Multi-omics approach to socioeconomic disparity in metabolic syndrome reveals roles of diet and microbiome

The epidemy of metabolic syndrome (MetS) is typically preceded by adoption of a "risky" lifestyle (e.g., dietary habit) among populations. Evidence shows that those with low socioeconomic status (SES) are at an increased risk for MetS. To investigate this, we recruited 123 obese subjects (body mass index [BMI] ≥ 30) from Chicago. Multi-omic data were collected to interrogate fecal microbiota, systemic markers of inflammation and immune activation, plasma metabolites, and plasma glycans. Intestinal permeability was measured using the sugar permeability testing. Our results suggest a heterogenous metabolic dysregulation among obese populations who are at risk of MetS. Systemic inflammation, linked to poor diet, intestinal microbiome dysbiosis, and gut barrier dysfunction may explain the development of MetS in these individuals. Our analysis revealed 37 key features associated with increased numbers of MetS features. These features were used to construct a composite metabolic-inflammatory (MI) score that was able to predict progression of MetS among at-risk individuals. The MI score was correlated with several markers of poor diet quality as well as lower levels of gut microbial diversity and abnormalities in several species of bacteria. This study reveals novel targets to reduce the burden of MetS and suggests access to healthy food options as a practical intervention.

Evaluating the prospective utility of pharmacogenetics reporting among Canadian Armed Forces personnel receiving pharmacotherapy: a preliminary assessment towards precision psychiatric care

Pharmacological interventions for treating posttraumatic stress disorder in Canadian Armed Forces (CAF) members and Veterans often achieve modest results. The field of pharmacogenetics, or the study of how genes influence an individual's response to different medications, offers insight into how prior knowledge of gene-drug interactions may potentially improve the trial-and-error process of drug selection in pharmacotherapy, thereby improving treatment effects and remission rates. Given the relative recency of pharmacogenetics testing and sparse research in military samples, we used pharmacogenetics testing in a small pilot group (n=23) of CAF members and Veterans who were already engaged in pharmacotherapy for a service-related mental health condition to better understand the associated opportunities and challenges of pharmacogenetics testing in this population. Our preliminary evaluation involved: (1) reporting the prevalence of pharmacogenetics testing 'bin' status according to participants' reports ('green', 'yellow' or 'red'; intending to signal 'go', 'caution' or 'stop', regarding the potential for gene-drug interactions); (2) calculating the percentage of currently prescribed psychotropic medications that were assessed and included in the reports; (3) evaluating whether prescribers used pharmacogenetics testing information according to clinical notes and (4) collecting informal feedback from participating psychiatrists. While pharmacogenetics testing appeared to provide valuable information for a number of clients, a major limitation was the number of commonly prescribed medications not included in the reports.

Controlled tumor heterogeneity in a co-culture system by 3D bio-printed tumor-on-chip model

Cancer treatment resistance is a caused by presence of various types of cells and heterogeneity within the tumor. Tumor cell-cell and cell-microenvironment interactions play a significant role in the tumor progression and invasion, which have important implications for diagnosis, and resistance to chemotherapy. In this study, we develop 3D bioprinted in vitro models of the breast cancer tumor microenvironment made of co-cultured cells distributed in a hydrogel matrix with controlled architecture to model tumor heterogeneity. We hypothesize that the tumor could be represented by a cancer cell-laden co-culture hydrogel construct, whereas its microenvironment can be modeled in a microfluidic chip capable of producing a chemical gradient. Breast cancer cells (MCF7 and MDA-MB-231) and non-tumorigenic mammary epithelial cells (MCF10A) were embedded in the alginate-gelatine hydrogels and printed using a multi-cartridge extrusion bioprinter. Our approach allows for precise control over position and arrangements of cells in a co-culture system, enabling the design of various tumor architectures. We created samples with two different types of cells at specific initial locations, where the density of each cell type was carefully controlled. The cells were either randomly mixed or positioned in sequential layers to create cellular heterogeneity. To study cell migration toward chemoattractant, we developed a chemical microenvironment in a chamber with a gradual chemical gradient. As a proof of concept, we studied different migration patterns of MDA-MB-231 cells toward the epithelial growth factor gradient in presence of MCF10A cells in different ratios using this device. Our approach involves the integration of 3D bioprinting and microfluidic devices to create diverse tumor architectures that are representative of those found in various patients. This provides an excellent tool for studying the behavior of cancer cells with high spatial and temporal resolution.

A phase II open-label trial of avelumab plus axitinib in previously treated non-small-cell lung cancer or treatment-naïve, cisplatin-ineligible urothelial cancer

BACKGROUND

We hypothesized that avelumab plus axitinib could improve clinical outcomes in patients with advanced non-small-cell lung cancer (NSCLC) or urothelial carcinoma (UC).

PATIENTS AND METHODS

We enrolled previously treated patients with advanced or metastatic NSCLC, or untreated, cisplatin-ineligible patients with advanced or metastatic UC. Patients received avelumab 800 mg every 2 weeks (Q2W) and axitinib 5 mg orally two times daily. The primary endpoint was objective response rate (ORR). Immunohistochemistry was used to assess programmed death-ligand 1 (PD-L1) expression (SP263 assay) and the presence of CD8+ T cells (clone C8/144B). Tumor mutational burden (TMB) was assessed by whole-exome sequencing.

RESULTS

A total of 61 patients were enrolled and treated (NSCLC, n = 41; UC, n = 20); 5 remained on treatment at data cut-off (26 February 2021). The confirmed ORR was 31.7% in the NSCLC cohort and 10.0% in the UC cohort (all partial responses). Antitumor activity was observed irrespective of PD-L1 expression. In exploratory subgroups, ORRs were higher in patients with higher (≥median) CD8+ T cells in the tumor. ORRs were higher in patients with lower TMB (<median) in the NSCLC cohort and higher TMB (≥median) in the UC cohort. Treatment-related adverse events (TRAEs) occurred in 93.4% of patients, including grade ≥3 TRAEs in 55.7%. Avelumab exposures with 800 mg Q2W dosing were similar to those observed with 10 mg/kg Q2W dosing.

CONCLUSIONS

In previously treated patients with advanced/metastatic NSCLC, ORR appeared to be superior to anti-PD-L1 or anti-programmed cell death protein 1 monotherapy, irrespective of PD-L1 status, whereas in untreated, cisplatin-ineligible patients with advanced/metastatic UC, ORR was lower than expected, potentially limited by small patient numbers.

TRIAL REGISTRATION

Clinicaltrial.gov NCT03472560; https://clinicaltrials.gov/ct2/show/NCT03472560.

Developing a platform for Fresnel diffractive radiography with 1 μm spatial resolution at the National Ignition Facility

An x-ray Fresnel diffractive radiography platform was designed for use at the National Ignition Facility. It will enable measurements of micron-scale changes in the density gradients across an interface between isochorically heated warm dense matter materials, the evolution of which is driven primarily through thermal conductivity and mutual diffusion. We use 4.75 keV Ti K-shell x-ray emission to heat a 1000 μm diameter plastic cylinder, with a central 30 μm diameter channel filled with liquid D₂, up to 8 eV. This leads to a cylindrical implosion of the liquid D₂ column, compressing it to ∼2.3 g/cm³. After pressure equilibration, the location of the D₂/plastic interface remains steady for several nanoseconds, which enables us to track density gradient changes across the material interface with high precision. For radiography, we use Cu He-α x rays at 8.3 keV. Using a slit aperture of only 1 μm width increases the spatial coherence of the source, giving rise to significant diffraction features in the radiography signal, in addition to the refraction enhancement, which further increases its sensitivity to density scale length changes at the D₂/plastic interface.

Abstract C023: A microbiome-produced metabolite drives immunostimulatory macrophages and boosts response to immune checkpoint inhibitors in pancreatic cancer

The composition of the gut microbiome controls innate and adaptive immunity and has emerged as a key regulator of tumor growth and the success of immune checkpoint blockade (ICB) therapy. However, the underlying mechanisms remain unclear. Pancreatic ductal adenocarcinoma (PDAC) tends to be refractory to therapy, including ICB. We found that the gut microbe-derived metabolite trimethylamine N-oxide (TMAO) enhances anti-tumor immunity to PDAC. Delivery of TMAO given intraperitoneally or via dietary choline supplement to PDAC-bearing mice reduces tumor growth and is associated with an immunostimulatory tumor-associated macrophage (TAM) phenotype and activated effector T cell response in the tumor microenvironment. Mechanistically, TMAO signals through potentiating type-I interferon (IFN) pathway and confers anti-tumor effects in a type-I IFN dependent manner. Notably, delivering TMAO-primed macrophages alone produced similar anti-tumor effects. Combining TMAO with ICB (anti-PD1 and/or anti-Tim3) significantly reduced tumor burden and improved survival beyond TMAO or ICB alone. Finally, the levels of trimethylamine (TMA)-producing bacteria and of CutC gene expression correlate with improved survivorship and response to anti-PD1 in cancer patients. Together, our study identifies the gut microbial metabolite TMAO as an important driver of anti-tumor immunity and lays the groundwork for new therapeutic strategies.

