Recurrent (or episodic) fever of unknown origin (FUO) as a variant subgroup of classical FUO: a French Multicenter Retrospective study of 170 patients

BACKGROUND

Recurrent-FUO (fever of unknown origin) is a rare subtype of FUO for which diagnostic procedures are ill-defined and outcome data are lacking.

METHODS

We performed a retrospective multicentre study of patients with recurrent-FUO between 1995 and 2018. By multivariate analysis, we identified epidemiological, clinical, and prognostic variables independently associated with final diagnosis and mortality.

RESULTS

Of 170 patients, 74 (44%) had a final diagnosis. Being ≥ 65 years of age (OR=5.2; p<0.001), contributory history (OR=10.4; p < 0.001), and abnormal clinical examination (OR=4.0; p=0.015) independently increased the likelihood of reaching a diagnosis, whereas lymph node and/or spleen enlargement decreased it (OR = 0.2; p=0.004). The overall prognosis was good; 58% of patients recovered (70% of those with a diagnosis). Twelve (7%) patients died; patients without a diagnosis had a fatality rate of 2%. Being ≥ 65 years of age (OR = 41.3; p < 0.001) and presence of skin signs (OR = 9.5; p = 0.005) significantly increased the risk of death.

CONCLUSION

This study extends the known yield of recurrent-FUO and highlights the importance of repeated complete clinical examinations to discover potential diagnostic clues during follow- up. Moreover, their overall prognosis is excellent.

Abstract 1801: STK-012, an a/b-selective IL-2 activates tumor antigen specific CD25+ CD8 T cells to reject tumors without acute vascular toxicity

High-dose Interleukin-2 (IL-2) monotherapy induces complete responses in cancer patients but its use is limited by acute vascular toxicities including capillary leak syndrome and severe hypotension 1,2. IL-2 activates lymphocytes and NK-cells through the intermediate-affinity dimeric IL-2 receptor, IL-2Rβ/γ (CD122/CD132), while antigen activated T-cells and regulatory T-cells (Tregs) have increased sensitivity to IL-2 by expressing the high-affinity trimeric IL-2 receptor, IL-2Rα/β/γ (CD25/CD122/CD132)3. CD25-independent IL-2s (“non-α-IL-2s”) aim to increase the therapeutic efficacy of IL2 in cancer patients by avoiding Treg activation through selective binding to IL-2Rβ/γ 4. However, those molecules still are reported to induce fever and hypotension and have limited efficacy as a monotherapy or in combination with anti-PD-1 5,6. Here we show that a novel α/β-IL-2 agonist that was designed to preferentially bind to the IL-2Rα/β/γ receptor highly upregulated on antigen activated T-cells can greatly improve on the efficacy of IL-2 while avoiding the vascular toxicity commonly associated with IL-2 treatment. In syngeneic tumor models, this α/β-IL-2 agonist significantly reduced exhaustion of tumor infiltrating T cells compared to WT-IL-2 or a non-α-IL-2 leading to improved expansion of tumor antigen specific CD25+PD-1+CD8+ T cells systemically and in the tumor microenvironment. This resulted in complete responses and tumor immune memory with α/β-IL-2 monotherapy as well as improved outcomes in combination with anti-PD-1 therapy in PD-1 refractory syngeneic tumors. In contrast, WT-IL-2 reduced T cell exhaustion and drove antigen specific T cell responses to a lesser degree, resulting in reduced combinatorial efficacy with anti-PD-1, while the non-α-IL-2 failed to do either. Furthermore, the α/β-IL-2 agonist reduced intratumoral Tregs compared to treatment with WT-IL-2 or PBS improving the intratumoral CD8 to Treg ratio. In non-human primates and mice, WT-IL-2 and a non-α-IL-2 led to broad extravasation of lymphocytes and NK cells and activation of intra-pulmonal T cells resulting in systemic tissue inflammation and NK cell-mediated lethal capillary leak syndrome whereas the α/β-IL-2 agonist, which avoids binding the dimeric IL-2Rβ/γ expressed on NK cells, avoided systemic lymphocyte activation which facilitated continuous treatment without acute vascular toxicities. Overall, through selective engagement of CD25+ T cells, this α/β-IL-2 agonist demonstrated improved efficacy and tolerability of IL-2 in preclinical tumor models. Clinical trials with STK-012, a human α/β-IL-2 agonist, are in progress.1 Atkins, et al.; JCO 1999, 2 Dutcher, et al.; JITC 2014, 3 Liao, et al.; Immunity 2013, 4 Levin, et al.; Nature 2012, 5 Janku, et al.; Cancer Research 2021; 6 Diab, et al.; Cancer Disc. 2020

Citation Format: Martin Oft, Navneet Ratti, Sandro Vivona, Jan Emmerich, Romina Riener, Ievgen O. Koliesnik, Scott McCauley, Michele Bauer, Marie Semana, Deepti Rokkam, Bhargavi Jayaraman, Rene de Waal Malefyt, Paul-Joseph Aspuria, Michael Totagrande, Anita Mehta-Damani, Patrick J. Lupardus, Rob A. Kastelein. STK-012, an a/b-selective IL-2 activates tumor antigen specific CD25+ CD8 T cells to reject tumors without acute vascular toxicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1801.

