Combination Treatment of Intratumoral Vidutolimod, Radiosurgery, Nivolumab, and Ipilimumab for Microsatellite Stable Colorectal Carcinoma With Liver Metastases

INTRODUCTION

Microsatellite stable metastatic colorectal cancer (MSS mCRC) is largely refractory to immune checkpoint inhibition. We hypothesized that a combination of intratumoral TLR9 agonist, radiosurgery and dual PD-1 and CTLA-4 blockade would induce a local focus of immune stimulation, evoking a systemic immune response.

PATIENTS AND METHODS

In this phase I single-institution study, patients with MSS mCRC were treated with a priming dose of s.c vidutolimod, 3 intratumoral injections of vidutolimod and radiosurgery, combined with nivolumab and ipilimumab. Cytokine levels were measured at baseline and at 7 (± 2) weeks. Patients were accrued to 4 consecutive cohorts: (1) Safety run-in without radiosurgery, (2) Radiosurgery prior to intratumoral therapy, (3) Radiosurgery prior to intratumoral therapy with a condensed timeline, and (4) Radiosurgery to extrahepatic lesion following completion of intratumoral therapy.

RESULTS

A total of 19 patients were accrued. Median age was 59 years (range 40-71), 68% were male, median number of previous systemic treatments was 3 (range 2-5). None of the patients responded, aside from 1 patient, attributed to high tumor mutational burden. Grade 3 liver toxicity was reported in 0%, 0%, 75%, and 17% in cohorts 1 to 4, respectively. Systemic levels of CXCL10 and IL-10 increased, with a median of 407 versus 78 pg/mL (P = .01), and 66 versus 40 pg/mL (P = .03), respectively.

CONCLUSIONS

The combination of intratumoral vidutolimod, radiosurgery, nivolumab and ipilimumab was not found to be efficacious in MSS mCRC with liver metastases. The juxtaposition of liver irradiation and intratumoral vidutolimod injection was associated with high hepatic toxicity.

A clinical evaluation of an ex vivo organ culture system to predict patient response to cancer therapy

Introduction

Ex vivo organ cultures (EVOC) were recently optimized to sustain cancer tissue for 5 days with its complete microenvironment. We examined the ability of an EVOC platform to predict patient response to cancer therapy.

Methods

A multicenter, prospective, single-arm observational trial. Samples were obtained from patients with newly diagnosed bladder cancer who underwent transurethral resection of bladder tumor and from core needle biopsies of patients with metastatic cancer. The tumors were cut into 250 μM slices and cultured within 24 h, then incubated for 96 h with vehicle or intended to treat drug. The cultures were then fixed and stained to analyze their morphology and cell viability. Each EVOC was given a score based on cell viability, level of damage, and Ki67 proliferation, and the scores were correlated with the patients' clinical response assessed by pathology or Response Evaluation Criteria in Solid Tumors (RECIST).

Results

The cancer tissue and microenvironment, including endothelial and immune cells, were preserved at high viability with continued cell division for 5 days, demonstrating active cell signaling dynamics. A total of 34 cancer samples were tested by the platform and were correlated with clinical results. A higher EVOC score was correlated with better clinical response. The EVOC system showed a predictive specificity of 77.7% (7/9, 95% CI 0.4-0.97) and a sensitivity of 96% (24/25, 95% CI 0.80-0.99).

Conclusion

EVOC cultured for 5 days showed high sensitivity and specificity for predicting clinical response to therapy among patients with muscle-invasive bladder cancer and other solid tumors.

Spectrum of Response to Platinum and PARP Inhibitors in Germline BRCA-Associated Pancreatic Cancer in the Clinical and Preclinical Setting

Germline BRCA-associated pancreatic ductal adenocarcinoma (glBRCA PDAC) tumors are susceptible to platinum and PARP inhibition. The clinical outcomes of 125 patients with glBRCA PDAC were stratified based on the spectrum of response to platinum/PARP inhibition: (i) refractory [overall survival (OS) <6 months], (ii) durable response followed by acquired resistance (OS <36 months), and (iii) long-term responders (OS >36 months). Patient-derived xenografts (PDX) were generated from 25 patients with glBRCA PDAC at different clinical time points. Response to platinum/PARP inhibition in vivo and ex vivo culture (EVOC) correlated with clinical response. We deciphered the mechanisms of resistance in glBRCA PDAC and identified homologous recombination (HR) proficiency and secondary mutations restoring partial functionality as the most dominant resistant mechanism. Yet, a subset of HR-deficient (HRD) patients demonstrated clinical resistance. Their tumors displayed basal-like molecular subtype and were more aneuploid. Tumor mutational burden was high in HRD PDAC and significantly higher in tumors with secondary mutations. Anti-PD-1 attenuated tumor growth in a novel humanized glBRCA PDAC PDX model. This work demonstrates the utility of preclinical models, including EVOC, to predict the response of glBRCA PDAC to treatment, which has the potential to inform time-sensitive medical decisions.

SIGNIFICANCE

glBRCA PDAC has a favorable response to platinum/PARP inhibition. However, most patients develop resistance. Additional treatment options for this unique subpopulation are needed. We generated model systems in PDXs and an ex vivo system (EVOC) that faithfully recapitulate these specific clinical scenarios as a platform to investigate the mechanisms of resistance for further drug development.

Abstract 957: Prediction of patient response to targeted and immunotherapies from the tumor transcriptome in a wide set of indications and clinical trials

Background: Precision oncology is gradually advancing into mainstream clinical practice, demonstrating significant survival benefits. However, eligibility and response rates remain limited in many cases, calling for better predictive biomarkers.

Methods: We present ENLIGHT, a transcriptomics-based computational approach that identifies clinically relevant genetic interactions and uses them to predict a patient’s response to a variety of therapies in multiple cancer types, importantly, without training on previous treatment response data. Consequently, in addition to its ability to predict patients' response to approved and well-studied therapies, ENLIGHT can predict the response to new treatments in early development, even before clinical data has accumulated. Accordingly, we study ENLIGHT in two translationally relevant scenarios: Personalized Oncology (PO), aimed at prioritizing approved treatments to a given patient, and Clinical Trial Design (CTD), selecting the subset of most likely responders in a patient cohort.

Results: Evaluating ENLIGHT’s performance on 21 blinded clinical trial datasets spanning 11 indications and 15 different drugs in the PO setting, we show that it can effectively predict a patient’s treatment response across multiple therapies and cancer types, with an overall odds ratio of 2.59 (p=3.41e-8), and a 36% increase in response rate over the baseline (p=3.30e-13). Its prediction accuracy is better than other state-of-the-art transcriptomics-based signatures. Unlike most signatures that are prognostic or provide insights for only very few, specific treatments, ENLIGHT provides matching scores to a broad range of treatments. Quite strikingly, its performance is comparable to that of supervised predictors developed for specific indications and drugs. In combination with the IFN-γ signature, ENLIGHT achieves an odds ratio larger than 4 in predicting response to immune checkpoint therapy. In the CTD scenario, our results show that by excluding non-responders ENLIGHT can enhance clinical trial success for immunotherapies and other monoclonal antibodies, achieving &gt; 90% of the response rate attainable under an optimal exclusion strategy.

Conclusion: ENLIGHT is a powerful transcriptomics-based precision oncology pipeline developed by Pangea Biomed that broadly predicts response to both extant and novel targeted and immune therapies, going beyond context-specific biomarkers.

Citation Format: Gal Dinstag, Eldad D. Shulman, Efrat Elis, Doreen S. Ben-Zvi, Omer Tirosh, Eden Maimon, Isaac Meilijson, Emmanuel Elalouf, Boris Temkin, Philipp Vitkovsky, Eyal Schiff, Danh-Tai Hoang, Sanju Sinha, Nishanth Ulhas Nair, Joo Sang-Lee, Alejandro A. Schäffer, Ze'ev Ronai, Dejan Juric, Andrea B. Apolo, William L. Dahut, Stanley Lipkowitz, Raanan Berger, Razelle Kurzrock, Antonios Papanicolau-Sengos, Fatima Karzai, Mark R. Gilbert, Kenneth Aldape, Padma S. Rajagopal, Tuvik Beker, Eytan Ruppin, Ranit Aharonov. Prediction of patient response to targeted and immunotherapies from the tumor transcriptome in a wide set of indications and clinical trials [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 957.

Clinically oriented prediction of patient response to targeted and immunotherapies from the tumor transcriptome

BACKGROUND

Precision oncology is gradually advancing into mainstream clinical practice, demonstrating significant survival benefits. However, eligibility and response rates remain limited in many cases, calling for better predictive biomarkers.

