PFO closure for the prevention of cerebrovascular events in high-risk individuals: an updated and across-the-board meta-analysis

Introduction

Patent foramen ovale (PFO) closure has emerged as a secondary prevention option in patients with PFO and cerebrovascular events. Despite its seemingly established efficacy, its associated long-term outcomes – including safety – remain unclear.

Purpose

To ascertain the extent to which PFO percutaneous closure is able to improve long-term clinical outcomes in patients with cryptogenic vascular events.

Methods

We systematically searched MEDLINE, Embase and Cochrane CENTRAL for randomized controlled trials (RCTs) and observational studies comparing PFO percutaneous closure with antithrombotic therapy, in what concerns recurrent cerebrovascular and serious adverse events, as well as mortality. A composite of stroke and transient ischemic attack (TIA) was the primary endpoint. Data related to RCTs, patients with high-risk PFO features, subjected to PFO closure with the most represented device and with antiplatelet therapy as control were further investigated separately. Study-specific odds ratios (ORs) were pooled using traditional meta-analytic techniques, under a random- (DerSimonian-Laird method) or a fixed-effects (Mantel-Haenszel method) model.

Results

Literature search yielded 2145 references, of which 26 – 8 regarding RCTs – were included. Patients undergoing PFO closure reached 4304, whereas 4180 were treated with antithrombotic therapy. PFO closure was significantly associated with lower stroke/TIA recurrence (OR 0.35 [0.24–0.53], I2=58%). Moreover, such reduction met statistical significance for both stroke (OR 0.34 [0.21–0.54], I2=29%) and TIA (OR 0.53 [0.34–0.82], I2=39%), individually. Subgroup analyses focusing only on RCTs and on studies featuring the most represented device confirmed these trends, while the effects were even more pronounced in patients with high-risk PFO characteristics and in those controlled with antiplatelet therapy. On the other hand, PFO closure was not associated with neither lower all-cause (OR 0.76 [0.46–1.27], I2=0%) nor lower cardiovascular mortality (OR 0.92 [0.37–2.29], I2=0%). Moreover, neither a composite of serious adverse events (SAEs) (OR 1.10 [0.94–1.29], I2=0%) nor major bleeding episodes (OR 0.75 [0.40–1.38], I2=23%) differed significantly between groups. However, PFO closure was associated with increased odds of procedure- or device-related complications (OR 12.94 [5.56–30.13], I2=0%) and atrial fibrillation or flutter (OR 3.35 [1.78–6.30], I2=30%).

Conclusion

In patients with history of cryptogenic vascular events, when compared with medical management, PFO percutaneous closure is indeed associated with a reduction in the odds of recurrent stroke and TIA. However, mortality seems not to be impacted by this apparently enhanced effect. While general SAEs and major bleeding are comparable between both approaches, PFO closure may bring upon procedure- or device-related complications and increase the odds of atrial fibrillation or flutter.

Funding Acknowledgement

Type of funding sources: None.

Fetal neurosonography at 31-35 weeks reveals altered cortical development in pre-eclampsia with and without small-for-gestational-age fetus

OBJECTIVE

To explore the pattern of fetal cortical development in pregnancies complicated by pre-eclampsia (PE), with and without a small-for-gestational-age (SGA) fetus, compared to uncomplicated pregnancies.

METHODS

This was a prospective observational study including singleton pregnancies complicated by normotensive SGA (birth weight < 10^th centile) (n = 77), PE with an appropriate-for-gestational-age (AGA) fetus (n = 76) or PE with a SGA fetus (n = 67), and 128 uncomplicated pregnancies (normotensive AGA) matched by gestational age at ultrasound. All pregnancies underwent detailed neurosonography, using a transabdominal and transvaginal approach, at 31-35 weeks' gestation to assess the depth of the insula, Sylvian fissure, parieto-occipital sulcus, cingulate sulcus and calcarine sulcus. All measurements were adjusted for biparietal diameter (BPD). In addition, a grading score of cortical development was assigned to each brain structure, ranging from Grade 0 (no development) to Grade 5 (maximum development). Univariate and multiple regression analyses were conducted.

RESULTS

Similar to findings in previous studies, normotensive pregnancies with a SGA fetus showed significant differences in cortical development compared with controls, with reduced Sylvian fissure depth adjusted for BPD (14.5 ± 2.4 vs 16.6 ± 2.3; P < 0.001) and increased insula depth adjusted for BPD (33.2 ± 2.0 vs 31.8 ± 2.0; P < 0.001). Interestingly, a similar cortical development pattern was observed in PE pregnancies with a SGA fetus and in PE pregnancies with an AGA fetus, manifested by reduced Sylvian fissure depth adjusted for BPD (14.2 ± 2.3 and 14.3 ± 2.3 vs 16.6 ± 2.3; P < 0.001 for both) and greater insula depth adjusted for BPD (33.2 ± 2.1 and 32.8 ± 1.7 vs 31.8 ± 2.0; P < 0.001 for both) compared with controls. No significant differences were observed in parieto-occipital, cingulate sulcus or calcarine sulcus depth across the study groups. The Sylvian fissure was scored as Grade 4 in significantly more (93.2% vs 59.5%) and as Grade 5 in significantly fewer (2.7% vs 37.3%) PE pregnancies with an AGA fetus compared with controls (P < 0.05 for both). These differences remained significant even after statistical adjustment for potential confounders, including ethnicity, low socioeconomic status, nulliparity, chronic hypertension, pregestational diabetes, assisted reproductive technologies, smoking and fetal gender, with the application of Benjamini-Hochberg procedure for multiple comparisons.

CONCLUSIONS

PE with or without SGA is associated with a differential fetal cortical development pattern which is similar to that described previously in small fetuses. Future research is warranted to elucidate better the mechanism(s) underlying these changes. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal endoscopic tracheal occlusion reverses the natural history of right-sided congenital diaphragmatic hernia: European multicenter experience

OBJECTIVE

To evaluate the neonatal outcome of fetuses with isolated right-sided congenital diaphragmatic hernia (iRCDH) based on prenatal severity indicators and antenatal management.

METHODS

This was a retrospective review of prospectively collected data on consecutive cases diagnosed with iRCDH before 30 weeks' gestation in four fetal therapy centers, between January 2008 and December 2018. Data on prenatal severity assessment, antenatal management and perinatal outcome were retrieved. Univariate and multivariate logistic regression analysis were used to identify predictors of survival at discharge and early neonatal morbidity.

RESULTS

Of 265 patients assessed during the study period, we excluded 40 (15%) who underwent termination of pregnancy, two cases of unexplained fetal death, two that were lost to follow-up, one for which antenatal assessment of lung hypoplasia was not available and six cases which were found to have major associated anomalies or syndromes after birth. Of the 214 fetuses with iRCDH included in the neonatal outcome analysis, 86 were managed expectantly during pregnancy and 128 underwent fetal endoscopic tracheal occlusion (FETO) with a balloon. In the expectant-management group, lung size measured by ultrasound or by magnetic resonance imaging was the only independent predictor of survival (observed-to-expected lung-to-head ratio (o/e-LHR) odds ratio (OR), 1.06 (95% CI, 1.02-1.11); P = 0.003). Until now, stratification for severe lung hypoplasia has been based on an o/e-LHR cut-off of 45%. In cases managed expectantly, the survival rate was 15% (4/27) in those with o/e-LHR ≤ 45% and 61% (36/59) for o/e-LHR > 45% (P = 0.001). However, the best o/e-LHR cut-off for the prediction of survival at discharge was 50%, with a sensitivity of 78% and specificity of 72%. In the expectantly managed group, survivors with severe pulmonary hypoplasia stayed longer in the neonatal intensive care unit than did those with mildly hypoplastic lungs. In fetuses with an o/e-LHR ≤ 45% treated with FETO, survival rate was higher than in those with similar lung size managed expectantly (49/120 (41%) vs 4/27 (15%); P = 0.014), despite higher prematurity rates (gestational age at birth: 34.4 ± 2.7 weeks vs 36.8 ± 3.0 weeks; P < 0.0001). In fetuses treated with FETO, gestational age at birth was the only predictor of survival (OR, 1.25 (95% CI, 1.04-1.50); P = 0.02).

CONCLUSIONS

Antenatal measurement of lung size can predict survival in iRCDH. In fetuses with severe lung hypoplasia, FETO was associated with a significant increase in survival without an associated increase in neonatal morbidity. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

P4396Patients explanations of self-care in chronic heart failure: a grounded theory analysis of qualitative data from PANACEA-HF Phase 1

Background

Sub-optimal self-care and non-adherence to treatments are important predictors of poor clinical outcomes in patients with heart failure. Task-sharing and technology have each contributed modest improvements, but the combined effect on outcomes is unknown. We aim to develop a complex intervention package to improve self-care predicated on task sharing and smartphone based remote monitoring among heart failure patients.

