PL02.3.A Survival and T-cell tumor reactivity in patients treated with nivolumab and bevacizumab for recurrent glioblastoma in the clinical trial CA209-9UP

Background

Glioblastoma (GBM) is an aggressive brain tumor with a median survival of 14.6 months. We have no standard treatment for relapse and current treatment options have limited effect. Novel treatments are necessary to improve survival and quality of life.

Material and Methods

We present data from; a phase II open label, two-armed clinical trial studying nivolumab and bevacizumab in treatment of recurrent GBM, with progression after Stupp’s regime. Patients were included in two arms depending on the possibility of salvage neurosurgical resection. All patients had biopsies for genome sequencing at primary tumor and recurrence. Both arms received nivolumab and bevacizumab administrated every second week and the surgical arm also received neoadjuvant nivolumab 7 days prior to surgery. Fresh tissue samples were collected for tumor digest, TILs (tumor infiltrating lymphocytes) for phenotype exploration and intracellular staining to test reactivity. Patients were treated until progression, death, or intolerable side effects. Toxicity screens were reported, and follow-up ended in Marts 2022.

Results

Forty-four patients were included from November 2018 to January 2022; 20 in each arm (four screen-failures). Treatment was overall well tolerated. Median (m) age at inclusion was 57,5 years (arm A) and 50,5 years (arm B), and the groups had an even distribution. The surgical and non-surgical arm had an mPFS of 5.95 and 3.83 months respectively, while the mOS was 13.96 months and 6.77 months, respectively. Multivariate analysis was performed by variables such us steroid, MGMT, gender, age at diagnosis, resection extent and arm. Steroid at inclusion was a significant negative predictor of outcome (p = 0.0378). Controls from our GBM registry (N=140), which were treated with neurosurgical resection and then bevazicumab and irinotecan in recurrent setting had an mOS of 8.64 months (log-rank p=0.0181).Furthermore, reactive tumor infiltrating lymphocytes (TIL) were detected in four of the patients who presented with a longer mOS and mPFS of 16.75 months and 9.18 months, while the 16 patients without TIL reactivity had mOS and mPFS of 12.63 months and 5.13 months, respectively (not significant).

Conclusion

We found an increased mOS in patients treated with nivolumab and bevacizumab at recurrence, compared to our controls: 13.96 months and 8.64 months, respectively. Four patients with T-cell reactivity towards tumor cells showed an even longer mPFS and mOS. Though not significant, these results warrant further research evaluation in larger patient cohorts. We are currently investigating proteomics and sequencing data to identify predictive biomarkers.

Mycobacterium marinum dermatitis and panniculitis with chronic pleuritis in a captive white whale (Delphinapterus leucas) with aortic rupture

A 16-year-old female white whale, Delphinapterus leucas, died after nearly 18 months of chronic lymphopenia and pyogranulomatous dermatitis. Necropsy revealed rupture of the aorta with hemorrhage into the cranial mediastinum and between fascial planes of the ventral neck musculature. Multiple foci of ulcerative dermatitis and panniculitis were present across the thorax and abdomen and surrounded the genital folds. In addition, there was a chronic proliferative pleuritis with over 20 liters of histiocytic exudate in the thoracic cavity. Acid-fast bacteria consistent with Mycobacterium sp. were identified in sections of skin lesions and in cytospins of pleural exudate. Cultures of pleura and 1 skin lesion collected at necropsy yielded sparse growth of an acid-fast bacillus with colony characteristics and morphology consistent with Mycobacterium marinum. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis confirmed the presence of M. marinum DNA in samples of skin. This is the first documented occurrence of mycobacteriosis in a white whale and is a unique presentation of mycobacterial dermatitis and panniculitis with chronic pleuritis in a cetacean. The improved PCR-RFLP protocol utilized in this case unifies techniques from several protocols to differentiate between species of Nocardia and rapidly growing mycobacteria clinically relevant to aquatic animals.