METHODS

We present ENLIGHT, a transcriptomics-based computational approach that identifies clinically relevant genetic interactions and uses them to predict a patient's response to a variety of therapies in multiple cancer types without training on previous treatment response data. We study ENLIGHT in two translationally oriented scenarios: personalized oncology (PO), aimed at prioritizing treatments for a single patient, and clinical trial design (CTD), selecting the most likely responders in a patient cohort.

FINDINGS

Evaluating ENLIGHT's performance on 21 blinded clinical trial datasets in the PO setting, we show that it can effectively predict a patient's treatment response across multiple therapies and cancer types. Its prediction accuracy is better than previously published transcriptomics-based signatures and is comparable with that of supervised predictors developed for specific indications and drugs. In combination with the interferon-γ signature, ENLIGHT achieves an odds ratio larger than 4 in predicting response to immune checkpoint therapy. In the CTD scenario, ENLIGHT can potentially enhance clinical trial success for immunotherapies and other monoclonal antibodies by excluding non-responders while overall achieving more than 90% of the response rate attainable under an optimal exclusion strategy.

CONCLUSIONS

ENLIGHT demonstrably enhances the ability to predict therapeutic response across multiple cancer types from the bulk tumor transcriptome.

FUNDING

This research was supported in part by the Intramural Research Program, NIH and by the Israeli Innovation Authority.

Fibrolamellar carcinoma transcriptomic-based treatment prediction: complete response after nivolumab and ipilimumab

Fibrolamellar carcinoma (FLC) is a rare cancer of the liver that most commonly affects children and young adults. There is no clear standard of care for the disease, whose response to treatment seems to be very different from that of hepatocellular carcinoma. We present a case of FLC in a patient in her mid 30s that recurred and persisted despite resection and multiple lines of treatment. Following transcriptomic analysis, a combination of ipilimumab (anti-CTLA4) and nivolumab (anti-PD-1) led to complete remission, although common biomarkers for immune checkpoint blockade were all negative in this case. The patient is still in remission. Here, combined checkpoint blockade guided by novel transcriptomic analysis led to complete remission after failure of several lines of treatment.

Abstract A063: PARPi and ATRi (AZD6738) in BRCA associated PDAC patient derived xenograft model

Pancreatic ductal adenocarcinoma (PDAC) is a dismal disease, with the majority of patients diagnosed at an advanced stage. Comprehensive genomic analysis identified the homologous recombination deficiency (HRD) subgroup which is predominantly enriched in patients harboring germline BRCA1/2 mutations (glBRCA) and presents ~7% and up to 15% in selected high-risk populations. Tumors with HRD are susceptible to DNA-damaging agents and PARP inhibition. However, not all patients demonstrate a similar response, and a spectrum is observed. We analyzed the clinical outcome of ninety-one glBRCA PDAC patients treated at Sheba Medical Center. We identify three main subgroups of response spanning from ~25% patients refractory to first line platinum agents and ~9% patients with durable long-term response with no evidence of disease for over three years. The majority of the patients display a prolonged response to platinum and PARPi maintenance (&gt;24 months) followed by acquired resistance. ATR, a central mediator in DDR, is activated by multiple DNA damage events. Activated ATR induces cell-cycle arrest and facilitates DNA repair. Inhibition of ATR has been suggested as an attractive approach for sensitization of tumor cells to DNA-damaging agents. Therefore, we propose combinational therapy of PARPi with ATRi. This combination treatment is expected to enhance response to PARPi in BRCA-mutated PDAC patients naïve to treatment and might extend efficacy. We generated unique patient derived xenograft (PDX) models (n=25) at distinct clinical scenarios - from naïve to treatment tissue and at clinical resistance. In-vivo efficacy to platinum agents and PARPi demonstrates that these models recapitulate the specific clinical spectrum of response. However, accumulating resistance emerges and additional therapies need to be investigated. Furthermore, we have generated an in-vivo resistant paired models from an initially platinum sensitive BRCA-PDXs, mimicking the patient clinical scenario from sensitivity to resistance. PARP and ATR combined inhibition was assessed in a PDX model generated from a glBRCAmut PDAC patient, naïve to platinum/PARPi treatment. PDX were randomized to the following groups: 1. vehicle control; 2. PARPi olaparib AZD2281 (100 mg/kg, 5 days a week IP); 3. ATRi AZD6738 (25 mg/kg, 5 days a week; PO); 4. ATRi + PARPi combination. PARPi treatment attenuated tumor growth for 42 days followed by re-growth. A significant difference in tumor growth was obtained with the combined PARPi and ATRi treatment (p&lt;0.05). Experiment is ongoing currently on day 84 and we intend to proceed while tolerated or until resistance will develop. Our preliminary in-vivo results suggest that the combinatorial treatment of PARPi and ATRi may delay resistance to single agent PARPi. This extensive preclinical and clinical collection of BRCA associated PDAC, enables further understanding and investigation of this unique subtype in aim to develop alternative treatments to overcome resistance.

Citation Format: Talia Golan, Dikla Atias, Chani Stossel, Maria Raitses Gurevich, Yulia Gurmon Glick, Sharon Halparin, Elina Haimov Talmoud, Nora Amison, Tamar Beller, Raanan Berger. PARPi and ATRi (AZD6738) in BRCA associated PDAC patient derived xenograft model [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A063.

Discrimination and sexual harassment – Results from the largest German medical university

Background

Discrimination and sexual harassment in the workplace and in higher education institutions are important public health issues. Here we aim at analyzing the prevalence of discrimination and sexual harassment of lecturers and students at one of the largest teaching hospitals in Europe. We assess whether there are differences between lecturers and students, women and men, and different study programs.

Methods

An online questionnaire was sent to N = 7095 students of all study programs and N = 2528 lecturers at Charité - Universitätsmedizin Berlin. The survey was conducted from November 2018 to February 2019. We investigated experienced or observed discrimination or sexual harassment at the medical faculty. Furthermore, we analyzed frequency, perpetrators, situational factors, attributed reasons and forms of harassment encountered.

Results

A total of 964 (14%) students (S) and 275 (11%) of lecturers (L) participated in the survey. Discriminatory behavior was witnessed and/or experienced by 49,6% of students (L: 31%), sexual harassment by 23,6% of students (L: 19,2%). Students state lecturers (85,9%) as main source of discriminatory behavior (L: directors/supervisors: 47,4%; students 41,0%). Sex/Gender (S: 71%; L: 60,3%) is cited most frequently as reason for discriminatory experiences. Female students and faculty experience more discrimination and sexual harassment.

Conclusions

Discrimination and sexual harassment are prevalent in academic medicine. There are differences in the reasons and sources of discrimination and sexual harassment between students and lecturers. Specific programs for lecturers and students are necessary to educate the faculty on how to prevent and respond to it and whom to address.

Key messages

• National preventive strategies should be implemented to tackle issues of discrimination and harassment in higher education institutions.

• Special attention should be paid to female students and lecturers.

Transcriptomics in Tumor and Normal Lung Tissues Identify Patients With Early-Stage Non-Small-Cell Lung Cancer With High Risk of Postsurgery Recurrence Who May Benefit From Adjuvant Therapies

PURPOSE

The prognosis of patients with non-small-cell lung cancer (NSCLC), traditionally determined by anatomic histology and TNM staging, neglects the biological features of the tumor that may be important in determining patient outcome and guiding therapeutic interventions. Identifying patients with NSCLC at increased risk of recurrence after curative-intent surgery remains an important unmet need so that known effective adjuvant treatments can be offered to those at highest risk of recurrence.

METHODS

Relative gene expression level in the primary tumor and normal bronchial tissues was used to retrospectively assess their association with disease-free survival (DFS) in a cohort of 120 patients with NSCLC who underwent curative-intent surgery.

RESULTS

Low versus high Digital Display Precision Predictor (DDPP) score (a measure of relative gene expression) was significantly associated with shorter DFS (highest recurrence risk; P = .006) in all patients and in patients with TNM stages 1-2 (P = .00051; n = 83). For patients with stages 1-2 and low DDPP score (n = 29), adjuvant chemotherapy was associated with improved DFS (P = .0041). High co-overexpression of CTLA-4, PD-L1, and ICOS in normal lung (28 of 120 patients) was also significantly associated with decreased DFS (P = .0013), suggesting an immune tolerance to tumor neoantigens in some patients. Patients with DDPP low and immunotolerant normal tissue had the shortest DFS (P = 2.12E-11).

