Persistence of Granuloma or granulomatous Inflammation after Six Months of CAT-1 Anti Tuberculosis Therapy in Tubercular Lymphadenitis Patients

Background: Tuberculous Lymphadenitis is the most common form of extra-pulmonary tuberculosis. Paradoxical enlargement and new lymph nodes appearance are observed after completion of anti-tuberculous therapy. Objective: The objective of the study was to assess whether granuloma can persist in persisted or paradoxically enlarged lymph node after anti-TB treatment in tubercular lymphadenitis patient. Method: An observational cross sectional study was conducted in the Department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University from March 2014 to February 2016 among patients of TB-lymphadenitis who had persistent or enlargement of previous or developed new lymph node after anti-TB therapy. History was taken; previous records were analyzed to ascertain the diagnostic basis of tuberculosis. History and physical examination were done for present status. Cytological or histopathological analysis was done at Department of Pathology, BSMMU. Result: Most of the patients were in the 21-30 years age group (Mean 25.53±7.93). Majority of them were female. Most of the respondents were student. More than half of the patients came from lower socioeconomic status. About 89% had typical symptoms of tuberculosis like fever, weight loss and loss of appetite during initial diagnosis and about one third had typical symptom of TB like fever weight loss and loss of appetite and one third had no symptoms after treatment. Majority mode of diagnostic tool was FNAC in both initial and after treatment. Majority (88.9 %) cases granuloma persisted after treatment. Conclusion: In spite of anti TB treatment with good compliance granuloma or granulomatous inflammation persisted in majority patients of persisted lymph nodes. Bangladesh Journal of Medical Science Vol. 22 No. 01 January’23 Page : 216-221

Can subcentimetre ultrasound detected angiomyolipomas be safely disregarded?

AIM

To optimise follow-up by dismissing lesions on baseline ultrasound (US) if renal lesions conform to US criteria of an angiomyolipoma (AML).

METHOD AND MATERIALS

The present study was a 10-year retrospective review of patients who were found to have incidental hyperechoic renal lesions on US to ascertain the outcome from subsequent imaging, clinical encounters, and cancer registrations. Exclusions included renal calculi, tuberous sclerosis, Von-Hippel-Lindau, or a known cancer.

RESULTS

After excluding 39 patients, 1,493 patients were identified. One hundred and sixty had more than one lesion with 87 patients having bilateral lesions. Regardless of indication, 889 patients had subsequent imaging within 5 years (59.5%). The average size of all AMLs was 13.2 mm. In the group with lesions that were <10 mm (807), 438 had imaging follow-up with an average follow-up time of 1.5 years. Mean lesion size in this group was 7 mm, with an average increase of <0.5 mm on follow-up. No lesions were found to be malignant on subsequent imaging nor did any of these patients have a subsequent renal cancer diagnosis registered at local multidisciplinary team meetings.

CONCLUSION

No incidental subcentimetre hyperechoic renal lesion with imaging characteristics of an AML demonstrated significant growth or developed into a malignancy on follow-up.

Etiological Evaluation of Patients with Lymphadenopathy by Clinical, Histopathological and Microbiological Assessment

Lymph node enlargement is a common presenting complaint in outpatient and inpatient department. The present observational cross sectional study was conducted in department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh during the period from December 2014 to May 2016 to evaluate etiologies of significant lymphadenopathy by clinical, histopathological and microbiological assessment. Biopsy/FNA materials of 177 patients of 18-75 years age range with significant lymphadenopathy were sent for histopathology/cytology, Gram stain & culture, AFB stain & culture and Gene Xpert. Among them, 102(57.62%) were granulomatous lymphadenitis, 52(29.38%) were lymphoma, 12(6.78%) reactive lymphadenitis, 7(3.95%) metastatic malignancy, 2(1.13%) atypical lymphoid hyperplasia, 1(0.57%) myeloid sarcoma and 1(0.57%) chronic sialadenitis. Growth of MTB was on 23(22.55%) cases; among 102 granulomatous lymphadenitis and Gene Xpert was positive in 73(71.56%) cases with 100% Rif. sensitive. Gene Xpert is an important tool for diagnosis of tuberculous lymphadenitis. Time of symptoms to diagnosis of most of the TBL patients was within 2-8 months.