Abstract 1833: Novel IL-12 Partial Agonist For Cancer Immunotherapy Avoids NK-cell Mediated Toxicity

Here we report on a novel human IL-12 partial agonist (hIL-12v) that has diminished binding to IL-12Rb1. IL-12v is designed to more selectively engage antigen activated T-cells, which strongly upregulate IL-12Rb1 upon activation, and to reduce stimulation of NK cells or resting T cells, which express modest levels of IL-12Rb1. To explore anti-tumor efficacy and toxicity in mouse syngeneic tumor models, we generated a half-life extended mouse surrogate of the IL-12 partial agonist (mIL-12v Fc) and compared it to a similarly engineered half-life extended version of wild type mouse IL-12 (mIL-12wt Fc). At efficacious doses, systemic administration of mIL-12wt Fc induced significant weight loss and lethality characterized by early proinflammatory cytokine release and systemic NK cell activation. Conversely, mIL-12v Fc was well tolerated and avoided the robust and rapid NK cell activation and peripheral NK count decreases seen with mIL-12v Fc, suggestive of extravasation to tissues. Both mIL-12v Fc and mIL-12 WT Fc showed similar robust single-agent anti-tumor efficacy in syngeneic tumor models. Depletion of NK cells did not diminish anti-tumor efficacy. Efficacy for both molecules was characterized by CD8 T cell activation, myeloid cell reprograming and antigen presentation. Moreover, combination of mIL-12v Fc with systemic immunotherapies further enhanced anti-tumor activity without compromising tolerability. Overall, mIL-12v Fc retained anti-tumor efficacy without induction of severe toxicities compared to mIL-12wt Fc. These data suggest IL-12 partial agonists may represent a novel immunotherapy approach to maintain efficacy while avoiding classical toxicity associated with IL-12 therapy.1 Atkins, et al.; (1997) Clinical Cancer Research 3(3):409-172 Carson, et al. (1999) J Immunology 162 (8): 4943-4951.

Citation Format: Ievgen Koliesnik, Jan Emmerich, Kim Q. Tran, Michele Bauer, Michael Totagrande, Bhargavi Jayaraman, Cindy Buffone, Priyanka Balasubrahmanyam, Deepti Rokkam, Rene de Waal Malefyt, Luis Zuniga, Heiko Greb, Navneet Ratti, Sandro Vivona, Martin Oft, Patrick J. Lupardus, Robert A. Kastelein. Novel IL-12 Partial Agonist For Cancer Immunotherapy Avoids NK-cell Mediated Toxicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1833.

Abstract 2824: Engineered human IL-2/IL-2Rb orthogonal pairs selectively enhance anti-GPC3 CAR T cells to drive complete responses in solid epithelial tumor models

CAR T cell therapy has demonstrated clinical efficacy against hematological malignancies. However, prominent barriers including poor T cell effector function, lack of proliferation, and limited CAR T cell persistence have prevented CAR T cell therapies from reaching their full curative potential, especially in solid tumors. Interleukin-2 (IL-2) is a potent stimulator of T cell proliferation, survival, and cytotoxic function, thereby making it an attractive cytokine to support CAR T cell therapy. However, therapeutic use of IL-2 is limited by systemic toxicity due its promiscuous activation of undesired immune cell populations, including non-tumor reactive T cells and NK cells.

To facilitate selective ex vivo and in vivo expansion of engineered T cells we have developed a human orthogonal (ortho) ligand/receptor system consisting of a IL-2 mutein (STK-009) that does not significantly stimulate cells expressing wild type IL-2 receptor and a mutated IL-2 Receptor Beta (orthoIL-2Rβ) that responds to STK-009 but not wild type IL-2. This system enables in vivo IL-2 signaling in engineered cells that express the orthoIL-2Rβ while avoiding stimulation of native T cells and NK cells. Previously, we demonstrated the ability of the STK-009/orthoIL-2Rβ receptor pair to selectively enhance the anti-tumor efficacy of orthoIL-2Rβ (hoRb) expressing CD19 CAR T cells (SYNCAR-001) in preclinical lymphoma mouse models. We also demonstrated that STK-009 is selective for the orthoIL-2Rβ expressing cells and therefore in a non-human primate model does not stimulate native T or NK cells.

Here, we demonstrate the ability of the STK-009/hoRb system to enhance the anti-tumor activity and persistence of anti-glypican 3 (GPC3) CAR T cells. GPC3 overexpression is associated with various malignancies such as hepatocellular carcinoma (HCC), pediatric sarcomas, and non small cell lung carcinoma (NSCLC). Clinical trials of GPC3 CAR T therapy are ongoing, but early data suggests a need to boost CAR T cell function and persistence to achieve significant clinical responses. We incorporated the hoRb downstream of an anti-GPC3_28z CAR via a T2A cleavage peptide (SYNCAR-002). In vivo, STK-009 administration enhanced the anti-tumor efficacy of SYNCAR-002 in highly aggressive subcutaneous and intraperitoneal HCC models. STK-009 treatment resulted in significant expansion of SYNCAR-002 and drove infiltration of SYNCAR-002 into tumors. STK-009 treatment also induced intratumoral granzyme B+ and IFN-γ+ production by SYNCAR-002 indicating activation of effector T cell function.

These findings validate that the orthogonal IL-2 platform has the potential to improve the efficacy and durability of CAR T therapy for solid tumor targets such as GPC3 by selectively expanding CAR-T cells in vivo, driving CAR-T cells into the tumor, and activating CAR-T cells in the tumor microenvironment.

Citation Format: Paul-Joseph Aspuria, Marie Semana, Sandro Vivona, Mahalaksmi Ramadass, Navneet Ratti, Romina Riener, Michele Bauer, Mohammed Ali, Deepti Rokkam, Rob A. Kastelein, Patrick J. Lupardus, Martin Oft. Engineered human IL-2/IL-2Rb orthogonal pairs selectively enhance anti-GPC3 CAR T cells to drive complete responses in solid epithelial tumor models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2824.

