Multidimensional biomarker predicts disease control in response to immunotherapy in recurrent or metastatic head and neck squamous-cell carcinoma

PURPOSE

Anti-PD-1 therapy provides clinical benefit in 40-50% of patients with relapsed and/or metastatic head and neck squamous cell carcinoma (RM-HNSCC). Selection of anti- PD-1 therapy is typically based on patient PD-L1 immunohistochemistry (IHC) which has low specificity for predicting disease control. Therefore, there is a critical need for a clinical biomarker that will predict clinical benefit to anti-PD-1 treatment with high specificity.

METHODS

Clinical treatment and outcomes data for 103 RM-HNSCC patients were paired with RNA-sequencing data from formalin-fixed patient samples. Using logistic regression methods, we developed a novel biomarker classifier based on expression patterns in the tumor immune microenvironment to predict disease control with monotherapy PD-1 inhibitors (pembrolizumab and nivolumab). The performance of the biomarker was internally validated using out-of-bag methods.

RESULTS

The biomarker significantly predicted disease control (65% in predicted non-progressors vs. 17% in predicted progressors, p < 0.001) and was significantly correlated with overall survival (OS; p = 0.004). In addition, the biomarker outperformed PD-L1 IHC across numerous metrics including sensitivity (0.79 vs 0.64, respectively; p = 0.005) and specificity (0.70 vs 0.61, respectively; p = 0.009).

CONCLUSION

This novel assay uses tumor immune microenvironment expression data to predict disease control and OS with high sensitivity and specificity in patients with RM-HNSCC treated with anti-PD-1 monotherapy.

Detectable Post-operative Circulating Tumor Human Papillomavirus (HPV) DNA And Association with Recurrence in Patients with HPV-Associated Oropharyngeal Squamous Cell Carcinoma

PURPOSE

  To determine the rate of detectability of ctHPVDNA after surgery but before adjuvant therapy in patients with HPV-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) and to investigate whether detectable ctHPVDNA at this time point may be associated with risk of recurrence.

METHODS AND MATERIALS

 Prospectively collected samples from patients with OPSCC were examined in a blinded fashion using a multi-analyte PCR assay. 45 samples were collected from HPV(+)OPSCC patients pre-op (prior to any treatment), and 159 samples post-op (before or at the start of adjuvant RT). Samples were identified via the radiation oncology biobank or via participation in a clinical trial. RT consisted of 60 Gy +/- cisplatin or de-escalation (30 Gy to 36 Gy in 20 b.i.d. fractions + docetaxel). 32 patients had paired samples available pre and post-op for the primary analysis. Additional exploratory analyses including associations of patient and tumor characteristics with recurrence were assessed using Cox proportional hazards models for all 159 post-op samples.. Detectability of ctHPVDNA was compared across groups utilizing logistic regression. Estimates of recurrence free survival (RFS) were made using Kaplan-Meier (KM).

RESULTS

In a paired analysis of 32 pre and post-op timepoints, 94% of patients had detectable ctHPVDNA pre-op and 41% post-op. RFS at 18 months was 83% (95% CI: 47-95%) for patients with detectable post-op ctHPVDNA compared to 100% for patients with undetectable post-op ctHPVDNA (p=.094).In an exploratory analysis of non-paired post-op samples, ctHPVDNA was detectable in 26% (41 of 159) of patients (median of 22 days post-op). Age (1.06, p=0.025), LVSI (OR 3.17, p=0.011) and ENE (OR=5.67, p=0.001) were associated with detectable ctHPVDNA after surgery. Detectable post-op ctHPVDNA was significantly associated with RFS (p<0.001).

CONCLUSION

Amongst patients with detectable pre-op ctHPVDNA, a significant proportion have detectable post-op ctHPVDNA in paired post-op samples, collected prior to the initiation of adjuvant radiation therapy. Future prospective study is warranted to investigate the association of detectable post-op ctHPVDNA with recurrence, including in comparison to established clinical and pathologic risk factors.

