An in-vacuo optical levitation trap for high-intensity laser interaction experiments with isolated microtargets

We report on the design, construction, and characterisation of a new class of in-vacuo optical levitation trap optimised for use in high-intensity, high-energy laser interaction experiments. The system uses a focused, vertically propagating continuous wave laser beam to capture and manipulate micro-targets by photon momentum transfer at much longer working distances than commonly used by optical tweezer systems. A high speed (10 kHz) optical imaging and signal acquisition system was implemented for tracking the levitated droplets position and dynamic behaviour under atmospheric and vacuum conditions, with ±5 μm spatial resolution. Optical trapping of 10 ± 4 μm oil droplets in vacuum was demonstrated, over timescales of >1 h at extended distances of ∼40 mm from the final focusing optic. The stability of the levitated droplet was such that it would stay in alignment with a ∼7 μm irradiating beam focal spot for up to 5 min without the need for re-adjustment. The performance of the trap was assessed in a series of high-intensity (10(17) W cm(-2)) laser experiments that measured the X-ray source size and inferred free-electron temperature of a single isolated droplet target, along with a measurement of the emitted radio-frequency pulse. These initial tests demonstrated the use of optically levitated microdroplets as a robust target platform for further high-intensity laser interaction and point source studies.

Consequences of a missed ankle dislocation in an adolescent

Ankle dislocation without associated malleolar fracture(s) remains a rare presentation, especially in adolescence. Identified and treated promptly, these injuries can result in good to excellent outcome. We present an anterior ankle dislocation in a 14 year old, missed for approximately 12 months, necessitating multiple surgical interventions to provide a pain-free and stable joint. A review of the current literature is also provided.

Abstract P2-15-02: The efficacy of recruitment and retention strategies for research subjects in an early phase investigator-initiated breast cancer trial

Background: One of the biggest challenges faced by investigators is the implementation of effective strategies to improve the recruitment and retention of research participants. This is especially true for investigator-initiated, federally funded (e.g. NIH and DOD), early phase clinical trials that involve the treatment of serious diseases such as metastatic breast cancer (MBC). These studies may face additional barriers to participation since patients have often already undergone maximal treatment and are usually not in a financial position that for allows the travel and lodging necessary to receive further investigative treatment. Moreover, efficacy and toxicology in early phase clinical trials are unknown. Thus, when study budget constraints do not allow monetary incentives to participation, it is difficult to provide motivation for patients to enroll and remain adherent to the protocol requirements. However, many MBC patients are motivated to join clinical trials for altruistic purposes alone, and evidence supports that the researcher-patient relationship may be the most important factor in clinical trial participation. Recognizing that many patients are willing to participate if provided the appropriate resources despite limited monetary incentives, we developed a system to improve patient recruitment and retention to our studies, which are primarily federally funded. We report here on the strategies developed and used by our group to recruit and retain patients in a federally-funded investigator-initiated phase I/II vaccine study in MBC patients.

Methods: This study was funded by the NIH/NCI and involved infusion of HER2 specific T cells in HER2+ MBC patients after completing in vivo priming with a HER2 vaccine. It required 11 visits to Seattle, Washington. Working with agencies that offer free services to patients enrolled in clinical trials, a list of available resources was compiled and a visit flowchart with specific information on travel and lodging resources (e.g. Angel Flights and ACS sponsorship), local transportation and entertainment was developed. During screening, patients were given the list of resources and trial information. An email system was used to quickly communicate and follow-up with patients. Eligible patients were given the visit flowchart to help with their planning of study visits. An enrollment packet was provided at the first visit with a calendar to keep track of the visit schedule. Coordination of care between the patient's primary oncologist and the research staff was maintained throughout the study.

Results: 17 of 19 patients enrolled were not from Washington State. Two out-of-state patients withdrew early from the trial for reasons unrelated to disease progression or toxicity; one subject completed 8 visits and enrolled in another study and the other completed 2 visits and discontinued the trial to resume chemotherapy.

Conclusion: We have developed a successful system to enroll and retain patients in a trial requiring multiple study visits. Development and implementation of site-specific standard procedures are critical to improve study participation and retention, especially when patients receive no financial benefit.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-15-02.