Purpose

As a formative step, we conducted a qualitative study among heart failure patients and their caregivers to explore self-care and to inform the development of a contextualized intervention package.

Methods

We conducted in-depth interviews among 22 patients admitted to in-patient wards with a clinical diagnosis of chronic heart failure (diagnosis made at least 1 month prior to index hospitalization) and 18 caregivers (n=40), sampled from 4 states in southern India. Patients were purposively sampled based on sex, socioeconomic status, health literacy and past one month's history of adherence to heart failure medications. The middle range theory of self-care informed the drafting of the interview guide. We recorded and transcribed interviews translated from 5 regional languages. We inductively coded the data from a social constructionist viewpoint, created categories, prepared memos, compared extreme cases, identified key emergent themes and their inter-relationships.

Results

Patients' mean age was 60.5 (±13.4), with representation from socioeconomic strata, urban and rural areas. Patients had a high pill burden [median 10; IQR (6, 31)] and 8 (44%) reported irregular adherence to prescribed medications in the last month. Key categories associated with sub-optimal self-care included “Passivity”, “Entrenched Belief systems”, “Negative Emotions/Affect”, “Ageing causes disease”, and “inability to control situations” across all socioeconomic strata. These themes appear to impair self-actualization that negatively impacts self efficacy/confidence and in turn self-care reciprocally (Refer Figure). Key facilitators of self-care were: Intrinsic patient distinctive facilitators (situational awareness, resilience) and extraneous facilitators (insurance/financial protection, positive caregiver relationships and ease of healthcare access). Patients and caregivers generally expressed their readiness to use mobile technology for remote monitoring and to be counseled by trained lay workers to address beliefs and be trained on self-care.

Framework explaining self-care in HF

Conclusions

Findings from this formative study show opportunities for providers and community-based care workers to address task-sharing of beliefs by educating patients on self-care, including through the use of technology-based solutions. These findings regarding a self-care framework identify opportunities to improve self-care among heart failure patients using task-sharing and technology to support the patient-caregiver-provider triad.

Acknowledgement/Funding

India Alliance - Wellcome Trust and Department of Biotechnology

Abstract P1-14-02: A phase 2 study of low dose metronomic eribulin in metastatic breast cancer

Background: Eribulin mesylate is a non-taxane microtubule dynamics inhibitor approved by FDA in treatment of metastatic breast cancer (MBC) based on improvements in overall survival in the pivotal EMBRACE trial. Eribulin is approved at 1.4mg/m2 administered D1,8 of q21d cycle. However, this dose and schedule may have significant myelosuppression and peripheral neuropathy requiring dose reductions and treatment delays for some patients. We hypothesized that a low dose metronomic schedule will allow responding patients to remain on treatment, resulting in longer TTP (time to progression) and decreased incidence of toxicities and treatment-related discontinuations.

Methods: A multi-site prospective open-label phase II trial of metronomic dosing of eribulin in patients with MBC has completed accrual of 60 patients, outcomes will be updated at presentation. Patients whose disease had progressed following 1-6 prior regimens with prior exposure to a taxane, ECOG performance status of 0 – 2, measurable disease per RECIST 1.1, with normal marrow and organ function were eligible. Eribulin was administered at 0.9mg/m2 weekly for 3 out of 4 weeks. For patients with HER2 positive disease, concurrent trastuzumab administration was allowed. Concurrent denosumab or bisphosphonates were allowed for patients with bone disease.

Results: 60 patients were enrolled, average age 58 (range 34-83). Majority were postmenopausal Caucasian females, but the study included African American, Hispanic, native American, male patients. The majority of tumors were ER+, infiltrating ductal, but the study included 13 HER2+, and 12 TN tumors, with 5 ILC, and 5 mixed ILC/IDC. Nearly half of the enrolled patients had clinical benefit from the regimen, remaining on therapy for 6 months or longer, with stable disease or response; 50% had progression PD at 3 months 32% had stable disease and 18% had a partial or complete response (1, long term). Overall Survival, OS, for the entire group of heavily pre-treated patients was 1.2 years, with TN and HER2 positive patients faring better than ER+ in this small study. One HER2+ patient remains in long-term remission, off chemotherapy.

The regimen was extremely well tolerated. The majority of the patients experienced grade 0 or 1 toxicity for alopecia (48/60) and peripheral neuropathy (7 with grade 2 neuropathy, 5 pre-existing, 2 with grade 3 neuropathy). There were few dose reductions (n=15), thrombocytopenia (11 grade 1 only), or use of G-CSF (14).

Conclusions: Metronomic weekly low dose eribulin appears to be an active and tolerable regimen with less myelosuppression, alopecia and peripheral neuropathy than is seen with approved dose, allowing longer duration of use and disease control, with similar outcomes compared to the standard dose regimen. Outcomes will be updated at presentation.

Citation Format: Chalasani P, Liu AJ, Khanjian JA, Peha M, Buening BJ, Gadi VK, Specht JM, Salazar L, Linden HM. A phase 2 study of low dose metronomic eribulin in metastatic breast cancer [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 P1-14-02.

Paediatric interventional cardiology in Costa Rica: diagnostic reference levels and estimation of population dose

The goal of the present study was to propose a set of national diagnostic reference levels (DRLs) in Costa Rica for paediatric interventional cardiology (IC) procedures classified by age and weight and to estimate the collective dose of the paediatric population from these intervention practices. The data collection period was May 2016 to May 2017. The third quartile of patient dose data distributions for kerma-area product (KAP) values was set as the national DRLs. A sample of 154 paediatric IC procedures (collected in the national paediatric hospital with a single x-ray system) was used and divided into four age ranges and five weight ranges. The national DRLs obtained for KAPs by age range were 1.79 Gy cm² (<1 year) to 23.0 Gy cm² (10-15 years). The national DRLs obtained for KAPs by weight range were 1.0 Gy cm² (<10 kg) to 49.6 Gy cm² (50-79 kg). The contribution to the collective dose of the population of Costa Rica amounted to 0.78 person Sv.

The burden and epidemiology of community-acquired central nervous system infections: a multinational study

Risk assessment of central nervous system (CNS) infection patients is of key importance in predicting likely pathogens. However, data are lacking on the epidemiology globally. We performed a multicenter study to understand the burden of community-acquired CNS (CA-CNS) infections between 2012 and 2014. A total of 2583 patients with CA-CNS infections were included from 37 referral centers in 20 countries. Of these, 477 (18.5%) patients survived with sequelae and 227 (8.8%) died, and 1879 (72.7%) patients were discharged with complete cure. The most frequent infecting pathogens in this study were Streptococcus pneumoniae (n = 206, 8%) and Mycobacterium tuberculosis (n = 152, 5.9%). Varicella zoster virus and Listeria were other common pathogens in the elderly. Although staphylococci and Listeria resulted in frequent infections in immunocompromised patients, cryptococci were leading pathogens in human immunodeficiency virus (HIV)-positive individuals. Among the patients with any proven etiology, 96 (8.9%) patients presented with clinical features of a chronic CNS disease. Neurosyphilis, neurobrucellosis, neuroborreliosis, and CNS tuberculosis had a predilection to present chronic courses. Listeria monocytogenes, Staphylococcus aureus, M. tuberculosis, and S. pneumoniae were the most fatal forms, while sequelae were significantly higher for herpes simplex virus type 1 (p < 0.05 for all). Tackling the high burden of CNS infections globally can only be achieved with effective pneumococcal immunization and strategies to eliminate tuberculosis, and more must be done to improve diagnostic capacity.

Abstract P4-22-11: Combined targeted therapies for advanced triple negative breast cancer: A phase II trial of nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib

Background: Chemotherapy remains the mainstay of therapy for patients with metastatic triple negative breast cancer (TNBC). We hypothesized that the addition of biologic agents targeting key pathways (bevacizumab targeting angiogenesis and erlotinib directed against EGFR) may prolong progression free survival (PFS) and offer a novel treatment strategy free from chemotherapy for patients with metastatic TNBC.

Methods: Patients with TNBC receiving initial therapy for metastatic disease were eligible for this multicenter phase II trial (NCT00733408) conducted at an academic center and affiliated, community practice sites. Induction therapy included nab-paclitaxel 100 mg/m2 IV Qweek (wk) and Bevacizumab 10 mg/kg IV Q2wks x 24 weeks. Patients free of progression at 24 wks began maintenance therapy with bevacizumab 10 mg/kg IV Q2wks and erlotinib 150 mg po daily until progression with radiographic assessment every 8 wks. Primary objective was PFS with secondary objectives of response rate, overall survival (OS) and safety. All eligible patients were included in the analysis of PFS and OS. Response was evaluated among patients with measurable disease by RECIST 1.1 with central review. Patients with inadequate disease assessments were coded as non-responders. Kaplan-Meier method was used to estimate PFS and OS with patients censored at date of last tumor assessment (PFS) or date of last follow up (OS).

