Clinical Response of Live-Attenuated, Listeria monocytogenes Expressing Mesothelin (CRS-207) with Chemotherapy in Patients with Malignant Pleural Mesothelioma

PURPOSE

Malignant pleural mesothelioma (MPM) is an aggressive cancer associated with poor prognosis. CRS-207 is a live-attenuated Listeria monocytogenes engineered to express mesothelin, a tumor-associated antigen highly expressed in MPM. CRS-207 induces antitumor immune responses and increases susceptibility of neoplastic cells to immune-mediated killing.

PATIENTS AND METHODS

Patients with unresectable MPM, ECOG 0 or 1, and adequate organ and pulmonary function were enrolled in this multicenter, open-label phase Ib study. They received two priming infusions of 1 × 109 CFU CRS-207, followed by pemetrexed/cisplatin chemotherapy, and CRS-207 booster infusions. Primary objectives were safety and induction of immune response. Secondary/exploratory objectives included tumor response, progression-free survival (PFS), overall survival (OS), immune subset analysis, and gene-expression profiling of tumor.

RESULTS

Of 35 evaluable patients, 89% (31/35) had disease control with one complete response (3%), 19 partial responses (54%), and 10 stable disease (29%). The estimated median duration of response was 5.0 months (95% CI, 3.9-11.5). The median PFS and OS were 7.5 (95% CI, 7.0-9.9) and 14.7 (95% CI, 11.2-21.9) months, respectively. Tumor size reduction was observed post-CRS-207 infusion prior to chemotherapy in 11 of 35 (31%) patients. No unexpected treatment-related serious adverse events or deaths were observed. IHC analysis of pre- and post-CRS-207 treatment tumor biopsies revealed possible reinvigoration and proliferation of T cells, increased infiltration of dendritic and natural killer cells, increased CD8:Treg ratio, and a shift from immunosuppressive M2-like to proinflammatory M1-like macrophages following CRS-207 administration.

CONCLUSIONS

Combination of CRS-207 and chemotherapy induced significant changes in the local tumor microenvironment and objective tumor responses in a majority of treated patients.

Randomized phase II study of the safety, efficacy, and immune response of GVAX pancreas (with cyclophosphamide) and CRS-207 with or without nivolumab in patients with previously treated metastatic pancreatic adenocarcinoma (STELLAR)

TPS486

Background: A heterologous prime-boost vaccination strategy using GVAX pancreas and CRS-207 is showing promise in patients with pancreatic adenocarcinoma (PDA) (Le, JCO 2015). Furthermore, blockade of the immune checkpoint programmed death-1 (PD-1) is active in some cancers. Combinatorial strategies aimed at priming tumor antigen-specific T cells while simultaneously blocking negative checkpoints may be necessary to improve outcomes in PDA. GVAX is composed of allogeneic pancreatic cancer cells modified to express GM-CSF and induces a broad response against multiple tumor antigens. GVAX is given with low-dose cyclophosphamide (CY) to inhibit regulatory T cells. CRS-207 is live-attenuated Listeria monocytogenes engineered to express the tumor-associated antigen mesothelin. CRS-207 boosts responses against mesothelin and is unique in its capacity to stimulate both innate and adaptive immunity by activating T cells and NK cells. Nivolumab is an antibody against PD-1. Methods: This is a phase 2 study comparing CY/GVAX and CRS-207 with or without nivolumab in subjects with PDA who failed only one chemotherapy regimen for metastatic disease. Subjects are randomized in a 1:1 ratio to receive either 2 doses of CY/nivolumab/GVAX and 4 doses of nivolumab/CRS-207 (Arm A) or 2 doses of CY/GVAX and 4 doses of CRS-207 (Arm B). The primary objective is to compare OS between Arms A and B. Secondary/exploratory objectives include: assessment of safety and clinical responses (tumor assessments and CA19-9 levels) and correlation of Lm- and mesothelin-specific T cell and other immunological responses with OS, progression-free survival and best overall response. Clinical trial information: NCT02243371.