Abstract OT3-1-02: Phase II randomized study of combination immunotherapy with or without Polysaccharide Krestin (PSK®) concurrently with a HER2 ICD peptide-based vaccine and trastuzumab in patients with stage IV breast cancer

Background: Endogenous immunity in patients with HER2+ metastatic breast cancer (MBC) is likely dampened by an immune-suppressive tumor microenvironment and not sufficient to control tumor growth. Thus, most patients have disease relapse after achieving complete remission with standard therapies. Immunomodulation directed at enhanced stimulation of tumor specific immunity could result in immunologic eradication of residual HER2+ tumor cells and prevent BC relapse. We have shown PSK to be a potent TLR-2 agonist that stimulates both innate and adaptive immunity in a BC mouse model. Additionally, we have shown combination immunotherapy with HER2 peptide vaccines and trastuzumab (TRAZ) to be safe and able to elicit HER2 specific Th1 immunity and epitope spreading (ES) which has been associated with survival in vaccinated patients. Lastly, decreased serum TGF-β elicited by HER2 vaccination correlates with Th1 ES and may serve as a biomarker to predict cancer vaccine efficacy. We hypothesize that PSK, when given with TRAZ can augment vaccine induced HER2 specific TH1 immunity and prevent disease relapse in patients with optimally treated HER2+ MBC.

Trial design: Phase II randomized two-arm clinical trial. Patients will be enrolled and randomly assigned in equal numbers to 1 of 2 arms (15 patients/arm) as follows: Arm 1:HER2 ICD vaccine, TRAZ and placebo or Arm 2:HER2 ICD vaccine, TRAZ and PSK. All patients will receive 3 monthly HER2 ICD vaccines plus TRAZ and 4 months of concomitant PSK or placebo. Serial blood draws for immunologic monitoring will be done.

Eligibility criteria: Patients with Stage IV HER2+ BC who have been treated with definitive therapy and are: (1) without evidence of disease or have stable-bone only disease, (2) receiving TRAZ monotherapy, and (3) without clinically significant autoimmune disease. Patients must have normal LVEF per MUGA scan or echocardiogram.

Aims: (1) Evaluate safety of PSK when given with a HER2 vaccine and TRAZ (2) Evaluate the effect of PSK on serum TGF-β levels when given with a HER2 vaccine and TRAZ and (3) Evaluate the effect of PSK on intermolecular ES when given with a HER2 vaccine and TRAZ. A secondary objective is to evaluate progression free survival (PFS) and overall survival (OS).

Statistical methods: (1) Toxicity will be determined by clinical and chemical parameters and grading will be done per CTEP CTCAE 4.0.; (2) Evaluation of TGF-β levels, pre and post-PSK treatment will be assessed with linear regression models; and analysis of multiple post-baseline measurements will be performed using generalized estimating equations; (3) A positive antigen-specific immune response will be defined as a precursor frequency >1:20,000 antigen-specific peripheral blood mononuclear cells. Differences in the levels of HER2 immunity will be evaluated between arms using a two-tailed T test. The degree of ES in each arm will be evaluated with generalized linear modeling; (4) Large differences in PFS and OS observed between groups will be noted and described.

Target accrual: 30 patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-1-02.

The ontogeny of New Zealand groper (Polyprion oxygeneios) lymphoid organs and IgM

This study investigates the ontogeny of New Zealand groper (Polyprion oxygeneios) immune system, a new species for aquaculture in the Southern Pacific Ocean. In the eggs, both lysozyme and IgM were detected. Egg IgM was found at 1.07-1.56 μg/g wet weight and consisted of monomers compared to the polymerized IgM found in adult serum. In larvae, the head-kidney (HK) was first observed at 6 dph, followed by the spleen at 16 dph, and thymus at 20 dph, and within these organs IgM(+) cells were first detected in the HK (12 dph), then the spleen (32 dph) and finally in the thymus and the gastrointestinal tract (45 dph). Low levels of Igμ heavy chain transcripts were detected at 2 and 3 dph and they increased at 9 dph. Igμ expression further increased from day 45 onwards. In juveniles (115 dph), the HK and blood showed similar percentages of IgM(+) cells as the adult groper. These results highlight the important maturation steps that occur during the development of the immune system in the marine teleost P. oxygeneios.

