Endoscopic Endonasal Transsphenoidal Surgery for the Resection of Pituitary Adenomas: A Prime Candidate for a Shortened Length of Stay Enhanced Recovery after Surgery Protocol? A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a perioperative model of care aimed at optimizing postoperative rehabilitation and reducing hospital length of stay (LOS). Decreasing LOS avoids hospital-acquired complications, reduces cost of care, and improves patient satisfaction. Given the lack of ERAS protocols for endoscopic endonasal transsphenoidal surgery (EETS) resection of pituitary adenomas, a systematic review of EETS was performed to compile patient outcomes and analyze factors that may lead to increased LOS, reoperation, and readmission rates with the intention to contribute to the development of a successful ERAS protocol for EETS.

METHODS

The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines-based systematic review of the literature. Information was extracted regarding patient LOS, surgery complications, and readmission/reoperation rates. Pearson's correlations to LOS and reoperation/readmission rates were performed with variables normalized to the number of participants. Statistical significance was set at P value <0.05.

RESULTS

Fourteen studies were included, consisting of 2083 patients. The most common complications were cerebrospinal fluid leaks (37%) and postoperative diabetes insipidus (DI) (9%). Transient DI was significantly correlated with shorter LOS. Functional pituitary adenomas were significantly correlated with lower readmission rates while nonfunctional pituitary adenomas were correlated with higher readmission rates. No other factor was found to be significantly correlated with a change in LOS or reoperation rate.

CONCLUSIONS

EETS may be an ideal candidate for the development of ERAS cranial protocols. While our data largely supports the safe implementation of shortened LOS protocols in EETS, our findings highlight the importance of transient DI and nonfunctional pituitary adenomas management when formulating ERAS protocols.

POS0479 STAT3 DEGRADERS PROTECT FROM IMMUNOFIBROTIC CHANGES IN PRECLINICAL MODELS

Background

The ubiquitin-proteasome system (UPS) is the endogenous intracellular mechanism for maintaining protein homeostasis through protein degradation and turnover. Heterobifunctional small molecules are a new class of compounds that form a ternary complex with an E3 ligase and protein of interest leading to ubiquitination and subsequent degradation of the protein of interest in a process known as Targeted Protein Degradation. This new therapeutic modality enables targeting of “undruggable” proteins such as STAT3, a transcription factor activated in immunofibrotic diseases.

Objectives

Kymera has developed heterobifunctional molecules that potently and selectively target STAT3 for degradation and elimination by the ubiquitin-proteasome pathway. The aim of these studies was to evaluate the therapeutic potential of pharmacologically removing STAT3 by targeted protein degradation in various human cell types in vitro, and to prevent the development of skin and lung fibrosis in vivo.

Methods

Dermal fibroblasts obtained from healthy and systemic sclerosis patients activated with TGF-β were analyzed for development of α-smooth muscle actin (α-SMA)-positive stress fibers and for contractility using collagen gel contraction assay. Contraction assay was also performed using human dermal smooth muscle cells. Human aortic endothelial cells (HAECs) were activated with LPS, and their adhesive properties were assessed in the microcapillary system by the ability to bind peripheral blood mononuclear cells (PBMCs) under shear stress. HAECs proliferation was induced with VEGF. THP-1 cells and CD14+ monocytes were activated with IL-6 or LPS, and secreted cytokines were assessed by CBA. PBMCs activated with LPS, IL-6, IL-21, or IL-23 alone (pSTAT3 induction), or with a combination of anti-CD3/CD38 beads and a pro-Th17 cocktail comprised of cytokines and antibodies to evaluate the development of a Th17 and Treg phenotype by flow cytometry. Cytokines were analyzed by ELISA. All cell types were pre-treated with STAT3 degraders 20h prior to experiment start. Intratracheal instillation of bleomycin was used to induce pulmonary fibrosis. Transgenic Tsk-1 mice were used as a model of spontaneous skin fibrosis.