Identification of herpes simplex virus genital infection: comparison of a multiplex PCR assay and traditional viral isolation techniques

Genital herpes simplex virus (HSV) is of major public health importance, as indicated by the marked increase in the prevalence of genital herpes over the past two decades. Viral culture has traditionally been regarded as the gold standard for diagnosis. In this study, we compared viral culture and the amplification of HSV DNA by the polymerase chain reaction (PCR) with respect to sensitivity, cost, clinical utility, and turnaround time. Patient sample swabs from 100 individuals were inoculated onto MRC-5 cells for isolation. Positive results were confirmed via a direct fluorescent antibody technique, and serotyping, when requested, was performed using HSV-1 and -2-type-specific sera. PCR techniques employed an extraction step of the same initial swab specimen, followed by PCR amplification, using a multiplex assay for HSV-1, 2 DNA. HSV-positive results were found in 32/100 samples via culture and in 36/100 samples via PCR. PCR-positive results yielded 16 (44%) patients infected with HSV-1 and 20 (56%) patients infected with HSV-2. Turnaround time for viral culture averaged 108 hours for positive results and 154 hours for negative results; PCR turnaround time averaged 24--48 hours. Laboratory cost using viral culture was $3.22 for a negative result and $6.49 for a positive result (including direct fluorescent antibody). Serotyping added $10.88 to each culture-positive test. Although laboratory costs for PCR were higher at $8.20/sample, reimbursement levels were also higher. We propose a multiplex PCR assay for diagnosis of HSV-1 and HSV-2 from patient swabs for use in a routine clinical laboratory setting. This assay offers increased sensitivity, typing, and improved turnaround time when compared with traditional viral culture techniques. Although it appears that PCR testing in a routine clinical laboratory setting is cost prohibitive compared with the case of nonserotyped viral culture, it may be very useful when clinical utility warrants distinguishing between HSV 1 and 2 and may be cost effective when reimbursement issues are examined.

Polymorphisms in the genes for coagulation factors II, V, and VII in patients with ischemic heart disease

BACKGROUND

Cardiovascular disease remains the leading cause of mortality in the United States, accounting for approximately 33% of all deaths in this country. Of these deaths, most are due to acute myocardial infarctions (AMIs), which are associated with thrombotic coronary artery obstruction and/or occlusion. These events could potentially be due to alterations in genes coding for coagulation factors. Several polymorphisms have been described in the factor II, V, and VII genes, which may predispose one to increased risk for ischemic heart disease (IHD).

OBJECTIVE

To determine if mutations in 3 coagulation factor genes could predispose an individual to increased risk for arterial thrombosis as a mechanism for developing unstable angina (UA) or AMI.

METHODS

We examined 125 hospitalized patients (mean age, 53 +/- 6 years, 79 men and 46 women), including 32 with AMI, 68 with UA, and 25 noncardiac controls, for a genetic predisposition for increased risk of IHD. EDTA-anticoagulated whole blood was collected at the time of hospital admission. DNA was extracted, and the polymorphisms were detected by polymerase chain reaction amplification of these genes with subsequent restriction enzyme digestion and gel electrophoresis.

RESULTS

Our results showed that 3 (9.4%), 3 (4.4%), and 1 (4%) individuals were heterozygous for prothrombin G20210A and 3 (9.4%), 5 (7.4%), and 1 (4%) individuals were heterozygous for factor V Leiden in the AMI, UA, and control groups, respectively. The following genotype frequencies for the factor VII R353Q polymorphism were identified: 25 (78.1%), 56 (82.4%), and 18 (72%) with RR and 7 (21.9%), 12 (17. 6%), and 7 (28%) with RQ in the AMI, UA, and control groups, respectively. No QQ homozygotes were identified. For the HVR4 size polymorphism, the following genotypes were identified: 3 (9.4%), 4 (5.9%), and 5 (20%) individuals with H7H7; 11 (34.4%), 33 (48.5%), and 12 (48%) with H6H7; and 18 (56.2%), 31 (45.6%), and 8 (32%) with H6H6 genotypes in the AMI, UA, and control groups, respectively. There were no H7H5 and H6H5 genotypes found in this study.

CONCLUSIONS

Although the frequency differences of these polymorphisms in patients with AMI and UA were not statistically significant from those in controls, several trends are consistent with what has been reported in the literature. Although any of these or other undefined genetic abnormalities may result in IHD, it is possible that phenotypic predisposition to IHD initially presents as UA. A larger population study addressing the significance of these polymorphisms in the sequence of events that lead to IHD, including cases of UA, is warranted.