LA CACHESSIA NEOPLASTICA Prof. Giovanni Mantovani Cattedra di Oncologia Medica Università degli Studi di Cagliari LA CACHESSIA NEOPLASTICA Prof. Giovanni.

LA CACHESSIA NEOPLASTICALA CACHESSIA NEOPLASTICA

Prof. Giovanni MantovaniProf. Giovanni MantovaniCattedra di Oncologia MedicaCattedra di Oncologia Medica

Università degli Studi di CagliariUniversità degli Studi di Cagliari

LA CACHESSIA NEOPLASTICALA CACHESSIA NEOPLASTICA

Prof. Giovanni MantovaniProf. Giovanni MantovaniCattedra di Oncologia MedicaCattedra di Oncologia Medica

Università degli Studi di CagliariUniversità degli Studi di Cagliari

SYMPTOMS OF SYMPTOMS OF CANCER-RELATED CANCER-RELATED

CACHEXIACACHEXIA

anorexiaanorexia

nausea/vomitingnausea/vomiting weight loss weight loss

depletion of both fat depletion of both fat and muscle tissue and muscle tissue

resistance to antineoplastic treatments resistance to antineoplastic treatments and enhancement of their side effectsand enhancement of their side effects

anemiaanemia

immunodepressionimmunodepression

fatiguefatigue

Incidence of weight loss in cancers of different sites (Laviano A, et al. Nature Clinical Practice Oncology (2005) 2, 158-165)

Approximately 2/3 of patients who die with advanced cancer suffer Approximately 2/3 of patients who die with advanced cancer suffer from cancer cachexiafrom cancer cachexia

20% of cancer patients die from effects of malnutrition rather than 20% of cancer patients die from effects of malnutrition rather than from direct effects of malignancyfrom direct effects of malignancy

INCIDENCE OF CANCER CACHEXIA/ANOREXIA SYNDROMEINCIDENCE OF CANCER CACHEXIA/ANOREXIA SYNDROME

Marion M. Support Line. 1998;20:3 Marion M. Support Line. 1998;20:3 Ottery FD. Cancer Pract. 1994;2:123Ottery FD. Cancer Pract. 1994;2:123DeWys WD, et al. Am J Med. 1980;69:491DeWys WD, et al. Am J Med. 1980;69:491

Cancer-induced cachexia is invariably associated with the presence and growth of the tumor.

PATHOGENESIS OF CACS

In addition, the competition for nutrients between tumor and host leads to an accelerated starvation state characterised by

severe metabolic disturbances and hypermetabolism resulting in an increased energetic inefficiency

Neoplastic Cachexia Syndrome

The main factors leading to CACS

anorexia

decreased food intake

metabolic changes (cytokines)

increased REE.

METABOLIC CHANGES:METABOLIC CHANGES:CACHEXIA VS. STARVATIONCACHEXIA VS. STARVATION

Cachexia Starvation

Body Weight – /

Body Cell Mass (Lean Body Mass)

Body Fat

Caloric Intake

Total Energy Expenditure (TEE) –

Resting EE (REE)

Protein Synthesis

Protein Degradation

Proteolysis-Inducing Factor (PIF) YES NO

Adapted from Kotler DP. 2000. Ann Intern Med. 133:622

In cancer patients in advanced stage of disease, a characteristic In cancer patients in advanced stage of disease, a characteristic deregulation of energy metabolism is frequently observed:deregulation of energy metabolism is frequently observed:

increased energy expenditureincreased energy expenditure due to tumor growth and due to tumor growth and activation of the immune system activation of the immune system

- intake of energetic substrates (especially glucose) due intake of energetic substrates (especially glucose) due to symptoms such as anorexia, nausea and vomitingto symptoms such as anorexia, nausea and vomiting

- cytokine-induced metabolic alterations (insuline cytokine-induced metabolic alterations (insuline resistance, etc)resistance, etc)

CHANGES OF ENERGY METABOLISM

GLYCEROL +

FREE FATTY ACIDS

GLUCONEOGENESIS

PROTEIN AND LIPID STORES

CHANGES OF GLUCOSE METABOLISM IN CANCER CACHEXIA

CORI CYCLE

a)

b)

c) IMPAIRED GLUCOSE TOLERANCE

hyperglicaemia

hypoglicaemia

d) INSULIN RESISTANCE

CHANGES OF PROTEIN METABOLISM IN CANCER CACHEXIA

muscle and liver sinthesis of albumin, etc and liver synthesis of acute phase proteins (APP=C Reactive Protein and Fibrinogen)

serum levels of Proteolysis Inducing Factor (PIF) selective muscle wasting

CHANGES OF LIPID METABOLISM IN CANCER CHANGES OF LIPID METABOLISM IN CANCER CACHEXIA CACHEXIA

Lipolysis (fatty acids beta oxidation)Lipolysis (fatty acids beta oxidation)

LipogenesisLipogenesis

Free fatty acids turnover (FFA)Free fatty acids turnover (FFA)

synthesis of free fatty acids (FFA)synthesis of free fatty acids (FFA)

lipoproteinlipase activity lipoproteinlipase activity

HypertrigliceridaemiaHypertrigliceridaemia

HYPERMETABOLISM

In cancer cachexia the decreased caloric intake is not accompanied by a drop in energy expenditure.

Hyltander et al, in a wide population study, have showed that cancer patients have a higher resting energy expenditure as compared with normal controls.