Results

STAT3 degraders completely ablated STAT3 in all analyzed cell types with DC50 ranging from 0.25-0.8 nM. STAT3 degradation prevented TGF-β-induced formation of α-SMA-positive stress fibers in dermal fibroblasts (IC50 = 0.35nM) and 2 and 10nM degrader completely abrogated their contractility. Similarly, STAT3 degradation reduced the constitutive contractility of dermal smooth muscle cells of 13% (p<0.05, n=6). Treatment of HAECs with STAT3 degraders resulted in anti-adhesive 178±21 for LPS and 93±12 for LPS +degrader, p<0.05, n=6) and anti-proliferative 1.2±0.1 for VEGF and 0.95±0.1 for VEGF +degrader, p<0.05, n=10-11) effects. In monocyte-focused assays (CD14+ monocytes and THP-1 cells), STAT3 degradation potently and dose-dependently inhibited IL-6 and LPS-induced pSTAT3 levels and the ensuing release of MCP-1/CCL2 (24.3±3.7 for LPS and 20.2±3.2 for LPS +degrader, p<0.05, n=6). In CD4+ T lymphocytes, STAT3 degradation promoted a Treg phenotype and suppressed the development of Th17 cells. Systemic treatment in vivo showed that prophylactic STAT3 degradation (7 mg/kg twice a week, i.p.) reduced disease severity in the bleomycin-induced pulmonary fibrosis model (Ashcroft‘s score, 4.7±1.9 vs. 3.1±1.6, p<0.05, n=11). In Tsk-1 mice that show co-occurrence of spontaneous skin thickening and robust STAT3 activation, STAT3 degrader treatment (2 or 7 mg/kg twice a week, i.p.) for 7 weeks significantly reduced thickness of the skin (701±238 vs. 480±205 vs. 365±107, p<0.05, n=6-8).

Conclusion

STAT3 degraders that selectively and potently eliminate STAT3 show robust anti-inflammatory and anti-fibrotic potential in vitro and in vivo. Our results suggest that targeted protein degradation is a promising approach to modulate the STAT3 pathway, making it a novel therapeutic opportunity to treating multiple immunofibrotic diseases.

Disclosure of Interests

Przemyslaw Blyszczuk Grant/research support from: Kymera, Gabriela Kania: None declared, Elena Pachera: None declared, Filip Rolski: None declared, Amela Hukara: None declared, Vanessa Tela: None declared, Michele Mayo Employee of: Kymera, Vaishali Dixit Employee of: Kymera, Bin Yang Employee of: Kymera, Jared Gollob Employee of: Kymera, Nello Mainolfi Employee of: Kymera, Anthony Slavin Employee of: Kymera, Cedric Hubeau Employee of: Kymera, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim.

OP0080 STAT3 DEGRADERS INHIBIT Th17 DEVELOPMENT AND CYTOKINE PRODUCTION RESULTING IN PROFOUND INHIBITION OF COLLAGEN-INDUCED AUTOIMMUNE MURINE ARTHRITIS

Background

Signal transducer and activator of transcription 3 (STAT3) is a transcription factor that belongs to a class of targets devoid of catalytic function, thus deemed “undruggable” by standard modalities such as small molecule inhibitors or biologics. STAT3 can be activated by various receptor- and non-receptor tyrosine kinases, playing a critical role in activation pathways triggered by cytokines, hormones, and growth factors, making it an attractive target for the treatment of inflammatory diseases.

Objectives

Kymera has developed heterobifunctional molecules that selectively target STAT3 for degradation and elimination by the ubiquitin-proteasome pathway. We sought to evaluate the pharmacologic potential of these STAT3 degraders through in vitro and in vivo studies relevant to human autoimmune disease, including murine collagen-induced arthritis.

Methods

We evaluated the impact of STAT3 degraders on the activation of human monocytes, dermal fibroblasts, CD4+ T cells, and PBMC by LPS, IL-6/IL-6R, IL-21, IL-23, as well as anti-CD3/CD28 plus a cocktail of cytokines and antibodies. STAT3 degradation and pSTAT3 inhibition were determined in comparison to a JAK1/2 small molecule inhibitor. Inhibition of cytokines, chemokines, and collagen release, as well as Th17 (CD4+CD25-RORγt+CXCR6+) and Treg (CD4+CD25+CD127lowFOXP3+) expansion were used as in vitro efficacy assays. Finally, STAT3 degraders were tested in vivo, in a mechanistic (IL-6 challenge) as well as a disease model (murine CIA) relevant to rheumatology indications.

