Minimal clinically important differences in six-minute walking distance in late-onset Pompe disease

BACKGROUND

The minimal clinically important difference (MCID) is the smallest change in outcome that physicians or patients would consider meaningful and is relevant when evaluating disease progression or the efficacy of interventions. Studies of patients with late-onset Pompe disease (LOPD) have used the 6-min walk distance (6MWD) as an endpoint to assess motor function. However, an MCID for 6MWD (% predicted and meters) has yet to be established in LOPD. The objective of the study was to derive 6MWD MCID (% predicted and meters) with different analysis methods and for subgroups of different disease severity for LOPD.

METHODS

Data from the PROPEL trial were used to calculate 6MWD MCID in the overall PROPEL population and subgroups of baseline severity as assessed by walking distance and body mass index (BMI), using anchor- and distribution-based approaches.

RESULTS

The 6MWD MCIDs varied widely, depending on the method and subgroup, ranging from 2.27%-8.11% predicted for the overall LOPD population (23.7 m-57.2 m). For patients with baseline 6MWD < 150 m, MCIDs ranged from -0.74%-3.37% (-2.1 m-11.3 m). MCIDs increased with distance walked at baseline until a plateau was reached. For BMI subgroups, the MCIDs were generally lowest in obese patients.

CONCLUSION

Our analysis shows that MCID depends on the chosen method and disease severity. The findings suggest that applying a single MCID to all patients can be misleading; consequently, a range of possible MCIDs should be considered. This may also be highly relevant for other neuromuscular diseases. This study provides a range of 6MWD MCIDs for LOPD, with lower MCIDs for more severe patients.

Therapeutic Role of Pharmacological Chaperones in Lysosomal Storage Disorders: A Review of the Evidence and Informed Approach to Reclassification

The treatment landscape for lysosomal storage disorders (LSDs) is rapidly evolving. An increase in the number of preclinical and clinical studies in the last decade has demonstrated that pharmacological chaperones are a feasible alternative to enzyme replacement therapy (ERT) for individuals with LSDs. A systematic search was performed to retrieve and critically assess the evidence from preclinical and clinical applications of pharmacological chaperones in the treatment of LSDs and to elucidate the mechanisms by which they could be effective in clinical practice. Publications were screened according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting guidelines. Fifty-two articles evaluating 12 small molecules for the treatment of seven LSDs are included in this review. Overall, a substantial amount of preclinical and clinical data support the potential of pharmacological chaperones as treatments for Fabry disease, Gaucher disease, and Pompe disease. Most of the available clinical evidence evaluated migalastat for the treatment of Fabry disease. There was a lack of consistency in the terminology used to describe pharmacological chaperones in the literature. Therefore, the new small molecule chaperone (SMC) classification system is proposed to inform a standardized approach for new, emerging small molecule therapies in LSDs.

A combinatorial droplet microfluidic device integrated with mass spectrometry for enzyme screening

Mass spectrometry (MS) enables detection of different chemical species with a very high specificity; however, it can be limited by its throughput. Integrating MS with microfluidics has a tremendous potential to improve throughput and accelerate biochemical research. In this work, we introduce Drop-NIMS, a combination of a passive droplet loading microfluidic device and a matrix-free MS laser desorption ionization technique called nanostructure-initiator mass spectrometry (NIMS). This platform combines different droplets at random to generate a combinatorial library of enzymatic reactions that are deposited directly on the NIMS surface without requiring additional sample handling. The enzyme reaction products are then detected with MS. Drop-NIMS was used to rapidly screen enzymatic reactions containing low (on the order of nL) volumes of glycoside reactants and glycoside hydrolase enzymes per reaction. MS "barcodes" (small compounds with unique masses) were added to the droplets to identify different combinations of substrates and enzymes created by the device. We assigned xylanase activities to several putative glycoside hydrolases, making them relevant to food and biofuel industrial applications. Overall, Drop-NIMS is simple to fabricate, assemble, and operate and it has potential to be used with many other small molecule metabolites.

Evaluation of Public Health Contact Tracing for Mpox Among Gay, Bisexual, and Other Men Who Have Sex With Men-10 US Jurisdictions, May 17-July 31, 2022

Objectives. To examine the potential impact of contact tracing to identify contacts and prevent mpox transmission among gay, bisexual, and other men who have sex with men (MSM) as the outbreak expanded. Methods. We assessed contact tracing outcomes from 10 US jurisdictions before and after access to the mpox vaccine was expanded from postexposure prophylaxis for persons with known exposure to include persons at high risk for acquisition (May 17-June 30, 2022, and July 1-31, 2022, respectively). Results. Overall, 1986 mpox cases were reported in MSM from included jurisdictions (240 before expanded vaccine access; 1746 after expanded vaccine access). Most MSM with mpox were interviewed (95.0% before vaccine expansion and 97.0% after vaccine expansion); the proportion who named at least 1 contact decreased during the 2 time periods (74.6% to 38.9%). Conclusions. During the period when mpox cases among MSM increased and vaccine access expanded, contact tracing became less efficient at identifying exposed contacts. Public Health Implications. Contact tracing was more effective at identifying persons exposed to mpox in MSM sexual and social networks when case numbers were low, and it could be used to facilitate vaccine access. (Am J Public Health. Published online ahead of print May 4, 2023:e1-e4. https://doi.org/10.2105/AJPH.2023.307301).