Results: From April 2009 – December 2015, 58 patients (median age 54, range 33-83) were enrolled; 56 (97%) had measurable disease, and all had metastatic TNBC by local assessment. 33 (57%) patients completed induction; 22 (38%) came off study during induction; 3 (5%) continue on maintenance therapy. 4 patients discontinued therapy prior to first assessment. As of June 8, 2016, 53 patients (91%) have progressed. Median follow up for surviving patients is 14.5 months (range 4.1-65.4). Median PFS is 7.7 months (95% CI 5.7, 9.5). Of 56 patients with measurable disease, 38 (66%) had partial response (PR); 10 (17%) with stable disease for clinical benefit rate (CBR) of 86%. Median OS is 18.2 months (95% CI 16.3, 24.5). Most common grade 3-4 toxicities during induction were neutropenia [17 (29%), 1 grade 4], fatigue [13 (22%), all grade 3], leukopenia [7 (12%), all grade 3], and neuropathy [7 (12%), all grade 3]. Rash was most common ≥ grade 3 toxicity during maintenance [4 (7%), grade 3]. One patient experienced clinical CHF during maintenance month 16 requiring bevacizumab discontinuation. Conclusions: Nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib was well tolerated. While the observed PFS did not meet pre-specified criteria of interest, the majority of patients experienced clinical benefit (86%) with 30 (57%) receiving maintenance targeted therapy. Correlative studies are ongoing. Supported by Genentech (OSI4266s), Celegene (AX-CL-BRST-PI-003828) and Janssen.

Citation Format: Specht JM, Gadi VK, Gralow JR, Korde LA, Linden HM, Salazar LG, Rodler ET, Cundy A, Buening BJ, Baker KK, Redman MW, Kurland BF, Garrison MA, Smith JC, vanHaelst C, Anderson JE. Combined targeted therapies for advanced triple negative breast cancer: A phase II trial of nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-11.

Abstract P2-11-03: Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy

Natural killer (NK) cell defects, commonly seen in metastatic breast cancer (MBC) lead to decrease in dendritic cell (DC) maturation, proinflammatory cytokine production, and tumor infiltrating T-cells (TILs). This results in a protumorigenic Th2 immune microenvironment with low response rates to immunotherapy (i.e., immune checkpoint blockade) and standard chemotherapy. PSK, a potent TLR-2 agonist, activates NK cells to produce IFN-γ and IL-12 and promote DC maturation/differentiation toward a Th1 profile in the tumor microenvironment which results in antigen specific TIL that can eradicate tumor. The combination immunotherapy of PSK and HER2 directed therapy described here, aims at inducing Th1 immunity and tumor specific T-cells. This proposed regimen could eradicate microscopic residual disease and prevent recurrence in optimally treated HER2+ MBC patients. Moreover, the regimen could result in enhanced trafficking of TILs to the site of tumor and improve the efficacy of checkpoint inhibitors and other therapies. A phase I/II randomized 2 arm study of combination immunotherapy with oral PSK (or placebo) given with a HER2 peptide vaccine and HER2 mAb therapy (trastuzumab (TZ) +/- pertuzumab (PZ)) was initiated to assess the safety of the approach and evaluate the effect of PSK on NK cell activity, pro-inflammatory cytokine/chemokine profile; and HER2 vaccine-induced T cell immunity.

Methods: Up to 30 patients with HER2+ MBC who are without evidence of disease after definitive therapy and currently on maintenance TZ +/- PZ are enrolled and randomly assigned in equal numbers to 1 of 2 arms (15 patients/arm): Arm 1: HER2 ICD vaccine + placebo or Arm 2: HER2 ICD vaccine + PSK. All patients receive concomitant treatment with 4 months of daily oral PSK or placebo, 3 monthly intradermal HER2 ICD vaccinations and continued TZ +/- PZ. Toxicity is evaluated per CTEP CTCAE 4.0, during and post vaccination. Serial blood draws for immunologic evaluation of NK cell activity and antigen-specific T cell immunity via flow cytometry and IFN-γ ELISPOT, respectively; and pro-inflammatory cytokines/chemokines.

Results: 24 subjects have been enrolled and 60 vaccines have been given. 16 subjects have completed all 3 vaccines and PSK/placebo; and 6 subjects are currently in progress. 2 subjects received &lt; 3 vaccines and were taken off study. Of 144 reported adverse events (AEs), 97% were Grade 1-2; 66 (46%) were possibly, probably, or definitely related to study treatment. Most common AEs are injection site reaction and flu-like symptoms. There have been a total of four Grade 3 AEs, 1 episode of self-limited nausea/vomiting attributed to study treatment; and cognitive disturbance, fatigue, and lymphopenia all in 1 subject and attributed to disease progression. There have been no Grade 4 AEs. Immunologic analyses are ongoing and will be presented along with completed clinical data on all patients.

Conclusion: Combination immunotherapy with PSK/placebo and concurrent HER2 directed therapy is safe and well-tolerated. Further ongoing immunologic studies will help define the immunogenicity of the approach.

Citation Format: Salazar LG, Higgins D, Childs J, Coveler AL, Liao J, Stanton S, Gooley T, Standish LJ, Sasagawa M, DISIS ML. Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-03.

Abstract P2-11-05: Overall survival in inflammatory breast cancer patients receiving Her-2 Neu directed tumor vaccine therapy: Matched comparison with SEER registry patients

Background

Patients with inflammatory breast cancer (IBC) have a poor prognosis, primarily due to distant dissemination. Additionally, IBC patients have an increased rate of HER2 overexpression when compared to patients with non-inflammatory breast cancer. The forms the rationale for HER2 directed tumor vaccine therapy in these patients. The purpose of this study was to examine overall survival in IBC patients receiving HER2 directed tumor vaccine therapy when compared with matched control patients from the SEER Registry.

Methods

Patients with diagnosis of Stage III or IV HER2 positive IBC having completed standard initial therapy and without evidence of disease received HER2 vaccinations after being enrolled on 5 prospective clinical trials. Overall survival data were pooled and analyzed. A control group of matched IBC patients were identified by querying the SEER database from 1997-2011. The control group was identified as any individual in the database with a code for IBC. A secondary analysis comparing survival in HER2 positive IBC vs HER2 negative IBC patients was performed by querying the SEER database from 2010 onwards, the time point when the HER2 status was coded in the database. Propensity score adjustment were made to the control group to account for any imbalances between groups in measured covariates such as stage, race, age, sex, and era of enrollment and the time interval from diagnosis to enrollment on vaccine trial (median ∼2 years).

Results

A total of 37 IBC patients received HER2 directed vaccine therapy and 676 patients were identified for the SEER control group; Stage at enrollment: stage IIIB: 30 patients in the vaccine group and 639 patients in the control group; stage IIIC: 1 patient in the vaccine group and 15 patients in the control group; stage IV 6 patients in the vaccine group and 22 in the control group. The median survival of the overall population was 112 months for the vaccine group and 47 months for the control group (p=0.04). After using propensity scores to adjust the control for imbalances in measured covariates, the median survival for the overall population was 112 months for the vaccine group and 37 months for the control group (p=0.03). There was no difference in survival between HER2 positive and HER2 negative IBC patients in the control group (p=0.6).

Conclusion

These results demonstrate promising overall survival in HER2 positive IBC patients receiving HER2 directed vaccine therapy after initial therapy. Propensity matching was performed to adjust for imbalances in measured covariates and resulted in a modest decrease in survival of the control group after adjustment, suggesting that the vaccine trial group had relatively unfavorable pre-treatment characteristics. Despite these unfavorable characteristics, patients receiving vaccine had a median survival of 112 months. These results must be further confirmed in a prospective randomized trial.

Citation Format: Rengan R, Baker K, Salazar L, Childs J, Higgins D, Redman M, Reichow J, Disis ML. Overall survival in inflammatory breast cancer patients receiving Her-2 Neu directed tumor vaccine therapy: Matched comparison with SEER registry patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-05.

Tumour cell lysate-loaded dendritic cell vaccine induces biochemical and memory immune response in castration-resistant prostate cancer patients

Background:

Recently, we produced a tumour antigen-presenting cells (TAPCells) vaccine using a melanoma cell lysate, called TRIMEL, as an antigen source and an activation factor. Tumour antigen-presenting cells induced immunological responses and increased melanoma patient survival. Herein, we investigated the effect of TAPCells loaded with prostate cancer cell lysates (PCCL) as an antigen source, and TRIMEL as a dendritic cell (DC) activation factor; which were co-injected with the Concholepas concholepas haemocyanin (CCH) as an adjuvant on castration-resistant prostate cancer (CRPC) patients.