Results

STAT3 degraders showed broad and potent activity in-vitro against TLR receptor and cytokine-induced activation of immune and stromal cells, including soluble mediator release such as MCP-1/CCL2 and Collagen1a1. STAT3 degradation in CD4+ T cells robustly inhibited the development of Th17 cells, abrogating IL-17, IL-22, IL-8/CXCL8, and TNFα production, and increased Treg numbers in a manner superior to JAK1/2 inhibition. In mice injected with IL-6, plasma levels of serum amyloid A were dose-dependently suppressed by STAT3 degradation. In the murine collagen-induced arthritis model, STAT3 degradation resulted in robust, dose-dependent delay of disease onset and decreased disease incidence, clinical scores, local cytokine expression (paws) and histopathological scores, including the complete alleviation of periosteal bone growth.

Conclusion

These data demonstrate the broad activity of STAT3 degradation in alleviating autoimmune inflammation in models relevant to human disease. Targeted protein degradation of STAT3 thus represents a novel therapeutic approach to treating autoimmune/autoinflammatory diseases such as rheumatoid arthritis.

Disclosure of Interests

Cedric Hubeau Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Jeffrey Sullivan Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Crystal Brown Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Michele Mayo Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Vaishali Dixit Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Bradley Enerson Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Haojing Rong Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Bin Yang Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Chris De Savi Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Jared Gollob Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Nello Mainolfi Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Anthony Slavin Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics.

Genotype/Phenotype Interactions and First Steps Toward Targeted Therapy for Sphingosine Phosphate Lyase Insufficiency Syndrome

Sphingosine-1-phosphate lyase insufficiency syndrome (SPLIS) is a rare metabolic disorder caused by a deficiency in sphingosine-1-phosphate lyase (SPL), the final enzyme in the sphingolipid degradative pathway. Inactivating mutations of SGPL1-the gene encoding SPL-lead to a deficiency of its downstream products, and buildup of sphingolipid intermediates, including its bioactive substrate, sphingosine-1-phosphate (S1P), the latter causing lymphopenia, a hallmark of the disease. Other manifestations of SPLIS include nephrotic syndrome, neuronal defects, and adrenal insufficiency, but their pathogenesis remains unknown. In this report, we describe the correlation between SGPL1 genotypes, age at diagnosis, and patient outcome. Vitamin B6 serves as a cofactor for SPL. B6 supplementation may aid some SPLIS patients by overcoming poor binding kinetics and promoting proper folding and stability of mutant SPL proteins. However, this approach remains limited to patients with a susceptible allele. Gene therapy represents a potential targeted therapy for SPLIS patients harboring B6-unresponsive missense mutations, truncations, deletions, and splice-site mutations. When Sgpl1 knockout (SPL^KO) mice that model SPLIS were treated with adeno-associated virus (AAV)-mediated SGPL1 gene therapy, they showed profound improvement in survival and kidney and neurological function compared to untreated SPL^KO mice. Thus, gene therapy appears promising as a universal, potentially curative treatment for SPLIS.

Spin-Hall nano-oscillator with oblique magnetization and Dzyaloshinskii-Moriya interaction as generator of skyrmions and nonreciprocal spin-waves

Spin-Hall oscillators (SHO) are promising sources of spin-wave signals for magnonics applications, and can serve as building blocks for magnonic logic in ultralow power computation devices. Thin magnetic layers used as “free” layers in SHO are in contact with heavy metals having large spin-orbital interaction, and, therefore, could be subject to the spin-Hall effect (SHE) and the interfacial Dzyaloshinskii-Moriya interaction (i-DMI), which may lead to the nonreciprocity of the excited spin waves and other unusual effects. Here, we analytically and micromagnetically study magnetization dynamics excited in an SHO with oblique magnetization when the SHE and i-DMI act simultaneously. Our key results are: (i) excitation of nonreciprocal spin-waves propagating perpendicularly to the in-plane projection of the static magnetization; (ii) skyrmions generation by pure spin-current; (iii) excitation of a new spin-wave mode with a spiral spatial profile originating from a gyrotropic rotation of a dynamical skyrmion. These results demonstrate that SHOs can be used as generators of magnetic skyrmions and different types of propagating spin-waves for magnetic data storage and signal processing applications.