Abstract C085: Spatial arrangements of immune cells of the pancreatic ductal adenocarcinoma tumor microenvironment correlated with outcomes in the phase 3 APACT trial

Introduction The newly diagnosed pancreatic ductal adenocarcinoma (PDAC) population has a high unmet need for effective treatments, with median survival of &lt; 1 year. The phase 3 APACT (Adjuvant Pancreatic Adenocarcinoma Clinical Trial) evaluated the use of adjuvant nab-paclitaxel plus gemcitabine vs. gemcitabine in 866 patients with surgically resected PDAC. We explored the tumor microenvironment (TME) of &gt;500 baseline resected APACT tumors to identify TME features that are associated with adverse outcomes. Methods Biopsy analyses included RNA-seq, DNA-seq, and multiplexed immunohistochemistry (mIHC). We quantified, for 533 patient biopsies, via mIHC the spatial arrangement of 7 immune cell types and 2 checkpoint markers relative to tumor and nontumor regions, and pairwise colocalization relative to each other. We identified combinations of biomarkers that correlate significantly with molecular signatures, predefined patient subsets, and overall survival (OS). Hazard ratios (HR) and p-values were computed via a Cox proportional hazards regression model which included resection and lymph node status as covariates. Significantly differentially-expressed transcripts were associated with biomarkers derived from the mIHC via unpaired t-test. Results Higher densities of CD8+ T cells within tumor regions correlated with longer OS (hazard ratio HR=0.76; p=0.03), and higher overall densities of CD163+ macrophages correlated with shorter OS (HR=1.44; p=0.006). We furthermore identified a patient subset (n=72) with a combination of higher CD8+ T cell and lower CD163+ macrophage densities that had a strikingly significant decreased HR of 0.46 (p=0.009). Moreover, patients with a high degree of spatial colocalization between CD8+ T cells and dual-positive CMAF+CD163+ M2-like macrophages observed a significant increased HR of 1.51 (p=0.0006), a biomarker only surpassed by nodal status in significance of correlation with OS (HR=1.9; p=0.00015). While this cellular colocalization was computed to be independent of cell densities, we found that the association of this colocalized pair of cell types with shorter OS was most significant for patients with lower overall CD8+ T cell densities (HR=1.84; p=0.0004). We further identified differentially regulated transcripts associated with this interaction and found specific putative ligand-receptor pairs that were also associated with lower OS. Conclusion A combination of greater infiltration of CD8+ cytotoxic T cells and lower infiltration of macrophages is associated with longer OS in the APACT trial. Moreover, the spatial colocalization between CD8+ T cells and CMAF+ M2 macrophages is associated with shorter OS. These findings were observed across both treatment arms of the study. Future investigation of this apparent interaction, and associated differentially expressed transcripts, may inform management of patients with pancreatic adenocarcinoma and increase effectiveness of PDAC therapies.

Citation Format: David J. Reiss, Andrew Browne, Brian Fox, Alexander V. Ratushnyy, Maria Wang, Andrew V. Biankin, Thomas Lila. Spatial arrangements of immune cells of the pancreatic ductal adenocarcinoma tumor microenvironment correlated with outcomes in the phase 3 APACT trial [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr C085.

Predicting individual differences in motor learning: a critical review

The ability to predict individual differences in motor learning has significant implications from both theoretical and applied perspectives. However, there is high variability in the methodological and analytical strategies employed as evidence for such predictions. Here, we critically examine the evidence for predictions of individual differences in motor learning by reviewing the literature from a 20-year period (2000-2020). Specifically, we examined four factors: (i) the predictor and predicted variables used, (ii) the strength of the prediction and associated sample size, (iii) the timescale over which the prediction was made, and (iv) the type of motor task used. Overall, the results highlight several issues that raise concerns about the quality of the evidence for such predictions. First, there was a large variation in both predictor and predicted variables, suggesting the presence of a large number of researcher degrees of freedom. Second, sample sizes tended to be small, and the strength of the correlation showed an inverse relation with sample size. Third, the timescale of most predictions was very short, mostly constrained to a single day. Last, most studies were largely restricted to two experimental paradigms - adaptation and sequence learning. Based on these issues, we highlight recommendations for future studies to improve the quality of evidence for predicting individual differences in motor learning.

Durvalumab as monotherapy and in combination therapy in patients with lymphoma or chronic lymphocytic leukemia: The FUSION NHL 001 trial

BACKGROUND

Studies suggest that immune checkpoint inhibitors may represent a promising strategy for boosting immune responses and improving the antitumor activity of standard therapies in patients with relapsed/refractory hematologic malignancies.

AIMS

Phase 1/2 FUSION NHL 001 was designed to determine the safety and efficacy of durvalumab, an anti-programmed death ligand 1 (PD-L1) antibody, combined with standard-of-care therapies for lymphoma or chronic lymphocytic leukemia (CLL).

METHODS AND RESULTS

The primary endpoints were to determine the recommended phase 2 dose of the drugs used in combination with durvalumab (durvalumab was administered at the previously recommended dose of 1500 mg every 4 weeks) and to assess safety and tolerability. Patients were enrolled into one of four arms: durvalumab monotherapy (Arm D) or durvalumab in combination with lenalidomide ± rituximab (Arm A), ibrutinib (Arm B), or rituximab ± bendamustine (Arm C). A total of 106 patients with relapsed/refractory lymphoma were enrolled. All but two patients experienced at least one treatment-emergent adverse event (TEAE); those not experiencing a TEAE were in Arm C (diffuse large B-cell lymphoma [DLBCL]) and Arm D (DLBCL during the durvalumab monotherapy treatment period). No new safety signals were identified, and TEAEs were consistent with the respective safety profiles for each study treatment. Across the study, patients with follicular lymphoma (FL; n = 23) had an overall response rate (ORR) of 59%; ORR among DLBCL patients (n = 37) was 18%. Exploratory biomarker analysis showed that response to durvalumab monotherapy or combination therapy was associated with higher interferon-γ signature scores in patients with FL (p = .02).

