B-cell depletion is a new strategy for treating patients with rheumatoid arthritis (RA). In the past years, several studies have proven the efficacy of anti-CD20 mediated B-cell depletion with rituximab (Mabthera®) in RA patients who failed TNF-blocking therapy. The important role of B-cells in the pathogenesis of RA is deducted from the specific detection of autoantibodies in RA and infiltration of B-cells and plasma cells in inflamed synovium. Pharmacological studies in RA patients treated with rituximab showed that half-life was approximately 3 weeks leading to a 6- to 8-month period of B-cell depletion in peripheral blood. Rituximab treatment led to significant improvements in disease activity of RA patients and the current review summarizes the results from phase III, randomized clinical trials that have been performed. Lastly, data on safety and quality of life are summarized. Although relatively low numbers of RA patients have been treated and long-term data are lacking, current data thus far suggest a relatively good safety profile for rituximab. Future studies will need to focus on predicting responsiveness to rituximab, investigating efficacy of re-treatment with rituximab and extending data on safety and patient-focused outcomes.

Respiratory diseases provide an attractive target for gene silencing using small nucleic acids since the respiratory epithelium can be reached by inhalation therapy. Natural surfactant appears to facilitate the uptake and distribution of these types of molecules making aerosolized nucleic acids a possible new class of therapeutics. This article will review the rationale for the use of External Guide Sequence (EGS) in targeting specific mRNA molecules for RNase P-mediated intracellular destruction. Specific destruction of target mRNA results in gene-specific silencing similar to that instigated by siRNA via the RISC complex. The application of EGS molecules specific for influenza genes are discussed as well as the potential for synergy with siRNA. Furthermore, EGS could be adapted to target other respiratory diseases of viral etiology as well as conditions such as asthma.

Medullary thyroid carcinoma (MTC), a neuroendocrine tumor arising from the thyroid gland, is known to be poorly responsive to conventional chemotherapy. The root of Stemona tuberosa Lour, also called Bai Bu, is a commonly used traditional Chinese anti-tussive medicine. The present study investigated this medicinal herb for the first time with respect to its anticancer activity in human medullary thyroid carcinoma cells. Four extracts of Stemona tuberosa Lour, including the n-hexane fraction, (ST-1), dichloromethane (DCM) fraction, (ST-2), ethyl acetate (EtOAc) fraction, (ST-3), and methanol fraction, (ST-4) were examined for antiproliferative effects in two MTC cell lines. We observed that only the DCM fraction ST-2 inhibited cell growth and viability in a dose-dependent manner. Furthermore, we found that ST-2 also induced the apoptosis of MTC-SK cells. Caspase-3/7 was activated, while caspase-9 was not, implying that at least a caspase-dependent apoptotic pathway was involved in this process. In addition, the multicellular spheroids of MTC-SK were destroyed and the cell morphology was changed by ST-2. Our results show the strong apoptotic effects of the DCM fraction of Stemona tuberosa Lour on human medullary thyroid carcinomas, so suggesting a new candidate for chemotherapy of the so far chemo-resistant medullary thyroid carcinoma.

Although the advent of infliximab has changed the treatment paradigm and goals in inflammatory bowel diseases (IBD), it does not provide a cure for IBD and recent evidence has demonstrated that the immunogenicity of this chimeric anti-TNF antibody is associated with secondary loss of response and intolerance. In ulcerative colitis (UC) the efficacy of infliximab was demonstrated in two large clinical trials, but long-term maintenance efficacy data are lacking. Novel biological agents have entered clinical development and pioneering trials have been reported in the last two years. For Crohn’s disease (CD) two anti-TNF agents, the fully human IgG1 anti-TNF monoclonal adalimumab and the humanized pegylated Fab-fragment certolizumab-pegol and the humanized anti α4 integrin IgG4 antibody both have demonstrated efficacy as maintenance agents. Adalimumab has been approved to treat active rheumatoid arthritis, psoriatric arthritis, and ankylosing spondylitis, and recently moderate-to-severe luminal CD has been added as an indication for this agent both by the FDA and EMEA. Further evidence is needed to establish the therapeutic potential of adalimumab in fistulizing CD and in UC. The benefit to risk ratio of anti-TNF agents in refractory IBD is clearly positive and since most of the toxicity is class specific, adalimumab is expected to have a safety profile similar to that of infliximab except for adverse events related to infusions.

