Recenti progressi in medicina最新文献

Brexucabtagene autoleucel (brexu-cel), a CD19-directed chimeric antigen receptor (CAR) T-cell therapy, is a promising and available salvage option for relapsed/refractory philadelphia-positive B-Cell Acute Lymphoblastic Leukemia patients, potentially effective even after several previous lines of therapy and a previous allogeneic stem cell transplant (HSCT). This reported clinical case allowed us to highlight different relevant factors for the optimal, complex and multidisciplinary management of this subgroup of patients: bridging therapy selection, the need of reevaluating CD19 expression, disease burden as an outcome predictor and the role of HSCT as a further therapeutic consolidation.

Introduction: Relapsed or refractory B-cell acute lymphoblastic leukemia (R/R B-ALL) represents a complex clinical scenario, and the advent of immunotherapy has radically changed the therapeutic options available for these patients. The introduction of CAR-T cell therapy for patients over 25 years old offers a new treatment opportunity, with high remission rates and durable responses.

Clinical case: A 67-year-old female patient with multiple comorbidities was diagnosed with Philadelphia-negative B-ALL and treated with induction therapy according to the GIMEMA LAL1913 protocol plus rituximab with dose reductions due to age, achieving a complete MRD-negative complete remission (CR). During the sixth month of maintenance therapy, a relapse was diagnosed. The patient was then referred for brexu-cel treatment, following bridging therapy with inotuzumab which led to the achievement of MRD-positive remission. Brexu-cel therapy was complicated by grade 1 CRS, grade 1 ICANS, and an episode of atrial fibrillation, but ultimately led to a complete MRD-negative CR. The patient remains in complete MRD-negative remission over one year after therapy, without the need for further treatment.

Conclusion: Brexu-cel represents an effective treatment option for patients with R/R B-ALL. In patients with comorbidities and significant transplant-related risks, prolonged remissions can be maintained even without additional consolidation therapies. Optimization of bridging therapy, monitoring, and toxicity management is essential.

In recent years, proximity of care has taken on a fundamental role in oncological management, improving the humanization and accessibility of treatments. The model of decentralizing oncological care from hospitals to local areas has been supported by national and international healthcare policies, such as the National Cancer Plan 2023-2027 and Ministerial Decree No. 77/2022. The aim of this work is to assess the impact of a hospital-territory integration pathway started by the G. Mazzini Hospital in Teramo, considering both the quality of the services offered and the economic implications for the National Health Service. The integration was achieved through the creation of a territorial oncology center, which provides care through a team of professionals working under the "migrant unit" model. This model focuses on chronic patients and long-term survivors, reducing waiting times and improving access to services. It has alleviated hospital overcrowding, improved organizational efficiency, treatment quality, and the psychological well-being of patients, which was measured using specific quality of life (QoL) questionnaires and financial toxicity assessments. From 1st January 2024 until 31 December 2024 the center managed approximately 3,000 visits, easing the hospital workload by rationalizing space and human resources, and improving access to treatments. An analysis of financial toxicity showed improved cost management, with a significant reduction in the cost per service, dropping from 30 euros in 2021 to about 17 euros in 2024 (-43%). The reorganization also helped reduce hospitalizations by optimizing care settings. Patient satisfaction was high, both in terms of service quality and stress reduction, thanks to a less crowded and more welcoming environment. Decentralization reduced the burden on hospital departments, improved efficiency and patient satisfaction, and lowered costs. The experience suggests that this model could be implemented and scaled in other regional healthcare systems to further enhance overall efficiency.

CAR-T cell therapy revolutioned the therapeutic landscape of the relapsed/refractory B-cell acute lymphoblastic leukemia (ALL-R/R), improving relapse-free survival and overall survival of patients. Optimal management of late complications, such as hematological toxicity as well as allogeneic transplantation role in the therapeutic sequence, are specific topics currently being debated. We report a case of a young woman with ALL-B R/R extramedullary relapsed after a first allogeneic transplant and second-line immunotherapy, successfully treated with brexu-cel obtaining a complete remission status confirmed after one year. We adopted a conservative strategy choosing to delay the option of a second allogeneic transplantation to manage a prologed severe hematological toxicity and to consolidate the remission obtained.

Modern oncology faces the need to integrate high-level evidence, non-pharmacological interventions into care pathways. Among these, structured physical exercise is shifting from a simple "virtuous recommendation" to a treatment that concretely influences clinical outcomes. The phase III CHALLENGE trial, conducted on 889 patients with stage II-III colon cancer, demonstrated a 6.4% absolute increase in 5-year disease-free survival (DFS) (HR 0.72) and a 37% reduction in overall mortality (HR 0.63). Observational evidence further confirms benefits in breast, prostate, and lung cancers. This review summarizes the literature, analyzes barriers and implementation strategies (tele-exercise, dedicated professionals, hub-and-spoke models), and assesses psychological and economic impacts.

Introduction: Malignant fungating wounds (MFW) pose a significant clinical challenge, affecting patients' quality of life through debilitating symptoms such as pain, exudate, and odor. This study aimed to translate, adapt, and validate the Malignant Wound Assessment Tool-Clinical version (MWAT-C) to assess malignant fungating wounds in Italy.

Methods: The study followed a multi-phase methodological design, including a backward and forward translation process and evaluation of the Italian version by 18 healthcare experts. Face and content validity were assessed using a Likert scale to rate item relevance and clarity.

Results: The overall S-CVI value was 0.96, with I-CVI values ranging from 0.78 to 1.00. Experts considered items related to pain, odor, and exudate particularly relevant. Some items, such as patient perception of the wound, received lower ratings, highlighting challenges in self-assessment.

Conclusion: Adopting this tool could improve the quality of care, reduce variability in clinical practices, and facilitate a multidimensional approach. However, further studies are needed to evaluate the scale's inter-rater reliability and internal consistency.

The therapy of patients with acute lymphoblastic leukemia (ALL) in the latter has achieved significant progress by increasing the complete remission (CR) rate, re-binding allogeneic transplantation to patients with high-risk disease and/or not in MRD-negative CR. The flip side of these successes is the more difficult management for patients who are refractory to modern treatment regimens or who relapse. Historically, it was necessary to aim for a CR and consolidate the result with allogeneic transplantation, an option available only to young and fit patients. Introduction of CAR therapy T seems to undermine this dogma by allowing to offer a lasting therapeutic perspective even for elderly patients who do not obtain a clinical response with second line therapy.

Here we report the case of a 39 years old patient who experienced a hematological relapse of B-cell acute lymphoblastic leukemia 23 months after completion of maintenance therapy. Relapse occurred two days after brexu-cel approval for reimbursement within the Italian National Health System. This favourable timing enabled the prompt apheresis for brexu-cel manufacturing, bridge therapy with inotuzumab ozogamicin and subsequently brexu-cel infusion. The patient achieved a complete molecular remission and thereafter performed an allogeneic stem cell transplantation. Currently, at 19 and 15 months after brexu-cel infusion and transplant, respectively, the patient presents sustained MRD negative remission with no graft-versus-host-disease evidence and a good quality of life.