Costs of Definitive Chemoradiation, Surgery, and Adjuvant Radiation Versus De-Escalated Adjuvant Radiation per MC1273 in HPV+ Cancer of the Oropharynx

PURPOSE

De-escalated treatment for human papillomavirus (HPV)+ oropharynx squamous cell carcinoma (OPSCC) has shown promising initial results. Health-care policy is increasingly focusing on high-value care. This analysis compares the cost of care for HPV+ OPSCC treated with definitive chemoradiation (CRT), surgery and adjuvant radiation (RT), and surgery and de-escalated CRT on MC1273.

METHODS AND MATERIALS

MC1273 is a prospective, phase 2 study evaluating adjuvant CRT to 30 to 36 Gy plus docetaxel for HPV+ OPSCC after surgery for high-risk patients. Matched standard-of-care control groups were retrospectively identified for patients treated with definitive CRT or adjuvant RT. Standardized costs were evaluated before radiation, during treatment (during RT), and at short-term (6 month) and long-term (7-24 month) follow-up periods.

RESULTS

A total of 56 definitive CRT, 101 adjuvant RT, and 66 MC1273 patients were included. The CRT arm had more T3-4 disease (63% vs 17-21%) and higher N2c-N3 disease (52% vs 20-24%) vs both other groups. The total treatment costs in the CRT, adjuvant RT, and MC1273 groups were $47,763 (standard deviation [SD], $19,060], $57,845 (SD, $17,480), and $46,007 (SD, $9019), respectively, and the chemotherapy and/or RT costs were $39,936 (SD, $18,480), $26,603 (SD, $12,542), and $17,864 (SD, $3288), respectively. The per-patient, per-month, average short-term follow-up costs were $3860 (SD, $10,525), $1072 (SD, $996), and $972 (SD, $833), respectively, and the long-term costs were $978 (SD, $2294), $485 (SD, $1156), and $653 (SD, $1107), respectively. After adjustment for age, T-stage, and N-stage, treatment costs remained lower for CRT and MC1273 versus adjuvant RT ($45,450 and $47,114 vs $58,590, respectively; P < .001), whereas the total per-patient, per-month follow-up costs were lower in the MC1273 study group and adjuvant RT versus CRT ($853 and $866 vs $2030, respectively; P = .03).

CONCLUSIONS

MC1273 resulted in 10% and 20% reductions in global costs compared with standard-of-care adjuvant RT and definitive CRT treatments. Substantial cost savings may be an added benefit to the already noted low toxicity and maintained quality of life of treatment per MC1273.

Altered synaptic structure in the hippocampus in a mouse model of Alzheimer's disease with soluble amyloid-β oligomers and no plaque pathology

Background

Mounting evidence suggests that soluble oligomers of amyloid-β (oAβ) represent the pertinent synaptotoxic form of Aβ in sporadic Alzheimer’s disease (AD); however, the mechanistic links between oAβ and synaptic degeneration remain elusive. Most in vivo experiments to date have been limited to examining the toxicity of oAβ in mouse models that also possess insoluble fibrillar Aβ (fAβ), and data generated from these models can lead to ambiguous interpretations. Our goal in the present study was to examine the effects of soluble oAβ on neuronal and synaptic structure in the amyloid precursor protein (APP) E693Q (“Dutch”) mouse model of AD, which develops intraneuronal accumulation of soluble oAβ with no detectable plaques in AD-relevant brain regions. We performed quantitative analyses of neuronal pathology, including dendrite morphology, spine density, and synapse ultrastructure in individual hippocampal CA1 neurons.

Results

When assessing neuronal morphology and complexity we observed significant alterations in apical but not in basal dendritic arbor length in Dutch mice compared to wild type. Moreover, Dutch mice exhibited a significant decrease in dendritic arborization with a decrease in dendritic length and number of intersections at 120 μm and 150 μm from the soma, respectively. We next examined synaptic parameters and found that while there were no differences in overall synaptic structure, Dutch mice displayed a significant reduction in the post-synaptic density (PSD) length of synapses on mushroom spines, in comparison to wild type littermates.

Conclusion

The structural alterations to individual neurons in Dutch mice along with the changes in larger dendritic spines support the Aβ oligomer hypothesis, which postulates that the early cognitive impairments that occur in AD are attributed to the accumulation of soluble oAβ first affecting at the synaptic level with subsequent structural disturbances and cellular degeneration.