Aptamers are nucleic acid ligands which have been validated to bind to epitopes with a specificity similar to that of monoclonal antibodies. Aptamers have been primarily investigated for their direct function in terms of inhibition of protein targets; however, recent evidence gives reason to actively explore aptamers as targeting moieties for delivery of anticancer therapeutics. Many aptamers have been developed to bind to extracellular membrane domains of proteins overexpressed on cancer cells and have the potential to be modified for use in targeting cancer therapeutics. The use of DNA vector-based short hairpin RNA (shRNA) for RNA interference (RNAi) is a precise means for the disruption of target gene expression but its clinical usage in cancer is limited by obstacles related to delivery into cancer cells. Nucleic acid aptamers are attractive candidates for targeting of shRNA therapies. Their small size, ease of production and modification, and high specificity are valued attributes in comparison to other targeting moieties currently being tested. Here we review the development of aptamers directed to PSMA, Nucleolin, HER-3, RET, TN-C, and MUC1 and focus on their potential for use in targeting of shRNA-based cancer therapeutics.

Acute respiratory distress syndrome (ARDS) is a potential lethal disease. At present time no evidence based intervention reduces mortality. The pathophysiology of ARDS include intraalveolar fibrin deposition, hyperinflammation and reduced cellular host defense in the airspace. The normal lung activates protein C (PC) to activated protein C (APC), in contrast to the ARDS lung where the PC-APC axis is disrupted. The lungs have targets for inhaled APC as illustrated by a patient case with ARDS, unresponsive to conventional therapy. After inhalation of 190 μg/kg of APC (Drotrecogin alpha activated) three times a day for seven days, a clear reduction in infiltrates on chest X-ray and a 138% increase in oxygenation capacity as reflected by the PaO2/FiO2 ratio was brought about. The patient, however, died later after cardiac arrest after suspected recurrence of the T-cell lymphoma. No local or systemic adverse effects was found related to the iAPC, during, after or at the time of death. It is suggested based on existing studies and the presented case that inhaled APC is a new treatment option in patients with ARDS – a hypothesis which should be substantiated in a larger series of ARDS patients.

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue tumor with tendency to recur locally and only rarely metastasizes to vital organs. Surgery with wide margins remains the standard treatment. DFSP is characterized by specific chromosomal abnormalities involving the platelet derived growth factor B locus (PDGFB). In the majority of cases a supernumerary ring chromosome containing amplified t(17; 22) translocation or a linear unbalanced t(17; 22) containing the COL1A1 –PDGFB fusion gene is present. This molecular event causes aberrant expression of a functional PDGFB leading to activation of PDGFR. Imatinib mesylate is a tyrosine kinase inhibitor with activity against activated PDGFR, and has significant activity against DFSP. Clinical evidence suggests that it has a role in locally advanced and metastatic disease and clinical trials are ongoing examining its role in this rare but potentially fatal sarcoma.

Chronic myeloid leukemia (CML) is a stem cell disease, in which the BCR/ABL oncoprotein is considered essential for abnormal growth and accumulation of neoplastic cells. During the past 10 years, the BCR/ABL tyrosine kinase inhibitor imatinib (STI571) has successfully been introduced in the treatment of the disease. However, intrinsic as well as acquired resistance against the drug have been described and have been recognized as an emerging problem and challenge in clinical practice, and a key issue in CML research. Most of the respective concepts focus on imatinib-resistant mutants of BCR/ABL that are detectable in a high proportion of cases. However, other factors also contribute to resistance against imatinib, including the genetic background, the biologic features of CML stem cells, gene amplifications, silencing of tumor suppressor genes, and various pharmacologic aspects. In this article, the mechanisms of resistance against imatinib and other BCR/ABL tyrosine kinase inhibitors in CML are discussed together with strategies to overcome and to prevent resistance with available drugs or with novel antileukemic approaches.

