Ibrutinib combination therapy for advanced gastrointestinal and genitourinary tumours: results from a phase 1b/2 study

BACKGROUND

Ibrutinib, a first-in-class inhibitor of Bruton's tyrosine kinase, is approved for the treatment of various B-cell malignancies and chronic graft-versus-host disease. Based on encouraging preclinical data, safety and efficacy of ibrutinib combined with companion drugs for advanced renal cell carcinoma (RCC), gastric/gastroesophageal junctional adenocarcinoma (GC), and colorectal adenocarcinoma (CRC) were evaluated.

METHODS

Ibrutinib 560 mg or 840 mg once daily was administered with standard doses of everolimus for RCC, docetaxel for GC, and cetuximab for CRC. Endpoints included determination of the recommended phase 2 dose (RP2D) of ibrutinib in phase 1b and efficacy (overall response rate [ORR] for GC and CRC; progression-free survival [PFS] for CRC) in phase 2.

RESULTS

A total of 39 (RCC), 46 (GC), and 50 (RCC) patients were enrolled and received the RP2D. Safety profiles were consistent with the individual agents used in the study. Confirmed ORRs were 3% (RCC), 21% (GC), and 19% (CRC). Median (90% CI) PFS was 5.6 (3.9-7.5) months in RCC, 4.0 (2.7-4.2) months in GC, and 5.4 (4.1-5.8) months in CRC.

CONCLUSIONS

Clinically meaningful increases in efficacy were not observed compared to historical controls; however, the data may warrant further evaluation of ibrutinib combinations in other solid tumours.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02599324.

Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology

Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed.

Performance of the 2021 CKD-EPI equations without a race coefficient in a multi-racial population of adults with solid tumors: A prospective cross-sectional study

12064

Background: We previously showed that estimated glomerular filtration rate (eGFR) based on serum creatinine (Scr)(eGFRcr) using the 2009 CKD-EPI equation performed better than Cockroft-Gault equation (CG) in solid tumor patients in Brazil (Onco-GFR Study). In that study, eGFR based on Scr and cystatin C (Scys)(eGFRcr-cys) using the 2012 CKD-EPI was the most accurate equation and suitable for use as a confirmatory test. The CKD-EPI 2009 eGFRcr and 2012 eGFRcr-cys equations include a term for race (Black vs. non-Black). The 2021 CKD-EPI eGFRcr and eGFRcr-cys equations do not include race and are now recommended in the US, but have not been assessed in a multi-racial population or in cancer patients. The aim of this study is to evaluate the performance of the 2021 CKD-EPI equations in the Onco-GFR Study. Methods: Measured GFR (mGFR) was determined using the plasma clearance of 51Cr-EDTA. Scr and Scys assays were traceable to international standards. Results: A group of 1,200 patients recruited between April 2015 and September 2017 were included for analysis. Patients were 58.8±13.2 years, 50.8% male. Race distribution was Black participants 12.8% and non-Black participants 81.2%. Mean (SD) mGFR was 78.5±21.7 ml/min/1.73 m2. For eGFRcr, the overestimation of mGFR was larger for the 2021 vs. 2009 equation -10.0 vs. 8.1 ml/min/1.73m2, resulting in lesser accuracy 1-P30 of 22.3 vs. 19.1, but still more accurate than CG equation (1-P30 of 24.9, P = 0.05). For eGFRcr-cys, the overestimation of mGFR was larger for the 2021 vs. 2012 equation (-4.1 vs. -2.0 ml/min/1.73m2). eGFRcr-cys using the 2021 equation was more accurate than eGFRcr using the 2021 equation and eGFRcys using the 2012 equation (1-P30 9.8 vs. 22.3 and 12.3, p-values < 0.001 and 0.01, respectively) (Table). Conclusions: 2021 CKD-EPI eGFRcr equation race performed better than CG. 2021 CKD-EPI eGFRcr-cys performed better than 2021 eGFRcr and 2012 eGFRcys equations. Removing race from eGFR equations represents an advance and should be incorporated in cancer care. [Table: see text]

A prospective cross-sectional study estimated glomerular filtration rate from creatinine and cystatin C in adults with solid tumors

Current guidelines recommend estimating glomerular filtration rate (eGFR) using creatinine (eGFRcr) with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation as the first test for GFR evaluation, but the Cockcroft-Gault (CG) equation is still commonly used in oncology practice and clinical trials despite increasing evidence of its inaccuracy compared to measured GFR (mGFR). Guidelines recommend eGFR using cystatin C (eGFRcys) or both markers (eGFRcr-cys) as a confirmatory test, but neither was carefully evaluated in cancer patients. Therefore, we compared performance of the CKD-EPI equations and others to the CG equation in adults with a variety of solid tumors. The mGFR was determined by plasma clearance of ⁵¹Cr-EDTA. Bias was defined as the median of the differences between mGFR and eGFR while accuracy was defined as the percentage of estimates that differed by more than 30% from the measured GFR (1-P30). We prospectively recruited 1,200 patients between April 2015 and September 2017 with a mean age and mGFR of 58.8 years and 78.4 ml/min/1.73m², respectively. Bias among eGFRcr equations varied from -8.1 to +6.1 ml/min/1.73 m². CG was the least accurate, 1-P30 (95% confidence interval) was 24.9 (22.4- 27.3)%; CKD-EPI had 1-P30 of 19.1 (16.8-21.2)% while eGFRcr-cys had the best performance: bias -2.0 (-2.6 to -1.1) ml/min/1.73m² and 1-P30 7.8 (6.3-9.4)%. Thus, the CG equation should not be preferred over CKD-EPI equation, and eGFRcr-cys can be used as a confirmatory test in adults with solid tumors. Hence, a major policy implication would be to adopt general practice guideline-recommended methods for GFR evaluation in oncology practice and clinical trials.

499. Rapid and Sustained Decline in CXCL-10 (IP-10) Annotates Clinical Outcomes Following TNF-α Antagonist Therapy in Hospitalized Patients with Severe and Critical COVID-19 Respiratory Failure

Background

TNFα and IFN-γ may synergize to induce cytokine-driven lethal hyperinflammation and immune exhaustion in COVID-19 illness.

Methods

To assess TNFα-antagonist therapy, 18 hospitalized adults with hypoxic respiratory failure and COVID-19 pneumonia received single-dose infliximab-abda therapy 5mg/kg intravenously between April and December 2020. The primary endpoint was time to increase in oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) by ≥ 50 compared to baseline and sustained for 48 hours. Secondary endpoints included 28-day mortality, dynamic cytokine profiles (Human Cytokine 48-Plex Discovery Assay), secondary infections, duration of supplemental oxygen support and hospitalization.

Consort diagram

Hospitalized patients with SARS-COV2 infection and pneumonia that were referred to the infliximab-abda study team for evaluation.

Results

Patients were predominantly in critical respiratory failure (15/18, 83%), male (14/18, 78%), above 60 years (median 63 yrs, range 31-80), race-ethnic minorities (13/18, 72%), lymphopenic (13/18, 72%), steroid-treated (17/18, 94%), with a median ferritin of 1953ng/ml. Sixteen patients (89%) met the primary endpoint within a median of 4 days, 15/18 (83%) recovered from respiratory failure, and 14/18 (78%) were discharged in a median of 8 days and were alive at 28-day follow-up. Deaths among three patients ≥ 65 years age with pre-existing lung disease or multiple comorbidities were attributed to secondary lung infections. Mean plasma IP-10 levels declined sharply from 9183 pg/ml to 483 pg/ml at Day 3 and 146 pg/ml at Day 14/discharge. Significant declines in IFN-γ, TNFα, IL-27, IL-6 (baseline above 10pg/ml), CRP and ferritin were specifically observed at Day 3 whereas other cytokines were unaffected. Among 13 lymphopenic patients, six (46%) had resolution of lymphopenia by day 3, and 11 by day 14. CXCR3-ligand (IP-10 and CXCL-9) declines were strongly correlated among patients with lymphopenia reversal (Day 3, Pearson r: 0.98, p-value: 0.0006).