The generation of memory CD8 T cells is regulated by intracellular Galectin-3

The ability of tumors to induce immunosuppression and reduce the cytolytic function of tumor-infiltrating lymphocytes (TIL) is a major obstacle to creating effective therapies for cancer patients. The levels of Galectin-3 (Gal3) protein are increased during tumor progression in many cancers. Gal3 induces the polarization of tumor-associated macrophages and plays a role in the survival and metastasis of cancer cells. Gal3 is functional within cells as well as in the extracellular space and recent studies suggest that it has opposing functions in these two compartments. The biology of extracellular Gal3 has been extensively studied, however, the function and mechanisms by which intracellular Gal3 regulates CD8 T cells responses are poorly understood. CD8+ T cells are a critical component of anti-tumor immunity and enhancing their function can promote tumor elimination. Intracellular Gal3 has been suggested to positively regulate CD8+ T cell activation and survival. In the current study, we demonstrate that Gal3-deficient CD8+ T cells has no defect in early activation in vitro. However, Gal3−/− OT-I CD8+ T cells exhibit decreased proliferation, activation, survival and transition to memory in response to cognate antigen in vivo. Together, these data implicate Gal3 as a critical mediator of CD8 T cell survival and memory formation following antigen challenge in vivo.

ALT-803, an IL-15 superagonist, in combination with nivolumab in patients with metastatic non-small cell lung cancer: a non-randomised, open-label, phase 1b trial

BACKGROUND

Immunotherapy with PD-1 or PD-L1 blockade fails to induce a response in about 80% of patients with unselected non-small cell lung cancer (NSCLC), and many of those who do initially respond then develop resistance to treatment. Agonists that target the shared interleukin-2 (IL-2) and IL-15Rβγ pathway have induced complete and durable responses in some cancers, but no studies have been done to assess the safety or efficacy of these agonists in combination with anti-PD-1 immunotherapy. We aimed to define the safety, tolerability, and activity of this drug combination in patients with NSCLC.

METHODS

In this non-randomised, open-label, phase 1b trial, we enrolled patients (aged ≥18 years) with previously treated histologically or cytologically confirmed stage IIIB or IV NSCLC from three academic hospitals in the USA. Key eligibility criteria included measurable disease, eligibility to receive anti-PD-1 immunotherapy, and an Eastern Cooperative Oncology Group performance status of 0 or 1. Patients received the anti-PD-1 monoclonal antibody nivolumab intravenously at 3 mg/kg (then 240 mg when US Food and Drug Administration [FDA]-approved dosing changed) every 14 days (either as new treatment or continued treatment at the time of disease progression) and the IL-15 superagonist ALT-803 subcutaneously once per week on weeks 1-5 of four 6-week cycles for 6 months. ALT-803 was administered at one of four escalating dose concentrations: 6, 10, 15, or 20 μg/kg. The primary endpoint was to define safety and tolerability and to establish a recommended phase 2 dose of ALT-803 in combination with nivolumab. Analyses were per-protocol and included any patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov, number NCT02523469; phase 2 enrolment of patients is ongoing.

FINDINGS

Between Jan 18, 2016, and June 28, 2017, 23 patients were enrolled and 21 were treated at four dose levels of ALT-803 in combination with nivolumab. Two patients did not receive treatment because of the development of inter-current illness during enrolment, one patient due to leucopenia and one patient due to pulmonary dysfunction. No dose-limiting toxicities were recorded and the maximum tolerated dose was not reached. The most common adverse events were injection-site reactions (in 19 [90%] of 21 patients) and flu-like symptoms (15 [71%]). The most common grade 3 adverse events, occurring in two patients each, were lymphocytopenia and fatigue. A grade 3 myocardial infarction occurred in one patient. No grade 4 or 5 adverse events were recorded. The recommended phase 2 dose of ALT-803 is 20 μg/kg given once per week subcutaneously in combination with 240 mg intravenous nivolumab every 2 weeks.

INTERPRETATION

ALT-803 in combination with nivolumab can be safely administered in an outpatient setting. The promising clinical activity observed with the addition of ALT-803 to the regimen of patients with PD-1 monoclonal antibody relapsed and refractory disease shows evidence of anti-tumour activity for a new class of agents in NSCLC.

FUNDING

Altor BioScience (a NantWorks company), National Institutes of Health, and Medical University of South Carolina Hollings Cancer Center.

The role of Galectin-3 in modulating tumor growth and immunosuppression within the tumor microenvironment

The efficacy of cancer immunotherapy is limited, in part, by the multitude of immunosuppressive mechanisms present within the tumor microenvironment (TME). Galectin-3 (Gal-3) is a lectin that contributes to TME immunosuppression and regulates diverse functions including cellular homeostasis and cancer biology. Increased Gal-3 expression during cancer progression augments tumor growth, invasiveness, metastatic potential, and immune suppression, which highlights the potential use of Gal-3 as a therapeutic target capable of modulating anti-tumor immunity. Here, we discuss the mechanisms by which Gal-3 regulates lymphocytes, the role of Gal-3 in lung and prostate tumors, and the contribution of Gal-3 to TME immunosuppression.