Citation Format: Gauri Mirji, Alison Worth, Sajad Bhat, Mohamed Sayed, Toshitha Kannan, Aaron Goldman, Hsin-Yao Tang, Qin Liu, Noam Auslander, Chi Dang, Mohamed Abdel-Mohsen, Andrew Kossenkov, Ben Stanger, Rahul Shinde. A microbiome-produced metabolite drives immunostimulatory macrophages and boosts response to immune checkpoint inhibitors in pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr C023.

UPPER ARM CONTOURING - A NARRATIVE REVIEW

Disfigurement of upper arms is a common esthetic problem. All soft tissues contribute with skin and subcutaneous adipose tissue as the major targets of medical intervention. This narrative review describes the complex pathogenesis of upper arm ptosis and its classification. Surgical and non-surgical methods to improve upper arm contour are discussed. With the broad spectrum of available treatments, a tailored approach is possible to address the individual patient's needs.

The real-world safety profile of SGLT2 inhibitors among adults 75 years or older: a retrospective, pharmacovigilance study

Introduction

As indications for sodium-glucose co-transporter-2 (SGLT2) inhibitors treatment are expanding, more older adults become candidates for treatment. However, data regarding the treatment's safety profile in the older population are limited.

Methods

A retrospective, pharmacovigilance study of the FDA's global database of safety reports (7/1/2014–6/30/2021). To assess reporting of pre-specified adverse events following SGLT2-inhibitors treatment among adults (18≥age&lt;75) and older adults (age≥75), we performed disproportionality analysis using the reporting odds ratio (ROR).

Results

Of 10,526,408 patients in the full database, 279,619 eligible patients with non-insulin-dependent diabetes mellitus were identified (mean age 63.4 [SD 13.0] years, 54,791 [19.6%] aged ≥75 years), among whom 29,431 receiving SGLT-2 inhibitors. Compared to other non-insulin anti-diabetics, SGLT2-inhibitors were significantly associated with amputations (ROR=127.87 [95% CI: 111.31–146.90] vs ROR=74.91 [49.99–112.25]), Fournier gangrene (ROR=53.27 [44.38–63.92] vs ROR=33.33 [20.33–54.64]), diabetes ketoacidosis (ROR=39.25 [37.20–41.42] vs ROR=58.46 [49.41–69.1]), genitourinary infections (ROR=4.36 [4.12–4.61] vs ROR=5.08 [4.45–5.79]), nocturia (ROR=2.81 [2.13–3.73] vs ROR=3.51 [1.84–6.68]), and dehydration (ROR=2.22 [2.05–2.40] vs ROR=2.33 [1.93–2.81]) in both adults and older adults, respectively. The relative reporting of these safety signals was consistent between age groups (all P interaction &gt;0.05). Acute kidney injury was associated with SGLT2-inhibitors treatment in adults (ROR=1.47 [1.40–1.54]) but not older adults (ROR=0.84 [0.72–0.98]). No new safety signals were observed in older adults. Falls, fractures, hypotension, and syncope were not associated with SGLT2-inhibitors among either adults or older adults.

Conclusion

In this global post-marketing study, treatment with SGLT-2 inhibitors in older adults was associated with increased reporting of amputations, Fournier gangrene, DKA, genitourinary infections, and dehydration. Nevertheless, the relative reporting was consistent between adults and older adults, and no new safety signals were found in the older population.

Funding Acknowledgement

Type of funding sources: None.

Agent-based computational modeling of glioblastoma predicts that stromal density is central to oncolytic virus efficacy

Oncolytic viruses (OVs) are emerging cancer immunotherapy. Despite notable successes in the treatment of some tumors, OV therapy for central nervous system cancers has failed to show efficacy. We used an ex vivo tumor model developed from human glioblastoma tissue to evaluate the infiltration of herpes simplex OV rQNestin (oHSV-1) into glioblastoma tumors. We next leveraged our data to develop a computational, model of glioblastoma dynamics that accounts for cellular interactions within the tumor. Using our computational model, we found that low stromal density was highly predictive of oHSV-1 therapeutic success, suggesting that the efficacy of oHSV-1 in glioblastoma may be determined by stromal-to-tumor cell regional density. We validated these findings in heterogenous patient samples from brain metastatic adenocarcinoma. Our integrated modeling strategy can be applied to suggest mechanisms of therapeutic responses for central nervous system cancers and to facilitate the successful translation of OVs into the clinic.

Boosting Natural Killer Cell Therapies in Glioblastoma Multiforme Using Supramolecular Cationic Inhibitors of Heat Shock Protein 90

Allogeneic natural killer (aNK) cell adoptive therapy has the potential to dramatically impact clinical outcomes of glioblastoma multiforme (GBM). However, in order to exert therapeutic activity, NK cells require tumor expression of ligands for activating receptors, such as MHC Class I peptide A/B (MICA/B) and ULBPs. Here, we describe the use of a blood-brain barrier (BBB) permissive supramolecular cationic drug vehicle comprising an inhibitor of the chaperone heat shock protein 90 (Hsp90), which sustains a cytotoxic effect on GBM cells, boosts the expression of MICA/B and ULBPs on the residual population, and augments the activity of clinical-grade aNK cells (GTA002). First, we identify Hsp90 mRNA transcription and gain of function as significantly upregulated in GBM compared to other central nervous system tumors. Through a rational chemical design, we optimize a radicicol supramolecular prodrug containing cationic excipients, SCI-101, which displays >2-fold increase in relative BBB penetration compared to less cationic formulations in organoids, in vitro. Using 2D and 3D biological models, we confirm SCI-101 sustains GBM cytotoxicity 72 h after drug removal and induces cell surface MICA/B protein and ULBP mRNA up to 200% in residual tumor cells compared to the naked drug alone without augmenting the shedding of MICA/B, in vitro. Finally, we generate and test the sequential administration of SCI-101 with a clinical aNK cell therapy, GTA002, differentiated and expanded from healthy umbilical cord blood CD34⁺ hematopoietic stem cells. Using a longitudinal in vitro model, we demonstrate >350% relative cell killing is achieved in SCI-101-treated cell lines compared to vehicle controls. In summary, these data provide a first-of-its-kind BBB-penetrating, long-acting inhibitor of Hsp90 with monotherapy efficacy, which improves response to aNK cells and thus may rapidly alter the treatment paradigm for patients with GBM.

Nanotherapeutic approaches to overcome distinct drug resistance barriers in models of breast cancer

Targeted delivery of drugs to tumor cells, which circumvent resistance mechanisms and induce cell killing, is a lingering challenge that requires innovative solutions. Here, we provide two bioengineered strategies in which nanotechnology is blended with cancer medicine to preferentially target distinct mechanisms of drug resistance. In the first 'case study', we demonstrate the use of lipid-drug conjugates that target molecular signaling pathways, which result from taxane-induced drug tolerance via cell surface lipid raft accumulations. Through a small molecule drug screen, we identify a kinase inhibitor that optimally destroys drug tolerant cancer cells and conjugate it to a rationally-chosen lipid scaffold, which enhances anticancer efficacy in vitro and in vivo. In the second 'case study', we address resistance mechanisms that can occur through exocytosis of nanomedicines. Using adenocarcinoma HeLa and MCF-7 cells, we describe the use of gold nanorod and nanoporous vehicles integrated with an optical antenna for on-demand, photoactivation at ~650 nm enabling release of payloads into cells including cytotoxic anthracyclines. Together, these provide two approaches, which exploit engineering strategies capable of circumventing distinct resistance barriers and induce killing by multimodal, including nanophotonic mechanisms.

Systems biology informed neural networks (SBINN) predict response and novel combinations for PD-1 checkpoint blockade

Anti-PD-1 immunotherapy has recently shown tremendous success for the treatment of several aggressive cancers. However, variability and unpredictability in treatment outcome have been observed, and are thought to be driven by patient-specific biology and interactions of the patient's immune system with the tumor. Here we develop an integrative systems biology and machine learning approach, built around clinical data, to predict patient response to anti-PD-1 immunotherapy and to improve the response rate. Using this approach, we determine biomarkers of patient response and identify potential mechanisms of drug resistance. We develop systems biology informed neural networks (SBINN) to calculate patient-specific kinetic parameter values and to predict clinical outcome. We show how transfer learning can be leveraged with simulated clinical data to significantly improve the response prediction accuracy of the SBINN. Further, we identify novel drug combinations and optimize the treatment protocol for triple combination therapy consisting of IL-6 inhibition, recombinant IL-12, and anti-PD-1 immunotherapy in order to maximize patient response. We also find unexpected differences in protein expression levels between response phenotypes which complement recent clinical findings. Our approach has the potential to aid in the development of targeted experiments for patient drug screening as well as identify novel therapeutic targets.