Demographics and clinical characteristics

Demographics, comorbidities, clinical features, inflammatory markers, and outcomes of 18 patients with COVID-19 respiratory failure treated with infliximab-abda between April and December 2020.

Changes in oxygen support status following infliximab-abda treatment

Colored bars indicate the maximal level of oxygen support for each individual following treatment with infliximab-abda. The status of the patient at last follow-up (discharged, alive or dead) is indicated. ECMO: extracorporeal membrane oxygenation

Control of inflammatory markers and cytokines following infliximab therapy

Values from individuals are connected with solid lines, with deceased individuals indicated in red. Statistics: n=18, paired ratio t-test compared to baseline; *: P<0.05, **: P<0.01, ***: P<0.001, ****: P<0.0001, n.s.: not significant.

Conclusion

Consistent with a central role of TNFα, the clinical and cytokine data indicate that infliximab-abda may rapidly abrogate pathological inflammatory signaling to facilitate clinical recovery in severe and critical COVID-19. Randomized studies are formally evaluating infliximab therapy in this context. Funding: National Center for Advancing Translational Sciences

Disclosures

All Authors: No reported disclosures

A multidisciplinary early mobility model for cardiac patients in coronary intensive care unit

Funding Acknowledgements

This is an unfunded project

Background

Early mobilization is considered as a complex task in an intensive care unit (ICU) and patients are often on prolonged bed rest leading to physical deconditioning. Intensive care early mobility programs have been recognized to be safe and have shown positive outcomes. However, implementing early mobility program as a standard of care remains a challenge.

Coronary Intensive Care Unit (CICU) provides complex care for cardiac critically ill patients. In February 2018, the CICU multidisciplinary team (MDT) started a quality improvement project to implement early mobility program in the unit.

Purpose

This project aimed to investigate the feasibility of implementing an Early Mobility Protocol in CICU to increase the number of patients mobilized to more than 95%. Secondary objective was to explore the impact of the protocol on the mobility level of the patients at the time of discharge or transfer from the CICU.

Methods

A multidisciplinary mobility task force including Physicians, nurses, physiotherapists and respiratory therapists was formed to analyze the barriers in implementing an early mobility program. A staff survey was conducted to identify the need for a standard early mobility protocol. Root cause analysis and Pareto analysis was done. An evidence based early mobility protocol was developed and implemented. All non-mechanical ventilated patients were included in the first phase and all mechanical ventilated patients were included in the second phase of the project. A standard ICU Mobility scale (IMS) was used for scoring the mobility level of the patients. This quality improvement project is based on "Institute for Healthcare Improvement" model. Periodical staff education and training programs about early mobilization were conducted to improve staff confidence. Change ideas were implemented using multiple Plan Do Study Act cycles.

Results

The total number of patients included from 1st March 2018 till 31st December 2019 was 2356. This included both the genders. In March 2018, only 68% of non-mechanical ventilated patients were mobilized, that reached to 88% by November 2018. This gradually increased to 100% in May 2019 and is currently sustained at 100%.

In November 2019, only 50% of mechanical ventilated patients were mobilized which gradually increased to 66.66% and 75% in middle and end of December 2019. The mean IMS score at discharge or transfer from CICU was "8". From patient-family experience survey, 93.75% of patients perceived that the program was helpful in regaining mobility and 96.25% of patients felt that the program helped in regaining their autonomy.

Conclusion

The result shows that it is safe and feasible to implement an early mobility program in a Coronary Intensive Care Unit. A standardized mobility protocol can lead to efficient mobilization practice facilitating early transfers from ICUs without any complications. This could further enhance the collaboration of the MDT members leading to culture change in ICUs.

Intravenous Ketorolac Infusion for Intractable Pleuritic Pain Secondary to Metastatic Epithelioid Hemangioendothelioma

Background: Epithelioid hemangioendothelioma (EHE) patients can experience severe pain. Nonsteroidal anti-inflammatory drugs, including ketorolac tromethamine, can effectively treat cancer-related pain, provide an opioid-sparing effect, and may be particularly effective for EHE pain. There are limited data describing prolonged (>5 days) continuous intravenous (IV) ketorolac infusion for cancer-related pain and no data on its use in EHE. Case Description: A 67-year-old woman with metastatic hepatic EHE suffered from chronic intractable pleuritic pain unresponsive to trials of nonopioid, opioid, adjuvant medications, and nonpharmacological interventions. In the hospital, continuous IV ketorolac infusion at 3.8 mg/hour (91.2 mg/day) effectively managed pain. With thorough monitoring, the patient was discharged on continuous IV ketorolac infusion at 3 mg/hour (72 mg/day). Infusion continued for 79 days without clinical or laboratory evidence of ketorolac toxicity. Conclusion: Ketorolac tromethamine as a long-term infusion is a potentially viable analgesic for patients with intractable EHE-related pain unresponsive to standard therapies.

Rapid and sustained decline in CXCL-10 (IP-10) annotates clinical outcomes following TNFα-antagonist therapy in hospitalized patients with severe and critical COVID-19 respiratory failure

BACKGROUND

A feedforward pathological signaling loop generated by TNFα and IFN-γ synergy in the inflamed lung, driving CXCL-10 (IP-10) and CXCL-9 chemokine-mediated activated T-cell and monocyte/macrophage tissue recruitment, may define the inflammatory biology of lethal COVID-19 respiratory failure.

METHODS

To assess TNFα-antagonist therapy, 18 hospitalized adults with hypoxic respiratory failure and COVID-19 pneumonia received single-dose infliximab-abda therapy 5 mg/kg intravenously between April and December 2020. The primary endpoint was time to increase in oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) by ≥50 compared to baseline and sustained for 48 h. Secondary endpoints included 28-day mortality, dynamic cytokine profiles, secondary infections, duration of supplemental oxygen support, and hospitalization.

FINDINGS

Patients were predominantly in critical respiratory failure (15/18, 83%), male (14/18, 78%), above 60 years (median 63 years, range 31-80), race-ethnic minorities (13/18, 72%), lymphopenic (13/18, 72%), steroid-treated (17/18, 94%), with a median ferritin of 1953 ng/ml. Sixteen patients (89%) met the primary endpoint within a median of 4 days; 14/18 (78%) were discharged in a median of 8 days and were alive at 28-day follow-up. Three deaths were attributed to secondary lung infection. Mean plasma IP-10 levels declined sharply from 9183 to 483 pg/ml at Day 3 and 146 pg/ml at Day 14/discharge. Significant Day 3 declines in IFN-, TNFα, IL-27, CRP, and ferritin occurred. IP-10 and CXCL-9 declines were strongly correlated among patients with lymphopenia reversal (Day 3, Pearson r: 0.98, P-value 0.0006).

INTERPRETATION

Infliximab-abda may rapidly abrogate pathological inflammatory signaling to facilitate clinical recovery in severe and critical COVID-19.

Rapid and sustained decline in CXCL-10 (IP-10) annotates clinical outcomes following TNF-α antagonist therapy in hospitalized patients with severe and critical COVID-19 respiratory failure

Background

A feed-forward pathological signaling loop generated by TNFα and IFN-γ in inflamed lung tissue, driving CXCL-10 (IP-10) and CXCL-9 chemokine-mediated activated T-cell and monocyte/macrophage tissue recruitment, may define, sustain and amplify the inflammatory biology of lethal COVID-19 respiratory failure.

Methods

To assess TNFα-antagonist therapy, 18 hospitalized adults with hypoxic respiratory failure and COVID-19 pneumonia received single-dose infliximab-abda therapy 5mg/kg intravenously between April and December 2020. The primary endpoint was time to increase in oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) by ≥ 50 compared to baseline and sustained for 48 hours. Secondary endpoints included 28-day mortality, dynamic cytokine profiles (Human Cytokine 48-Plex Discovery Assay, Eve Technologies), secondary infections, duration of supplemental oxygen support and hospitalization.