Abstract 586: Orthogonal IL-2/IL-2RB signaling in adoptively transferred T cells controls tumor growth without the need for lymphodepletion in a B16 tumor model

Multiple adoptive T-cell therapy modalities (ACT) have delivered promising clinical responses in cancer patients. However, challenges including poor T cell effector function, lack of proliferation, and limited persistence have prevented ACTs from reaching their full curative potential. In addition, ACTs typically require lymphodepletion to aid cell engraftment. Lymphodepletion has been shown to improve persistence and efficacy of ACTs by elevating T-cell common gamma-chain cytokines like IL-7 and IL-15. However, lymphodepletion regimens have been identified as a risk factor for cytokine release syndrome (CRS) and infectious complications from opportunistic pathogens. IL-2, another common gamma-chain cytokine, is a potent stimulator of T cells, making it an attractive cytokine to support ACT and potentially bypass the need for lymphodepletion. However, therapeutic use of IL-2 is limited by systemic toxicity due its promiscuous activation of immune cells.

To facilitate selective delivery of an IL-2 signal to engineered T cells and avoid signaling in bystander T cells and NK cells, we developed a mouse orthogonal receptor/ligand system consisting of a mutated IL-2 Receptor Beta (moRβ) and a pegylated, IL-2 mutein (moIL-2) that does not significantly activate the wild type IL-2β receptor but does activate moRβ. T cells from pmel-1 T cell receptor-transgenic mice, recognizing gp100 on B16 melanoma cells were transduced with moRβ (orthoPmel). A highly active moIL-2 was continuously dosed for four weeks in mice. Thy1.1+ orthoPmel T cells were tracked by FACS and IHC systemically and in the tumor.

During orthoPmel manufacturing, moIL-2 specifically enriched orthoPmel compared to mouse WT IL-2. OrthoPmel in combination with moIL-2 controlled tumor growth in lymphoreplete mice bearing established B16 tumors while neither component alone inhibited tumor growth. moIL-2 significantly expanded orthoPmel systemically and intratumorally, with orthoPmel ultimately accounting for greater than 80% or 40% of all peripheral and intratumoral T cells, respectively. Systemic orthoPmel maintained a consistent central memory and effector memory mix throughout the four-week moIL-2 treatment course. moIL-2 also induced the expression of activation markers, CD25 and Granzyme B, in intratumoral orthoPmel.

These findings validate than an orthogonal IL-2/IL-2Rβ platform can enhance efficacy of ACTs without peripheral expansion or activation of NK cells or non-tumor specific T cells and the toxicities typically associated with high dose IL-2 therapy. Importantly, these results demonstrate the potential of this platform overcome the requirement of lymphodepletion in adoptive cell therapies.

Citation Format: Christina Kochel, Meng Sun, Navneet Ratti, Sandro Vivona, Mahalaksmi Ramadass, Marie Semana, Michele Bauer, Mohammed Ali, Jan Emmerich, Rob Kastelein, Patrick J. Lupardus, Paul-Joseph Aspuria, Martin Oft. Orthogonal IL-2/IL-2RB signaling in adoptively transferred T cells controls tumor growth without the need for lymphodepletion in a B16 tumor model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 586.

An orthogonal IL-2 and IL-2Rβ system drives persistence and activation of CAR T cells and clearance of bulky lymphoma

[Figure: see text].

Abstract 1512: OrthoCARs: Engineered human IL-2/IL-2Rb orthogonal pairs selectively enhance CAR T cell antitumor efficacy by driving T cell expansion and fitness

CAR T cell therapy (CAR) has demonstrated remarkable clinical efficacy in hematological malignancies. However, barriers such as poor T cell effector function, lack of proliferation, and limited persistence prevent CARs from reaching their full curative potential. IL-2 is a potent stimulator of T cell proliferation, survival, and cytotoxic function, making it an attractive cytokine to support CARs. However, therapeutic use of IL-2 is limited by systemic toxicity due its promiscuous activation of undesired immune cell populations.

To facilitate selective expansion and activation of CARs we have developed a human orthogonal ligand/receptor system consisting of a pegylated IL-2 mutein (STK-009) that does not significantly activate the wild type IL-2 receptor and a mutated IL-2 Receptor Beta (hoRb) that is fully activated by STK-009, but does not respond to the native IL-2 ligand. This system enables in vivo IL-2 signaling in CARs engineered to express hoRb while avoiding signaling bystander T cells and NK cells. Here, we demonstrate the ability of the STK-009/hoRb receptor pair to selectively enhance the anti-tumor efficacy of hoRb expressing CD19 CARs (SYNCAR-001) in preclinical lymphoma mouse models at will. We also demonstrate, in non-human primates (NHP), that STK-009 is selective for hoRb expressing cells.

SYNCAR-001 + STK-009 can lead to complete responses in subcutaneous Raji mouse models, even with SYNCAR-001 dosed at sub-efficacious levels (400,000 CAR-Ts/mouse). Subcutaneous dosing of STK-009 expands SYNCAR-001 systemically and drives infiltration of SYNCAR-001 into tumors. UMAP analysis of STK-009 treated SYNCAR-001 reveal a small PD1+LAG3+ subpopulation during tumor rejection which disappeared once tumors are controlled. The majority of T cells showed no exhaustion markers. Further, an IL-7R+ population arises and remains after tumor control, indicating long term memory development. Nanostring analysis confirms upregulation of IL-7R and other critical genes involved in cytotoxic activity and persistence in SYNCAR-001 when treated with STK-009. These data demonstrate that STK-009 treatment expands SYNCAR-001 and delivers a gene signature indicative of enhanced T cell fitness and activity.

Subcutaneous administration of STK-009 in NHP shows no evidence of toxicity or physiological IL-2 mediated activity on immune cells, including Teffs, Tregs, and NK cells. Pharmacokinetic analysis of STK-009 shows stable exposure with minimal clearance, demonstrating the selectivity of STK-009.

