Successful Treatment of Refractory Post-Transplant Lymphoproliferative Disorder With Chimeric Antigen Receptor T-Cell Therapy in a Heart Transplant Recipient

Post-transplant lymphoproliferative disorders (PTLDs) are opportunistic malignancies that complicate the success of hematopoietic stem cell or solid organ transplantation. These disorders often arise post-transplant due to the immunosuppression required for minimizing the risk of rejection of donor tissue. First-line treatment of these disorders includes limiting immunosuppression when permissible. Subsequent treatment includes the use of monoclonal anti-CD20 antibody (rituximab), and/or combination chemotherapy. Chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment paradigm in many lymphoid malignancies. It is not approved for PTLD due to exclusion of PTLD patients from pivotal clinical trials. Also, its utilization post-transplant can be complex and multidisciplinary care is of utmost importance for successful administration of a potentially curative treatment. We present a 68-year-old patient with history of heart transplant for non-ischemic cardiomyopathy, diagnosed with PTLD that was refractory to treatment using current guidelines until successfully receiving CAR T-cell therapy.

Post-infusion PD-1+CD8+CAR-T cells identify patients responsive to CD19-CAR-T therapy in non-Hodgkin's lymphoma

Chimeric antigen receptor T cell therapy (CAR-T) has revolutionized treatment for relapsed/refractory (r/r) B-cell non-Hodgkin's lymphoma (NHL). Robust biomarkers and a complete understanding of CAR-T cell function in the post-infusion phase remain limited. Here we used a 37-color spectral flow cytometry panel to perform high dimensional single cell analysis of post-infusion samples in 26 patients treated with CD28 co-stimulatory domain containing commercial CAR-T (CD28-CAR-T) for NHL and focused on computationally gated CD8+ CAR-T cells. We found that the presence of post-infusion PD-1+ CD8+ CAR-T cells at the Day 14 timepoint highly correlated with the ability to achieve complete response (CR) by 6 months. Further analysis identified multiple subtypes of CD8+ PD-1+ CAR-T cells including PD-1+ TCF1+ stem-like CAR-T cells and PD-1+ TIM3+ effector-like CAR-T cells that correlated with improved clinical outcomes such as response and progression free survival. Additionally, we identified a subset of PD-1+ CD8+ CAR+ T cells with effector-like function that was increased in patients who achieved a CR and was associated with Grade 3 or higher immune effector cell-associated neurotoxicity syndrome. Here we identified robust biomarkers of response to CD28-CAR-T and highlight the importance of PD-1 positivity in CD8+ CAR-T cells post-infusion in achieving CR.

The prevalence of chiropractic-related terminology on South African chiropractors' webpages: a cross-sectional study

BACKGROUND

Effective communication is imperative for successful interprofessional collaborative interactions that augment both patient-centred and evidence based care. Inquiry into the prevalence of chiropractic-related terminology on South African chiropractor's webpages has not been explored to date. The implications of such analysis could indicate the professions' ability to effectively communicate in interdisciplinary settings.

METHOD

From 1 to 15 June 2020, Google search was used to identify the webpages (excluding social media accounts) of South African private practice chiropractors registered with the Allied Health Professions Council of South Africa (AHPCSA). Webpages were word-searched for eight chiropractic terms with context: subluxation; manipulate(-ion); adjust(-ing/-ment); holism(-tic); alignment; vital(-ism/-istic); wellness; and innate intelligence. Data collected was transferred to an Excel spreadsheet. Accuracy of information was verified by the researchers through a process of double checking. The number of instances each term was used, and certain socio-demographic data were recorded. Descriptive statistics and bivariate analyses were used to summarise and analyse the data.

RESULTS

Among 884 AHPCSA-registered South African chiropractors, 336 webpages were identified and analysed. From 1 to 15 June 2020, the most commonly found terms on 336 South African chiropractic webpages were 'adjust(-ing/-ment)', 'manipulate/manipulation', and 'wellness', with prevalence estimates of 64.1% (95% confidence interval [CI], 59.0% to 69.2%), 51.8% (95% CI, 46.5% to 57.1%), and 33.0% (95% CI, 28.2% to 38.2%), respectively. The least commonly found terms were 'innate intelligence' and 'vital(-ism/-istic)', with prevalence estimates of 0.60% (95% CI, 0.16% to 2.1%) and 0.30% (95% CI, 0.05% to 1.7%), respectively. Manipulate(-ion) was used more by male chiropractors (p = 0.015). The longer a chiropractor was in practice the more likely they were to use profession-specific terms (p = 0.025). The most frequently occurring combination of terms were adjust(-ing/-ment) and manipulate(-ion), found in 38 out of 336 webpages (11.3%; 95% CI, 8.4% to 15.1%).

CONCLUSION

The use of chiropractic-related terminology on South African chiropractic webpages was common, with the prevalence of term use varying by type of terms, by gender of the chiropractor, and by clinical practice experience. Better understanding of the effects of chiropractic terminology use on interprofessional and patient interactions and communication is warranted.

Prophylactic Anticoagulation in Patients With Pancreatic Adenocarcinoma: A Single Tertiary Care Center Retrospective QI Project

BACKGROUND/AIM

A well-known complication of pancreatic adenocarcinoma (PDAC) is venous thromboembolism (VTE). The Khorana score is used as a tool to help determine the role of primary prophylaxis (PPx) in cancer patients with VTE. This study compared outcomes in PDAC patients who received primary PPx (anticoagulation) versus those who did not.