CONCLUSION

Durvalumab as monotherapy or in combination is tolerable but requires close monitoring. The high rate of TEAEs during this study may reflect on the difficulty in combining durvalumab with full doses of other agents. Durvalumab alone or in combination appeared to add limited benefit to therapy.

Abstract 3165: Stroma-immune landscape in lymphoma: new mechanisms of immunosuppression and therapeutic targeting

Tumor cells engage in bidirectional interactions with stroma and immune cells to promote disease progression and immune evasion. Stroma-specific gene signatures have been associated with outcome in diffuse large B-cell lymphoma (DLBCL), but their immunobiology has been understudied.

To characterize the stromal landscape in lymphoma, we performed high-dimensional imaging mass cytometry analysis of the major stroma subsets and revealed a marked expansion and remodeling of the immuno-specialized fibroblastic reticular cells (FRCs) in human DLBCL biopsies (n=53). The FRC network was similarly remodeled in tumors from the IμBcl6 transgenic model of lymphoma, and aberrant fibroblasts were in close proximity to cancer cells.

Modelling the interactions between murine and patient FRCs and tumor cells, using 2D and 3D cultures, showed that lymphoma drives the acquisition of an inflammatory-like, pro-tumoral (upregulation of fibroblast activating protein-α, FAP) phenotype and associated functional capabilities. Comparative bulk transcriptomic analysis revealed that lymphoma-FRCs undergo transcriptional reprogramming and activate gene pathways associated with inflammatory responses. Moreover, single-cell RNA-seq revealed an expansion of activated FRC clusters expressing B cell supporting genes, while T cell-associated FRCs were contracted. Altered chemokine signaling pathways in DLBCL-FRCs were functionally linked to reduced attraction of T cells and impeded migration along the lymphoma-reticular network. Moreover, lymphoma-FRCs upregulated expression of inhibitory PD-1 ligands that reduced the anti-tumor cytolytic activity of CD8+ T cells, a T cell bispecific antibody (CD20-TCB, glofitamab) and anti-CD19 CAR T cells in our coculture models.

To overcome the immunosuppressive activity of DLBCL-FRCs, we investigated the use of CD20-TCB in combination with stroma-targeting immunocytokine fusion protein drug (FAP-IL2v, RG7461) or costimulatory fusion protein (FAP-4-1BBL, RG7827). Functional cytotoxicity assays using human and murine primary DLBCL patient samples revealed that both stroma-targeting drugs paired effectively with the CD20-TCB to enhance the cytotoxic activity of autologous CD8+ T cells. In addition, the ability of immune-/stroma- targeted combination immunotherapy to trigger anti-tumor activity and CD8+ T cell retention within the FRC-TME was demonstrated using 3D precision-cut lymph node slice-based organotypic cultures of DLBCL and other B cell malignancies.

In conclusion our data reveal that lymphoma cells actively reprogram FRCs that acquire altered immunoregulatory function which prevents effective T cell motility and suppresses the anti-tumor function of cytolytic T cells. Importantly, we demonstrate that combination immunotherapy incorporating fibroblast-targeting fusion proteins could effectively recover anti-tumor T cell activity.

Citation Format: Benedetta Apollonio, Nedyalko Petrov, Filomena Spada, Peter Jarvis, Domenico Cozzetto, Shichina Kannambath, David Kuo, Mansoor Saqui, Rose-Marie Amini, Gunilla Enblad, Graham Charlotte, Reuben Benjamin, Anna Vardi, Elisabeth Phillips, Jon Salisbury, Eric N. Olson, Brian Fox, Patrick Hagner, Anita Gandhi, Ruth F. Jarrett, Sylvia Herter, Marina Bacac, Christina Klaus, Christian Klein, Alexander Deutsch, Alan G. Ramsay. Stroma-immune landscape in lymphoma: new mechanisms of immunosuppression and therapeutic targeting [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 3165.

Lung organoids and other preclinical models of pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive fatal disease affecting over 100 000 people in Europe with an increasing incidence. Available treatments offer only slowing of disease progression and are poorly tolerated by patients leading to cessation of therapy. Lung transplant remains the only cure. Therefore, alternative treatments are urgently required. The pathology of IPF is complex and poorly understood and thus creates a major obstacle to the discovery of novel treatments. Additionally, preclinical assessment of new treatments currently relies upon animal models where disparities with human lung biology often hamper drug development. At a cellular level, IPF is characterized by persistent and abnormal deposition of extracellular matrix by fibroblasts and alveolar epithelial cell injury which is seen as a key event in initiation of disease progression. In-depth investigation of the role of alveolar epithelial cells in health and disease has been impeded due to difficulties in primary cell isolation and culture ex vivo. Novel strategies employing patient-derived induced pluripotent stem cells engineered to produce type 2 alveolar epithelial cells (iAEC2) cultured as three-dimensional organoids have the potential to overcome these hurdles and inform new effective precision treatments for IPF leading to improved survival and quality of life for patients worldwide.

