Towards the validation of quantitative contrast sensitivity as a clinical endpoint: correlations with vision-related quality of life in bilateral AMD

AIM

To investigate if active learning of contrast sensitivity (CS) in bilateral age-related macular degeneration (AMD) correlates better than visual acuity (VA) with vision-related quality of life (VRQoL) using factor analysis-calibrated National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25).

METHODS

Prospective cross-sectional observational study in 93 patients (186 eyes) with bilateral AMD. CS was measured in one eye at a time with the quantitative CS function (qCSF) method (Adaptive Sensory Technology). Same-day VRQoL was assessed with factor analysis-calibrated NEI VFQ-25 visual function and socioemotional scales. Mixed-effects multiple linear regression analyses evaluated the associations of the qCSF outcomes and VA with the NEI VFQ-25 scales. A subgroup analysis on patients with AMD with VA more than 20/25 in both eyes was performed.

RESULTS

Compared with VA, CS outcomes were associated with larger effect on both visual function scale (standardised beta coefficients (β*) for area under the logarithm of CSF (AULCSF) curve and CS thresholds at 1.5, 3 and 6 cycles per degree (cpd): β*=0.50, 0.48, 0.52, 0.46, all p<0.001, respectively, vs β*=-0.45 for VA, all p<0.001) and socioemotional scale (β* for AULCSF and CS threshold at 6 cpd: β*=0.44, 0.44 vs β*=-0.42 for VA, all p<0.001). In patients with AMD with VA more than 20/25 in both eyes (N=20), both VFQ-25 scales and all CS outcomes were significantly reduced.

CONCLUSIONS

qCSF-measured CS strongly correlates with patient-reported VRQoL in bilateral AMD, even stronger than VA does. This study further validates qCSF-measured CS as a promising functional endpoint for future clinical trials in AMD.

Inhibiting DNA-PK induces glioma stem cell differentiation and sensitizes glioblastoma to radiation in mice

Glioblastoma (GBM), a lethal primary brain tumor, contains glioma stem cells (GSCs) that promote malignant progression and therapeutic resistance. SOX2 is a core transcription factor that maintains the properties of stem cells, including GSCs, but mechanisms associated with posttranslational SOX2 regulation in GSCs remain elusive. Here, we report that DNA-dependent protein kinase (DNA-PK) governs SOX2 stability through phosphorylation, resulting in GSC maintenance. Mass spectrometric analyses of SOX2-binding proteins showed that DNA-PK interacted with SOX2 in GSCs. The DNA-PK catalytic subunit (DNA-PKcs) was preferentially expressed in GSCs compared to matched non-stem cell tumor cells (NSTCs) isolated from patient-derived GBM xenografts. DNA-PKcs phosphorylated human SOX2 at S251, which stabilized SOX2 by preventing WWP2-mediated ubiquitination, thus promoting GSC maintenance. We then demonstrated that when the nuclear DNA of GSCs either in vitro or in GBM xenografts in mice was damaged by irradiation or treatment with etoposide, the DNA-PK complex dissociated from SOX2, which then interacted with WWP2, leading to SOX2 degradation and GSC differentiation. These results suggest that DNA-PKcs-mediated phosphorylation of S251 was critical for SOX2 stabilization and GSC maintenance. Pharmacological inhibition of DNA-PKcs with the DNA-PKcs inhibitor NU7441 reduced GSC tumorsphere formation in vitro and impaired growth of intracranial human GBM xenografts in mice as well as sensitized the GBM xenografts to radiotherapy. Our findings suggest that DNA-PK maintains GSCs in a stem cell state and that DNA damage triggers GSC differentiation through precise regulation of SOX2 stability, highlighting that DNA-PKcs has potential as a therapeutic target in glioblastoma.