Early evidence of anti-PD-1 activity in enzalutamide-resistant prostate cancer

While programmed cell death 1 (PD-1) inhibitors have shown clear anti-tumor efficacy in several solid tumors, prior results in men with metastatic castration resistant prostate cancer (mCRPC) showed no evidence of activity. Here we report unexpected antitumor activity seen in mCRPC patients treated with the anti-PD-1 antibody pembrolizumab. Patients with evidence of progression on enzalutamide were treated with pembrolizumab 200 mg IV every 3 weeks for 4 doses; pembrolizumab was added to standard dose enzalutamide. Three of the first ten patients enrolled in this ongoing phase II trial experienced rapid prostate specific antigen (PSA) reductions to ≤ 0.2 ng/ml. Two of these three patients had measurable disease upon study entry; both achieved a partial response. There were three patients with significant immune-related adverse events. One had grade 2 myositis, one had grade 3 hypothyroidism, and one had grade 2 hypothyroidism. None of these patients had a response. Two of the three responders had a baseline tumor biopsy. Immunohistochemistry from those biopsies showed the presence of CD3⁺, CD8⁺, and CD163⁺ leukocyte infiltrates and PD-L1 expression. Genetic analysis of the two responders revealed markers of microsatellite instability in one. The surprising and robust responses seen in this study should lead to re-examination of PD-1 inhibition in prostate cancer.

Toll-like receptor ligands in conjunction with agonist anti-OX40 mAb immunotherapy possess differential capacity to revive anergic self-reactive CD8 T cells

Previous work has shown that the induction of CD8 T cell anergy to a prostate-specific self-antigen can be reversed following ligation of the TNFR family member OX40 (CD134) with an agonist anti-OX40 mAb plus vaccination. The provision of the Toll-like receptor 4 (TLR4) ligand bacterial lipopolysaccharide (LPS) further enhanced T cell responses following combined anti-OX40/vaccine immunotherapy. Although this approach facilitated increased CD8 T cell infiltration into the prostate, these cells were unable to elicit significant destruction of the prostate tissue. In the current study, we examined the extent to which co-administration of select TLR ligands would affect the ability of anti-OX40/vaccine therapy to revive prostate-specific CD8 T cells rendered anergic in vivo. These data revealed a differential capability of TLR agonists in conjunction with anti-OX40/vaccine immunotherapy to generate robust effector CD8 T cells capable of trafficking into normal prostate epithelia and inducing tissue-specific damage. These data provide the framework for translational studies to evaluate the efficacy of administering OX40 agonists with tumor-specific vaccination and TLR ligand adjuvants to maximize T cell-mediated therapeutic responses.

Galectin-3 inhibition using novel inhibitor GR-MD-02 improves survival and immune function while reducing tumor vasculature

Immunosuppression and reduced cytotoxic function of tumor-infiltrating lymphocytes (TIL) are major obstacles to creating effective therapies for patients. It is known that Galectin-3 (Gal3), a lectin family member, is expressed and secreted by numerous cancers and immune cell subsets. Serum Gal3 expression is higher in patients with metastatic versus non-metastatic disease, and is associated with reduced survival in metastatic melanoma. Furthermore, Gal3 has been implicated in disease progression via the promotion of angiogenesis and metastasis, the inhibition of TIL function, and promoting M2 polarization of macrophages and mobilization of myeloid cells from the bone marrow to promote a metastatic niche within the tumor.

We hypothesized that Gal3 inhibition would improve TIL function while inhibiting the growth and metastasis of tumors. Through collaboration with Galectin Therapeutics, we tested Gal3 inhibition using the novel Gal3 inhibitor, GR-MD-02, with agonist anti-OX40 therapy. We observed that Gal3 inhibition/OX40 agonism improved survival in the MCA-205 sarcoma and 4T-1 mammary carcinoma models, and prolonged survival in the TRAMP-C1 prostate cancer model. Importantly, Gal3 inhibition/OX40 agonism reduced lung metastases in the 4T-1 model. Within the tumor, we observed an increase in the number of proliferating and IFNg-producing TIL. Gal3 inhibition/OX40 agonism was also associated with a decrease in tumor vasculature, as determined by CD31 staining by IHC within the tumors. These studies, along with clinical data from a liver fibrosis trial, supported testing GR-MD-02 in combination with additional immunotherapies to augment T cell function in patients with metastatic melanoma.

Multispectral Imaging of T and B Cells in Murine Spleen and Tumor

Recent advances in multiplex immunohistochemistry techniques allow for quantitative, spatial identification of multiple immune parameters for enhanced diagnostic and prognostic insight. However, applying such techniques to murine fixed tissues, particularly sensitive epitopes, such as CD4, CD8α, and CD19, has been difficult. We compared different fixation protocols and Ag-retrieval techniques and validated the use of multiplex immunohistochemistry for detection of CD3(+)CD4(+) and CD3(+)CD8(+) T cell subsets in murine spleen and tumor. This allows for enumeration of these T cell subsets within immune environments, as well as the study of their spatial distribution.