Electronic supplementary material

The online version of this article (doi:10.1186/1750-1326-9-41) contains supplementary material, which is available to authorized users.

Creativity in later life

The ageing population presents significant challenges for the provision of social and health services. Strategies are needed to enable older people to cope within a society ill prepared for the impacts of these demographic changes. The ability to be creative may be one such strategy. This review outlines the relevant literature and examines current public health policy related to creativity in old age with the aim of highlighting some important issues. As well as looking at the benefits and negative aspects of creative activity in later life they are considered in the context of the theory of "successful ageing". Creative activity plays an important role in the lives of older people promoting social interaction, providing cognitive stimulation and giving a sense of self-worth. Furthermore, it is shown to be useful as a tool in the multi-disciplinary treatment of health problems common in later life such as depression and dementia. There are a number of initiatives to encourage older people to participate in creative activities such as arts-based projects which may range from visual arts to dance to music to intergenerational initiatives. However, participation shows geographical variation and often the responsibility of provision falls to voluntary organisations. Overall, the literature presented suggests that creative activity could be a useful tool for individuals and society. However, further research is needed to establish the key factors which contribute to patterns of improved health and well-being, as well as to explore ways to improve access to services.

Adjusting the compass: new insights into the role of angiogenesis in Alzheimer's disease

Growing evidence suggests that vascular perturbation plays a critical role in the pathogenesis of Alzheimer’s disease (AD). It appears to be a common feature in addition to the classic pathological hallmarks of amyloid beta (Aβ) plaques and neurofibrillary. Moreover, the accumulation of Aβ in the cerebral vasculature is closely associated with cognitive decline, and disruption of the blood–brain barrier (BBB) has been shown to coincide with the onset of cognitive impairment. Although it was originally hypothesized that the accumulation of Aβ and the subsequent disruption of the BBB were due to the impaired clearance of Aβ from the brain, a body of data now suggests an alternative hypothesis for vascular dysfunction in AD that amyloidogenesis promotes extensive neoangiogenesis leading to increased vascular permeability and subsequent hypervascularization. In this review, we discuss the role Aβ plays in angiogenesis of the neurovasculature and BBB and how it may contribute to the pathogenesis of AD. These studies suggest that interventions that directly or indirectly affect angiogenesis could have beneficial effects on amyloid and other pathways in AD.

Determinants of muscle carnosine content

The main determinant of muscle carnosine (M-Carn) content is undoubtedly species, with, for example, aerobically trained female vegetarian athletes [with circa 13 mmol/kg dry muscle (dm)] having just 1/10th of that found in trained thoroughbred horses. Muscle fibre type is another key determinant, as type II fibres have a higher M-Carn or muscle histidine containing dipeptide (M-HCD) content than type I fibres. In vegetarians, M-Carn is limited by hepatic synthesis of β-alanine, whereas in omnivores this is augmented by the hydrolysis of dietary supplied HCD’s resulting in muscle levels two or more times higher. β-alanine supplementation will increase M-Carn. The same increase in M-Carn occurs with administration of an equal molar quantity of carnosine as an alternative source of β-alanine. Following the cessation of supplementation, M-Carn returns to pre-supplementation levels, with an estimated t_1/2 of 5–9 weeks. Higher than normal M-Carn contents have been noted in some chronically weight-trained subjects, but it is unclear if this is due to the training per se, or secondary to changes in muscle fibre composition, an increase in β-alanine intake or even anabolic steroid use. There is no measureable loss of M-Carn with acute exercise, although exercise-induced muscle damage may result in raised plasma concentrations in equines. Animal studies indicate effects of gender and age, but human studies lack sufficient control of the effects of diet and changes in muscle fibre composition.