Systematicity in Organizational Research Literature Reviews: A Framework and Assessment

In this study, we first develop a framework that presents systematicity as an encompassing orientation toward the application of explicit methods in the practice of literature reviews, informed by the principles of transparency, coverage, saturation, connectedness, universalism, and coherence. We then supplement that conceptual development with empirical insights into the reported practices of systematicity in a sample of 165 published reviews across three journals in organizational research. We finally trace implications for the future conduct of literature reviews, including the potential perils of systematicity without mindfulness.

The accuracy of computed tomography for clavicle non-union evaluation

BACKGROUND

The primary aim of this study is to determine the accuracy of CT scanning when evaluating non-union of the clavicle.

METHODS

A retrospective review was performed of all CT scans undertaken for suspected nonunion of midshaft clavicle fractures over a 10-year period. The influence of scan timing, callus and patient characteristics was evaluated.

RESULTS

One hundred eighty-four CT scans were analysed. No patient was incorrectly diagnosed with union (n = 85). Ninety-nine scans were reported as non-union with inadequate bridging callus, 19 of which were united at operation or on repeat CT imaging and represented delayed unions. Atrophic callus was found in 57 patients and all of which had a confirmed non-union (positive predictive value 100%). A hypertrophic callus was found in 42 patients, all of the delayed unions were found in this group (positive predictive value for non-union 55%, p < 0.001). CT compared to radiographs showed greater inter-observer agreement for union (weighted kappa 0.75 vs. 0.50 respectively). Overall, CT is 100% sensitive and 81.7% specific for non-union diagnosis.

DISCUSSION

CT has excellent accuracy to determine clavicle union but approximately one in five suspected non-unions went onto unite. Hypertrophic callus finding resulted in a delayed union in approximately half of the cases in our study.

Abstract PO-008: Multi-omic Profiling of primary pancreatic adenocarcinomas obtained from the APACT adjuvant trial of nab-paclitaxel + gemcitabine vs gemcitabine

Pancreatic ductal adenocarcinoma (PDAC) remains a difficult disease to treat, with few therapies available that target specific patient subgroups. Translational studies in pancreatic cancer can be technically challenging due to biopsy specimen characteristics including low tumor cellularity and dense fibrotic stroma. Resected primary pancreatic tumors obtained during the phase 3 APACT clinical trial (NCT01964430 adjuvant nab-paclitaxel + gemcitabine versus gemcitabine monotherapy n = 866) are a unique resource for characterizing molecular and immune subtypes among PDAC tumors and their association with treatment outcomes in the adjuvant chemotherapy setting. Tumor-infiltrating immune cells were assessed in serial sections of 453 tumors by dual-chromogen immuno-histochemical (IHC) staining (CD4 CD8 CD20 CD163 CMAF CD56 FoxP3 PD-1 PD-L1). Image alignment, segmentation, and spatial localization of stained cells relative to a pan-cytokeratin staining-based tumor epithelial mask was performed using a commercial analysis platform. Expression profiles were obtained for 515 macrodissected tumor biopsy regions by RNA-seq. Transcriptional subtypes were assigned based on schema previously reported by Moffit and Bailey, and molecular pathway correlates were characterized using gene set enrichment analysis. Based on immunochemical staining, higher intratumoral CD8+ or lower CD163+ cell densities were associated with modestly longer disease-free or overall survival in patients treated with nab-paclitaxel plus gemcitabine. The combination of both high CD8+ and low CD163+ cell density was notably associated with longer overall survival compared to other subjects treated with the combination regimen (mOS&gt;55months versus 36 months HR=0.46 p=&lt;0.01) Transcriptional subtyping of tumors, based on schema such as those previously reported by Moffit et al or Bailey et al, identified groups defined by anticipated signatures. Classical/progenitor subtypes differentially expressed genes involved in oxidative respiration and endodermal cell fate, while basal/squamous subtypes showed high expression of signatures for hypoxia, mesenchymal transformation, and TGFb signaling. Longer overall survival in subjects treated with nab-paclitaxel plus gemcitabine as compared to gemcitabine monotherapy was seen principally in subjects with tumors of Moffit classical (HR=0.59 P=0.01) and Bailey progenitor (HR=0.42 P&lt;0.01) subtypes. The observations highlighted provide insight into primary PDAC tumor characteristics that are associated with treatment-specific outcomes to nab-paclitaxel based adjuvant chemotherapy. Future work will combine data described here with mutational and genetic studies in progress as well as with other public, proprietary, or commercial data sources. In combination, we anticipate that these data may be useful in identifying patient subsets and molecular mechanisms that might be targeted by novel combination therapies for improved treatment of pancreatic cancer.

Citation Format: Thomas Lila, Andrew Biankin, Andrew Browne, David J. Reiss, Brian Lu, Daniel Pierce, Alexander Ratushny, Kao-tai Tsai, Sneh Lata, Sitharthan Kamalakaran, Tomas Babak, Brian Fox, Sam Danziger, Konstantinos Mavrommatis, Matthew W. B. Trotter, David Chang, Fadi Towfic. Multi-omic Profiling of primary pancreatic adenocarcinomas obtained from the APACT adjuvant trial of nab-paclitaxel + gemcitabine vs gemcitabine [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2020 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2020;80(22 Suppl):Abstract nr PO-008.