CONCLUSION

TNM stage, DDPP score, and immune competence status of normal lung are independent prognostic factors in multivariate analysis. Our findings open new avenues for prospective prognostic assessment and treatment assignment on the basis of transcriptomic profiling of tumor and normal lung tissue in patients with NSCLC.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Abstract 2148: Pre-clinical models recapitulating the spectrum of response of BRCA associated pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is a dismal disease, with the majority of patients diagnosed at an advanced stage. Comprehensive genomic analysis identified the homologous recombination deficiency (HRD) subgroup which is predominantly enriched in patients harboring germline BRCA1/2 mutations (glBRCA) and presents ~7% and up to 15% in selected high-risk populations. Tumors with HRD are susceptible to DNA-damaging agents and PARP inhibition. However, not all patients demonstrate a similar response, and a spectrum is observed. We analyzed the clinical outcome of ninety-one glBRCA PDAC patients treated at Sheba Medical Center. We identify three main subgroups of response spanning from ~25% patients refractory to first line platinum agents and ~9% patients with durable long-term response with no evidence of disease for over three years. The majority of the patients display a prolonged response to platinum and PARPi maintenance (&gt;24 months) followed by acquired resistance. We generated patient derived xenograft (PDX) models and an ex-vivo culture system (EVOC) from naïve to treatment tissue and at clinical resistance. In vivo efficacy to platinum agents and PARPi demonstrates that these models recapitulate the specific clinical spectrum of response. We demonstrate the utility of both pre-clinical models in their ability to predict response to platinum-based agents and PARPi, with EVOC having a potential to assist in medical decisions while treating the patient. Whole genome sequencing of the tumors revealed that BRCA monoallelic tumors are associated with innate resistance while biallelic tumors reflect sensitivity to platinum agents and PARPi. In the acquired resistance models, the main identified mechanism of resistance was due to reversion mutations in 4/6 of samples. Whole genome analysis demonstrates high mutational and neo-antigen load in majority of the glBRCA tumors. In a preliminary study, we show the efficacy of anti PD1 in a novel humanized glBRCA PDAC PDX model. This extensive preclinical and clinical collection of BRCA associated PDAC, enables further understanding and investigation of this unique subtype in aim to develop alternative treatments to overcome resistance.

Citation Format: Talia Golan, Chani Stossel, Maria Raitses-Gurevitch, Dikla Atias, Tamar Beller, Steven Gallinger, Raanan Berger. Pre-clinical models recapitulating the spectrum of response of BRCA associated pancreatic cancer [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 2148.

Nuclear Export Inhibition for Radiosensitization; a Proof-of-Concept Phase I Clinical Trial of Selinexor (KPT-330) Combined with Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer

BACKGROUND

Selinexor (KPT-330, XPOVIO®) is a first-in-class, oral selective inhibitor of nuclear export (SINE) compound that blocks XPO1, forcing nuclear retention of tumor suppressor proteins. Selinexor potentiates radiation-induced cell death in preclinical models, but has yet to be combined with radiation in the clinic. We hypothesized that selinexor would increase the activity of neoadjuvant fluoropyrimidine-based chemoradiation (ChRT) for locally advanced rectal cancer (LARC).

METHODS

A phase I clinical trial of selinexor plus ChRT for LARC was performed, 3+3 design. Eligibility criteria included stage II-III LARC requiring neoadjuvant chemoradiation, and ECOG 0-1 performance status. Patients received 50.4 Gy over 5.5 weeks plus capecitabine 825 mg/m² twice daily on radiation days. Three selinexor dose-levels were tested: 1) 20 mg/m² twice weekly concurrent with ChRT, 2) 35 mg/m² twice weekly concurrent with ChRT, and 3) 35 mg/m² twice weekly concurrent with ChRT, and for an additional two weeks. Subsequently, patients underwent definitive curative resection. DNA variant analysis and RNAseq were performed to characterize responders.

RESULTS

Eleven patients were enrolled, median age 60.5 years, six were stage III. Nine completed selinexor plus ChRT; two patients withdrew consent. Side effects attributed to selinexor included fatigue, hyponatremia and mild thrombocytopenia. Dose level 3 was poorly tolerated, (dehydration, anorexia). Of the 9 patients who completed treatment, median volumetric tumor shrinkage was 93% (IQR 59-98). Comparing baseline clinical stage to final pathological stage, 82% of patients were down-staged. Two patients experienced a complete / near-complete pathological response. Expression of PTGS2 and CD177 were identified as potential biomarkers of response.

CONCLUSION

Selinexor combined with neoadjuvant ChRT in LARC is well tolerated. Potential biomarkers were identified based upon a preliminary analysis.

Seropositivity and neutralising antibodies at six months after BNT162b2 vaccination in patients with solid tumours

Aim

Patients with cancer are at an increased risk for severe coronavirus disease of 2019. We previously reported initial findings from a single centre prospective study evaluating antibody response after BNT162b2 vaccine, showing that adequate antibody response was achieved after two doses, but not after one, in patients with cancer vaccinated during anticancer therapy. Herein, we report a follow-up study, evaluating antibody response six months after the second vaccine dose.

Methods

The study included patients with solid tumours undergoing anticancer treatment, and immunocompetent health-care workers serving as controls. Serum titres of the receptor-binding domain (RBD) IgG and neutralising antibodies (Nabs) were measured approximately six months after the second vaccine dose. Complete blood count values were collected and evaluated as predictors for antibody response.

Results

The analysis included 93 patients with cancer (66.7% metastatic). Six months after the second vaccine dose (mean 176 ± 20 days), seropositivity rate among patients and controls was 83.9% versus 96.3% (p = 0.0001), respectively. Median RBD-IgG titre was lower among patients compared with controls (2.3 versus 3.2, p = 0.0002). Among seropositive individuals, median Nabs titre was similar between patients with cancer and controls (p = 0.566). Among patients with cancer, lymphocyte and neutrophil counts were not correlated with either RBD-IgG or Nabs titres.

Conclusions

Seropositivity rates and RBD-IgG titre at six months after second BNT162b2 vaccine dose are lower among patients with cancer compared with healthy controls. However, Nabs titre is similar, suggesting a comparable protection among seropositive individuals. Lymphocyte count is not predictive of antibody response.

ENLIGHT: Pancancer response prediction to targeted and immunotherapies via tumor transcriptomics

e13556

Background: Precision oncology is gradually advancing into mainstream clinical practice. Despite the significant recent growth in the number of approved biomarkers for immune and targeted therapies, demonstrating significant survival benefits, eligibility and response rates remain limited in many cases, calling for better predictive biomarkers. Methods: We developed ENLIGHT - a transcriptomics-based computational platform that identifies and utilizes clinically relevant genetic interactions (GIs) to predict a patient’s response to cancer treatments. ENLIGHT markedly extends and improves upon SELECT, a previous GI-based framework for obtaining transcriptomics-based response biomarkers. In this study, we focus on three key translational aspects: (i) the number of drugs for which predictions can be obtained (ii) defining a biomarker-based test for Personalized Medicine (PM) that would identify favorable treatments for an individual; and (iii) Improving clinical trial design by excluding a sub-population of patients likely not to respond to the treatment. A key translational feature of the approach is that it does not require training on treatment response data. Thus, in addition to its ability to predict patients' response to approved and well-studied therapies, it can predict the response to new, unexplored treatments. Results: We first tested Enlight in the PM scenario, analyzing 21 patient cohorts from diverse indications, treated with a variety of targeted and immunotherapies. The ENLIGHT treatment matching score is associated with better response with an aggregate Odds Ratio (OR) of 2.59 (95% confidence interval [1.85, 3.55], p= 3.41 e-8). Applied to the WINTHER trial data, encompassing multiple indications and individualized treatments, ENLIGHT recommendations achieved a highly remarkable OR of 11.15 ([2.3, 54.5], p = 8 e-04), demonstrating ENLIGHT’s strong predictive power across a broad spectrum of treatments and cancer types. Second, using ENLIGHT to exclude patients from clinical trials increases the trial response rate, achieving more than 90% of the response rate attainable under an optimal exclusion strategy. Conclusions: ENLIGHT is a powerful transcriptomics-based precision oncology pipeline developed by Pangea Biomed that broadly predicts response to both extant and novel targeted and immune therapies in translationally oriented, clinical terms, going beyond case-specific biomarkers.

Immune-Related Thyroiditis as a Predictor for Survival in Metastatic Renal Cell Carcinoma

Simple Summary

In this study, we evaluated the association of immune mediated thyroid dysfunction (irT) with survival in 123 metastatic renal cell carcinoma patients treated with immunotherapy in a single center. We found that irT is a prevalent and early event associated with prolonged survival in high-risk patients.