These findings validate an orthogonal platform that selectively drives potent T cell effector functions of engineered cells without the toxicities mediated by NK cells or non-tumor specific T cells associated with high dose IL-2 therapy. These results demonstrate the ability of this orthogonal platform to improve the efficacy and durability of CARs.

Citation Format: Paul-Joseph P. Aspuria, Sandro Vivona, Michele Bauer, Marie Semana, Navneet Ratti, Scott McCauley, Romina Riener, Rene de Waal Malefyt, Deepti Rokkam, Jan Emmerich, Patrick J. Lupardus, Rob A. Kastelein, Martin Oft. OrthoCARs: Engineered human IL-2/IL-2Rb orthogonal pairs selectively enhance CAR T cell antitumor efficacy by driving T cell expansion and fitness [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1512.

Immunologic and tumor responses of pegilodecakin with 5-FU/LV and oxaliplatin (FOLFOX) in pancreatic ductal adenocarcinoma (PDAC)

Background Treatment options for pancreatic ductal adenocarcinoma (PDAC) are limited and checkpoint blockade inhibitors have been disappointing in this disease. Pegilodecakin has demonstrated single agent anti-tumor activity in immune-sensitive tumors. Phase 1 and preclinical data indicate synergy of pegilodecakin with 5-FU and platins. We assessed the safety and activity of pegilodecakin+FOLFOX in patients with PDAC. Methods IVY (NCT02009449) was an open-label phase 1b trial in the United States. Here we report on all enrolled patients from cohort C. Heavily pretreated patients were treated with pegilodecakin (self-administered subcutaneously daily at 2.5, 5, or 10 μg/kg) + 5-flurouracil/leucovorin/oxaliplatin (FOLFOX), dosed per manufacturers prescribing information, until tumor progression. Eligible patients had measurable disease per immune-related response criteria (irRC), were ≥ 18 years of age, and had ECOG performance status of 0 or 1. Patients were evaluated for primary(safety) and secondary (tumor response per irRC) endpoints. Results From 5 August 2014-12 July 2016, 39 patients enrolled in cohort C. All patients were evaluable for safety. In this advanced population, regimen had manageable toxicities with no immune-related adverse events (irAEs) greater than grade 1. The most common grade 3/4/5 TEAEs were thrombocytopenia (21[53.8%] of 39) and anemia (17[43.6%] of 39). In evaluable PDAC patients, the best overall response of pegilodecakin+FOLFOX was 3(14%) with CRs in 2(9%) patients. Conclusions Pegilodecakin+FOLFOX had an acceptable tolerability profile in PDAC, with no substantial irAEs seen, and promising efficacy with the combination yielding a 2-year OS of 24% (95% CI 10-42). These data led to the phase 3 study with pegilodecakin+FOLFOX as second-line therapy of PDAC (SEQUOIA).

Abstract 3252: OrthoCARs: Engineered human IL-2/IL-2Rb orthogonal pairs selectively enhance CAR T cell anti-tumor efficacy and durability of response

CAR T cell therapy has demonstrated remarkable clinical efficacy against relapsed and refractory hematological malignancies, such as B cell non-Hodgkin lymphoma (NHL) and acute lymphoblastic leukemia (ALL). Despite these advances, prominent barriers including poor T cell effector function, lack of proliferation, and limited CAR T cell persistence prevent CAR T cell therapies from reaching their full curative potential. Interleukin-2 (IL-2) is a potent stimulator of CD4 and CD8 effector T cell proliferation, survival, and cytotoxic function, thereby making it an attractive molecule to support CAR T cell therapy. However, therapeutic use of IL-2 is limited by systemic toxicity due its promiscuous activation of undesired immune cell populations, including non-tumor reactive T cells and NK cells. To facilitate selective in vivo expansion of engineered T cells we have developed an orthogonal (ortho) ligand/receptor system consisting of a pegylated, IL-2 mutein (STK-009) and a mutated IL-2 Receptor Beta (orthoIL-2Rβ) that selectively bind each another, but do not interact with their wild type receptor and cytokine counterparts. This system allows for in-vivo IL-2 signaling in engineered adoptive cell therapies that express the orthoIL-2Rβ while avoiding signaling in non-tumor reactive T cells and NK cells. Here, we demonstrate the ability of STK-009/orthoIL-2Rβ pair to selectively potentiate human orthoIL-2Rβ expressing CD19 CAR T cells in vitro and in vivo. We incorporated orthoIL-2Rβ into a CD19 directed CAR lentiviral construct utilizing a T2A peptide linker, allowing the use of a single lentiviral plasmid to generate orthoCAR T cells. Transduction of donor T cells with the CAR+orthoIL-2Rβ lentivirus and the use of STK-009 during in vitro manufacturing enabled selective proliferation and enrichment of orthoCAR transduced T cells. orthoCAR T cells grown in STK-009 maintained a similar immunophenotype and cytotoxic function compared to T cells manufactured with wild type IL-2. Subcutaneous administration of STK-009 dramatically enhanced the expansion (&gt;100-fold) and efficacy of orthoCAR T cells in an aggressive pre-clinical mouse model of B cell malignancy (Raji), demonstrating 100% durable complete responses, compared to 50% relapsed and refractory lymphoma in CD19 CAR alone. Immunoprofiling of in vivo orthoCAR T cells revealed that STK-009 treatment significantly increased both naïve and effector memory RA (TEMRA) populations. RNAseq and IHC analysis also showed that STK-009 treatment increases expression of cytotoxic molecules such as Granzyme B and perforin specifically in the CAR T cells, without inducing GranzymeB in other cells. These findings validate a potent platform that selectively harnesses the potent anti-tumoral T cell effector functions of IL-2 to improve the efficacy and durability CAR T cell therapy.