PATIENTS AND METHODS

PDAC patients from 2017-2019 at Allegheny General Hospital were retrospectively reviewed. Descriptive statistics were presented via medians with interquartile ranges for continuous variables and percentages for categorical variables. Predictors of VTE development were determined using univariable and multivariable logistic regression models. T-tests and Chi-square tests were used to compare means and percentages, respectively.

RESULTS

A total of 102 patients with full VTE PPx data were reviewed. At least one VTE event was identified in 29 patients (28.2%). A total of 4 out of these 29 patients (13.8%) were on PPx anticoagulation. Death secondary to VTE occurred in one patient without PPx. Two (2.0%) patients experienced bleeding events of those prescribed VTE PPx. On univariable analysis, stage IV disease, planned surgery, and unresectable disease were predictors of VTE development. On multivariate analysis, total pancreatectomy was a predictor of VTE development. There was no difference in average time to progression amongst patients who had developed VTE versus those who did not.

CONCLUSION

The Khorana score for VTE PPx in PDAC patients in underutilized.

Insulin facilitates corneal wound healing in the diabetic environment through the RTK-PI3K/Akt/mTOR axis in vitro

Diabetic patients can develop degenerative corneal changes, termed diabetic keratopathy, during the course of their disease. Topical insulin has been shown to reduce corneal wound area and restore sensitivity in diabetic rats, and both the insulin receptor (IR) and insulin-like growth factor 1 receptor (IGF-1R) stimulate cell signaling of the PI3K-Akt pathway. The purpose of this study was to assess a mechanism by which improved wound healing occurs by characterizing expression within the PI3K-Akt pathway in corneal epithelial and stromal cells. In vitro scratch tests were used to evaluate wound healing outcomes under variable glucose conditions in the presence or absence of insulin. Protein expression of intracellular kinases in the PI3K pathway, stromal cell markers, and GLUT-1 was evaluated by immunoblotting.TGF-β1 expression was evaluated by ELISA. Insulin promoted in vitro wound healing in all cell types. In human corneal epithelial cells, insulin did not induce PI3K-Akt signaling; however, in all other cell types evaluated, insulin increased expression of PI3K-Akt signaling proteins compared to vehicle control. Fibroblasts variably expressed α-SMA under all treatment conditions, with significant increases in α-SMA and TGF-β1 occurring in a dose-dependent manner with glucose concentration. These results indicate that insulin can promote corneal cellular migration and proliferation by inducing Akt signaling. Exogenous insulin therapy may serve as a novel target of therapeutic intervention for diabetic keratopathy.

Molecular chaperone GP96 is a potential target to modulate dendritic cell programming and shape anti-tumor immunity

Dendritic cells (DCs) are professional antigen-presenting cells providing costimulatory signals to adaptive immune cells. Currently, the lack of strategies to improve antigen presentation is a hindrance in tumor immunology. Despite studies focusing on antigen cross-presenting Type-1 DCs (DC1s), a study published by our lab revealed Type-2 DCs (DC2s) with significant survival across multiple human cancers. Our research group has a long-term interest in studying immune chaperone GP96, which is an essential molecular chaperone for TLRs, GARP, and other vital innate receptors. The immune-related client network of GP96 creates opportunities to unmask the roles of multiple receptors on DCs. We have generated DC-specific GP96 deficient mice and reported increased tumor-infiltrating DC2 and delayed tumor development on the spontaneous breast cancer model. However, the mechanism by which GP96 regulates DCs function is under investigation. Using different tumor models, we found that deletion of GP96 on DCs improved immune response and decreased tumor growth. However, macrophage-GP96KO mice showed a loss of benefits observed on DC-GP96KO mice. Also, differential stimulatory/inhibitory molecules on DC1 vs. DC2 were tumor-dependent. To determine the role of DC-intrinsic GP96 in T cell activation, we used in vitro antigen-cross presentation assay. We found that OT-I CD8+ T cell activation was delayed at the initial days of the co-culture with GP96KO DCs but restored in the late phase compared with WT DCs. Collectively, the results show beneficial inflammatory DC2 molecular activation, with DC1 able to cross-present antigens to CD8+ T cells. Our study indicated that targeting GP96 on DCs may contribute to shaping T cell anti-tumor immunity.

Supported by grants from NIH NCI (R01:CA193939) and NIH NIAID (U01:AI125859)

Limited prognostic value of pain duration in non-specific neck pain patients seeking chiropractic care

BACKGROUND

Pain chronicity is considered an important prognostic factor for outcome. Here, it was investigated whether pain duration influences outcome when only chronic patients (pain > three months) are considered. Secondary aims were to determine, in patients of any pain duration, how much variance in outcome is explained by pain duration and whether pain duration truly predicts outcomes, i.e. out-of-sample prediction in independent data.

METHODS

Secondary analysis of a cohort study of neck pain patients. Patients were assessed before start of treatment and at one week, one, three, six- and 12-months follow-up. Outcomes were Patient Global Impression of Change (PGIC) and percent change of patients' perceived pain intensity, rated on a numerical rating scale (NRS). Regression analyses (linear and logistic) and supervised machine learning were used to test the influence of pain duration on PGIC and percent NRS change at one week, one, three, six- and 12-months follow-up within sample and out-of-sample. Separate analyses were performed for the full sample (n=720) and for chronic patients (n=238) only.

RESULTS

No relationship between pain duration and outcome was found for chronic patients only. For the full sample, statistical relationships between pain duration and outcomes were observed at all tested follow-up time points. However, the amount of variance in outcome explained by pain duration was low and no out-of-sample prediction was possible.