PIGMENTED NODULAR CYSTIC HIDRADENOMA OF THE ANKLE

Solid-cystic hidradenoma is a benign cutaneous tumor that is most commonly found in the head, neck, trunk, and upper extremity regions of patients in the middle to older aged groups. Presentation on lower extremities and in particular on the foot is uncommon. Nodular hidradenomas represent a dermatological pitfall, being difficult to differentiate from basal cell carcinoma and melanoma. We report on a 53-year-old male patient with a pigmented nodular hidradenoma on his ankle that was surgically removed. We discuss histopathology and differential diagnosis of this eccrine tumor of skin. This is the second reported case in the English literature.

Assessment of the Implementation of Pharmacogenomic Testing in a Pediatric Tertiary Care Setting

IMPORTANCE

Pharmacogenomic (PGx) testing provides preemptive pharmacotherapeutic guidance regarding the lack of therapeutic benefit or adverse drug reactions of PGx targeted drugs. Pharmacogenomic information is of particular value among children with complex medical conditions who receive multiple medications and are at higher risk of developing adverse drug reactions.

OBJECTIVES

To assess the implementation outcomes of a PGx testing program comprising both a point-of-care model that examined targeted drugs and a preemptive model informed by whole-genome sequencing that evaluated a broad range of drugs for potential therapy among children in a pediatric tertiary care setting.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted at The Hospital for Sick Children in Toronto, Ontario, from January 2017 to September 2020. Pharmacogenomic analyses were performed among 172 children who were categorized into 2 groups: a point-of-care cohort and a preemptive cohort. The point-of-care cohort comprised 57 patients referred to the consultation clinic for planned therapy with PGx targeted drugs and/or for adverse drug reactions, including lack of therapeutic benefit, after the receipt of current or past medications. The preemptive cohort comprised 115 patients who received exploratory whole-genome sequencing-guided PGx testing for their heart conditions from the cardiac genome clinic at the Ted Rogers Centre for Heart Research.

EXPOSURES

Patients received PGx analysis of whole-genome sequencing data and/or multiplex genotyping of 6 pharmacogenes (CYP2C19, CYP2C9, CYP2D6, CYP3A5, VKORC1, and TPMT) that have established PGx clinical guidelines.

MAIN OUTCOMES AND MEASURES

The number of patients for whom PGx test results warranted deviation from standard dosing regimens.

RESULTS

A total of 172 children (mean [SD] age, 8.5 [5.6] years; 108 boys [62.8%]) were enrolled in the study. In the point-of-care cohort, a median of 2 target genes (range, 1-5 genes) were investigated per individual, with CYP2C19 being the most frequently examined; genotypes in 21 of 57 children (36.8%) were incompatible with standard treatment regimens. As expected from population allelic frequencies, among the 115 children in the whole-genome sequencing-guided preemptive cohort, 92 children (80.0%) were recommended to receive nonstandard treatment regimens for potential drug therapies based on their 6-gene pharmacogenetic profile.

CONCLUSIONS AND RELEVANCE

In this cohort study, among both the point-of-care and preemptive cohorts, the multiplex PGx testing program provided dosing recommendations that deviated from standard regimens at an overall rate that was similar to the population frequencies of relevant variants.

LONG-PULSED ND:YAG LASER TO TREAT TELANGIECTASIA OF THE NOSE: A COMPREHENSIVE 5-YEAR SINGLE CENTER STUDY

Telangiectases of the nose are of esthetic concern and treatment is warranted. The study provides the results of 5 years of treatment of telangiectases of the nose region with the long-pulsed Nd:YAG 1,064 nm laser. A retrospective analysis was conducted in patients of Fitzpatrick skin type II-V. Exclusion criteria were patients with a previous history of treatment of the nose region, pregnant or lactating patients or patients with unrealistic expectations regarding the treatment risks, limitations and results. Standardized photographs were obtained before each session and at least 2 months after the last treatment session. A long-pulsed Nd:YAG 1,064 nm laser was used with a spot size of 2.5mm, fluence of 100 - 175 J/cm2, pulse duration of up to 135ms and repetition rate of 2-4 Hz. The follow-up ranged from 2 months to 5 years. The number of laser sessions varied from 1 to 5 monthly. Assessment was made by comparing pre-treatment and post-treatment photographs by two independent specialists and also by the patients' own assessment. All patients presented improvement of the vascular alterations. Evaluation of independent specialists as well as the evaluation of the patients themselves showed a high degree of satisfaction with the treatment. The treatment presented only few transitory side effects. Treatment of telangiectasia on the nose skin with the long-pulsed Nd:YAG 1,064 nm laser demonstrated to be safe and effective even in darker pigmented skin. The major limitation of this study is its retrospective nature.

Engineering in Medicine To Address the Challenge of Cancer Drug Resistance: From Micro- and Nanotechnologies to Computational and Mathematical Modeling

Drug resistance has profoundly limited the success of cancer treatment, driving relapse, metastasis, and mortality. Nearly all anticancer drugs and even novel immunotherapies, which recalibrate the immune system for tumor recognition and destruction, have succumbed to resistance development. Engineers have emerged across mechanical, physical, chemical, mathematical, and biological disciplines to address the challenge of drug resistance using a combination of interdisciplinary tools and skill sets. This review explores the developing, complex, and under-recognized role of engineering in medicine to address the multitude of challenges in cancer drug resistance. Looking through the "lens" of intrinsic, extrinsic, and drug-induced resistance (also referred to as "tolerance"), we will discuss three specific areas where active innovation is driving novel treatment paradigms: (1) nanotechnology, which has revolutionized drug delivery in desmoplastic tissues, harnessing physiochemical characteristics to destroy tumors through photothermal therapy and rationally designed nanostructures to circumvent cancer immunotherapy failures, (2) bioengineered tumor models, which have benefitted from microfluidics and mechanical engineering, creating a paradigm shift in physiologically relevant environments to predict clinical refractoriness and enabling platforms for screening drug combinations to thwart resistance at the individual patient level, and (3) computational and mathematical modeling, which blends in silico simulations with molecular and evolutionary principles to map mutational patterns and model interactions between cells that promote resistance. On the basis that engineering in medicine has resulted in discoveries in resistance biology and successfully translated to clinical strategies that improve outcomes, we suggest the proliferation of multidisciplinary science that embraces engineering.

Nanoengineered Disruption of Heat Shock Protein 90 Targets Drug-Induced Resistance and Relieves Natural Killer Cell Suppression in Breast Cancer

Drug-induced resistance, or tolerance, is an emerging yet poorly understood failure of anticancer therapy. The interplay between drug-tolerant cancer cells and innate immunity within the tumor, the consequence on tumor growth, and therapeutic strategies to address these challenges remain undescribed. Here, we elucidate the role of taxane-induced resistance on natural killer (NK) cell tumor immunity in triple-negative breast cancer (TNBC) and the design of spatiotemporally controlled nanomedicines, which boost therapeutic efficacy and invigorate "disabled" NK cells. Drug tolerance limited NK cell immune surveillance via drug-induced depletion of the NK-activating ligand receptor axis, NK group 2 member D, and MHC class I polypeptide-related sequence A, B. Systems biology supported by empirical evidence revealed the heat shock protein 90 (Hsp90) simultaneously controls immune surveillance and persistence of drug-treated tumor cells. On the basis of this evidence, we engineered a "chimeric" nanotherapeutic tool comprising taxanes and a cholesterol-tethered Hsp90 inhibitor, radicicol, which targets the tumor, reduces tolerance, and optimally reprimes NK cells via prolonged induction of NK-activating ligand receptors via temporal control of drug release in vitro and in vivo. A human ex vivo TNBC model confirmed the importance of NK cells in drug-induced death under pressure of clinically approved agents. These findings highlight a convergence between drug-induced resistance, the tumor immune contexture, and engineered approaches that consider the tumor and microenvironment to improve the success of combinatorial therapy. SIGNIFICANCE: This study uncovers a molecular mechanism linking drug-induced resistance and tumor immunity and provides novel engineered solutions that target these mechanisms in the tumor and improve immunity, thus mitigating off-target effects.

