Diffuse Idiopathic Skeletal Hyperostosis Prevalence, Characteristics, and Associated Comorbidities: A Cross-Sectional Study of 1815 Whole Spine CT Scans

STUDY DESIGN

A Retrospective Study.

OBJECTIVE

To determine the prevalence and characteristics of DISH using whole spine CT scans and to evaluate the association of DISH with co-morbidities and other ossified lesions.

METHOD

A retrospective study of whole-spine CT scans of polytrauma patients from 2018-2021 above the age of 20 years. The screening was done using modified Resnick criteria. Overall and age-specific prevalence, characteristics, and associations with obesity, diabetes mellitus (DM), ischemic heart disease (IHD), aortic calcification (AC), ossified posterior longitudinal ligament (OPLL), and ossified ligamentum flavum (OLF) were evaluated.

RESULTS

Out of 1815 patients, 347 had DISH, with a prevalence rate of 19.1% and a mean age of 61.7 years. The highest prevalence of DISH was seen in individuals over 80 years of age (45.5%). The prevalence among males (20.2%) was higher than for females (14.9%). The most commonly involved level was T8-T9 (95.4%), followed by T9-T10 (91.9%), and the most common vertebra involved was T9 (96%). All the cases involving T9 had ossification on the right anterior aspect of the vertebral body. The presence of DM, high BMI, and IHD was found to be significantly higher in patients with DISH (P value < .001). The incidence of aortic calcification was 22.5%, OPLL was 13.3%, and OLF was 4.9% in patients with DISH.

CONCLUSION

This study reports a prevalence rate of 19.1% for DISH, with the highest prevalence among individuals above 80 years of age (45.5%). DISH has a higher propensity to affect the right anterior aspect of the vertebral body in the thoracic spine and is strongly associated with obesity, DM, IHD, and AC.

Intra-islet glucagon signalling regulates beta-cell connectivity, first-phase insulin secretion and glucose homoeostasis

BACKGROUND

Type 2 diabetes (T2D) is characterised by the loss of first-phase insulin secretion. We studied mice with β-cell selective loss of the glucagon receptor (Gcgrfl/fl X Ins-1Cre), to investigate the role of intra-islet glucagon receptor signalling on pan-islet calcium activity and insulin secretion.

METHODS

Metabolic profiling was conducted on Gcgrβ-cell-/- and littermate controls. Crossing with GCaMP6f (STOP flox) animals further allowed for β-cell specific expression of a fluorescent calcium indicator. These islets were functionally imaged in vitro and in vivo. Wild-type mice were transplanted with islets expressing GCaMP6f in β-cells into the anterior eye chamber and placed on a high fat diet. Part of the cohort received a glucagon analogue (GCG-analogue) for 40 days and the control group were fed to achieve weight matching. Calcium imaging was performed regularly during the development of hyperglycaemia and in response to GCG-analogue treatment.

RESULTS

Gcgrβ-cell-/- mice exhibited higher glucose levels following intraperitoneal glucose challenge (control 12.7 mmol/L ± 0.6 vs. Gcgrβ-cell-/- 15.4 mmol/L ± 0.0 at 15 min, p = 0.002); fasting glycaemia was not different to controls. In vitro, Gcgrβ-cell-/- islets showed profound loss of pan-islet [Ca2+]I waves in response to glucose which was only partially rescued in vivo. Diet induced obesity and hyperglycaemia also resulted in a loss of co-ordinated [Ca2+]I waves in transplanted islets. This was reversed with GCG-analogue treatment, independently of weight-loss (n = 8).

CONCLUSION

These data provide novel evidence for the role of intra-islet GCGR signalling in sustaining synchronised [Ca2+]I waves and support a possible therapeutic role for glucagonergic agents to restore the insulin secretory capacity lost in T2D.

An innovative analysis of nasolabial dynamics of surgically managed adult patients with unilateral cleft lip and palate using 3D facial motion capture

AIM

To compare dynamic nasolabial movement between end-of-treatment cleft and a matched non-cleft group in adult patients.

MATERIALS AND METHODS

Thirteen treated adult participants with unilateral cleft lip and palate had images taken using a facial motion capture system performing a maximum smile. Seventeen landmarks were automatically tracked. For each landmark pair, on either side of the midline, changes in the x, y, and z directions were used to analyze the magnitude of displacement and path of motion. An asymmetry score was developed at rest, mid-smile, and maximum smile to assess the shape of the mouth and/or nose.

RESULTS

At maximum smile, displacement of right and left cheilion was clinically and statistically (p < 0.05) less in the cleft group. The lip asymmetry score was greater (p < 0.05) at each time point in the cleft group using the clinical midline. Using Procrustes superimposition, the differences were significant (p < 0.05) only at rest and mid-smile. The alar bases were displaced significantly less (p < 0.05) in the z direction in the cleft group. The asymmetry score of the alar base was significantly higher using the clinical midline than using Procrustes superimposition in patients with cleft conditions (p < 0.001). In the cleft group, at maximum smile, the right and left cristae philter moved significantly less (p < 0.05) in the x and z directions.

CONCLUSIONS

There was an increase in asymmetry score of the corners of the mouth and alar bases from rest to maximum smile. The lips were similar in shape but oriented differently in the faces of patients with cleft conditions than in individuals without those conditions.

Comparison Between Relative Efficacy of Erector Spinae Plane Block and Caudal Epidural Block for Postoperative Analgesia in Lumbar Fusion Surgery- A Prospective Randomized Controlled Study

STUDY DESIGN

Prospective, randomized controlled double-blinded study.

OBJECTIVE

To compare the relative efficacy of ultrasound-guided ESPB and CEB for postoperative analgesia after a single-level lumbar fusion surgery and compared it with conventional multimodal analgesia.

METHODS

81 patients requiring single-level lumbar fusion surgery were randomly allocated into 3 groups (ESPB group, CEB group, and the control group). Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization, and complications were recorded.

RESULTS

The total opioid consumption in the first 24 hours was significantly lower in both the block groups than in the control group (103.70 ± 13.34 vs 105 ± 16.01 vs 142.59 ± 40.91mcg; P < .001). The total muscle relaxant consumption was also significantly less in block groups compared to controls (50.93 ± 1.98 vs 52.04 ± 3.47 vs 55.00 ± 5.29 mg; P < .001). The intraoperative blood loss was significantly less in both the block group (327.78 ± 40.03 mL, 380.74 ± 77.80 mL) than the control group (498.89 ± 71.22 mL) (P < .001). Among the block groups, the immediate postoperative pain relief was better in the CEB group, however, the ESPB group had a longer duration of postoperative pain relief.

CONCLUSION

Both ESPB and CEB produce adequate postoperative analgesia after lumbar fusion however the duration of action was significantly longer in the ESPB group with relatively shorter surgical time and lesser blood loss compared to the CEB group.

Giant Anomalous Cervical Spinous Process Causing Dynamic Cord Compression: An Unusual Cause for Myelopathy: A Case Report

CASE

A 47-year-old male patient presented with progressively worsening gait instability caused by a giant anomalous, free-floating C5 spinous process resulting in dynamic cord compression and myelopathy. The patient was successfully managed with a C5 laminectomy and total excision of the anomalous spinous process with a good functional outcome at the final follow-up.

CONCLUSION

Anomalies of the posterior arch of the subaxial cervical spine are relatively uncommon and asymptomatic. This case is being reported for its rarity and to highlight the role of dynamic imaging in patients presenting with congenital anomalies of the cervical spine presenting with compressive myelopathy.

Abstract 3784: miR-489 induces apoptosis and immunogenic cell death through targeting FOXM1 in triple negative breast cancer cells

It has been well established that microRNAs (miRNAs) have an important role in cancer sustenance and progression. Our previous studies have established the role of miR-489 as a tumor suppressor miRNA in breast cancer. However, the multiple targets of this miRNA have diversified its mechanism from preventing tumor cell proliferation to promoting cell death pathways. In this study we have aimed to establish the role of miR-489 in cell cycle inhibition, leading to Endoplasmic Reticulum stress (ER stress) and ultimately immunogenic cell death (ICD). Firstly, we found that overexpression of miR-489 in triple negative breast cancer (TNBC) cell lines including MDA-MB-231, BT 549, drastically reduced cell proliferation using colony formation assay and real-time cell analysis. Furthermore, studies like GO analysis, sequence analysis and cell cycle analysis demonstrated that miR-489 induces cell cycle arrest and apoptosis in TNBC by directly targeting FOXM1 and regulating other kinases like CDK1. It was also shown for the first time that miR-489 overexpression induces ER stress and the release of damage associated molecular patterns (DAMPs), consistent with hallmarks of ICD like Calreticulin exposure on cellular surface and ATP release, triggering phagocytosis. It was also established that miR-489-induced apoptosis lead to the elevation of cleaved caspase 3, which was responsible for the activation of PANX1 and the consequent release of ATP. In conclusion, we tried to mechanistically understand the role of miR-489 in cell cycle arrest leading to cellular stress. Stress induced apoptosis and consequent ICD was also a possible outcome and it turned out miR-489 overexpression without any other ICD inducer was good enough to trigger the release of DAMPs and elucidate an immunogenic response.

