INNOVATIVE PROBLEM-ORIENTED APPROACHES TO DIAGNOSIS AND TREATMENT

research activity INNOVATIVE PROBLEM-ORIENTED APPROACHES TO DIAGNOSIS AND TREATMENT COORDINATOR: Paolo Corradini Research into the interaction between a tumor and its microenvironment and identification of molecular and genetic characteristics that can be translated into biomarkers for diagnosis of cancer at its earliest stages. Studies relative to the development of: i) radiopharmaceuticals for tumor characterization in molecular imaging and treatment; ii) new drugs and/or treatment approaches for solid tumors, including clinical-translational studies prompted by the need for a) the prognostic characterization of rare tumors, which resemble the big killers and constitute an as yet unsolved problem both from a diagnostic and therapeutic point of view; b) knowledge of the mechanisms responsible for the different degrees of toxicity of radiotherapy in different tumor types; c) anticancer vaccines, genetic and biological therapies in certain tumors for the clinical testing of new substances. PROJECTS AIMS: Selection of biomarkers for early diagnosis or cancer risk assessment; development of radiopharmaceuticals for biological characterization and use in imaging and treatment; detection of biomarkers that can be used as indicators of treatment response; testing and development of targeted molecular therapies; stratification of radiotoxicity by degree of severity and assessment of its potential indicators. Stroma-derived biomarkers with prognostic value in subjects with polygenic or monogenic inheritance predisposing to cancer (Tommaso Dragani) Development of a platform for the pre-clinic evaluation of new anti-tumor drugs and new therapeutic combinations (Nadia Zaffaroni) Study of immunosuppression mechanisms in patients with solid tumors and their influence on prognosis and response to drug treatment and immunotherapy (Licia Rivoltini) Establishing drug and transplant approaches for effective treatment of hematological malignancies (Paolo Corradini) Translational project for the development of drugs for personalized cancer treatment (Filippo de Braud) 87

SCIENTIFIC REPORT 2013 back to contents.tommaso A. Dragani. STROMA-DERIVED BIOMARKERS WITH PROGNOSTIC VALUE IN SUBJECTS WITH POLYGENIC OR MONOGENIC INHERITANCE PREDISPOSING TO CANCER OVERVIEW AND SCIENTIFIC GOALS The process of tumor progression and metastatic dissemination can involve germline polymorphisms and individual gene expression signatures in normal tissue. Our project is aimed to integrate genome and transcriptome data across multiple individuals, thus allowing identification of genetic biomarkers that are predictive of clinical phenotypes of colorectal (CRC) or lung cancer (LC). Importantly, the availability of RNA levels and genotype data on the same subjects will allow to define cis- and trans-controls of genes expressed in normal tissues, thus revealing the architecture of gene regulation in the microenvironment of CRC and LC. We have carried out a transcriptome study of non-involved lung tissue, excised from a discovery series of 204 lung adenocarcinoma patients, evaluated using whole-genome expression microarrays. Genes associated with survival status at 60 months were identified by Cox regression analysis (adjusted for gender, age and clinical stage) and re-tested in a validation series of 78 additional cases. RNA-Seq analysis from non-involved lung tissue of 12 patients was performed to characterize the different isoforms of candidate genes. Gene expression signatures associated with survival comprised 10 genes: CNTNAP1, PKNOX1, FAM156A, FRMD8, GALNTL1, TXNDC12, SNTB1, PPP3R1, SNX10, and SERPINH1. In CRC patients, we have carried out a study to test the possible role of known SNPs that have been reported to affect risk or other aspects of disease in the modulation of clinical parameters. We have investigated the possible influence of 86 informative SNPs on overall survival and time to recurrence (TTR) in a series of 770 colorectal adenocarcinoma patients with follow-up to 84 months. In Cox multivariate analysis, adjusted for gender, age at surgery, pathological stage, and adjuvant chemotherapy, SNPs rs1801133 (MTHFR), rs4939827 (SMAD7) and rs2306283 (SLCO1B1), showed the highest statistically significant association with overall survival. The highest association with TTR was observed for rs16892766, which maps downstream of the EIF3H gene. By crossing mouse strains that are resistant or susceptible to lung tumorigenesis, it has been observed that mice susceptible to lung tumors express, in normal lung tissue, higher levels of the Kras-4A transcript isoform, compared to mice resistant. This difference is modulated by genetic polymorphisms located near or within this same locus Pas1 where the K-ras gene maps and which modulates susceptibility to lung tumorigenesis in mice. 88