Findings

Patients were predominantly in critical respiratory failure (15/18, 83%), male (14/18, 78%), above 60 years (median 63 yrs, range 31-80), race-ethnic minorities (13/18, 72%), lymphopenic (13/18, 72%), steroid-treated (17/18, 94%), with a median ferritin of 1953ng/ml. Sixteen patients (89%) met the primary endpoint within a median of 4 days, 15/18 (83%) recovered from respiratory failure, and 14/18 (78%) were discharged in a median of 8 days and were alive at 28-day follow-up. Deaths among three patients ≥ 65yrs age with pre-existing lung disease or multiple comorbidities were attributed to secondary lung infection. Mean plasma IP-10 levels declined sharply from 9183 pg/ml to 483 pg/ml at Day 3 and further to 146 pg/ml at Day 14/discharge. Significant declines in IFN- γ , TNFα, IL-27, CRP and ferritin were specifically observed at Day 3 whereas other cytokines were unmodified. IL-6 levels declined sharply among patients with baseline levels >10 pg/ml. Among 13 lymphopenic patients, six (46%) had resolution of lymphopenia by day 3, and 11 by day 14. CXCR3-ligand (IP-10 and CXCL-9) declines were strongly correlated among patients with lymphopenia reversal (Day 3, Pearson r: 0.98, p-value: 0.0006).

Interpretation

Consistent with a pathophysiological role of TNFα, the clinical and cytokine data indicate that infliximab-abda may rapidly abrogate pathological inflammatory signaling to facilitate clinical recovery in severe and critical COVID-19. Randomized studies are required to formally assess mortality outcomes. Funding: National Center for Advancing Translational Sciences.

Rapid and sustained decline in CXCL-10 (IP-10) annotates clinical outcomes following TNF-α antagonist therapy in hospitalized patients with severe and critical COVID-19 respiratory failure

BACKGROUND

A feed-forward pathological signaling loop generated by TNFα and IFN-γ in inflamed lung tissue, driving CXCL-10 (IP-10) and CXCL-9 chemokine-mediated activated T-cell and monocyte/macrophage tissue recruitment, may define, sustain and amplify the inflammatory biology of lethal COVID-19 respiratory failure.

METHODS

To assess TNFα-antagonist therapy, 18 hospitalized adults with hypoxic respiratory failure and COVID-19 pneumonia received single-dose infliximab-abda therapy 5mg/kg intravenously between April and December 2020. The primary endpoint was time to increase in oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) by ≥ 50 compared to baseline and sustained for 48 hours. Secondary endpoints included 28-day mortality, dynamic cytokine profiles (Human Cytokine 48-Plex Discovery Assay, Eve Technologies), secondary infections, duration of supplemental oxygen support and hospitalization.

FINDINGS

Patients were predominantly in critical respiratory failure (15/18, 83%), male (14/18, 78%), above 60 years (median 63 yrs, range 31-80), race-ethnic minorities (13/18, 72%), lymphopenic (13/18, 72%), steroid-treated (17/18, 94%), with a median ferritin of 1953ng/ml. Sixteen patients (89%) met the primary endpoint within a median of 4 days, 15/18 (83%) recovered from respiratory failure, and 14/18 (78%) were discharged in a median of 8 days and were alive at 28-day follow-up. Deaths among three patients ≥ 65yrs age with pre-existing lung disease or multiple comorbidities were attributed to secondary lung infection. Mean plasma IP-10 levels declined sharply from 9183 pg/ml to 483 pg/ml at Day 3 and further to 146 pg/ml at Day 14/discharge. Significant declines in IFN- γ , TNFα, IL-27, CRP and ferritin were specifically observed at Day 3 whereas other cytokines were unmodified. IL-6 levels declined sharply among patients with baseline levels >10 pg/ml. Among 13 lymphopenic patients, six (46%) had resolution of lymphopenia by day 3, and 11 by day 14. CXCR3-ligand (IP-10 and CXCL-9) declines were strongly correlated among patients with lymphopenia reversal (Day 3, Pearson r: 0.98, p-value: 0.0006).

INTERPRETATION

Consistent with a pathophysiological role of TNFα, the clinical and cytokine data indicate that infliximab-abda may rapidly abrogate pathological inflammatory signaling to facilitate clinical recovery in severe and critical COVID-19. Randomized studies are required to formally assess mortality outcomes. Funding: National Center for Advancing Translational Sciences.

Fractionated docetaxel and radium-223 (Ra223) in metastatic castration-resistant prostate cancer (CRPC): A phase I trial

TPS175

Background: Disease progression following highly-active androgen-axis therapy (HAAT) in CRPC remains bone-dominant and docetaxel-responsive. Combination bone-homing Ra223 isotope therapy with docetaxel would be a logical combination therapy to follow but myelosuppression is dose-limiting. With 3-weekly bolus schedules of docetaxel (D), dose-reduction to 60mg/m2 Q3wkly and Ra223 to every 6 weeks has been required representing a reduction in the dose-intensity of both agents. Fractionated schedules of docetaxel Q2wkly (DQ2) have comparable activity to D 75mg/m2 Q3wkly (DQ3) with mitigated myelosuppression. We hypothesize that a fractionated dose-schedule of DQ2 in combination with standard Ra223 dosing will be feasible without reduction in dose-intensity of Ra-223 or D. Methods: Outcomes: The primary objective is to determine the feasibility and maximal tolerated dose (MTD) of the combination. Secondary objectives include PSA kinetics, objective response, bone marker outcomes, progression free and overall survival, and description of toxicity and quality of life. Eligibility: Progressive bone-metastatic CRPC, ECOG PS 0-2 with no prior Ra223, no prior docetaxel for CRPC, and no bulky visceral disease. Design: Phase I (6+6) design; 4 week lead-in with DQ2. Dose-level 1a: 40mg/m2; 2a: 50mg/m2, both with PEGylated G-CSF on Day 16. If tolerated (≤ Grade 2 toxicity, ANC ≥ 1500, Platelets ≥ 100,000), lead-in is followed by C1D1 of DQ2 plus Ra223 Q4wkly x 6 doses. Dose level 1a has accrued 6 subjects without DLT. Enrollment to Dose Level 2a began in August, 2020. An expansion cohort of 25 subjects is planned after the MTD is determined. Clinical trial information: NCT03737370.

An Ethically Justified Approach That Integrates Advance Directives Discussions With Care of the Patient With Cancer

Although the frequency of advance directives discussions may be increasing, there is a need to improve the quality of these discussions. In a range of advanced medical illnesses, including cancer, poor outcomes with advanced cardiopulmonary life support (ACLS) have been well documented. However, when speaking to patients at the end-of-life, physicians frequently withhold evidence-based information and guidance about prognosis or outcomes of ACLS. Tools and models developed to facilitate communication at the end-of-life do not explicitly include recommendations on advance directives and specifically do not discuss the available evidence on ACLS outcomes in the seriously ill. Here, we review the current literature on outcomes of ACLS and current tools and communications for end-of-life discussions. A majority of patients have a preference for truth-telling and guidance. We advocate an approach that integrates individual goals and preferences with a shared understanding of prognosis and appropriate management options, as judged and recommended by the disease experts, in order to reach an evidence-based decision on advance directives. This pragmatic and ethically justified approach emphasizes active empathic communication to prioritize the care of the patient over the mechanical details of ACLS, thereby aligning end-of-life discussions with current practices in other domains of medicine.