Methods:

The lysate mix capacity, for inducing T-cell activation, was analysed by flow cytometry and Elispot. Delayed-type hypersensitivity (DTH) reaction against PCCL, frequency of CD8⁺ memory T cells (Tm) in blood and prostate-specific antigen (PSA) levels in serum were measured in treated patients.

Results:

The lysate mix induced functional mature DCs that were capable of activating PCCL-specific T cells. No relevant adverse reactions were observed. Six out of 14 patients showed a significant decrease in levels of PSA. DTH⁺ patients showed a prolonged PSA doubling-time after treatment. Expansion of functional central and effector CD8⁺ Tm were detected.

Conclusion:

Treatment of CRPC patients with lysate-loaded TAPCells and CCH as an adjuvant is safe: generating biochemical and memory immune responses. However, the limited number of cases requires confirmation in a phase II clinical trial.

First Report of Meloidogyne marylandi Infecting Bermudagrass in Costa Rica

Bermudagrass plants (Cynodon dactylon cv. 419) from a soccer field in Santa Ana, San Jose Province, Costa Rica, were found with symptoms of decline with dried leaves and leaf yellowing in patches in February 2012. Roots of the affected plants presented small and smooth galls and protruding egg masses similar to those associated with root-knot nematodes (RKN), Meloidogyne spp. Morphometric and molecular analyses were conducted to identify the species present. Morphological measurements from 30 second-stage juveniles and perineal patterns from 10 adult females matched the description of Meloidogyne marylandi Jepson and Golden. Body length averaged 429.5 ± 18.5 (range: 392 to 459) μm, mean width averaged 16.0 ± 1.3 (range: 13.2 to 18.0) μm, stylet lengths averaged 10.7 ± 1.0 (range: 9.1 to 13.4) μm, dorsal gland orifice from stylet base averaged 2.8 ± 0.3 (range: 2.4 to 3.4) μm, tail lengths averaged 60.9 ± 4.9 (range: 45.5 to 74.7) μm, and the hyaline region of the tails averaged 12.4 ± 1.4 (range: 8.6 to 14.8) μm. Lower average tail length and hyaline tail terminal differentiate M. marylandi from the closely related species M. graminis, the grass root-knot nematode, that can also parasitize bermudagrass (1). Hemizonid position was posterior to the excretory pore. The overall shape of the perineal patterns was ovoid, and the dorsal arch was medium high with lateral lines and coarse striae. Males were rarely observed. DNA was extracted from 10 single mature females. Amplification and sequencing of the mitochondrial DNA region between COII and the lRNA gene was accomplished with primers C2F3 (5'-GGTCAATGTTCAGAAATTTGTGG-3') and 1108 (5'-TACCTTTGACCAATCACGCT-3') (2). A PCR product approximately 520 bp in length was obtained and the sequence (GenBank Accession Nos. KC473862 and KC473863) was compared with those in GenBank using BLAST and showed 99 to 100% identity with known sequences of M. marylandi (JN241916.1, JN241905.1, JN241917.1, JN241921.1, and JN241955.1) (3). Phylogenetic analysis with maximum likelihood (MEGA v.5.0) (4) of those sequences placed the Meloidogyne sp. from Costa Rica in a clade (100% bootstrap support) that included only M. marylandi sequences available from the GenBank database, thus confirming its identity. In addition, digestion of the PCR product with SspI restriction enzyme produced a four band pattern similar to what has been reported for M. marylandi from Israel and United States (Maryland) and this approach is considered useful for the separation of M. marylandi from M. graminis (3). To our knowledge, this is the first report of the root-knot nematode M. marylandi in Costa Rica. References: (1) A. M. Golden. J. Nematol. 21:453, 1989. (2) T. O. Powers and T. S. Harris. J. Nematol. 25:1, 1993. (3) M. A. McClure et al. Plant Dis. 96:635, 2012. (4) K. Tamura et al. Mol Biol Evol. 28:2731, 2011.

Abstract P2-15-02: The efficacy of recruitment and retention strategies for research subjects in an early phase investigator-initiated breast cancer trial

Background: One of the biggest challenges faced by investigators is the implementation of effective strategies to improve the recruitment and retention of research participants. This is especially true for investigator-initiated, federally funded (e.g. NIH and DOD), early phase clinical trials that involve the treatment of serious diseases such as metastatic breast cancer (MBC). These studies may face additional barriers to participation since patients have often already undergone maximal treatment and are usually not in a financial position that for allows the travel and lodging necessary to receive further investigative treatment. Moreover, efficacy and toxicology in early phase clinical trials are unknown. Thus, when study budget constraints do not allow monetary incentives to participation, it is difficult to provide motivation for patients to enroll and remain adherent to the protocol requirements. However, many MBC patients are motivated to join clinical trials for altruistic purposes alone, and evidence supports that the researcher-patient relationship may be the most important factor in clinical trial participation. Recognizing that many patients are willing to participate if provided the appropriate resources despite limited monetary incentives, we developed a system to improve patient recruitment and retention to our studies, which are primarily federally funded. We report here on the strategies developed and used by our group to recruit and retain patients in a federally-funded investigator-initiated phase I/II vaccine study in MBC patients.

Methods: This study was funded by the NIH/NCI and involved infusion of HER2 specific T cells in HER2+ MBC patients after completing in vivo priming with a HER2 vaccine. It required 11 visits to Seattle, Washington. Working with agencies that offer free services to patients enrolled in clinical trials, a list of available resources was compiled and a visit flowchart with specific information on travel and lodging resources (e.g. Angel Flights and ACS sponsorship), local transportation and entertainment was developed. During screening, patients were given the list of resources and trial information. An email system was used to quickly communicate and follow-up with patients. Eligible patients were given the visit flowchart to help with their planning of study visits. An enrollment packet was provided at the first visit with a calendar to keep track of the visit schedule. Coordination of care between the patient's primary oncologist and the research staff was maintained throughout the study.

Results: 17 of 19 patients enrolled were not from Washington State. Two out-of-state patients withdrew early from the trial for reasons unrelated to disease progression or toxicity; one subject completed 8 visits and enrolled in another study and the other completed 2 visits and discontinued the trial to resume chemotherapy.

Conclusion: We have developed a successful system to enroll and retain patients in a trial requiring multiple study visits. Development and implementation of site-specific standard procedures are critical to improve study participation and retention, especially when patients receive no financial benefit.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-15-02.

Abstract P5-16-04: A phase I study of a DNA plasmid based vaccine encoding the HER-2/neu intracellular domain in subjects with HER2+ breast cancer

HER2+ breast cancer (BC) is associated with early disease relapse, usually to distant sites. This would suggest relapse is due to residual microscopic disease. Generation of vaccine-induced HER2-specific CD4+ T helper immunity (Th1) may result in immunologic eradication of residual HER2+ tumor cells and subsequent development of immunologic memory and epitope spreading (ES), which has been associated with a survival benefit in vaccinated BC patients. We have shown HER2 peptide-based vaccines can generate immunity in BC however, more recently we developed a plasmid DNA based vaccine (pNGVL3-hICD) which may have additional advantages over synthetic peptides. DNA vaccines offer a strategy to immunize against multiple tumor antigens and are able to elicit both CTL and Th1 immunity. Plasmid DNA can also remain at the vaccine site, providing a constant source of antigen. Intradermal (i.d.) delivery of DNA vaccines with GM-CSF as adjuvant may enhance immunogenicity due to local influx of dermal Langerhans cells. We have recently completed a phase I trial utilizing pNGVL3-hICD in optimally treated stage III and IV HER2+ BC patients and have defined vaccine safety profile, optimal dose and schedule; and demonstrated vaccine biologic activity.

Methods: A total of 66 subjects with stage III and IV HER2+ BC in complete remission were enrolled sequentially into 1 of 3 pNGVL3-hICD dose arms (22 subjects/arm): Arm 1=10µg, Arm 2=100 µg, and Arm 3 = 500µg. All vaccines were admixed with 100µg GM-CSF and given i.d. monthly for a total of 3 vaccines. Toxicity was assessed at baseline, during vaccination and at follow-up. Immune responses to HER ICD and ECD were assessed with IFN-γ ELISPOT at baseline and serially through week 60 post-vaccination. Linear regression analysis was used to compare differences in immune responses from baseline over the whole study period between dose arms. Vaccine site skin biopsies and peripheral lymphocytes were serially analyzed for plasmid persistence via RT-PCR.