Citation Format: Gourab Gupta, Ryan Titus, Yogin Patel, Shakthika Sarvanan, Hexin Chen. miR-489 induces apoptosis and immunogenic cell death through targeting FOXM1 in triple negative breast cancer cells. [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 3784.

Abstract A54: Epi-RTM (epigenetic reprogramming) technology improves stemness, preserves polyclonality and enhances antitumor functionality of tumor infiltrating lymphocytes in nonclinical studies

Background: Adoptive cell therapy (ACT) is an evolving area for drug development in advanced solid tumors. Tumor infiltrating lymphocyte (TIL) therapy as an autologous ACT has shown promising efficacy in select solid tumor types, eliciting clinical responses through tumor specific antigen recognition and maintaining T-cell receptor (TCR) diversity. Growing evidence indicates that TIL products with increased T-cell stemness, tumor antigen recognition, and clonal diversity may result in improved clinical outcomes. Epi-R reprogramming technology is designed to improve T-cell stemness, polyclonality, and antitumor functionality in ACT products, including TIL. Method: The Epi-R protocol is composed of an extensively formulated proprietary cell culture media and well-defined cytokines with specific cell activation and expansion manufacturing parameters and methods. In nonclinical experiments, research-scale TIL products were produced from 3 different tumor types (melanoma, lung, and colorectal cancer) using either the Epi-R technology or a standard protocol (control TIL). Characteristics of the resulting products were compared using flow cytometry to assess stemness markers. An autologous cell line was generated from a melanoma patient tumor, and antitumor function and cytokine production were measured upon co-culture with the TIL products. Clonal diversity was assessed using TCR Vbeta sequencing. Results: Nonclinical evaluations of Epi-R TIL demonstrated increased stemness, functional cytokine production and antitumor activity compared to control TIL. Epi-R TIL products were enriched for CD8+ T cells, co-receptor (CD27 and CD28) positive CD8+ T cells, and stem-like CD8+ T cells, as demonstrated by enrichment for CD39-CD69- T cells compared to control TIL. Epi-R TIL demonstrated superior functionality by IFNg response upon co-culture with an autologous melanoma tumor cell line. Polyclonality was preserved in Epi-R TIL as measured by Simpson clonality index using bulk TCR Vbeta sequencing data. Conclusion: Results from research-scale TIL productions demonstrated that Epi-R reprogramming technology enables successful TIL expansion while maintaining a greater proportion of stem-like and co-stimulatory positive CD8+ TIL with preserved polyclonality compared to control TIL. Moreover, Epi-R TIL show improved antitumor activity compared to control TIL product in a melanoma tumor cell line. Further studies of Epi-R TIL using RNA sequencing will allow further characterization of this product and determine whether key product attributes are maintained at large-scale TIL manufacturing. An Investigational New Drug (IND) submission for LYL845, our autologous TIL product manufactured with Epi-R reprogramming technology, for melanoma and other advanced solid tumors is anticipated to occur in the second half of 2022.

Citation Format: Yogin Patel, Ngoc-Han Ha, Melissa Bedard, Joanna Kritikou, Rigel Kishton, Suman Kumar Vodnala. Epi-RTM (epigenetic reprogramming) technology improves stemness, preserves polyclonality and enhances antitumor functionality of tumor infiltrating lymphocytes in nonclinical studies [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy; 2022 Oct 21-24; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(12 Suppl):Abstract nr A54.

Internal checkpoint regulates T cell neoantigen reactivity and susceptibility to PD1 blockade

BACKGROUND

Adoptive transfer of tumor-infiltrating lymphocytes (TIL) fails to consistently elicit tumor rejection. Manipulation of intrinsic factors that inhibit T cell effector function and neoantigen recognition may therefore improve TIL therapy outcomes. We previously identified the cytokine-induced SH2 protein (CISH) as a key regulator of T cell functional avidity in mice. Here, we investigate the mechanistic role of CISH in regulating human T cell effector function in solid tumors and demonstrate that CRISPR/Cas9 disruption of CISH enhances TIL neoantigen recognition and response to checkpoint blockade.

METHODS

Single-cell gene expression profiling was used to identify a negative correlation between high CISH expression and TIL activation in patient-derived TIL. A GMP-compliant CRISPR/Cas9 gene editing process was developed to assess the impact of CISH disruption on the molecular and functional phenotype of human peripheral blood T cells and TIL. Tumor-specific T cells with disrupted Cish function were adoptively transferred into tumor-bearing mice and evaluated for efficacy with or without checkpoint blockade.

FINDINGS

CISH expression was associated with T cell dysfunction. CISH deletion using CRISPR/Cas9 resulted in hyper-activation and improved functional avidity against tumor-derived neoantigens without perturbing T cell maturation. Cish knockout resulted in increased susceptibility to checkpoint blockade in vivo.

CONCLUSIONS

CISH negatively regulates human T cell effector function, and its genetic disruption offers a novel avenue to improve the therapeutic efficacy of adoptive TIL therapy.

FUNDING

This study was funded by Intima Bioscience, U.S. and in part through the Intramural program CCR at the National Cancer Institute.

Cancer genes disfavoring T cell immunity identified via integrated systems approach

Adoptive T cell therapies (ACT) have been curative for a limited number of cancer patients. The sensitization of cancer cells to T cell killing may expand the benefit of these therapies for more patients. To this end, we use a three-step approach to identify cancer genes that disfavor T cell immunity. First, we profile gene transcripts upregulated by cancer under selection pressure from T cell killing. Second, we identify potential tumor gene targets and pathways that disfavor T cell killing using signaling pathway activation libraries and genome-wide loss-of-function CRISPR-Cas9 screens. Finally, we implement pharmacological perturbation screens to validate these targets and identify BIRC2, ITGAV, DNPEP, BCL2, and ERRα as potential ACT-drug combination candidates. Here, we establish that BIRC2 limits antigen presentation and T cell recognition of tumor cells by suppressing IRF1 activity and provide evidence that BIRC2 inhibition in combination with ACT is an effective strategy to increase efficacy.

miR-489 Confines Uncontrolled Estrogen Signaling through a Negative Feedback Mechanism and Regulates Tamoxifen Resistance in Breast Cancer

Approximately 75% of diagnosed breast cancer tumors are estrogen-receptor-positive tumors and are associated with a better prognosis due to response to hormonal therapies. However, around 40% of patients relapse after hormonal therapies. Genomic analysis of gene expression profiles in primary breast cancers and tamoxifen-resistant cell lines suggested the potential role of miR-489 in the regulation of estrogen signaling and development of tamoxifen resistance. Our in vitro analysis showed that loss of miR-489 expression promoted tamoxifen resistance, while overexpression of miR-489 in tamoxifen-resistant cells restored tamoxifen sensitivity. Mechanistically, we found that miR-489 is an estrogen-regulated miRNA that negatively regulates estrogen receptor signaling by using at least the following two mechanisms: (i) modulation of the ER phosphorylation status by inhibiting MAPK and AKT kinase activities; (ii) regulation of nuclear-to-cytosol translocation of estrogen receptor α (ERα) by decreasing p38 expression and consequently ER phosphorylation. In addition, miR-489 can break the positive feed-forward loop between the estrogen-Erα axis and p38 MAPK in breast cancer cells, which is necessary for its function as a transcription factor. Overall, our study unveiled the underlying molecular mechanism by which miR-489 regulates an estrogen signaling pathway through a negative feedback loop and uncovered its role in both the development of and overcoming of tamoxifen resistance in breast cancers.

POS0512 ANTI-CITRULLINATED PROTEIN ANTIBODY SEROSTATUS DETERMINES 2-YEAR RETENTION OF IV AND SC ABATACEPT IN PATIENTS WITH RA IN A REAL-WORLD SETTING

Background

A treat-to-target approach for RA management is recommended.1,2 However, up to half of patients discontinue DMARD treatment within 18 months.2 Predictive biomarkers, such as anti-citrullinated protein antibodies (ACPAs) and RF, may be useful to stratify patients to the most appropriate treatment. ACTION (AbataCepT In rOutiNe clinical practice; NCT02109666) and ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) were 2-year, international, observational, prospective, multicenter studies of IV and SC abatacept, respectively, for the treatment of RA in routine clinical practice.3,4 Higher retention has been previously reported in patients with double ACPA/RF seropositive RA compared with double ACPA/RF seronegative RA.3,4

Objectives

To assess the independent effect of ACPA or RF single seropositivity on abatacept retention in patients with RA receiving abatacept in a post hoc analysis of ACTION and ASCORE.

Methods

This post hoc analysis included patients aged ≥ 18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who initiated IV (body weight–adjusted dosing) or SC (125 mg once weekly) abatacept.3,4 Patients were stratified by baseline ACPA/RF status: ACPA+/RF− (ACPA+ only), ACPA/RF double positive (+/+), ACPA−/RF+ (RF+ only), and ACPA/RF double negative (−/−). Abatacept retention rate at 2 years was estimated by Kaplan–Meier (KM) analysis.