CONCLUSIONS

Pain duration did not emerge as an important predictor of outcome in this database of 720 neck pain patients receiving chiropractic treatment.

Systematic Review and Meta-Analysis of Cisplatin Based Neoadjuvant Chemotherapy in Muscle Invasive Bladder Cancer

BACKGROUND: Cisplatin-based neoadjuvant chemotherapy is the standard of care for muscle invasive bladder cancer (MIBC). OBJECTIVE: To compare the efficacy and safety of the two most commonly used cisplatin-based regimens; gemcitabine, and cisplatin (GC) vs. accelerated (dose-dense: dd) or conventional methotrexate, vinblastine, adriamycin, and cisplatin (MVAC). METHODS: We searched MEDLINE, Embase, Scopus and other sources. Outcomes of interest included overall survival, downstaging to pT≤1, pathologic complete response (pCR), recurrence, and toxicity. Meta-analysis was conducted using the random-effects model. RESULTS: We identified 24 studies. Efficacy outcomes were comparable between MVAC and GC for MIBC. dd-MVAC was associated with favorable efficacy compared to GC in terms of downstaging (OR 1.45; 95%CI 1.15–1.82) and all-cause mortality at longest follow-up (OR 0.63; 95%CI 0.44–0.81). However, GC was associated with a better safety profile in terms of febrile neutropenia (OR 0.32; 95%CI 0.13–0.80), anemia (OR 0.32; 95%CI 0.18–0.54), nausea and vomiting (OR 0.27; 95%CI 0.12–0.65) compared to dd-MVAC. Compared to MVAC, patients receiving GC had an increased risk of developing grade 3–4 thrombocytopenia (OR 4.70; 95%CI 1.59–13.89) and a lower risk of nausea and vomiting (OR 0.05; 95%CI 0.01–0.31). Certainty in the estimates was very low for most outcomes. CONCLUSIONS: Efficacy and safety outcomes were comparable between MVAC and GC for MIBC. Including non-peer-reviewed studies showed higher efficacy with dd-MVAC. A phase III randomized trial comparing the two regimens is needed to guide clinical practice.

A Case of COVID-19 Induced Thrombotic Thrombocytopenic Purpura

Thrombotic Thrombocytopenic Purpura (TTP) is a challenging thrombotic diathesis which requires prompt diagnosis and therapeutic intervention in order to avoid life-threatening consequences. There are two forms of TTP, congenital and acquired, with the acquired form constituting about 90% of cases. Both forms are associated with a deficiency of ADAMTS-13, a metalloproteinase enzyme responsible for cleaving ultra-large von Willebrand factor (uLvWF), preventing its pathologic accumulation. Within the last year, many of the diverse and serious effects of the COVID-19 virus have come to recognition, with some of the most dire consequences involving devastating vascular and hematologic complications. As with many viruses, it seems that the endothelium and the vasculature are often prime targets. Here, we report a case of a 30 year old male who was diagnosed with TTP approximately one week after a positive COVID-19 test result. He responded appropriately to plasma exchange (PLEX), caplacizumab, and steroids. We believe it is important to investigate a potential link between these two conditions, as TTP has significant morbidity and mortality risk if left unattended. We hope that our report will contribute to a better understanding of this potential link.

Induction of the integrated stress response in the rat cornea

Keratoconus (KC), a progressive, degenerative corneal disease, represents the second leading indication for corneal transplantation globally. We have previously demonstrated that components of the Integrated Stress Response (ISR) are upregulated in human keratoconic donor tissue, and treatment of normal tissue with ISR agonists attenuates collagen production. With no consistently accepted animal models available for translational KC research, we sought to establish an in vivo model based on ISR activation to elucidate its role in the development of the KC phenotype. Four-week-old female SD rats were treated with topical SAL003 formulated as a nanosuspension or vehicle every 48 h for four doses. Animals were subject to monitoring for ocular inflammation and discomfort before being euthanized at 1, 14, or 28 days after treatment was withdrawn. Schirmer's tear test, intraocular pressure, and body weight measurements were obtained at baseline and prior to euthanasia. Globes were subject to routine histopathology, immunohistochemistry for ATF4, and qPCR for Col1a1 expression. ANOVAs and Student's t tests were used to assess statistical significance (α = 0.05). SAL003 treatment did not produce any adverse ocular or systemic phenotype but did result in decreased keratocyte density. Col1a1 transcripts were reduced, corresponding to nuclear ATF4 expression within the axial cornea. In vivo topical treatment with a gel-formulated ISR agonist recapitulates key features of the activated ISR including nuclear ATF4 expression and decreased extracellular matrix (ECM) production. Exogenous ISR agonists may present one approach to establishing a rodent model for keratoconus, a charge essential for future evaluations of pathogenesis and therapeutic interventions.

Methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) versus gemcitabine, and cisplatin (GC) as neoadjuvant chemotherapy in muscle-invasive bladder cancer, a systematic review and meta-analysis

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Background: Cisplatin-based neoadjuvant chemotherapy is the standard of care for muscle invasive bladder cancer (MIBC) in cisplatin-eligible patients. This systematic review and meta-analysis provide an updated efficacy and safety comparison between the two most commonly used cisplatin-based regimens; dose-dense (dd) or conventional MVAC versus GC. Methods: We searched different databases for studies comparing MVAC versus GC in the neoadjuvant setting. Outcomes of interest included overall survival, downstaging to pT≤1, pathologic complete response (pCR), recurrence, and toxicity. Meta-analysis was conducted using the random-effects model. Results: We identified 24 studies from inception to March 2020; among them 17 were peer reviewed and 7 were only reported as abstracts in national or international meetings, including a phase 3, randomized-controlled clinical trial. Among peer-reviewed published studies, efficacy outcomes such as OS, downstaging and pCR were comparable between conventional MVAC and GC for MIBC. If including non-peer-reviewed studies, dd-MVAC was associated with favorable efficacy compared to GC in terms of downstaging (OR 1.45; 95% CI 1.15–1.82), and OS at longest follow-up (OR 0.63; 95% CI 0.44–0.81). However, GC was associated with a better safety profile in terms of febrile neutropenia (OR 0.32; 95% CI 0.13–0.80), anemia (OR 0.32; 95% CI 0.18–0.54), nausea and vomiting (OR 0.27; 95% CI 0.12–0.65) compared to dd-MVAC. Compared to MVAC, patients receiving GC had an increased risk of developing grade 3–4 thrombocytopenia (OR 4.70; 95% CI 1.59–13.89) and a lower risk of nausea and vomiting (OR 0.05; 95% CI 0.01-0.31). Certainty in the estimates was very low for most outcomes. Conclusions: Among peer-reviewed published studies, efficacy and safety outcomes were comparable between conventional MVAC and GC for MIBC. However, If including non-peer-reviewed studies, this analysis showed higher efficacy with dd-MVAC. A phase III randomized trial comparing the two regimens is needed to guide clinical practice

Prophylactic anticoagulation in pancreatic adenocarcinoma patients: A single tertiary care center retrospective quality improvement project

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Background: Pancreatic ductal adenocarcinoma (PDAC) cancer portends a poor prognosis with a high case-fatality rate. Venous thromboembolism (VTE) is a common complication in PDAC, due expression of tissue factor on neoplastic cells. Per most recent guidelines, anticoagulation for primary prophylaxis (PPx) of VTE is to be considered based on the Khorana score. The purpose of this study is to identify patients with PDAC and compare the outcomes of those receiving anticoagulation for primary prophylaxis versus those who did not. Methods: We performed a retrospective review of all patients diagnosed with PDAC from 2017-2019 at Allegheny General Hospital. Data analysis was completed using IBM SPSS v23. Summary statistics were presented using percentages for categorical variables and medians with interquartile ranges for continuous variables. Univariable and multivariable logistic regression models were used to study the predictors of developing VTE, expressed as odds ratio (OR). Means and percentages were compared using t-test and Chi-square test, respectively. Results: Out of 171 patients, 121 received treatment at our institution and were included in the analysis. Median age was 69 years, 54 (45%) were male. The majority were white (88%). Only 92 patients had complete data regarding VTE PPx and events. 26 patients (28.2%) developed at least one VTE event. Out of 92 patients, 12 (13%) were on one form of VTE PPx and 1 had a contraindication to VTE PPx. One patient without VTE PPx died secondary to VTE. Of the patients on VTE PPx, only 3 (30%) experienced bleeding events. Seven patients were on VTE PPx prior to diagnosis of malignancy. 58 patients (63%) had a Khorana score of 2; 21 (23%) patients had a Khorana score of 3; 9 (10%) patients had a Khorana score of 4; and 4 (4%) patients had a Khorana score of 5. On univariable analysis, St. IV disease (OR 3.34, CI.22-8.40, P < 0.01), planned surgery (OR 0.26, CI 0.12-0.55, p < 0.01) and unresectable disease (OR 3.19, 95% CI 1.17-8.70, p 0.02) were predictors of developing VTE. On multivariate analysis, total pancreatectomy had a predictive association in the development of VTE (OR 5.01, 95% CI 1.65-23.60, p < 0.01). There was no difference in average time to progression (months) between patients who had VTE vs those who did not (12.5 vs 11.4, p 0.60). Conclusions: Our analysis indicate that we may be underutilizing Khorana score to prescribe VTE PPx in patients with PDAC. Additionally, patients undergoing total pancreatectomy demonstrated predictive association with the development of VTE. With these findings, we believe education and increased awareness of the importance of the Khorana score may decrease the morbidity and mortality associated with VTE in patients with PDAC. The use of electronic medical records to prompt physicians to calculate the Khorana score will also likely be a helpful tool.

Disparities in ovarian cancer treatment and overall survival according to race: An update

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Background: It has long been identified that black women with ovarian cancer have worse overall survival when compared to white women. Disparities in the adherence to NCCN guideline-directed treatment and socioeconomic characteristics may be responsible for the differences in these outcomes. Methods: A retrospective review of National Cancer Database (NCDB) was performed to identify patients diagnosed with ovarian cancer from 2012-2016. We defined adherence to NCCN (National Comprehensive Cancer Network) guidelines as having stage and year-appropriate chemotherapy and surgery. Differences in guideline adherence, socioeconomic characteristics and survival outcomes were assessed. Results: In total, 32,163 were identified meeting the study criteria; 27,744 identified their race as “white” and 2,204 identified their race as “black”. Characteristics associated with higher likelihood of black race were advanced stage of disease- stage III (OR = 1.1869, CI = 1.03-1.37) or stage IV disease (OR = 1.4495, CI = 1.23-1.70) and treatment in a comprehensive (OR = 1.5757, CI = 1.16-2.15) or academic (OR = 2.3023, CI = 1.70-3.12) treatment facility. Variables associated with a lower likelihood of black race were higher education level (OR for high school degree < 6.5 % = 0.2501, CI = 0.21-0.30) and higher median household income (OR for income > $63,333 = 0.4218, CI = 0.36-0.49). Whether the care received was adherent to NCCN guidelines did not seem to be associated with black race (OR for adherence = 1.0021, CI = 0.89-1.13). 5-year overall survival for patients who received adherent care was 58% for white patients vs. 49% for black patients. Among those who didn’t receive adherent care, the outcomes were 49% among white patients vs. 38% among black patients. Conclusions: Overall survival remains worse for black patients, regardless of whether their care adhered to NCCN guidelines as defined by our study. This suggests that while receipt of care that is not adherent to NCCN guidelines seems to be negatively associated with overall survival, we must consider and evaluate other socioeconomic, environmental and system factors that are contributing to this continued survival discrepancy in women being treated for ovarian cancer.