Abstract

Immune checkpoint inhibitors (CPI) are indicated for metastatic renal cell carcinoma (mRCC). Immune-related thyroiditis (irT), an immune-related adverse event (irAE), affects up to 30% of patients. We aimed to determine whether irT is associated with overall survival in mRCC. A retrospective cohort study of 123 consecutive patients treated with CPI for mRCC in a single center between 2015 and 2020 was conducted. Disease risk stratification was assessed by two methods: Heng criteria and a novel dichotomic stratification system to “Low risk” versus “High risk” adding number of metastatic sites. Thirty-eight percent of patients developed irT. In the general cohort, irT was not associated with a survival benefit. However, irT was associated with better survival in the poor risk group per Heng criteria (n = 17, HR = 0.25, p = 0.04) and in the novel “High risk” group (HR = 0.28, n = 42, p = 0.01), including after accounting for covariates in multivariate analysis (HR = 0.27, p = 0.003). Having any irAE was associated with improved survival in the whole cohort, with no significant correlation of any specific irAE, in either the whole cohort or the “High risk” group. We conclude that irT is an early and prevalent irAE, associated with prolonged survival in patients with poor/“High” risk mRCC.

Functional echocardiographic and serum biomarker changes following surgical and percutaneous atrial septal defect closure in children

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation

Background

Ventricular performance is temporarily reduced following surgical atrial septal defect (ASD) closure. Cardiopulmonary bypass and changes in loading conditions are considered important factors, but this phenomenon is incompletely understood. We aim to characterize biventricular performance following surgical and percutaneous ASD closure and to relate biomarkers to ventricular performance following intervention.

Methods

In this multicenter prospective study, children scheduled for surgical or percutaneous ASD closure were included. Subjects were assessed pre-operatively (T1); in the 2nd week post-intervention (T2) and 1 year post-intervention (T3). At each time point an echocardiographic study and a panel of biomarkers was obtained.

Results

Sixty-three patients (age 4.1 [3.1–6.1] years) were included. Forty-three patients underwent surgery. At T2 right ventricular (RV) global longitudinal strain (GLS) was decreased for the surgical, but not the percutaneous, group (-17.6 ± 4.1 versus -27.1 ± 3.4, p&lt;.001). A smaller decrease was noted for left ventricular (LV) GLS at T2 for the surgical group (surgical -18.6 ± 3.2 versus percutaneous -20.2 ± 2.4, p=.040). At T3 LV performance returned to baseline, while RV performance improved, but did not reach pre-intervention levels. Cadherin-5, chitotriosidase-1, integrin-beta-2 and urokinase differed across time points and related to favorable RV GLS at T2.

Conclusions

Right, and to a lesser degree left, ventricular performance was reduced early after surgical ASD closure, possibly related to cardiopulmonary bypass. RV performance at T3 remained below baseline levels, probably related to changed loading conditions. Several biomarkers showed a pattern over time similar to ventricular performance and related to cardiac function at early follow-up. These markers may provide insight into the processes that affect ventricular function.

Oncology Treatments during the COVID-19 Pandemic in Israel: the ONCOR Study

BACKGROUND

The increased susceptibility of cancer patients to coronavirus disease-2019 (COVID-19) infections and complications calls for special precautions while treating cancer patients during COVID-19 pandemics. Thus, oncology departments have had to implement a wide array of prevention measures.

OBJECTIVES

To address issues associated with cancer care during the COVID-19 pandemic and to assess the implementation of measures aimed at containment of COVID-19 diffusion while allowing continuation of quality cancer care.

METHODS

A national survey among oncology departments in Israel was conducted between 12 April 2020 and 14 April 2020. Eighteen heads of hospital-based oncology departments completed a self-report questionnaire regarding their institute's preparedness for treatment of cancer patients during the COVID-19 pandemic.

RESULTS

In this national survey, prevention measures against COVID-19 spread were taken prior to patients' arrival and at arrival or while staying in the departments. Most participants (78-89%) reported using a quick triage of patients and caregivers prior to their entrance to the oncology units, limiting the entrance of caregivers, and reducing unnecessary visits to the clinic. Switching to oral therapies rather than intravenous ones when possible was considered by 82% and shortage in personal protective equipment was reported by five (28%) heads of oncology departments. Some differences between large and small/medium sized medical centers were observed regarding issues related to COVID-19 containment measures and changes in treatment.

CONCLUSIONS

Oncology departments in Israel were able to prepare and adapt their services to guidelines and requirements related to the COVID-19 pandemic with little harm to their treatment capacity.

788 A novel T- lymphocyte binding aptamer assembled into a bispecifc compound for the treatment of solid tumors

Background

T-cell engagers are bispecific molecules directed against the CD3 complex on one end and a tumor specific antigen on the other end, allowing a physical link of T cell to a tumor cell, resulting in tumor killing and immune activation. Bispecific molecules harnessing and redirecting T-cells towards tumor cells are a promising therapeutic agents. Aptamers are single stranded oligonucleotides with binding and recognition propensities similar to those of antibodies. Aptamers have a number of advantages over bispecific antibodies including shorter generation time and low immunogenicity. Thus, aptamers capable of targeting T cells would have great potential for use as anti-cancer therapeutics

Methods

Systematic evolution of ligands by exponential enrichment (SELEX) methodology was employed in order to identify a novel CD3e binding aptamer. CD3 binding aptamer was subsequently linked into a bispecific T cell engager structure with a tumor-targeting aptameric arm. The tumor-targeting aptamer is developed by Aummune's proprietary tailored therapeutic platform.1 based on identifying functional aptamer sequences capable of specifically killing targeted tumor cells and sparing healthy tissue .Exemplary bispecific aptamers were tested for T cell stimulation by flow cytometry. In vivo antitumor activity was investigated in syngeneic and in xenograft tumor models.

Results

We have successfully identified a novel CD3e –targeting aptamer with a Kd of 31nM. A bispecific T cell engager comprised of this aptamer and a tumor-targeting aptamer induced a potent stimulation of T cells in vitro, resulting in CD69 upregulation and IFNg secretion.Next, the CD3e targeting aptamer was hybridized to tumoricidal aptamers identified by Aummune's platform (VS12) to target either the human colon carcinoma HCT116 cells or (VS32) the murine triple negative breast cancer 4T1 cells. Both bispecific entities (CS6-VS12 and CS6-VS32) effectively lead to inhibition of tumor growth in vivo and increased survival in the corresponding models.

Conclusions

Our data above provide a proof-of-concept for Aummune's Bispecific Aptamer efficacy and provide a framework for the clinical development of this novel tailored immune therapeutic agents. Indeed, we are currently in the process of developing a first-in-human clinical study in subjects with solid tumors.

Reference

Mamet N, et al, Commun Biol 2020.

Efficacy and safety of BNT162b2 vaccination in patients with solid cancer receiving anticancer therapy - a single centre prospective study

AIM

Patients with cancer are at an increased risk for severe coronavirus disease of 2019, thus data on the safety and efficacy of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccines are essential. We conducted this prospective study of patients with cancer vaccinated with BNT162b2 and monitored for antibody response and safety. The aim was to evaluate the rate of seropositivity and define predictors for non-reactive immune response. Furthermore, we evaluated the frequency and the severity of adverse events.

METHODS

The study included patients with solid tumours undergoing anticancer treatment and immunocompetent health-care workers serving as controls. Serum titres of the receptor-binding domain (RBD) immunoglobulin G (IgG) and neutralising antibodies were measured 2-4 weeks after each vaccine dose.

RESULTS

The analysis included 129 patients, of which 70.5% patients were metastatic. Patients were treated with chemotherapy (55%), immunotherapy (34.1%), biological agents (24.8%), hormonal treatment (8.5%) and radiotherapy (4.6%), that were given either alone or in combinations. The seropositivity rate among patients with cancer and controls was 32.4% versus 59.8% (p < 0.0001) after the first dose and 84.1% versus 98.9% (p < 0.0001) after the second dose, respectively. Median RBD-IgG titre was lower among patients than controls (p < 0.0001). Patients who were seronegative after the second dose had significantly more comorbidities than that with patients with seropositivity (77.8% vs 41.1%, respectively, p = 0.0042).

CONCLUSION

Adequate antibody response after BNT162b2 vaccination was achieved after two doses but not after one dose, in patients with cancer vaccinated during anticancer therapy.

Fourfold Differential Photoelectron Circular Dichroism

We report on a joint experimental and theoretical study of photoelectron circular dichroism (PECD) in methyloxirane. By detecting O 1s photoelectrons in coincidence with fragment ions, we deduce the molecule's orientation and photoelectron emission direction in the laboratory frame. Thereby, we retrieve a fourfold differential PECD clearly beyond 50%. This strong chiral asymmetry is reproduced by ab initio electronic structure calculations. Providing such a pronounced contrast makes PECD of fixed-in-space chiral molecules an even more sensitive tool for chiral recognition in the gas phase.