Routine group and save unnecessary for gastric band surgery: a retrospective case review audit of 1018 bariatric patients

What is already known about this subject •  The demand for bariatric surgery is increasing. •  NHS Trusts are expected to instigate cost-efficiency measures. •  Previous articles have discussed the need for routine preoperative cross-match. What this study adds •  No gastric band patient suffered a significant drop in haemoglobin or needed a blood transfusion. •  Group and save samples could be safely stored in the laboratory and only sent for analysis if clinically indicated. •  Even greater cost savings could be achieved if prudent use of perioperative blood testing and blood transfusion was implemented.

SUMMARY

Current guidance at our Trust is that all bariatric surgical patients should have preoperative group and save (G&S) and full blood count (FBC) tests, as well as a FBC check 1 d post-operatively. Our aim was to investigate blood transfusion requirements of these patients and whether we could reduce the number of investigations requested. 1018 consecutive elective laparoscopic gastric band and laparoscopic Roux-en-Y gastric bypass patients who were operated on in our bariatric unit from March 2000 until January 2011 were identified. Patients' haemoglobin levels, G&S status and blood transfusion requirements were analyzed using our online pathology system. 607 patients had a laparoscopic gastric band, with 411 undergoing a laparoscopic Roux-en-Y gastric bypass. None of our gastric band patients required a transfusion; however, nine patients (2.2%) undergoing a gastric bypass needed a transfusion. Two patients required transfusion within 24 h of surgery while six of the remaining seven patients received blood 3-4 d post-operatively. Costs incurred on FBC and G&S tests during this time were estimated to exceed £15 700. G&S and post-operative FBC tests could be abandoned for laparoscopic gastric band patients with significant financial and person-time savings. However, given that 2.2% of laparoscopic Roux-en-Y gastric bypass patients needed a blood transfusion, we believe that post-operative FBC tests are still warranted in this patient group, with a G&S sample stored in pathology. Much greater financial savings could be achieved if prudent use of preoperative investigations, including storing G&S samples in the laboratory, was adopted for all elective operations.

P1-13-04: Phase II Study of Topical Imiquimod and Abraxane for Treatment of Breast Cancer Cutaneous Metastases

Background: Breast cancer (BC) cutaneous lesions can present as local chest wall recurrence or isolated sites of metastatic disease. Current treatments with full thickness chest wall resection, radiation therapy and chemotherapy are not curative; and have significant morbidity and poor overall response rates. Combining local immunomodulation and systemic chemotherapy may be more effective in treating cutaneous disease. Topical imiquimod (IMQ), a TLR-7 agonist, has shown clinical activity against cutaneous metastasis. Pre-clinical studies have shown IMQ to stimulate Th1 cytokine secretion and up-regulate immune co-stimulatory molecules at the tumor site; resulting in augmented tumor specific T cell immunity and tumor growth inhibition. Use of paclitaxel in BC, has demonstrated immunostimulatory effects of increased serum IFN-γ and enhanced NK/LAK cell activity. Abraxane (albumin-bound paclitaxel) may be used in conjunction with IMQ as steroid pre-treatment is not required. We hypothesize the immune effects of Abraxane may synergize and augment the IMQ anti-tumor effects, resulting in greater clinical response. A phase II single-arm study of chemoimmunotherapy with topical IMQ and Abraxane was initiated to determine its safety and therapeutic efficacy; and examine its effect on augmenting endogenous tumor specific immunity and inducing tumor molecular alterations associated with inhibition of tumor growth and/or common pathways of BC immune escape.

Materials and Methods: Up to 15 BC patients with cutaneous lesions no longer amenable to standard therapy are enrolled and receive 3 treatment cycles. A treatment cycle consist of topical 5% IMQ to target lesions 4 days/week (wk.) and Abraxane 100 mg/m2 on Days 1, 8, 15 every 28 Days. Toxicity is evaluated per CTCAE v3.0 on Days 1, 8, 15 of each cycle and wks. 13, 16, 20, 24. Target lesion antitumor activity is assessed per modified WHO criteria (Complete response (CR); Partial response (PR); Stable disease (SD); Progressive disease (PD)) at baseline, wks. 4, 8, 12, 16, 20, 24. 2-mm target lesion skin biopsies are obtained pre-and post-treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature associated with tumor inhibition. Immunity to HER2, IGFBP-2, TOPO-IIα, p53 and serum TGF-β levels are evaluated at baseline and wks. 12, 24 with IFN-γ ELISPOT and ELISA, respectively.