An internal review of chemotherapy toxicities in patients with pancreatic cancer

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Background: Cytotoxic chemotherapy remains the standard of care in the treatment of pancreatic ductal adenocarcinoma (PDAC). There is more excitement in the last few years regarding the use of neoadjuvant chemotherapy even when the disease is resectable. In this analysis, we sought to study the different regimens used in our institutions, in regards to setting and toxicity. Methods: We retrospectively reviewed all patients diagnosed with pancreatic adenocarcinoma at Allegheny General Hospital between 2009-2020. Data was extracted from electronic medical records and de-identified. Institutional Review Board approval was obtained. Descriptive analysis was undertaken and multivariate analysis was performed to compare differences in the prevalence of toxicity across the regimens and demographics using Stata version 16. The primary outcome was the rate of toxicity that prompted dose adjustment, stratified by the setting chemotherapy was administered (neoadjuvant, adjuvant, or palliative). Results: Of the 121 patients studied, 88 patients received chemotherapy. Median age was 69 years. 66 patients (55%) were females. 40 patients suffered from adverse effects requiring a dose adjustment. 85% of the adverse effects occurred in Caucasians. 15 out of 37 patients (42.9%) who received Folfirinox, 15 out of 31 patients (48.4%) who received gemcitabine and nab-paclitaxel, 6 out of 10 patients (60.0%) who received gemcitabine and capecitabine, 3 out of 4 patients (75.0%) who received gemcitabine monotherapy required dose adjustment (table). Folfirinox and gemcitabine with nab-paclitaxel were statistically compared and found to be not significant (p-value=0.12). No significant impacts of race, gender, or age were noted in a multivariate model. Conclusions: Approximately 42% of patients receiving chemotherapy suffered from toxicities that required dose adjustments. We found a trend toward more use of neoadjuvant chemotherapy in resectable PDAC with a similar toxicity rate compared with other settings.[Table: see text]

Treatment patterns and outcomes of locally advanced gall bladder cancer: A National Cancer Database (NCDB) analysis

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Background: Gall bladder (GB) cancer is rare but an aggressive disease especially when presenting at an advanced stage. There is controversy regarding the best treatment approach for locally advanced disease. In this NCDB analysis, we aim to study treatment patterns for T3, T4, and/or N1 GB cancer and estimate survival for each treatment modality. We also sought to investigate clinical and socioeconomic predictors of treatment selection. Methods: We conducted a retrospective cohort analysis using de-identified data accessed from the NCDB. The NCDB provided records of 39,229 patients diagnosed with GB cancer between 2004-2017. We excluded patients who were not treated at the reporting facility, those with no histologic confirmation of the diagnosis, those with no survival data available and those with T1, T2 and metastatic disease. We did exploratory analysis and divided patients into six arms based on treatment modality (Table). Stepwise multivariable regression models were used to analyze predictors of treatment selection. Survival estimates were calculated using the Kaplan Meier and proportional Cox hazard regression methods. Results: We identified 7,004 patients with GB cancer who fulfilled the inclusion and exclusion criteria. Median age was 68 years. There were 69.5% females, and the majority of patients were white (66.1%). Receiving treatment at an academic/research center (OR 0.37, 95% CI 0.19-0.73, p <0.01), black patients (OR 0.55 95% CI 0.36-0.85, p <0.01) and higher education (OR 0.58, 95% CI 0.37-0.91, p 0.02) decreased the odds of receiving surgery. Meanwhile, the presence of lymphovascular invasion was seen more amongst patients with receipt of surgery. For patients who underwent radiation, increasing age (OR 0.97, 95% CI 0.97-0.98, p <0.01) and higher histologic grade (OR 0.65, CI 0.46-0.92, p .02) were associated with less radiation use. Median income between $50,354-$63,332 (OR 1.28, 95% CI 1.02-1.60, p 0.04) was associated with more radiation use. Patient who received triple therapy had improved survival compared with other modalities (HR 0.51, CI 0.46-0.57, p <0.01). Median overall survival (OS) for the whole population was 13.0 months (CI 12.6-13.5) (Table) Conclusions: American patients with T3, T4, and/or N1 GB cancer received variable treatment modalities. Patients who underwent triple-modality therapy in our analysis had improved adjusted-overall survival compared with other modalities. Limitations include unmeasured confounding factors, selection bias and the retrospective design. We also identified clinical and socioeconomic factors that affect treatment selection.[Table: see text]

Cutaneous Lesion of the Nose as Initial Presentation of Esophageal Adenocarcinoma

BACKGROUND/AIM

Cutaneous manifestations of disease are exceedingly rare and commonly overlooked in clinical practice. Allergies or contact dermatitis, autoimmune disease or skin cancer are the most common conditions typically associated with skin lesions. Rarely, cutaneous lesions may be the first sign of internal malignancy, or even resemble recurrent disease in those with history of cancer.