Association between Thyroid Stimulating Hormone with Components of Metabolic Syndrome in Postmenopausal Women

Introduction: Metabolic Syndrome (MS) identifies a group of metabolic disorders that includes glucose intolerance, central obesity, hypertension and dyslipidaemia that place the affected individual at exaggerated risk for developing disorder, in addition as exaggerated mortality from all causes. Aim: To evaluate serum Thyroid Stimulating Hormone (TSH) levels and to determine the correlation between serum concentrations of TSH with components of MS among postmenopausal women with MS. Materials and Methods: A cross-sectional observational study was conducted for the period of four months on 100 postmenopausal women between 45-65 years who attended Outpatient Department (OPD) of Obstetrics and Gynaecology, Adichunchanagiri Institute of Medical Sciences (AIMS), Mandya, Karnataka, India. A fasting blood sample was collected from all the subjects, serum was used for estimating Fasting Plasma Glucose (FPG), Lipid profile, and Serum TSH. Results were presented on Mean±SD (Standard Deviation) (Min-Max) and in Number (%). For the comparison of means, Analysis of Variance (ANOVA) test was used. Correlation was examined by determining Pearson correlation coefficient (r-value). A p-value <0.05 was taken as statistically significant. Results: Among the study population, the dysfunction in thyroid gland was found in 35 (35%). The major thyroid dysfunction was found to be hypothyroidism (32%) and only three had hyperthyroidism (3%). Waist Circumference (WC), Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) were 98.2±12 cm, 128.84±13.65 mmHg and 79.2±9.2 mmHg, respectively. Fasting Blood Glucose (FBS), Triglyceride (TAG), High Density Lipoprotein (HDL) cholesterol (HDL-C) and TSH were 166.7±71 mg/dL, 125.94±90.67 mg/dL, 45.46±13.13 mg/dL and 3.35±2.01 mIU/L, respectively. Statistically significant positive correlation was observed between FPG (p=0.049) and both SBP (p=0.0008) and DBP (p=0.001) and negative correlation was observed between TAG, HDL and TSH but not statistically significant in women with hypothyroidism when compared to euthyroid. A statistically negative correlation was found with WC (p=0.001) and positive correlation was found with TAG (p=0.008) and TSH among women with euthyroid condition. Conclusion: Hypothyroidism alters lipid levels and increases blood pressure leading to increased risk for cardiovascular disease (CVD). Together hypothyroidism and metabolic syndrome could increase the risk for CVD in postmenopausal women. Thus, assessing thyroid function in postmenopausal women with metabolic syndrome may aid in early detection of CVD risk and better clinical management among these patients and reduces the already existing high incidence of CVDs.

Non-Compartment and compartmental pharmacokinetics, efficacy, and safety of Kedrion FIX concentrate

BACKGROUND

An open-label phase II, multicenter clinical trial was conducted at 11  Haemophilia Centres in  Italy, Romania, and Turkey, to evaluate the pharmacokinetics (PK), efficacy, and safety of high purity, plasma-derived, double virus inactivated and double nano-filtered factor IX (pd-FIX) concentrate (Kedrion FIX), EudraCT Number: 2005-006186-14.

MATERIAL AND METHODS

16 previously treated patients (PTPs) with severe or moderately severe haemophilia B were enrolled in the study. At enrolment, 14 underwent the first PK assessment (PK I), and the second PK (PK II) assessment was performed after six months of treatment (5 on-demand and nine prophylaxis) at the end of the study. PK parameters were evaluated by Non-Compartmental Analysis (NCA), One-Compartment model (OCM), and Two-Compartment Model (TCM). Efficacy of Kedrion FIX in all 16 patients was evaluated by the number of bleeding events, and clinical response following the infusions. Periodic FIX inhibitor assays and thrombogenicity tests were scheduled throughout the study to assess the safety of the drug.

RESULTS

As compared to the published data on PK of pdFIX, Kedrion FIX displayed a longer half-life (22.37-55.73 hrs), reduced clearance, and regular volume of distribution at PK I by both NCA and OCM. The comparison of outcomes of PK II with those of PK I by OCM,  also showed significant changes, particularly in patients on prophylaxis, who showed some improved parameters of PK. Due to two outlier values at the end of the trial, the NCA parameters of PK I were not compared to those of PK II. Breakthrough bleeds were successfully treated with 1 or 2 infusions. No significant adverse events were observed during the study.

DISCUSSION

During the six-month clinical study period, the use of Kedrion FIX resulted in a safe and effective pd-FIX concentrate with excellent PK characteristics.

Low Dose Clenbuterol Toxicity: Case Report and Review of Literature

Description Clenbuterol is a long-acting β-agonist used in oral and inhaled form for asthma treatment outside the U.S. and in veterinary medicine within the U.S. It is also used off-label for anabolic effects worldwide. Toxicity with clenbuterol is increasingly seen in U.S. hospitals, primarily in younger individuals using the drug for competitive athletics or bodybuilding. We present a case of a young patient who presented after an intentional overdose and discuss the relevant literature. Presentations do not correlate with the dosage ingested. Signs and symptoms can range from simple nausea to myocardial ischemia, rhabdomyolysis and cardiogenic shock. Treatment of overdose is simple and should be promptly started using intravenous fluid hydration and potassium supplementation. Benzodiazepines may be utilized for agitation or delirium. β-blockers or phenylephrine may be used to give hemodynamic support. More research is needed to gain an understanding of the optimal treatment of clenbuterol toxicity, especially if it becomes a more frequent reason for medical encounters in the U.S.

Aberrant integrin αv and α5 expression in prostate adenocarcinomas and bone-metastases is consistent with a bone-colonizing phenotype

Background

Collaborative signaling between fibronectin-binding αv and α5 integrins has been implicated in the lethal dissemination of prostate cancer in the bone-metastatic niche, the major source of morbidity and mortality in the disease.

Methods

We assessed the frequency and pattern of expression of these integrins in primary high-grade adenocarcinomas and bone metastases compared to the physiological gland. Formalin-fixed paraffin-embedded (FFPE) radical prostatectomy (RP) samples (n=25) containing ≥ Gleason grade 4 cancer and decalcified surgical or diagnostic bone metastatic samples from 10 patients were stained for integrin αv (ITGAV) and integrin α5 (ITGA5) expression. Antibody optimization and antigen-retrieval was performed beforehand.

Results

ITGAV was exclusively expressed in the basal layer of physiological prostate glands whereas αv expression was invariably recapitulated in the malignant gland and bone metastases (100%) in multiple distinct patterns: epithelial membranous, basilar/luminal membranous, punctate cytoplasmic, intense foci as single cells or clusters, and rim stromal layers. The luminal/basilar layer of ITGAV expression was striking in cribriform carcinomas, suggestive of a role in molecular pathogenesis. ITGA5 infrequently highlighted the basal layer of the physiological gland, was absent in primary adenocarcinoma, but was expressed with ITGAV exclusively in bone metastases (71%).

Conclusions

We conclude that ITGAV expression is aberrantly expressed in high frequency in high-grade prostatic adenocarcinomas in patterns suggestive of recapitulated basal cell functions, consistent with a stem-regulatory role that has been proposed. Co-expression and enrichment of αv and α5 in osseous metastases supports their proposed collaborative role in colonization of the bone microenvironment and as candidate targets for therapy.

The Last Day Narratives: An Exploration of the End of Life for Patients with Cancer from a Caregivers' Perspective

Background: Surviving family caregivers describe the end-of-life experience as "very distressing" and half of those surveyed indicate inadequate emotional support; however, little is known about the causes of distress on the last day of life. Objective: The purpose of this study was to explore the experience of the last day of life from the perspective of the surviving caregiver. Design: The study used a narrative inquiry approach. Setting/Subject: Surviving caregivers of deceased adult cancer patients at a single institution were invited to participate. Measurements: After reviewing, coding, and categorizing the narratives individually, they were collectively considered and thematically analyzed across all cases to provide a summative analysis. Results: Six themes captured the overall experiences: (1) relationships and communication with health care providers impact overall experience, (2) being able to prepare for death was a source of comfort, (3) being a caregiver impacts quality of life and identity, (4) spiritual visitations as a welcome experience, (5) navigating the dying days and early grief period wrought with guilt and closure, and (6) loss of community contributes to distress and distracts from healing. Conclusions: In this study, distress was most often linked to communication failures. Caregivers also experienced distress and guilt related to the loss of their caregiver role. Findings also support a need for increased preparation for caregivers. Finally, the study showed the frequency of visitations/spiritual experiences during grieving.

