CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...

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CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
Che cosa è
l’Osteoncologia in Italia ?

       Toni Ibrahim BSc,MD, PhD
Head of Osteoncology and Rare Tumors Center
  Cancer Institute of Romagna,IRST-IRCCS
              Meldola, Italy
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
Dichiarazione conflitto di interessi

Relationship                            Company/Organization
Honoraria Consultant                    EISAI
Grant to Institution                    Novartis
Partecipation expenses to congress      Novartis, Pharmamar, Ipsen

                       Toni Ibrahim, 19/06/2019
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
Outline:
1- Hot topic in Oncology

2- Osteoncology = Evolution and Revolution

3- Conclusions
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
Hot topic in Oncology

         Cancer
          Cells

                  Microenvironment

Cross
 talk
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
TO DOMINATE CANCER….
We need to join forces and speak the same language…

                                        Lab
                                    Researchers
                     Clinical
                   Researchers

                                 Research
                                 Support
                                  Figures

              Better understand
             CANCER BIOLOGY and
               PATIENT NEEDS
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
NATIONAL PROJECT: MULTIDISCIPLINARY APPROACH TO PATIENTS WITH
                              BONE METASTASES
                                                Prof Dino Amadori

  2000                                                                                                  2019

  National training courses
  2002 Bologna, Rome     2003 Naples, Bologna        2004 Naples, Florence

  This strategy could be one of the oncology
           Publications: 3 books

      experiences, the recent discipline:
                   2003 - 2018
                   National training and practical courses in Osteoncology
                                                                                          Course
                                                                                          in Osteoncology
             THE OSTEONCOLOGY
                   (Modena – Forlì- Meldola- Roma- Verona- others)

                   2003 - 2005
                   II level University Masters in Osteoncology
                   (Modena/Bologna/Forlì)                                                 Masters/PhD
                   2009-2019                                                              in Osteoncology
                   PhD in Osteoncology (Campus Roma)
                                                                  2008
                                                                                      2014                      2016
                                                                             National            Multidisciplinary
Establishment of            Establishment of
Osteoncology                Osteoncology                                     Bone
                                                                                                 Osteoncology
field                       Center                                           Metastases
                                                                             Data Base           School (MOS)
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
Osteoncology = Evolution and Revolution in Oncology
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
Outline:
1- Hot topic in Oncology

2- Osteoncology = Evolution and Revolution

3- Conclusions
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
New Bone- Cancer relationship
                         EVOLUTION

Primitive tumors               1- Bone metastases
                               2- Cancer Treatment Induced Bone Loss
                                  (CTIBL)

                         REVOLUTION
- Foundation of a new field in Oncology: OSTEONCOLOGY

- Care: mono and multidisciplinary approach

- Research: thanks to new Knowledge in the pathogenesis of bone
 metastases, on 2018 the aim of treatments is not only to prevent SREs, but
 also to have an impact in the natural history of cancer.
                                                       Ibrahim T et al. Oncol Lett. 2013
CHE COSA È L'OSTEONCOLOGIA IN ITALIA ? - TONI IBRAHIM BSC,MD, PHD HEAD OF OSTEONCOLOGY AND RARE TUMORS CENTER CANCER INSTITUTE OF ...
Danno osseo indotto dai trattamenti antitumorali
                             Rate of BMD Loss

       Normal men           0.5%

Late menop. women             1%

Early menop women                   2%

 Aromatase Inhibitor                  2.6%

Bone Marrow transpl                      3.3%

Androgen deprivation                               4.6%

   AI + GNrh agonist                                                7.0%

  Ovarian failure due                                                  7.6%
        chemiother
                        0        2            4             6              8
                             Lumbar spine BMD (% /year Bone Loss)
Impact of bone metastases

                          Osteoporosis/
       Skeletal Related
                                 CTIBL
            Events

QoL        Outcome            Costs
New Bone- Cancer relationship
                         EVOLUTION

Primitive tumors               1- Bone metastases
                               2- Cancer Treatment Induced Bone Loss
                                  (CTIBL)

                         REVOLUTION
- Foundation of a new field in Oncology: OSTEONCOLOGY

- Care: mono and multidisciplinary approach

- Research: thanks to new Knowledge in the pathogenesis of bone
 metastases, on 2019 the aim of treatments is not only to prevent SREs, but
 also to have an impact in the natural history of cancer.
                                                     Ibrahim T et al. Oncol Lett. 2013
Oncologist
          Dedicated                                Radiotherapist
            Nurse
                                                           Palliative Care
Lab Reasearchers                                           Expert
                                                                 Orthopedic
Data Manager                                                     Specialist
                                                             Neurological
 Pathologist
                        Patient with bone                    surgeon
 Clinical                Cancer disease                    General and
 Pathologist                                               Endocrine surgeon