Argiles JM, Med Res Rev, 1999

Resting Resting EnergyEnergy

ExpenditureExpenditure

Glucose production Glucose production and turnoverand turnover

LipogenesisLipogenesis lipolysis lipolysis

Whole body protein turnover

Protein Protein synthesissynthesis

ProteinProtein catabolismcatabolism

APPRAPPR

CATABOLIC MEDIATORS IN CANCER

BOTH TUMOUR-DERIVED AND HUMORAL (CYTOKINES) FACTORS ARE INVOLVED IN MEDIATING ANOREXIA AND METABOLIC CHANGES, CHARACTERISTIC OF THE CACHECTIC STATE.

HUMORAL

PRO CACHECTIC CYTOKINES

TNF, IL-6, IL-1,IFN-

ANTI- CACHECTIC CYTOKINES

IL-4, IL-10, IL-15, sTNFR, sIL-6R

TUMOR-DERIVED

PIF, LMF, ETC..

METABOLIC ALTERATIONS

ANOREXIA

CACHEXIA

TUMORTUMORLYMPHOCYTES

MONOCYTES/

MACROPHAGES

CYTOKINES (IL-1, IL-6, TNF)

CENTRAL NERVOUS SYSTEM LIPID

METABOLISM

GLUCOSE METABOLISM

CRF AND CRF AND SOMATOSTATINESOMATOSTATINE

GH GH ANOREXIA ANOREXIA

IGF-1IGF-1

PROTEOLYSISPROTEOLYSIS

NAUSEA AND VOMITINGNAUSEA AND VOMITING

LIPOPROTEINLIPASELIPOPROTEINLIPASE

LYPOLISIS LYPOLISIS HYPERTRIGLICERIDEMIAHYPERTRIGLICERIDEMIA

ADIPOCYTE SIZEADIPOCYTE SIZE

FAT TISSUEFAT TISSUE

DAMAGE ON DAMAGE ON

PANCREATIC b CELLS PANCREATIC b CELLS

HYPOINSULINEMIAHYPOINSULINEMIA

IMPAIRED GLUCOSE IMPAIRED GLUCOSE METABOLISMMETABOLISM

HYPO/HYPERGLICAEMIAHYPO/HYPERGLICAEMIA

MUSCLE WASTE AND ACUTE-PHASE RESPONSEMUSCLE WASTE AND ACUTE-PHASE RESPONSE

IL-6, TNF, IL-1, IFN-

PROTEINS AA

ACUTE PHASE ACUTE PHASE PROTEINSPROTEINS

AA PROTEIN DEGRADATION

THE MOST PARADIGMATIC METABOLIC DERANGEMENTS INDUCED BY THE THE MOST PARADIGMATIC METABOLIC DERANGEMENTS INDUCED BY THE TUMOR ARE THE ACTIVATION OF PROTEOLYSIS IN SKELETAL MUSCLE AND TUMOR ARE THE ACTIVATION OF PROTEOLYSIS IN SKELETAL MUSCLE AND THE REDISTRIBUTION OF PROTEIN SYNTHESIS IN THE LIVER (THE REDISTRIBUTION OF PROTEIN SYNTHESIS IN THE LIVER ( SYNTHESIS OF SYNTHESIS OF ALBUMIN, ETC AND ALBUMIN, ETC AND CRP, ETC). THESE ALTERATIONS CAN BE INDUCED BY CRP, ETC). THESE ALTERATIONS CAN BE INDUCED BY DIFFERENT CYTOKINESDIFFERENT CYTOKINES

From Tisdale “Cachexia in Medicine” 2004From Tisdale “Cachexia in Medicine” 2004

HYPOTHALAMIC NEUROPEPTIDE CIRCUITRY IN CACS

ANOREXIGENIC NEUROPEPTIDESOREXIGENIC NEUROPEPTIDES

NEUROTENSIN

MELANOCORTIN

CRF

MCH

OREXIN/GALANIN

NPY

AGRP

CART/GLP-I

DECREASED FOOD INTAKE

INCREASED RESTING ENERGY EXPENDITURE

IL-1, IL-6,

TNF-a, IFN-

+

TRYPTOPHAN

SEROTONIN

-

LEPTIN

GHRELIN

PPHHYYSSIIOOLLOOGGYY

CCAACCSS

Leptin; ghrelin

PHYSIOLOGY OF CENTRAL EFFECT OF LEPTIN IN REGULATING NEUROENDOCRINE FUNCTION AND ENERGY

HOMEOSTASIS

food intake

energy expenditure

food intake

energy expenditure

0

10

20

30

40

50

CRP Fbg IL- 6 TNF

alpha

IL- 1 leptin

controls

cancer patients

LEVELS OF C-REACTIVE PROTEIN, FIBRINOGEN, PROINFLAMMATORY CYTOKINES AND LEPTIN IN ADVANCED

CANCER PATIENTS

* p<0.005 in comparison to controls

*

*

*

*

*

*

J Mol Med 2000; 78: 554-561

SERUM LEPTIN LEVELS IN CANCER PATIENTS ACCORDING TO STAGE

0

10

20

30

40

50

60

70

80

Controls stage I - I I stage I I I - IV

*

* p=0.009 Mann-Whitney test: patients versus controls

leptin (ng/ml)

J Mol Med 2001; 79: 406-414

0

10

20

30

40

50

60

controls ECOG 0 ECOG 1 ECOG 2 ECOG 3

leptin

TNF alpha

IL- 6

Lowest ECOG PS (2 and 3) are associated with lowest levels of leptin and Lowest ECOG PS (2 and 3) are associated with lowest levels of leptin and highest levels of proinflammatory cytokines (expecially IL-6). highest levels of proinflammatory cytokines (expecially IL-6).