research activity PROGRAM HIGHLIGHTS Our findings support the hypothesis that individual genetic characteristics, as shown by the expression pattern of non-involved tissue, can influence the outcome of lung adenocarcinoma patients. We have also found that a set of genetic variants (SNPs) previously found associated with risk of CRC was also associated with overall survival and TTR. The identification of alleles affecting subgroups of cancer patients with worse clinical outcome may have clinical application in future pharmacogenetic strategies to personalize treatment. PROGRAM MEMBERSHIP Tommaso A. Dragani, principal investigator. Giacomo Manenti, researcher, staff. Antonella Galvan, researcher. Francesca Colombo, researcher. Sara Noci, researcher. Alice Dassano, PhD student. Angela Pettinicchio, laboratory technician. SELECTED RECENT PUBLICATIONS Galvan A., Cabrera W., Vorraro F., Jensen J.R., Borrego A., Starobinas N., Ribeiro O.G., De Franco M., Knott S., Dragani T.A., Manenti G., Ibañez OC.: Genetic linkage analysis identifies Pas1 as the common locus modulating lung tumorigenesis and acute inflammatory response in mice. Genes Immun 2013; 14(8): 512-517 Galvan A., Frullanti E., Anderlini M., Manenti G., Noci S., Dugo M., Ambrogi F., De Cecco L., Spinelli R., Piazza R., Pirola A., Gambacorti- Passerini C., Incarbone M., Alloisio M., Tosi D., Nosotti M., Santambrogio L., Pastorino U., Dragani T.A.: Gene expression signature of noninvolved lung tissue associated with survival in lung adenocarcinoma patients. Carcinogenesis 2013; 34(12): 2767-2773 Falvella F.S., Alberio T., Noci S., Santambrogio L., Nosotti M., Incarbone M., Pastorino U., Fasano M., Dragani T.A.: Multiple isoforms and differential allelic expression of CHRNA5 in lung tissue and lung adenocarcinoma. Carcinogenesis 2013; 34(6): 1281-1285 Frullanti E., Colombo F., Falvella F.S., Galvan A., Noci S., De Cecco L., Incarbone M., Alloisio M., Santambrogio L., Nosotti M., Tosi D., Pastorino U., Dragani T.A.: Association of lung adenocarcinoma clinical stage with gene expression pattern in noninvolved lung tissue. Int J Cancer 2012; 131(5): E643-8 Dassano A., Noci S., Galbiati F., Colombo F., Trincucci G., Pettinicchio A., Dragani T.A., Manenti G.: Multigenic nature of the mouse pulmonary adenoma progression 1 locus. BMC Genomics 2013; 14: 152 SELECTED RECENT MAJOR GRANTS AIRC-2014, PI Dr. Tommaso A. Dragani AIRC 5x1000, PI Dr. Marco A. Pierotti KEYWORDS Single nucleotide polymorphisms, transcriptome, lung cancer, expression quantitative trait locus. 89

SCIENTIFIC REPORT 2013 back to contents.nadia Zaffaroni. DEVELOPMENT OF A PLATFORM FOR THE PRE-CLINICAL EVALUATION OF NEW ANTI-TUMOR DRUGS AND THERAPEUTIC COMBINATIONS OVERVIEW AND SCIENTIFIC GOALS The possibility to evaluate the preclinical effectiveness of new anticancer drugs, as well as novel therapeutic combinations, is strongly associated with the availability of appropriate preclinical models, which are representative of clinically relevant phenotypes. In this context, over the years, we generated a large panel of human tumor xenografts of different histological origin in immunodeficient mice. These models have been extensively characterized in terms of: i) frequency of mutations in genes involved in master pathways; ii) constitutive activation of the main mitogenic and cell survival signaling pathways; iii) gene and microrna expression profiles. In addition, for models with spontaneous or experimentally induced resistance to specific drugs, the molecular determinants of drug resistance have been identified. These models constitute the platform for the study of new therapeutic agents, including newly designed analogues of cytotoxic drugs, targeted drugs, and therapeutic nucleic acids (i.e. sirna, mirna mimics). Specifically, our research is focused on: 1) evaluation of effectiveness of new compounds as a function of histological type, genetic background and, more generally, molecular profile of tumor models; 2) the identification of new therapeutic combinations designed to target specific molecular alterations in tumor models. In addition, the availability of specific preclinical models will allow us to investigate new possible therapeutic indications for drugs already used in a clinical setting. Overall, the results of these studies should allow us to define new therapies for clinical development, as well as identify potential predictors of response (such as specific molecular alterations in tumors) that should be useful for patient selection. At the beginning of the study, both optimal route and schedule of administration will be determined. The antitumor efficacy of drugs, administered alone or in combination (i.e. contemporary or sequentially) will be evaluated in terms of tumor volume percentage reduction, induction of complete responses, and increased survival of animals. The modulation of putative molecular targets and specific pathways will be determined on tumor samples obtained after treatment. For promising drugs and/or combinations, the changes induced by treatment in the different signaling networks will be evaluated to obtain more accurate characterization of the mechanism of action. Finally, the histopathological evaluation of material, combined with morphometric and immunohistochemical techniques, will allow us to quantify the effects of treatment on angiogenesis, as well as to determine the infiltration of inflammatory and/or immune system cells and quantify the presence of apoptosis/necrosis. 90

research activity PROGRAM HIGHLIGHTS The project is making progress towards the improvement of therapeutic options for treatment of different tumor types, including rare diseases poorly responsive to conventional therapies, such as diffuse malignant peritoneal mesothelioma (DMPM) and solitary fibrous tumors (SFT). Specifically, concerning the preclinical development of new drugs, we evaluated the activities of: 1) new nortopsentin analogues (1H-pyrrolo[2,3-b]pyridine derivatives) in experimental models of diffuse DMPM. We demonstrated that the three most active compounds (shown to act as cyclin-dependent kinase 1 inhibitors) consistently reduced DMPM cell proliferation and induced a caspase-dependent apoptotic response, with concomitant reduction of the activation of the antiapoptotic protein survivin. In the mouse model, i.p. administration of these derivatives was effective, resulting in a significant tumor volume inhibition of DMPM xenografts at well-tolerated doses, and two complete responses were observed in each treatment group, suggesting a possible clinical relevance of these drugs for the treatment of DMPM; 2) hybrid agents formed by 7-oxyiminomethylcamptothecin derivatives and diaminedichloro-platinum (II) complex. The compounds (which produced platinum-dna adducts and topoisomerase I-mediated DNA damage with a cleavage pattern and persistence similar to SN38, the active principle of irinotecan) showed growth inhibitory activity against a panel of human tumor cell lines, including sublines resistant to topotecan and platinum compounds. The most active compound also exhibited an appreciable antitumor activity in vivo against human H460 tumor xenograft, in the absence of toxicity, comparable to that of irinotecan at lower well-tolerated dose levels and superior to cisplatin. The results support these conjugates as a new class of anticancer agents of potential clinical interest. As far as the identification of new therapeutic combinations is concerned, through collaboration with other research groups at INT, we reported the antitumor activity of CpG oligonucleotides (synthetic DNA sequences recognized by Toll-like receptor 9 and able to induce innate/adaptive immune responses) administered alone or in combination with chemotherapy in preclinical models of human cancer. Considering preclinical experiments performed on xenografts generated from biopsies of patients with rare tumors, we explored the activity of conventional and targeted agents on a human high-grade dedifferentiated SFT characterized by overexpression and