60 Post Inpatient Fall Medical Assessment (PIFMA) Performa Quality Improvement Project

Introduction

Inpatient falls are the most commonly reported patient safety incidents and in the United Kingdom, there are 250,000 reported falls per year 1. A rapid response report (RRR) issued in 2011 by the NPSA highlighted need for improvement in identifying fractures and neurological observations. These figures reflect significant implications to patients’ health and financial burden to the NHS.

Aims

To improve assessment and documentation of inpatient falls assessment.

Methods

Two PDSA cycles were completed. First PDSA cycle established a baseline of post fall assessment and documentation in which raising awareness and teaching (RAT) to junior doctors was done. Second PDSA cycle identified room for further improvement and post inpatient fall medical assessment (PIFMA) Performa was developed to aid assessment and documentation for use of junior doctors. Feedback regarding the usefulness of the PIFMA Performa was collected via survey.

Results

The RAT intervention involved 30 patients of the Elderly wards in November and December 2017 and the PIFMA intervention involved 29 patients in all Medical wards in January and February 2019. The PIFMA Performa improved the time taken to review patients as per doctors survey. On comparing the RAT against PIFMA Performa interventions, documentation improved in the categories of physical examination (from 80% to 97%), neurological observations (from 49% to 98%), medication review (from 53% to 83%), and measuring lying standing blood pressure (from 83% to 90%).

Conclusions

Feedback from junior doctors states that the PIFMA Performa was certainly a very useful guidance tool and help to speed up documentation. These improvements only translated if junior doctors utilize the PIFMA Performa and so this is now being implemented in the trust policy. Further PDSA cycle can reassess if improvements truly represent the population cross-section.

References

1. The incidence and costs of inpatient falls in hospitals (2017), NHS improvement.

2. National Patient Safety Agency NPSA/2011/RRR001 (13 January 2011).

Abstract 114: Aberrant integrin alpha v and alpha 5 expression patterns in prostate adenocarcinomas and bone-metastases from prostate cancer are consistent with a bone-colonizing phenotype

Background: Fibronectin-binding αv and α5 integrins mediate homing, adhesive and survival interactions of prostate cancer cells with bone-marrow mesenchymal stromal cells. Monospecific αv integrin antibody therapy slowed progression of bone metastases but failed to impact overall mortality in prostate cancer. Cross-regulation between αv and α5 integrin is a potential source of adaptive resistance to monospecific blockade of either integrin. We assessed the patterns of expression of these partner integrins in bone metastases and the transition from the physiological gland to the malignant phenotype.

Methods Formalin-fixed paraffin-embedded (FFPE) radical prostatectomy samples (n=25) from patients with a ≥ Gleason grade 4 component and decalcified FFPE samples of prostate cancer bone metastases (n=10) were obtained from institutional tissue biorepository. Optimized immunohistochemistry methods developed in prostate cancer cell suspensions were applied to assess expression patterns of αv and α5 integrins in benign and malignant glandular elements in primary tumors and bone specimens.

Results Integrin αv was universally expressed in the physiological basal layer of benign prostate glands (n=25;100%) but not in the luminal epithelium. With loss of the basal layer in malignant transition, αv expression was recapitulated in 100% of malignant glandular epithelium in distinct patterns including epithelial membranous (24/25;96%), luminal membranous (6/25; 24%), punctate cytoplasmic (14/25;56%), intense foci of membranous staining (single cells or clusters surrounded by αv-negative tumor) (10/25;40%), and rim stromal patterns (14/25;56%). Luminal membranous and rim stromal αv expression patterns were striking in tumors with cribriform morphology. Furthermore, integrin αv was identified in all evaluable bone metastatic samples (7/7:100%). By contrast, integrin α5 was identified infrequently in the physiological basal layer (1/10;10%), was not expressed in malignant glandular epithelium of primary tumors but was paradoxically expressed in malignant epithelium in bone metastases (5/7:71%).

Conclusion Integrin αv expression is universally and exclusively found in the physiological basal layer of the normal gland that harbors stem-functions and is recapitulated in high frequency in prostatic adenocarcinomas in diverse patterns suggestive of distinct biological functions that may contribute to disease progression. Co-expression and enrichment of integrins αv and α5 in osseous metastases is supportive of a proposed cooperative role of these fibronectin-binding integrins toward bone colonization. Given the adaptive cross-regulation we have observed with targeting of either integrin, combined αv and α5 integrin targeting in prostate cancer bone metastases may be required for effective therapy.

Citation Format: Brendan Connell, Pavel Kopach, Wenying Ren, Raghav Joshi, Steven Naber, Paul Mathew. Aberrant integrin alpha v and alpha 5 expression patterns in prostate adenocarcinomas and bone-metastases from prostate cancer are consistent with a bone-colonizing phenotype [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 114.

Abstract 1902: The comparative superiority of a bispecific antibody targeting alpha v and alpha 5 integrins is uniquely characterized by induced degradation of integrins

Background: Bispecific antibody blockade of alpha v and alpha 5 integrins (BsAbαvα5) resulted in superior anti-tumor activity in prostate cancer cells over monospecific αv (MsAbαv) and α5 blockade (MsAbα5), singly or in combination. We sought to define a molecular basis for this observation.

Methods: We examined the comparative impact of monospecific and bispecific antibody strategies on membrane-specific and cellular expression of integrins as well as their transcription, translation and degradation fate in integrin av/a5+ prostate cancer cells (VCAP, C4-2b, DU-145 and PC-3). These dynamic changes were assessed in the context of functional studies including tumor-stromal interactions and downstream signaling.

Results: With MsAbαv or MsAbα5 therapy, alone or in combination, upregulation of target integrin and/or the alternative integrin was observed which suggested both autoregulation as well as a cross-regulation among the target integrins. However, with BsAbαvα5 therapy, either a block in upregulation of target integrin/s or a marked decrease in cellular integrin expression was noted. Unexpectedly, these dynamic changes in cellular integrin expression with the BsAbαvα5 were retained up to 72 hours after antibody exposure with recovery of integrin expression in viable cells noted by 7 days. In cells recovered at 48-72 hours, a marked decrease in clonogenicity, adhesion and migration was observed. Flow cytometry indicated persistent membrane loss of integrin expression at 48-72 hours confirming that the impact of the BsAbαvα5 is not related to altered subcellular integrin trafficking alone. QRT-PCR studies did not identify upregulation of integrin transcription to account for upregulated integrin expression. Blockade of protein translation with cycloheximide failed to abrogate the differential impact of MsAbs or BsAbαvα5 on integrin expression. However, lysosomal inhibition with chloroquine blocked the downregulation of integrin expression with BsAbαvα5 therapy. Variable effects on downstream signaling in the Akt and MAPK pathway observed across cell types contrasted with consistent functional impairment of tumor-stromal interactions.

Conclusions: BsAbαvα5 therapy uniquely induces lysosomal degradation of target integrins compared to MsAbs, alone or in combination. Cellular depletion of integrin expression serves as a pharmacodynamic marker of BsAbαvα5activity. By contrast, upregulated cellular expression secondary to MsAb therapy is likely secondary to a block in both integrin degradation and membrane recycling within the endosomal/lysosomal pathway. These observations provide additional insight into the mechanistic impact of the BsAbαvα5 as well as a pharmacodynamic method for monitoring in vivo activity.

Citation Format: Raghav Joshi, Wenying Ren, Paul Mathew. The comparative superiority of a bispecific antibody targeting alpha v and alpha 5 integrins is uniquely characterized by induced degradation of integrins [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1902.

Validation of age and height based formulae to predict paediatric airway distances - a prospective observational study

Background:

Preoperative airway evaluation in children is an important part of routine preanesthetic evaluation before surgery. External airway measurements, viz., thyromental, mentohyoid, and sternomental distances, while being growth dependent, could identify pediatric patients with potentially difficult airways.

Objectives:

This study was conducted to validate the age- and height-based formulae, derived from a previous study conducted in our institute, to predict thyromental distance, sternomental distance, and mentohyoid distance in relation with the height and age of pediatric patients.