CASE REPORT

Herein, we report a case of an otherwise healthy male who presented to his primary care provider (PCP) with a skin lesion misdiagnosed as a furuncle, which eventually led to diagnosis of metastatic esophageal cancer. The patient was a 64-year-old male, presenting with a fungating lesion on the tip of his nose which was biopsied, confirming adenocarcinoma likely from a gastrointestinal source. Staging imaging showed extensive lung, liver, and boney metastatic disease. He was initially treated with chemotherapy and trastuzumab.

CONCLUSION

Cutaneous lesions are a rare presenting sign of malignancy, but rapidly growing lesions should be evaluated for possible metastatic disease.

Changes in sleep with transcranial magnetic stimulation in adults with treatment resistant depression: Preliminary results from a naturalistic study

Introduction

Sleep disturbance specifically insomnia, non-restorative sleep, and hypersomnia are common symptoms of major depressive disorder (MDD). As it alleviates major depressive disorder, transcranial magnetic stimulation (TMS) may improve associated sleep disturbances, and may also have inherent sedating or activating properties.

Objectives

To examine the impact of TMS on sleep disturbances in adults with treatment resistant depression in a clinical setting, we retrospectively reviewed de-identified data from naturalistically-treated MDD patients undergoing an initial acute course of TMS therapy at St.Louis Park MinCEP Clinic.

Methods

Adults with treatment-resistant depression received daily TMS treatments. 9-item Patient Health Questionnaire (PHQ-9) total scores were used to calculate % change at endpoint (relative to pretreatment baseline); response on both measures was defined as 50% reduction in scores, with remission defined as a final total score 4 on the PHQ-9. Insomnia was measured with a 3-item subscale of the Inventory of Depressive Symptomatology Self Report (IDS-SR). Hypersomnia was measured with a single IDS-SR item. Pairwise comparisons were performed using Student’s T-test. Categorical variables were compared using Fisher’s Exact test. Continuous outcome measures were tested with an analysis of covariance, using baseline PHQ-9 score as a fixed effect covariate.

Results

TMS appears to have differential modulatory effects on insomnia and hypersomnia in adults with treatment resistant depression.

Conclusions

These results may provide the basis for further investigation into therapeutic applications of TMS in addressing sleep disturbances in treatment-resistant depression. Measures that separate hypersomnia and insomnia should be implemented in future work addressing effects of TMS in treatment-resistant depression.

Disclosure

No significant relationships.

Idiopathic Purulent Pericarditis Caused by Methicillin-Sensitive Staphylococcus Aureus in an Immunocompetent Adult

Introduction: Acute purulent pericarditis is an exceedingly rare entity most often caused by direct intrathoracic contamination or hematogenous spread of a bacterial infection. Mortality nears 100% when left untreated. We present here a rare case of idiopathic bacterial pericarditis caused by methicillin-sensitive Staphylococcusaureus (MSSA).

Case: A 69-year-old male presented with chest pain and abdominal pain. He was found to have a pericardial effusion and tamponade and underwent emergent pericardiocentesis. Pericardial fluid culture grew methicillin-sensitive Staphylococcusaureus. The patient required multiple pericardial washouts and was then treated with four weeks of intravenous antibiotics.

Conclusion: While uncommon, clinical suspicion for purulent pericarditis should remain high due to the associated high mortality.

Abstract SP084: Replication stress response defects predict responses to ICT in non-hypermutated tumors

Immune checkpoint blockade (ICT) has provided robust, durable responses to a subset of patients. Many initial ICT trials were focused on highly mutated cancer types, such as melanoma and lung cancer, largely predicated on the idea that mutation-derived neoantigens would allow for generation of tumor-specific T cells. Subsequent analysis of patient responses in these highly mutated cancer types confirmed that increased tumor mutation burden (TMB) corresponded with improved patient outcomes. Further clinical studies identified additional predictive biomarkers, such as PD-L1 protein expression, and various gene expression signatures. Based on the success of ICT in hypermutated cancer types, further clinical trials with ICT were performed in cancers with overall lower mutational burden. These studies have indicated that many non-hypermutated cancer types with relatively low TMB may be effectively treated with ICT. For example, patients with clear cell renal cell carcinoma (ccRCC) display relatively low TMB overall, and a narrow distribution of TMB across patients, yet clinical response rates to ICT are ~30%, with some durable responses seen. Other tumor types with minimal mutation burdens, including glioblastoma (GBM) and triple negative breast cancer (TNBC), have likewise shown encouraging clinical responses to ICT. We recently demonstrated distinct tumor immunobiology between hypermutated and non-hypermutated tumor types, notably that relative neoantigen load/tumor mutation burden was only a relevant factor for immune infiltration in hypermutated tumor types. Consistent with this, clinical trials have demonstrated that TMB does not predict response to ICT in tumor types with minimal mutational load, such as breast cancer, ccRCC, and GBM. Thus, there remains a critical gap in knowledge as to how to identify which patients with non-hypermutated cancer may benefit from ICT. Here, we demonstrate that a replication stress response (RSR) defect gene expression signature accurately predicts ICT response in 11 independent non-hypermutated patient cohorts from 6 tumor types for which other biomarkers failed. Pre-clinical studies indicate that aberrant origin firing in RSR deficient tumor cells causes exhaustion of replication protein A, resulting in accumulation of immunostimulatory cytosolic DNA. Induction or suppression of RSR deficiencies was sufficient to modulate response to ICT. Taken together, the RSR defect gene signature can accurately identify patients who will benefit from ICT across numerous non-hypermutated tumor types, and pharmacological induction of RSR defects may further expand the benefits of ICT to more patients.