Results

Patients with ACPA/RF serostatus data from the ACTION and ASCORE studies (N = 1679 and N = 1748, respectively) were evaluated. Baseline demographic and disease characteristics were similar across studies and serostatus groups (Table 1). In patients with ACPA+ only RA, abatacept retention rates were similar to the +/+ group and greater than the RF+ only and −/− groups (Figure 1). In ASCORE (Figure 1A), retention rates were significantly higher in ACPA+ only and +/+ groups when compared with the −/− group. In contrast, retention rates for patients with RF+ only RA were not significantly different vs −/− patients. Results were similar in ACTION, although the higher retention in the ACPA+ group did not reach statistical significance (Figure 1B).

Table 1.

Baseline demographics and disease characteristics by ACPA/RF status for the ASCORE and ACTION studies

ASCORE+/+RF+ onlyACPA+ only−/−(n = 1079)(n = 142)(n = 184)(n = 343)Age, years57.1 (12.8)58.2 (11.8)57.4 (13.5)57.8 (13.9)DAS28 (CRP)4.7 (1.2)4.6 (1.1)4.4 (1.0)4.8 (1.2)CDAI26.6 (12.5)25.8 (12.0)23.6 (10.9)28.2 (13.2)SDAI28.1 (13.0)27.2 (12.4)24.4 (10.8)29.7 (13.9)ACTION+/+RF+ onlyACPA+ only−/−(n = 1028)(n = 161)(n = 98)(n = 392)Age, years58.2 (12.0)58.4 (13.4)58.5 (14.0)57.0 (13.3)DAS28 (CRP)4.9 (1.1)5.0 (1.1)4.9 (1.0)5.0 (1.1)CDAI28.7 (12.2)29.2 (12.4)28.7 (11.5)30.1 (12.9)SDAI30.4 (13.1)31.2 (13.4)29.8 (11.5)31.7 (13.4)

Data are mean (SD). Patients with missing data for baseline ACPA/RF status are excluded.

Conclusion

In this post hoc analysis of the real-world ACTION and ASCORE studies, ACPA positivity was associated with an increased likelihood of retention over 2 years. Patients with ACPA+ only RA were equally as likely to be retained on abatacept as patients with ACPA/RF double positivity. In contrast, patients with RF+ only RA were less likely to be retained on abatacept over 2 years. These findings suggest that ACPA positivity played a more important role than RF positivity in abatacept retention. The higher retention seen in patients with ACPA+ only vs RF+ only disease demonstrates the key role of ACPA in RA and supports the importance of precision medicine in treating patients.

References

[1]Fraenkel L, et al. Arthritis Care Res (Hoboken) 2021;73:924–39.

[2]Smolen JS, et al. Ann Rheum Dis 2020;79:685–99.

[3]Alten R, et al. Clin Rheumatol 2019;38:1413–24.

[4]Alten R, et al. Ann Rheum Dis 2021;80(suppl 1):OP0180.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance was provided by Fiona Boswell, PhD, of Caudex, and was funded by Bristol Myers Squibb. Study management provided by Syneos (CRO).

Disclosure of Interests

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Paid instructor for: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Janssen, MSD, Pfizer, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, Pfizer, Grant/research support from: Gilead, Pfizer, UCB, Peter Peichl Speakers bureau: GlaxoSmithKline, Janssen, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Consultant of: AbbVie, Galapagos, Pfizer, Sanofi; IMIDomics (executive role), Grant/research support from: AbbVie, Bristol Myers Squibb, Galapagos, Janssen, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Sanofi, UCB, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius-Kabi, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Hedley Griffiths Consultant of: Amgen, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Lilly, MSD, Pfizer, Roche, Sanofi, Grant/research support from: AbbVie, Bristol Myers Squibb, MSD, Pfizer, Roche, Bettina Bannert Speakers bureau: Novartis Pharma Schweiz AG, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb.

POS0107 ACPA POSITIVITY DETERMINES REMISSION IN PATIENTS WITH RA TREATED WITH IV AND SC ABATACEPT: A POST HOC ANALYSIS OF THE REAL-WORLD OBSERVATIONAL ACTION AND ASCORE STUDIES

Background

The goal of treatment for RA is achieving low disease activity and/or remission1,2; however, disease course and management can be complicated by additional factors that may be influenced by serostatus. Anti-citrullinated protein antibodies (ACPAs) and RF contribute to a more severe RA disease pattern3 and may be useful in predicting response to treatment.4 ACTION (AbataCepT In rOutiNe clinical practice; NCT02109666) and ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) were 2-year, international, observational, prospective, multicenter studies of IV and SC abatacept, respectively, for the treatment of RA in routine clinical practice.4,5 Previous analyses have shown that ACPA/RF double-positive serostatus was associated with better treatment outcomes compared with ACPA/RF double-negative serostatus.4–6

Objectives

To assess the independent effect of ACPA or RF single seropositivity among patients with RA on achieving remission after treatment with abatacept for 2 years, and to compare outcomes among patients with single versus double serostatus.

Methods

This post hoc analysis included patients from ACTION and ASCORE who initiated IV (body weight–adjusted dosing) or SC abatacept (125 mg once weekly), respectively. Patients were stratified by baseline ACPA/RF status: ACPA+/RF− (ACPA+ only), ACPA/RF double positive (+/+), ACPA−/RF+ (RF+ only), and ACPA/RF double negative (−/−). DAS28 (CRP) and CDAI remission rates (defined as < 2.6 and 0–2.8, respectively) at 2 years for patients who were ACPA+ or RF+ only at baseline were assessed and compared with those who were +/+ and −/−. Patients with missing baseline ACPA/RF status were excluded. Last observation carried forward efficacy analyses were used to impute missing values.

Results

This analysis included 1679 patients from ACTION (ACPA+ only, n = 98; +/+, n = 1028; RF+ only, n = 161; and −/−, n = 392) and 1748 patients from ASCORE (ACPA+ only, n = 184; +/+, n = 1079; RF+ only, n = 142; and −/−, n = 343). Across studies and serogroups, baseline demographics and disease characteristics were similar (data not shown). In both ACTION and ASCORE, a higher proportion of patients who were only ACPA+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were only RF+ (Figure 1). Additionally, a similar proportion of patients who were only ACPA+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were +/+. In contrast, a lower proportion of patients who were only RF+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were +/+.

Conclusion

In this post hoc analysis of real-world data from ACTION and ASCORE, ACPA positivity was associated with an increased likelihood of achieving DAS28 (CRP) and CDAI remission at 2 years. Patients who were ACPA+ only were as likely to achieve remission as +/+ patients, suggesting that RF serostatus had less influence than ACPA serostatus on remission status at 2 years. In line with this, patients who were RF+ only were less likely to achieve remission at 2 years. This is the first large, real-world study to show that ACPA positivity plays a more important role than RF positivity in achieving remission whilst on abatacept. These results highlight the importance of assessing baseline ACPA status when considering treatment options for patients with RA.

References

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–99.

[2]Fraenkel L, et al. Arthritis Care Res (Hoboken) 2021;73:924–39.

[3]Katchamart, W, et al. Rheumatol Int 2015;35:1693–9.

[4]Alten R, et al. Ann Rheum Dis 2021;80(suppl 1):OP0180.

[5]Alten R, et al. Clin Rheumatol 2019;38:1413–24.

[6]Alten R, et al. RMD Open 2017;3:e000345.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance was provided by Rachel Rankin, PhD, of Caudex, and was funded by Bristol Myers Squibb. Study management provided by Syneos (CRO).

Disclosure of Interests

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Paid instructor for: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Janssen, MSD, Pfizer, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, Pfizer, Grant/research support from: Gilead, Pfizer, UCB, Peter Peichl Speakers bureau: Janssen, GlaxoSmithKline, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Consultant of: AbbVie, Galapagos, Pfizer, Sanofi; IMIDomics (executive role), Grant/research support from: AbbVie, Bristol Myers Squibb, Galapagos, Janssen, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Sanofi, UCB, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius-Kabi, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Hedley Griffiths Consultant of: Amgen, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Lilly, MSD, Pfizer, Roche, Sanofi, Grant/research support from: AbbVie, Bristol Myers Squibb, MSD, Pfizer, Roche, Bettina Bannert: None declared, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

Abstract 1527: Integrated computational and experimental analysis identifies the mitochondrial uncoupling protein 2 (Ucp2) as a key regulator of T cell anti-tumor function