activation of PDGFRB and VEGFR1. In a xenograft model, dacarbazine and temozolomide were found to have a high and superimposable antitumor activity and to induce almost complete tumor volume inhibition, which was maintained after treatment interruption and confirmed pathologically. In contrast, sunitinib, pazopanib, and bevacizumab were found to be less active, with appreciable tumor relapse immediately after drug withdrawal. PROGRAM MEMBERSHIP Nadia Zaffaroni (PI), planning and coordination of experiments. Andrea De Cesare (Veterinarian), Denis Cominetti (junior researcher) and Monica Tortoreto (technician) will be involved in: i) subcutaneous and orthotopic xenotransplantation of cancer cells into nude, SCID, and NOD/SCID mice; ii) treatment with new therapeutic agents (alone or in combination); iii) assessment of tumorigenic potential and chemosensitivity profiles of different models; iv) tumor tissue collection and storage; and v) general animal care. Giovanni Beretta (senior researcher), Marzia Pennati (senior researcher), Valentina Zuco (senior researcher), Alessia Lopergolo (junior researcher) will be involved in: i) cell culture maintenance for xenotransplants; ii) molecular and biochemical assays in tumor specimens; and iii) immunohistochemical assessment of proliferation, apoptosis/necrosis, and microvessel density-related markers in explanted tumor xenografts. SELECTED RECENT PUBLICATIONS Carbone A., Pennati M., Parrino B., Lopergolo A., Barraja P., Montalbano A., SpanÚ V., Sbarra S., Doldi V., De Cesare M., Cirrincione G., Diana P., Zaffaroni N.: Novel 1H-pyrrolo[2,3-b]pyridine derivatives nortopsentin analogues: synthesis and antitumor activity in peritoneal mesothelioma experimental models. J Med Chem 2013; 56: 7060-7072 Cincinelli R., Musso L., Dallavalle S., Artali R., Tinelli S., Colangelo D., Zunino F., De Cesare M., Beretta GL, Zaffaroni N.: Design, modeling, synthesis and biological activity evaluation of camptothecin-linked platinum anticancer agents. Eur J Med Chem 2013; 63C: 387-400 Sfondrini L., Sommariva M., Tortoreto M., Meini A., Piconese S., Calvaruso M., Van Rooijen N., Bonecchi R., Zaffaroni N., Colombo M.P., Tagliabue E., Balsari A.: Anti-tumor activity of CpG-ODN aerosol in mouse lung metastases. Int. J. Cancer 2013; 133: 383-93 Sommariva M., De Cesare M., Meini A., Cataldo A., Zaffaroni N., Tagliabue E., Balsari A. High efficacy of CpG-ODN, cetuximab and cisplatin combination for very advanced ovarian xenograft tumors. J Transl Med 2013; 11: 25 Stacchiotti S., Tortoreto M., Bozzi F., Morosi A., Messina A., Libertini M., Palassini E., Cominetti D., Negri T., Gronchi A., Pilotti S., Zaffaroni N., Casali P.G.: Dacarbazine in solitary fibrous tumor: a case series retrospective analysis and preclinical evidence vis-a-vis temozolomide and antiangiogenics. Clin Cancer Res 2013; 19: 5192-5201 SELECTED RECENT MAJOR GRANTS AIRC Ministero dello Sviluppo Economico Mesothelioma Applied Research Foundation KEYWORDS Experimental models of human tumors, new drugs, new therapeutic combinations 91

SCIENTIFIC REPORT 2013 back to contents.licia Rivoltini. STUDY OF IMMUNOSUPPRESSION MECHANISMS IN PATIENTS WITH SOLID TUMORS AND THEIR INFLUENCE ON PROGNOSIS AND RESPONSE TO DRUG TREATMENT AND IMMUNOTHERAPY OVERVIEW AND SCIENTIFIC GOALS This project is aimed at characterizing interactions between tumor cells and the immune system to search for novel predicting/prognostic factors or therapeutic targets. Immunological studies are performed on peripheral blood, saliva, draining lymph nodes, and tumor lesions from patients with different stages of disease and undergoing specific drug treatments. A major focus is devoted to melanoma, sarcoma, liver carcinoma, and head and neck (H&N) cancer. The goal is to perform comprehensive and standardized immune profiling based on multiparametric assays for the visualization of immune cells and circulating factors. Gene-expression and mirna profiling is also performed to identify immune-related signatures. Specific attention is paid to regulatory cell subsets (including myeloid-derived suppressor cells MDSC -, regulatory T cells, and plasmocytoid dendritic cells) and plasma content of cyto- and chemokines. We also investigate tumor or immune exosomes to understand their impact on tumor immunity and the potential as source of biomarkers. Applying these strategies, we found that: 1. Multiparametric cytofluorimetry allows the simultaneous visualization of different immune cell subsets present in peripheral blood and lymph nodes, providing a reliable immune profile that differs substantially from that detected in age and sex-matched healthy donors. 