Pegbelfermin in Patients With Nonalcoholic Steatohepatitis and Compensated Cirrhosis (FALCON 2): A Randomized Phase 2b Study

BACKGROUND & AIMS

Pegbelfermin is a polyethylene glycol-conjugated analog of human fibroblast growth factor 21, a nonmitogenic hormone that regulates energy metabolism. This phase 2b study evaluated 48-week pegbelfermin treatment in patients with nonalcoholic steatohepatitis (NASH) with compensated cirrhosis.

METHODS

FALCON 2 (NCT03486912) was a randomized (1:1:1:1), double-blind, placebo-controlled study. Eligible adults had biopsy-confirmed NASH and stage 4 fibrosis. Pegbelfermin (10, 20, or 40 mg) or placebo was injected subcutaneously once weekly. The primary endpoint was 1 or more stages of improvement in the NASH Clinical Research Network fibrosis score without NASH worsening at week 48; pegbelfermin dose response was assessed using a Cochran-Armitage trend test across proportions (1-sided α = .05). Additional endpoints included histologic and noninvasive measures of steatosis, fibrosis, and liver injury/inflammation.

RESULTS

Overall, 155 patients were randomized, and 154 patients received treatment. At week 48, 24% to 28% of the pegbelfermin arms had primary endpoint responses vs 31% of the placebo arm (P = .361). Nonalcoholic fatty liver disease activity score improvements were more frequent with pegbelfermin vs placebo and were driven primarily by reduced lobular inflammation. Numerically higher proportions of the pegbelfermin arms had liver stiffness (magnetic resonance elastography) and steatosis (magnetic resonance imaging-proton density fat fraction) improvements vs placebo; these differences were not statistically significant. Mean N-terminal type III collagen propeptide, alanine aminotransferase, and aspartate aminotransferase values were numerically lower in the 20- and/or 40-mg pegbelfermin arms compared with placebo. Serious adverse events were more frequent with pegbelfermin vs placebo, although none were treatment related. One patient (40-mg pegbelfermin) discontinued treatment because of a treatment-emergent adverse event (worsening ascites).

CONCLUSIONS

FALCON 2 did not meet its primary endpoint of 1 or more stages of improvement in the NASH Clinical Research Network fibrosis without NASH worsening assessed via biopsy. Pegbelfermin generally was well tolerated in this advanced NASH population.

Pegbelfermin in Patients With Nonalcoholic Steatohepatitis and Stage 3 Fibrosis (FALCON 1): A Randomized Phase 2b Study

BACKGROUND & AIMS

Pegbelfermin is a polyethlene glycol-conjugated analog of human fibroblast growth factor 21, a nonmitogenic hormone that regulates energy metabolism. This phase 2b study evaluated 48-week pegbelfermin treatment in patients with nonalcoholic steatohepatitis (NASH) and stage 3 (bridging) fibrosis.

METHODS

The FALCON 1 study (NCT03486899) was a multicenter, randomized (1:1:1:1), double-blind, placebo-controlled study. Patients with biopsy-confirmed NASH and stage 3 fibrosis (N = 197) received weekly subcutaneous pegbelfermin (10, 20, or 40 mg) or placebo injections for 48 weeks. The week 24 primary endpoint was a ≥1-point decrease in fibrosis score without NASH worsening or NASH improvement without fibrosis worsening; pegbelfermin dose response was assessed using a Cochran-Armitage trend test across proportions (1-sided α = 0.05). Secondary/exploratory endpoints included histological and noninvasive measures of steatosis, fibrosis, and liver injury/inflammation.

RESULTS

At week 24, the primary endpoint was met by 14% (placebo) vs 24%-31% (pegbelfermin arms); statistical significance was not reached due to lack of pegbelfermin dose response (P = .134). At weeks 24 and 48, more patients who received pegbelfermin had ≥30% relative reductions in hepatic fat fraction (magnetic resonance imaging-proton density fat fraction) vs placebo, although no differences reached statistical significance. In the pegbelfermin arms, improvements in liver fibrosis (magnetic resonance elastography and N-terminal type III collagen propeptide) and liver injury/inflammation (alanine aminotransferase, aspartate aminotransferase) were observed vs placebo. Adverse events occurred at similar frequencies across arms. No treatment-related serious adverse events were observed.

CONCLUSIONS

The FALCON 1 study did not meet its primary endpoint; a ≥1-point decrease in fibrosis score without NASH worsening or NASH improvement without fibrosis worsening assessed via biopsy. Pegbelfermin was generally well tolerated during 48 weeks of treatment.