POS0902 EFFICACY AND SAFETY OF INTRAVENOUS GOLIMUMAB IN ANKYLOSING SPONDYLITIS PATIENTS WITH EARLY VS LATE DISEASE THROUGH WEEK 52 OF GO-ALIVE STUDY

Background:

The GO-ALIVE study assessed efficacy and safety of intravenous golimumab (IV GLM) in patients (pts) with ankylosing spondylitis (AS).1,2

Objectives:

In this post hoc analysis, we assessed IV GLM efficacy and safety in AS pts with early disease (ED) vs late disease (LD) based on pt-reported duration of inflammatory back pain (IBP).

Methods:

In this Phase 3, double-blind, placebo (PBO)-controlled trial, pts with active AS were randomized (1:1) to receive IV GLM 2 mg/kg at Week (W) 0, W4, then Q8W or PBO at W0, W4, and W12 with crossover to IV GLM at W16, W20, then Q8W through 52. The primary endpoint was achievement of SpondyloArthritis International Society 20% improvement response (ASAS 20) at W16. In this post hoc analysis, 208 pts were grouped into quartiles based on self-reported duration of IBP symptoms. Efficacy and safety in 60 pts with ED (1st quartile) were compared with 52 pts with LD (4th quartile).

Results:

For the overall study population, mean duration of IBP symptoms was 10.9 yr and mean time since diagnosis was 5.5 yr. For ED pts, the mean duration of IBP symptoms ranged from 2.3 yr (IV GLM) to 2.6 yr (PBO), and for LD pts ranged from 23.5 yr (IV GLM) to 24.4 yr (PBO). At W16, ASAS 20 was achieved by 72% IV GLM vs 32% PBO pts with ED and by 67% IV GLM vs 21% PBO pts with LD. Pts with ED had numerically better response than those with LD in Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and across more stringent endpoints, including ASAS 40, Bath Ankylosing Spondylitis Disease Activity Index 50% improvement (BASDAI 50), and Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease and major improvement (Table 1). Response rates at W16 among IV GLM-treated pts were generally consistent through 1 year in both ED and LD subgroups; also in ED and LD subgroups, pts crossing over to IV GLM at W16 demonstrated response at W52 consistent with pts who started IV GLM at W0. At W16, improvements in enthesitis score were similar for pts with ED (mean change -2.9 for IV GLM vs 0.1 for PBO) and LD (mean change -2.5 for IV GLM vs 0.6 for PBO); improvements were maintained at W52 for ED and LD pts. Treatment-emergent adverse events and serious adverse events through 1 year were 46% and 3% for pts with ED compared with 61% and 2% for pts with LD, respectively.

Conclusion:

While IV GLM provided clinically meaningful improvements in signs and symptoms of AS in pts regardless of disease duration, response generally appeared numerically better in pts with ED than in pts with LD. This supports the principle of prompt diagnosis and early treatment.

References:

[1]Deodhar A, et al. J Rheumatol. 2018;45:341-348.

[2]Reveille J, et al. J Rheumatol. 2019;46:1277-1283.

Table 1.

Efficacy Outcomes

EDLDWeek 16Week 52Week 16Week 52PBO(n=25)IV GLM(n=35)PBO→IV GLM(n=25)IV GLM(n=35)PBO(n=28)IV GLM(n=24)PBO→IV GLM(n=28)IV GLM(n=24)ASAS 2032%71%68%71%21%67%68%63%ASAS 4012%46%56%60%4%42%57%42%BASDAI 5012%40%64%60%7%33%57%42%ASDAS inactive disease (score <1.3)4%17%44%37%0%8%14%4%ASDAS major improvement (decrease ≥2.0)n=244%57%n=2454%51%0%n=2348%46%n=2330%ASDAS clinically important improvement (decrease ≥1.1)n=2429%77%n=2475%77%18%n=2391%61%n=2365%Mean change from baseline (SD) in BASFIn=23-0.4 (2.0)-2.3 (2.1)n=23-2.7 (2.7)-2.8 (2.6)n=27-0.3 (1.8)n=24-2.2 (1.7)n=27-2.4 (2.2)n=23-2.3 (1.7)Mean change from baseline (SD) in BASMIn=23-0.3 (0.7)-0.4 (0.7)n=23-0.6 (0.7)-0.3 (0.5)n=270.01 (0.5)n=21-0.3 (0.6)n=27-0.4 (0.7)n=20-0.3 (0.7)Mean change from baseline (SD) in enthesitis scoren=230.1 (3.6)-2.9 (2.9)n=23-2.0 (4.4)-3.2 (2.5)n=27-0.6 (3.4)n=21-2.5 (3.0)n=27-2.5 (3.1)n=20-3.5 (5.9)