J Mol Med 2001;79:406-414

SERUM LEVELS OF LEPTIN AND PROINFLAMMATORY SERUM LEVELS OF LEPTIN AND PROINFLAMMATORY CYTOKINES IN CANCER PATIENTS ACCORDING TO CYTOKINES IN CANCER PATIENTS ACCORDING TO

PERFORMANCE STATUSPERFORMANCE STATUS

TumorTumorT-LymphocytesT-Lymphocytes

MacrophagesMacrophages

AnorexiaAnorexia

REEREE

Weight lossWeight loss

CytokinesCytokines

IL-1, IL-,TNFIL-1, IL-,TNF

LOW LEPTIN LEVELSLOW LEPTIN LEVELS

ROSROS

CACS

Hyperphagia

REE

___

CRHCRH

Neuropeptide YNeuropeptide Y

REDUCED FOOD INTAKEREDUCED FOOD INTAKE

AnorexiaAnorexia

ACTIVATED IMMUNE SYSTEM

5-HT, CYTOKINESYTOKINES

emesisemesis

OXIDATIVE STRESSOXIDATIVE STRESS

“Imbalance between oxidants and antioxidants in favor of oxidants”

OO22- -

OHOH

HH22OO22

Enzymatic antioxidants:Enzymatic antioxidants:

Glutathione Peroxidase, Glutathione Peroxidase, Superoxide Dismutase, Catalase Superoxide Dismutase, Catalase

Non enzymatic antioxidants:Non enzymatic antioxidants:

GSH, Lipoic Acid, Vit C, Vit E, GSH, Lipoic Acid, Vit C, Vit E, Flavonoids, CarotenoidsFlavonoids, Carotenoids

MECHANISMS LEADING TO OXIDATIVE MECHANISMS LEADING TO OXIDATIVE STRESS IN CANCER PATIENTSSTRESS IN CANCER PATIENTS

- altered energy metabolismaltered energy metabolism

- reduced food intakereduced food intake - aspecific chronic activation of immune system aspecific chronic activation of immune system

(associated to an excessive production of (associated to an excessive production of proinflammatory cytokines)proinflammatory cytokines)

- use of antineoplastic drugsuse of antineoplastic drugs

Reduced energy intakeReduced energy intake

(especially glucose)(especially glucose)

Nausea/vomitingNausea/vomiting

metabolic alterationsmetabolic alterations

Reduction ofReduction of

antioxidant defences antioxidant defences

(GSH)(GSH)

Impairment of Impairment of

Immune systemImmune system

Free radicalsFree radicals

OXIDATIVEOXIDATIVE STRESSSTRESS

BLOOD LEVELS OF ROS, GPx AND SOD IN 60 CONTROLS BLOOD LEVELS OF ROS, GPx AND SOD IN 60 CONTROLS AND 120 CANCER PATIENTS.AND 120 CANCER PATIENTS.

The box plots in the figure represent columns of data as boxes whose extents The box plots in the figure represent columns of data as boxes whose extents indicate the 25th and the 75th percentile of the column. Capped bars indicate indicate the 25th and the 75th percentile of the column. Capped bars indicate

the min and the max value. p<0.001 versus controls (Student’s t- test)the min and the max value. p<0.001 versus controls (Student’s t- test)

Mantovani G, et al. J Mol Med 2003Mantovani G, et al. J Mol Med 2003

0

10

20

30

40

50

60

70

80

90

100

Controls Stage I I Stage I I I Stage IV

ECOG 0/1

Stage IV

ECOG 2/3

0

2000

4000

6000

8000

10000

12000

Controls Stage I I Stage I I I Stage IV

ECG 0/1

Stage IV

ECOG 2/3

*

Results are expressed as Results are expressed as mean values.mean values.

* p<0.05 as calculated with * p<0.05 as calculated with Student’s t-test in Student’s t-test in comparison to controlscomparison to controls

ERYTHROCYTE ACTIVITY OF SOD AND GPx IN CANCER ERYTHROCYTE ACTIVITY OF SOD AND GPx IN CANCER PATIENTS ACCORDING TO STAGE AND PERFORMANCE STATUSPATIENTS ACCORDING TO STAGE AND PERFORMANCE STATUS

U/L whole U/L whole bloodblood

U/ml whole U/ml whole bloodblood

SODSOD

GPxGPx

Mantovani G, et al. Int J Cancer, 2002Mantovani G, et al. Int J Cancer, 2002

*

MEGESTROL ACETATE IN NEOPLASTIC MEGESTROL ACETATE IN NEOPLASTIC ANOREXIA/CACHEXIA: CLINICAL EVALUATION AND ANOREXIA/CACHEXIA: CLINICAL EVALUATION AND

COMPARISON WITH CYTOKINE LEVELS IN COMPARISON WITH CYTOKINE LEVELS IN PATIENTS WITH HEAD AND NECK CARCINOMA PATIENTS WITH HEAD AND NECK CARCINOMA

TREATED WITH NEOADJUVANT CHEMOTHERAPY.TREATED WITH NEOADJUVANT CHEMOTHERAPY.

Mantovani G, et al. Mantovani G, et al.