Abstract 5086: The aged tumor microenvironment promotes melanoma metabolic plasticity and therapy

“Aged” melanoma patients (&gt;55 years old) have poorer prognosis and reduced response rates to targeted therapy relative to “young” patients (&lt;40 years old). Here, we report an altered metabolic landscape in the aged tumor microenvironment (TME) as critical for melanoma aggressiveness. Aged fibroblasts uptake high levels of glucose compared to their young counterparts, which fuels lipid production. Melanoma cells cultured in an aged TME in vitro or in vivo display elevated intracellular lipid levels and increased metastatic potential relative to melanoma cells in a young TME. Further, lipidomics reveal an elevated lipid profile (i.e., triglycerides, ceramides, and cholesterol) preferentially secreted by aged fibroblasts relative to young. In turn, we show that melanoma cells adaptively increase extracellular fatty acid scavenging via the lipid transporter FATP2 in the lipid rich aged TME. Melanoma cells cultured in the aged TME also display an increased oxygen consumption rate (OCR) relative to those grown in young TME, which could be ablated when fatty acid transport into the mitochondria is blocked with etomixir. Notably, melanoma cells in the aged TME treated with BRAFi/MEKi in combination with a FATP2 inhibitor display decreased OCR relative to BRAFi/MEKi inhibitor alone, which paralleled the increased overall survival of aged mice treated with BRAFi/MEKi/FATP2i relative to either agent alone. To rule out off-target effects of the FATP2 inhibitor, we used a doxycycline inducible system for FATP2 knockdown in melanoma cells and reproduced the abrogation of tumor growth and extension of survival in aged immune-competent mice when combined with BRAFi/MEK therapy. Additionally, elevated FATP2 levels correlate with worse response in human patients. We hypothesize the aged TME triggers adaptive metabolic plasticity of melanoma cells critical for therapy escape.

Citation Format: Gretchen Marie Alicea, Vito W. Rebecca, Aaron Goldman, Mitchell Fane, Reeti Behera, Marie Webster, Brett Ecker, Ian Blair, David Speicher, Zachary Schug, Ashani Weeraratna. The aged tumor microenvironment promotes melanoma metabolic plasticity and therapy [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5086.

IMPROVEMENT OF HYPERTROPHIC SCARS WITH INTRALESION INJECTIONS OF HYALURONIDASE

In contrast to intra-urine wounds, extra-uterine wounds will heal with a scar. A number of conservative and surgical methods have been developed, aiming at improving unsightly and hypertrophic scars. The authors report on their experience with intralesional injection of the enzyme hyaluronidase to improve hypertrophic scars. Hyaluronidase produces low-molecular weight fragments during digestion of high-molecular weight hyaluronic acid. These fragments are known to stimulate angiogenesis and to activate mesenchymal stem cells. The manuscript presents a clinical review of series of patients with hypertrophic scars, mainly resulted from tumor resection, who were treated by this technique.

GIANT PEDUNCULATED TUMORS OF SKIN

The clinical appearance of a skin tumor is of major importance for clinical diagnosis of both benign and malignant neoplasias. Pedunculated growth pattern is unusual to exceptionally rare, depending on a tumor type. A necessary prerequisite for pedunculated growth is a well vascularized stem. We provide a review on large and giant pedunculated tumors of skin to serve as an additional guidance for the clinicians to avoid diagnostic errors and mistreatment. The knowledge of unusual growth pattern of cutaneous neoplasia is an essential not only in outpatient care, but also in care of hospital-admitted patients.

Emerging Frontiers in the Study of Molecular Evolution

A collection of the editors of Journal of Molecular Evolution have gotten together to pose a set of key challenges and future directions for the field of molecular evolution. Topics include challenges and new directions in prebiotic chemistry and the RNA world, reconstruction of early cellular genomes and proteins, macromolecular and functional evolution, evolutionary cell biology, genome evolution, molecular evolutionary ecology, viral phylodynamics, theoretical population genomics, somatic cell molecular evolution, and directed evolution. While our effort is not meant to be exhaustive, it reflects research questions and problems in the field of molecular evolution that are exciting to our editors.

A computationally inspired in-vivo approach identifies a link between amygdalar transcriptional heterogeneity, socialization and anxiety

Pharmaceutical breakthroughs for anxiety have been lackluster in the last half-century. Converging behavior and limbic molecular heterogeneity has the potential to revolutionize biomarker-driven interventions. However, current in vivo models too often deploy artificial systems including directed evolution, mutations and fear induction, which poorly mirror clinical manifestations. Here, we explore transcriptional heterogeneity of the amygdala in isogenic mice using an unbiased multi-dimensional computational approach that segregates intra-cohort reactions to moderate situational adversity and intersects it with high content molecular profiling. We show that while the computational approach stratifies known features of clinical anxiety including nitric oxide, opioid and corticotropin signaling, previously unrecognized druggable biomarkers emerge, such as calpain11 and scand1. Through ingenuity pathway analyses, we further describe a role for neurosteroid estradiol signaling, heat shock proteins, ubiquitin ligases and lipid metabolism. In addition, we report a remarkable behavioral pattern that maps to molecular features of anxiety in mice through counterphobic social attitudes, which manifest as increased, yet spatially distant socialization. These findings provide an unbiased approach for interrogating anxiolytics, and hint toward biomarkers underpinning behavioral and social patterns that merit further exploration.

TMIC-23. A SEQUENTIAL IMAGING STRATEGY TO STUDY ONCOLYTIC VIRUS INFILTRATION, REPLICATION AND TUMOR MICROENVIRONMENTAL PERTURBATIONS, EX VIVO

The use of oncolytic viruses (OV) as therapeutic agents for glioblastoma multiforme (GBM) is an emerging clinical focus. OV have the potential to reinvigorate the immune contexture in the tumor microenvironment (TME). However, current pre-clinical models are insufficient to study the immune effects of OV. Here, we describe an imaging approach using a human ex-vivo platform to study the effects of OV on tumor-associated immune cells in GBM. Using the rQNestin34.5v.1 herpes simplex virus (rQNestin) we treated human GBM ex-vivo, incorporating autologous patient-derived peripheral-blood mononucleated cells and whole tissue fragments. We treated GBM (n=10) with rQNestin, capable of expressing GFP, and profiled GFP expression as a proxy for replication. We analyzed serial sections of H&E, HSV-1, and multiplex immunohistochemistry (mIHC) to investigate the impact of rQNestin on the spatial context of the immune compartment. Cell Signaling Technology antibodies, CD3e (D7A6E™,ID:85061), CD68 (D4B9C,ID:76437), CD11c (D3V1E,49420), MHC-Class II ((HLA-DRB)LGII-612.14,NA) and Pan-keratin (C11,4545) were optimized for identifying intratumoral T-cells (CD3e+), macrophages (CD68) and dendritic cells (CD11c+MHCII+) in relation to the surrounding tissue architecture (pan cytokeratin). Using the serial-section imaging approach, we overlaid infiltration and replication of rQNestin. Additionally, strategic sectioning identified dynamic spatial alterations in the immune compartment, via visualization of the tumor-immune interface with indications of infiltration and replication. Quantitative pathology showed dynamic re-arrangement of immune cells - in spatial orientation, quantity and localization, relative to the tumor, under rQnestin pressure, ex-vivo. Here, we report that our ex-vivo human tumor model can be used to evaluate the effects of OV in the TME – not only viral replication but also the direct effect on the immune compartment. In particular, we can assess changes in immune subsets post-OV treatment in a 3-D manner, therefore providing greater insight into their spatial arrangement and distribution. These findings could develop our understanding of anti-tumor OV mechanisms.

Targeting tumor phenotypic plasticity and metabolic remodeling in adaptive cross-drug tolerance

Metastable phenotypic state transitions in cancer cells can lead to the development of transient adaptive resistance or tolerance to chemotherapy. Here, we report that the acquisition of a phenotype marked by increased abundance of CD44 (CD44^Hi) by breast cancer cells as a tolerance response to routinely used cytotoxic drugs, such as taxanes, activated a metabolic switch that conferred tolerance against unrelated standard-of-care chemotherapeutic agents, such as anthracyclines. We characterized the sequence of molecular events that connected the induced CD44^Hi phenotype to increased activity of both the glycolytic and oxidative pathways and glucose flux through the pentose phosphate pathway (PPP). When given in a specific order, a combination of taxanes, anthracyclines, and inhibitors of glucose-6-phosphate dehydrogenase (G6PD), an enzyme involved in glucose metabolism, improved survival in mouse models of breast cancer. The same sequence of the three-drug combination reduced the viability of patient breast tumor samples in an explant system. Our findings highlight a convergence between phenotypic and metabolic state transitions that confers a survival advantage to cancer cells against clinically used drug combinations. Pharmacologically targeting this convergence could overcome cross-drug tolerance and could emerge as a new paradigm in the treatment of cancer.