SD=standard deviation

Disclosure of Interests:

Atul Deodhar Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, and UCB, Shelly Kafka Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Kim Hung Lo Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Lilianne Kim Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, John D Reveille Consultant of: Eli Lilly and UCB, Grant/research support from: Eli Lilly and Janssen

ETMM-08 METABOLIC REGULATION OF THE EPIGENOME DRIVES LETHAL INFANTILE EPENDYMOMA

Ependymomas are malignant glial tumours that occur throughout the central nervous system. Of the nine distinct molecular subgroups of ependymoma, Posterior Fossa A (PFA), is the most prevalent, occurring in the hindbrain of infants and young children. Lacking highly recurrent somatic mutations, PFAs are thought to be a largely epigenetically driven entity, defined by hypomethylation at the histone 3 lysine 27 residue. Previous transcriptional analysis of PFAs revealed an enrichment of hypoxia signaling genes. Thus, we hypothesized that hypoxic signaling, in combination with a unique metabolic milieu, drive PFA oncogenesis through epigenetic regulation. In this study, we identified that PFA cells control the availability of specific metabolites under hypoxic conditions, resulting in diminished H3K27 trimethylation and increased H3K27 acetylation in vitro and in vivo. Unique to PFA cells, transient exposure to ambient oxygen results in irreversible cellular toxicity. Furthermore, perturbation of key metabolic pathways is sufficient to inhibit growth of PFA primary cultures in vitro. PFA cells sequester s-adenosylmethionine while upregulating EZHIP, a polycomb repressive complex 2 (PRC2) inhibitor, resulting in decreased H3K27 trimethylation. Furthermore, hypoxia fine-tunes the abundance of alpha-ketoglutarate and acetyl-CoA to fuel demethylase and acetyltransferase activity. Paradoxically, a genome-wide CRISPR knockout screen identified the core components of PRC2 as uniquely essential in PFAs. Our findings suggest that PFAs thrive in a narrow “Goldilocks” zone, whereby they must maintain a unique epigenome and deviation to increased or decreased H3K27 trimethylation results in diminished cellular fitness. Previously, we showed that PFAs have a putative cell of origin arising in the first trimester of development. Using single-cell RNAseq and metabolomics, we demonstrate that PFAs resemble the natural metabolic-hypoxic milieu of normal development. Therefore, targeting metabolism and/or the epigenome presents a unique opportunity for rational therapy for infants with PFA ependymoma.

FSMP-08. TARGETING PYRIMIDINE SYNTHESIS ACCENTUATES MOLECULAR THERAPY RESPONSE IN GLIOBLASTOMA STEM CELLS

Glioblastoma stem cells (GSCs) reprogram glucose metabolism by hijacking high-affinity glucose uptake to survive in a nutritionally dynamic microenvironment. Here, we trace metabolic aberrations in GSCs to link core genetic mutations in glioblastoma to dependency on de novo pyrimidine synthesis. Targeting the pyrimidine synthetic rate-limiting step enzyme carbamoyl-phosphate synthetase 2, aspartate transcarbamylase, dihydroorotase (CAD) or the critical downstream enzyme dihydroorotate dehydrogenase (DHODH) inhibited GSC survival, self-renewal, and in vivo tumor initiation through the depletion of the pyrimidine nucleotide supply in rodent models. Mutations in EGFR or PTEN generated distinct CAD phosphorylation patterns to activate carbon influx through pyrimidine synthesis. Simultaneous abrogation of tumor-specific driver mutations and DHODH activity with clinically approved inhibitors demonstrated sustained inhibition of metabolic activity of pyrimidine synthesis and GSC tumorigenic capacity in vitro. Higher expression of pyrimidine synthesis genes portends poor prognosis of patients with glioblastoma. Collectively, our results demonstrate a therapeutic approach of precision medicine through targeting the nexus between driver mutations and metabolic reprogramming in cancer stem cells.