Clinical and immune characteristics of rapid dropout and long-term survival in a phase II safety and efficacy study of combination CRS-207/GVAX immunotherapy in pancreatic cancer

459

Background: Baseline patient characteristics may impact duration on study and survivorship of patients in immunotherapy trials. In this study, GVAX pancreas (GM-CSF–secreting allogeneic pancreatic tumor cells) was administered with low-dose cyclophosphamide (Cy), with or without subsequent CRS-207 (live-attenuated Listeria monocytogenes–expressing mesothelin) infusion. Baseline clinical and immunological data were examined for two patient subsets based on duration on study. Methods: Previously treated patients with metastatic pancreatic adenocarcinoma were randomly assigned at a ratio of 2:1 to 2 doses of Cy/GVAX followed by 4 doses of CRS-207 or 6 doses of Cy/GVAX every 3 weeks. Stable patients were offered additional courses. Patients were evaluated for post-randomization duration on study of < 60 days (rapid dropouts, RD) and > 18 months (long-term survivors, LTS). Baseline characteristics of these subsets were examined. Results: A total of 93 patients were randomized. Fifteen patients were RD; 13 were LTS. More RDs versus LTS had liver metastasis and lymph node involvement. On average, fewer RD patients had radiotherapy prior to randomization and fewer had prior surgical intervention. RD averaged 1.73 prior metastatic cancer treatment regimens versus 1.31 in LTS. RD also had higher average baseline CA 19-9 levels. Immune analysis showed higher circulating terminal effector CD8+ T cells and lower serum IL-6 in LTS compared to RD. Serum IL-6 concentration remained lower in LTS at four weeks following initiation of treatment. For patients who received CRS-207, CD8+ T cells specific to listeriolysin O (LLO) and mesothelin were higher in LTS than RD, as determined by ELISPOT. Conclusions: Baseline clinical and immunological characteristics may impact patient duration on immunotherapy trials. Immune monitoring and biomarker analysis in this study is ongoing to identify circulating cellular, tumor biomarkers and genomic (miRNA and mRNA) signatures that may correlate with survival. These findings warrant continued exploration of patient characteristics to identify best candidates for immunotherapy trials. Clinical trial information: NCT01417000.

The fellow eye in retinal detachment: findings from the Scottish Retinal Detachment Study

AIM

To characterise the predisposing pathology and clinical features in the fellow eyes of patients recruited as part of the Scottish Retinal Detachment Study.

METHODS

The Scottish Retinal Detachment Study was a 2-year prospectively recruited population-based epidemiology study that sought to recruit all incident cases of primary rhegmatogenous retinal detachment (RRD) in Scotland.

RESULTS

A total of 1202 incident cases of primary RRD were recruited in Scotland, over a 2-year period and in 94% (1130 cases) detailed data on the clinical features of fellow eyes with RRD were available. Full-thickness retinal breaks were found in 8.4% (95/1130) of fellow eyes on presentation. Lattice degeneration was present in 14.5% (164/1130) of fellow eyes. Thirteen per cent (148/1130) of affected fellow eyes had a best corrected visual acuity of 6/18 or worse with previous RRD, the second most common cause of poor vision. Overall, 7.3% (88/1202) of cases had RRD in both eyes; 60% of cases with consecutive bilateral RRD presented before the macula were affected.

CONCLUSIONS

Rhegmatogenous pathology in the fellow eye represents an important threat to vision. Fellow-eye detachments are more common in pseudophakic individuals and those with a more myopic refractive error. Fellow-eye RRD has a greater likelihood of prompt presentation.

Community pharmacy services for antidepressant users

Objective

To evaluate the communication and barriers to communication between community-based pharmacists and antidepressant users.

Method

A survey package designed to evaluate the communication between pharmacists and antidepressant users was distributed to 50 community pharmacies. Each package included one pharmacist survey and 10 sealed antidepressant user surveys to be distributed by the pharmacy staff. The survey addressed the components of communication, level of satisfaction and barriers to effective communication.

Setting

Urban and rural community pharmacies in the Canadian Maritime provinces of Nova Scotia and New Brunswick.

Key findings

Overall, pharmacists rated the value of their communication more highly than did antidepressant users, although the difference was not statistically significant. When beginning treatment, between one-half and two-thirds of antidepressant users recalled pharmacists inquiring about past use of the antidepressant and discussing information provided by the physician, time to onset of benefits and potential side effects. The purpose of the antidepressant, target symptoms, usual duration of therapy and risk of relapse with premature discontinuation were addressed less often according to antidepressant users, and monitoring of compliance was not a common activity. Antidepressant users estimated that initial communication with the pharmacist generally lasted less than five minutes, and often less than two minutes. However, pharmacists appeared to resolve misconceptions and concerns about antidepressant use efficiently. According to pharmacists, the major barrier to effective communication was a lack of privacy.