C-Jun N-terminal kinase controls TDP-43 accumulation in stress granules induced by oxidative stress

BACKGROUND

TDP-43 proteinopathies are characterized by loss of nuclear TDP-43 expression and formation of C-terminal TDP-43 fragmentation and accumulation in the cytoplasm. Recent studies have shown that TDP-43 can accumulate in RNA stress granules (SGs) in response to cell stresses and this could be associated with subsequent formation of TDP-43 ubiquinated protein aggregates. However, the initial mechanisms controlling endogenous TDP-43 accumulation in SGs during chronic disease are not understood. In this study we investigated the mechanism of TDP-43 processing and accumulation in SGs in SH-SY5Y neuronal-like cells exposed to chronic oxidative stress. Cell cultures were treated overnight with the mitochondrial inhibitor paraquat and examined for TDP-43 and SG processing.

RESULTS

We found that mild stress induced by paraquat led to formation of TDP-43 and HuR-positive SGs, a proportion of which were ubiquitinated. The co-localization of TDP-43 with SGs could be fully prevented by inhibition of c-Jun N-terminal kinase (JNK). JNK inhibition did not prevent formation of HuR-positive SGs and did not prevent diffuse TDP-43 accumulation in the cytosol. In contrast, ERK or p38 inhibition prevented formation of both TDP-43 and HuR-positive SGs. JNK inhibition also inhibited TDP-43 SG localization in cells acutely treated with sodium arsenite and reduced the number of aggregates per cell in cultures transfected with C-terminal TDP-43 162-414 and 219-414 constructs.

CONCLUSIONS

Our studies are the first to demonstrate a critical role for kinase control of TDP-43 accumulation in SGs and may have important implications for development of treatments for FTD and ALS, targeting cell signal pathway control of TDP-43 aggregation.

Membrane-targeted strategies for modulating APP and Abeta-mediated toxicity

Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by numerous pathological features including the accumulation of neurotoxic amyloid-β (Aβ) peptide. There is currently no effective therapy for AD, but the development of therapeutic strategies that target the cell membrane is gaining increased interest. The amyloid precursor protein (APP) from which Aβ is formed is a membrane-bound protein, and Aβ production and toxicity are both membrane mediated events. This review describes the critical role of cell membranes in AD with particular emphasis on how the composition and structure of the membrane and its specialized regions may influence toxic or benign Aβ/APP pathways in AD. The putative role of copper (Cu) in AD is also discussed, and we highlight how targeting the cell membrane with Cu complexes has therapeutic potential in AD.

Teaching trauma management in the accident and emergency department

Since their introduction into the United Kingdom, Advanced Trauma Life Support Courses (ATLS) have preferentially offered places to Consultants and Senior Registrars. It is usual, however, for the initial resuscitation of the seriously injured patient to be performed by relatively inexperienced junior staff. It is incumbent upon those medical staff who are ATLS providers or instructors to design local courses, based upon ATLS principals, to train their junior staff in a structured approach to managing these patients. We describe one such local course which may serve as a model for others.

Polycythaemia following renal transplantation: an association with azathioprine dosage?

Patients from a renal transplantation unit with an unusually high incidence of polycythaemia were divided into polycythaemic and control groups. The rate of rise of haemoglobin concentration was not significantly different in the two groups. The polycythaemic group received a significantly lower dose of azathioprine (p less than 0.005) and included more patients with polycystic disease than the control group (p less than 0.05). An effect of azathioprine on bone marrow function was suggested by the polycythaemic group also having a higher mean white cell count (p less than 0.02). Azathioprine dosage correlated negatively with post-transplantation polycythaemia regardless of the original cause of renal failure.

Effect of halothane on isometric twitch and tetanus response and the associated heat production in striated muscle of frogs

The purpose of these investigations was to determine the effect of halothane on isometric contraction of striated muscle and to measure the associated heat production. This basic information is necessary before studies more directly relating to malignant hyperthermia are undertaken. Sartorius muscles were isolate from Rana pipiens during winter and summer months. It appears from these experiments that there is a prolongation of the relaxation phase of the twitch and tetanus responses with low concentrations of halothane, with a more diffuse effect on the contractile process evident at higher administered concentrations. The results of heat measurements, using a sensitive thermopile-galvanometer system, are compatible with the hypotheses that this effect on relaxation could result from either an interference with calcium reuptake by the sarcoplasmic reticulum or an increased affinity of the troponintropomyosin complex for available calcium.