Spin wave excitations of a magnetic pillar with dipolar coupling between the layers

It is demonstrated analytically that the spectrum of small-amplitude spatially uniform magnetization excitations in an in-plane magnetized magnetic pillar with two ferromagnetic layers coupled by dipole-dipole interaction can be approximately described by the traditional Kittel formula with reduced saturation magnetization and effective anisotropy field. The spectrum consists of a quasi-symmetric and a quasi-antisymmetric mode, and the apparent reduction of saturation magnetization for the quasi-symmetric mode (≤50%) is much larger than that for the quasi-antisymmetric mode (≤10%). The effect of dynamic dipolar coupling between the nano-pillar layers could be partly responsible for the apparent reduction of static magnetization seen in many spin-torque experiments performed on magnetic nano-pillars.

Resonant nonlinear damping of quantized spin waves in ferromagnetic nanowires: a spin torque ferromagnetic resonance study

We use spin torque ferromagnetic resonance to measure the spectral properties of dipole-exchange spin waves in Permalloy nanowires. Our measurements reveal that geometric confinement has a profound effect on the damping of spin waves in the nanowire geometry. The damping parameter of the lowest-energy quantized spin-wave mode depends on applied magnetic field in a resonant way and exhibits a maximum at a field that increases with decreasing nanowire width. This enhancement of damping originates from a nonlinear resonant three-magnon confluence process allowed at a particular bias field value determined by quantization of the spin-wave spectrum in the nanowire geometry.

In vitro evidence that immunuaffinity-purified MOG contains immunogenic quantities of contaminating mouse IgG; techniques for producing Ig-free MOG

Myelin oligodendrocyte glycoprotein (MOG) has attracted considerable attention due to its possible role in multiple sclerosis (MS). Previous studies have shown that MOG-reactive T cells are more commonly detected in MS patients than controls. In this report, we studied human MOG-reactive T cell clones generated from healthy individuals as well as MS patients. Our results indicate that immunoaffinity-purified MOG, which was routinely used in prior studies, is contaminated by anti-MOG antibody (mouse IgG), despite the inability to detect IgG by Western blotting. Here, we used continuous SDS-PAGE, which enabled us to isolate highly purified MOG devoid of contaminating mouse IgG.

Genetic susceptibility or resistance to autoimmune encephalomyelitis in MHC congenic mice is associated with differential production of pro- and anti-inflammatory cytokines

Experimental allergic encephalomyelitis (EAE) is a T(h)1-type cell-mediated autoimmune disease induced by immunization with myelin proteins and mediated by CD4(+) T cells. Although susceptibility to EAE is dependent largely on MHC background, the B10.S strain is resistant to induction of EAE despite sharing the I-A(s) MHC locus with the susceptible SJL strain. Furthermore, NOD mice which spontaneously develop diabetes are susceptible to EAE induction with myelin oligodendrocyte glycoprotein (MOG) 35-55, whereas a MHC congenic strain, III, which also expresses I-A(g7) MHC haplotype does not develop diabetes and is also resistant to EAE induction. We induced EAE in these four strains of mice with MOG peptides 92-106 (for I-A(s) strains) and 35-55 (for I-A(g7) strains) in complete Freund's adjuvant. In the susceptible strains (SJL and NOD) in vitro, there are high levels of IFN-gamma production, whereas the resistant strains (B10.S or III) secreted primarily IL-4/IL-10 and transforming growth factor (TGF)-beta, and had decreased levels of IFN-gamma. When brains from susceptible and resistant mice were examined by immunohistochemical methods for cytokine expression, the brains from resistant mice showed fewer infiltrates which predominantly expressed IL-4 and IL-10 and/or TGF-beta. Brains from NOD and SJL with EAE showed mainly IL-2 and IFN-gamma positive cells. Thus, resistance to MOG induced EAE in B10.S and III mouse strains is related to non-MHC genes and is associated with an altered balance of pro- and anti-inflammatory cytokines both in lymphoid tissue and in the brain following immunization with myelin antigens.