Conclusion

Although compliance with antidepressants is low and treatment outcomes are sub-optimal, pharmacists are not using their opportunities to minimise this problem through effective communication and follow-up. Pharmacists, pharmacy administrators and regulators need to re-assess their contribution to this problem and how they can lead to its resolution in the patient's best interest.

Tidal peritoneal dialysis: comparison of different tidal regimens and automated peritoneal dialysis

BACKGROUND

The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) clinical practice guidelines have suggested minimal weekly Kt/V urea and creatinine clearance goals for peritoneal dialysis patients maintained on continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). Achieving these goals may present problems, particularly in larger patients whose residual renal function declines. Thus, modifications of the dialysis regimen, such as tidal peritoneal dialysis (TPD), have been developed. However, the ability of TPD to improve the efficiency of the dialysis procedure remains uncertain.

METHODS

Stable, cycling peritoneal dialysis patients were placed into two groups to study the effectiveness of different TPD prescriptions on peritoneal clearances of urea and creatinine. The volume of dialysis solution used and the duration of therapy were fixed in the two groups. Comparisons were made to conventional APD using multiple hourly cycles in which spent dialysis solution was completely drained with each cycle. Group I patients received a total of 15 L of PD solution over 9.5 hours in the dialysis unit. These patients received 10, 25, and 50% TPD and APD on four separate days. Group II patients received 24 L of PD solution over 9.5 hours. These patients received 25 and 50% APD on separate days in the dialysis unit. Peritoneal dialysis clearances for urea (pKt/V) and creatinine (pCCr) levels were calculated for both groups. The results were then analyzed to determine whether there was any significant difference among the various prescriptions.

RESULTS

The data in the group I patients indicated a mean daily pKt/V of 0.22 +/- 0.03 with 10% TPD, 0.23 +/- 0.02 with 25% TPD, 0.25 +/- 0.02 with 50% TPD, and 0.26 +/- 0.02 with APD. Paired t-test analysis for pKt/V demonstrated that 10 and 25% TPD resulted in significantly lower values than 50% TPD and APD (P < 0.05). Mean daily pCCr L/24 h/1.73 m2 was 6.03 +/- 0.72 for 10% TPD, 6.34 +/- 0.83 for 25% TPD, 6.65 +/- 0.51 for 50% TPD, and 7.01 +/- 0.96 for APD; these differences were not significantly different. The data in the group II patients demonstrated a mean daily pKt/V of 0.28 +/- 0.03 with 25% TPD, 0.29 +/- 0.05 with 50% TPD, and 0.30 +/- 0.05 for APD. The mean daily pCCr was 6.69 +/- 0.47 for 25% TPD, 8.09 +/- 1.30 for 50% TPD, and 7.63 +/- 1.13 for APD. There were no statistical differences for pKt/V and pCCr within the 24 L group.

CONCLUSION

When the duration of therapy and volume of dialysate volume are kept constant, TPD does not result in an improvement in clearances compared with conventional APD, at least with dialysate volumes up to 24 L.

Tidal peritoneal dialysis to achieve comfort in chronic peritoneal dialysis patients

Patients with end-stage renal disease on chronic peritoneal dialysis (CPD) can usually tolerate continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) without abdominal discomfort or pain. In some patients, pain or discomfort occurs with complete drain of the peritoneal dialysis solution or upon initiation of dialysis filling when the peritoneal cavity is empty. We report on the use of tidal peritoneal dialysis (TPD) as a modality to alleviate this pain. Of 136 patients in our CPD unit, 18 (13%) were complaining of pain with complete drain or upon instillation of PD fluid. All were placed on TPD after other causes for abdominal pain were excluded. Six patients were placed on 25% TPD, and 12 patients on 50% TPD. The mean Kt/V of the patients on TPD was 2.46 +/- 0.68. With TPD, all patients had complete relief of abdominal discomfort. Patients who develop abdominal pain with complete drain or fill when the abdominal cavity is empty would benefit from TPD and be able to continue with CPD.

Mineralocorticoid and glucocorticoid status in idiopathic haemochromatosis

OBJECTIVE

A number of studies have suggested that both primary (Addison's disease) and secondary adrenal failure may be caused by idiopathic haemochromatosis. There is little information on mineralocorticoid secretion. We have assessed the mineralocorticoid and glucocorticoid status of patients with idiopathic haemochromatosis.

DESIGN

Cross-sectional study.