Endocrinologist                                                  Radiologist

                                                       Nuclear Medicine
     Psicologist                                       Physician

                   Physiatrist                Otolaryngologist
NATIONAL PROJECT: MULTIDISCIPLINARY APPROACH TO PATIENTS WITH
                              BONE METASTASES
                                                Prof Dino Amadori

  2000                                                                                                  2019

  National training courses
  2002 Bologna, Rome     2003 Naples, Bologna        2004 Naples, Florence

           Publications: 3 books

                   2003 - 2018
                                                                                          Course
                   National training and practical courses in Osteoncology
                                                                                          in Osteoncology
                   (Modena – Forlì- Meldola- Roma- Verona- others)

                   2003 - 2005
                   II level University Masters in Osteoncology
                   (Modena/Bologna/Forlì)                                                 Masters/PhD
                   2009-2019                                                              in Osteoncology
                   PhD in Osteoncology (Campus Roma)
                                                                  2008
                                                                                      2014                      2016
                                                                             National            Multidisciplinary
Establishment of            Establishment of
Osteoncology                Osteoncology                                     Bone
                                                                                                 Osteoncology
field                       Center                                           Metastases
                                                                             Data Base           School (MOS)
Società Italiana di Osteoncologia
                    Mission
ASSISTENZA

Promuovere la formazione di gruppi multidisciplinari per la cura dei pazienti con
patologia oncologica ossea e favorire la nascita di nuovi centri specializzati

RICERCA

Promuovere e sostenere la ricerca di base, traslazionale e clinica, con particolare
riferimento agli studi multidisciplinari

DIDATTICA

Favorire la formazione dei professionisti delle discipline connesse all’osteoncologia
attraverso l’organizzazione di eventi formativi, convegni e la realizzazione di
pubblicazioni scientifiche dedicate
Società Italiana di Osteoncologia
                             Governance

Consiglio Direttivo 2017/2020

Presidente: Gaetano Lanzetta
Segretario: Stefano Severi
Tesoriere: Vittorio Fusco
Consiglieri :
              - Asssistenza: Alfredo Berruti
              - Ricerca preclinica: Francesco Pantano
              - Ricerca clinica: Toni Ibrahim
              - Formazione: Roberto Casadei

Collegio dei Sindaci : Stefania Zoveto (Presidente), Tiziana Falbo, Laura Mercatali

Sede legale: Via Pietro Marroncelli, 40 . 47014 Meldola (FC)
             C.F. 92068610408 P.I. 04113560405
Rete Osteoncologia Nazionale
                        www.osteoncology.it
Centri accreditati di eccellenza:

- Centro di Osteoncologia presso l’istituto Scientifico Romagnolo per lo Studio e la
Cura dei Tumori IRCCS di Meldola
- Centro di Osteoncologia presso l’istituto Oncologico Veneto IOV
- Centro di Osteoncologia presso l’istituto Tumori Regina Elena, Roma
- Centro di Osteoncologia presso l’Università Campus Biomedico, Roma

Centri che rispettano i requisiti minimi:

- Centro di Osteoncologia presso l’istituto Neurotraumatologico Italiano,
Grottaferrata (RM)
- Centro di Osteoncologia presso Ospedale Gradenigo (TO)
Multidisciplinary Osteoncology School (MOS)
              IRST,IRCCS, Meldola

    Aims: Promote training in Osteoncology (bone metastases/bone health):
 - Mono- and multidisciplinary care

 - Basic, translational and clinical research

 - Integration between assistance and research

   Target: All professionals interested in Osteoncology from lab to the clinic assistance
  Methodology: Theorical and practical courses
National Bone Metastases Data Base
                               Materials and Methods

BM Data Base is a multicenter prospective observational study, which has as Coordinating Center
(CC), IRCCS IRST of Meldola. The database will allow to gather information on the medical history of
patients with BM using an online software tailored for these data.

•The platform of the database consists of 4 files containing information regarding patient
demographics, characteristics of the primary tumors and BM, as well as their evolution, in particular
the onset and the types of SRE.

The data are updated every 6 months by the participating centers and reviewed by CC.
National Bone Metastases Data Base

  For information about project, please contact:
  Alberto Bongiovanni: alberto.bongiovanni@irst.emr.it
  Flavia Foca: flavia.foca@irst.emr.it
National Bone Metastases data Base : Currently Projects …..