No significant effect of caffeine on five kilometer running performance after muscle damage

Caffeine has documented hypoalgesic effects during exercise. However, there is a lack of research focusing on caffeine's potential analgesic effects to ameliorate delayed onset muscle soreness. A placebo controlled randomized cross-over trial was carried out to determine if 5 mg/kg of body weight (mg/kgBW) of caffeine attenuates muscle pain and improves 5 k running performance following delayed onset muscle soreness. Prior to participating, eleven runners (9 male; 2 female; age, 24.5 ± 6.3 years; height, 173.6 ± 7.8 cm; body mass, 66.3 ± 7.5 kg; BMI, 23.18 kg/m² ± 1.6; VO_2max 61.0 ± 6.1 ml/kg/min^-1), were asked to discontinue supplement use for 72 hours and abstain from caffeine consumption for 48 hours. Participants performed a 30-minute downhill run on a treadmill set at -10% grade at 70% VO_2max to induce delayed onset of muscle soreness. Participants then returned 48 hours after to complete a 5 k time trial run where they consumed either 5 mg/kgBW of caffeine or a placebo. Rate of perceived exertion and heart rate were taken every two minutes during the trial. There was no detectable statistical difference between 5 k performance between caffeine (1074.9 ± 119.7 sec) or placebo (1053.8 ± 86.8 sec) (p = .41). Algometer readings were similar between both treatments for muscle soreness in the rectus femoris (p = .791) and the vastus medialis oblique (p = .371). Muscle soreness ratings were found to be greater in the caffeine condition compared to the placebo condition (p = .030). There was no effect of treatment on rating of perceived exertion between conditions (p = .574). The present study suggests that caffeine is not effective at reducing muscle soreness, rating of perceived exertion, or improving running performance in a time trial in the presence of muscle soreness.

Bone marrow microenvironments that contribute to patient outcomes in newly diagnosed multiple myeloma: A cohort study of patients in the Total Therapy clinical trials

BACKGROUND

The tumor microenvironment (TME) is increasingly appreciated as an important determinant of cancer outcome, including in multiple myeloma (MM). However, most myeloma microenvironment studies have been based on bone marrow (BM) aspirates, which often do not fully reflect the cellular content of BM tissue itself. To address this limitation in myeloma research, we systematically characterized the whole bone marrow (WBM) microenvironment during premalignant, baseline, on treatment, and post-treatment phases.

METHODS AND FINDINGS

Between 2004 and 2019, 998 BM samples were taken from 436 patients with newly diagnosed MM (NDMM) at the University of Arkansas for Medical Sciences in Little Rock, Arkansas, United States of America. These patients were 61% male and 39% female, 89% White, 8% Black, and 3% other/refused, with a mean age of 58 years. Using WBM and matched cluster of differentiation (CD)138-selected tumor gene expression to control for tumor burden, we identified a subgroup of patients with an adverse TME associated with 17 fewer months of progression-free survival (PFS) (95% confidence interval [CI] 5-29, 49-69 versus 70-82 months, χ2 p = 0.001) and 15 fewer months of overall survival (OS; 95% CI -1 to 31, 92-120 versus 113-129 months, χ2 p = 0.036). Using immunohistochemistry-validated computational tools that identify distinct cell types from bulk gene expression, we showed that the adverse outcome was correlated with elevated CD8+ T cell and reduced granulocytic cell proportions. This microenvironment develops during the progression of premalignant to malignant disease and becomes less prevalent after therapy, in which it is associated with improved outcomes. In patients with quantified International Staging System (ISS) stage and 70-gene Prognostic Risk Score (GEP-70) scores, taking the microenvironment into consideration would have identified an additional 40 out of 290 patients (14%, premutation p = 0.001) with significantly worse outcomes (PFS, 95% CI 6-36, 49-73 versus 74-90 months) who were not identified by existing clinical (ISS stage III) and tumor (GEP-70) criteria as high risk. The main limitations of this study are that it relies on computationally identified cell types and that patients were treated with thalidomide rather than current therapies.

CONCLUSIONS

In this study, we observe that granulocyte signatures in the MM TME contribute to a more accurate prognosis. This implies that future researchers and clinicians treating patients should quantify TME components, in particular monocytes and granulocytes, which are often ignored in microenvironment studies.

Blood transcriptomic discrimination of bacterial and viral infections in the emergency department: a multi-cohort observational validation study

BACKGROUND

There is an urgent need to develop biomarkers that stratify risk of bacterial infection in order to support antimicrobial stewardship in emergency hospital admissions.

METHODS

We used computational machine learning to derive a rule-out blood transcriptomic signature of bacterial infection (SeptiCyte™ TRIAGE) from eight published case-control studies. We then validated this signature by itself in independent case-control data from more than 1500 samples in total, and in combination with our previously published signature for viral infections (SeptiCyte™ VIRUS) using pooled data from a further 1088 samples. Finally, we tested the performance of these signatures in a prospective observational cohort of emergency department (ED) patients with fever, and we used the combined SeptiCyte™ signature in a mixture modelling approach to estimate the prevalence of bacterial and viral infections in febrile ED patients without microbiological diagnoses.

RESULTS

The combination of SeptiCyte™ TRIAGE with our published signature for viral infections (SeptiCyte™ VIRUS) discriminated bacterial and viral infections in febrile ED patients, with a receiver operating characteristic area under the curve of 0.95 (95% confidence interval 0.90-1), compared to 0.79 (0.68-0.91) for WCC and 0.73 (0.61-0.86) for CRP. At pre-test probabilities 0.35 and 0.72, the combined SeptiCyte™ score achieved a negative predictive value for bacterial infection of 0.97 (0.90-0.99) and 0.86 (0.64-0.96), compared to 0.90 (0.80-0.94) and 0.66 (0.48-0.79) for WCC and 0.88 (0.69-0.95) and 0.60 (0.31-0.72) for CRP. In a mixture modelling approach, the combined SeptiCyte™ score estimated that 24% of febrile ED cases receiving antibacterials without a microbiological diagnosis were due to viral infections. Our analysis also suggested that a proportion of patients with bacterial infection recovered without antibacterials.