Int. J. Clin. Lab. Res. 25, 135-141, 1995Int. J. Clin. Lab. Res. 25, 135-141, 1995

11 male patients were enrolled in the study and were treated with 11 male patients were enrolled in the study and were treated with MA during neoadjuvant chemotherapyMA during neoadjuvant chemotherapy

Mantovani G, et al. Mantovani G, et al. Int. J. Clin. Lab. Res., 1995Int. J. Clin. Lab. Res., 1995

SERUM LEVELS OF IL-1SERUM LEVELS OF IL-1, IL-1, IL-1, IL-2, IL-6, TNF, IL-2, IL-6, TNF AND sIL- AND sIL-2R IN CANCER PATIENTS BEFORE AND AFTER 2R IN CANCER PATIENTS BEFORE AND AFTER

CHEMOTHERAPY + MA TREATMENTCHEMOTHERAPY + MA TREATMENT

0

10

20

30

40

50

60

I L-1

alpha

I L-1

beta

I L-2 I L-6 TNF

alpha

sI L-

2R

bef ore treatment

af ter treatment

Results are expressed as mean values.Results are expressed as mean values.

*p<0.05 as calculated with Student’s *p<0.05 as calculated with Student’s tt test in comparison to test in comparison to controls. N.S. non significantcontrols. N.S. non significant

**

N.S

N.S

N.S N.S

MEDROXYPROGESTERONE ACETATE REDUCES MEDROXYPROGESTERONE ACETATE REDUCES THE IN VITRO PRODUCTION OF CYTOKINES THE IN VITRO PRODUCTION OF CYTOKINES

AND SEROTONIN INVOLVED IN AND SEROTONIN INVOLVED IN ANOREXIA/CACHEXIA AND EMESIS BY PBMC OF ANOREXIA/CACHEXIA AND EMESIS BY PBMC OF

CANCER PATIENTS.CANCER PATIENTS.

Mantovani G, et al.

Eur J Cancer 33, 602-607, 1997

EFFECT OF MEDROXYPROGESTERONE ACETATE ON CYTOKINES EFFECT OF MEDROXYPROGESTERONE ACETATE ON CYTOKINES AND 5-HT PRODUCTION BY PBMC OF ADVANCED CANCER AND 5-HT PRODUCTION BY PBMC OF ADVANCED CANCER

PATIENTSPATIENTS

0

1000

2000

3000

4000

5000

6000

7000

Cyt

okin

es (

pg/

mL

); 5

-HT

(n

M/m

L)

IL-1 beta IL-6 TNFalpha

IL-2 5-HT

Controls PHA-stimulatedPBMC

Patients PHA-stimulatedPBMC

Patients PHA+MPA (0,2microg/ mL) stimulatedPBMC

Results are expressed as mean values.*p<0.05, calculated with Student’s t test versus controls § p<0.05, calculated with Student’s t test versus PHA-stimulated patients PBMC

*

Mantovani G, et al. Eur J Cancer, 1997Mantovani G, et al. Eur J Cancer, 1997

*

*

*

*

§

§

§

§

CANCER-RELATED ANOREXIA/CACHEXIA SYNDROME AND OXIDATIVE CANCER-RELATED ANOREXIA/CACHEXIA SYNDROME AND OXIDATIVE STRESS: AN INNOVATIVE APPROACH BEYOND CURRENT TREATMENTSTRESS: AN INNOVATIVE APPROACH BEYOND CURRENT TREATMENTCANCER-RELATED ANOREXIA/CACHEXIA SYNDROME AND OXIDATIVE CANCER-RELATED ANOREXIA/CACHEXIA SYNDROME AND OXIDATIVE STRESS: AN INNOVATIVE APPROACH BEYOND CURRENT TREATMENTSTRESS: AN INNOVATIVE APPROACH BEYOND CURRENT TREATMENT

Giovanni Mantovani, Clelia Madeddu, Antonio Macciò, Giulia Gramignano, Maria Rita Lusso, Elena Massa, Giorgio Astara and

Roberto Serpe Department of Medical Oncology, University of Cagliari, Italy

Cancer Epidemiol Biomarkers and Prev 2004; 13:1651-1659

Cancer Epidemiol Biomarkers and Prev 2006; 15:1030-1034

AIM OF THE STUDYAIM OF THE STUDY

CACS and Oxidative Stress (OS) play a key role in the progression and outcome of the neoplastic disease: their appearance and worsening are very important negative prognostic factors in the progression of cancer.

Aim of the study was to test the EFFICACY AND SAFETYEFFICACY AND SAFETY of an integrated treatment based on diet, p.o. pharmaconutritional support, and drugs in a population of advanced cancer patients with CACS/OS.

The efficacy was assessed in terms of:- clinical response- improvement of nutritional and functional variables- changes of laboratory variables (as indicators of CACS/OS)- and improvement of quality of life (QL).

The ultimate goalultimate goal of our study should be that of translating the results obtained on CACS/OS symptoms found in advanced cancer patients into a prevention trial in a population of individuals at risk of developing CACS/OS.

The trial design was:

AN OPEN NON RANDOMIZED PHASE II STUDYAN OPEN NON RANDOMIZED PHASE II STUDY

On the basis of the Simon two-stage design for phase II studies,

considering as P0 (i.e. non effective treatment) a total response 40% of patients, and as P1 (i.e. effective treatment) a total response 60% of patients,

the treatment has to be considered effective if at least 18/34 patients demonstrate a response in the first stage,

while in the second stage 21/39 patients should demonstrate a response.