Abstract 694: Mathematical modeling of stromal fibroblast-mediated adaptive resistance to bortezomib in multiple myeloma

Understanding intrinsic and adaptive resistance is crucial to overcoming multiple myeloma chemotherapy failure. We recently demonstrated that standard chemotherapy can induce cancer cells to phenotypically transition to a transient state of dormancy and drug tolerance. Further, targeting cells precisely during this transition can thwart the emergence of adaptive resistance (Goldman, 2015). However, it is not yet understood how the stromal contexture may contribute to this chemotherapy-induced drug tolerance.

We developed a deterministic mathematical model containing a system of differential equations to examine how stromal fibroblasts temporally affect phenotypic switching between active and dormant, bortezomib-tolerant cancer cell states. The equations describe the total growth rate of each cell state population, which is influenced by that population’s count and baseline growth rate, the frequencies of transitions to and from the other cell state, the drug treatment concentration, and the population carrying capacity. The model also establishes that the presence of fibroblasts affects the frequency of transitions between the cell states. This framework is calibrated to in vitro data, and model simulations predict that bortezomib-tolerant myeloma cells may escape more quickly from dormancy and proliferate when they are incubated in the presence of fibroblasts than in their absence. This prediction is supported by preliminary experimental observations. The mathematical model could be adapted to predict how stromal fibroblasts, or the tumor microenvironment generally, may influence phenotypic switching in other cancers.

Citation Format: Elliot Eton, Kamran Kaveh, Sachin Khiste, Andrea Fernandes, Ashima Agarwal, Shiladitya Sengupta, Aaron Goldman. Mathematical modeling of stromal fibroblast-mediated adaptive resistance to bortezomib in multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 694.

Abstract 3212: Patient-level pharmacodynamics of response to combined ipilimumab and nivolumab for gastric cancer using a human autologous ex-vivo platform, CANscript

Background: Combined cancer immunotherapy is an emerging paradigm for the treatment of cancer. PD-L1, the cognate receptor for the programmed death receptor 1 (PD-1) is expressed in up to 40% of gastric/gastroesophageal junction (GEJ) tumors. Despite this, patients show modest responses to PD-1 inhibitors. A recent clinical trial, Checkmate-032, demonstrated superior efficacy when PD-1 inhibitor, Nivolumab, was combined with CTLA-4 inhibitor, Ipilimumab. Despite this, biomarkers that predict clinical response remain poorly understood.

Methods: Here, with informed consent under IRB, fresh tumor biopsies were obtained from a randomly-selected cohort of gastric/GEJ patients (N=39). We then employed CANscriptTM, a clinically-validated human autologous ex-vivo tumor platform to interrogate the pharmacodynamics and prognostic efficacy (M-Score) of nivolumab +/- ipilimumab. PDL-1 status was determined for every patient by immunohistochemistry, flow cytometry was performed to analyze intratumor CD4+ and CD8+ T-cell profiles before and after treatment, and RNA seq. gene expression was performed to understand mechanistic changes under drug pressure.

Results: We predicted, based on M-Score, that single agent nivolumab results in an overall response rate (ORR) of 10%, which closely matched previous single agent results from Checkmate-032 (10%). In contrast, we determined the combination of ipi+nivo resulted in a response rate of 20%, a finding consistent with reported clinical data (Checkmate-032; ORR 18%). Interestingly, we determined that only 28% of patients who responded to the ipi+nivo combination were predicted to respond to the monotherapy, suggesting the increased efficacy of the combination. RNA seq revealed unique features of adaptive immunity in the subset of patients who were predicted to respond to the combination immunotherapy, while PD-L1 status was a less-important biomarker to predict response.

Conclusions: These results demonstrate the utility of the CANscript system to profile clinical response of immunotherapy. Our efforts may better inform clinical trial design and patient stratification before therapy to improve the potential for response.

Citation Format: Vidushi Kapoor, Munisha Smalley, Nandini Pal Basak, Abhishek Basu, Manjusha Biswas, Manas Kumar Mandal, Pinaki Roy, Pradip K. Majumder, Aaron Goldman. Patient-level pharmacodynamics of response to combined ipilimumab and nivolumab for gastric cancer using a human autologous ex-vivo platform, CANscript [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3212.

Abstract 5009: Translational efficacy of oncolytic HSV-1 in glioblastoma using a human autologous ex vivo platform, CANscript™

Background: Oncolytic viruses (OV) have been a topic of great interest as therapeutic agents for indications such as glioblastoma multiforme (GBM), where current treatment options are poor and limited. Alongside engineering these viruses, finding useful pre-clinical models to elucidate the efficacy of the OV has been challenging. In particular, these viruses have been developed to overcome immune resistance, allowing for the reinvigoration of the immune contexture in the tumor microenvironment (TME). Current pre-clinical models, such as mouse models, are limited in their ability to recapitulate the TME fully. Thus, there is a need for more relevant pre-clinical models to study the efficacy of OV and downstream effects in the TME.

Methods: rQNestin34.5v.1 herpes simplex virus (rQNestin) has previously been investigated in both in vitro and in vivo studies of GBM. To assimilate the effects of rQNestin on the TME, a more humanized system was employed; CANscriptTM. CANscript is an ex vivo human tumor model, that recapitulates the native, patient-autologous TME, incorporating autologous patient-derived peripheral blood mononucleated cells. We treated GBM tissue (n=10) with rQNestin, capable of expressing GFP, and profiled GFP expression as a proxy for replication efficiency. We coupled this analysis with gene expression of immune-related pathways to gauge the modulation of the immune contexture by rQNestin. In addition, we performed multiplex cytokine analysis and multiplex immunohistochemistry to investigate the impact of rQNestin on the spatial context and activity of the immune compartment in the TME, ex vivo.

Results: Immunohistochemistry established that viral replication and tissue penetration was observed, ex vivo. Furthermore, RNA transcriptional profiling and cytokine analysis revealed that the oHSV-1 was capable of dynamically altering the tumor microenvironment, and dysregulating immune subsets within the tumor. Further stratification of tumor samples based on the pharmacodynamic profile identified subsets of patient tumors that induce adaptive immunity.

Concluding remarks: Here, we report that CANscript, an ex vivo human tumor model, can be used to evaluate the effects of OV in the TME - not only viral replication but also the direct effect on the immune compartment. CANscript will be an invaluable tool to investigate the response and resistance to OV. This platform has the potential to enable better pre-clinical modeling of OV development.

Citation Format: Munisha Smalley, Vidushi Kapoor, Douglas Best, Carmela Passaro, Michal O. Nowicki, Suniti K. Saha, Komal Prasad, E. Antonio Chiocca, Sean E. Lawler, Aaron Goldman. Translational efficacy of oncolytic HSV-1 in glioblastoma using a human autologous ex vivo platform, CANscript™ [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5009.

cAMP regulated EPAC1 supports microvascular density, angiogenic and metastatic properties in a model of triple negative breast cancer

Breast cancer is a leading cause of cancer-related mortality in women. Triple-negative breast cancer (TNBC; HER2-, ER-/PR-) is an aggressive subtype prone to drug resistance and metastasis, which is characterized by high intratumor microvascular density (iMVD) resulting from angiogenesis. However, the mechanisms contributing to the aggressive phenotypes of TNBC remain elusive. We recently reported that down-regulation of exchange factor directly activated by cyclic AMP (cAMP), also known as EPAC1, leads to a reduction in metastatic properties including proliferation and cell migration in TNBC cell lines. Here, we report that EPAC1 supports TNBC-induced angiogenesis, tumor cell migration and invasiveness as well as pro-metastatic phenotypes in endothelial cells induced through the tumor secretome. Using an approach that integrates proteomics with bioinformatics and gene ontologies, we elucidate that EPAC1 supports a tumor-secreted network of angiogenic, cell adhesion and cell migratory pathways. Using confocal microscopy, we show that signaling molecules involved in focal adhesion, including Paxillin and MENA, are down-regulated in the absence of EPAC1, and electric cell substrate impedance sensing technique confirmed a role for EPAC1 on TNBC-induced endothelial cell permeability. Finally, to provide a translational bridge, we studied iMVD and therapy response using a primary human tumor explant assay, CANscriptTM, which suggests a link between therapy-modulated neovascularization and drug sensitivity. These data provide mechanistic insight into the role of EPAC1 in regulating the tumor microenvironment, iMVD and cancer cell-induced angiogenesis, a dynamic mechanism under drug pressure that may associate to treatment failure.