Epigenetic regulation of gene transcription by small molecule inhibitors of histone deacetylases (HDAC) is a novel cancer therapy. Vorinostat (Zolinza™) is the first FDA approved HDAC-inhibitor for treatment of patients with cutaneous T cell lymphoma (CTCL) who have progressive, persistent or recurrent disease on or following two systemic therapies. Vorinostat was active against solid tumors and hematologic malignancies as intravenous and oral preparations in Phase I development. In two Phase II trials, vorinostat was safe and effective at an oral dose of 400 mg/day with an overall response rate of 24%–30% in refractory advanced patients with CTCL including large cell transformation and Sézary syndrome (SS). The common side effects of vorinostat, similar in all studies, included gastro-intestinal symptoms, fatigue, and thrombocytopenia and the most common serious events were thrombosis. Vorinostat, in combination with other agents such as radiation therapy and chemotherapy, have shown synergistic or additive effects in a variety of cancers in clinical trials.

The management of metastatic urothelial carcinoma (UC) of the bladder is a common and complex clinical challenge. Despite the fact that UC is one of the most frequent tumors in the population, long term survival for metastatic disease remains low, and chemotherapy is curative for only a small minority of patients. UC is genetically heterogeneous, and it is surrounded by a complex tissue microenvironment. The problems of clinical practice in the field of metastatic bladder cancer have begun to stimulate translational research. Advances in the understanding of the molecular biology of urothelial cancer continue to contribute to the identification of molecular pathways upon which new therapeutic approaches can be targeted. New agents and strategies have recently been developed which can direct the most appropriate choice of treatment for advanced disease. A review of literature published on the targeted therapy for metastatic bladder cancer is presented, focusing on the molecular pathways shut down by the new therapeutic agents.

Epidermal growth factor receptor (EGFR) is a transmembrane receptor with a cytoplasmic tyrosine kinase (TK) domain present on many solid tumors including non-small cell lung cancer (NSCLC). Once stimulated by ligand, the downstream pathway is activated leading to cell growth, survival, and carcinogenesis. There are several methods of EGFR inhibition including monoclonal antibodies directed against the external region and small molecule inhibitors of TK domain. Erlotinib and gefitinib are orally available small molecule EGFR TK inhibitors, with proven efficacy in NSCLC. The most common side effects are skin toxicity and diarrhea. Erlotinib has been shown to improve survival compared to placebo in second or third-line therapy for NSCLC. However, erlotinib in combination with chemotherapy failed to show a survival advantage in two first-line studies which could be due to the timing of chemotherapy administration. In general, patients with adenocarcinoma histology, female gender, Asian ethnicity, and never smokers have a better response when treated with erlotinib. This could be related to the presence of EGFR mutations, lack of KRAS mutations, or overexpression of EGFR as measured by fluorescent in-situ hybridization (FISH) analysis. Future studies should concentrate on further development of predictors of clinical benefit with erlotinib, overcoming resistance to erlotinib that develops in initial responders, as well as more effective sequencing of erlotinib with chemotherapy and combinations of the drug with other “targeted” therapeutic agents.

An effective treatment for metastatic melanoma remains one of the most elusive goals in all of oncology. Several generations of therapeutic trials have yet to yield any agents that can significantly prolong survival for widespread disease. Despite this disheartening history, our understanding of the biology and molecular genetics of melanoma hold the promise of a new era of molecular targets. One pathway that appears to be universally activated in and critically needed for melanoma growth is the Ras/mitogen activated protein (MAP) kinase signaling cascade. Since the enzymatic functions of the signaling partners are well characterized, this pathway offers many potential “druggable” candidates including Braf, Mek and Ras itself. In this review, we describe this pathway in the context of melanoma tumorigenesis and discuss some of the current relevant pharmacologic treatments and clinical trials.