T cells play a central role in cancer immunosurveillance and current cancer immunotherapies, including adoptive cell transfer (ACT), T cell receptor or chimeric antigen receptor (CAR) T cell therapies and immune checkpoint blockade. Understanding the factors regulating T cell function is hence critical for improving the success of these immunotherapies. It has been recognized that metabolism can greatly affect different aspects of T cell function, including differentiation, cytokine production, longevity and exhaustion. Here we integrate genome-scale metabolic modeling (GEM) with biological experiments to discover novel metabolic determinants of T cell function. Previously we developed the metabolic transformation algorithm (MTA), a GEM method that was successfully applied to identify driving factors and targets for different diseases. Here applying MTA to data on CAR-T cell gene expression and patient response to anti-CD19 CAR-T therapy, we predicted mitochondrial metabolite transport and specifically proton transport in mitochondrial uncoupling, as key determinants of CAR-T therapy response. Mitochondrial uncoupling is also important for the in vivo persistence of adoptively transferred tumor-infiltrating lymphocytes, as further confirmed by analyzing their gene expressions from a KRAS-targeting ACT dataset. Focusing on the mitochondrial uncoupling protein 2 (Ucp2), which is abundantly expressed in T cells, we experimentally validated that it is required for T cell longevity and anti-tumor function. Specifically, the loss of Ucp2 either via knock-out (KO) or treatment by genipin (a Ucp2 inhibitor) in mice T cells results in accelerated differentiation into “terminal effector cells”, as shown by increased levels of T cell cytotoxicity and exhaustion markers, and decreased levels of central memory and stemness markers. Adoptive transfer of Ucp2-KO Pmel-1 T cells to mice bearing B16 melanomas displayed poorer anti-tumor efficacy and worse survival than the transfer of Ucp2-wildtype T cells. We find that Ucp2 modulates oxidative stress and DNA damage by regulating the levels of mitochondrial superoxide. Reducing mitochondrial reactive oxygen species was sufficient to rescue the loss of Ucp2-mediated effector T cell differentiation, senescence, cytokine production and anti-tumor activity Ucp2-KO Pmel-1 T cells. Tumor-specific CD8+ T cells could be metabolically reprogrammed by Ucp2 overexpression, which improved T cell longevity and anti-tumor function in the Pmel-1/B16 ACT mice model. In sum, our study establishes a novel role of Ucp2 in regulating T cell longevity and anti-tumor activity by repressing increased ROS levels accompanying mitochondrial dysfunction in differentiated and exhausted cells, suggesting that manipulating Ucp2 levels in T cells can be exploited to enhance T cell-based cancer immunotherapies.

Citation Format: Madhusudhanan Sukumar, Kuoyuan Cheng, Arunakumar Gangaplara, Yogin Patel, Suman K. Vodnala, Rafiqul Islam, Arash Eidizadeh, Carolyn Subramaniam, Ping Lee, Rigel Kishton, Amanda N. Henning, Michael J. Kruhlak, Zhiya Yu, Ethan M. Shevach, Toren Finkel, Eytan Ruppin, Nicholas P. Restifo. Integrated computational and experimental analysis identifies the mitochondrial uncoupling protein 2 (Ucp2) as a key regulator of T cell anti-tumor function [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 1527.

POS0447 PHYSICAL FUNCTION IN PATIENTS WITH RA, STRATIFIED BY SEROSTATUS AND TREATMENT LINE, FOLLOWING SC ABATACEPT: POST HOC ANALYSIS OF AN OBSERVATIONAL, 2-YEAR STUDY CONDUCTED IN ROUTINE CLINICAL PRACTICE (ASCORE)

Background:

RA is characterised by the production of autoantibodies, including RF and anti-citrullinated protein antibodies (ACPAs).1 Seropositive disease is associated with poorer prognosis in patients with RA,2 and response to different treatments has been shown to vary based on ACPA status.3 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for the treatment of RA.4

Objectives:

This post hoc analysis of the ASCORE study evaluated patient-reported outcomes, assessed using HAQ-DI, by RF/ACPA serostatus and treatment line over 24 months of treatment with abatacept.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: biologic (b)DMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis assessed mean change from baseline in HAQ-DI score at 6, 12, 18 and 24 months in response to treatment with abatacept stratified by baseline serostatus (RF/ACPA double positive [+/+]; RF/ACPA single positive [+/−; RF+/ACPA– or RF–/ACPA+] or RF/ACPA double negative [–/–]) and by line of therapy (all patients, patients receiving abatacept as a first-line bDMARD or as a ≥ second-line bDMARD [data not shown], and those receiving abatacept following 1 [data not shown] or ≥2 prior bDMARDs). Estimates of mean difference with 95% CIs between patients with different serostatus were calculated using a t-test for all patients and within different lines of therapy.

Results:

Among 2892 eligible patients in ASCORE, 1748 patients with RF/ACPA status available at baseline were included in this analysis (1079 +/+, 326 +/– and 343 –/–). Of these, 791 patients received abatacept as a first-line bDMARD therapy and 957 as a ≥ second-line bDMARD therapy (505 patients had received ≥2 prior bDMARDs). Among all patients, mean change from baseline in HAQ-DI score at 6 months was greater for patients with +/+ RA (mean difference [95% CI]: –0.2 [–0.3, –0.0]; p=0.0068) or +/– RA (mean difference [95% CI]: –0.2 [–0.3, –0.0]; p=0.0315) versus those with –/– RA at baseline (Figure 1). Similarly, mean change (95% CI) in HAQ-DI score at 6 months was greater for patients with +/+ RA versus –/– RA among those receiving abatacept as first-line therapy (–0.2 [–0.4, –0.0]; p=0.0407) or following treatment with ≥2 bDMARDs (–0.3 [–0.5, –0.0]; p=0.0265) (Figure 1). Among patients treated with abatacept following ≥2 prior bDMARDs, mean change in HAQ-DI score was higher among patients with +/– RA versus –/– RA at 18 months (data not shown) and 24 months (Figure 1). No other significant differences were observed by serostatus or line of therapy at any other time points.

Conclusion:

Patients with RA who were RF+/ACPA+ at baseline showed an enhanced initial response to abatacept compared with those who were RF–/ACPA–. Over 24 months of treatment in this real-world setting, abatacept was equally effective as a first- or ≥ second-line therapy.

References:

[1]Scott DL, et al. Lancet 2010;376:1094–1108.

[2]Hecht C, et al. Ann Rheum Dis 2015;74:2151–2156.

[3]Harrold LR, et al. J Rheumatol 2018;45:32–39.

[4]Alten R, et al. Ann Rheum Dis 2019;78(suppl 2):A1639.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Fiona Boswell, PhD, at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

OP0180 IMPACT OF RF AND ANTI-CITRULLINATED PROTEIN ANTIBODY SEROSTATUS ON 2-YEAR RETENTION OF ABATACEPT IN PATIENTS WITH RA

Background:

Up to 50% of patients with RA discontinue DMARD treatment within 18 months.1 However, up to 20% of patients who fail multiple treatments may have a good treatment response to another therapy.1 Predictive biomarkers, such as RF and anti-citrullinated protein antibodies (ACPAs), may be useful to stratify patients with RA to the most appropriate treatment.1 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for the treatment of RA in routine clinical practice.2

Objectives:

To determine if RF/ACPA serostatus and treatment line impact abatacept retention in patients with RA in a post hoc analysis of ASCORE.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: biologic (b)DMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis assessed abatacept retention rate at 2 years in a subset of patients with RF/ACPA serostatus data (n=1748) from the ASCORE study (N=2892; as observed). Baseline (BL) serostatus groups examined by treatment line were: RF/ACPA double positive (+/+) RA, RF/ACPA single positive (RF+/ACPA– or RF–/ACPA+) RA (data not shown) and RF/ACPA double negative (–/–) RA. Last observation carried forward (LOCF) analyses were used to assess change from BL and measures of disease remission (DAS28 [CRP] <2.6, CDAI ≤2.8, and SDAI ≤3.3) in patients with +/+ RA versus –/– RA.

Results:

BL demographic and disease characteristics were similar across serostatus groups and treatment lines (Table 1). Mean age was 57.1 and 57.8 years for +/+ RA and –/– RA, respectively. Mean DAS28 (CRP) was 4.7 and 4.8 for +/+ RA and –/– RA, respectively. In patients with +/+ RA, abatacept retention was greater when given as first-line treatment (57% vs 48% when given as ≥ second-line) (Figure 1). Retention was similar in patients with –/– RA regardless of treatment line. After 2 years, mean (SE) change from BL (LOCF) in DAS28 (CRP) was –1.41 (0.06) and –0.97 (0.09) for patients with +/+ and –/– RA, respectively. For patients with +/+ RA, mean (SE) change from BL in DAS28 (CRP) was –1.62 (0.08) for those in whom abatacept was first-line and –1.19 (0.08) for those in whom abatacept was ≥ second-line. For patients with –/– RA, mean (SE) change from BL in DAS28 (CRP) was –1.03 (0.13) for those in whom abatacept was first-line and –0.93 (0.12) for those in whom abatacept was ≥ second-line. Remission rates (LOCF) were significantly (p<0.0001) higher in patients with +/+ RA vs –/– RA respectively: DAS28 (CRP) 38.4% (n=393) versus 19.3% (n=62); CDAI 50.6% (n=513) versus 33.0% (n=107); and SDAI 49.5% (n=497) versus 32.5% (n=102).

Table 1.