•    Italian Bone Metastases Database: Breast Cancer Prospective Data

    - Abstract ASCO 2016 e AIOM 2016
    - Abstract AIOM 2019 ( submitted)
    - In corso Analisi dei dati e stesura Paper per pubblicazione nel 2019

• Italian Bone Metastases Database NSCLC: Cancer Prospective Data

• Bone Metastases NSCLC: ICI + DENOSUMAB vs ICI + Zoledronate

•    Prospective Study on BM management in elderly patient’s

•    Prospective Study Sarcoma Bone Metastases
Osteoncology Center
Osteoncology Center: Pathway Indicators

1- Effect on Quality of life and pain

2- Patient Satisfaction

3- Patient adherence

4- Attraction Index

5- Cost of service
Results: MDOT interventions
Results: BPI analysis

A significant improvement in the worst
(p
Results: Patient’s Satisfaction
Patient adherence

 236 visits (1° semester 2018)

only one patient did not attend

the appointment at the Clinic
Attraction Index
                  (2014-2018)

6961 patients (percorso metastasi ossee e CTIBL)
                 2509 (37 %) Area Vasta Romagna
                4452 (63 %) Ext. Area Vasta Romagna
                1016 (23 %) Ext. Emilia Romagna
Il percorso assistenziale in osteoncologia : l’esperienza del
      gruppo integrato di cure dell’Azienda Ospedaliera
                S. Giovanni battista di Torino

The cost analysis of the GIC group confirms this change:
     (120 patients GIC vs 35 patients pre-GIC):

•   A mean cost reduction of 225 euro per patient;
•   Diagnosis more expensive;
•   Lower cost of hospital admission (surgery);
•   Surgery definitive, not palliative kind (preventive fracture);
•   Fifty percent reduction in waiting time from hospitalisation
    to surgery

                                           Colangelo I, Mecosan 2006
New Bone- Cancer relationship
                         EVOLUTION

Primitive tumors               1- Bone metastases
                               2- Cancer Treatment Induced Bone Loss
                                  (CTIBL)

                         REVOLUTION
- Foundation of a new field in Oncology: OSTEONCOLOGY

- Care: mono and multidisciplinary approach

- Research: thanks to new Knowledge in the pathogenesis of bone
 metastases, on 2019 the aim of treatments is not only to prevent SREs, but
 also to have an impact in the natural history of cancer.
                                                    Ibrahim T et al. Oncol Lett. 2013
Bone Metastases Are a Mixture of
          Osteoblastic and Osteoclastic Lesions

            Osteoblastic               Mixed                 Osteolytic

                                                                 Myeloma
                                            Breast

                  Prostate

Adapted from: Halvorson K et al. Clin J Pain. 2006;22:587.
At
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Met_bone_list1.htm
OSTEOLYTIC MODEL: a vicious cycle

                 RANK

                                Buijs, The prostate,2009
OSTEOBLASTIC MODEL: a vicious cycle

(A) Prostate cancer cells secrete osteogenic growth factors, activating osteoblasts to deposit new bone matrix.
(B) Osteoblasts secrete a range of additional factors such as insulin-like growth factor (IGF), fibroblast growth factor
(FGF), and transforming growth factor-b (TGFb).
(C) These factors attract prostate cancer cells, further enhancing their proliferation and growth.
                                                                                                     Ibrahim T, Cancer 2010
Treatment of Bone Metastases

                        Medical treatment of bone
                        metastases has become
                        progressively complex and currently
                        includes:

                         well known antitumor agents

                         bone targeted molecules

                                     Ibrahim T, Tumori 2013
The Metastatic Process: hypothesis

                                                                                                        CTIBL

                                                                                                                    2
1                   MSC, HSC                                                           STRESSING
    Peripheral                       Bone                                Bone           FACTORS         Primitive
     tissues                       (HSC, MSC)                          (MSC, MF,       (cytokines,
                                                                                                         tumor
                                                                         Neut)        exosomes…)
                   physiologica      HSC                                                    MSC, TAM,
                   lHSC niche in   patrolling                                                 TAN
                      tissue

                                                                  HSC,                                                      3
                                                                  Mac
                                                                                   Peripheral
                                                                                    tissues
                                                                                                        Pre-metastatic
                                                                                   (bone, liver,            niche
                                                                                     lung…)

                 Death
                                                                          4
                                                                                                                        CTC, DTC
        Dormancy                                  Metastatic                                                            from primary
                                                                                                                         tumor/bone
                                                   niche
                                                (bone, liver, lung…)
            Metastatic
             growth
                                                                                                          Ibrahim T, not pubblished
The metastatic process/pre-metastatic Niche

                                               Osteoblast cells regulate HSC cells and are
  Tumour cell
                                               closely linked with vascular remodeling and
arriving in bone
                                                            osteoclast activity

                                     Perivascular
                                                          Osteoblastic
                                        Niche                                Osteoclast
                                                             Niche

                                                                                  Tumour cell
                   Hematopoietic
                                                                                  Osteoblast
                   stem cell niche
                                                                                   HSC
Bone Microenvironment

          CTIBL

          Shiozawa Y, Clinical Cancer Research, 2011
Summary
        Bone       Targeted         Therapy
-The use of adjuvant BTT has now been demonstrated to
reduce the development of bone metastasis, distant
recurrence, and breast cancer mortality among
               Advanced setting
postmenopausal women and in premenopausal women
undergoing ovarian suppression.