Citation Format: D McGrail, P Pilié, XHF Zhang, J Rosen, L Voorwerk, M Kok, A Heimberger, C Peterson, E Jonasch, S Lin. Replication stress response defects predict responses to ICT in non-hypermutated tumors [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SP084.

Hyperhemolysis Syndrome in a Patient With Sickle Cell Disease and Acute Chest Syndrome

Sickle cell anemia patients often present to the hospital with acute vaso-occlusive pain crisis. Symptoms can include, but are not limited to, chest pain, abdominal pain, and musculoskeletal pain. These symptoms are brought about due to the pathology of the disease. Abnormal hemoglobin S causes red blood cells to band together, otherwise known as "sickling." These patients also often present with very low hemoglobin levels on initial evaluation. In most cases, packed red blood cell transfusions are needed in order to replenish these patient's functional hemoglobin supply. Unfortunately, transfusing sickle cell patients can lead to an unwanted consequence, that of hyperhemolysis syndrome, in which blood transfusions prompt further hemolysis of the already sickled red blood cells. When this complication arises, caution must be exercised in deciding the next steps of treatment.

1637. SPR720, A Novel Benzamidazole Gyrase Inhibitor, Demonstrates Potent Efficacy Against Mycobacterium avium ATCC 700898 in a Chronic C3HeBFeJ Mouse Infection Model

Background

SPR719 (the active metabolite of phosphate prodrug SPR720) belongs to a novel class which targets the ATPase subunits of gyrase by a mechanism distinct from fluoroquinolones. SPR719 has potent antibacterial activity against nontuberculous mycobacteria strains (NTM), including Mycobacterium avium, and is under development for treatment of NTM pulmonary disease. Oral efficacy of SPR720 was evaluated alone and in combination treatment in the C3HeBFeJ chronic mouse infection model which produces necrotic granulomas, similar to humans.

Methods

Mice were infected with a pulmonary aerosol of 1x10^8.5 CFU of M. avium ATCC 700898, (SPR719 MIC = 2 mg/mL). Treatment started on day 28 for 8 weeks with: saline, clarithromycin 250 mg/kg (CLR) QD, SPR720 at 10, 30 and 100 mg/kg QD, or SPR720 at 50 mg/kg BID. SPR720 at 30 mg/kg QD was also combined with CLR +/- ethambutol at 100 mg/kg (EMB), or CLR + rifabutin at 100 mg/kg (RFB) +/- EMB. Mice were evaluated for bacterial burden (CFU) on days 1, 27 and 60 after infection by plating serial dilutions of organ homogenates on nutrient 7H11 and charcoal agar plates. Lung pathology was evaluated by assessing prevalence and size of pulmonary lesions.

Results

CLR treatment for 28 days showed a significant reduction in the bacterial burden in the lung, spleen, and liver compared to the untreated control. SPR720 demonstrated a dose dependent reduction in bacterial burden, including at 100 mg/kg which showed a statistically significant reduction in the bacterial burden in the lung, spleen, and liver. CLR + EMB + SPR720 at 30 mg/kg reduction in the bacterial burden in the lung, spleen, and liver. RFB when added to the treatment regimen did not demonstrate enhanced efficacy compared the additive effect of EMB + CLR +/- SPR720. Lung pathology showed that lesions were less numerous and smaller in infected mice treated with all regimens.

Conclusion

Oral administration of SPR720 demonstrated a statistically significant reduction in the bacterial burden in all tissues with concomitant improvement in lung pathology, both alone and in combination with standard of care agents. These results support the continued development of SPR720 for treatment of NTM pulmonary infections.

Disclosures

Nicole S. Cotroneo, BS, Spero Therapeutics (Employee, Shareholder) Suzanne Stokes, PhD, Spero Therapeutics (Employee, Shareholder)

Hippocampal subfield pathologic burden in Lewy body diseases vs. Alzheimer's disease

AIMS

Lewy body diseases (LBD) are characterized by alpha-synuclein (SYN) pathology, but comorbid Alzheimer's disease (AD) pathology is common and the relationship between these pathologies in microanatomic hippocampal subfields is understudied. Here we use digital histological methods to test the association between hippocampal SYN pathology and the distribution of tau and amyloid-beta (Aβ) pathology in LBD and contrast with AD subjects. We also correlate pathologic burden with antemortem episodic memory testing.

METHODS

Hippocampal sections from 49 autopsy-confirmed LBD cases, 30 with no/low AD copathology (LBD - AD) and 19 with moderate/severe AD copathology (LBD + AD), and 30 AD patients were stained for SYN, tau, and Aβ. Sections underwent digital histological analysis of subfield pathological burden which was correlated with antemortem memory testing.

RESULTS

LBD - AD and LBD + AD had similar severity and distribution of SYN pathology (P > 0.05), CA2/3 being the most affected subfield (P < 0.02). In LBD, SYN correlated with tau across subfields (R = 0.49, P < 0.001). Tau burden was higher in AD than LBD + AD (P < 0.001), CA1/subiculum and entorhinal cortex (ERC) being most affected regions (P = 0.04 to <0.01). However, tau pathology in LBD - AD was greatest in CA2/3, which was equivalent to LBD + AD. Aβ severity and distribution was similar between LBD + AD and AD. Total hippocampal tau and CA2/3 tau was inversely correlated with memory performance in LBD (R = -0.52, -0.69, P = 0.04, 0.009).