CONCLUSIONS

Blood transcriptional biomarkers offer exciting opportunities to support precision antibacterial prescribing in ED and improve diagnostic classification of patients without microbiologically confirmed infections.

560 The inclusion of pulmonary arterial pressure misclassifies diastolic function using the current EACVI guidelines in pre-capillary pulmonary hypertension

Background

Pulmonary hypertension (PH) can be pre-capillary or post-capillary (PVH) etiology based on left-sided filling pressures and pulmonary vascular resistance. The 2016 EACVI/ASE Recommendations for the Evaluation of Left Ventricular Diastolic Function (LVDF) provides flow-diagrams to categorize patients. Parameters used include left atrial volume, Doppler-derived transmitral and mitral annular velocities, and systolic PA pressure (sPAP). There are no dedicated criteria to assess the diastolic function in pulmonary arterial hypertension (PAH). Additionally, diseases such as scleroderma can result in both PAH and PVH, thus including sPAP may alter LVDF diagnostic reliability in this population.

Purpose

Because elevated PAP is fundamental to PAH, we hypothesized that the EACVI/ASE diastolic function algorithm has a lower predictive value in correctly classifying diastolic function in scleroderma.

Methodology

We performed a single-center retrospective analysis of scleroderma patients who underwent complete echocardiography and comprehensive right and left heart catheterization for PH evaluation. PH categorization was defined using the 6th World Symposium hemodynamic definitions (PAH as mPAP ≥20 mmHg, PCWP ≤15 mmHg, PVR ≥ 3 WU). Diastolic function categorization used 2016 EACVI/ASE recommendations. Index catheterization and echocardiogram closest to cardiac catheterization were analyzed.

Results

260 patients underwent evaluation and 63 were diagnosed with PH. PAH was diagnosed in 35 (age 64 ±10, mPAP 55± 18 mmHg, LVEF 60 ± 6%) and PVH in 28 (age 65 ± 10, mPAP 34 ± 14 mmHg, LVEF 63 ± 6%). Of the PAH patients, 20 had normal LVEDP (≤ 12 mmHg) and 15 increased LVEDP. In the PAH normal LVEDP patients, the EACVI algorithm classified diastolic function as normal in 25%, grade 2 in 5%, Grade 3 in 5%, and "indeterminate" in 65%. In the PAH group with increased LVEDP (&gt; 12 mmHg), 27% were incorrectly identified as normal, 7% as grade 2 dysfunction, and 66% as indeterminate. The diastolic function algorithm has a sensitivity of 27% and specificity of 75% to diagnose a LVEDP ≤ 12 mmHg, with an AUC of 0.508 (p = 0.91). With exclusion of sPAP from the algorithm, indeterminate cases in both PAH groups were reclassified as normal, resulting in improved sensitivity (93%) but poorer specificity (10%), and a similar AUC (0.517, p = 0.72). In PVH patients, the algorithm performed better with a sensitivity of 63% and specificity of 83% to predict LVEDP &gt; 12 mmHg with AUC 0.773, p = 0.017.

Conclusion

In scleroderma patients with PAH, the EACVI diastolic algorithm performs poorly and is confounded by including PAP as a parameter. The sensitivity of the algorithm is improved by the exclusion of sPAP although with reduced specificity. It remains inadequate to reliably diagnose normal LVEDP. While useful in other populations, algorithm modifications including exclusion of PAP, must be employed in suspected scleroderma PAH.

Abstract A43: Spatial organization of pancreatic ductal adenocarcinoma (PDAC)–associated immune cells from the Adjuvant Pancreatic Adenocarcinoma Clinical Trial (APACT) study

Introduction: It is strikingly difficult to develop successful treatments for PDAC; even with curative resection, most patients die from early occult metastases. Prior studies identified the presence of tumor-infiltrating lymphocytes (TILs) in primary PDAC tumors as having prognostic significance in the PDAC adjuvant setting, sharpening the questions of what fraction of patients have immune-infiltrated tumors and what therapeutic strategies should be pursued in these patients vs. the non-infiltrated group. The phase 3 APACT trial evaluated the use of adjuvant nab-paclitaxel plus gemcitabine vs. gemcitabine in 866 patients with PDAC who had undergone primary tumor resection, with the primary endpoint of disease-free survival evaluated by independent review. We extended studies of the tumor microenvironment of PDAC to a large set of resected APACT primary tumors in an effort to further refine features of tumor or immune infiltrate that influence disease progression and to determine if chemotherapy regimen–specific predictive signatures are identifiable. Tissue analyses for a large subset of APACT samples included RNA-seq, DNA-seq, multiplexed immunohistochemistry (IHC), and proteomics.

Methods: We imaged and quantified markers for tumor cells, 7 different immune cells, and 2 immune checkpoint markers using bright-field chromogenic multiplexed IHC from pretreatment samples for more than 500 APACT primary tumor samples. We computationally defined the tumor, tumor margin, and distal stromal (&gt; 150 μm from tumor boundary) regions, and quantified densities and distributions of immune cells in these regions. As part of an initial analysis of more than 400 samples, we applied both unsupervised clustering and supervised classification to these IHC measurements to identify patient subgroups with similar spatial arrangements of immune cells relative to tumor regions.