2. MDSC frequency and activation state are associated with disease progression in melanoma and sarcoma patients, and with insensitivity to different therapeutic strategies including target therapies. 3. Drugs such as ipilimumab and BRAF-inhibitors have an impact on the frequency and function of MDSC, Treg and effector/helper T cells. The role of immune profile in the sensitivity or resistance to treatment is under investigation. 4. MDSC accrual involves the conditioning activity of tumor exosomes on myeloid cells through the delivery of selected chemokines and mirna affecting HLA-DR, IL-6, HIF1-alpha, and TGF-beta pathways. The presence of exosomes bearing a myeloid-modulating signature is under evaluation in plasma samples from melanoma patients with different disease stage. 5. Salivary cytokines, detected by cytokine-bead array assay, accumulate in H&N cancer patients upon chemoradiotherapy and predict the severity of treatment-induced mucosites. 6. Gene expression profiling of sentinel nodes provides information about immune pathways that are associated with recurrence and poor prognosis. 92

research activity 7. Acidity is a powerful tool for tumor microenviroment to anergize immune responses in melanoma. A clinical trial investigating the ability of anti-acid drugs to improve tumor immunity and control tumor growth is ongoing in melanoma patients. Altogether, these data strongly confirm the potentiality of immune-related pathways as novel source of biomarkers for patient selection and management in cancer PROGRAM HIGHLIGHTS The recent success of novel cancer therapeutics based on immunomodulation has finally shown the key role of the immune system in controlling tumor growth. Evidence is also emerging regarding the influence that immunity exerts on disease progression and on the response to cancer treatment including targeted therapies. Hence, the study of immune-tumor interactions aimed at characterizing the immune profile at the single patient level represents a promising tool for the identification of novel predicting/prognostic factors and new therapeutic targets. Thanks to our long-standing experience in tumor immunology, continuously updated at the scientific and technological levels through collaboration with several national and international groups and networks, we are collecting a broad and comprehensive picture of immune-cancer cross-talk and its outcome in patients. Immunomonitoring is performed according to standardized protocols and SOPs, including sample collection and immunological testing. The active and productive collaboration with several clinical units allows the design of studies that meet specific and relevant clinical needs as well as timely patient selection and accrual. Based on these features, we are dissecting the mechanisms of cancer-mediated immunosuppression, possibly finding common features and patterns across different tumor histologies. Focusing on patients and defined questions, we are committed to verify whether investigating the immune system can provide relevant information about patient prognosis and response to treatment. Understanding the pathways regulating tumor immunity may also contribute to the identification of novel therapeutic strategies for cancer patients. PROGRAM MEMBERSHIP Unit of Immunotherapy of Human Tumors Study design and management, immunological and genetic analyses, data interpretation. Melanoma Unit Patient selection, collaboration in study design. Liver Unit Collaboration in study design, patient selection, result discussion and data interpretation. Sarcoma Unit Patient selection, collaboration in study design. Head and Neck Oncology Patient selection, collaboration in study design, result discussion and data interpretation. Unit of Functional Genomics Genetic profiling, data analysis MIA consortium Imaging studies Unit of Statistics and Epidemiology Collaboration in study design, data analysis SELECTED RECENT PUBLICATIONS Camisaschi C., Filipazzi P., Tazzari