Abstract 2044: Pharmacokinetics (PK) of nivolumab in patients with relapsed or refractory lymphoid malignancies

Objectives: Nivolumab, a fully human anti-programmed death-1 immunoglobulin G4 antibody, has demonstrated clinically meaningful responses and overall survival benefits in patients with solid tumors following administration of 3 mg/kg every 2 weeks (Q2W)—the currently approved dosing regimen for the treatment of advanced melanoma and non-small-cell lung cancer (NSCLC). Nivolumab has also demonstrated strong antitumor activity in lymphoid malignancies with an objective response rate of 87% in relapsed or refractory classical Hodgkin lymphoma (cHL) (Ansell SM, et al. N Engl J Med. 2015). The present analysis aimed to characterize the PK of nivolumab in 4 different lymphoid malignancies, including multiple myeloma (MM), T-cell non-Hodgkin lymphoma (NHL), B-cell NHL, and cHL, and to compare the PK to that seen in solid tumors.

Methods: This analysis was conducted as part of an open-label, dose-escalation phase 1 study (NCT01592370) investigating the safety, PK, and antitumor activity of nivolumab in patients with relapsed or refractory lymphoid malignancies. Patients were treated with nivolumab 1 mg/kg Q2W or 3 mg/kg Q2W in the dose-escalation phase, and with nivolumab 3 mg/kg Q2W during the dose-expansion phase. Serial blood samples were collected and analyzed for PK using a validated ligand-binding enzyme-linked immunosorbent assay. PK parameters of nivolumab, including area under the curve over the 2-week (336 hours) interval following the first dose (AUC336) and maximum plasma concentration (Cmax) after the first dose were characterized using noncompartmental analysis.

Results: The geometric mean (coefficient of variation [CV]) values of dose-normalized AUC336 of nivolumab in the MM (n = 22), B-cell NHL (n = 30), T-cell NHL (n = 19), and HL (n = 18) groups were 3759 μg•h/mL (23%), 3298 μg•h/mL (24%), 2800 μg•h/mL (29%), and 2977 μg•h/mL (27%), respectively. The geometric mean (CV) values of dose-normalized Cmax of nivolumab in the MM, B-cell NHL, T-cell NHL, and HL groups were 24 μg/mL (30%), 20 μg/mL (26%), 18 μg/mL (31%), and 18 μg/mL (25%), respectively. Dose-normalized exposures were similar at the 1- and 3-mg/kg dose levels.

Conclusions: The PK of nivolumab is similar among patients with different lymphoid malignancies and is similar to what has previously been observed for patients with solid tumors, including melanoma, renal cell carcinoma, and NSCLC, following administration of nivolumab 3 mg/kg Q2W. Based on the observed tolerable safety profile and strong antitumor activity, nivolumab 3 mg/kg Q2W is an appropriate dosing regimen for study in patients with lymphoid malignancies.

Citation Format: Xiaoli Wang, Matthew Hruska, M. Brigid Bradley-Garelik, Bradly Boone, Akintunde Bello. Pharmacokinetics (PK) of nivolumab in patients with relapsed or refractory lymphoid malignancies. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2044.

Mohs micrographic surgery for basal cell carcinoma: evaluation of the indication criteria and predictive factors for extensive subclinical spread

BACKGROUND

The incidence of basal cell carcinoma (BCC) is rising and BCC treatment has an important impact on healthcare budget. Mohs micrographic surgery (MMS) has the highest 5-year cure rate but is an expensive technique.

OBJECTIVES

To study the indication criteria for MMS, using a series of 1062 patients treated for facial BCCs between 1998 and 2011.

METHODS

The accuracy of the indication criteria was evaluated by comparing the characteristics of BCC requiring one vs. more than one round of MMS. Predictors for extensive subclinical spread (three or more rounds) were examined using the preoperative patient and all tumour characteristics.

RESULTS

BCCs with a surface > 1 cm(2) and aggressive histology (morphoeaform and micronodular), and a patient age > 80 years are strong predictors for two or more rounds of MMS being required. Extensive subclinical spread was present in recurrent tumours, morphoeaform BCC or BCC with mixed histology.

CONCLUSIONS

We found that tumour size and aggressive histology are the strongest indication criteria for MMS. Recurrence and aggressive histology are predictors for extensive subclinical spread but not for two or more rounds of MMS. Evidence-based indications for MMS are necessary to ensure cost-effective management of BCC.