Results: The preliminary analysis of normalized cell densities across all 3 tissue regions revealed 3 patient subgroups: one in which immune cells are mixed within the tumor regions; a second where immune cells approach the tumor boundary but are depleted within the tumor; and a third in which immune cells are depleted in both tumor and its margin, remaining at high densities only in the distal stromal regions. Within these latter subgroups, CD20+, CD4+, and CD8+ cells were more prevalently depleted from tumor and/or margin, whereas CD163+ and CD163+CMAF+ cells showed less of this arrangement. Nearly 85% of patients fell in the second or third patient group.

Conclusions: We are pursuing analyses of these data in conjunction with upcoming molecular and genetic profiling data to further elucidate the association of the immune cell populations and these subgroups with clinical outcomes. These data will provide an unprecedented opportunity for exploratory analysis and discovery of immune, molecular, and genetic biomarkers for PDAC patient stratification.

Citation Format: David J. Reiss, Thomas Lila, Suzana Couto, Sitharthan Kamalakaran, Yan Ren, Doug Bowman, Amber Ortiz, Maria Wang, Clifton Drew, Kao-Tai Tsai, Mathieu Marella, Brian Fox, Garth McGrath, Matthew Trotter, Fadi Towfic, Ian Cushman, Alexander Ratushny, Brian Lu, Daniel Pierce, Jim Cassidy. Spatial organization of pancreatic ductal adenocarcinoma (PDAC)–associated immune cells from the Adjuvant Pancreatic Adenocarcinoma Clinical Trial (APACT) study [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2019 Sept 6-9; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2019;79(24 Suppl):Abstract nr A43.

Function-driven single-cell genomics uncovers cellulose-degrading bacteria from the rare biosphere

Assigning a functional role to a microorganism has historically relied on cultivation of isolates or detection of environmental genome-based biomarkers using a posteriori knowledge of function. However, the emerging field of function-driven single-cell genomics aims to expand this paradigm by identifying and capturing individual microbes based on their in situ functions or traits. To identify and characterize yet uncultivated microbial taxa involved in cellulose degradation, we developed and benchmarked a function-driven single-cell screen, which we applied to a microbial community inhabiting the Great Boiling Spring (GBS) Geothermal Field, northwest Nevada. Our approach involved recruiting microbes to fluorescently labeled cellulose particles, and then isolating single microbe-bound particles via fluorescence-activated cell sorting. The microbial community profiles prior to sorting were determined via bulk sample 16S rRNA gene amplicon sequencing. The flow-sorted cellulose-bound microbes were subjected to whole genome amplification and shotgun sequencing, followed by phylogenetic placement. Next, putative cellulase genes were identified, expressed and tested for activity against derivatives of cellulose and xylose. Alongside typical cellulose degraders, including members of the Actinobacteria, Bacteroidetes, and Chloroflexi, we found divergent cellulases encoded in the genome of a recently described candidate phylum from the rare biosphere, Goldbacteria, and validated their cellulase activity. As this genome represents a species-level organism with novel and phylogenetically distinct cellulolytic activity, we propose the name Candidatus ‘Cellulosimonas argentiregionis’. We expect that this function-driven single-cell approach can be extended to a broad range of substrates, linking microbial taxonomy directly to in situ function.

Novel small-molecule RORγ agonist immuno-oncology agent LYC-55716: Tumor selection and evaluation of renal cell and bladder cancer for inclusion in phase 2a expansion

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Background: The master transcription factor retinoic acid receptor–related orphan receptor γt (RORγ) controls Type 17 effector T cell differentiation and function. Synthetic RORγ agonists modulate gene expression to enhance immune effector functions and decrease regulatory T cell (Treg) development and expression of checkpoint pathways. RORγ agonists have shown promise as mono- and combination therapy in syngeneic tumor models. Translational and bioinformatics analyses were performed to evaluate renal cell carcinoma (RCC) and bladder cancer (BC) for inclusion in a Phase 2a expansion trial of the investigational RORγ agonist LYC-55716 (NCT02929862). Methods: A gene signature was identified through transcriptional profiling of murine and human T cells treated ± RORγ agonists. Bioinformatics analyses were then conducted using data on RCC and BC patients from The Cancer Genome Atlas (TCGA) to determine (a) RORγ and RORγ-inducing cytokine expression; (b) signature genes associated with RORγ biology, biomarkers for endogenous RORγ ligands, and correlations with patient survival rates; and (c) tumor microenvironment (TME) immune profiles. Results: Expression: RNA sequencing analysis identified RORγ+ cells in a significant fraction of RCC and BC samples. RORγ-inducing cytokines IL6, IL23a, and IL1b as well as other genes that support Type 17 differentiation were highly expressed in RCC and BC. Biology: Low expression of sterol efflux genes in RCC and BC tumors suggested low levels of endogenous RORγ ligands in the TME. Importantly, analysis revealed a positive correlation between patient survival and expression of RORγ (or the RORγ signature gene IL17A) for RCC. Immune profile: Analysis of RCC and BC tumors indicated high infiltration of CD3+, CD4+, and CD8+ T cells and high mutation burden, which are associated with immunotherapy efficacy. Conclusions: Translational and bioinformatics studies of RORγ expression, biology, and tumor immune profiles support the inclusion of RCC and BC patients in an ongoing Phase 2a expansion trial of LYC-55716.