EPEN-52. METABOLIC REGULATION OF THE EPIGENOME DRIVES LETHAL INFANTILE EPENDYMOMA

PFA ependymomas are a lethal glial malignancy of the hindbrain found in infants and toddlers. Lacking any highly recurrent somatic mutations, PFAs have been proposed to be a largely epigenetically driven entity, defined by hypomethylation at the histone 3 lysine 27 residue. Unfortunately, an almost complete lack of model systems has limited the discovery of novel PFA therapies. In this study, we have identified that the PFA hypoxic microenvironment controls the availability of specific metabolites, resulting in diminished H3K27 trimethylation and increased H3K27 acetylation in vitro and in vivo. Unique to PFA cells, transient exposure to ambient oxygen results in irreversible cellular toxicity. Furthermore, perturbation of key metabolic pathways is sufficient to inhibit growth of PFA primary cultures in vitro. Although PFA tumors exhibit a low basal level of H3K27me3, inhibition of H3K27 methylation paradoxically demonstrates significant and specific activity against PFA. Thus, we propose a “Goldilocks Model” of metabolic-epigenetic regulation in PFA ependymoma, whereby increased or decreased H3K27 trimethylation results in cell death. Mapping of PFA ependymoma tumours suggests a cell of origin arising in the first trimester of human development where there is a known hypoxic microenvironment. Therefore, targeting metabolism and/or the epigenome presents a unique opportunity for rational therapy for infants with PFA ependymoma.

Disorganisation of retinal inner layers is associated with reduced contrast sensitivity in retinal vein occlusion

BACKGROUND/AIMS

To determine if disorganisation of retinal inner layers (DRIL) is associated with reduced contrast sensitivity (CS) in patients with retinal vein occlusion (RVO) with a history of macular oedema (ME).

METHODS

Prospective, observational cohort study. Patients with a history of ME secondary to central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) from October 2017 to July 2019 at a single institution were included. Patients underwent complete ophthalmic examination, spectral domain optical coherence tomography (SD-OCT) and CS testing using the quick contrast sensitivity function (qCSF) method. Eyes with coexisting macular disease were excluded. SD-OCT images were analysed for presence and extent of DRIL, intraretinal fluid (IRF), subretinal fluid (SRF), hyperreflective foci, epiretinal membrane (ERM), external limiting membrane (ELM) disruption, ellipsoid zone (EZ) disruption, central macular thickness (CMT) and central foveal thickness (CFT). Multivariable mixed-effect linear regressions were performed for the area under the log contrast sensitivity function (AULCSF) using Stata (StataCorp). P values <0.05 were considered significant.

RESULTS

58 visits from 31 patients were included (1.9±1.2 visits per patient). 29 (50%) were for CRVO. The average age was 63.9±10.5 years. On multivariable analysis, DRIL extent (p<0.001), CMT (p=0.007), CFT (p=0.024) and moderate cataract (p=0.001) were significantly associated with worse AULCSF.

CONCLUSIONS

DRIL extent is associated with reduced CS in eyes with ME secondary to RVO. DRIL is an imaging feature that has important implications for visual function.