Design:

Prospective cross-sectional single arm observational study.

Setting:

Tertiary level university teaching hospital from July 2015 to December 2016.

Patients:

Children (202) in the age group of 3-15 years with no obvious external airway anomaly scheduled for elective surgery under general anesthesia.

Outcomes Measured:

The thyromental, mentohyoid, and sternomental distances were measured preoperatively. The same parameters were then calculated based on age- and height-related formulae derived in the earlier study.

Results:

Bland-Altman analysis of the sample patients showed a mean difference (bias) between measured and calculated values ranging from 0.14 to –0.60 (3 - 13%). Overall agreement in terms of bias were found to be more with height-based equation for mentohyoid distance and thyromental distance and age-based equation for sternomental distance.

Conclusion:

Our study validates the formulae derived in the earlier study to predict thyromental, mentohyoid, and sternomental distances in children with no obvious external airway anomalies. Further studies are needed to extend the applicability of these formulae in obese children and those with craniofacial anomalies coming for general anesthesia and surgery.

Shifting patterns of care in localized prostate cancer: Impact on patient reported outcome measures (PROMs)

e16603

Background: In localized prostate cancer (LPC), evolving therapeutic techniques and patterns of care including the use of active surveillance (AS) are expected to have had a positive effect on quality of life. A longitudinal assessment of changes in disease presentations and patterns of care in LPC correlated to PROMs is required. Methods: All cases of LPC (T1-T4, N0-N1) at a tertiary care institution were identified between 2005 and 2015. Two cohorts (C1: 2005-10, C2: 2010-15) with a minimum of 2-years follow-up, were identified. Demographics, disease characteristics and management strategies were compared across cohorts. To assess PROMs, a one-time questionnaire including EPIC-26 and Clark’s Quality of Life was administered. Domain summary scores were compared across cohorts. Results: 873 patients met criteria [C1: 422, C2: 535]. Demographics were well balanced (p = 0.10): overall 64.1% white, 12.7% AA, 12.7% Asian. D’Amico risk scores increased over time (p = 0.001): fewer low-risk cases [C1: 49.2%, C2: 43.7%], higher intermediate-risk disease [C1: 34.6%, C2: 40.3%], and stable high-risk proportions [C1: 15.7%, C2: 14.9%]. Patterns of care shifted significantly (p = 0.005) with a marked decrease in radiation therapy [C1: 25.7%, C2: 15.4%], unchanged radical prostatectomy rates [C1: 47.9%, C2: 51.0%], a shift to robotic surgery [C1: 23.8%, C2: 90.3%], and an increase in AS [C1: 21.8%, C2: 30.8%], particularly in low-risk disease [C1: 32.4%, C2: 53.5%]. Questionnaire response rate was 45.1%. Using multivariate regression, C2 demonstrated an improvement in bowel function (p = 0.031) but not in urinary, sexual, or psychometric scores. Conclusions: Notwithstanding an increase in AS utilization for low-risk disease, an improvement in bowel function and lack of improvement in urinary/sexual PROMs in LPC across time-cohorts was noted. This may be accounted for by increased presentations of higher-risk disease managed with robotic surgeries at the expense of radiation therapy. Although time-length bias can influence comparisons, given national trends with a similar shift in presentation and care patterns, these PROM correlations are likely generalizable to the U.S. population.

Prospective Comprehensive Genomic Profiling of Primary and Metastatic Prostate Tumors

PURPOSE

Comprehensive genomic profiling (CGP) is increasingly used for routine clinical management of prostate cancer. To inform targeted treatment strategies, 3,476 clinically advanced prostate tumors were analyzed by CGP for genomic alterations (GAs) and signatures of genomic instability.

METHODS

Prostate cancer samples (1,660 primary site and 1,816 metastatic site tumors from unmatched patients) were prospectively analyzed by CGP (FoundationOne Assay; Foundation Medicine, Cambridge, MA) for GAs and genomic signatures (genome-wide loss of heterozygosity [gLOH], microsatellite instability [MSI] status, tumor mutational burden [TMB]).

RESULTS

Frequently altered genes were TP53 (44%), PTEN (32%), TMPRSS2-ERG (31%), and AR (23%). Potentially targetable GAs were frequently identified in DNA repair, phosphatidylinositol 3-kinase, and RAS/RAF/MEK pathways. DNA repair pathway GAs included homologous recombination repair (23%), Fanconi anemia (5%), CDK12 (6%), and mismatch repair (4%) GAs. BRCA1/2, ATR, and FANCA GAs were associated with high gLOH, whereas CDK12-altered tumors were infrequently gLOH high. Median TMB was low (2.6 mutations/Mb). A subset of cases (3%) had high TMB, of which 71% also had high MSI. Metastatic site tumors were enriched for the 11q13 amplicon (CCND1/FGF19/FGF4/FGF3) and GAs in AR, LYN, MYC, NCOR1, PIK3CB, and RB1 compared with primary tumors.

CONCLUSION

Routine clinical CGP in the real-world setting identified GAs that are investigational biomarkers for targeted therapies in 57% of cases. gLOH and MSI/TMB signatures could further inform selection of poly (ADP-ribose) polymerase inhibitors and immunotherapies, respectively. Correlation of DNA repair GAs with gLOH identified genes associated with homologous recombination repair deficiency. GAs enriched in metastatic site tumors suggest therapeutic strategies for metastatic prostate cancer. Lack of clinical outcome correlation was a limitation of this study.

Imprecise Kidney Function Thresholds in Cancer Clinical Trials and the Potential for Harm

Current guidance for evaluation of kidney function and drug dosing emphasize using measured or estimated glomerular filtration rate (GFR) rather than measured or estimated creatinine clearance or serum creatinine (Scr) alone. We assessed the definitions of kidney function thresholds for eligibility in cancer clinical trials. A random sample of active Phase I–III trials with cisplatin (n = 465) and studies in cancer with decreased kidney function (n = 74) were identified from clinicaltrials.gov. Among cisplatin trials, kidney function thresholds were defined by Scr alone or a composite of Scr or creatinine clearance in 46% (212/465) of studies. Only 2% (n = 11) used GFR. Among trials in participants with decreased kidney function, the proportion utilizing GFR (14%, 10/74) was modestly higher. Imprecise and logically inconsistent kidney function thresholds are in frequent use in clinical trials in cancer and may cause harm from either toxicity or impaired efficacy. We recommend the adoption and harmonization of recommended standards.

Abstract 182: Superior targeting of tumor-stromal interactions and endothelial migration with a bispecific antibody to α5 and αv integrins

Introduction: The integrin α5β1 has been implicated in the adhesive and migratory response of prostate cancer cells induced by fibronectin fragments secreted by human bone-marrow derived mesenchymal stromal cells (hBM-MSCs) [Joshi, Cell Adh and Migr 2016). Genetic inactivation of integrin α5 in PC-3 cells downregulated the bcl-2 family of proteins and induced programmed cell death (Ren, Mol Cell Res 2017) - linking hBM-MSCs to a putative bone marrow niche survival program for prostate cancer cells. We hypothesized that the fibronectin-binding integrins α5β1 and integrin αv collaborate in broader tumor-stromal interactions and sought to examine the impact of combinatorial inactivation of these integrins.

Methods: Monospecific antibodies to α5 (or its obligate α5β1 heterodimer) and to integrin alpha v (or the αvβ3 heterodimer) were utilized to assess the efficacy of a combinatorial neutralization approach over either single agent in α5/αv co-expressing cells from diverse tumor types including prostate, breast, glioma, cervix and uterine cancer. Assays included adhesion, migration, cell survival and the induction of endothelial migration in co-culture with stromal cells. To address the hypothesis that a bispecific integrin targeting antibody would be superior to a combinatorial approach with monospecific integrin antibodies, a bispecific antibody prototype that simultaneously targets the α5β1 and αv integrins [Bsα5β1/αvAb] was constructed and deployed in comparative assays.