BL demographics and disease characteristics by RF/ACPA status

+/+ RA(n=1079)–/– RA(n=343)First-line (n=511)≥ second-line (n=568)First-line(n=140)≥ second-line(n=203)Age57.1 (13.4)57.1 (12.2)59.5 (14.7)56.6 (13.2)DAS28 (CRP)4.7 (1.2)4.7 (1.2)4.8 (1.1)4.8 (1.2)CDAI26.6 (12.5)26.6 (12.4)27.7 (12.5)28.6 (13.8)SDAI28.1 (13.1)28.1 (12.9)29.1 (12.9)30.2 (14.7)

Data are mean (SD). Patients with missing data for BL RF/ACPA status are excluded.

ACPA=anti-citrullinated protein antibody; BL=baseline.

Conclusion:

In this real-world analysis, patients with +/+ RA treated with first-line abatacept had higher retention than patients receiving abatacept as a ≥ second-line therapy. Remission rates on abatacept were higher in patients with +/+ RA versus –/– RA. These results support early treatment with abatacept and highlight the importance of further evaluating precision medicine approaches in RA.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–699.

[2]Alten R, et al. Ann Rheum Dis 2019;78(suppl 2):A1639.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Lindsay Craik at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Gebro, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Consultant of: AbbVie, Bristol Myers Squibb, Gebro, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Grant/research support from: Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

POS0599 DISEASE ACTIVITY IN PATIENTS WITH RA BY SEROSTATUS AND TREATMENT LINE, FOLLOWING TREATMENT WITH ABATACEPT: RESULTS FROM AN INTERNATIONAL OBSERVATIONAL STUDY

Background:

RF and anti-citrullinated protein antibodies (ACPAs) are associated with a severe and aggressive disease course in patients with RA.1 Abatacept is a selective co-stimulation modulator for the treatment of RA.2 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for the treatment of RA in routine clinical practice.3

Objectives:

To determine if serostatus and treatment line impacted disease activity in patients enrolled in the ASCORE study.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: biologic (b)DMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis assessed the mean change in disease activity (CDAI, SDAI and DAS28 [ESR]) from baseline (BL) at 6, 12, 18 and 24 months in response to treatment with abatacept. Patients were stratified by BL serostatus (all patients, RF/ACPA double positive [+/+] RA; RF/ACPA single positive [+/–; RF+/ACPA– or RF–/ACPA+] RA and RF/ACPA double negative [–/–] RA) and by line of therapy (all patients, patients receiving abatacept as a first-line or ≥ second-line therapy and those receiving abatacept following 1 or ≥2 prior bDMARDs). Overall patient data, as well as data for patients who were +/– or those who had 1 or ≥2 previous bDMARDs, are not shown. Estimates of mean difference are from t-test.

Results:

Among 2892 eligible patients in ASCORE, 1748 patients with RF/ACPA status available at BL were included in this analysis (1079 +/+ RA, 326 +/− RA and 343 −/− RA). After 6 months, patients with +/+ RA on first-line abatacept therapy had better improvements in CDAI and SDAI scores from BL than patients on ≥ second-line abatacept therapy (mean difference [95% CI]: –3.4 [–5.6, –1.1]; p=0.0032 and –3.9 [–6.5, –1.3]; p=0.0035, respectively); better improvements in SDAI were also seen after 12 months (mean difference [95% CI]: –3.5 [–6.5, –0.5]; p=0.0207). Changes in CDAI and SDAI scores were comparable after 18 and 24 months. At 6 and 12 months, patients with +/+ RA on first-line therapy had better improvements from BL in DAS28 (ESR) than those on ≥ second-line therapy (mean differences [95% CI]: –0.5 [–0.8, –0.2]; p=0.0002 and –0.4 [–0.7, –0.0]; p=0.0317, respectively); changes were comparable at 18 and 24 months (Figure 1). For patients on ≥ second-line therapy, at 18 months those with +/+ RA had better improvements from BL in DAS28 (ESR) than those with –/– RA (mean difference [95% CI]: –0.7 [–1.2, –0.1]; p=0.0232). For patients not stratified by line of therapy, changes in DAS28 (ESR) were comparable between the +/+ and –/– RA subgroups over time, with the exception of 6 months where patients with –/– RA had better improvements from BL compared with patients with +/+ RA (mean difference [95% CI]: –0.3 [–0.6, –0.0]; p=0.0495).

Conclusion:

In this real-world, post hoc analysis, patients with +/+ RA who received abatacept as a first-line therapy had greater early improvements in disease activity compared with patients who received abatacept as a ≥ second-line therapy. Improvements in disease activity at 24 months were comparable between patients who were +/+ and those who were –/–. Larger studies are needed to further corroborate these findings.

References:

[1]Katchamart W, et al. Rheumatol Int 2015;35:1693–1699.

[2]Malmström V, et al. Nat Rev Immunol 2017;17:60–75.

[3]Alten R, et al. Ann Rheum Dis 2019;78(Suppl 2):A1639.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Rachel Rankin, PhD, at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Gebro, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Consultant of: AbbVie, Bristol Myers Squibb, Gebro, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Grant/research support from: Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

AB0207 ANALYSIS OF ABATACEPT TREATMENT RETENTION AND EFFICACY ACCORDING TO DISEASE DURATION AND TREATMENT LINE IN A REAL-WORLD SETTING

Background:

Longer disease duration and greater number of prior DMARDs have been associated with lower treatment efficacy in patients with RA.1 Abatacept is a biologic (b)DMARD for treatment of moderate-to-severe RA and is available in SC formulation, which may offer convenience benefits with efficacy similar to IV administration.2 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for treatment of RA in routine clinical practice.3

Objectives:

This post hoc analysis was conducted to determine if retention and efficacy of abatacept were impacted by disease duration and/or treatment line.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: bDMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis evaluated abatacept retention using Kaplan-Meier estimates, as well as disease activity scores (DAS28 [ESR]), CDAI and SDAI in patients with disease duration of ≤2, 3–5, 6–10 or >10 years, and in patients taking abatacept as first-line or ≥ second-line treatment.

Results:

Table 1 shows baseline (BL) characteristics. Mean age increased with disease duration; other characteristics were comparable across groups. Retention proportions (95% CIs) at Month 24 were 0.50 (0.4, 0.5), 0.47 (0.4, 0.5), 0.51 (0.5, 0.5) and 0.46 (0.4, 0.5) in the ≤2, 3–5, 6–10 and >10 years’ duration groups, respectively. Proportion of patients (95% CI) with ≤2 years’ duration retaining treatment at Month 24 were 0.51 (0.4, 0.6) among those using abatacept as first-line treatment and 0.44 (0.3, 0.6) among those using abatacept as a ≥ second-line treatment (Figure 1). Proportions (95% CI) at Month 24 were 0.51 (0.5, 0.6), 0.57 (0.5, 0.6) and 0.52 (0.5, 0.6) in first-line patients and 0.43 (0.4, 0.5), 0.48 (0.4, 0.5) and 0.44 (0.4, 0.5) in ≥ second-line patients in the 3–5, 6–10 and >10 years’ duration groups, respectively. Mean (SE) changes from BL in DAS28 (ESR) at Month 24 were –2.12 (0.205), –1.86 (0.151), –2.07 (0.140) and –2.05 (0.115) in the ≤2, 3–5, 6–10 and >10 years’ duration groups, respectively; respective mean (SE) changes in CDAI were –18.74 (1.604), –15.60 (1.099), –18.50 (1.038) and –17.68 (0.850); and respective mean (SE) changes in SDAI were –19.10 (1.873), –15.72 (1.345), –19.54 (1.103) and –17.07 (0.939).

Conclusion:

In this post hoc analysis of the real-world ASCORE trial, patients with RA receiving abatacept in clinical practice as first-line therapy had better retention versus those receiving it as a ≥ second-line treatment, regardless of disease duration at BL. Retention rates were similar across disease duration subgroups. Improvements in disease activity were seen in all duration subgroups, without consistently greater or lesser improvement seen with longer disease duration.

References:

[1]Aletaha D, et al. Ann Rheum Dis 2019;78:1609–1615.

[2]Genovese MC, et al. Arthritis Rheumatol 2011;63:2854–2864.

[3]Alten R, et al. Ann Rheum Dis 2019;78(suppl 2):A1639.

Table 1.

BL characteristics (n=2872)

RA disease duration, years≤2(n=338)3–5(n=655)6–10(n=686)>10(n=1193)Age, years n3386556861193 Mean (SD)55.2 (12.8)55.6 (12.7)56.9 (13.0)59.9 (12.2)Weight, kg n3276296651150 Mean (SD)75.3 (18.1)76.4 (19.0)74.7 (17.4)72.9 (16.0)DAS28 (ESR) n247439441743 Mean (SD)5.2 (1.3)4.9 (1.3)5 (1.2)5.1 (1.3)DAS28 (CRP) n267460467799 Mean (SD)4.7 (1.2)4.6 (1.2)4.7 (1.1)4.7 (1.2)CDAI n269477474805 Mean (SD)26.9 (12.7)25.3 (12.2)26.8 (12.4)26.6 (12.2)SDAI n255448445749 Mean (SD)28.3 (13.3)26.8 (12.9)27.9 (12.6)28.0 (12.7)RF status, n (%) RF+159 (47.0)342 (52.2)345 (50.3)597 (50.0) RF–103 (30.5)152 (23.2)158 (23.0)215 (18.0)Anti-CCP status, n (%) Anti-CCP+165 (48.8)332 (50.7)333 (48.5)516 (43.3) Anti-CCP–89 (26.3)126 (19.2)137 (20.0)175 (14.7)

Patients with missing duration of disease are excluded.