PATIENTS

Eighteen males and one female with confirmed idiopathic haemochromatosis were investigated. Seven of the subjects had hepatic cirrhosis and three had hypogonadotrophic hypogonadism.

MEASUREMENTS

A short Synacthen (tetracosactrin) test was undertaken in addition to an overnight metyrapone test and an insulin stress test. In addition, plasma aldosterone (PA) and plasma renin activity (PRA) were measured in a group of patients in the basal state and again in the upright position.

RESULTS

The short Synacthen test, overnight metyrapone test and insulin stress test were normal in all subjects. The PA, PRA, and PA/PRA ratios in the upright position were not significantly different in the patients with idiopathic haemochromatosis compared to control subjects.

CONCLUSION

In this patient population, no abnormality of either the pituitary adrenal axis or mineralocorticoid status was detected. Adrenocortical dysfunction is likely to be exceptionally rare in idiopathic haemochromatosis.

Clinical results and quality of life after percutaneous transluminal coronary angioplasty: a preliminary report

To evaluate the effect of percutaneous transluminal coronary angioplasty (PTCA) on quality of life, data on symptomatic status, functional capacity, life satisfaction, and psychological wellness were collected on 102 patients at 1 day pre-PTCA and 2 months post-PTCA, and on the first 50 of these patients at 10 months post-PTCA. There were highly significant changes (p < 0.001) in all quality of life measures between pre-PTCA and the 1st follow-up measurements. No further significant changes occurred in these measures between the 1st and 2nd follow-up measurements, indicating that the initial improvement in quality of life was sustained over this period. Data on primary success rate, complications, and pre- and post-PTCA risk factor scores are also reported.

Carotid sinus hypersensitivity in elderly nursing home patients

Fourteen of 100 geriatric nursing home patients were shown to have evidence of carotid sinus hypersensitivity. The incidence of syncope and falls was noted in prospective follow-up over 33 months. Falls were classified as either simple or complicated by laceration or fracture. Patients experienced simple falls at similar rates whether carotid sinus hypersensitivity was present or absent. For patients with carotid sinus hypersensitivity, the risk of a laceration was increased more than twofold, that of fracture more than threefold, and that of syncope tenfold. Carotid sinus hypersensitivity warrants greater attention as a contributory factor to serious falls and syncope in the elderly; and its importance may have been underestimated in the past.

The effect of diazepam on induction of anesthesia with alfentanil

This study investigated the effect of intravenous diazepam on induction of anesthesia with alfentanil. Forty ASA physical status I and II patients were given one of four treatments: alfentanil 100 micrograms/kg or 200 micrograms/kg, without diazepam or preceded by 0.125 mg/kg diazepam intravenously. Blood pressure, heart rate, respiration, response to verbal command, and movement were assessed for 5 min, and blood was taken for measurement of histamine, epinephrine, and norepinephrine. All ten patients receiving 100 micrograms/kg and five of the ten patients receiving 200 micrograms/kg of alfentanil responded to voice after 5 min, but only one in each group responded when it was preceded by diazepam. There was no rigidity or serious arrhythmias in any patient. Heart rate increased in patients receiving alfentanil alone. Blood pressure increased in those receiving 100 micrograms/kg but not 200 micrograms/kg. In patients given diazepam, tachycardia did not occur, but blood pressure decreased after administration of alfentanil. There were no significant changes in plasma levels of histamine or catecholamines. Five of the six cases of inadequate postoperative ventilation were in patients given diazepam. Despite these effects, diazepam or some other hypnotic agent may be indicated when alfentanil is used for induction.

Right heart thrombus: recognition, diagnosis and management

The clinical, echocardiographic, hemodynamic, angiographic and pathologic features of five patients who had right heart thrombus are presented and their management is discussed. Two modes of presentation were recognized. In four patients, right heart thrombus complicated peripheral venous thrombosis and was associated with major pulmonary thromboembolism and right heart obstruction. In the fifth, it complicated myocarditis with heart failure and appeared to cause right heart obstruction. Two-dimensional echocardiography was diagnostic of right heart thrombus in four patients and showed evidence of right heart dysfunction in those with major pulmonary thromboembolism. The diagnosis was confirmed at surgery in three patients and at autopsy in one. Three patients successfully underwent surgical removal of the thrombus followed by anticoagulation. One patient was treated successfully with anticoagulation alone. The only death occurred in the patient with myocarditis.

The Present Status of the Internal Fixation of Fractures

Images