Citation Format: Paul-Joseph Aspuria, Michele Bauer, Sandro Vivona, Steven E. Kauder, Scott McCauley, Romina Riener, Rene De Waal Malefyte, Navneet Ratti, Deepti Rokkam, Jan Emmerich, Patrick J. Lupardus, Rob A. Kastelein, Martin Oft. OrthoCARs: Engineered human IL-2/IL-2Rb orthogonal pairs selectively enhance CAR T cell anti-tumor efficacy and durability of response [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3252.

Pegilodecakin combined with pembrolizumab or nivolumab for patients with advanced solid tumours (IVY): a multicentre, multicohort, open-label, phase 1b trial

BACKGROUND

IL-10 has anti-inflammatory and CD8+ T-cell stimulating activities. Pegilodecakin (pegylated IL-10) is a first-in-class, long-acting IL-10 receptor agonist that induces oligoclonal T-cell expansion and has single-agent activity in advanced solid tumours. We assessed the safety and activity of pegilodecakin with anti-PD-1 monoclonal antibody inhibitors in patients with advanced solid tumours.

METHODS

We did a multicentre, multicohort, open-label, phase 1b trial (IVY) at 12 cancer research centres in the USA. Patients were assigned sequentially into cohorts. Here, we report on all enrolled patients from two cohorts treated with pegilodecakin combined with anti-PD-1 inhibitors. Eligible patients were aged at least 18 years with histologically or cytologically confirmed advanced malignant solid tumours refractory to previous therapies, and an Eastern Cooperative Oncology Group performance status of 0 or 1. Patients with uncontrolled infectious diseases were excluded. Pegilodecakin was provided in single-use 3 mL vials and was self-administered subcutaneously by injection at home at 10 μg/kg or 20 μg/kg once per day in combination with pembrolizumab (2 mg/kg every 3 weeks or 200 mg every 3 weeks) or nivolumab (3 mg/kg every 2 weeks or 240 mg every 2 weeks or 480 mg every 4 weeks at the approved dosing), both of which were given intravenously at the study site. Patients received pembrolizumab or nivolumab with pegilodecakin until disease progression, toxicity necessitating treatment discontinuation, patient withdrawal of consent, or study end. The primary endpoints were safety and tolerability, assessed in all patients enrolled in the study who received any amount of study medication including at least one dose of pegilodecakin, and pharmacokinetics (previously published). Secondary endpoints included objective response by immune-related response criteria in all patients who were treated and had evaluable measurements. The study is active but no longer recruiting, and is registered with ClinicalTrials.gov, NCT02009449.

FINDINGS

Between Feb 13, 2015, and Sept 12, 2017, 111 patients were enrolled in the two cohorts. 53 received pegilodecakin plus pembrolizumab, and 58 received pegilodecakin plus nivolumab. 34 (31%) of 111 patients had non-small-cell lung cancer, 37 (33%) had melanoma, and 38 (34%) had renal cell carcinoma; one (<1%) patient had triple-negative breast cancer and one (<1%) had bladder cancer. Data cutoff was July 1, 2018. Median follow-up was 26·9 months (IQR 22·3-31·5) for patients with non-small-cell lung cancer, 33·0 months (29·2-35·1) for those with melanoma, and 22·7 months (20·9-27·0) for those with renal cell carcinoma. At least one treatment-related adverse event occurred in 103 (93%) of 111 patients. Grade 3 or 4 events occurred in 73 (66%) of 111 patients (35 [66%] of 53 in the pembrolizumab group and 38 [66%] of 58 in the nivolumab group), the most common of which were anaemia (12 [23%] in the pembrolizumab group and 16 [28%] in the nivolumab group), thrombocytopenia (14 [26%] in the pembrolizumab group and 12 [21%] in the nivolumab group), fatigue (11 [21%] in the pembrolizumab group and 6 [10%] in the nivolumab group) and hypertriglyceridaemia (three [6%] in the pembrolizumab group and eight [14%] in the nivolumab group). There were no fatal adverse events determined to be related to the study treatments. Of the patients evaluable for response, objective responses were 12 (43%) of 28 (non-small-cell lung cancer), three (10%) of 31 (melanoma), and 14 (40%) of 35 (renal cell carcinoma).

INTERPRETATION

In this patient population, pegilodecakin with anti-PD-1 monoclonal antibodies had a manageable toxicity profile and preliminary antitumour activity. Pegilodecakin with pembrolizumab or nivolumab could provide a new therapeutic opportunity for previously treated patients with renal cell carcinoma and non-small-cell carcinoma.

FUNDING

ARMO BioSciences, a wholly owned subsidiary of Eli Lilly and Company.

Function of CSF1 and IL34 in Macrophage Homeostasis, Inflammation, and Cancer

Colony-stimulating factor 1 (CSF1) and interleukin 34 (IL34) signal via the CSF1 receptor to regulate macrophage differentiation. Studies in IL34- or CSF1-deficient mice have revealed that IL34 function is limited to the central nervous system and skin during development. However, the roles of IL34 and CSF1 at homeostasis or in the context of inflammatory diseases or cancer in wild-type mice have not been clarified in vivo. By neutralizing CSF1 and/or IL34 in adult mice, we identified that they play important roles in macrophage differentiation, specifically in steady-state microglia, Langerhans cells, and kidney macrophages. In several inflammatory models, neutralization of both CSF1 and IL34 contributed to maximal disease protection. However, in a myeloid cell-rich tumor model, CSF1 but not IL34 was required for tumor-associated macrophage accumulation and immune homeostasis. Analysis of human inflammatory conditions reveals IL34 upregulation that may account for the protection requirement of IL34 blockade. Furthermore, evaluation of IL34 and CSF1 blockade treatment during Listeria infection reveals no substantial safety concerns. Thus, IL34 and CSF1 play non-redundant roles in macrophage differentiation, and therapeutic intervention targeting IL34 and/or CSF1 may provide an effective treatment in macrophage-driven immune-pathologies.