M., Casati C., Beretta V., Pilla L., Patuzzo R., Maurichi A., Cova A., Maio M., Chiarion-Sileni V., Tragni G., Santinami M., Vergani B., Villa A., Berti E., Umansky L., Beckhove P., Umansky V., Parmiani G., Rivoltini L., Castelli C.: Effects of cyclophosphamide and IL-2 on regulatory CD4+ T cell frequency and function in melanoma patients vaccinated with HLA-class I peptides: impact on the antigen-specific T cell response. Cancer Immunol Immunother 2013; 62(5): 897-908 Castelli C., Tazzari M., Negri T., Vergani B., Rivoltini L., Stacchiotti S., Pilotti S.: Structured myeloid cells and anti-angiogenic therapy in alveolar soft part sarcoma. J Transl Med 2013; 11:237 Filipazzi P., Pilla L., Mariani L., Patuzzo R., Castelli C., Camisaschi C., Maurichi A., Cova A., Rigamonti G., Giardino F., Di Florio A., Asioli M., Frati P., Sovena G., Squarcina P., Maio M., Danielli R., Chiarion-Sileni V., Villa A., Lombardo C., Tragni G., Santinami M., Parmiani G., Rivoltini L.: Limited induction of tumor cross-reactive T cells without a measurable clinical benefit in early melanoma patients vaccinated with human leukocyte antigen class I-modified peptides. Clin Cancer Res 2012; 18(23): 6485-6496 Calcinotto A., Filipazzi P., Grioni M., Iero M., De Milito A., Ricupito A., Cova A., Canese R., Jachetti E., Rossetti M., Huber V., Parmiani G., Generoso L., Santinami M., Borghi M., Fais S., Bellone M., Rivoltini L.: Modulation of microenvironment acidity reverses anergy in human and murine tumor-infiltrating T lymphocytes. Cancer Res 2012; 72(11): 2746-2756 ASSOCIATED CLINICAL TRIALS Experimental Clinical Study no Profit AdESOM: Effetto immunomodulatorio e antitumorale dell esomeprazolo ad alte dosi in regime neoadiuvante e adiuvante in pazienti con melanoma in stadio III. Studio pilota randomizzato trattamento vs controllo PROVAX: Studio di vaccinazione, in aperto, di fase II con peptidi di survivina emulsionati in Montanide ISA 51VG dopo somministrazione di IMP321TM, in pazienti con carcinoma prostatico in recidiva biochimica MULTIMELMARKERS: Identificazione di marcatori molecolari del melanoma multiplo NIBIT-001: A Phase II Study of the Combination of Ipilimumab and Fotemustine in Patients with Unresectable Locally Advanced or Metastatic Malignant Melanoma Experimental Clinical Study Profit GINGER: Studio multicentrico, randomizzato, in doppio cieco, controllato verso placebo per valutare l attività di un integratore alimentare a base di Ginger (Zingiber officinalis) nella gestione della nausea in pazienti che ricevono trattamenti altamente emetizzanti e la terapia antiemetica standard 93

SCIENTIFIC REPORT 2013 back to contents METRIC/MEK114267: Studio di Fase III randomizzato, in aperto, per confrontare GSK1120212 verso chemioterapia in soggetti con melanoma avanzato o metastatico positivo alle mutazioni di BRAF V600E/K NYESO-1: An open Phase I study of immunization with the recny ESO 1 + AS15 Antigen-Specific Cancer Immunotherapeutic in patients with NY-ESO-1 positive unresectable and progressive metastatic cutaneous melanoma PRAME: An open, dose-escalation Phase I/II study to assess the safety, immunogenicity and clinical activity of recprame + AS15 Antigen- Specific Cancer Immunotherapeutic as first-line treatment of patients with PRAME-positive metastatic melanoma Observational Clinical Studies (Non-profit) EPApHIL-6: Analisi dell infiltrato infiammatorio come fattore prognostico e target terapeutico in pazienti con carcinoma epatico. Ruolo della componente mieloide e dei pathway coinvolti nella regolazione del ph mirna: Identificazione di microrna circolanti quali potenziali indicatori di progressione nel melanoma metastatico BRAF-MEK: Studio dell effetto immunomodulatorio degli inibitori di BRAF e MEK in pazienti con melanoma Target Therapy: Valutazione del ruolo dei meccanismi immunosoppressivi nella prognosi e nella risposta al trattamento con farmaci targeted therapy in pazienti affetti da sarcoma SELECTED RECENT MAJOR GRANTS Project MCO-9998 Special Program Molecular Clinical Oncology, AIRC 5 per Mille Cell therapy with TRAIL-armed, genetically engineered or phenotypically redirected, effectors Duration: 01/07/2010-30/06/2015 Project n. 12162 - AIRC 5 per Mille Tumor-Microenvironment related changes as new tools for early detection and assessment of high-risk