STUDY DESIGN- PHASE II STUDYSTUDY DESIGN- PHASE II STUDY

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

PATIENT ELIGIBILITY CRITERIA:PATIENT ELIGIBILITY CRITERIA:

18 to 80 years old

hystologically confirmed tumors of any site especially cancers inducing early CACS (head and neck and gastrointestinal cancer)

patients with the following nutritional characteristics: 1) patients who had lost at least 5% of ideal or pre-illness body weight in the last 3 months (clinical CACS); 2) and/or with abnormal values of proinflammatory cytokines, ROS and antioxidant enzymes predictive of the onset of CACS

patients treated with either antineoplastic therapy with curative or palliative intent or supportive care

patients with a life expectancy > 4 months.

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

PATIENT EXCLUSION CRITERIA:PATIENT EXCLUSION CRITERIA:

pregnancy

significant comorbidities

Impaired food intake due to mechanical obstruction

medical treatments inducing significant changes of patient metabolism or body weight such as enteral or parenteral nutrition, corticosteroids, insulin, or any other drug potentially capable of influencing body weight.

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

TREATMENT PLANTREATMENT PLAN

1. diet with . diet with high poliphenols content (400 mg)high poliphenols content (400 mg) obtained by obtained by alimentary sources (onions, apples, oranges, red wine, or green tea) alimentary sources (onions, apples, oranges, red wine, or green tea) or supplemented by tablets per os;or supplemented by tablets per os;

2.2. pharmaco-nutritional support enriched with pharmaco-nutritional support enriched with n-3 PUFAn-3 PUFA containing EPA containing EPA and DHA;and DHA;

3. oral progestagen:3. oral progestagen: medroxyprogesterone acetate 500 mg/daymedroxyprogesterone acetate 500 mg/day;;

4. 4. antioxidant treatmentantioxidant treatment with alpha lipoic acid 300 mg/day + with alpha lipoic acid 300 mg/day + carboxycysteine lysine salt 2.7 g/day + vitamin E 400 mg/day + carboxycysteine lysine salt 2.7 g/day + vitamin E 400 mg/day + vitamin A 30000 IU + vitamin C 500 mg/day. vitamin A 30000 IU + vitamin C 500 mg/day.

5.5. Selective Selective COX-2 inhibitorCOX-2 inhibitor:: Celecoxib 200 mg/day orally Celecoxib 200 mg/day orally

The planned treatment duration is 16 weeks.The planned treatment duration is 16 weeks.

On the basis of several of our previously published studies and our clinical experience we have developed an innovative approach which consists of an integrated nutritional and pharmacological treatment:

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

RATIONALE FOR SELECTED AGENTSRATIONALE FOR SELECTED AGENTS

1. The polyphenols, in particular quercetin have been included for their high activity as antioxidants.

2. The oral dietary supplement has the objective to integrate the energetic/proteic intake with the supplementation of n-3 PUFA, which are able to inhibit cytokine production (TNFa).

3. The treatment with medroxyprogesterone acetate has the objective to inhibit the cytokine production and to act positively on patients cenestesis: our previous experimental and clinical experience with MPA supports this choice.

4. The selected antioxidant treatment has been demonstrated effective in reducing blood levels of ROS and increasing blood levels of physiological antioxidant enzymes in a series of our published papers.

5. The COX-2 selective inhibitor Celecoxib has been chosen for its ability, demonstrated both in experimental and in clinical studies, to inhibit cancer-related inflammatory mediators (PGE2), angiogenesis and therefore cancer progression as well as CACS causal factors.

EFFICACY VARIABLES:EFFICACY VARIABLES:

The following The following CLINICAL VARIABLESCLINICAL VARIABLES have been evaluated and the have been evaluated and the following changes were to be considered as significant for response:following changes were to be considered as significant for response:

Objective clinical response before and after treatment: Objective clinical response before and after treatment: improvement or disease stabilityimprovement or disease stability

Performance status according to ECOG scale before and after Performance status according to ECOG scale before and after treatment: improvement of 1 unittreatment: improvement of 1 unit

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

EFFICACY VARIABLES:EFFICACY VARIABLES:

The following NUTRITIONAL/FUNCTIONALNUTRITIONAL/FUNCTIONAL variables have been evaluated and the following changes were to be considered as significant for response:

Body Weight: increase of at least 5%

Lean Body Mass (LBM) by BIA: increase of at least 10%

Appetite evaluated by analogue visual scale (VAS): an increase of at least 2 units;

REE by indirect calorimetry: a decrease of at least 10%

grip strenght by dinamometer: an increase of at least 30%

EFFICACY VARIABLES:EFFICACY VARIABLES:

The following The following LABORATORY variablesLABORATORY variables have been evaluated and have been evaluated and the following changes were to be considered as significant for the following changes were to be considered as significant for response:response:

blood levels of blood levels of reactive oxygen species (ROS):reactive oxygen species (ROS): a decrease of at a decrease of at least 80-100 Fort U in comparison to baseline values; least 80-100 Fort U in comparison to baseline values;

erythrocyte levels of erythrocyte levels of glutathione peroxidase (GPx):glutathione peroxidase (GPx): an increase an increase of at least 2000 Units (50%) in comparison to baseline.of at least 2000 Units (50%) in comparison to baseline.