Abstract P6-07-03: A live tissue platform allows dynamic measurement of neovascularization and prediction of clinical response in human breast cancer samples, ex vivo

Background: Outgrowth of new blood vessels (neovascularization) allows tumors to supply themselves with oxygen and nutrients, and to rapidly metastasize throughout the body. Triple negative breast cancer (TNBC) is particularly susceptible to neovascularization. However, success with anti-angiogenics is highly variable and often patient-specific. This is particularly true as anti-angiogenics are being combined with immunotherapies. Thus, there is a huge unmet need for clinicians to test and predict clinical efficacy of anti-angiogenics at the individual patient level, prior to treatment.

Methods: Here, we characterize a patient-autologous, ex-vivo tumor model, termed CANscript, as a platform to study the intratumor microvascular density (iMVD) of breast cancer samples (N=15). To profile iMVD we used immunohistochemical (IHC) analysis of CD34, an early biomarker of neovascularization. We then introduced anticancer and anti-angiogenic agents (e.g. Avastin) for 72 hours, and subsequently quantified phenotypic response to drugs by testing viability, cell death, proliferation and morphology. These quantitative data were then fed into a machine learning algorithm that provides a clinical response prediction (M-Score).

Results: We determined that ex-vivo culture reliably retains baseline heterogeneity of iMVD based on expression of CD34+ nodes per visual field by IHC. Furthermore, we show that anticancer and anti-angiogenic agents will dynamically alter iMVD, ex-vivo, in a patient-specific manner. Finally, we show that prediction of clinical response using the 'M-Score' algorithm associates with diminished expression of CD34 per visual field of IHC after drug pressure.

Summary: Neovascularization and iMVD are features of aggressive cancers, such as TNBC. CANscript provides a rapid assessment of clinical response to anticancer drugs, many of which induce their antitumor effect by targeting the tumor vasculature. We show that pharmacodynamics of antiangiogenics can be captured during acute ex-vivo culture under drug pressure, which associate to clinical response prediction. Therefore, we highlight the ability of CANscript as a platform to predict clinical response to anti-angiogenic drugs, and may therefore be a logical 'testing ground' to predict clinical efficacy of antiangiogenic drugs combined with immunotherapies.

Citation Format: Smalley M, Alam N, Murmu N, Somashekhar S, Ulaganathan B, Thayakumar A, Maciejko L, Ganesh J, Lawson M, Gertje H, Shanthappa BU, Goldman A. A live tissue platform allows dynamic measurement of neovascularization and prediction of clinical response in human breast cancer samples, ex vivo [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-07-03.

Perspective on nanochannels as cellular mediators in different disease conditions

Tunnelling nanotubes (TNTs), also known as membrane nanochannels, are actin-based structures that facilitate cytoplasmic connections for rapid intercellular transfer of signals, organelles and membrane components. These dynamic TNTs can form de novo in animal cells and establish complex intercellular networks between distant cells up to 150 μm apart. Within the last decade, TNTs have been discovered in different cell types including tumor cells, macrophages, monocytes, endothelial cells and T cells. It has also been further elucidated that these nanotubes play a vital role in diseased conditions such as cancer, where TNT formation occurs at a higher pace and is used for rapid intercellular modulation of chemo-resistance. Viruses such as HIV, HSV and prions also hijack the existing TNT connections between host cells for rapid transmission and evasion of the host immune responses. The following review aims to describe the heterogeneity of TNTs, their role in different tissues and disease conditions in order to enhance our understanding on how these nanotubes can be used as a target for therapies.

A call to arms: Unifying the fight against resistance

This Editorial discusses the state of research on drug resistance in the fields of cancer, infectious disease, and agriculture. Reaching across the aisle for a more cross-collaborative approach may lead to exciting breakthroughs toward tackling the challenges of drug resistance in each field.

HYPERCALCEMIA DUE TO POLYMETHYLMETHACRYLATE INJECTIONS? (LITERATURE REVIEW AND CASE REPORTS)

Hypercalcemia is a common feature of malignancy, bone metabolic conditions and granulomatous disorders. In the latter, hypercalcemia is usually calcitriol-related. As eventual association of silicone and polymethylmethacrylate (PMMA) injections with granulomatous disease and hypercalcemia the condition has become an issue of recent interest. Authors report on two cases of calcitriol-related hypercalcemia where PMMA injections had been previously administered. The association, even though intriguing, requires additional confirmation by follow-up studies.

Abstract LB-346: Case study: Non-uniform response to therapy in multiple metastatic is predicted using CANscriptTM, a live tissue, ex-vivo, platform

Background: It is now clear that the tumor microenvironment drives response or resistance to therapy. More specifically, the stroma, vasculature and immune compartment shape tumor response to therapy. In addition, heterogeneity within a tumor and between metastatic sites will invariably affect the outcome of treatment. Due in large part to these biological complexities, predicting how treatment response varies among multiple metastatic sites may impact overall outcome remains poorly established.

Methods: Here, we interrogated the genomic and transcriptomic profile of three metastatic lesions from a patient diagnosed with relapsed head and neck squamous cell carcinoma (HNSCC), refractory to second-line Pembrolizumab (PD-1 checkpoint blockade). In addition, we employed CANscript™, a patient-derived ex-vivo model, which uses live tissue to recapitulate the native 3D tumor microenvironment coupled with an algorithm-driven strategy to predict clinical response in the form of an S-Score (Majumder et al., Nat. Comm., 2015). Using this platform, we tested two combination therapies; carboplatin with gemcitabine, and adriamycin with cyclophosphamide. Moreover, we characterized the tumor microenvironment, following combination treatment, using a multiplexed immunohistochemistry (IHC) panel (Ki67, PanCK, CD3, CD4, CD8, DAPI).

Results: We determined that the three metastatic sites displayed distinct transcription and whole exome signatures, prior to CANscriptTM. Based on CANscriptTM predicted responses (S-Score) for the two combinations tested, all three sites responded in a non-uniform manner. Interestingly, each site also displayed distinct patterns of proliferative immune subsets (Ki67 staining) and CD4:CD8 ratios, following treatment with each combination therapy.

Conclusion: Together, these findings demonstrate that, due to the underlying genetic and tumor microenvironment heterogeneity, metastatic sites might each confer distinct clinical responses to the same drug regimen, even in immunotherapy-resistant disease. Moreover, we highlight the utility of ex-vivo profiling as a tool to predict therapeutic response - not only at the individual patient level, but also at the level of multiple metastatic sites from a single patient. These findings underscore the importance of characterizing the entire tumor-immune contexture under pressure anticancer drugs. Such information can revise our understanding of personalized cancer care, and may impact rational treatment options.

Citation Format: Chukwuemeka Ikpeazu, Munisha Smalley, Baraneedharan Ulaganathan, Allen Thayakumar, Laura Majeiko, Jyothsana Ganesh, Basavaraja Shanthappa, Hans Gertje, Mark Lawson, Sara Lapomarda, Aaron Goldman. Case study: Non-uniform response to therapy in multiple metastatic is predicted using CANscriptTM, a live tissue, ex-vivo, platform [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-346.

Abstract 51: Role of hematopoietic cell kinase (HCK) in breast cancer dormancy

Background: Triple negative breast cancer (TNBC) is an aggressive basal-like malignancy, which recurs more frequently than any other subtype of breast cancer. We recently discovered that TNBC can overcome drug pressure by switching to a hybrid basal-like (CD44Hi) and epithelial-like (CD24Hi) cell state, which is accompanied by a transient period of quiescence, or dormancy. These dormant, ‘hybrid' cells highly express the phosphorylated SRC family kinase, hematopoietic cell kinase (HCK). Methods: Here, we used a panel of novel HCK inhibitors to study the effect of signaling-disruption in drug tolerance and tumor cell dormancy. Using flow cytometry and immunofluorescent microscopy we examined how HCK inhibition perturbs common features associated with dormancy such as proliferation and cell cycle status, intracellular levels of reactive oxygen species, and state of glucose metabolism. Finally, we validated the results using an ex-vivo human tumor model that predicts clinical response and recreates the native tumor microenvirnoment, CANscriptTM. Results: We determined that targeted inhibition of HCK down-regulates the features of tumor cell dormancy and drug tolerance, eliminating cells with a hybrid mesenchymal-epithelial phenotype, diminishing polyploidy and hyper-G2 endoreduplication, and suppressing features of a dysregulated glycolytic state. Conclusion: Expression of HCK drives cancer cells to a quiescent cancer cells subpopulation, resulting in tolerance to chemotherapy. Targeted disruption of HCK overcomes these features of dormancy. HCK inhibitors could emerge as a novel treatment for chemotherapy-induced breast cancer dormancy.