CCP=cyclic citrullinated peptide.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Rob Coover, MPH, at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Gebro, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Consultant of: AbbVie, Bristol Myers Squibb, Gebro, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Grant/research support from: Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

Strengthened capacity of India´s bedaquiline Conditional Access Programme for introducing new drugs and regimens

BACKGROUND: Addressing TB in India is critical to meeting global targets. With the scale-up of diagnostic networks and the availability of new TB drugs, India had the opportunity to improve the detection and treatment outcomes in drug-resistant TB (DR-TB).OBJECTIVE: To document how the introduction of new drugs and regimens is helping India improve the care of DR-TB patients.DESIGN: In 2016, India´s National TB Programme (NTP) introduced bedaquiline (BDQ) under a Conditional Access Programme (BDQ-CAP) at six sites after providing extensive training and strengthening laboratory testing, pre-treatment evaluation, active drug safety monitoring and management (aDSM) and follow-up systems.RESULTS: An interim analysis reflected earlier and better culture conversion rates: 83% of the 620 patients converted within a median time of 60 days. However, 248 serious adverse events were reported, including 73 deaths (12%) and 100 cardiotoxicity events (16.3%). Encouraged by the evidence of safety and efficacy of BDQ, the NTP took steps to systematically expand its access to cover the entire population by 2018.CONCLUSION: The cautious yet focused approach used to introduce BDQ under BDQ-CAP paved the way for the rapid introduction of delamanid, as well as the shorter treatment regimen and the all-oral regimen for DR-TB.

Is lower limb salvage worthwhile after severe open tibial fractures in a developing country? An analysis of surgical outcomes, quality of life and cost implications

INTRODUCTION

Open tibial fractures are rare and difficult-to-treat injuries because of the involvement of bony, skin and neuromuscular injury along with co-morbidities. Often, during the management of very severe cases these injuries, the question arises, should we amputate or salvage the limb? This question has been explored previously in civilian and military contexts in the US and UK but remains unstudied in the alternative sociocultural and economic context of the developing world.

METHODS

We studied 78 adult patients with severe open tibial fracture that presented to our institution, a Level 1 trauma center in India, from February 2018 to June 2019. 20 patients underwent above-knee amputation (AKA), 16 underwent below-knee amputation (BKA), and 42 underwent limb salvage. We assessed injury severity using [our institution's] Open Injury Severity Score (GHOISS), which has separate sub-scores for bony injury, skin injury, neuromuscular injury and co-morbidities, and patients were only included with GHOISS > 13. We assessed functional outcome measures as well as economic costs as primary cost levied by our institution and other secondary costs.

RESULTS

Salvage (LEFS: mean=51, SF-12 PCS: mean=48, SF-12 MCS: mean=49) provided better outcomes to BKA (LEFS: mean=39, p=0.005, SF-12 PCS: mean=40, p=0.003, SF-12 MCS: mean=43, p=0.052) and AKA (LEFS: mean=31, p<0.001, SF-12 PCS: mean=34, p<0.001, SF-12 MCS: mean=43, p=0.043). Primary costs were higher for limb salvage (index: mean=$3100, total: mean=$4400) than both BKA (index: mean=$2500, p=0.012, total: mean=$2600, p<0.001) and AKA (index: mean=$2800, p=0.020, total: mean=$3200, p<0.001). Secondary costs were higher for limb salvage than both BKA and AKA (p<0.001). Patients who underwent salvage were more likely to return to work at 36 months post-injury compared to below-knee amputees (adjusted OR=0.11, p=0.010).

CONCLUSIONS

Limb salvage results in better functional outcomes compared with amputation at a higher upfront cost but a likely lower lifetime cost. Unlike other literature on the topic, amputation carries a heavy mental and physical toll in India, likely due to sociocultural differences and stigma. Amputation is a difficult decision for patients to accept and results in poorer outcomes; therefore, we believe that limbs should be aggressively salvaged in our developing country.

STUDY DESIGN

Therapeutic Level II Prospective Cohort Study.

Maturation of the Human Cerebral Cortex During Adolescence: Myelin or Dendritic Arbor?

Previous in vivo studies revealed robust age-related variations in structural properties of the human cerebral cortex during adolescence. Neurobiology underlying these maturational phenomena is largely unknown. Here we employ a virtual-histology approach to gain insights into processes associated with inter-regional variations in cortical microstructure and its maturation, as indexed by magnetization transfer ratio (MTR). Inter-regional variations in MTR correlate with inter-regional variations in expression of genes specific to pyramidal cells (CA1) and ependymal cells; enrichment analyses indicate involvement of these genes in dendritic growth. On the other hand, inter-regional variations in the change of MTR during adolescence correlate with inter-regional profiles of oligodendrocyte-specific gene expression. Complemented by a quantitative hypothetical model of the contribution of surfaces associated with dendritic arbor (1631 m2) and myelin (48 m2), these findings suggest that MTR signals are driven mainly by macromolecules associated with dendritic arbor while maturational changes in the MTR signal are associated with myelination.

Are Dilated Fundus Examinations Needed for OCT-Guided Retreatment of Exudative Age-Related Macular Degeneration?

PURPOSE

To determine whether presence of macular hemorrhage on dilated fundus examination (DFE) or fundus photography influences vision outcomes with OCT-guided pro re nata (PRN) ranibizumab retreatment in patients with neovascular age-related macular degeneration (nAMD), we investigated whether hemorrhage without OCT-detectable fluid impacted vision outcomes.

DESIGN

Post hoc analysis of prospectively collected data from the 24-month pHase III, double-masked, multicenter, randomized, Active treatment-controlled study of the efficacy and safety of 0.5 mg and 2.0 mg Ranibizumab administered monthly or on an as-needed Basis (PRN) in patients with subfoveal neOvascular age-related macular degeneration (HARBOR) trial (ClinicalTrials.gov identifier, NCT00891735).

PARTICIPANTS

This post hoc analysis examined 1097 patients from the intention-to-treat population of HARBOR.

METHODS

Dilated fundus examination and fundus photography were evaluated for hemorrhage, and spectral-domain (SD) OCT images from HARBOR participants were analyzed for macular fluid secondary to macular neovascularization. Agreement between methods was determined for each time point. Visual outcomes were evaluated for 82 patients with evidence of hemorrhage on DFE or fundus photography at 3 months and no evidence of SD-exudative activity requiring retreatment at month 3.

MAIN OUTCOME MEASURES

Pooled data from the intention-to-treat population of HARBOR were analyzed for hemorrhage on DFE or fundus photography and exudative activity on SD OCT. A subgroup of PRN patients were analyzed for best-corrected visual acuity gains at 24 months.

RESULTS

Most study eyes (89% [973/1095]) showed macular hemorrhages at baseline, declining to 31% (319/1042) at month 3 and stabilizing at 11% (111/989) by month 6 of follow-up. After baseline, exudative activity was detected on SD-OCT in more than 89% of eyes when hemorrhage was present on DFE or fundus photography. Patients not requiring a month 3 PRN ranibizumab injection achieved similar visual gains over 24 months, regardless of month 3 hemorrhage presence versus absence: 9.4 and 8.7 Early Treatment Diabetic Retinopathy Study letter scores, respectively (P = 0.74).

CONCLUSIONS

After 3 initial ranibizumab injections, SD-OCT detected nAMD activity in 89% of eyes when hemorrhage was present on fundus photography. Ranibizumab retreatment guided by monthly SD-OCT achieved similar vision gains with or without injection when hemorrhage was present without OCT-detectable fluid. This suggests that macular hemorrhages without OCT-detectable macular fluid may not require treatment and DFE may not be needed at every visit. These conclusions should be confirmed in a prospective randomized trial before firm recommendations regarding clinical practice can be made.

Salvage Chemoimmunotherapy With Inotuzumab Ozogamicin Combined With Mini-Hyper-CVD for Patients With Relapsed or Refractory Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia: A Phase 2 Clinical Trial

Importance

The outcome of patients with relapsed or refractory (R/R) acute lymphoblastic leukemia (ALL) is poor. Inotuzumab ozogamicin, a CD22 monoclonal antibody bound to calicheamicin, has single-agent activity in R/R ALL.

Objective

To evaluate the efficacy and safety of inotuzumab ozogamicin plus low-intensity chemotherapy in patients with R/R ALL.