Results: Combined α5 and av neutralization with dual monospecific antibodies was superior to individual single agents in blocking adhesion, migration and the induction of endothelial chemotaxis across diverse tumor types that co-expressed α5 and αv integrins. However, a significant superiority of the Bsα5β1/αvAb was noted over the combinatorial approach with monospecific antibodies in these assays. In addition, a significant reduction in cell survival was noted in selected tumor types with the Bsα5β1/αvAb. Strikingly, the Bsα5β1/αvAb was significantly more potent than bevacizumab in the inhibition of endothelial migration induced by tumor-stromal cell interactions

Conclusions: Combinatorial α5 and av integrin targeting in tumor cells that co-express α5 and av integrins effectively abrogates tumor-stromal interactions and the resultant endothelial migratory response. A Bsα5β1/αvAb demonstrates a significant improvement over combinatorial monospecific antibodies likely through diverse mechanisms including cross-priming. Targeting tumor, stromal and endothelial cells simultaneously with a Bsα5β1/αvAb approach represents a potentially effective therapeutic strategy for targeting diverse mechanisms of progressive disease in the tumor microenvironment.

Citation Format: Raghav Joshi, Wenying Ren, Paul Mathew. Superior targeting of tumor-stromal interactions and endothelial migration with a bispecific antibody to α5 and αv integrins [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 182.

Abstract 5499: A potent BH3 mimetic targeting BCL-XL induces apoptosis regulated by PTEN loss and integrin alpha 5 in prostate cancer cells

Background: PTEN-loss is a highly prevalent genomic event associated with higher risk of metastatic progression and resistance to hormonal therapy in prostate cancer. Akt inhibitor therapy in combination with abiraterone demonstrates early promise in the clinical control of PTEN-deficient prostate cancers. We have previously implicated BCL-XL in the survival of PTEN-null PC-3 prostate cancer cells in vitro, regulated by integrin alpha 5 (ITGA5) (Ren, MCR 2016). Toward advancing therapeutic strategies in PTEN-deficient prostate cancer we further assessed the link between PTEN and BCL-XL mediated prostate cancer cell survival.

Methods: Isogenic PTEN knockdown stable cell lines (VCAP and DU145) were generated by lentiviral transduction of pLKO-control-shRNA and two pLKO-PTEN-shRNAs, respectively. PTEN was exogenously expressed in PTEN-null prostate cancer cell lines (PC-3, LNCaP and C4-2B) by 1) transfecting cells with pCMV-Flag-vector or pCMV-Flag-PTEN 2) transfecting cells with pcDNA3-GFP-PTEN and then sorting GFP-PTEN-negative and GFP-PTEN-positive cells by flow cytometry. Cells were then treated with a single agent BCL-XL inhibitor (A1331852 or navitoclax (ABT263); AbbVie), PI3K (buparlisib; Selleck Chem) or Akt (ipatasertib, Selleck Chem) inhibitors or combined PI3K and BCL-2 family inhibitors. Cell survival was assessed by cell viability assay. Expression of pAkt, ITGA5 and apoptotic markers was assayed by Western blot analysis and/or flow cytometry.

Results: Notwithstanding the reduction of phospho-bad expression with PI3K inhibition, the potent BCL-XL-targeting BH3 mimetic, A1331852, compared to single agent PI3K or Akt inhibitors in titrated doses was alone sufficient to induce apoptosis and loss of cell viability in all PTEN-null prostate cancer lines tested. PTEN expression reversed the apoptotic response to BCL-XL targeting and blocked the anti-proliferative effect of PI3K or Akt inhibition in PTEN-mutant cells. PTEN knockdown induced membrane expression of ITGA5 whereas PTEN overexpression diminished ITGA5 expression.

Conclusions: PTEN regulates the apoptotic threshold in prostate cancer cells via BCL-XL independent of the PI3K/Akt pathway. The induction of ITGA5 membrane localization by PTEN loss defines a potential upstream signaling mechanism for the BCL-XL regulated apoptotic threshold in these cells. Highly potent BCL-XL inhibition requires further investigation as a therapeutic strategy in PTEN-deficient prostate cancer.

Citation Format: Wenying Ren, Raghav Joshi, Paul Mathew. A potent BH3 mimetic targeting BCL-XL induces apoptosis regulated by PTEN loss and integrin alpha 5 in prostate cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5499.

Packaged scalable energy information systems for hotels

Purpose

Building energy information systems (EIS) are performance monitoring software, data acquisition hardware and communication systems used to store, analyze and display building energy data. Some $60bn are spent annually on wasted energy in the US buildings, and actions taken based on EIS data can enable operational energy savings of approximately 10 per cent in the US commercial sector (approximately two quads of primary energy). However, EIS adoption is low because of various technical and market challenges. This paper aims to provide technical specifications for standardized EIS packages that can help overcome barriers and accelerate scale.

Design/methodology/approach

A five-step approach was followed: identifying business drivers as key determinants for hotel sector-specific packages; addressing heterogeneity to develop standardized, tiered packages; determining performance metrics for key stakeholders; recommending streamlined data architecture; and developing visualization enabling insights and actions.

Findings

Technical specifications for two tiers (entry and advanced) of EIS packages for hotels have been developed. EIS vendor, integrator and client organization’s facilities and IT staff have been considered as key stakeholders. Findings from six field demonstrations show benefits of cost-effectiveness, through reduced transactional, first and operational costs, scalability, by accommodating heterogeneity across the building sub-sector, simplicity, by integrating meters, gateways and software in the package and actionability in organizations, across various decision-making levels.

Originality/value

Building owners and operators can use these specifications to ease procurement and installation of EIS in their facilities. EIS software vendors can use them to develop new product offerings for underserved sectors.

Lack of efficacy of levetiracetam in oromandibular and cranial dystonia

OBJECTIVE

To determine the efficacy of levetiracetam in oromandibular or cranial dystonia.

METHODS

We recruited seven subjects with oromandibular or cranial dystonia. Five completed the study, median age was 71 years (range 42-79 years), median disease duration was 12 years (range 2-30 years). Participants were randomized to receive levetiracetam or placebo and were then crossed over. They titrated up to a total daily dose of 4000 mg or the maximum tolerated dose over 3 weeks and maintained that dose for another 3 weeks. The primary endpoint was the percent change of the eyes, mouth, speech, and swallowing Burke-Fahn-Marsden (BFM) subscores from baseline to weeks 6 and 14. Additional endpoints included the BFM subscore at weeks 3 and 11, and the global dystonia severity (GDS) subscore at weeks 3, 6, 11, and 14, as well as all adverse side effects.

RESULTS

The mean percent increase in the BFM subscore (placebo: 31.25%, levetiracetam: 12.16%) was not significantly different between the two arms according to the Friedman analysis. The Wilcoxon signed-rank test showed that these percent changes were not significant, indicating that there was no statistical clinical worsening in either arm. The mean percent change of the BFM subscore at weeks 3 and 11 and the mean percent change of the GDS subscore at weeks 3, 6, 11, and 14 were not significantly different between the two arms, and the Wilcoxon signed-rank test did not show statistical significance.

CONCLUSION

Levetiracetam does not appear to be efficacious in patients with oromandibular or cranial dystonia.

Abstract 2162: MEK signaling marks resistance to synthetic lethality induced by PI3K/Akt and BCL-XL inhibition in PTEN-mutant cancers

Background: Loss of PTEN represents one of the most common disruptions of tumor suppressor activity in the progression of human neoplasia. There are no established precision medicine approaches defined in PTEN-deficient neoplasms which include prostate, breast, glioblastoma (GBM) and uterine cancers. In PTEN-mutant prostate cancer cells, the PI3K/Akt pathway collaborates with BCL-XL specifically, to regulate the apoptotic threshold (Ren, MCR 2016). Whereas single agent PI3K/Akt inhibitors are ineffective in inducing cell death, combined inhibition of PI3K/Akt and BCL-XL in PTEN-mutant prostate cancer cells results in synergistic apoptosis suggesting a novel therapeutic strategy with translational potential in this important subset of disease.