Results: 64 subjects (20 in Arm 1; 22 in Arm 2; 22 in Arm 3) completed 3 vaccines. Age, stage/status, number of previous chemotherapy regimens, and use of bisphosphonate and trastuzumab therapies was similar across dose arms. Vaccine-related toxicity was primarily Grade 1/2 injection site reactions, myalgias, arthralgias and not significantly different between arms; no cardiac or grade IV toxicity was observed. Immune responses to HER2 ICD were significantly better in Arms 2 and 3 vs Arm 1 (p = 0.001 and 0.002, respectively) but not statistically different between Arms 2 and 3. 38 patients had DNA plasmid persistence at the vaccination site with no difference between arms. There has been no detection of DNA plasmid in lymphocytes from patients in all arms. Analyses of survival and ES (HER ECD immune responses) are on-going and will be presented.

Conclusions: pNGVL3-hICD was safe and effectively induced persistent HER2 ICD specific Th1 immunity without increased cardiac toxicity. Moreover, immunity was present more than 1 year after end of vaccination, indicative of vaccine-induced immunologic memory.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-16-04.

Abstract OT3-1-02: Phase II randomized study of combination immunotherapy with or without Polysaccharide Krestin (PSK®) concurrently with a HER2 ICD peptide-based vaccine and trastuzumab in patients with stage IV breast cancer

Background: Endogenous immunity in patients with HER2+ metastatic breast cancer (MBC) is likely dampened by an immune-suppressive tumor microenvironment and not sufficient to control tumor growth. Thus, most patients have disease relapse after achieving complete remission with standard therapies. Immunomodulation directed at enhanced stimulation of tumor specific immunity could result in immunologic eradication of residual HER2+ tumor cells and prevent BC relapse. We have shown PSK to be a potent TLR-2 agonist that stimulates both innate and adaptive immunity in a BC mouse model. Additionally, we have shown combination immunotherapy with HER2 peptide vaccines and trastuzumab (TRAZ) to be safe and able to elicit HER2 specific Th1 immunity and epitope spreading (ES) which has been associated with survival in vaccinated patients. Lastly, decreased serum TGF-β elicited by HER2 vaccination correlates with Th1 ES and may serve as a biomarker to predict cancer vaccine efficacy. We hypothesize that PSK, when given with TRAZ can augment vaccine induced HER2 specific TH1 immunity and prevent disease relapse in patients with optimally treated HER2+ MBC.

Trial design: Phase II randomized two-arm clinical trial. Patients will be enrolled and randomly assigned in equal numbers to 1 of 2 arms (15 patients/arm) as follows: Arm 1:HER2 ICD vaccine, TRAZ and placebo or Arm 2:HER2 ICD vaccine, TRAZ and PSK. All patients will receive 3 monthly HER2 ICD vaccines plus TRAZ and 4 months of concomitant PSK or placebo. Serial blood draws for immunologic monitoring will be done.

Eligibility criteria: Patients with Stage IV HER2+ BC who have been treated with definitive therapy and are: (1) without evidence of disease or have stable-bone only disease, (2) receiving TRAZ monotherapy, and (3) without clinically significant autoimmune disease. Patients must have normal LVEF per MUGA scan or echocardiogram.

Aims: (1) Evaluate safety of PSK when given with a HER2 vaccine and TRAZ (2) Evaluate the effect of PSK on serum TGF-β levels when given with a HER2 vaccine and TRAZ and (3) Evaluate the effect of PSK on intermolecular ES when given with a HER2 vaccine and TRAZ. A secondary objective is to evaluate progression free survival (PFS) and overall survival (OS).

Statistical methods: (1) Toxicity will be determined by clinical and chemical parameters and grading will be done per CTEP CTCAE 4.0.; (2) Evaluation of TGF-β levels, pre and post-PSK treatment will be assessed with linear regression models; and analysis of multiple post-baseline measurements will be performed using generalized estimating equations; (3) A positive antigen-specific immune response will be defined as a precursor frequency &gt;1:20,000 antigen-specific peripheral blood mononuclear cells. Differences in the levels of HER2 immunity will be evaluated between arms using a two-tailed T test. The degree of ES in each arm will be evaluated with generalized linear modeling; (4) Large differences in PFS and OS observed between groups will be noted and described.

Target accrual: 30 patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-1-02.

P1-13-04: Phase II Study of Topical Imiquimod and Abraxane for Treatment of Breast Cancer Cutaneous Metastases

Background: Breast cancer (BC) cutaneous lesions can present as local chest wall recurrence or isolated sites of metastatic disease. Current treatments with full thickness chest wall resection, radiation therapy and chemotherapy are not curative; and have significant morbidity and poor overall response rates. Combining local immunomodulation and systemic chemotherapy may be more effective in treating cutaneous disease. Topical imiquimod (IMQ), a TLR-7 agonist, has shown clinical activity against cutaneous metastasis. Pre-clinical studies have shown IMQ to stimulate Th1 cytokine secretion and up-regulate immune co-stimulatory molecules at the tumor site; resulting in augmented tumor specific T cell immunity and tumor growth inhibition. Use of paclitaxel in BC, has demonstrated immunostimulatory effects of increased serum IFN-γ and enhanced NK/LAK cell activity. Abraxane (albumin-bound paclitaxel) may be used in conjunction with IMQ as steroid pre-treatment is not required. We hypothesize the immune effects of Abraxane may synergize and augment the IMQ anti-tumor effects, resulting in greater clinical response. A phase II single-arm study of chemoimmunotherapy with topical IMQ and Abraxane was initiated to determine its safety and therapeutic efficacy; and examine its effect on augmenting endogenous tumor specific immunity and inducing tumor molecular alterations associated with inhibition of tumor growth and/or common pathways of BC immune escape.

Materials and Methods: Up to 15 BC patients with cutaneous lesions no longer amenable to standard therapy are enrolled and receive 3 treatment cycles. A treatment cycle consist of topical 5% IMQ to target lesions 4 days/week (wk.) and Abraxane 100 mg/m2 on Days 1, 8, 15 every 28 Days. Toxicity is evaluated per CTCAE v3.0 on Days 1, 8, 15 of each cycle and wks. 13, 16, 20, 24. Target lesion antitumor activity is assessed per modified WHO criteria (Complete response (CR); Partial response (PR); Stable disease (SD); Progressive disease (PD)) at baseline, wks. 4, 8, 12, 16, 20, 24. 2-mm target lesion skin biopsies are obtained pre-and post-treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature associated with tumor inhibition. Immunity to HER2, IGFBP-2, TOPO-IIα, p53 and serum TGF-β levels are evaluated at baseline and wks. 12, 24 with IFN-γ ELISPOT and ELISA, respectively.

Results: 10 patients have been enrolled. Median (range) values include: age, 54 years (48-92), time from metastatic diagnosis, 134 months (58-728), prior chemotherapy regimens, 5 (2-10). 5/10 patients had received prior local therapy, e.g., radiation. 5/10, 4/10, and 2/10 patients had triple negative, HER2+ and ER+/PR+ tumors, respectively. In 5 patients completing 3 treatment cycles, overall response rate (ORR) = 100% (3 CR, 2 PR). In the 5 patients who completed 1–2 treatment cycles, ORR = 80% (2 PR, 2 SD, 1 PD). Treatment related toxicity is primarily grade I/II neutropenia, anemia; grade I skin toxicity. Immunologic analyses are ongoing and will be presented with completed clinical data on all patients.

Conclusions: Chemoimmunotherapy with topical IMQ and Abraxane is well-tolerated and shows excellent clinical efficacy in treating metastatic cutaneous lesions in heavily pretreated BC patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-13-04.

OT3-01-19: Phase II Study of Topical Imiquimod and Weekly Abraxane for the Treatment of Breast Cancer Cutaneous Metastases

Background

Breast cancer (BC) cutaneous lesions present as local chest wall recurrence or as isolated sites of metastatic disease. The treatment of cutaneous lesions is challenging and includes chest wall resection, local radiation therapy, and/or salvage chemotherapy which is not curative, associated with significant morbidity, and results in overall response rates of 20–30%. Thus, investigation of novel treatment strategies is warranted. This study incorporates multimodality treatment with topical imiquimod, a TLR-7agonist which generates an immune signal similar to that of pathogenic bacteria and Abraxane, a conventional systemic chemotherapy with potential immunostimulatory effects. Combined, these two agents provide local and systemic strategies which are potentially synergistic; and more effective than as single-agents in treating and controlling cutaneous disease.

Trial design: A Phase II single arm, non-randomized study. Patients will be sequentially enrolled and receive a maximum of 3 treatment cycles. A treatment cycle consists of topical imiquimod daily to target lesions for 4 days/week for 4 weeks in addition to Abraxane on Days 1, 8, and 15 every 28 days. Toxicity will be evaluated weekly during treatment then monthly for four months. Defined lesions are assessed at baseline and monthly. Skin biopsies are obtained pre and post treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature previously associated with tumor inhibition. Immunity to BC antigens and serum TGF-β levels are also evaluated.