Design, Setting, and Participants

A single-arm, phase 2 study of adults with R/R B-cell ALL conducted at The University of Texas MD Anderson Cancer Center, Houston.

Interventions

The chemotherapy used was lower intensity than hyper-CVAD (cyclophosphamide, vincristine, doxorubicin [trade name, Adriamycin; Pfizer], and dexamethasone) and is referred to as mini-hyper-CVD (mini-HCVD: cyclophosphamide and dexamethasone at 50% dose reduction, no anthracycline, methotrexate at 75% dose reduction, and cytarabine at 0.5 g/m2 × 4 doses). Inotuzumab was given on day 3 of the first 4 courses at 1.8 to 1.3 mg/m2 for cycle 1 followed by 1.3 to 1.0 mg/m2 for subsequent cycles.

Main Outcomes and Measures

The primary end points were the overall response rate and overall survival (OS). Secondary end points included safety, relapse-free survival (RFS), the rate of allogeneic stem cell transplantation (ASCT), and the minimal residual disease (MRD) negativity rate.

Results

Fifty-nine patients (30 women and 29 men) with a median age of 35 years (range, 18-87 years) were treated. Overall, 46 patients (78%) responded, 35 of them (59%) achieving complete response. The overall MRD negativity rate among responders was 82%. Twenty-six patients (44%) received ASCT. Grade 3 to 4 toxic effects included prolonged thrombocytopenia (81%; n = 48), infections (73%; n = 43), and hyperbilirubinemia (14%; n = 8). Veno-occlusive disease (VOD) occurred in 9 patients (15%). With a median follow-up of 24 months, the median RFS and OS were 8 and 11 months, respectively. The 1-year RFS and OS rates were 40% and 46%, respectively. The 1-year OS rates for patients treated in salvage 1, salvage 2, and salvage 3 or beyond were 57%, 26%, and 39%, respectively (P = .03).

Conclusions and Relevance

The combination of inotuzumab with low-intensity mini-HCVD chemotherapy shows encouraging results in R/R ALL. The risk of VOD should be considered carefully in patients with previous liver damage and among transplant candidates.

Trial Registration

clinicaltrials.gov Identifier: NCT01371630.

Abstract P6-05-06: Estrogen induced miR-489 acts as a negative feedback to confine uncontrolled estrogen signaling and cell proliferation in breast cancer

Estrogen induced miR-489 acts as a negative feedback to confine uncontrolled estrogen signaling and cell proliferation in breast cancer.

Mithil Soni1,2, Yogin Patel1,2,3, Ryann Shealy1, Hexin Chen1,2,4.

1Dept. of Biological Sciences, University of South Carolina, 2Center for colon cancer research, 3current location, National cancer institute, surgery branch, 4corrosponding author.

Approximately 75% of diagnosed breast cancer tumors are Estrogen receptor positive tumors and are associated with better prognosis due to response to hormonal therapies. However, around 40% of patients relapse after hormonal therapies. Identification of novel molecular targets is necessary to combat such resistant tumors. In the current study, using microarray, qRT-PCR, western blot, luciferase reporter assay and immunofluorescence, we found that miR-489 is an estrogen regulated miRNA that negatively regulates estrogen signaling. Depletion of miR-489 using Anti-miR-489 siRNA or CRISPR-Cas9 significantly increased estrogen induced proliferation, colony formation ability and stem like cell population. Loss of miR-489 also induced estrogen independent proliferation. Mechanistically we found that depletion of miR-489 enhanced nuclear localization of estrogen receptor while restoration of miR-489 increased cytosolic ER and inhibited estrogen induced transcription. Furthermore, we found that miR-489 depletion also increases estrogen independent growth through activation of MAPK and PI3K-AKT pathway. We also observed loss of miR-489 in tamoxifen resistance breast cancer cell line and found increased resistance to tamoxifen upon miR-489 inhibition while miR-489 restoration sensitized Tamoxifen resistant cell lines. Clinical analysis of estrogen receptor positive breast cancer patient showed that ER+ve breast cancers with low miR-489 expression represents aggressive cancers with significant reduction in survival time. In summary, these results indicate potential role of miR-489 as a biomarker to predict aggressiveness of ER+ve breast cancer and response to tamoxifen therapy and can potentially be used as a therapeutic agent to treat or sensitize tamoxifen resistant tumors.

Citation Format: Soni M, Patel Y, Shealy R, Chen H. Estrogen induced miR-489 acts as a negative feedback to confine uncontrolled estrogen signaling and cell proliferation in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-05-06.

Revisiting the evolutionary origins of obesity: lazy versus peppy-thrifty genotype hypothesis

The recent global obesity epidemic is attributed to major societal and environmental changes, such as excessive energy intake and sedentary lifestyle. However, exposure to 'obesogenic' environments does not necessarily result in obesity at the individual level, as 40-75% of body mass index variation in population is attributed to genetic differences. The thrifty genotype theory posits that genetic variants promoting efficient food sequestering and optimal deposition of fat during periods of food abundance were evolutionarily advantageous for the early hunter-gatherer and were positively selected. However, the thrifty genotype is likely too simplistic and fails to provide a justification for the complex distribution of obesity predisposing gene variants and for the broad range of body mass index observed in diverse ethnic groups. This review proposes that gene pleiotropy may better account for the variability in the distribution of obesity susceptibility alleles across modern populations. We outline the lazy-thrifty versus peppy-thrifty genotype hypothesis and detail the body of evidence in the literature in support of this novel concept. Future population genetics and mathematical modelling studies that account for pleiotropy may further improve our understanding of the evolutionary origins of the current obesity epidemic.

Overexpression of miR-489 derails mammary hierarchy structure and inhibits HER2/neu-induced tumorigenesis

Although it has been demonstrated that transformed progenitor cell population can contribute to tumor initiation, factors contributing to this malignant transformation are poorly known. Using in vitro and xenograft based models, previous studies demonstrated that miR-489 acts as a tumor suppressor miRNA by targeting various oncogenic pathways. It has been demonstrated that miR-489 directly targets HER2 and inhibits the HER2 signaling pathway; however, its role in mammary gland development and HER2 induced tumor initiation hasn’t been studied. To dissect the role of miR-489, we sorted different populations of mammary epithelial cells and determined that miR-489 was highly expressed in mammary stem cells. MMTV-miR-489 mice that overexpressed miR-489 in mammary epithelial cells were developed and these mice exhibited an inhibition of mammary gland development in early ages with a specific impact on highly proliferative cells. Double transgenic MMTV-Her2-miR489 mice were then generated to observe how miR-489 overexpression affects HER2 induced tumorigenesis. miR-489 overexpression delayed HER2 induced tumor initiation significantly. Moreover, miR-489 overexpression inhibited tumor growth and lung metastasis. miR-489 overexpression reduced mammary progenitor cell population significantly in preneoplastic mammary glands of MMTV-Her2 mice which showed a putative transformed population in HER2 induced tumorigenesis. The miR-489 overexpression reduced CD49f^hiCD61^hi populations in tumors that have stem- like properties, and miR-489 overexpression altered the HER2 signaling pathway in mammary tumors. Altogether, these data indicate that the inhibition of HER2 induced tumorigenesis by miR-489 overexpression was due to altering progenitor cell populations while decreasing tumor growth and metastasis via influencing tumor promoting genes DEK and SHP2.

Seroprevalence of brucellosis in small ruminants in organized and unorganized sectors of Gujarat state, India

Aim:

The present study aimed to study the seroprevalence of brucellosis in small ruminants of Gujarat state, India, using Rose Bengal Plate test (RBPT) and indirect enzyme-linked immunosorbent assay (iELISA).

Materials and Methods:

A total of 2444 sera samples (675 sheep and 1769 goat) from unorganized sector and 1310 sera samples (861 sheep and 449 goat) from seven organized farms were collected for brucellosis screening.

Results:

In unorganized sector, 23.70% sheep (160/675) and 15.99% goat (283/1769) were positive by RBPT and 24.44% sheep (165/675) and 17.24% goat (305/1769) by iELISA. The organized sector samples showed higher seroprevalence in goat (7.79 %, 35/449) than sheep (4.06 %, 35/861) by RBPT. Similarly, in iELISA, goat samples showed a higher seroprevalence (9.35%, 42/449) compared to sheep (7.50%, 65/861). The diagnostic sensitivity and specificity of RBPT with ELISA were 88.69% and 99.65%, respectively, and showed a significant difference (p≤0.0001). The Chi-square analysis revealed a significant difference in seroprevalence between sectors (p≤0.01) and species (p≤0.01).

Conclusion:

The seroprevalence of brucellosis in small ruminants of Gujarat was investigated and showed a higher prevalence of brucellosis and warrants the implementation of proper preventive measures.