Hypothesis: We hypothesized that synthetic lethality following combinatorial PI3K/BCL-XL inhibition is conserved across the range of PTEN-mutant cancers.

Methods: PTEN-mutant cell lines (ATCC), validated for PTEN-loss and p-Akt expression, were assessed in apoptosis (cleaved Parp) and cell-viability assays following combined PI3K (Buparlisib, SelleckChem) and BCL-XL (A-1331852, AbbVie) inhibition (1µM each, 24h). Since MEK signaling has been associated with resistance to PI3K pathway inhibition, p-Erk was profiled as a candidate marker of resistance. The contribution of MEK signaling to the apoptotic threshold in p-Erk expressing PTEN-mutant cells was tested with pharmacological MEK inhibition (Trametinib, SelleckChem; 1,3,5 µM 48h) in combination.

Results:

MEK signaling and PI3K/BCL-XL inhibition in PTEN-mutant cancersSourceCell linePTENp-Aktp-ErkSynergistic Apoptosis with PI3K / BCL-XL inhibitionLoss of cell viabilityp-Erk suppression with MEK inhibitionApoptosis with concomitant MEK inhibitionProstatePC3AbsentPresentAbsentYesYesN/AN/AProstateLNCaPAbsentPresentAbsentYesYesN/AN/AProstateC4-2BAbsentPresentAbsentYesYesN/AN/ABreastZR-75-1AbsentPresentWeakYesYesN/AN/AUterineSK-UT-1AbsentPresentPresentNoNoYesYesGBMA-172AbsentPresentPresentNoNoYesNoCervixC33-AAbsentPresentPresentNoNo--

Conclusions: Synthetic lethality in PTEN-mutant tumor cells with PI3K/BCL-XL inhibition was confined to tumor cells without active MEK signaling. MEK inhibition inconsistently overcomes resistance to therapy suggesting heterogeneity of survival pathways in p-erk expressing PTEN-deficient tumors. These data have implications for precision medicine approaches in PTEN-deficient tumors as absence of p-Erk expression may predict for a responsive phenotype.

Citation Format: Raghav Joshi, Wenying Ren, Paul Mathew. MEK signaling marks resistance to synthetic lethality induced by PI3K/Akt and BCL-XL inhibition in PTEN-mutant cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2162. doi:10.1158/1538-7445.AM2017-2162

Evaluation of the utility of the ISTH-BAT in haemophilia carriers: a multinational study

INTRODUCTION

There has been increasing recognition in recent years that female carriers of haemophilia manifest abnormal bleeding; however, data on the use of bleeding assessment tools in this population are lacking.

AIM

Our objective was to validate the ISTH-BAT in haemophilia carriers to describe bleeding symptoms and allow for comparisons with factor levels and other patient groups.

METHODS

This was a prospective, observational, cross-sectional study performed by members of Global Emerging HEmostasis Panel (GEHEP). Unselected consecutive haemophilia carriers were recruited and a CRF and the ISTH-BAT were completed by study personnel.

RESULTS

A total of 168 haemophilia carriers were enrolled: 155 haemophilia A and 13 haemophilia B. The mean age was 40 years (range: 20-82). Carriers had higher mean bleeding scores (BS) compared with age-matched controls (n = 46; 5.7 vs. 1.43; P < 0.0001) and Type 3 VWD OC (n = 32; 3.0; P = 0.009), but lower BS compared with women with Type 1 VWD (n = 83; 8.7; P < 0.0001). Fifteen carriers reported haemarthrosis, and of those six had normal FVIII/FIX levels. There was a significant but weak negative correlation between BS and factor level (Spearman's r²  = -0.36, P < 0.001).

CONCLUSION

Our results show that haemophilia carriers experience abnormal bleeding, including haemarthrosis. Overall, BS in women with Type 1 VWD > haemophilia carriers > Type 3 VWD OC > controls. Understanding the performance of the ISTH-BAT in this population is a critical step in future research aimed at investigating the underlying pathophysiology of abnormal bleeding, with the ultimate goal of optimizing treatment.

Complications of haemophilia in babies (first two years of life): a report from the Centers for Disease Control and Prevention Universal Data Collection System

AIM

To describe the prevalence and complications in babies ≤2 years with haemophilia.

METHODS

We used a standardized collection tool to obtain consented data on eligible babies aged ≤2 years with haemophilia enrolled in the Centers for Disease Control and Prevention Universal Data Collection System surveillance project at US Hemophilia Treatment Centers (HTCs).

RESULTS

Of 547 babies, 82% had haemophilia A, and 70% were diagnosed within one month of birth. Diagnosis was prompted by known maternal carrier status (40%), positive family history (23%), bleeding (35%) and unknown 2%; 81% bled during the first two years. The most common events were bleeding (circumcision, soft tissue, oral bleeding) and head injury. There were 46 episodes of intracranial haemorrhage (ICH) in 37 babies (7%): 18 spontaneous, 14 delivery related, 11 traumatic, 2 procedure related and 1 unknown cause. Of the 176 central venous access devices (CVADs) in 148 (27%) babies, there were 137 ports, 22 surgically inserted central catheters and 20 peripherally inserted central catheters. Ports had the lowest complication rates. Inhibitors occurred in 109 (20%) babies who experienced higher rates of ICH (14% vs. 5%; P = 0.002), CVAD placement (61% vs. 19%; P < 0.001) and CVAD complications (44% vs. 26%; P < 0.001). The most common replacement therapy was recombinant clotting factor concentrates.

CONCLUSION

Bleeding events in haemophilic babies ≤2 years were common; no detectable difference in the rates of ICH by the mode of delivery was noted. Neonatal factor exposure did not affect the inhibitor rates. Minor head trauma, soft tissue and oropharyngeal bleeding were the leading indications for treatment.

Synthetic Lethality in PTEN-Mutant Prostate Cancer Is Induced by Combinatorial PI3K/Akt and BCL-XL Inhibition

The bone-conserved metastatic phenotype of prostate cancer is a prototype of nonrandom metastatic behavior. Adhesion of prostate cancer cells to fibronectin via the integrin α5 (ITGA5) has been proposed as a candidate bone marrow niche localization mechanism. We hypothesized that the mechanisms whereby ITGA5 regulates the adhesion-mediated survival of prostate cancer cells will define novel therapeutic approaches. ITGA5 shRNA reduced expression of BCL-2 family members and induced apoptosis in PC-3 cells. In these PTEN-mutant cells, pharmacologic inhibition of the PI3K signaling pathway in combination with ITGA5 knockdown enhanced apoptosis. Chemical parsing studies with BH3 mimetics indicated that PI3K/Akt inhibition in combination with BCL-X_L-specific inhibition induces synergistic apoptosis specifically in PTEN-mutant prostate cancer cells, whereas single-agent PI3K/Akt inhibitors did not. Given the importance of PTEN loss in the progression of prostate and other cancers, synthetic lethality induced by combinatorial PI3K/Akt and BCL-X_L inhibition represents a valuable therapeutic strategy.

IMPLICATIONS

Activation of the PI3K pathway through PTEN loss represents a major molecular pathway in the progression of prostate and other cancers. This study defines a synthetic lethal therapeutic combination with significant translational potential.

OVERVIEW

Synthetic lethality in PTEN-mutant prostate cancer cells with combined PI3K/Akt and BCL-X_L inhibition. PTEN-mutant prostate cancer cells expressing ITGA5 bind to fibronectin in the putative bone marrow niche and transduce survival signals to BCL-X_L Additional PTEN-regulated signals independent of the PI3K/Akt pathway likely feed into the BCL-X_L-regulated survival program to explain synthetic lethality observed with the combination.Visual Overview: http://mcr.aacrjournals.org/content/early/2016/12/02/1541-7786.MCR-16-0202/F1.large.jpg. Mol Cancer Res; 14(12); 1176-81. ©2016 AACR.