer - immunotherapy - cancer vaccines - drug response biomarkersThis work was supported by MEYS - NPS I - LO1413.The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 10. 6. 2016Accepted: 16. 6. 2016.

Time-course pattern of blood 25-hydroxycholecalciferol is a significant predictor of survival outcome in metastatic colorectal cancer: a clinical practice-based study.

Vitamin D deficiency has been implicated in the epidemiology of common malignancies including colorectal cancer. We studied consecutive blood levels of 25-hydroxycholecalciferol (25-OHD) in relation to other clinical and laboratory variables in metastatic colorectal cancer patients to ascertain whether their variations may be prognostic or predictive parameters of survival outcomes. Eighty four patients treated with first-line oxaliplatin-based chemotherapy with or without bevacizumab were included. The patients were enrolled on the intent-to-treat basis considering their performance status, comorbidities and laboratory parameters to be medically apt for intensive chemotherapy. Overall survival and progression-free survival were selected as the primary outcomes. Progression free survival and overall survival medians were 15.4 months and 41.2 months, respectively. The cut-off levels of 40 nmol/l for 25-OHD and 11 µg/l for first CEA were identified to be clinical decision levels stratifying patients to the respective prognostic groups. We found that the most consistent outcome predictors were i) any patient surgery, ii) CEA and, independently, iii) time-related blood levels of 25-OHD. We confirmed fundamental and consistent vitamin D deficiency in metastatic colorectal cancer. We demonstrated that all patients with at least one blood level above 40 nmol/l versus all below this cut-off showed profound differences in their disease outcomes. The primary disease stage or time to metastatic stage did not influence the predictive power of blood 25-OHD levels, implying that the time-course pattern of 25-OHD but not the first single measurement may be an independent prognostic factor.

[Immunological Aspects in Oncology--Circulating γδ T Cells]. / Imunologické aspekty v onkologii--cirkulující γδ T lymfocyty.

γδ T cells present a minor population of the T cell family which basically differs in construction of their T cell receptor (TCR). Thanks to the features of γδ TCR, these cells can acquire unique effector functions and play a specific role (not only) in antitumor immune response. In this article, we describe the basic characteristics of this cell population and their connection to cancer. In the experimental part we performed exploratory analysis of circulating γδ T cells in reference population and comparison with melanoma and breast carcinoma patients. The median percentage of γδ T cells from all lymphocytes was 2.9% (interquartile range-IQR 1.7-4%). The median absolute numbers of γδ cells per liter of blood was 5.05×10(7) (IQR 2.9-7.84×10(7)). The median percentage of γδ cells between all CD3 T cells was 3.9% (IQR 2.3-5.6%). No correlation between γδ T cells levels and gender or age was observed in reference population. Detailed immunophenotyping was also conducted describing representation of memory subsets (using CD45RO and CD27 markers) and presence of surface markers HLADr, CD69, CD25, CD28, CCR7, CTLA 4, ICOS, PD 1L and PD 1 between γδ T cells of the controls and breast carcinoma patients. From this analysis, it is evident that γδ T cells do not represent a uniform population but they differ in surface markers as well as in their effector functions.

[Natural antibodies against α(1,3) galactosyl epitope in the serum of cancer patients]. / Prirozené protilátky proti α(1,3) galaktosylovému epitopu v séru nemocných s maligními nádory.

BACKGROUND: Natural antibodies against saccharide antigens are found in the human serum; most of them are directed against α-galactosyl epitope (Galα1-3Galß1-4GlcNAc-R). Experimental and initial clinical studies show the potential for use of anti-galactosyl antibodies in the immunotherapy of cancer patients with glycolipids containing the α-galactosyl epitope. This therapeutic approach is based on the presence of these antibodies in the serum of cancer patients. Only scarce literature data is available on the incidence of these antibodies in cancer patients. Data is lacking on their amounts and isotype characteristics in different types of cancer. MATERIAL AND METHODS: An ELISA test with a polyacrylamide-conjugated synthetic disaccharide, Galα1-3Galß, has been designed for quantitative detection of anti-galactosyl IgM, IgG, and IgA antibody isotypes. This test was used to screen the sera from 57 patients with breast, colorectal, or panceatic cancer or malignant melanoma and from 145 healthy controls. RESULTS: The serum concentration of anti-galactosyl antibodies (anti-Gal) is gender dependent: anti-Gal IgM antibodies are present in higher titres in healthy women than in healthy men (p < 0.01). Patients with breast, colorectal, or pancreatic cancer or malignant melanoma had comparable serum levels of anti-Gal IgM, IgG, and IgA antibody isotypes to healthy controls. Male patients with colorectal cancer had higher anti-Gal IgA antibodies than healthy men (p< 0.01). CONCLUSION: Comparable concentrations and isotypes of anti-galactosyl antibodies are found in the serum of cancer patients and healthy controls.

[Vitamin D as an important steroid hormone in breast cancer]. / Vitamin D jako významný steroidní hormon u karcinomu prsu.

Vitamin D is the third steroid hormone playing important bio-logical roles in the development of breast cancer. Decreased plasma levels of its 25- hydroxyderivative, 25OHD, display robust associations with higher incidence of breast cancer and shorter overall survival. Although no consensus exists, most authors agree that optimal plasma levels shall be within 75- 150 nmol/ l whereas levels higher than 375 nmol/ l can be potentially toxic with higher risk of hypercalcemia. To date, no data are available on the optimal levels of vitamin D related to the risk of breast cancer development, its phenotype features and the course of the disease. Published studies mostly describe associations among higher levels of 25OHD and lower bio-logically aggressiveness of the tumor. The polymorphism of VDR gene coding for the steroid receptor for vitamin Dmay be associated with higher disease incidence and also be of negative prognostic significance in breast cancer. This review presents an overall summary of the current knowledge and publications on vitamin D and breast cancer.

NKT-like cells are expanded in solid tumour patients.

CD3+ CD56+ NKT-like cells have been shown to produce substantial amounts of pro-inflammatory cytokines and to mediate lysis of malignant cells. Using flow cytometry, we evaluated the absolute NKT-like cell count in peripheral blood from individuals in a reference population and the median number was 0.085 x 10(9)/l. The average number of NKT-like cells in patients with disseminated cancer was 2.65 fold higher than in the reference population. The number of CD3+ CD56+ cells in solid tumour patients who achieved complete remission was comparable to the reference population. In breast cancer patients with initially (prior to therapy) increased number of NKT-like cells, we observed a trend toward longer disease-free survival. Thus we conclude that CD3+ CD56+ NKT-like cells have potential to suppress tumour evasion and are expanded in peripheral blood of some epithelial tumour patients.

The role of platelets in tumour growth.

Platelets, as initial responders to vascular injury, play a very important role in the initial stages of the haemostatic process. While the role of platelets in coagulation has been well studied and documented, their role in other physiological and pathological processes is just emerging. Platelets contain many biologically active molecules and, as they adhere to sites of tumour activated or injured endothelium, many of these molecules are released into the local microenvironment leading to platelet-mediated effects on vascular tone, repair and neo-angiogenesis. Platelets are likely play important roles in the tumour microenvironment that may be thought of as "a wound that never heals".