- The use of Denosumab has now been demonstrated in
prostate cancer patients at high risk of reccurence, to reduce
the development of bone metastasis. No effect on mortality.
                Adjuvant setting
Outline:
1- Hot topic in Oncology

2- Osteoncology = Evolution and Revolution

3- Conclusions
Osteoncology

      Bone Health/Omeostasis

QoL                            Costs
          Outcome

NATURAL HISTORY OF CANCER
New Bone- Cancer relationship
                         EVOLUTION

Primitive tumors               1- Bone metastases
                               2- Cancer Treatment Induced Bone Loss
                                  (CTIBL)

                         REVOLUTION
- Foundation of a new field in Oncology: OSTEONCOLOGY

- Care: mono and multidisciplinary approach

- Research: thanks to new Knowledge in the pathogenesis of bone
 metastases, on 2018 the aim of treatments is not only to prevent SREs, but
 also to have an impact in the natural history of cancer.
                                                  Ibrahim T et al. Oncol Lett. 2013
Normal bone turnover: bone breackdown
and bone formation are in equilibrium
                          T5

                                                                                      T5

                     T11

                     L1
                                                                                     T11

                                                                                     L1

- Progressivo calo del CA 15.3 (10/10: 50, 02/11: 29): Ca duttale inf mammario ER/PgR + in trattamento con Letrozolo
- Stabilità pleurica: eupnoica;
- Dicembre 2010: si reca al PS per dolore acuto rachide con crolli e vertebroplastica T11 e L1;
- Persistenza del dolore che ha necessitato un ulteriore lungo ricovero e inserimento catetere epidurale;
- Gennaio 2011: consulenza CDO, inizia bisfosfonato ev con supplementazione di calcio e vitamina D3
- Aprile 2011: TC visceri e osso stabili, markers negativi e pz con analgesici orali (Oxycontin 30 x 2).
CDO-TR strategies for a new tarsversal discipline as
        Osteoncology and Rare Tumors

                        Method: Team
                          (Lab/Clinic)

                 Mono/multidisciplinary approach:
                    assistance and reasearch

                                                    2005
                       Specific expertise
                                                    2011
                 National and International
                  Network/Collaborations
                                                    2019
                 Pharmaceutical companies

                   Spontaneous Reasearch
National and International Collaborations

                                           Princeton
                                           Univ. NY
                  Duke                                           Leiden
                                             (USA)
                University                                     Univ Medical
                   (USA)                     Y. Kang
                                                               Centre (Olanda)
                  X. Wang                                        G. Van der
                                                                   Pluijm
                               Osteoncology National Network
  Pathology
     Unit                                                                        TMHRI
    AVR
                                        CDO-TR                                 Texas Univ.
                                                                              Houston,USA
                                        CCCN Romagna
                                                                                M. Ferrari
Campus Bio-
medico Univ
   Rome
Prof Santini                                                              Istituti
                                    Rare Tumors Network
                                                                         Ortopedici
               Regina Elena                                              Rizzoli, BO
                                                                        (Prof Donati)
                 Institute                      Modena
                   Rome                        University
                Prof Biagini                   Prof Catani
L’Osteoncologia ……
Osteoncology and
                                             Rare Tumors Center
                                                  CDO-TR
                                             Director: Toni Ibrahim

Oncologists:            Lab Researchers:
Alberto Bongiovanni     Laura Mercatali
Sebastiano Calpona      Chiara Liverani                                            Centro di
Giandomenico Di Menna   Alessandro De Vita                                         Eccellenza
Lorena Gurrieri         Chiara Spadazzi             Member and Collaborations:
Federica Recine         Giacomo Miserocchi         - CCCN of Romagna
Nada Riva               Claudia Cocchi             - National Network of Osteoncology
Valentina Fausti (Tr)                              - National Network of Rare Tumors
Sivia De Bonis (Tr)     Specialist Nurse:
                                                   - EURACAN (European Reference Network)
                        Venetia Zavoiu             - University of Bologna, Modena, Milan and Ferrara
Data Manager:                                      - Alleanza Contro il Cancro
                        Pharmacyst:
Benedetta Rossi                                    - Istituto Ortopedico Rizzoli
                        Valentina Di Iorio
Monia Dall’Agata                                   - Princeton University, USA
Alessandra Affatato                                - The Methodist Research Institute, Houston,USA
                        Statistic:                 - Leiden University, The Netherlends            50
                        Flavia Foca
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