Autophagy, Cell Viability, and Chemoresistance Are Regulated By miR-489 in Breast Cancer

It is postulated that the complexity and heterogeneity in cancer may hinder most efforts that target a single pathway. Thus, discovery of novel therapeutic agents targeting multiple pathways, such as miRNAs, holds promise for future cancer therapy. One such miRNA, miR-489, is downregulated in a majority of breast cancer cells and several drug-resistant breast cancer cell lines, but its role and underlying mechanism for tumor suppression and drug resistance needs further investigation. The current study identifies autophagy as a novel pathway targeted by miR-489 and reports Unc-51 like autophagy activating kinase 1 (ULK1) and lysosomal protein transmembrane 4 beta (LAPTM4B) to be direct targets of miR-489. Furthermore, the data demonstrate autophagy inhibition and LAPTM4B downregulation as a major mechanism responsible for miR-489-mediated doxorubicin sensitization. Finally, miR-489 and LAPTM4B levels were inversely correlated in human tumor clinical specimens, and more importantly, miR-489 expression levels predict overall survival in patients with 8q22 amplification (the region in which LAPTM4B resides).Implications: These findings expand the understanding of miR-489-mediated tumor suppression and chemosensitization in and suggest a strategy for using miR-489 as a therapeutic sensitizer in a defined subgroup of resistant breast cancer patients. Mol Cancer Res; 16(9); 1348-60. ©2018 AACR.

HER2 Overexpression Triggers an IL1α Proinflammatory Circuit to Drive Tumorigenesis and Promote Chemotherapy Resistance

Systemic inflammation in breast cancer correlates with poor prognosis, but the molecular underpinnings of this connection are not well understood. In this study, we explored the relationship between HER2 overexpression, inflammation, and expansion of the mammary stem/progenitor and cancer stem-like cell (CSC) population in breast cancer. HER2-positive epithelial cells initiated and sustained an inflammatory milieu needed to promote tumorigenesis. HER2 induced a feedforward activation loop of IL1α and IL6 that stimulated NFκB and STAT3 pathways for generation and maintenance of breast CSC. In mice, Il1a genetic deficiency delayed MMTV-Her2-induced tumorigenesis and reduced inflammatory cytokine expression as well as CSC in primary tumors. In clinical specimens of human breast tumor tissues, tissue microarray analysis revealed a strong positive correlation between IL1α/IL6 expression and CSC-positive phenotype. Pharmacologic blockade of IL1α signaling reduced the CSC population and improved chemotherapeutic efficacy. Our findings suggest new therapeutic or prevention strategies for HER2-positive breast cancers.Significance: IL1α signaling driven by HER2 promotes chronic inflammation needed to support cancer stem-like cell maintenance in HER2-positive breast cancers. Cancer Res; 78(8); 2040-51. ©2018 AACR.

Cancer Drugs: An International Comparison of Postlicensing Price Inflation

PURPOSE

The cost of cancer drugs forms a rising proportion of health care budgets worldwide. A number of studies have examined international comparisons of initial cost, but there is little work on postlicensing price increases. To examine this, we compared cancer drug prices at initial sale and subsequent price inflation in the United States and United Kingdom and also reviewed relevant price control mechanisms.

METHODS

The 10 top-selling cancer drugs were selected, and their prices at initial launch and in 2015 were compared. Standard nondiscounted prices were obtained from the relevant annual copies of the RED BOOK and the British National Formulary.

RESULTS

At initial marketing, prices were on average 42% higher in the United States than in the United Kingdom. After licensing in the United States, all 10 drugs had price rises averaging an overall annual 8.8% (range, 1.4% to 24.1%) increase. In comparison, in the United Kingdom, six drugs had unchanged prices, two had decreased prices, and two had modest price increases. The overall annual increase in the United Kingdom was 0.24%.

CONCLUSION

Cancer drug prices are rising substantially, both at their initial marketing price and, in the United States, at postlicensing prices. In the United Kingdom, the Pharmaceutical Price Regulation Scheme, an agreement between the government and the pharmaceutical industry, controls health care costs while allowing a return on investment and funds for research. The increasing costs of cancer drugs are approaching the limits of sustainability, and a similar government-industry agreement may allow stability for both health care provision and the pharmaceutical industry in the United States.

A novel double-negative feedback loop between miR-489 and the HER2-SHP2-MAPK signaling axis regulates breast cancer cell proliferation and tumor growth

Human epidermal growth factor receptor 2 (HER2 or ErBb2) is a receptor tyrosine kinase overexpressed in 20-30% of breast cancers and associated with poor prognosis and outcome. Dysregulation of several microRNAs (miRNAs) plays a key role in breast cancer progression and metastasis. In this study, we screened and identified miRNAs dysregualted in HER2-positive breast cancer cells. Our molecular study demonstrated that miR-489 was specifically downregulated by the HER2-downstream signaling, especially through the MAPK pathway. Restoration or overexpression of miR-489 in HER2-positive breast cancer cells significantly inhibited cell growth in vitro and decreased the tumorigenecity and tumor growth in xenograft mice. Mechanistically, we found that overexpression of miR-489 led to the decreased levels of HER2 and SHP2 and thus attenuated HER2-downstream signaling. Furthermore, we for the first time demonstrated that HER2 is a direct target of miR-489 and therefore HER2-SHP2-MAPK and miR-489 signaling pathways form a mutually inhibitory loop. Using quantitative real-time PCR analysis and Fluorescent in situ hybridization technique (FISH), we found that miR-489 was expressed at significantly lower level in tumor tissues compared to the adjacent normal tissues. Downregulation of miR-489 in breast cancers was associated with aggressive tumor phenotypes. Overall, our results define a double-negative feedback loop involving miR-489 and the HER2-SHP2-MAPK signaling axis that can regulate breast cancer cell proliferation and tumor progression and might have therapeutic relevance for HER2-positive breast cancer.

Fundamentals of cutting

The process of cutting is analysed in fracture mechanics terms with a view to quantifying the various parameters involved. The model used is that of orthogonal cutting with a wedge removing a layer of material or chip. The behaviour of the chip is governed by its thickness and for large radii of curvature the chip is elastic and smooth cutting occurs. For smaller thicknesses, there is a transition, first to plastic bending and then to plastic shear for small thicknesses and smooth chips are formed. The governing parameters are tool geometry, which is principally the wedge angle, and the material properties of elastic modulus, yield stress and fracture toughness. Friction can also be important. It is demonstrated that the cutting process may be quantified via these parameters, which could be useful in the study of cutting in biology.

Fracture investigation in starch-based foods

The study of oral processing and specifically cutting of the food piece during mastication can lead towards optimization of products for humans or animals. Food materials are complex biocomposites with a highly nonlinear constitutive response. Their fracture properties have not been largely investigated, while the need for models capable of predicting food breakdown increases. In this study, the blade cutting and the essential work of fracture (EWF) methodologies assessed the fracture behaviour of starch-based pet food. Tensile tests revealed rate-dependent stiffness and stress softening effects, attributed to viscoplasticity and micro-cracking, respectively. Cutting data were collected for 5, 10 and 30 mm s(-1) sample feed rates, whereas the EWF tests were conducted at 1.7, 3.3 and 8.3 mm s(-1) crosshead speeds corresponding to average crack speeds of 4, 7 and 15 mm s(-1), respectively. A reasonable agreement was achieved between cutting and EWF, reporting 1.26, 1.78, 1.76 kJ m(-2) and 1.52, 1.37, 1.45 kJ m(-2) values, respectively, for the corresponding crack speeds. These toughness data were used in a novel numerical model simulating the 'first' bite mastication process. A viscoplastic material model is adopted for the food piece, combined with a damage law that enabled predicting fracture patterns in the product.

Clinicopathological Analysis of miRNA Expression in Breast Cancer Tissues by Using miRNA In Situ Hybridization

In this article, we describe a detailed protocol for miRNA detection in breast cancer tissue using in situ hybridization with a digoxigenin-labelled LNA (Locked Nucleic Acid) probe. The probe was recognized by anti-DIG alkaline phosphatase antibodies and later developed using alkaline phosphatase substrate producing fluorescence signals. Here we utilized miRNA in situ hybridization (MISH) technique to analyze expression of miR-489 in tissues from breast cancer patients. This technique can detect the localization of miRNA of interest in individual tissue samples. This technique can be used to compare the expression of desired miRNA in tumor tissue with that in adjacent normal tissue and to identify the specific structures responsible for expressing this miRNA. This technique can be very useful in answering certain clinical questions, such as role of specific miRNA in the development of cancer. Our results indicate that mammary epithelial cells express significantly higher levels of miR-489 than adjacent tumor cells.

Identification of new miRNA biomarkers associated with HER2-positive breast cancers

Human epidermal growth factor receptor 2 (HER2) is overexpressed/amplified in ∼30% breast cancers which are associated with poor prognosis. microRNAs are small non-coding RNA which play an important role in many physiological conditions including cancer. Here we screened and identified many miRNAs which are dysregulated by HER2 overexpression. In line with our quantitative PCR analysis data, in silico analysis of microRNA expression profiles of 1302 breast tumors revealed that miR-146a-5p is up-regulated and miR-181d and miR-195-5p are down-regulated in HER2-positive tumors. Furthermore, the expression levels of these microRNAs can significantly predict patient survival and thus potentially serve as new prognostic markers for HER2-positive breast cancer.