Results: 10 patients have been enrolled. Median (range) values include: age, 54 years (48-92), time from metastatic diagnosis, 134 months (58-728), prior chemotherapy regimens, 5 (2-10). 5/10 patients had received prior local therapy, e.g., radiation. 5/10, 4/10, and 2/10 patients had triple negative, HER2+ and ER+/PR+ tumors, respectively. In 5 patients completing 3 treatment cycles, overall response rate (ORR) = 100% (3 CR, 2 PR). In the 5 patients who completed 1–2 treatment cycles, ORR = 80% (2 PR, 2 SD, 1 PD). Treatment related toxicity is primarily grade I/II neutropenia, anemia; grade I skin toxicity. Immunologic analyses are ongoing and will be presented with completed clinical data on all patients.

Conclusions: Chemoimmunotherapy with topical IMQ and Abraxane is well-tolerated and shows excellent clinical efficacy in treating metastatic cutaneous lesions in heavily pretreated BC patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-13-04.

OT3-01-19: Phase II Study of Topical Imiquimod and Weekly Abraxane for the Treatment of Breast Cancer Cutaneous Metastases

Background

Breast cancer (BC) cutaneous lesions present as local chest wall recurrence or as isolated sites of metastatic disease. The treatment of cutaneous lesions is challenging and includes chest wall resection, local radiation therapy, and/or salvage chemotherapy which is not curative, associated with significant morbidity, and results in overall response rates of 20–30%. Thus, investigation of novel treatment strategies is warranted. This study incorporates multimodality treatment with topical imiquimod, a TLR-7agonist which generates an immune signal similar to that of pathogenic bacteria and Abraxane, a conventional systemic chemotherapy with potential immunostimulatory effects. Combined, these two agents provide local and systemic strategies which are potentially synergistic; and more effective than as single-agents in treating and controlling cutaneous disease.

Trial design: A Phase II single arm, non-randomized study. Patients will be sequentially enrolled and receive a maximum of 3 treatment cycles. A treatment cycle consists of topical imiquimod daily to target lesions for 4 days/week for 4 weeks in addition to Abraxane on Days 1, 8, and 15 every 28 days. Toxicity will be evaluated weekly during treatment then monthly for four months. Defined lesions are assessed at baseline and monthly. Skin biopsies are obtained pre and post treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature previously associated with tumor inhibition. Immunity to BC antigens and serum TGF-β levels are also evaluated.

Aims: To evaluate the safety and anti-tumor effects of chemoimmunotherapy with topical imiquimod and Abraxane.

Eligibility criteria: Patients with progressive or relapsed BC after standard therapy who 1) have measurable cutaneous metastatic lesions, 2) are at least 7 days from last chemotherapy, 30 days from local radiotherapy and/or systemic steroids, 3) have adequate blood counts and 4) no history of active autoimmune disease. Bisphosphonates, trastuzumab, and/or hormonal therapy is allowed.

Statistical methods: Antitumor activity of target lesions will be assessed per modified WHO criteria. Complete response (CR)-complete clearance of lesions; Partial response (PR) ≥ 50% decrease in lesion size; Stable disease (SD) < 50% decrease in lesion size; Progressive disease (PD) increase in ≥ 25% lesion size). Historical overall response rates (ORR) with second and third line salvage chemotherapy range from 20–30%, with CR rates less than 2%. Based on these numbers, an ORR of 50% or a CR rate of 10% will be used as benchmarks for success (i.e., ≥8 responses or ≥2 CRs among 15 patients (observed ORR of ≥ 53% or observed CR rate of ≥ 13%) to consider the treatment worthy of further study. As a measure of the precision of the estimate of ORR achievable with 15 patients, if the response rate is 60%, we will be 80% confident that the observed RR is within 0.16 of the true RR with 15 patients treated. Toxicity will be evaluated by CTCAE v. 3.0 and descriptive statistics will be used to summarize changes from baseline and for reporting of immunological parameters.

Accrual: 10 patients received treatment with a target accrual of 15.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-01-19.