Fermented Wheat Germ Extract (FWGE) as a Treatment Additive for Castration-Resistant Prostate Cancer: A Pilot Clinical Trial

Castration-resistant prostate cancer (CRPC) is a devastating and incurable disease. Combined therapy using conventional anticancer drugs and a proprietary medical nutriment, fermented wheat germ extract (FWGE), also known as Avemar, has been suggested as a treatment for progressing prostate cancer (PCa) patients, who have become resistant to first line hormonal therapy (gonadotropin releasing hormone, GnRH). The primary aim of this study was to test if this combined therapy would slow down disease progression in CRPC patients. We tested the nontoxic, readily available, inexpensive FWGE, together with the conventional treatment, GnRH analogue, in 36 CRPC patients. Although this is a pilot study, with the drawback of a statistically small sample size, some anticancer clinical activity of FWGE could be seen in the CRPC patients, as measured by prostate specific antigen doubling time (PSADT). We found that the intake of GnRH with FWGE for at least 4 months, improved the overall health as well as the quality of life (QOL) in 4 patients (11%) and was instrumental in extending the PSADT in about 17 (out of 26) patients (65.4%), six of whom were significant. Since no mentionable adverse events were noticed, this treatment may permit the postponement of chemotherapy for these patients.

Isotope Shifts of Radium Monofluoride Molecules

Isotope shifts of ^{223-226,228}Ra^{19}F were measured for different vibrational levels in the electronic transition A^{2}Π_{1/2}←X^{2}Σ^{+}. The observed isotope shifts demonstrate the particularly high sensitivity of radium monofluoride to nuclear size effects, offering a stringent test of models describing the electronic density within the radium nucleus. Ab initio quantum chemical calculations are in excellent agreement with experimental observations. These results highlight some of the unique opportunities that short-lived molecules could offer in nuclear structure and in fundamental symmetry studies.

Abstract CT209: A clinical trial of cResponse, a functional assay for cancer precision medicine

Precision cancer therapy has the potential to revolutionize treatment outcome. While genomic analysis has become central to cancer personalized medicine, recent studies have not shown that it drastically improves patient survival as compared to standard drug selection. Additionally, genomic mutations may suggest several treatment protocols without elucidating which approach will yield the best clinical response. Moreover, for many drugs no genetic predictive biomarkers are available. To advance cancer precision diagnostics, we have developed cResponse, a functional drug sensitivity platform to determine individualized patient treatment regimens. Fresh patient cancer samples are taken by biopsy or resection and sectioned into 300 uM slices which when cultured in the cResponse platform demonstrate similar architecture and tissue proliferation to those found in vivo. We show that cResponse is able to preserve human cancer tissue in 3D together with its microenvironment, including endothelial and immune cells, at a high viability (&gt;90%) with continued cell division for 7 days in over twenty types of solids tumors. Importantly, the high viability of the tissue over an extended period of time allows for a rapid genomic profiling to help prioritize drugs to be tested by cResponse, as well as the capacity to evaluate the effects of slow acting drugs such as targeted therapy. To validate the capacity of the cResponse platform to predict patient response to cancer treatment, forty two patients with different cancer types receiving diverse chemotherapeutic and targeted agents were recruited to the study and their tumors were tested using cResponse prior to initiation of treatment. Cancer types included bladder, pancreatic, lung, colorectal, breast and sarcoma. After five days of treatment ex-vivo, the samples were fixed and designated a viability score (ranging from 0 to 100) based on an algorithm composed of a panel of histological and morphological markers. The cResponse score was compared to the clinical response to treatment of 27 patients for which this data is already available. The results demonstrated that cResponse could predict the patient's response with a specificity of 82% (9/11) and a sensitivity of 93.75% (15/16) when compared to the patient's imaging results. In the future, the integration of this platform in directing anti-cancer treatment may lead to better response rate of cancer patients to therapy.

Citation Format: Seth Salpeter, Vered Bar, Sara Aharon, Luba Torovsky, Adi Zundelevich, Hamutal Shachar, Hagit Shapira, Nancy Gavert, Ravid Straussman, Shay Golan, Eli Rosenbaum, Talia Golan, Raanan Berger, Zohar Dotan, Dan Leibovici, Shani Breuer, Yakir Rotenberg, Aviad Zick, Ayala Hubert, Hovav Nechushtan, Guy Neev. A clinical trial of cResponse, a functional assay for cancer precision medicine [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 CT209.

Is Ultra Hypofractionated Radiation Therapy a Safe and Effective Treatment for Invasive Bladder Cancer in the Elderly?: A Retrospective Single Institution Review

PURPOSE

The aim was to determine the efficacy, safety, and tolerability of weekly ultra hypofractionated radiation therapy for older unfit patients with invasive bladder cancer.

METHODS

We retrospectively analyzed a cohort of patients with muscle invasive bladder cancer deemed unfit for chemoradiation therapy and thus treated with 6 weekly doses of 6 Gy using intensity modulated radiotherapy. Charlson comorbidity was calculated retrospectively. Cystoscopy and computed tomography were used to evaluate local control and toxicity using the common terminology criteria. Survival outcomes were estimated using the Kaplan-Meier method.

RESULTS

Twenty-two patients with a median age of 84 (range: 70 to 96) years were included. The median comorbidity index was 6±1.5 SD. Nineteen (90%) patients received the full 36 Gy dose. Median follow-up was 10±7 months (range: 6 to 27 mo). Local control in the bladder was achieved in 16 of 19 evaluable patients (84%). One-year overall survival was 62.5%, 1 patient had a retroperitoneal nodal recurrence and 3 patients developed distant metastasis. Grade 3 genitourinary and gastrointestinal toxicity was observed in 4 (18%) and 1 (4.5%) patients, respectively.

CONCLUSION

Weekly ultra hypofractionated intensity modulated radiotherapy with image guidance and bladder training is an effective, safe, and well-tolerated regimen for older patients with invasive bladder cancer unfit for radical treatment.

Salvage re-irradiation using stereotactic body radiation therapy for locally recurrent prostate cancer: the impact of castration sensitivity on treatment outcomes

Background

Advances in imaging, biomaterials and precision radiotherapy provide new opportunities to salvage locally recurrent prostate cancer (PC). This study evaluates the efficacy and safety of re-irradiation using stereotactic body radiation therapy (SBRT). We hypothesized that patients with castrate-resistant PC (CRPC) would benefit less from local salvage.

Methods

A prospective clinical database was reviewed to extract 30 consecutive patients treated with prostate re-irradiation. Gallium prostate specific membrane antigen (PSMA) ligand positron emission tomography was performed following prostate-specific antigen failure in all patients and biopsy was obtained in 18 patients (60%). Re-irradiation was either focal (n = 13) or whole-gland (n = 17). Endo-rectal balloons were used in twenty-two patients and hydrogel spacers in eight patients. The median prescription dose was 5 fractions of 6.5 (range: 6–8) Gray (Gy).

Results

Median follow-up was 28 months. Failure occurred in 10 (out of 11) CRPC patients versus 6 (out of 19) castrate-sensitive patients (91% vs. 32%, p = 0.008) after a median of 13 and 23 months, respectively. Metastases occurred in 64% (n = 7) of CRPC patients versus 16% (n = 3) of castrate-sensitive patients (p = 0.007). Two patients experienced local in-field recurrence, thus local control was 93%. The 2 and 3-year recurrence-free survival were 84% and 79% for castrate-sensitive patients versus 18% and 9% for CRPC patients (p < 0.001), and 3-year metastasis-free survival was 90% versus 27% (p < 0.01) for castrate-sensitive and CRPC patients, respectively. Acute grade II and III genitourinary (GU) toxicity occurred in 27% and 3%, and late GU toxicity in 30% and 3%, respectively. No ≥ grade II acute gastrointestinal (GI) toxicity occurred, and only one patient (3%) developed late grade II toxicity.

Conclusions

Early delivery of salvage SBRT for local recurrence is associated with excellent 3-year disease control and acceptable toxicity in the castrate-sensitive phenotype. PSMA imaging for detection of local recurrence and the use of precision radiotherapy with rectal protective devices should be further investigated as a novel salvage strategy for radio-recurrent PC.