Induction of a multiple sclerosis-like disease in mice with an immunodominant epitope of myelin oligodendrocyte glycoprotein

Myelin oligodendrocyte glycoprotein (MOG) is postulated to be a target autoantigen in multiple sclerosis (MS). Here we investigated the encephalitogenicity of an immunodominant epitope of MOG, peptide 35-55, in various strains of mice. An MS-like disease was induced in NOD/Lt mice (H-2g7) and C57BL/6 mice (H-2b) by a single injection of MOG35-55 in CFA. The disease followed a relapsing-remitting course in NOD/Lt mice, whereas C57BL/6 mice developed a chronic paralytic disease. Histologically, the disease in both strains was characterized by cellular infiltration and multifocal demyelination in the CNS. Significant DTH type reactions to MOG35-55 were only seen in MOG-susceptible animals, with the NOD/Lt mice showing the strongest responses. Susceptible mice also showed specific antibody responses to MOG35-55 but not to a panel of other MOG peptides. These results provide further evidence for the role of MOG as a highly autoantigenic molecule capable of inducing severe demyelinating disease.

Delayed and incomplete myelination in a transgenic mouse mutant with abnormal oligodendrocytes

In search of animal models suitable for investigating myelin repair, we have analysed myelinogenesis in a transgenic mouse mutant with delayed myelination, but with a normal life-span. The 2-50 mutant which carries a c-myc gene under the regulation of the myelin basic protein promoter has been described previously (Orian et al.: J Neurosci Res 39:604-612, 1994). Here we show that appropriate mRNA transcripts and their corresponding protein products are generated, but that the accumulation of these products is delayed in transgenic mice with respect to nontransgenic littermates. This phenomenon is associated with aberrant myelin and paucity of normal oligodendrocytes. Myelination appears to be carried out by abnormal, oligodendrocyte-like cells. We propose that the primary defect in the 2-50 mutant is an inability to generate the normal number of mature oligodendrocytes. This mutant represents a novel class of mutant in which oligodendrocyte development and myelination can be studied in the absence of interference with a gene for a structural protein of myelin, in an animal with normal survival. It may also represent a new tool to investigate in vivo gliogenesis and regulatory events bringing about the coordinated regulation of myelin protein synthesis.

Myelin oligodendrocyte glycoprotein: a novel candidate autoantigen in multiple sclerosis

Myelin oligodendrocyte glycoprotein (MOG) is a member of the immunoglobulin superfamily expressed exclusively in central nervous system (CNS) myelin. While the function of MOG is unknown, a number of studies have shown that immune responses to MOG contribute to the autoimmune-mediated demyelination seen in animals immunized with whole CNS tissue. This paper summarizes our recent studies, which unequivocally demonstrate that MOG by itself is able to generate both an encephalitogenic T cell response and an autoantibody response in Lewis rats and in several strains of mice. In Lewis rats the injection of both native MOG and MOG35-55 peptide produces a paralytic relapsing-remitting neurological disease with extensive plaque-like demyelination. The antibody response to MOG35-55 was highly restricted, as no reactivity to either other MOG peptides or myelin proteins could be detected. Fine epitope mapping showed that antibody from serum and cerebrospinal fluid of injected rats reacted strongly to MOG37-46, which is contiguous to the dominant T cell epitope contained within MOG44-55. NOD/Lt and C57BL/6 mice were also susceptible to severe neurological disease following injection with recombinant MOG or MOG35-55 peptide, indicating that this specific CNS autoantigen, or some of its determinants, can induce a pathogenic response across animal species. Severe paralysis and extensive demyelination were seen in both strains, but NOD/Lt mice experienced a chronic relapsing disease whereas C57BL/6 mice had a chronic non-remitting disease. Moreover, transfer of MOG35-55 T cells into naive NOD/Lt mice also produced severe neurological impairment as well as histological lesions. These results emphasize that a synergism between a T cell-response and anti-MOG antibodies may be important for the development of severe demyelinating disease. This, together with our demonstration that there is a predominant T cell response to MOG in patients with multiple sclerosis, clearly indicates that MOG is probably an important target autoantigen in this disease.

Axial dynamic compression plates in the management of complex orbital fractures via transconjunctival orbitotomy

We describe our 4 years' experience using axial dynamic compression plates in the management of 46 zygomatico-orbital and complex infraorbital fractures. Surgical exposure of the fracture sites was accomplished in all cases by transconjunctival orbitotomy with lateral cantholysis. Transconjunctival orbitotomy with lateral cantholysis provides excellent surgical exposure of periorbital fractures, and axial dynamic compression plates are an excellent method for repairing these fractures.