Farnesyltransferase inhibitors (FTIs) are a new class of biologically active anticancer drugs. The exact anti-tumorigenic mechanism is currently unknown. FTIs inhibit farnesylation of a wide range of target proteins. In preclinical models, tipifarnib (R115777, Zarnestra®), a non-peptidomimetic competitive FTI, showed great potency against leukemic cells. Although it has recently demonstrated clinical responses in adults with refractory and relapsed acute myeloid leukemia (AML), and in older adults with newly diagnosed poor-risk AML, its activity was far less than anticipated. However, it appears that tipifarnib as a single agent may be important in selected groups of patients. Much remains to be learned to optimize such therapy in patients with AML. To this end, trials that combine tipifarnib with cytotoxics are ongoing.

Background

Early glucosteroid treatment in preterm infants has a negative impact on physical growth and development. So far, data on dexamethasone effect on the GH/IGF axis and the clinical outcome are conflicting.

Objective

Therefore, we studied the effect of dexamethasone treatment on parameters of somatic growth and on the secretion of insulin like growth factors (IGFs) and insulin like growth factors binding proteins (IGFBPs) in preterm infants.

Methods

In 75 preterm infants somatic development was assessed at birth and after 3 months of corrected age. IGF-I/II and IGFBP-1-3 were measured at the same time. According to their treatment regime the infants were assigned to the dexamethasone treated or the non-treated group.

Results

At 3 months the 13 infants with dexamethasone had a lower body weight, slightly lower body length and a lower head circumference. IGF-II (464.4 ± 97.4 vs 638 ± 201.4 μg/l, p = 0.001) and IGFBP-3 (1800 ± 426 vs 2105 ± 547 μg/l, p = 0.045) were significantly reduced under the influence of glucocorticoids, whereas IGFBP-1 was elevated (59.6 ± 61.0 vs 21.1 ± 21.7 μg/l, p = 0.002). The ratio IGFBP-3/(IGFBP-1 + 2) was reduced in the dexamethasone group (1.827 ± 0.868 vs 3.098 ± 1.898 μg/l, p = 0.016), implying a significant retardation in the somatic development.

Conclusion

Dexamethasone impairs IGF and IGFBP secretion and stimulates IGFBP-1, an inhibitor of IGF-I. These pathways might contribute to alterations of the GH/IGF axis, particularly the ratio IGFBP-3/(IGFBP-1 + 2).

The development of immunosuppressive drugs has in recent years been focused on prevention of acute rejection. This has led to an increase in one-year allograft survival. However, these drugs have non-immune effects which contribute to the high incidence of late graft loss, as a consequence of chronic allograft nephropathy, and the death of patients. As an immune-specific alternative to conventional immunosuppressants, new biotechnology tools have been developed; they target the costimulation signal of T-cell activation, particularly by the “classical” B7/CD28 and CD40/CD40L pathways. Here, we review the limitations of current immunosuppressive protocols, the benefits of classical B7/CD28 costimulation blockade, and the first large-scale clinical application of this strategy to human transplantation with belatacept. We will also consider novel costimulatory molecules of the B7/CD28 and TNF/TNF-R families, which appear to be important for the functions of memory and effector T-cells.

Carcinomatous encephalitis is a rapidly fatal form of metastasis caused by miliary spread of systemic cancer into the brain parenchyma. The diagnostic criteria and optimal treatment for this disease are not well defined. We report a patient with rapid neurologic deterioration from carcinomatous encephalitis from lung adenocarcinoma. She was treated with gefitinib and high-dose fractionated whole brain radiotherapy, and eventually improved neurologically and was discharged home on hospital day 48. Gefitinib and high-dose fractionated radiotherapy may have synergistic activity in patients with carcinomatous encephalitis from non-small cell lung cancer having favorable prognostic factors. More importantly, timely recognition of this disease and the use of large fraction radiation therapy are necessary to control rapid neurologic deterioration.