Associations between T cell infiltration, T cell receptor clonality, histology and recurrence in renal cell carcinoma

Renal cell carcinoma (RCC) is comprised of clear-cell (ccRCC) and non-clear-cell (nccRCC) tumors. Despite definitive surgical resection in localized disease, recurrence often occurs. A commercial method based on a multiplex polymerase chain reaction (PCR) assay exclusively targets rearranged T cell receptor (TCR) genes to generate high-throughput sequencing-based data, allowing characterization of the immune repertoire within tumors. In this study we performed a retrospective analysis on archived tumor samples from patients with recurring versus non-recurring T3 ccRCC and on samples from early nccRCC versus ccRCC. Following genomic DNA extraction and multiplex PCR, the fraction of T cells within tumors, the number of unique receptors ('richness') and their relative abundances ('clonality') were calculated. Statistical significance and correlations were calculated using Student's t-test and Spearman's rho, respectively. Average fraction and clonality of T cells in tumors from non-recurring patients was 2.5- and 4.3-fold higher than in recurring patients (P = 0.025 and P = 0.043, respectively). A significant positive correlation was found between T cell fraction and clonality (Spearman's rho = 0.78, P = 0.008). The average fraction of T cells in ccRCC tumors was 2.8-fold higher than in nccRCC tumors (P = 0.015). Clonality and estimated richness were similar between ccRCC and nccRCC tumors. In summary, recurrence of ccRCC is associated with a lower fraction and clonality of T cells within tumors; nccRCC tumors are more 'deserted' than ccRCC, but similar in their ability to generate a clonal T cell repertoire. Our work suggests associations between the characteristics of T cell infiltrate, histology and tumor recurrence.

Genomic Features and Classification of Homologous Recombination Deficient Pancreatic Ductal Adenocarcinoma

BACKGROUND AND AIMS

Homologous recombination deficiency (HRD) in pancreatic ductal adenocarcinoma (PDAC), remains poorly defined beyond germline (g) alterations in BRCA1, BRCA2, and PALB2.

METHODS

We interrogated whole genome sequencing (WGS) data on 391 patients, including 49 carriers of pathogenic variants (PVs) in gBRCA and PALB2. HRD classifiers were applied to the dataset and included (1) the genomic instability score (GIS) used by Myriad's MyChoice HRD assay; (2) substitution base signature 3 (SBS3); (3) HRDetect; and (4) structural variant (SV) burden. Clinical outcomes and responses to chemotherapy were correlated with HRD status.

RESULTS

Biallelic tumor inactivation of gBRCA or PALB2 was evident in 43 of 49 germline carriers identifying HRD-PDAC. HRDetect (score ≥0.7) predicted gBRCA1/PALB2 deficiency with highest sensitivity (98%) and specificity (100%). HRD genomic tumor classifiers suggested that 7% to 10% of PDACs that do not harbor gBRCA/PALB2 have features of HRD. Of the somatic HRDetect^hi cases, 69% were attributed to alterations in BRCA1/2, PALB2, RAD51C/D, and XRCC2, and a tandem duplicator phenotype. TP53 loss was more common in BRCA1- compared with BRCA2-associated HRD-PDAC. HRD status was not prognostic in resected PDAC; however in advanced disease the GIS (P = .02), SBS3 (P = .03), and HRDetect score (P = .005) were predictive of platinum response and superior survival. PVs in gATM (n = 6) or gCHEK2 (n = 2) did not result in HRD-PDAC by any of the classifiers. In 4 patients, BRCA2 reversion mutations associated with platinum resistance.

CONCLUSIONS

Germline and parallel somatic profiling of PDAC outperforms germline testing alone in identifying HRD-PDAC. An additional 7% to 10% of patients without gBRCA/PALB2 mutations may benefit from DNA damage response agents.

Digital Display Precision Predictor: the prototype of a global biomarker model to guide treatments with targeted therapy and predict progression-free survival

The expanding targeted therapy landscape requires combinatorial biomarkers for patient stratification and treatment selection. This requires simultaneous exploration of multiple genes of relevant networks to account for the complexity of mechanisms that govern drug sensitivity and predict clinical outcomes. We present the algorithm, Digital Display Precision Predictor (DDPP), aiming to identify transcriptomic predictors of treatment outcome. For example, 17 and 13 key genes were derived from the literature by their association with MTOR and angiogenesis pathways, respectively, and their expression in tumor versus normal tissues was associated with the progression-free survival (PFS) of patients treated with everolimus or axitinib (respectively) using DDPP. A specific eight-gene set best correlated with PFS in six patients treated with everolimus: AKT2, TSC1, FKB-12, TSC2, RPTOR, RHEB, PIK3CA, and PIK3CB (r = 0.99, p = 5.67E-05). A two-gene set best correlated with PFS in five patients treated with axitinib: KIT and KITLG (r = 0.99, p = 4.68E-04). Leave-one-out experiments demonstrated significant concordance between observed and DDPP-predicted PFS (r = 0.9, p = 0.015) for patients treated with everolimus. Notwithstanding the small cohort and pending further prospective validation, the prototype of DDPP offers the potential to transform patients' treatment selection with a tumor- and treatment-agnostic predictor of outcomes (duration of PFS).

Closed-loop recycling of rare liquid samples for gas-phase experiments

Many samples of current interest in molecular physics and physical chemistry exist in the liquid phase and are vaporized for use in gas cells, diffuse gas targets, or molecular gas jets. For some of these techniques, the large sample consumption is a limiting factor. When rare, expensive molecules such as custom-made chiral molecules or species with isotopic labels are used, wasting them in the exhaust line of the pumps is quite an expensive and inefficient approach. Therefore, we developed a closed-loop recycling system for molecules with vapor pressures below atmospheric pressure. Once filled, only a few valves have to be adjusted, and a cold trap must be moved after each phase of recycling. The recycling efficiency per turn exceeds 95%.

Ocular side effects of novel anti-cancer biological therapies

To examine the ocular side effects of selected biological anti-cancer therapies and the ocular and systemic prognosis of patients receiving them. We retrospectively reviewed all medical records of patients who received biological anti-cancer treatment from 1/2012 to 12/2017 and who were treated at our ocular oncology service. The following data was retrieved: primary malignancy, metastasis, type of biological therapy, ocular side effects, ophthalmic treatment, non-ocular side effects, and ocular and systemic disease prognoses. Twenty-two patients received biological therapies and reported ocular side effects. Eighteen patients (81.8%) had bilateral ocular side effects, including uveitis (40.9%), dry eye (22.7%), and central serous retinopathy (22.7%). One patient (4.5%) had central retinal artery occlusion (CRAO), and one patient (4.5%) had branch retinal vein occlusion (BRVO). At the end of follow-up, 6 patients (27.27%) had resolution of the ocular disease, 13 patients (59.09%) had stable ocular disease, and 3 patients (13.64%) had progression of the ocular disease. Visual acuity improved significantly at the end of follow-up compared to initial values. Eighteen patients (81.8%) were alive at study closure. Biological therapies can cause a wide range of ocular side effects ranging from dry eye symptoms to severe pathologies that may cause ocular morbidity and vision loss, such as uveitis, CRAO and BRVO. All patients receiving biological treatments should be screened by ophthalmologists before treatment, re-screened every 4–6 months during treatment, and again at the end of treatment. Patients on biological treatment who have ocular complaints should be urgently referred to ocular consultation for early identification and early intervention.

Prasugrel compared to ticagrelor in primary PCI

Background

Prasugrel and ticagrelor have similar recommendations in the setting of primary PCI by current guidelines. Data comparing both in daily clinical practice of primary PCI for ST-elevation myocardial infarction is limited.

Purpose

To compare the effect of prasugrel and ticagrelor on in-hospital outcomes after primary PCI.

Methods and results

We prospectively enrolled 5365 patients treated with prasugrel (n=2785, 51.9%) or ticagrelor (n=2580; 48.1%) in the setting of primary PCI from January 2011 to December 2018 in a nationwide registry. In-hospital outcomes were compared and multiple logistic regression analysis was performed. Prasugrel treated patients were younger, less often in cardiogenic shock, with lower rates of previous stroke and had shorter ischemic time. Both groups showed similar rates of previous MI, diabetes and current resuscitation. In the univariate analysis mortality was lower in patients with prasugrel (2.5% vs. 4.4% p&lt;0.01). Similarly, MACE (3.3% vs. 5.3%, p&lt;0.01) and NACE (4.0% vs. 5.7% p&lt;0.01) were lower in prasugrel treated patients, whereas major bleeding events did not differ (0.4% vs. 0.6% p=0.24).

After adjustment in multivariable analysis mortality (0.99 95% CI 0.57 to 1.72), MACE (OR 0.99 95% CI 0.65 to 1.52) as well as NACE (0.86 95% CI 0.61 to 1.22) did not differ in patients treated with prasugrel compared to ticagrelor.