serum levels of proinflammatory serum levels of proinflammatory cytokines (cytokines (IL-6 and TNF IL-6 and TNF ): a decrease of ): a decrease of at least 25% in comparison to baseline at least 25% in comparison to baseline values; values;

serum serum leptin levelsleptin levels: an increase of at : an increase of at least 100% in comparison to baseline least 100% in comparison to baseline values ;values ;

by ELISA ASSAY

EFFICACY VARIABLES:EFFICACY VARIABLES:

The following The following QUALITY OF LIFEQUALITY OF LIFE variables have been evaluated and the variables have been evaluated and the following changes were to be considered as significant for response:following changes were to be considered as significant for response:

EORTC QLQ-C30: an increase of at least 25% of the score

EQ-5D INDEX and VAS: an increase of at least

25% of the score

Multidimensional Fatigue Symptom Inventory-Short Form is a 30-item questionnaire evaluating the principal manifestations of fatigue: a decrease of at least 25% of the score

PATIENT CHARACTERISTICS

No. %Patients evaluable 39

M/F: 23/16Mean age 58.9 y, range 42-78Mean weight 55.8 kgs, range 36-76Body mass index (kg/m2)<18.5 9 23.118.5-25 25 64.1>25 5 12.8

StageIIIA 1 2.6IV 38 97.4

Performance Status (ECOG) ECOG 0 2 5.1 ECOG 1 27 69.2 ECOG 2 10 25.7

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

PATIENT CHARACTERISTICS: TUMOR SITES

0 5 10 15 20

head and neck

lung

breast

ovary

stomach

pancreas

uterine sarcoma

kidney

number of patients

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

BODY WEIGHT AND LEAN BODY MASS (LBM) CHANGE AFTER 1, BODY WEIGHT AND LEAN BODY MASS (LBM) CHANGE AFTER 1, 2 AND 4 MONTHS OF TREATMENT COMPARED TO BASELINE2 AND 4 MONTHS OF TREATMENT COMPARED TO BASELINE

-1

0

1

2

3

4

5

6

7

8

1 month 2 months 4 months

weight

LBM

dry LBM

kg

Bars represent the mean increase in comparison to baseline (0). Significance was evaluated by Student’ s t -test for paired data. N.S., not significant

p=0.001

39 patients were evaluable after 1 , 2 and 4 months of treatment

p=0.036N.S. p=0.045

p=0.031

N.S.N.S.

p=0.024p=0.011

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

PROINFLAMMATORY CYTOKINES AND LEPTIN BEFORE AND PROINFLAMMATORY CYTOKINES AND LEPTIN BEFORE AND AFTER 1, 2 AND 4 MONTHS OF TREATMENTAFTER 1, 2 AND 4 MONTHS OF TREATMENT

0

5

10

15

20

25

I L- 6 TNF alfa Leptin

baseline

1 month

2 months

4 months

Results are expressed as mean values. Significance was calculated by Student’ t test for paired data. N.S. not significant

pg/ml

pg/ml

ng/ml

p=0.0006p=0.01

p=0.016

N.S.

p=0.021

p=0.011 P<0.0001

39 patients were evaluable after 1 , 2 and 4 months of treatment

p=0.025p=0.016

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

BLOOD LEVELS OF REACTIVE OXYGEN SPECIES (ROS) AND BLOOD LEVELS OF REACTIVE OXYGEN SPECIES (ROS) AND GLUTATHIONE PEROXIDASE (GPx) BEFORE AND AFTER 1, GLUTATHIONE PEROXIDASE (GPx) BEFORE AND AFTER 1,

2 AND 4 MONTHS OF TREATMENT2 AND 4 MONTHS OF TREATMENT

250

300

350

400

450

500

550

ROS

baseline 1 month 2 months 4 months

Results are expressed as mean values. Significance was calculated by Student’ t test for paired data. N.S. not significant

Fort U

4000

5000

6000

7000

8000

9000

10000

GPx

baseline 1 month 2 months 4 months

U/lN.S. N.S.

N.S.N.S N.S

39 patients were evaluable after 1 , 2 and 4 months of treatment

p=0.033

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

-15

-10

-5

0

5

10

15

20

25

30

PT MG CG

Patients

Baseline

2 months

4 months

Change of Resting Energy Expenditure in 3 ouf of 5 patients studied with indirect calorimetry before and after treatment

Bars represent the observed minus expected values of REE

REE values

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

EVALUATION OF APPETITE AND QUALITY OF LIFE AFTER 1 EVALUATION OF APPETITE AND QUALITY OF LIFE AFTER 1 MONTH, 2 AND 4 MONTHS OF TREATMENTMONTH, 2 AND 4 MONTHS OF TREATMENT

QuestionnaireQuestionnaire baseline baseline 1 month1 month 2 months2 months 4 months4 months

VAS-APPETITEVAS-APPETITE 5.5± 2.5 6.6 ± 2.2* 6.8 ± 1.9* 7.0 ± 1.6*

EORTC-QLQ C30EORTC-QLQ C30 66 ± 16.4 72.4 ± 15.6* 71.8± 14.6* 70.9 ± 14.6*

EQ-5D indexEQ-5D index 0.50 ± 0.4 0.58 ± 0.4 0.56 ± 0.4 0.59 ± 0.4

EQ-5D vasEQ-5D vas 49.4 ± 21.4 58.9 ± 22.7* 58.6± 20.6* 58.7± 19.4 *

MSFI-SFMSFI-SF 20.1 ± 22.1 20.1 ± 22.1 14.4 ±20.3 14.4 ±20.3 11.8 ± 17.211.8 ± 17.2** 10.8 ± 14.4 10.8 ± 14.4**

Results are espressed as mean score ± SD. Significance was calculated in comparison to baseline by Student’s t-test for paired data. ** p<0.05 p<0.05