Aims: To evaluate the safety and anti-tumor effects of chemoimmunotherapy with topical imiquimod and Abraxane.

Eligibility criteria: Patients with progressive or relapsed BC after standard therapy who 1) have measurable cutaneous metastatic lesions, 2) are at least 7 days from last chemotherapy, 30 days from local radiotherapy and/or systemic steroids, 3) have adequate blood counts and 4) no history of active autoimmune disease. Bisphosphonates, trastuzumab, and/or hormonal therapy is allowed.

Statistical methods: Antitumor activity of target lesions will be assessed per modified WHO criteria. Complete response (CR)-complete clearance of lesions; Partial response (PR) ≥ 50% decrease in lesion size; Stable disease (SD) &lt; 50% decrease in lesion size; Progressive disease (PD) increase in ≥ 25% lesion size). Historical overall response rates (ORR) with second and third line salvage chemotherapy range from 20–30%, with CR rates less than 2%. Based on these numbers, an ORR of 50% or a CR rate of 10% will be used as benchmarks for success (i.e., ≥8 responses or ≥2 CRs among 15 patients (observed ORR of ≥ 53% or observed CR rate of ≥ 13%) to consider the treatment worthy of further study. As a measure of the precision of the estimate of ORR achievable with 15 patients, if the response rate is 60%, we will be 80% confident that the observed RR is within 0.16 of the true RR with 15 patients treated. Toxicity will be evaluated by CTCAE v. 3.0 and descriptive statistics will be used to summarize changes from baseline and for reporting of immunological parameters.

Accrual: 10 patients received treatment with a target accrual of 15.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-01-19.

OT2-05-05: Phase I/II Study of Adoptive T Cell Therapy Following In Vivo Priming with a HER2 Peptide-Based Vaccine in Patients with Stage IV Breast Cancer

Background

Adoptive T cell therapy has evolved from preclinical setting to a potentially feasible treatment strategy for advanced breast cancer (BC). However, the ability to expand tumor antigen specific T cells ex vivo has been one of the major hurdles that has limited clinical translation of adoptive T cell therapy. Tumor specific T cells are rare in unprimed patients and generating large bulk cultures from rare precursor frequencies is difficult. We have found immunizing HER2+ patients to increase tumor specific T cell precursor frequencies to the levels of a vaccinated foreign antigen markedly improves the ability to generate large numbers of tumor specific T cells in vitro. We hypothesize that T cell expansion strategies that are facilitated by prior immunization will be clinically useful in the treatment of advanced BC.

Design: A Phase I/II non-randomized, single arm study. Priming with a HER2 ICD vaccine will be performed at 1 week intervals for a total of 3 vaccines. Patients will undergo leukapheresis 2 weeks after the 3rd vaccine to collect PBMC for T cell expansion. Patients will be pre-treated with cyclophosphamide 24 hours prior to 1st T cell infusion and then receive up to 3 dose-escalating infusions of T cells given 7–10 days apart. Three HER2 vaccine booster immunizations will then be administered at 1, 2, and 4 months after the final T cell infusion. Follow-up for persistent and continued immunity will then ensue.

Aims: To evaluate the safety of infusing escalating doses of HER2 specific T cells into patients with advanced HER2+ BC using ex vivo expanded autologous T cells, to investigate to what extent HER2 specific T cell immunity can be boosted or generated in individuals after infusion of HER2 specific T cells, to evaluate how long T cell immune augmentation persists in vivo after adoptive transfer of HER2 specific T cells and subsequent booster immunizations.

Criteria: Patients with HER2+ Stage IV BC who: have been maximally treated and not achieved a complete remission, have stable or slowly progressive disease, HER2+, and have adequate LVEF.

Statistical Methods: Toxicity will be determined by chemical and clinical parameters evaluated at various time points. If the true probability of a DLT is 0.11, then the probability of observing 0 DLT's in 20 patients is 0.097. If the true probability of a DLT is 0.18, then the probability of observing ≤1 DLT's in 20 patients is 0.102, and if the true probability of a DLT is 0.27, then the probability of observing ≤2 DLT's in 20 patients is 0.064. Therefore, with low observed rates of DLT (≤10%), we can be reasonably confident (∼90%) with 20 patients that the true DLT rate is &lt; 0.27. Immunologic response, defined as the successful boosting of precursor frequency with infusion of HER2−specific T cells, will be evaluated by assessing the change in T cell level from baseline. To assess the durability of the T cell response, we are primarily interested in estimating the proportion of patients whose T cells persist at a level the same or greater as the level after the final T cell infusion as long as 6 months following the final booster vaccine.

Accrual: Target=20/Actual=14

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-05-05.

OT1-02-10: Phase I-II Study of HER2 Vaccination with Poly(I) • Poly(C12U) (Ampligen®) as an Adjuvant in Optimally Treated Breast Cancer Patients

Background

Despite improved response rates and overall survival, many HER2+ breast cancer (BC) patients have disease relapse suggesting residual microscopic disease. HER2 vaccines given with adjuvants that can enhance, sustain, and skew antigen immunogenicity toward a Th1 phenotype could induce robust tumor-specific Th1 immunity resulting in immunologic eradication of residual tumor cells and potentially prevent relapse. One such adjuvant is Ampligen which is highly selective as a TLR-3 agonist. Our pre-clinical studies show a dose effect in the tumor prevention efficacy of Ampligen when given as an adjuvant with vaccines. We hypothesize HER2 peptide vaccination given with standard adjuvant 100mcg GMCSF and Ampligen can induce a higher incidence and magnitude of protective HER2−specific Th1 immunity than with GMCSF alone.

Trial design: Phase I-II randomized 2-stage HER2 vaccine study. Stage I will enroll 40 patients (10/arm) into one of 4 Ampligen dose arms (4, 20, 79, or 495 mcg + HER2 vaccine). The Ampligen “maximum biologic dose” (MBD), the dose with the highest incidence/magnitude of immune response and lowest incidence of toxicity will be defined. Stage II will enroll 48 patients (24/arm) receiving Ampligen MBD + HER2 vaccine + GMCSF or HER2 vaccine + GMCSF to evaluate if Ampligen MBD increases the incidence and magnitude of immunity vs HER2 vaccine + GMCSF alone. Patients will be enrolled sequentially and randomized equally into all arms via a permuted block design. Patients will receive 3 monthly vaccines. Toxicity and immune response will be assessed.

Aims: 1) To evaluate toxicity and define the MBD of Ampligen as an adjuvant with HER2 vaccination 2) determine if Ampligen MBD when combined with GMCSF as adjuvant and HER2 vaccination increases incidence/magnitude of HER2 Th1 immunity compared to standard GMCSF alone.

Eligibility criteria: Stage II–IV HER2+ BC patients who: 1) have completed definitive standard treatment, and in clinical remission 2) 14 days post chemotherapy and steroids 3) have adequate blood counts 4) are off trastuzumab 5) have no active autoimmune disease.

Statistical methods: In aim 1, we expect mild toxicity between the 4 dose arms, thus lack of efficacy based on incidence of immune response will be evaluated. Six responses must be observed within a dose arm to move forward based on historical 60% response rate (RR) with standard GMCSF (probability of continuing if true RR is 40% and 70% is 0.17, 0.85, respectively). In aim 2, 24 patients/arm provides 80% power to detect 40% difference in incidence of immune response between the 2 groups (Pearson chi-square test, two-sided alpha of 0.05) and 82% power to assess a 0.85 SD unit difference in change between control and MBD, based on a 2-sample t-test (p=0.05) and effect size defined as the difference in the means divided by the common SD. Incidences of HER2 Th1 immunity will be compared across treatment arms via Pearson chi-square test; magnitude of immune response will be compared across groups via linear regression model.

Study Accrual: Target accrual is 88 patients: Stage 1 (n=40) and Stage II (n=48). There has been no accrual at this time.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-02-10.

First isolation and molecular characterization of Ehrlichia canis in Costa Rica, Central America

The present study investigated Ehrlichia species in blood samples from dogs suspected of clinical ehrlichiosis, using molecular and isolation techniques in cell culture. From a total of 310 canine blood samples analyzed by 16S rRNA nested PCR, 148 (47.7%) were positive for Ehrlichia canis. DNA from Ehrlichia chaffeensis or Ehrlichia ewingii was not detected in any sample using species-specific primers in separated reactions. Leukocytes from five PCR-positive dogs were inoculated into DH82 cells; successful isolation of E. canis was obtained in four samples. Partial sequence of the dsb gene of eight canine blood samples (including the five samples for in vitro isolation) was obtained by PCR and their analyses through BLAST showed 100% of identity with the corresponding sequence of E. canis in GenBank. This study represents the first molecular diagnosis, isolation, and molecular characterization of E. canis in dogs from Costa Rica.