[Hemorrhagic syndrome due to a heparin-like anticoagulant in a patient with systemic lupus erythematosus]

INTRODUCTION

In systemic lupus erythematosus, hemostasis disorders are mainly thrombotic, but more rarely hemorrhagic.

CASE REPORT

A 25-year-old man presented with a macrophagic activation syndrome revealing a systemic lupus erythematosus, secondarily complicated by a hemorrhagic syndrome ; biological investigations revealed an increase thrombin time and an activated partial thromboplastin time, normalized by protamin neutralization in vitro, thus confirming the presence of a heparin-like anticoagulant. The hemostasis balance normalized after the specific treatment of lupus.

CONCLUSION

This rare anomaly of hemostasis balance has been described in blood cancers and solid cancers. This is the first description of a case associated with an autoimmune connective tissue disorder such as lupus. After one year of follow-up, no diagnosis of blood or solid cancer was made.

PEGylated human IL-10 (AM0010) in combination with pembrolizumab in anti-PD1 and CTLA-4 refractory melanoma

3084

Background: Melanoma has a high response rate to anti-PD-1 alone. More than 50% of melanoma on anti-PD-1 progress within one year. IL-10 inhibits inflammation and stimulates the cytotoxicity and proliferation of tumor infiltrating CD8+ T cells at higher concentrations. IL-10 receptors and PD1 are induced on activated CD8 T cells, providing a mechanistic rationale for combining AM0010 and anti-PD1. AM0010 alone has established tolerability and anti-tumor activity in a phase 1 study. Objective responses were observed in 4 of 15 pts with RCC, one patient with uveal melanoma and cutaneous T cell lymphoma, each. Methods: 25 melanoma pts who had progressed on prior anti-CTLA4 and on prior anti-PD-1 containing regimen were treated with AM0010 (20mg/kg qd, SQ) and pembrolizumab (2mg/kg, q3wk IV). Patients had a median of 3.5 prior therapies (range 2-6) and a median of 2 prior immune therapies (range 1-6). Tumor responses were monitored following irRC. Immune responses were measured by analysis of serum cytokines, activation of blood derived T cells and peripheral T cell clonality. Results: AM0010 plus pembrolizumab was well tolerated. All treatment related adverse events (TrAE) were reversible. DLTs and SAEs leading to study discontinuation were not observed. G3/4 TrAEs were observed in 11 of 25 pts and included fatigue (8) thrombocytopenia (6), anemia (4), rash (1) and hypertriglyceridemia (1). There were no objective tumor responses. 9 of 20 evaluable pts had stable disease (DCR = 45%). As of Jan. 31 2017, the mPFS was 2.0 mo. and the mOS was not reached, with a mFU of 15.5 mos (range 10.0-18.4). AM0010 plus pembrolizumab increased Th1 cytokines as well as the number and proliferation of PD1+ Lag3+ activated CD8 T cells in the blood while reducing inflammatory cytokines and TGFb. A de-novo oligoclonal expansion of T cell clones in the blood and an increase of tumor infiltrating Granzyme+ PD1+ CD8+ T cells in tumor biopsies of treated patients was observed. Conclusions: AM0010 in combination with anti-PD1 is well-tolerated in refractory melanoma pts. The clinical activity and the observed CD8+ T cell activation may suggest to study AM0010 in combination with an anti-PD-1 in melanoma patients with less prior treatments. Clinical trial information: NCT02009449.

Efficacy, safety, and immune activation with pegylated human IL-10 (AM0010) plus FOLFOX in metastatic pancreatic adenocarcinoma (PDAC)

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Background: Oxaliplatin or nal-irinotecan plus 5-FU are used as 2nd-line PDAC therapy (mOS 5-6 months (m)). PDAC also has been largely refractory to immune therapies which may depend on the expansion of activated, intratumoral, tumor specific cytotoxic CD8+ T cells that are low in most PDACs. AM0010 stimulates survival, expansion and cytotoxicity of intratumoral CD8+ T cells. Immune activation, durable stable disease and a 1yr survival of 22.5% was seen in salvage PDAC patients (pts) receiving AM0010 alone. Platins or 5-FU may activate immune responses to cancer and AM0010 has shown synergistic anti-tumor results with FOLFOX in preclinical models. In this phase 1b clinical study, the safety and efficacy of AM0010 +FOLFOX was studied in PDAC pts. Methods: PDAC pts progressing on a median of 1 prior therapy (range 1-3) were treated with AM0010 (5ug/kg SQ, qd) + FOLFOX (n = 21), an additional 4 pts with prior oxaliplatin and 5-FU were included in the safety population (n = 25). Tumor responses were assessed using irRC. Serum cytokines, activation of blood derived T cells and peripheral T cell clonality were analyzed. Pretreatment archival tissue samples were evaluated by IHC for tumor infiltration by CD8+ T cells. Results: On AM0010 + FOLFOX, G3/4 TrAEs included thrombocytopenia (52%), anemia (36%) and neutropenia (36%). A modified AM0010 dose schedule (5 days on 2 days off) avoided G3/4 thrombocytopenia. As of 01/31/2017, 2 patients remained on treatment for > 1 year. 19 pts had objective tumor response assessment; 2 had irCR, 1 irPR, 11 irSD. ORR is 15.8%, DCR is 73.7%. With median follow-up of 11.0 m (range 5.8-16.3), mPFS was 3.5 m and mOS 10.0 m. Pts with more intra-tumoral CD8+ T cells had longer OS. AM0010 + FOLFOX increased serum Th1 cytokines and reduced mediators of chronic inflammation and TGFb. AM0010 induced de-novo oligoclonal expansion of T cell clones in patients with prolonged survival. Conclusions: AM0010 plus FOLFOX is well tolerated in patients with PDAC. The observed immune activation including clonal T cell expansion and prolonged objective tumor responses are encouraging in this advanced PDAC population. This regimen is currently being studied in a phase 3 trial. Clinical trial information: NCT02009449.