Management of male infertility is always a difficult task, and the pathologic process is often poorly understood. Even though modern assisted reproduction techniques (ART) can help overcome severe male factor infertility, the application of these methods in all infertile couples would definitely represent over-treatment. Several conditions can interfere with spermatogenesis and reduce sperm quality and production. A careful diagnostic work-up is necessary before any andrological treatment can be initiated so that adequate treatment options can be selected for individual patients. Most hormonal imbalances can be readily identified and successfully treated nonsurgically. However, the treatment of men with unexplained idiopathic infertility remains a challenge. In the absence of a correctable etiology, patients are managed with either empirical medical therapy or ART. Empiric medical therapy continues as a viable option. However, physicians and patients must understand that the success rates with any of the pharmacological therapies remain suboptimal.

After nearly three decades with little change in the treatment for B-cell non-Hodgkin’s lymphoma, the addition of immunotherapy has had a profound effect on the treatment of this group of diseases. A more subtle addition to the armentarium has been the radiolabeled monoclonal antibodies, 90yttrium ibritumomab tiuxetan and 131iodine tositumomab. Unfortunately these drugs have been underutilized. This is, in part, because of the need for coordination between specialties, concern about long-term effects, possible limitations on the tolerance of subsequent therapies and, in part, because of reimbursement factors. In this review, the studies in relapsed and refractory disease are discussed and the very promising results reported from phase II studies using radioimmunotherapy as first-line. Potential mechanisms of resistance to monoclonal antibodies are postulated based on alterations in cell signaling pathways that have been observed in lymphoma cell lines resistant to rituximab. It is anticipated that as mechanisms of resistance are better understood for both unlabeled and labeled monoclonal antibodies, biomarkers will not only predict their efficacy but also lead to the development of therapies to overcome resistance.

The humanized antibody efalizumab is currently the only T-cell directed biologic approved for the treatment of moderate-to-severe psoriasis by both American and European authorities. Binding to and blocking the function of the adhesion molecule leukocyte function associated antigen 1 (LFA-1), it is believed to interfere with T-cell activation in the lymph node, migration through the circulation into the skin, and re-activation in-loco, all of these representing central steps in the pathogenesis of psoriasis. A comprehensive clinical development program provided large and consistent evidence that efalizumab induces a major clinical benefit in psoriasis. Efalizumab rapidly and substantially improves psoriatic skin symptoms and leads to profound gain in quality of life. It allows safe and effective long-term control of psoriasis. Therefore, evidence-based treatment guidelines recommend its use in moderate to severe plaque-type psoriasis.

Objectives

Noninvasive objective tests are needed to diagnose primary Sjogren’s syndrome (pSS) and to evaluate treatment responses. Ultrasound imaging of the salivary glands is rapid and noninvasive. Recent open-label studies suggested that anti-CD20 (rituximab) may be effective in pSS. The purpose of this study was to look for ultrasound evidence of the effects of rituximab in pSS.

Methods

We compared 16 patients fulfilling the new American-European consensus group criteria for pSS to 9 controls, using B-mode ultrasound features (parenchymal homogeneity and gland size) and Doppler waveform analysis of the transverse facial artery of parotid glands. We compared the same parameters in the patients before and after 12 weeks of intravenous rituximab therapy.

Results

Compared to controls, untreated patients had significant abnormalities in salivary gland structure (p < 0.0001) and parotid size (2.05 ± 0.33 cm versus 1.70 ± 0.28 cm; p = 0.001). Doppler waveform analysis showed significant differences before, but not after, lemon stimulation between untreated patients and controls. After rituximab treatment, significant size reductions were noted in the parotids (2.05 ± 0.3 cm at baseline and 1.86 ± 0.27 cm at week 12; p = 0.002) and submandibular glands (2.02 ± 0.54 cm at baseline and 1.66 ± 0.34 cm at week 12; p = 0.001). Doppler resistive indices after lemon stimulation were significantly increased after rituximab treatment.

Conclusion

Salivary gland measurements and blood inflow responses to salivary stimulation as assessed by ultrasound hold promise as objective noninvasive tools for evaluating rituximab effects in patients with pSS.