Phase I-II Study of Denileukin Diftitox (ONTAK®) in Patients with Advanced Refractory Breast Cancer

Background: CD4+CD25+Foxp3+ regulatory T cells (Tregs) are potent suppressors of CD4+ and CD8+ T cells, produce the immunosuppressive cytokine TGF-β; and as such, may down-regulate immune responses to tumor antigens. Additionally, Tregs are increased in the peripheral blood (PB) and tumors of breast cancer patients; and are associated with poor prognosis. Depletion of PB and tumor-associated Tregs may induce anti-tumor immunity by augmenting anti-tumor effector T cells and enhancing endogenous tumor specific immunity. ONTAK®, a diphtheria/IL-2R fusion protein depletes PB Tregs when given intravenously (IV) and selectively targets tumor cells that overexpress IL-2R. Breast tumors have been shown to overexpress IL-2R which is associated with their malignant potential. We hypothesized that ONTAK® could (1) have direct anti-tumor activity in breast cancers that overexpress IL-2R, and (2) deplete Tregs resulting in generation of functional immune effector cells and enhanced anti-tumor immunity. A phase I-II study was conducted to evaluate the safety of IV ONTAK® and assess its effect on Tregs and endogenous immunity in patients with advanced refractory breast cancer.Materials and Methods: 15 patients with progressive stage IV breast cancer following standard therapy were sequentially enrolled and received IV ONTAK® 18 mcg/kg/day on Days1-5 every 21 days for a total of 6 cycles and/or maximal tumor response. Toxicity was evaluated on Days 1 8, and 14 of each cycle per CTEP CTCAE v3.0. Tumor response was evaluated per RECIST at baseline, and after cycles 3 and 6. PB was collected at baseline and after cycles 2, 4, and 6 for evaluation of Tregs, sIL-2R, and endogenous tumor-antigen specific T cell immunity to HER-2/neu (HER2), CEA, and MAGE-3 via RT-PCR, LUMINEX and IFN-γ ELISPOT assay, respectively. Expression of IL-2R in patient paraffin embedded tumor samples was analyzed by IHC analysis.Results: 15 subjects have been enrolled and 14/15 have completed treatment; median age is 58 years (range, 32-69) and median salvage regimens is 3 (range, 2-8). 7/14 subjects had triple negative tumors. 7 subjects completed 1-2 and 7 completed 3-6 ONTAK® cycles, respectively. 4 subjects who completed 6 cycles of ONTAK® had SD or PR per RECIST. ONTAK®-related toxicities have been primarily grade I and II fatigue, nausea, and headache; and transient grade 3 hypoalbuminemia and lymphopenia. Preliminary data in 2 subjects shows enhanced tumor-antigen specific T cell immunity defined as mean tumor antigen-specific T cell precursors:PBMC to CEA (pre- ONTAK® 1:250,000; post- ONTAK® 1:15,000) and HER2 (pre- ONTAK® 1:63,000; post- ONTAK® 1:6,312). Immunologic analyses are ongoing and will be presented along with clinical data on all patients.Conclusions: ONTAK® is well-tolerated when used as a salvage regimen in heavily pretreated breast cancer patients. Additionally, ONTAK® treatment can enhance endogenous immunity to known breast cancer antigens and potentially lead to more effective eradication of tumor.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4130.

Phase II Study of a HER-2/Neu (HER2) Intracellular Domain (ICD) Vaccine Given Concurrently with Trastuzumab in Patients with Newly Diagnosed Advanced Stage Breast Cancer

HER2 is a tumor antigen in breast cancer and several trials have demonstrated that breast cancer patients can be immunized against this protein. We have developed HER2 peptide based vaccines that are aimed at eliciting CD4+ Th1 tumor antigen specific T cell responses. Th1 effectors provide immunologic memory, enhance cross priming which will allow the elaboration of tumor specific CD8+ T cells, and stimulate epitope spreading which we have shown to be a potential biomarker of clinical response. 52 patients will be enrolled with the primary objective to determine relapse free survival after active immunization. Eligible patients are newly diagnosed with Stage III (B or C) or Stage IV breast cancer and begin vaccination within 6 months of starting maintenance trastuzumab. This interim report will present data on the first 25 patients enrolled; 21 stage IV and 4 locally advanced patients. The vaccine is well tolerated with all adverse events (AE) being Grade I or 2. The most common AE is injection site reaction. Moreover, the combination of HER2 vaccination with trastuzumab did not result in additive cardiac toxicity in these patients. Immune responses were evaluated by IFN-gamma ELISPOT. To date, 88% of patients immunized developed significant immunity to the components of the ICD vaccine. The majority, 75%, developed robust immunity to the HER2 protein. Our group has recently demonstrated that a broadening of immunity throughout the HER2 protein, to components of the protein that weren't in the vaccine, i.e. epitope spreading, may be associated with improved survival in vaccinated patients. 63% of immunized patients demonstrated evidence of intramolecular epitope spreading. We questioned whether such high frequencies of homing Type 1 T cells might modulate the immunosuppressive tumor microenvironment, so we evaluated whether circulating serum immunosuppressive cytokines were impacted by immunization. TGF-beta is an immunosuppressive cytokine secreted by tumor stroma and regulatory T cells. We found that the levels of serum TGF-beta decreased significantly in the majority of patients after vaccination. We further analyzed the correlation between the change of serum levels of TGF-beta post vaccination and HER2 ICD vaccine-induced T cell responses. We found that the greater the magnitude of the HER2 specific T cell response, as demonstrated by IFN-gamma secretion, the greater the decrease in serum TGF-beta (p=0.0045, r=0.742). The correlation between the increased epitope spreading T cell response and decreased levels of TGF-beta was even more significant (p=0.0003). The median overall survival has not been reached with 100% of patients alive at this time. Relapse free survival data will be presented.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5102.

The Impact of National Press Coverage on Early Phase Clinical Trial Recruitment and Enrollment

The American Society of Clinical Oncologists reports that only 5% of cancer patients ultimately enroll in a clinical trial. According to the National Cancer Institute, one key barrier to participation is a lack of knowledge about clinical trials, both on behalf of oncologists and the patients themselves. Unfortunately, many investigator-initiated and academic clinical trials simply do not have budgets that permit implementation of large-scale recruitment efforts. Recent experience by our group demonstrates that press coverage by national media is a particularly effective tool for generating public interest in clinical research, as well as increasing trial enrollment.In the third quarter of 2008, our academic translational research group was featured on a national news program. In the week following the broadcast, our group's website, which had been listed in the broadcast and accompanying web story, received an unprecedented number of hits. Not only did the broadcast generate interest in our group's research; more specifically, it translated to substantial increases in potential clinical trial candidates, and subsequently, increased trial enrollment. In the month following the broadcast, our group received 125 new clinical trial inquiries as a result of the feature. That number represented a seven-fold increase in new inquiries during the same period in 2007. Of those 125 contacts, more than half of patients were potentially eligible for one of our clinical trials based on an initial screening. From November 2008 to the present, nearly one-third of all clinical trial enrollments can be attributed to the news story. Enrollment to the vaccine trial specifically described in the news feature increased four fold in comparison to the same 6-month period in 2008-2009, with half of all new enrollments attributable to the news feature.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6078.

Association of the level of HER2/neu (HER2) gene amplification in breast cancer and the magnitude of antigen specific T-cell immunity achieved after HER2 vaccination

3059

Background: Studies have demonstrated that the level of HER2 gene amplification in breast cancer, assessed by fluorescence in situ hybridization (FISH), correlates with favorable clinical response after treatment with trastuzumab. We questioned whether HER2 gene amplification impacted the development of HER2-specific T-cell immunity following immunization with a HER2 vaccine. Methods: Patients with HER2+ stage III or IV breast cancer, treated to complete remission or stable bone only disease, were enrolled in one of two concurrent clinical trials of HER2-specific vaccines. Eligibility criteria between the two studies were similar. Patients received either a plasmid DNA-based vaccine encoding the HER2 intracellular domain or a peptide-based vaccine composed of 3 HER2 class II epitopes. Peripheral blood was assessed for HER2-specific T-cell responses by interferon gamma (IFN-g) ELISPOT prior to, immediately after, and 6 months to 1 year after the end of vaccinations. Both immune response and FISH data were available on 31 patients. Results: Correlation of FISH levels to IFN-g spots/well in evaluable patients revealed the level of HER2 gene amplification was not related to the presence of pre-existent HER2-specific T-cell immunity prior to vaccination (p=0.43), the generation of a HER2-specific immune response after vaccination (p=0.35), or the persistence of the HER2-specific T-cell response (p=0.33). However, the magnitude of the T-cell response achieved was less as HER2 gene amplification increased (p=0.05). Conclusions: The level of HER2 gene amplification in the primary tumor can adversely impact the magnitude of HER2-specific T-cell immunity achieved after vaccination.