RORγ agonist LYC-55716, a novel small molecule immunotherapy: Rationale for clinical evaluation in non-small cell lung cancer based on translational and bioinformatic evaluation

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Background: Retinoic acid receptor–related orphan receptor γ (RORγ) agonists modulate immune cell gene expression to enhance effector function and decrease regulatory T cell formation and expression of checkpoint pathways. RORγ agonists have demonstrated antitumor activity in syngeneic tumor models. Translational and bioinformatic assessments were conducted to support inclusion of patients with non–small-cell lung cancer (NSCLC) in a Phase 2a expansion of clinical trial LYC-55716-1001 (NCT02929862). Methods: The Cancer Genome Atlas (TCGA) NSCLC dataset was evaluated for (a) expression of RORγ and RORγ-inducing cytokines and correlation with survival; (b) genes related to RORγ biology, biomarkers of endogenous RORγ agonists; and (c) tumor microenvironment (TME) immune profiles. RORγ expression and the in vitro effects of a RORγ agonist on peripheral blood mononuclear cells (PBMCs) from lung adenocarcinoma (LA) and squamous cell carcinoma (SCC) patients were assessed. Results: In TCGA, 25% of NSCLC tumors expressed moderate/high levels of RORγ, suggesting infiltration of Type 17 cells. There was a statistically significant correlation between high RORγ expression and improved survival in LA patients. Genes that support Type 17 cell formation (IL1B, IL23A, IL6) were expressed in ~50% of tumors. RORγ expression was confirmed in PBMCs isolated from LA and SCC patients. Analysis of TCGA data and patient samples identified low expression of sterol efflux and uptake genes, suggesting low levels of endogenous RORγ agonist in TME. In TCGA, high mutational burden and high expression of immune-related genes were found in NSCLC tumors. RORγ agonist treatment of PBMCs from LA and SCC patients increased IL-17A and IL-26 (LA and SCC) and decreased PD1 (LA). In Phase 1 clinical testing, LYC-55716 has been well tolerated, demonstrating long-term disease stabilization in heavily pretreated patients. Conclusions: Bioinformatic analyses of RORγ expression/biology, correlation with improved survival, plus in vitro findings support inclusion of NSCLC in an ongoing Phase 2 clinical trial of LYC-55716.

Lyc-55716: A novel small-molecule RORγ agonist immuno-oncology agent: Rationale for tumor selection and clinical evaluation of gastric and esophageal carcinoma in phase 2a expansion

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Background: Type 17 effector T cell differentiation and function are regulated by the master transcription factor retinoic acid receptor–related orphan receptor γt (RORγ). Synthetic RORγ agonists, which modulate immune cell gene expression to enhance effector functions and decrease Treg and checkpoint pathways, have shown promise as mono- and combination therapy in syngeneic tumor models. Translational and bioinformatics assessments were performed during Phase 1 testing of the investigational RORγ agonist LYC-55716 to support inclusion of patients with gastric carcinoma (GC) and esophageal carcinoma (EC) in a Phase 2a expansion of clinical trial LYC-55716-1001 (NCT02929862). Methods: Transcriptional profiling of murine and human T cells treated ± RORγ agonists identified a gene signature. Using The Cancer Genome Atlas (TCGA), and other public datasets, data on GC and EC patients were evaluated to determine: (a) RORγ and RORγ-inducing cytokine expression; (b) signature genes associated with RORγ biology, surrogate biomarkers for endogenous RORγ ligands, and correlations with prognosis; (c) tumor microenvironment (TME) immune profiles. Results: Expression: In TCGA RNA sequencing data analysis, 50%-70% of GC and EC samples expressed moderate to high levels of RORγ, indicating infiltration of Type 17 T cells into the tumors. Furthermore, genes that support expression of RORγ were highly expressed in ~75% of GC and EC tumors. Biology: TCGA data showed that GC and EC tumors express low levels of sterol efflux genes, suggesting low levels of endogenous agonists in the TME. In analysis of public datasets, expression of the RORγ target gene IL17A correlated with a favorable prognosis for EC. In addition, some of the other RORγ signature genes also correlated with good prognosis in GC and EC. Immune profile: TCGA showed infiltration of T cells and a high mutational burden in GC and EC, which are positively associated with efficacy of immunotherapy. Conclusions: Bioinformatics assessments of RORγ expression, biology, and tumor immune profiles support the inclusion of GC and EC patients in an ongoing Phase 2 clinical trial of LYC-55716.

Geriatric oncology in Spain: survey results and analysis of the current situation

Introduction

Geriatric oncology (GO) is a discipline that focuses on the management of elderly patients with cancer. The Spanish Society of Medical Oncology (SEOM) created a Working group dedicated to geriatric oncology in February 2016.

Objectives

The main goal of this study was to describe the current situation in Spain regarding the management of elderly cancer patients through an online survey of medical oncologists.

Methods

A descriptive survey was sent to several hospitals by means of the SEOM website. A personal e-mail was also sent to SEOM members.

Results

Between March 2016 and April 2017, 154 answers were collected. Only 74 centers (48%) had a geriatrics department and a mere 21 (14%) medical oncology departments had a person dedicated to GO. The vast majority (n = 135; 88%) had the perception that the number of elderly patients with cancer seen in clinical practice had increased. Eighteen (12%) oncologists had specific protocols and geriatric scales were used at 55 (31%) centers. Almost all (92%) claimed to apply special management practices using specific tools. There was agreement that GO afforded certain potential advantages. Finally, 99% of the oncologists surveyed believed it and that training in GO had to be improved.

Conclusions

From the nationwide survey promoted by the Spanish Geriatric Oncology Working Group on behalf of SEOM, we conclude that there is currently no defined care structure for elderly cancer patients. There is an increasing perception of the need for training in GO. This survey reflects a reality in which specific needs are perceived.