Classification of segmental vitiligo on the trunk

BACKGROUND

Segmental vitiligo is characterized by a unilateral and localized distribution. A classification for segmental vitiligo on the face has been proposed, while this is still unavailable for lesions on the trunk.

OBJECTIVES

To design a classification for segmental vitiligo lesions on the trunk by evaluating their distribution pattern.

METHODS

In this retrospective observational study, the distribution pattern of 106 segmental vitiligo lesions on the trunk was analysed and classified into recurring subtypes.

RESULTS

Segmental vitiligo was more frequently observed on the ventral side (85·8%) than the lateral side (52·8%) or the back (36·8%) of the trunk. Based on recurring similarities in distribution patterns, lesions were categorized into six distinct subtypes: types 1, 2 and 3 involved the upper part of the trunk, type 4 and 5 the middle part and type 6 the lower part of the trunk. In total, 67·9% of all segmental vitiligo lesions fitted into these subtypes. The most frequent type of lesion was subtype 3 (22·6%), which showed a characteristic V-shaped pattern on the upper trunk, followed by subtype 5 (17·9%), with a band-like pattern on the lateral side, and subtype 6 (13·2%), with a rectangular depigmentation on the lower abdomen.

CONCLUSIONS

Based on our observations we suggest a new classification into six subtypes for segmental vitiligo lesions on the trunk, allowing categorization of the majority of segmental vitiligo patterns on the trunk. This may have important prognostic and diagnostic significance in early developing lesions.

Disruption of PPARgamma signaling results in mouse prostatic intraepithelial neoplasia involving active autophagy

Peroxisome proliferator-activated receptor-gamma (PPARgamma) regulates the interface between cellular lipid metabolism, redox status and organelle differentiation. Conditional prostatic epithelial knockout of PPARgamma in mice resulted in focal hyperplasia which developed into mouse prostatic intraepithelial neoplasia (mPIN). The grade of PIN became more severe with time. Electron microscopy (EM) showed accumulated secondary lysosomes containing cellular organelles and debris suggestive of autophagy. Consistent with this analysis the autophagy marker LC-3 was found to be upregulated in areas of PIN in PPARgamma KO tissues. We selectively knocked down PPARgamma2 isoform in wild-type mouse prostatic epithelial cells and examined the consequences of this in a tissue recombination model. Histopathologically grafted tissues resembled the conditional PPARgamma KO mouse prostates. EM studies of PPARgamma- and PPARgamma2-deficient epithelial cells in vitro were suggestive of autophagy, consistent with the prostatic tissue analysis. This was confirmed by examining expression of beclin-1 and LC-3. Gene expression profiling in PPARgamma-/gamma2-deficient cells indicated a major dysregulation of cell cycle control and metabolic signaling networks related to peroxisomal and lysosomal maturation, lipid oxidation and degradation. The putative autophagic phenotypes of PPARgamma-deficient cells could be rescued by re-expression of either gamma1 or gamma2 isoform. We conclude that disruption of PPARgamma signaling results in autophagy and oxidative stress during mPIN pathogenesis.

Clinical markers and driving mechanisms in melanoma progression: VEGF-C, RhoC, c-Ski/SnoN and EGFR

This research project aimed at evaluating the clinical and prognostic value of different molecules involved in signalling transduction pathways involved in melanoma progression. Vascular endothelial growth factor-C or VEGF-C induces lymphangiogenesis. This study showed high VEGF-C expression to be associated with the presence of a positive sentinel lymph node. The presence of VEGF-C expression in melanoma cells was associated with reduced disease free and overall survival. RhoC is important in the organization of the actin filamental system. We observed RhoC mRNA and protein expression to be upregulated in a highly metastatic melanoma cell line (DX3aza), whereas only low expression levels were found in a melanoma cell line with low proliferative and invasive capacity (MeWo). RhoC immunoreactivity in melanoma tissue was associated with high Breslow tumour thickness and the presence of ulceration. C-Ski and SnoN have been identified as negative regulators in the TGF-beta pathway. We found a significant association between the presence of nuclear c-Ski and thicker, ulcerated melanomas. SnoN expression was associated with the presence of ulceration and a positive sentinel lymph node. Epidermal Growth Factor Receptor (EGFR) expression has been associated with tumour progression and poor outcome in a variety of solid tumours, EGFR immunoreactivity was more frequently present in patients with a positive sentinel lymph node. EGFR gene amplification was not observed; however, the presence of polysomy was associated with higher Breslow tumour thickness. Treating BLM melanoma cells with different concentrations of cetuximab reduced the invasive capacity of the melanoma cells, without impact on cell viability and growth.