No significant financial relationships to disclose.

Sources of referral to early phase clinical trials: a case for putting all your eggs in one basket

Abstract #3116

Background: Studies suggest that only 2% to 3% of all adult cancer patients and approximately 5% of breast cancer patients enroll in clinical trials. To better understand the factors that contribute to enrollment we collected data from patients on sources that prompted them to contact us.&#x2028; Methods: From Jan 2005 to Apr 2008 we screened nearly 400 patients for 8 Phase I/II clinical trials focused on immunotherapy of breast and ovarian cancer. We queried subjects about informational sources that led them to consider our clinical studies. Patients learned about our trials from sources including: Clinicians, the Internet (advocacy group websites, search engines, government/university sites), Other patients, Family/friends, Media, Community events and Postings seeking research participants. Many patients who cited a clinician as their referral source specifically referenced a private, multi-site breast cancer clinic in Southern California with which our clinical group has formed a partnership, or consortium. To ensure that this was represented in the data and because the clinician category comprised a large percentage of the referral sources we split the category into 2 groups-one being the private practice in California (to be referred to as “consortium”) and the other being all other clinicians.&#x2028; Results: Of the 399 patients screened, 336 (84%) were considered potentially eligible for study. A total of 72 patients, or 18% of those screened have enrolled in one of our trials to date.&#x2028; Among patients screened, most learned about our trials from clinicians outside the consortium (34%), the Internet (27%), and consortium clinicians (15%). Patients most often named her2support.org (35%) and clinicaltrials.gov (23%) as their specific Internet sources. The remaining sources, family/friends, patients, media sources, community events and postings in medical facilities, were each cited by &lt;5% of patients.&#x2028; Although consortium clinicians were responsible for only 15% of referrals, 50% of their referrals enrolled in a study. Only 16% of patients referred by other clinicians and 9% referred via the Internet were enrolled. Though other clinicians and the Internet are the most common referral sources, referrals from our consortium were significantly more likely to enroll than any other source (p&lt;0.001).&#x2028; This may be due to the fact that patients referred by the consortium were more likely to meet eligibility criteria. Relative to 93% of consortium referrals, 87% of other clinician and 79% of Internet referrals were potentially eligible for trial (p&lt;0.05). Patients referred by our consortium were significantly more likely to meet study criteria relative to those referred by other sources.&#x2028; Discussion: Physician referrals often lead to higher accrual to clinical trials relative to other referral sources. Our data reveal that accrual can be further improved by forming a close collaborative relationship with a single select practice of clinicians.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3116.

Fluctuating asymmetry in quantitative dermatoglyphic traits: twins and singletons

Fluctuating asymmetry for the digital quantitative value was analyzed in a sample of twins (mono and dizygotic) and singletons. The aim was to check if the influence of twinning on the development is expressed in a higher fluctuating asymmetry in twins than in singletons. The results have shown that significant differences exist among the three groups studied, and these differences are fundamentally expressed when the radial and ulnar counts are considered separately.

Modulation of established murine collagen-induced arthritis by a single inoculation of short-term lipopolysaccharide-stimulated dendritic cells

BACKGROUND

The use of regulatory or immature dendritic cells (DCs) as tools for modulating experimental rheumatoid arthritis is very recent. Tumour necrosis factor (TNF)-stimulated DCs have been shown to restore tolerance in experimental autoimmune encephalomyelitis and collagen-induced arthritis (CIA).

OBJECTIVE

We investigated the capacity of short-term lipopolysaccharide (LPS)-stimulated DCs pulsed with type II collagen (CII) to induce tolerance against established CIA.

METHODS

Bone marrow-derived DCs were generated in the presence of granulocyte monocyte colony-stimulating factor (GM-CSF). After CIA induction, mice were injected at day 35 with a single dose of 4- or 24-h LPS-stimulated DCs that had been loaded with CII (4hLPS/CII/DCs or 24hLPS/CII/DCs). Arthritis progression was monitored by clinical and histological evaluations.

RESULTS

Flow cytometry of 4hLPS/CII/DCs showed intermediate CD40 and CD86 expression, lower than that of 24hLPS/CII/DCs (fully mature) and higher than that of CII/DCs (immature). A functional assay showed that 4hLPS/CII/DCs display increased endocytosis ability with respect to 24hLPS/CII/DCs, indicating a semimature state. The single inoculation of 4hLPS/CII/DCs in mice with established CIA reduced disease severity significantly over time. Histological evaluation of mice treated with 4hLPS/CII/DCs revealed diminished inflammatory synovitis, cartilage damage and fibrosis. Co-cultures of DCs with splenocytes from CIA mice showed that collagen-specific interferon (IFN)gamma production was dramatically inhibited by 4hLPS/CII/DCs. 4hLPS/CII/DCs were high IL10 producers, which could explain the inhibition of arthritis progression in mice receiving this treatment because neither antibodies nor regulatory CD4+CD25+Foxp3+ T lymphocytes were demonstrated to be involved.

CONCLUSION

Short-term LPS-modulated DCs inoculation interferes with CIA progression when loaded with CII.

Identification of fatty acid esters and hydrocarbon derivatives fromCyrtocarpa proceraKunth by GC–MS

Extracts obtained from Cyrtocarpa procera Kunth were evaluated to determine their toxicity on Artemia salina Leach. All the extracts showed a significant activity. Bioguided fractionation of these extracts led to the isolation of beta-sitosterol and the identification of 1,3-propyl-dipentadecanoate, 3-hydroxypropyl-9-octadecenoate, pentadecylbenzene, eicosylbenzene, docosane, heptacosane, dotriacontane and 2,6,10-trimethyltetradecane by GC-MS.

The ambrosanolide cumanin inhibits macrophage nitric oxide synthesis: some structural considerations

Since its role in inflammatory diseases was recognized, nitric oxide (NO) has become an important mediator to evaluate anti-inflammatory agents. Sesquiterpene lactones, which occur in several medicinal plants, inhibit the NO production in macrophage-like cells. This action is probably due to a 1,4 addition reaction between its alpha,beta-unsaturated carbonyl group with sulfhydryl (SH)-containing compounds. For this reason it is believed that these compounds are cytotoxic, which restricts their therapeutic use. In this contribution, the ability of the ambrosanolide-type sesquiterpene lactone cumanin (from the Asteraceae Ambrosia psilostachya) to inhibit NO biosynthesis was evaluated in lipopolisaccharide-induced peritoneal murine macrophages and its cytotoxicity was assessed in the MTT assay. Cumanin showed a potent inhibitory effect in NO production (IC(50) = 9.38+/-0.38 microM) with low cytotoxicity. The 1,4-addition reaction of thiols was slow, which does not explain the inhibition of NO production but does explain the low cytotoxicity of cumanin with respect to other lactones.

Spasmolytic activity of several extracts obtained from some Mexican medicinal plants

A total of ten extracts from different parts of eight medicinal plants that are used in the treatment of gastrointestinal disorders, were evaluated to determine their spasmolytic action on in vitro isolated rat ileum. All extracts were less potent than papaverine, which was used as a positive control.

Psychosocial impact of serological diagnosis of herpes simplex virus type 2: a qualitative assessment

OBJECTIVES

To assess the emotional and psychosocial responses to a serological diagnosis of HSV-2 infection in individuals without previous history of genital herpes.

METHODS

24 individuals who had a positive HSV-2 serology by western blot and no clinical history of disease were recruited from four clinics (sexually transmitted disease, maternal and infant care, family medicine, and virology research) over a 10 month period. In-depth qualitative interviews were conducted to elicit an individual's responses to the HSV-2 diagnosis.

RESULTS

Three categories of themes were identified from the interviews. Short term emotional responses included surprise, denial, confusion, distress, sadness, disappointment, and relief to know. Short term psychosocial responses included fear of telling sex partners, anger at the source partner, guilt about acquiring or transmitting, and concern about transmitting to a child. Perceived ongoing responses included fear of telling future partners, concern about transmitting to a sex partner, feeling sexually undesirable, feeling socially stigmatised, feeling like "damaged goods," sex avoidance due to social responsibility, fear of transmitting to a newborn, and relationship concerns relating to the diagnosis.

CONCLUSIONS

Individuals exhibit strong emotional and psychosocial responses to a serological diagnosis of HSV-2 infection. Many of the negative responses may be time limited and influenced by factors that are potentially amenable to counselling.