Conclusion

Patients treated with prasugrel showed improved outcomes compared to ticagrelor in a large cohort of primary PCI. However, after adjustment for confounders the Advantage of prasugrel in primary PCI did not persist.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Austrian Society of Cardiology

Incidental pulmonary embolism in CT scans of oncological patients with metastatic disease undergoing clinical trials: frequency and linkage with onset of disease progression (PE-PD association)

Objectives:

We aimed to analyze the association between the onsets of PE and of progressive disease (PD) in CT scans of oncological patients undergoing clinical trials.

Methods:

We retrospectively searched our oncological clinical trials database (1/2012 - 6/2017). We retrieved patients who underwent protocol baseline and follow-up CT scans. RECIST 1.1 categories of response were calculated for each scan at interpretation. The entire dataset was searched for reports with incidental PE. For patients with incidental PE, we collected all the scans conducted up to and including the scan with PE. For each scan, we retrieved the recorded RECIST 1.1 category. We excluded patients with PE at baseline. The frequency of incidental PE in oncological clinical trial patients was calculated. For patients with incidental PE, we evaluated the association between PE and PD.

Results:

During the study period, 1,070 patients underwent 3,818 CTs. The total number of follow-up months was 7,292 months. 18 patients developed incidental PE during follow-up. Thus, the frequency of incidental PE in oncological clinical trial patients was 3% per year of follow-up. Patients with incidental PE underwent 60 scans up to development of PE. Of 42 non-baseline scans, 6/6 (100%) PD showed PE, and 5/36 (13.9%) non-PD showed PE, making PE onset associated with PD onset (p < 0.001).

Conclusion:

In oncological clinical trials, the frequency of incidental PE is 3% per year of follow-up. The onset of incidental PE is linked to the onset of PD.

Advances in knowledge:

Incidental PE is associated with the onset of disease progression. Radiologists interpret oncological scans should be aware of the association between PE and PD.

Effect of the botanical compound LCS102 on innate immunity

Innate immunity serves an important role in the healthy population, providing surveillance and protection against infections. Chemotherapy suppresses the body's immune system, including neutrophil and natural killer (NK) cell numbers and activity. This leads to an increased risk of infection which often requires the reduction or even discontinuation of the chemotherapeutic regimens. The botanical formula LCS102 was designed to stimulate the body's immune system. The effect of the formula on innate immunity was examined in human blood samples, as were its effect on the anti-cancer activity of chemotherapeutic agents on human cancer cells. Blood samples drawn from 20 volunteers (19 healthy subjects; 1 patient with breast cancer undergoing chemotherapy) and were exposed to LCS102. The effects on neutrophil and NK cell activity were tested using FACS. The anti-cancer effects of LCS102 were tested on T24, A549, MCF7, PANC-1 and U2OS human cancer cell lines, as were the effects of the formula on doxorubicin, Taxol, etoposide and cisplatin-treated cells using a sulforodamine B viability assay. LCS102 was shown to significantly increase the percentage of activated neutrophils and NK cells in the blood samples tested. The formula did not inhibit the cytotoxic effects of the chemotherapeutic agents, and in certain cases increased their anti-cancer activity. Further research is required to improve our understanding of the clinical value of LCS102; however, it may serve as an adjuvant during chemotherapy, to reduce the effects of chemotherapy on innate immunity.

Mechanical circulatory support for cardiovascular complications in a young COVID-19 patient

Background: The current coronavirus (COVID‐19) pandemic is associated with severe pulmonary and cardiovascular complications.

Case presentation: This report describes a young patient with COVID‐19 without any comorbidity presenting with severe cardiovascular complications, manifesting with pulmonary embolism, embolic stroke, and right heart failure.

Conclusion: Management with short‐term mechanical circulatory support, including different cannulation strategies, resulted in a successful outcome despite his critical cardiovascular status.

A Retrospective Analysis of the Safety and Activity of Lutetium-177-Prostate-Specific Membrane Antigen Radionuclide Treatment in Older Patients with Metastatic Castration-Resistant Prostate Cancer

BACKGROUND

Prostate cancer is a common malignancy of the elderly, and with the aging of the population, the need is growing for therapies suitable for this age group. Lutetium-177-prostate-specific membrane antigen (Lu-PSMA), a radiolabeled small molecule, binds with high affinity to prostate-specific membrane antigen, enabling beta particle therapy targeted to metastatic castration-resistant prostate cancer (mCRPC). In a recent single-arm phase II trial and a subsequent expansion cohort, a prostate-specific antigen (PSA) decline of ≥50% was observed in approximately 60% of patients receiving Lu-PSMA. Taking into account the specific challenges and potential toxicities of Lu-PSMA administration in elderly men, we sought to retrospectively analyze the safety and activity of Lu-PSMA in men aged older than 75 years with mCRPC.

PATIENTS AND METHODS

The electronic medical records of 24 patients aged older than 75 years treated with Lu-PSMA "off-trial" were reviewed, and clinical data were extracted. Clinical endpoints were toxicity and activity, defined as a PSA decline ≥50%. Descriptive statistics were performed using Excel.

RESULTS

The median age at treatment start was 81.7 years (range 75.1-91.9). The median number of previous treatment lines was four. The number of treatment cycles ranged from one to four; the mean administered radioactivity was 6 GBq per cycle. Treatment was generally tolerable; side effects included fatigue (n = 8, 33%), anemia (n = 7, 29%), thrombocytopenia (n = 5, 21%), and anorexia/nausea (n = 3, 13%). Clinical benefit was observed in 12 of 22 patients (54%); PSA decline above 50% was observed in 11 patients (48%) and was associated with significantly longer overall survival.

CONCLUSION

Our results indicate that Lu-PSMA is safe and active in elderly patients with mCRPC.

IMPLICATIONS FOR PRACTICE

Lutetium-177-prostate-specific membrane antigen (Lu-PSMA), a radiolabeled small molecule, binds with high affinity to prostate-specific membrane antigen, enabling beta particle therapy targeted to metastatic castration-resistant prostate cancer (mCRPC). The recently published single-arm phase II trial with Lu-PSMA, describing its safety and activity, did not include patients aged older than 75 years. In this study, Lu-PSMA activity was retrospectively analyzed in patients aged older than 75 years and results indicate that treatment was tolerable and similarly active in this age group, with no new emerging safety signals. Despite the small cohort size, this analysis suggests that Lu-PSMA can serve as an advanced palliative treatment line in mCRPC in elderly patients.

A template for generic asssessment of tumor response: "myRECIST"

e14149

Background: Oncologists often need an objective, quantitative assessment of a patient's response to therapy. Lacking a standardized format, the oncologist may request a RECIST (Response Evaluation Criteria in Solid Tumors) analysis. RECIST, however, was developed to provide standardized assessment in the context of randomized clinical trials. RECIST is based on the prospective analysis of a limited sample of tumor lesions or lymph nodes, whereas the clinician naturally makes clinical decisions retrospectively. Furthermore, RECIST has definitions, rules, and criteria for classifying responses that may not apply in the clinical setting, and it does not include consistent rules for merging or splitting lymph nodes, mixed tumor responses, lesions that may cavitate, and a wide range of individualistic responses encountered in clinical practice. Methods: To address these issues, we have modified our working Excel-based template for RECIST 1.1 assessment to include a "myRECIST" feature, so that the radiologist can enter data and examine a range of pre-defined or customizable scenarios, including RECIST1.1, iRECIST, Lugano, volumetric and other parametric protocols. With a few interactions, this template can produce exportable tables and graphs of tumor responses that can guide therapy, as shown in the attached image. Definitions are standardized and linked to RADLEX ontology for specificity and subsequent analysis. Results: This template has been developed for clinical use and is available for downloading from our institutional web-site. Conclusions: We have developed, for public use, a free, easy-to-use, down-loadable Excel template for evaluating prospective or retrospective scenarios of tumor response to therapy that avoids the restrictions of the RECIST methodology. This template may prove useful to oncologists both in and out of the context of randomized clinical trials. We call this "myRECIST."