Quantification of PD-L1 and PD-1 expression on tumor and immune cells in non-small cell lung cancer (NSCLC) using non-enzymatic tissue dissociation and flow cytometry

OBJECTIVE

We report a truly quantitative technology for PD-L1 expression in non-small cell lung cancer (NSCLC). In addition, we present a non-enzymatic technology that creates a cell suspension from fresh tumor tissue so that either fine-needle aspiration (FNA) or fresh tissue can be used in this assay.

METHODS

Non-enzymatic tissue homogenization (IncellPREP; IncellDx, Menlo Park, California) was performed on 4-mm punch biopsies. An FNA was taken from the same tumor to create matched sample sets. Cells were labeled with antibodies directed against CD45, PD-1, and PD-L1 and then stained with DAPI to identify intact, single cells, and to analyze cell cycle.

RESULTS

Comparing the IncellPREP homogenization and FNA demonstrated a strong correlation (r 2 - 0.8) for expression of PD-L1. We compared PD-L1 expression by flow cytometry using a 1 % cutoff for positivity in the tumor cell population and a 1 % cutoff of cells with at least 1+ intensity in immunohistochemically stained tissue sections as positive. Ten of 12 lung tumor samples were concordant while 2 were discordant. PD-L1 expression by flow cytometry varied widely (1.2-89.4 %) even in the positive concordant cases. In addition, PD-L1 expression in the aneuploid tumor population did not necessarily agree with the expression in the diploid tumor population. Fine, unequivocal quantification of PD-L1 on tumor and immune cells in NSCLC may allow for better prediction of response to therapies. The present study also offers a technology that can create a universal sample type from either FNA or fresh tissue.

Crisis in the psychiatric patient: A structured illness-management-oriented group intervention

Introduction

Crisis prevention and management of the psychiatric patient have obtained a central role in the policies of Mental Health Services. In this context, Mental Health Centre of Ravenna has launched a “Crisis Center”, a rehabilitation group project applied to three types of users: users in an early stage of crisis, users in a post-critical stage and users at high risk of crisis. Intervention was based on the Illness Management and Recovery practice, an evidence-based program which consists in social skills training activities, emotions management, symptom management, coping skills training, psycho-education and, more generally, supporting users in their personal recovery process.

Objective

Objectives of this project is to prevent crisis and hospitalization and to provide an alternative to institutionalization for mental health users.

Aims

The aims of this study was to analyze and show effects and results of the project, in its first three years of life.

Methods

Through the database “Infoclin”, we analyzed data of 94 users who took part in the project between January 2012 and December 2014.

Results

Analysis showed, primarily, that out of 94 users, 64 (68%) have not needed hospitalization in the following two years after intervention. Furthermore, out of 39 users with a history of one or more hospitalizations at time of entry, 22 (56.4%) have not needed hospitalization in the next two years.

Conclusions

Despite the low number of users analyzed, it is believed that this study should be considered a further evidence of the positive effects of the IMR practice within mental health services.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Functional consequences of the macrophage stimulating protein 689C inflammatory bowel disease risk allele

Background

Macrophage stimulating protein (MSP) is a serum growth factor that binds to and activates the receptor tyrosine kinase, Recepteur d'Origine Nantais (RON). A non-synonymous coding variant in MSP (689C) has been associated with genetic susceptibility to both Crohn's disease and ulcerative colitis, two major types of inflammatory bowel disease (IBD) characterized by chronic inflammation of the digestive tract. We investigated the consequences of this polymorphism for MSP-RON pathway activity and IBD pathogenesis.

Methods

RON expression patterns were examined on mouse and human cells and tissues under normal and disease conditions to identify cell types regulated by MSP-RON. Recombinant MSP variants were tested for their ability to bind and stimulate RON and undergo proteolytic activation. MSP concentrations were quantified in the serum of individuals carrying the MSP 689R and 689C alleles.

Results

In intestinal tissue, RON was primarily expressed by epithelial cells under normal and disease conditions. The 689C polymorphism had no impact on the ability of MSP to bind to or signal through RON. In a cohort of normal individuals and IBD patients, carriers of the 689C polymorphism had lower concentrations of MSP in their serum.

Conclusions

By reducing the quantities of circulating MSP, the 689C polymorphism, or a variant in linkage disequilibrium with this polymorphism, may impact RON ligand availability and thus receptor activity. Given the known functions of RON in regulating wound healing and our analysis of RON expression patterns in human intestinal tissue, these data suggest that decreased RON activity may impact the efficiency of epithelial repair and thus underlie the increased IBD susceptibility associated with the MSP 689C allele.