Modern tools of genomics and proteomics reveal potential therapeutic antisense targets in asthma, increasing the interest in the development of anti-mRNA drugs. In allergic asthma experimental models, antisense oligonucleotides (ASO) are administered by inhalation or systemically. ASO can be used for a large number of molecular targets: cell membrane receptors (G-protein coupled receptors, cytokine and chemokine receptors), membrane proteins, ion channels, cytokines and related factors, signaling non-receptor protein kinases (tyrosine kinases, and serine/threonine kinases) and regulators of transcription belonging to Cys4 zinc finger of nuclear receptor type or beta-scaffold factors with minor groove contacts classes/superclasses of transcription factors. A respirable ASO against the adenosine A1 receptor was investigated in human trials. RNase P-associated external guide sequence (EGS) delivered into pulmonary tissues represents a potentially new therapeutic approach in asthma as well as ribozyme strategies. Small interfering RNA (siRNA) targeting key molecules involved in the patho-physiology of allergic asthma are expected to be of benefit as RNAi immunotherapy. Antagomirs, synthetic analogs of microRNA (miRNA), have important roles in regulation of gene expression in asthma. RNA interference (RNAi) technologies offer higher efficiency in suppressing the expression of specific genes, compared with traditional antisense approaches.

Lung cancer is the leading cause of cancer death in the United States. The majority of patients present with advanced stage disease, and treatment with standard cytotoxic chemotherapy agents have been shown to provide a modest improvement in survival, reduce disease-related symptoms, and improve quality of life. However, with standard chemotherapy treatments the prognosis is poor with the majority of patients dying in less than a year from diagnosis. Treatment with standard chemotherapy agents has reached a therapeutic plateau, and recent investigations have focused on therapies that target a specific pathway within the malignant cell or related to angiogenesis. The most promising of the targeted therapies are agents that target the process of angiogenesis. Bevacizuamab is a monoclonal antibody that binds to circulating vascular endothelial growth factor (VEGF)-A, and prevents binding of VEGF to vascular endothelial growth factor receptors, thus inhibiting activation of the VEGF pathway and angiogenesis. A recent phase III trial of first-line treatment of advanced non-small cell lung cancer revealed a statistically significant improvement in response, progression-free survival, and overall survival with the combination of bevacizumab and standard chemotherapy in comparison to standard chemotherapy alone. Bevacizumab is the only targeted therapy that has been shown to improve survival when combined with standard chemotherapy in the first-line setting.

The glycogen storage disease type II (GSD-II), or Pompe disease, is due to the deficit of lysosomal glycogen degradation enzyme acid α-glucosidase (GAA). In infants, Pompe disease is characterized by prominent hypotonia, muscle weakness, motor delay, feeding problems, and respiratory and cardiac insufficiency. In a retrospective study, the median age at death was 8.7 months. Enzyme replacement therapy with recombinant human GAA is recently used to treat patients with Pompe disease, and has been shown to prolong survival, reverse cardiomyopathy, and improve motor function. This article briefly reviews the history and manifestations of Pompe disease, and then focuses on the development of the drug for Pompe disease, alglucosidase alfa. Current status of treatment and future developments are also discussed.

Breast cancer is a complex, molecular disease, in which a number of cellular pathways involving cell growth and proliferation, such as the MAPK, RB/E2F, P13K/AKT/mTOR, and TP53 pathways, are altered. These pathways represent molecular mechanisms that are composed and regulated by various genes. The genes that are altered in terms of cell growth and proliferation include the oncogenes HER2, c-MYC, and RAS, the ER genes, and the genes for cell cyclin D1 and E, and the tumor suppressor genes RB, TP53, and PTEN, and the breast cancer susceptibility genes BRCA1 and BRCA2. Although the nature of breast cancer is complex and has frustrated previous attempts at treatment or prevention, the elucidation of its molecular nature over the last several decades is now providing targets for effective therapies to treat the disease and hopefully one day to prevent it.