disease Duration: 31/12/2011-30/12/2016 Project AIRC IG-14285 Modulation of melanoma immunosuppressive microenvironment by proton pump inhibitors. Duration: 02/01/2014-01/01/2015 Project AIRC IG-13335 From regional node to systemic immunity suppression in melanoma metastatic progression Duration: 02.01.2014-01.01.2015 MINISTERO della SALUTE convenzione n. 52/RF-2010-2312620 IL-6-related inflammation signatures as a predictive marker of recurrence in liver cancer patients Duration: 03/12/2012-02/12/2015 Harry J Lloyd Charitable Trust Study of microrna related to myeloid derived suppressor cells in early melanoma patients Duration: 14/06/2013-30/06/2015 KEYWORDS Immune suppression, myeloid-derived suppressor cells, exosomes, mirna Figure: Immunosuppressive and exhausted lymphocytes in metastatic sentinel node from melanoma patients with unfavorable disease course at 5 years follow-up. Double staining for CD30 and CD147, Foxp3, and PD1 in a representative PP sample showing cells expressing one or both markers (magnification, 100). Confocal images of sections stained for CD30 in green and for CD147 or PD1 in red are shown (merge). In the CD30-Foxp3 double staining, CD30+ cells are indicated by red, and nuclear staining for Foxp3 is indicated by brown. From Vallacchi V et al. Cancer Res 2014;74:130-140 94

research activity.paolo Corradini. ESTABLISHING DRUG AND TRANSPLANT APPROACHES FOR EFFECTIVE TREATMENT OF HEMATOLOGICAL MALIGNANCIES OVERVIEW AND SCIENTIFIC GOALS Treatment options for patients with hematological malignancies include chemotherapy, radiotherapy, immunotherapy, and high-dose chemotherapy followed by autologous and allogeneic stem cell transplantation (auto- and allo-sct). These therapeutic strategies have an established role in the management of patients at diagnosis, with cure rates ranging between 30% and 90% depending on histology. However, a significant proportion of patients affected by aggressive lymphomas display primary chemo-refractoriness or early relapse and have dismal long-term disease control, and thus represent an unmet medical need. In addition, the mechanisms driving chemo-refractoriness still remain largely unclear. Also, new biomarkers for upfront identification of refractory patients or those requiring intensified approaches (auto- or allo-sct) as first-line treatment are mandatory. New treatments tailored to overcome aggressiveness and refractorinessdriving lesions are required. Ongoing clinical and biological studies in the field of multiple myeloma (MM), indolent and aggressive non-hodgkin s lymphoma (NHL), acute myeloid leukemia (AML), myelodysplastic and myeloproliferative disorders, and graft-versus-host disease (GVHD) are aimed at: Evaluating the efficacy of new, targeted therapies alone or in combination with standard chemotherapy to allow individualized treatment options designed to target each patient s specific genetic lesions, thereby reducing toxicity and increasing effectiveness. Massive sequencing technologies will help in identifying genetic lesions/mechanism(s) driving lymphoma aggressiveness and/or chemo-refractoriness and to define new targets for treatment. Exploiting the role of potential genes/proteins as diagnostic tools and novel biomarkers for the early recognition/ stratification of patients requiring intensified treatment options or those unlikely to respond to standard chemoimmunotherapies. The discovery of biological and/or molecular biomarker(s) of aggressiveness or chemo-refractoriness will lead to the development of innovative clinical programs with substantial impact in clinical practice Introducing new molecular methods for diagnosis of hematological malignancies. In B cell malignancies, several methods have been developed for the detection of minimal residual disease (MRD). We are now applying a new, next generation sequencing technology strategy based on the use of Ion Torrent Personal Genome Machine (PGM, Life Technologies) to monitor MRD in B cell malignancies and clonal evolution in MM patients. We have also introduced and developed molecular tests for the detection of mutation with diagnostic impact (BRAF V600E in hairy cell leukemia, MYD88 L265P in Waldenstrom macroglobulinemia, TET2 and IDH mutations in peripheral T cell lymphomas, and JAK2 V617F in myeloproliferative disorders). 95