The ciliary G-protein-coupled receptor Gpr161 negatively regulates the Sonic hedgehog pathway via cAMP signaling

The primary cilium is required for Sonic hedgehog (Shh) signaling in vertebrates. In contrast to mutants affecting ciliary assembly, mutations in the intraflagellar transport complex A (IFT-A) paradoxically cause increased Shh signaling. We previously showed that the IFT-A complex, in addition to its canonical role in retrograde IFT, binds to the tubby-like protein, Tulp3, and recruits it to cilia. Here, we describe a conserved vertebrate G-protein-coupled receptor, Gpr161, which localizes to primary cilia in a Tulp3/IFT-A-dependent manner. Complete loss of Gpr161 in mouse causes midgestation lethality and increased Shh signaling in the neural tube, phenocopying Tulp3/IFT-A mutants. Constitutive Gpr161 activity increases cAMP levels and represses Shh signaling by determining the processing of Gli3 to its repressor form. Conversely, Shh signaling directs Gpr161 to be internalized from cilia, preventing its activity. Thus, Gpr161 defines a morphogenetic pathway coupling protein kinase A activation to Shh signaling during neural tube development.

Neuropilin-2 expression in cancer

AIMS

Neuropilin-2 is a coreceptor for vascular endothelial growth factor family members. Blockade of neuropilin-2 is able to suppress lymphogenous metastasis in preclinical models. The aim of this study was to validate a protocol for the evaluation of neuropilin-2 protein expression in situ, by comparison with in-situ hybridization, western blotting, and mRNA expression levels.

METHODS AND RESULTS

Immunohistochemistry was performed on normal human tissues, and whole sections for 79 primary non-small-cell lung carcinomas, 65 primary breast carcinomas, 79 primary colorectal cancers, and 52 metastases. Neuropilin-2 expression was observed in lymphatic and blood vessels from all normal and malignant tissues examined. In addition, 32% of primary non-small-cell lung carcinomas, 15% of primary breast carcinomas and 22% of primary colorectal cancers showed tumour cell expression. Fifty-five primary and nine secondary malignant melanomas were also examined for neuropilin-2 expression by in-situ hybridization. All showed vascular expression, and 85% of primary malignant melanomas showed tumour cell expression.

CONCLUSIONS

In the majority of lung, breast and colorectal cancers, the effects of anti-neuropilin-2 are likely to be restricted to the vasculature. These results will assist in pharmacokinetic evaluations, tolerability assessments and the choice of setting to evaluate the activity of anti-neuropilin-2 therapies.

Improvement in bioavailability of tricalcium phosphate to Cymbopogon martinii var. motia by rhizobacteria, AMF and Azospirillum inoculation

The interactive effects of phosphate solubilizing bacteria, N2 fixing bacteria and arbuscular mycorrhizal fungi (AMF) were studied in a low phosphate alkaline soil amended with tricalcium insoluble source of inorganic phosphate on the growth of an aromatic grass palmarosa (Cymbopogon martinii). The microbial inocula consisted of the AM fungus Glomus aggregatum, phosphate solubilizing rhizobacteria Bacillus polymyxa and N2 fixing bacteria Azospirillum brasilense. These rhizobacteria behaved as "mycorrhiza helper" and enhanced root colonization by G. aggregatum in presence of tricalcium phosphate at the rate of 200 mg kg(-1) soil (P1 level). Dual inoculation of G. aggregatum and B. polymyxa yielded 21.5 g plant dry weight (biomass), while it was 21.7 g in B. polymyxa and A. brasilense inoculated plants as compared to 14.9 g of control at the same level. Phosphate content was maximum (0.167%) in the combined treatment of G. aggregatum, B. polymyxa and A. brasilense at P1 level, however acid phosphatase activity was recorded to be 4.75 pmol mg(-1) min(-1) in G. aggregatum, B. polymyxa and A. brasilense treatment at P0 level. This study indicates that all microbes inoculated together help in the uptake of tricalcium phosphate which is otherwise not used by the plants and their addition at 200 mg kg(-1) of soil gave higher productivity to palmarosa plants.

Surveillance of occupational and work-related diseases between 1993 and 1996 in an engineering company

There are established reporting schemes for some occupational and work-related illnesses but these schemes may underestimate the true incidence of such diseases. Not all cases may be referred to a participating physician and access to adequate diagnostic facilities are not always available. Collecting data directly from occupational health departments may overcome some problems related to under-reporting as they have good access to the entire working population within their company. The aim of this paper is to report the results from such a reporting scheme operated by a large multi-national engineering company during the period 1993-96. All UK sites of Lucas Industries (later LucasVarity) participated. A report form was completed by the occupational health department of each participating site each month. The report form gave abbreviated details of each case of occupational and work-related disease occurring at that site during the previous month. Forms were posted to a central office where the data was collated and analyzed. The incidence of respiratory diseases was broadly similar or slightly higher to that reported from other schemes. Musculoskeletal diseases were by far the most common category of disease reported. During a four year period of reporting the incidence of occupational and work-related diseases decreased overall by approximately 75%. As the reported incidence of respiratory disease was comparable with or slightly higher than that from other schemes, it appears that reporting schemes such as this can provide useful and accurate data. Musculoskeletal diseases are the most common type of disease attributed to work and should probably receive greater attention. The decrease in incidence seen in LucasVarity over time may reflect increased emphasis given to health and safety issues within the company during the reporting period.

Occupational infection in an offal porter: a case of Q fever

This case report describes the job activities of an offal porter who developed Q fever while processing livers from sheep. The diagnosis was confirmed by an increase in specific serial antibody titre. The main clinical features were anorexia, nausea, headache, pyrexia and elevated gamma-glutamyl transferase. Twenty-four cases of occupationally-acquired Q fever were noted by the Communicable Diseases Surveillance Centre (CDSC) between 1984 and 1994. This case report has an important feature in that a workplace visit was performed to evaluate the system of work and the circumstances of exposure to the infectious agent. Relevant preventive measures for this zoonotic infection are discussed.