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

CORRELATION BETWEEN LBM CHANGES AND CHANGES OFCLINICAL, NUTRITIONAL/FUNCTIONAL, LABORATORY AND

QUALITY OF LIFE VARIABLES

Spearman’s r pCLINICAL

ECOG PS -0.09 0.568

NUTRITIONAL/FUNCTIONALAPPETITE 0.08 0.664GRIP STRENGHT 0.01 0.949

LABORATORYIL-6 -0.40 0.013TNFa -0.17 0.321LEPTIN +0.26 0.121ROS 0.11 0.529GPx 0.05 0.747

QL QUESTIONNAIRESEORTC QLQ C30 0.17 0.303EQ-5D INDEX 0.02 0.913EQ-5D VAS 0.28 0.097MSFI-SF 0.21 0.271

THE CONCLUSIVE ANALYSIS ON 39 PATIENTS WHO HAVE THE CONCLUSIVE ANALYSIS ON 39 PATIENTS WHO HAVE COMPLETED THE TREATMENT SHOWED COMPLETED THE TREATMENT SHOWED

17 PATIENTS “RESPONDERS”17 PATIENTS “RESPONDERS”

AND AND 5 “HIGH RESPONDERS”5 “HIGH RESPONDERS”

THE 22/39 “RESPONDERS” PATIENTS DEMONSTRATE THE THE 22/39 “RESPONDERS” PATIENTS DEMONSTRATE THE EFFICACY OF TREATMENT.EFFICACY OF TREATMENT.

THE MINIMUM REQUIRED ACCORDING TO THE SIMON’S DESIGN THE MINIMUM REQUIRED ACCORDING TO THE SIMON’S DESIGN WAS 21/39“RESPONDERS”.WAS 21/39“RESPONDERS”.

ASSESSMENT OF “RESPONDERS” ASSESSMENT OF “RESPONDERS” AND “NON RESPONDERS”AND “NON RESPONDERS”

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

The treatment has demonstrated to be EFFECTIVE as for:

- increase of body weight

- increase of lean body mass- increase of lean body mass

-decrease of proinflammatory cytokines

-improvement of quality of life parameters

- amelioration of fatigue symptom

The treatment has demonstrated to be

SAFE with good compliance of patients.

CONCLUSIONSCONCLUSIONS

Mantovani G, et al Cancer Epidemiol, Biomarkers and Prev,

2004, 13:1651-9 and 2006,15:1030-4

A phase III randomised study has started in February 2005 as a multicenter trial.

AIM OF THE STUDY:AIM OF THE STUDY: to demonstrate which is/are the most effective treatment or

treatments for CACS in terms of amelioration of some “key” of CACS, i.e. LBM, resting energy expenditure, daily physical

activity, proinflammatory cytokines and quality of life parameters.

STUDIO CLINICO RANDOMIZZATO DI FASE III PER VALUTARE L'EFFICACIA E LA TOLLERABILITÀ DI UN TRATTAMENTO INTEGRATO (DIETETICO, FARMACO-

NUTRIZIONALE E FARMACOLOGICO) IN PAZIENTI NEOPLASTICI CON CACS E STRESS OSSIDATIVO.

PATIENT ELIGIBILITY CRITERIA:PATIENT ELIGIBILITY CRITERIA:

18 to 80 years old

hystologically confirmed tumors of any site especially cancers inducing early CACS (head and neck and gastrointestinal cancer)

patients with the following nutritional characteristics: 1) patients who had lost at least 5% of ideal or pre-

illness body weight in the last 3 months (clinical CACS); 2) and/or with abnormal values of proinflammatory

cytokines, ROS and antioxidant enzymes predictive of the onset of CACS

patients treated with either antineoplastic therapy with curative or palliative intent or supportive care

patients with a life expectancy > 4 months.

PATIENT EXCLUSION CRITERIA:PATIENT EXCLUSION CRITERIA:

pregnancy

significant comorbidities

Impaired food intake due to mechanical obstruction

controindications to use of MPA such as positive history of thromboembolic event and deep venous thrombosis

medical treatments inducing significant changes of patient metabolism or body weight, such as enteral or parenteral nutrition, corticosteroids, insulin, etc..

TREATMENT PLANTREATMENT PLAN

Patients will be randomised to the following 5 arms of treatment. Patients will be randomised to the following 5 arms of treatment.

Poliphenols (300 mg/day) + antioxidants agents (alpha lipoic acid Poliphenols (300 mg/day) + antioxidants agents (alpha lipoic acid 300 mg/day + carbocysteine 2.7 g/day + vitamin E 400 mg/day 300 mg/day + carbocysteine 2.7 g/day + vitamin E 400 mg/day + vitamin A 30000 IU + Vitamin C 500 mg/day) are the basic + vitamin A 30000 IU + Vitamin C 500 mg/day) are the basic treatment. treatment.