Citation Format: Sachin Khiste, Elliot Eton, Kevin Hodgetts, Hrvoje Lusic, Kodaganur Gopinath, S Krishnamurthy, Shiladitya Sengupta, Aaron Goldman. Role of hematopoietic cell kinase (HCK) in breast cancer dormancy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 51.

Abstract 2045: Mechanistic insights into the role of cAMP-regulated EPAC1 in tumor-induced angiogenesis and metastatic potential in triple-negative breast cancer

Background: Breast cancer is the leading cause of cancer-related mortality in women. Triple negative breast cancer (TNBC) is one of most aggressive subtypes, which is often accompanied by metastasis, a feature that requires development of new blood vessels (neovasculature) to disseminate tumor cells throughout the body. We recently reported that down-regulation of exchange factor directly activated by Cyclic AMP (cAMP), also known as EPAC1, leads to a reduction in proliferation and inhibition of cell migration.

Methods: Here, using gene knockdown by siRNA and a 3-dimensional in-vitro TNBC co-culture model with Human Vascular Endothelial Cells (HUVECs), we studied microvascular density and the role of EPAC1. Angiogenesis proteome profiling was employed to examine protein networks that were regulated by EPAC1 in the TNBC cell line, MDA-MB-231. Immunofluorescence along with Electric cell-substrate impedance sensing (ECIS) was used to study vascular permeability. To confirm these findings in a translational context, we employed a human tumor explant assay that predicts clinical response to therapy (CANscriptTM) and studied CD34+ nodes to determine how neovasculature associates to drug response.

Results: We determined that downregulation of EPAC1 in the TNBC cell line, MDA-MB-231, leads to reduction of proteins involved in cell migration, metastasis, angiogenesis and adhesion. Interestingly, we determined that loss of EPAC1 leads to increased expression of negative regulators in these same pathways. Immunofluorescence imaging showed that EPAC1 downregulation in MDA-MB-231 cells leads to diminished expression of proteins such as Paxillin, MENA, MMP-9 and tubulin. indicated that EPAC1 role in vascular permeability. Finally, CANscriptTM demonstrated a link between response to therapy and microvascular density, which was reduced under drug pressure in patients that were predicted to respond to treatment.

Conclusion: Our results suggest that EPAC1 is a driver of microvascular density in the tumor microenvironment, a feature that may play a key role in distant metastasis and therapy failure. Ex-vivo modeling of neovasculature may be a novel strategy to predict clinical response and distant metastasis.

Citation Format: Muthu Dhandapani, Aaron Goldman, Naveen Kumar, Peeyush Prasad, Eshna Jash, Itender Singh, Kodaganur S. Gopinath, Krishnamurthy S, Prabhusankar P, Seema Sehrawat. Mechanistic insights into the role of cAMP-regulated EPAC1 in tumor-induced angiogenesis and metastatic potential in triple-negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2045.

Abstract 4064: Spatial re-distribution of natural killer cells targets drug resistance and anti-tumor response, ex-vivo

Background: It is now clear that response or resistance to therapy is contingent on the tumor microenvironment, which is comprised of malignant cells, normal stroma, and immune landscape; attributes that are unique to each individual patient. This is particularly true for emerging anticancer drugs, such as immune checkpoint inhibitors, which recalibrate the body's own immune defense largely by modulating exhaustion of cytotoxic lymphocytes including T cells and natural killer (NK) cells. However, clinical response to therapy varies enormously. There is a critical gap in our understanding for the mechanisms that drive response or resistance to conventional drugs and immunotherapies at the individual patient level. Methods: Here, we used in-vitro and in-vivo experiments to study the role of NK cells in models of drug tolerance. Next, we employed (CANscriptTM), a clinically-validated ex-vivo tumor model that recreates and preserves the native, patient tumor microenvironment, which integrates an algorithm-driven method to predict clinical response to therapy (M-Score). Utilizing tissue from patients diagnosed with luminal, HER2 positive, and triple-negative (ER- PR- HER2-) breast cancers (N=10), we studied spatial heterogeneity of the tumor-immune contexture, M-Score, and phenotypic alterations under pressure of conventional standard-of-care regimens and immunotherapies including immune-checkpoint inhibitors. To do this, we used a comprehensive panel of immunological assays to evaluate changes in cytotoxic lymphocytes by flow cytometry, immunohistochemistry and cytokine profiling (i.e. CD56, MHC class 1A/B, NKG2D/C, CD8, CD3, PD-1, CTLA-4, TIM-3, LAG-3, 4-1BB, granzyme A/B). Results: We identified that drug resistance is associated to downregulation of activating proteins on NK cells including NKG2D/C, reducing their cytotoxic capability. Furthermore, tumor response, predicted by M-Score, correlates to a unique pattern of spatially-distributed NK cells, which associated a pro-inflammatory cytokine signature from the tumor microenvironment. Interestingly, we determined that therapy-induced expression of exhaustion biomarkers on NK cell exhaustion inversely correlated to the expression of cytotoxic granzyme B in the tumor microenvironment. Conclusions: Taken together, these data demonstrate an integral role that NK cells contribute to resistance and the antitumor response to therapy including both conventional and immuno-modulatory drugs. We further demonstrate that CANscriptTM can be harnessed to study response and resistance of the innate and adaptive immune system. Such an advance in our preclinical methods to study anticancer drugs at the individual patient level can help guide treatment decisions for clinicians while simultaneously functioning as a platform to study clinical efficacy of novel and emerging agents.

Citation Format: Munisha Smalley, Basava U. Shanthappa, Hans Gertje, Mark Lawson, Manjusha Biswas, Saravanan Thiyagarajan, Biswanath Majumder, D. C. Doval, Anurag Mehta, Neyaz Alam, Nabendu Murmu, S. P. Somashekhar, Aaron Goldman. Spatial re-distribution of natural killer cells targets drug resistance and anti-tumor response, ex-vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4064.

Abstract 2835: Temporal sequencing of anticancer drugs, ex vivo, optimizes therapeutic effect by targeting drug-induced glucose-6-phosphate dehydrogenase

Background: Phenotypic cell state transitions are emerging as novel drivers of transient resistance to cancer chemotherapy. We recently demonstrated that non-cancer stem cells are able to undergo a phenotypic cell state transition that enables acquire a ‘reversible' drug tolerant state. Consequently, we made two key discoveries, drug tolerance 1) results in a cross-resistance to other classes of anticancer drugs 2) coincidental to a switch in the metabolic behavior. Further, evidences prompted to investigate if drug-induced metabolic reprogramming contributes to combination therapy resistance in a population of cancer cells that have gained tolerance to a primary therapy. Methods: We investigated the metabolic phenotype of drug tolerant cells using 3-D in-vitro models of breast cancer. A systems biology approach was used to identify key, interconnecting proteins involved in metabolic dysregulation, drawing inferences among signaling networks and events in a temporal context. Using an in-silico simulation we perturbed glucose metabolism, and tested how timing, combination and drug order impact the therapeutic effect of combination therapy and validated our findings using in-vivo experiments. Finally, to provide a direct clinical translation, we tested temporally-sequenced 3-drug combinations using CANscriptTM, a human explant tumor assay that captures the entire tumor ecosystem. Results: We report that conventional chemotherapies used to treat breast cancer, results in an adaptive cross-tolerance against an unrelated chemotherapeutic agent via induction of both glycolytic and oxidative pathways. These drug-tolerant cells switch to a CD44Hi phenotypic cell state, and rely on both the Akt pathway and HIF1α-Glut1 axis in a reactive oxygen species-dependent manner, which temporally cooperate to remodel a glucose shunt towards the pentose phosphate pathway. Mathematically modeling these pathways, we demonstrate how a sequentially-applied, 3-drug combination that includes G6PD metabolic inhibitors and cytotoxic agents can improve therapeutic effect. The use of CANscriptTM demonstrated that pharmacodynamics, biomarkers of resistance, and temporal ordering of drugs can influence the phenotypic response to therapy, reflecting in-vitro and in-vivo evidence, in a patient-specific manner. Conclusions: Timing, sequence and order of drugs is emerging as a critical component of combination therapy for cancer. Our results demonstrate that timing the order of G6PD inhibitors in exquisitely sequenced combination with chemotherapy can emerge as a new paradigm in the treatment of cancer. Ex-vivo, human tumor models that fully capture the tumor microenvironment can contribute to and potentially uncover the mechanisms of action, phenotypic effect, and pharmacodynamics of anticancer drug combinations in distinct temporal sequences.