CONCLUSIONS

Our findings suggest that tau burden in hippocampal subfields may map closely with the distribution of SYN pathology in subfield CA2/3 in LBD diverging from traditional AD and contribute to episodic memory dysfunction in LBD.

Haematopoietic stem cells: entropic landscapes of differentiation

The metaphor of a potential epigenetic differentiation landscape broadly suggests that during differentiation a stem cell approaches a stable equilibrium state from a higher free energy towards a stable equilibrium state which represents the final cell type. It has been conjectured that there is an analogy to the concept of entropy in statistical mechanics. In this context, in the undifferentiated state, the entropy would be large since fewer constraints exist on the gene expression programmes of the cell. As differentiation progresses, gene expression programmes become more and more constrained and thus the entropy would be expected to decrease. In order to assess these predictions, we compute the Shannon entropy for time-resolved single-cell gene expression data in two different experimental set-ups of haematopoietic differentiation. We find that the behaviour of this entropy measure is in contrast to these predictions. In particular, we find that the Shannon entropy is not a decreasing function of developmental pseudo-time but instead it increases towards the time point of commitment before decreasing again. This behaviour is consistent with an increase in gene expression disorder observed in populations sampled at the time point of commitment. Single cells in these populations exhibit different combinations of regulator activity that suggest the presence of multiple configurations of a potential differentiation network as a result of multiple entry points into the committed state.

Lack of effect of a topical regenerative agent on re-epithelialization rate of canine spontaneous chronic corneal epithelial defects: A randomized, double-masked, placebo-controlled study

Spontaneous chronic corneal epithelial defects (SCCEDs) are characteristic ulcers in dogs that are refractory to healing. The aim of the study was to evaluate the use of a topical regenerative agent to promote healing of SCCEDs. Nineteen dogs (20 eyes) were randomized to receive either regenerative agent (10 eyes) or placebo (10 eyes) every 48h following corneal debridement, which was repeated 1 week later if the SCCED had not yet healed. The mean±standard deviation time to re-epithelialization was 17.3±12.8 days for the group treated with a topical regenerative agent and 19.3±11.7 days for the group treated with a placebo; the cumulative healing rates were not statistically different (P>0.650). A positive association was found between the initial size of the ulcer and the time to re-epithelialization (r=0.555, P=0.011). Although well tolerated by dogs, there was no therapeutic advantage in using a topical regenerative agent for re-epithelialization of SCCEDs.

A highly stable blood meal alternative for rearing Aedes and Anopheles mosquitoes

We investigated alternatives to whole blood for blood feeding of mosquitoes with a focus on improved stability and compatibility with mass rearing programs. In contrast to whole blood, an artificial blood diet of ATP-supplemented plasma was effective in maintaining mosquito populations and was compatible with storage for extended periods refrigerated, frozen, and as a lyophilized powder. The plasma ATP diet supported rearing of both Anopheles and Aedes mosquitoes. It was also effective in rearing Wolbachia-infected Aedes mosquitoes, suggesting compatibility with vector control efforts.

On the Cellular Pharmacokinetics of 6-Thioguanine in Acute Myelogenous Leukemia

The pharmacokinetics of 6-thioguanine were studied in 10 patients with acute myelogenous leukemia treated with 25-100 mg/m(2) orally. The concentration of 6-thioguanine in plasma was determined with reversed phase high performance liquid chromatography (HPLC). After isolation of leukemic cells and erythrocytes by density centrifugation, HClO4 extraction of nucleotides and isolation of thiol containing substances on mercurial cellulose, the intracellular concentration of phosphorylated 6-thioguanine metabolites was measured by anion exchange HPLC. The plasma peak concentration of 6-thioguanine was significantly correlated (r(2) = 0.60) to the dose administered. In the leukemic cells, the 5'-mono-(TGMP) and 5'-triphosphates (TGTP) of 6-thioguanosine could be detected in nine of the patients. In one patient only TGMP was seen. The diphosphate could be detected in low concentrations in 6 patients. In all patients, the concentration of TGMP was higher than that of TGTP which was higher than the diphosphate. The interindividual variation in cellular TGMP and TGTP concentration was > 100-fold and independent of dose, while the variation in plasma 6-TG was < 15-fold. There was no correlation between dose or plasma area under the concentration versus time curve (AUC) of 6-TG and the cellular AUC of TGMP or TGTP. However, the AUC of TGMP and TGTP correlated significantly (r(2) = 0.64). The t1/2 of the intracellular metabolites and of 6-thioguanine in plasma were in the same order (4.4, 5.2 and 5.0 h for plasma 6-thioguanine, the intracellular mono- and triphosphate respectively). Phosphorylated metabolites of 6-thioguanine were detectable in erythrocytes from 8 patients. The kinetic pattern of the metabolites in erythrocytes was different from that in leukemic cells. While shortly after administration being eliminated according to first order kinetics in the leukemic cells, the concentration of intracellular metabolites in the erythrocytes was raising during the first 24 h after the treatment. The concentration of the metabolites were, however, much (100-fold) lower in erythrocytes compared to leukemic cells. Furthermore, the triphosphate was the predominant metabolite in the erythrocytes and considerable amounts of the diphosphate was seen while the concentration in the monophosphate was low. We conclude that there is a considerable interindividual variation in the cellular pharmacokinetics of TGMP and TGTP. The concentration of the phosphorylated metabolites in the leukemic cells cannot be predicted by determination of plasma 6-thioguanine concentration, nor by the concentration of the same metabolites in the erythrocytes.