Proximal row carpectomy versus four-corner arthrodesis as a treatment for SLAC (scapholunate advanced collapse) wrist

Four-corner arthrodesis and proximal row carpectomy are motion-preserving salvage solutions for the scapholunate advanced collapse wrist. We compared both procedures in a non-randomised, retrospective study of 30 cases with a mean follow-up of 3(1/2) years. Pain relief and functional gain were equal in both treatment groups. However, the complication rate was higher in the four-corner arthrodesis group, partly because of the need for internal fixation. The higher incidence of carpal tunnel syndrome following four-corner arthrodesis is intriguing. We also found significant differences in the duration of hospital stay and of postoperative sick leave in favour of proximal row carpectomy. If the cartilage on the capitate head is well preserved (Stages I-II), we prefer proximal row carpectomy because of the socio-economic benefits, the lower complication rate and the ease of the procedure. Degenerative changes following proximal row carpectomy may be a concern in young manual labourers, but have not been observed.

Effect of soil depth and texture on fecal bacteria removal from septic effluents

This study evaluated the effectiveness of soils with different texture and depth to treat fecal bacteria eluted from a house-hold septic effluent. The assessments were accomplished by leaching undisturbed soil monoliths of 30, 45, and 60cm thickness and 25cm in diameter, representing the four different textural groups and hydraulic loadings recommended by the Kentucky Health Department, with domestic wastewater effluent collected regularly from a house-hold septic system. Eluent concentrations were monitored daily over a 15 day period for fecal coliform and fecal streptococci concentrations. The results of the study indicate an alarming frequency of failure to comply with United States Environmental Protection Agency (USEPA) criteria for depth to groundwater, when using a 30 cm vertical separation distance between the bottom of the drain-field and a limiting soil interface. The treatment performance was especially poor in coarse-textured soils. Although biomat development over time is expected to improve treatment, the high influent levels of fecal bacteria pose great concerns for surface and groundwater contamination. Fine-textured soils generally provided better treatment efficiency and more consistent compliance with EPA standards. Treatment efficiency and compliance usually improved with increasing soil depth, with the 60cm thickness providing the most consistent performance and compliance with maximum discharge limit (MDL) requirements. The findings of this study document a general inadequacy of the 30cm vertical separation distance to provide effective treatment of septic effluents in Kentucky soils, particularly in coarse-textured soils. Considering that increasing the soil depth thickness may be impractical in many marginal soils, complementary or alternative treatment technologies should be adopted to improve treatment efficiency and prevent further deterioration of the quality of water resources.

Nutrient removal from septic effluents as affected by soil thickness and texture

This study evaluated the effectiveness of soils with different textures and thickness to treat BOD, N and P eluted from household septic effluent. The assessments were accomplished by leaching undisturbed soil monoliths of 30, 45 and 60 cm thickness and 25 cm in diameter, representing the four different textural groups and hydraulic loadings recommended by the Kentucky Health Department, with domestic wastewater effluent collected regularly from a household septic system. Effluent concentrations were monitored daily over a 15d period for biochemical oxygen demand (BOD), total-N, NH4-N, NO3-N and total-P concentrations. The results of the study indicate an alarming frequency of failure to comply with EPA criteria for BOD, total-N and NH4-N concentrations when using a 30 cm vertical separation distance between the bottom of the drain field and a limiting soil interface. The treatment performance was particularly poor in coarse-textured soils, apparently due to insufficient reactive surface area. Although biomat development over time is expected to improve the treatment for some of these parameters, the high influent levels of BOD pose great concerns for surface and groundwater contamination during the early stages of operation. Fine-textured soils generally provided better treatment efficiency and more consistent compliance with EPA standards for BOD, total-N, NH4-N and total-P, as well as greater nitrification/denitrification potential. Treatment efficiency and compliance usually improved with increasing soil depth, with the 60 cm thickness providing the most consistent performance and compliance with MDL requirements. Considering that increasing soil thickness requirements may be impractical in many marginal soils, complementary or alternative treatment technologies should be adopted to improve treatment efficiency and prevent further deterioration of the quality of water resources.