Citation Format: Baraneedharan Ulaganathan, Andrew Dhawan, Biswanath Majumder, Munisha Smalley, Saravanan Thiyagarajan, Gopinath S. Kodaganur, S Krishnamurthy, Mohammed Mamunur Rahman, Elizaveta Freinkman, Pradip Majumder, Mohammad Kohandel, Aaron Goldman. Temporal sequencing of anticancer drugs, ex vivo, optimizes therapeutic effect by targeting drug-induced glucose-6-phosphate dehydrogenase [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2835.

Thromboelastography as a Predictor of Outcomes Following Liver Transplantation

BACKGROUND

Thromboelastography (TEG) has been used perioperatively during liver transplantation (LT) to provide a real-time global hemostasis assessment for targeted blood product replacement. We aimed to analyze the relationship between post-LT TEG results and outcomes.

METHODS

We retrospectively analyzed patients undergoing LT from November 2008 to December 2014 at Mayo Clinic Florida. All 441 single-organ 1st-time LT patients aged ≥18 years requiring post-LT intensive care unit management were included. TEG parameters including r time, k time, α angle, and maximum amplitude were measured regularly during the first 24 hours after LT. Outcomes included return to the operating room secondary to bleeding, length of hospitalization, survival, and early allograft dysfunction.

RESULTS

A prolonged and/or lengthening r time, k time, and r+k time were all independently associated with increased length of hospitalization after LT. Increased maximum amplitude on the first post-LT TEG was associated with early allograft dysfunction. No notable associations of TEG parameters with survival or return to operating room were observed.

CONCLUSIONS

The association of absolute and temporal TEG value changes with increased length of hospitalization and early allograft dysfunction suggests that TEG may have a role in identifying patients at high risk for these outcomes.

Abstract P5-11-04: Therapy-induced priming of natural killer cells predicts patient-specific tumor rejection in multiple breast cancer indications

Background: Predicting patient-specific clinical response to anticancer therapy is the holy grail of treatment-selection. It is now clear that response or resistance to therapy depends on the heterogeneous tumor microenvironment, which is comprised of malignant cells, normal stroma, soluble ligands, and tumor-immune contexture; attributes that are unique to each individual patient. This is particularly true for emerging anticancer drugs, such as immune checkpoint inhibitors, which recalibrate the body's own immune defense largely by modulating exhaustion of cytotoxic lymphocytes including T cells and natural killer (NK) cells. However, clinical response to therapy varies enormously. There is a critical gap in our understanding for the mechanisms that drive response or resistance to conventional drugs and immunotherapies at the individual patient level.

Methods: Here, we used a fully patient-autologous, clinically-validated ex-vivo tumor model that recreates and preserves the native, patient tumor microenvironment (CANscriptTM), which incorporates an algorithm-driven method to predict clinical response to therapy (M-Score). Utilizing tissue from patients diagnosed with luminal, HER2 positive, and triple-negative (ER- PR- HER2-) breast cancers (N=10), we studied phenotypic alterations to the tumor-immune contexture under pressure of conventional standard-of-care regimens and immunotherapies including immune-checkpoint inhibitors, ex-vivo. To do this, we used a comprehensive panel of immunological assays to evaluate changes in cytotoxic lymphocytes by flow cytometry and multiplex immunohistochemistry (i.e. CD56, MHC class 1A/B, NKG2D/C, CD8, CD3, PD-1, CTLA-4, TIM-3, LAG-3, 4-1BB, granzyme A/B). In addition, we used multiplex cytokine analysis to study the soluble components of the tumor microenvironment.

Results: We identified that tumor response, predicted by M-Score, correlates to increased infiltration of NK cells, which associated a pro-inflammatory cytokine signature from the tumor microenvironment. Interestingly, these evidences were concordant with induction of the tumor-expressing biomarker MICA/B, which is known to attract and recruit active NK cells. Furthermore, we determined that therapy-induced expression of protein biomarkers associated with NK cell exhaustion inversely correlated to the expression of cytotoxic granzyme B in the tumor microenvironment.

Conclusions: Taken together, these data demonstrate an integral role that NK cells contribute to the antitumor effect of therapy including conventional and immuno-modulatory drugs. It further demonstrates how a novel ex-vivo platform can be harnessed to study the mechanisms of response and resistance, which couldn't otherwise be known in a drug naïve state. Such an advance in our preclinical methods to study anticancer drugs at the individual patient level can help guide treatment decisions for clinicians while simultaneously functioning as a platform to study clinical efficacy of novel and emerging agents.

Citation Format: Smalley M, Shanthappa BU, Gertje H, Lawson M, Ulaganathan B, Thayakumar A, Maciejko L, Radhakrishnan P, Biswas M, Thiyagarajan S, Majumder B, Gopinath KS, K GB, Goldman A. Therapy-induced priming of natural killer cells predicts patient-specific tumor rejection in multiple breast cancer indications [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-11-04.

UNILATERAL FRONTALIS MUSCLE PARALYSIS: MANAGEMENT WITH BOTULINUM TOXIN A (CASE REPORTS)

Unilateral frontalis muscle palsy is a debilitating disease with a heterogeneous etiology. Congenital or acquired unilateral paralysis of the frontalis muscle causes ipsilateral brow ptosis and contralateral hypermobility of the non-paralytic frontalis muscle, resulting in a bizarre asymmetry and emotional embarrassment. We present five patients with unilateral frontal muscle paralysis, two males and three females, aged between 32 and 68, treated with botulinum toxin A injection to the contralateral (non-affected) side. A total dose between 10 to 30 U botulinum toxin A (onabotulinum or incobotulinum toxin A) successfully improve symmetry and facial esthetics without any adverse events. Botulinum toxin A is an alternative to facial palsy surgery but may also be used as an adjunct after the surgical procedure to optimize the outcome.

KERATOACANTHOMA OF THE UPPER LIP: REVIEW OF THE LITERATURE AND REPORT OF CASE WITH CENTRAL UPPER LIP RECONSTRUCTION

Keratoakanthoma (KA) is a common non-melanoma skin tumor of sun-exposed skin. Recently it has been classified as a highly differentiated squamous cell carcinoma, based on the evidence of local destruction, tissue invasion and malignant transformation with metastatic spread described in the medical literature. Lower lip KA is not uncommon on lower lip, and quite rare on upper lip. The authors present a case of 78-year-old Caucasian male patient with a rapidly growing keratotic tumor of the central region of upper lip. After complete surgical excision, single-stage reconstruction of the defect was performed by modified Goldstein's bilateral advancement myocutaneous vermilion flap. The histologic examination confirmed KA with excision margins within healthy tissue. Healing was unremarkable and functional and esthetic outcomes were very good. KA of the upper lip is a rare tumor that warrants complete surgical excision. Reconstruction of the central part of the upper lip is a challenge, but bilateral advancement myocutaneous vermilion flap resulted in good outcome.

Notch-Jagged signalling can give rise to clusters of cells exhibiting a hybrid epithelial/mesenchymal phenotype

Metastasis can involve repeated cycles of epithelial-to-mesenchymal transition (EMT) and its reverse mesenchymal-to-epithelial transition. Cells can also undergo partial transitions to attain a hybrid epithelial/mesenchymal (E/M) phenotype that allows the migration of adhering cells to form a cluster of circulating tumour cells. These clusters can be apoptosis-resistant and possess an increased metastatic propensity as compared to the cells that undergo a complete EMT (mesenchymal cells). Hence, identifying the key players that can regulate the formation and maintenance of such clusters may inform anti-metastasis strategies. Here, we devise a mechanism-based theoretical model that links cell–cell communication via Notch-Delta-Jagged signalling with the regulation of EMT. We demonstrate that while both Notch-Delta and Notch-Jagged signalling can induce EMT in a population of cells, only Jagged-dominated Notch signalling, but not Delta-dominated signalling, can lead to the formation of clusters containing hybrid E/M cells. Our results offer possible mechanistic insights into the role of Jagged in tumour progression, and offer a framework to investigate the effects of other microenvironmental signals during metastasis.

MIXED TYPE BASAL CELL CARCINOMA OF THE AURICLE - SINGLE STAGE RECONSTRUCTION AFTER R0-RESECTION BY A MODIFIED ANTIA-BUCH FLAP (CLINICAL CASE REPORT)

Basal cell carcinoma (BCC) is the most common neoplasia in Caucasians with a pre-dominance for the sun-exposed anatomical areas including the auricle. The treatment of choice is surgery achieving an R0-resection status. On the other hand, functional and aesthetic results are of importance. We report a case of 79-year-old Caucasian man with a BCC of the helical rim that was treated surgically using a modified Antia-Buch flap for single stage reconstruction. Article is discussing peculiarities of BCC on the auricle and options for auricular reconstruction.