Biomarker analysis from the KEYNOTE-199 trial of pembrolizumab in patients (pts) with docetaxel-refractory metastatic castration-resistant prostate cancer (mCRPC)

5526

Background: In the phase II KEYNOTE-199 study (NCT02787005), pembrolizumab monotherapy demonstrated antitumor activity in pts with docetaxel-refractory mCRPC (n = 258). Here we evaluated the association between prespecified molecular biomarkers and clinical outcomes. Methods: Cohorts 1 (C1) and 2 (C2) enrolled pts with RECIST-measurable PD-L1–positive (combined positive score [CPS] ≥1 using immunohistochemistry) and PD-L1–negative (CPS <1) disease, respectively. C3 enrolled pts with nonmeasurable, bone-predominant disease, irrespective of PD-L1 status. Biomarkers evaluated in this analysis were tumor mutational burden ([TMB; mutations/exome] n = 155), PD-L1 CPS (n = 255), tumor microenvironment–based 18-gene RNA expression profile ([GEP] n = 196), and microsatellite instability ([MSI] as determined by Promega PCR analysis; n = 147). Outcomes evaluated for C1 and C2 (n = 200) were ORR, disease control rate (DCR), and radiographic PFS (rPFS) per blinded, independent central review per PCWG-modified RECIST v1.1. Outcomes evaluated for C1-C3 (n = 258) were prostate-specific antigen (PSA) response, time to PSA progression, and OS. Significance of continuous biomarkers (CPS; TMB; GEP) was prespecified at 0.05 for one-sided P values from logistic (ORR; DCR; PSA response) and Cox proportional hazard regression (rPFS; OS; PSA progression) adjusted for Eastern Cooperative Oncology Group performance status. Binary biomarkers (MSI) were analyzed using Fisher’s exact test (ORR; DCR; PSA response). Clinical data cutoff date: Jun 24, 2019. Results: Median TMB was 53.0 (interquartile range [IQR], 40.5 to 78.0), median CPS was 1 (IQR, 0 to 5), and median GEP was –0.64 (IQR, –0.88 to –0.46); 6 pts (2.3%) had MSI-high tumors. In C1-C3, TMB was associated with PSA response (one-sided nominal P = 0.0016) and time to PSA progression (one-sided nominal P = 0.00092). In C1-C3, PD-L1 CPS was associated with PSA response (one-sided nominal P = 0.046) and time to PSA progression (one-sided nominal P = 0.021). In C1-C3, GEP was not significantly associated with response. In C1-C3, MSI was associated with PSA response (one-sided nominal P = 0.019). Conclusions: In this biomarker analysis from KEYNOTE-199 C1-C3, TMB and PD-L1 CPS were associated with better PSA response; however, small pt numbers limit definitive conclusions on ORR, DCR, and OS. Further evaluation of molecular biomarkers in pts with mCRPC treated with pembrolizumab is warranted. Clinical trial information: NCT02787005 .

Phase II study of pembrolizumab in docetaxel-pretreated patients with metastatic castration-resistant prostate cancer (mCRPC): Updated follow-up of cohorts (C) one to three from KEYNOTE-199

e17584

Background: Pembrolizumab monotherapy has shown antitumor activity and acceptable safety in patients with mCRPC previously treated with a next-generation hormone agent (NHA) and docetaxel. Presented herein are updated results from KEYNOTE-199 (NCT02787005), a multicohort phase 2 study, in patients with RECIST-measurable PD-L1+ disease (C1), RECIST-measurable, PD-L1− disease (C2), and bone-predominant disease, irrespective of PD-L1 (C3). Methods: Patients who previously received ≥1 NHA and 1 or 2 chemotherapies, including docetaxel, received pembrolizumab 200 mg Q3W for 35 cycles or until progression/toxicity. The primary end point was ORR per RECIST v1.1 by blinded independent central review (BICR). Key secondary end points were DCR, PSA response rate (≥50% decrease from baseline), time to PSA progression, rPFS, OS, DOR, and safety. rPFS and OS were evaluated using the Kaplan-Meier method. Results: Of 258 treated patients (C1, 133; C2, 67; C3, 58), 6 completed therapy (C1, 4; C3, 2) and 252 discontinued (C1, 129; C2, 67; C3, 56), primarily due to progression (C1, 106; C2, 61; C3, 45). Median (range) time from enrollment to data cutoff was 31.3 mo (26.7-34.7) in C1, 30.6 mo (28.0-34.1) in C2, and 32.6 mo (27.4-34.4) in C3. Efficacy results are displayed in the table. ORR (95% CI) for patients with measurable disease was 6% (2.6-11.5) in C1 and 3% (0.4-10.4) in C2. Of 10 responders, 6 had a DOR ≥18 mo. Median time to PSA progression was 4 mo across cohorts. Any grade treatment-related AEs (TRAEs) occurred in 57-60% of patients across C1-3. Grade ≥3 TRAEs occurred in 16% of patients in C1, 15% in C2, and 17% in C3; 1 patient in each cohort died of a TRAE (C1, sepsis; C2, unknown; C3, immune-related pneumonitis). Conclusions: Pembrolizumab monotherapy was well tolerated and showed durable, antitumor activity and disease control with survival up to 24 mo in 3 cohorts of docetaxel and NHA-pretreated patients with RECIST-measurable or bone-predominant mCRPC. Clinical trial information: NCT02787005 . [Table: see text]

Spectroscopy of short-lived radioactive molecules

Molecular spectroscopy offers opportunities for the exploration of the fundamental laws of nature and the search for new particle physics beyond the standard model1-4. Radioactive molecules-in which one or more of the atoms possesses a radioactive nucleus-can contain heavy and deformed nuclei, offering high sensitivity for investigating parity- and time-reversal-violation effects5,6. Radium monofluoride, RaF, is of particular interest because it is predicted to have an electronic structure appropriate for laser cooling6, thus paving the way for its use in high-precision spectroscopic studies. Furthermore, the effects of symmetry-violating nuclear moments are strongly enhanced5,7-9 in molecules containing octupole-deformed radium isotopes10,11. However, the study of RaF has been impeded by the lack of stable isotopes of radium. Here we present an experimental approach to studying short-lived radioactive molecules, which allows us to measure molecules with lifetimes of just tens of milliseconds. Energetically low-lying electronic states were measured for different isotopically pure RaF molecules using collinear resonance ionisation at the ISOLDE ion-beam facility at CERN. Our results provide evidence of the existence of a suitable laser-cooling scheme for these molecules and represent a key step towards high-precision studies in these systems. Our findings will enable further studies of short-lived radioactive molecules for fundamental physics research.

Proteomic analysis of combined IGF1 receptor targeted therapy and chemotherapy identifies signatures associated with survival in breast cancer patients

Clinical, epidemiological and experimental data identified the insulin-like growth factor-1 receptor (IGF1R) as a candidate therapeutic target in oncology. While this paradigm is based on well-established biological facts, including the potent anti-apoptotic and cell survival capabilities of the receptor, most Phase III clinical trials designed to target the IGF1R led to disappointing results. The present study was aimed at evaluating the hypothesis that combined treatment composed of selective IGF1R inhibitor along with classical chemotherapy might be more effective than individual monotherapies in breast cancer treatment. Analyses included comprehensive measurements of the synergism achieved by various combination regimens using the CompuSyn software. In addition, proteomic analyses were conducted to identify the proteins involved in the synergistic killing effect at a global level. Data presented here demonstrates that co-treatment of IGF1R inhibitor along with chemotherapeutic drugs markedly improves the therapeutic efficiency in breast cancer cells. Of clinical relevance, our analyses indicate that high IGF1R baseline expression may serve as a predictive biomarker for IGF1R targeted therapy. In addition, we identified a ten-genes signature with potential predictive value. In conclusion, the use of a series of bioinformatics tools shed light on some of the biological pathways that might be responsible for synergysm in cancer therapy.

Clinical Variables Associated with PSA Response to Lutetium-177-PSMA ([177Lu]-PSMA-617) Radionuclide Treatment in Men with Metastatic Castration-Resistant Prostate Cancer

Lutetium-177-PSMA ([177Lu]-PSMA-617), a radiolabeled small molecule, binds with high affinity to prostate-specific membrane antigen (PSMA), enabling targeted radiation therapy to metastatic prostate lesions. Our objective was to retrospectively analyze the activity of [177Lu]-PSMA-617 given off-trial to men with metastatic castration resistant prostate cancer (mCRPC) and identify clinical factors associated with PSA response. Electronic medical records of all men treated with [177Lu]-PSMA-617 were reviewed and analyzed. Overall survival was calculated using the Kaplan-Meier method. The association between potential variables and PSA response was analyzed by univariate analysis, using either logistic regression or χ²/Fisher's exact test. Multivariable analysis was carried out using logistic regression on all categorical variables with a P-value of <0.1 on univariate analysis. Variables found to be statistically significant were then used to define a categorical score. A total of 52 patients received at least one cycle of [177Lu]-PSMA-617. Clinical benefit was observed in 28 patients (52%). PSA decline ≥20% and ≥50% was observed in 26 (50%) and 18 patients (35%), respectively. Achievement of any PSA decline at first measurement was significantly associated with survival. There was a negative association between the number of previous chemotherapy lines and PSA decline above 20%. Univariate analysis followed by multivariable analysis showed that older age and higher hemoglobin were significantly associated with a PSA decline >20%. A score combining these two parameters was significantly associated with PSA response. In summary, [177Lu]-PSMA-617 is active in the 'real-life' setting of heavily pretreated men with mCRPC.