The following components all orally The following components all orally are added to each arm: are added to each arm: Arm 1. Medroxyprogesterone acetate (MPA) 500 mg/day. Arm 1. Medroxyprogesterone acetate (MPA) 500 mg/day. Arm 2. Pharmaco-nutritional support containing EPA, 2-3 Arm 2. Pharmaco-nutritional support containing EPA, 2-3 briks/daybriks/dayArm 3. L-carnitine 4 g/day.Arm 3. L-carnitine 4 g/day.Arm 4. Thalidomide 200 mg/dayArm 4. Thalidomide 200 mg/dayArm 5. MPA + Pharmaco-nutritional support + L-carnitine + Arm 5. MPA + Pharmaco-nutritional support + L-carnitine + ThalidomideThalidomide

The planned treatment duration is 16 weeks.The planned treatment duration is 16 weeks.

Fatigue is a multidimensional symptom that is described in terms of perceived energy, mental capacity, and psychological status: it can impair daily functioning and lead to negative effects on quality of life.

AIM OF THE STUDY: to test the efficacy and safety of LC supplementation in a population of patients who had advanced cancer and developed fatigue, high blood levels of reactive oxygen species, or both.

OUTCOME MEASURES: - fatigue and quality of life - nutritional status- laboratory variables: levels of reactive oxygen species,glutathione peroxidase, and proinflammatory cytokines

TREATMENT PLAN:L-Carnitine was administered orally at 6 g/day for 4 weeks.

From March to July 2004, 12 patients who had advanced tumors (50% at stage IV) at different sites were enrolled

(M/F ratio 2:10, mean age 60 y, range 42–73).

RESULTS

0

5

10

15

20

25

30

t0 t1 t2

0

20

40

60

80

t0 t1 t2

0

1

2

3

4

5

6

7

t0 t1 t2

MFSI-SF

EQ-5D VAS

APPETITE (VAS)

36

37

38

39

40

41

t0 t1 t2

LEAN BODY MASS

KEY VARIABLESKEY VARIABLES

Nutritional/Functional:Nutritional/Functional: - - lean body masslean body mass; ;

- - grip strenght; grip strenght;

- resting energy expenditure- resting energy expenditure

- total daily physical activity and - total daily physical activity and related energy related energy expenditureexpenditure

Laboratory:Laboratory: - Proinflammatory cytokines IL-6 and TNF - Proinflammatory cytokines IL-6 and TNF ;;

Quality of LifeQuality of Life:: - - fatigue assessed by Multidimensional Fatigue fatigue assessed by Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF) Symptom Inventory Short Form (MFSI-SF)

STATISTICAL ANALYSISSTATISTICAL ANALYSIS

Hypothesizing a difference between arms of 20%, considering an alpha type error of 0.05 and a beta type error of 0.20, 95 patients will be enrolled for each arm for a total of 475 patients.

The efficacy of each arm versus the other ones will be made comparing the arms by the ANOVA t-test for repeated measures (or the Kruskall-Wallis test for non parametric variables) for the "key variables".

Moreover, the benefit obtained by the patients enrolled in each arm following the treatment will be evaluated using the paired Student's t test or Wilcoxon Signed Rank test when appropriate (pre-treatment vs post-treatment values).

Survival (overall survival and progression-free survival) will be evaluated starting from the date of enrollment in the study using the Kaplan-Meier method.

PATIENT CHARACTERISTICS

No. %Patients enrolled at October 2006 111

M/F: 45/36Mean age 61 y, range 35-81Mean weight 58.0 kgs, range 38-62Body mass index (kg/m2)<18.5 13 11.718.5-25 88 79.3>25 10 9.0

Stage III 6 5.4 IV 105 94.6

Performance Status (ECOG) ECOG 0 3 2.7 ECOG 1 57 51.4 ECOG 2 49 44.1 ECOG 3 2 1.8

PATIENT CHARACTERISTICS: TUMOR SITESPATIENT CHARACTERISTICS: TUMOR SITES

0 5 10 15 20

pancreasbreast

colorectalovary

stomachhead and neck

lunguterus

biliary ductbladderkidney

LNHneuroendocrine

thymomaprostate

peritonealoesophagus

melanoma

number of patients

RANDOMIZATION

0 5 10 15 20 25 30

ARM 1

ARM 2

ARM 3

ARM 4

ARM 5

number of patients

CHANGES OF BODY COMPOSITION DURING TREATMENT:

AN EXAMPLE

FAT MASS: +0.8 KG

BODY CELL MASS:+2.5 KG

Phase angle at baseline: 3.1

Phase angle at the end of treatment: 3.9

CHANGES OF PHASE ANGLE DURING TREATMENT:

AN EXAMPLE

CHANGE OF TOTAL DAILY PHYSICAL ACTIVITY CHANGE OF TOTAL DAILY PHYSICAL ACTIVITY AND RELATED ENERGY EXPENDITUREAND RELATED ENERGY EXPENDITURE

BASELINE

Total energy expenditure (TEE)=1677 Kcal

Step count = 1273

Physical activity = 6 minutes

AFTER 2 MONTHS OF TREATMENT

Total energy expenditure (TEE)=1677 Kcal

Step count = 1273

Physical activity = 6 minutes

Center already included in the study:

-Oncologia Medica 1 Policlinico Universitario, Cagliari (Prof. Mantovani)

- Oncologia Medica 2 Policlinico Universitario, Cagliari (Prof. Massidda)

- Oncologia Medica 2, Ospedale Businco, Cagliari (Dott. Floris)

- O. Oncologia Clinica, Azienda Ospedaliera Universitaria, Ferrara (Dott. Lelli)

- Dipartimento di Gastroenterologia, Università degli Studi di Bari (Dott. Guglielmi)

PARTICIPATING CENTERS

Thank you for your attentionand interest!