TAMI-59. METABOLIC REGULATION OF THE EPIGENOME DRIVES LETHAL INFANTILE EPENDYMOMA

Ependymomas are malignant glial tumors that occur throughout the central nervous system. Of the nine distinct molecular types of ependymoma, Posterior Fossa A(PFA) ependymomas, found in the hindbrain of infants and young children, are the most prevalent type. They rarely harbor recurrent somatic single nucleotide or copy number aberrations, but rather display epigenetic dysregulations. Transcriptional analyses show that PFAs, but not other molecular ependymoma variants, have elevated hypoxic signaling. We hypothesized that the metabolic environment of the developing human fetal hindbrain contributes to PFA ependymomas through the intermediary metabolic mechanism. Hypoxia microenvironment is essential for PFA survival and upholding their epigenetic dysregulation. Hypoxia blocks methyltransferase activity by upregulating EZHIPs expression and restricting SAM abundance. Fine-tuning the abundance of a-KG and acetyl-CoA, hypoxia fuels demethylase, and acetyltransferase activity which collectively resulting in H3K27 hypomethylation and hyperacetylation. Genome-wide essentially screen further underscore that minimal basal level of H3K27me3 is essential for PFA survival and further attenuation of H3K27me3 decreases the fitness of PFAs. PFA Ependymomas have a unique epigenome, suggesting a model in which they thrive in a narrow Goldilocks zone, with deviation to either increased or decreased H3K27me3 levels leading to diminished cellular fitness. PFAs are maintained under hypoxia, associated with restricted availability of specific metabolites to diminish histone methylation and increase histone demethylation and acetylation at H3K27. PFAs initiate from a cell lineage in the first trimester of human development that resides in restricted oxygen. Unlike other ependymomas, transient exposure of PFA cells to ambient oxygen induces irreversible cellular toxicity. PFA tumors exhibit a low basal level of H3K27me3 and, paradoxically, inhibition of H3K27 methylation specifically disrupts PFA growth. Microenvironmental regulation of PFA ependymoma epigenome appears to play a major role in tumorigenesis. Targeting metabolism and/or the epigenome presents a unique opportunity for rational therapy for infants with PFA ependymoma.

1094 Depression Is Not Associated With The Presence Of Or The Severity Of Obstructive Sleep Apnea: Retrospective Study Of 841 Polysomnography Subjects

Introduction

Both depression and obstructive sleep apnea (OSA) are very common medical conditions. Studies showed a co-occurrence of depression and OSA with a higher prevalence of one if the other is present. However, there is relative paucity of studies assessing the rate of depression based on the OSA severity.

Methods

Retrospective analysis of data collected from patients undergoing polysomnography (PSG) at an academic sleep disorders center was performed. A total of 841 subjects were included and stratified into four groups using AHI. A Chi-square analysis was applied to assess the association of varying levels of AHI and the presence of depression.

Results

Although a significant proportion of patients with AHI greater than 5 endorsed depression (60/165 in group with AHI 15 or greater and 115/278 in group with AHI between 5 and 15), this finding was also replicated in patients with AHI less than 5 (86/202 in AHI between 1 and 5 and 88/196 in those with AHI less than 1). As there was significant difference in rate of depression among women (54.1%) and men (26.1%) (p &lt;0.0001), Chi-square analysis was performed for the rate of depression based on the level of AHI, adjusted for gender. In women the rate of depression from the most severe AHI to less severe AHI group were 0.48, 0.53, 0.60, and 0.53 respectively and in men it was 0.30, 0.27, 0.20, and 0.27 respectively, with no statistical difference between any groups.

Conclusion

Among patients who seek PSG assessment, depression appears to be more prevalent than the general public. Rate of depression is much higher among women than men in this group. However, the presence of OSA or severity of OSA does not have any correlation with the rate of depression in both women and men. These findings might be suggestive of the complexity of the association between depression and OSA. One limitation of this study is the dichotomous nature of depression (presence or absence of). The finding from this study warrants a future study utilizing a numerical rating scale of depression for severity measure to correlate it with the severity of OSA.

Support

NA.

A case report of temple squamoid eccrine ductal carcinoma: A diagnostic challenge beneath the tip of the iceberg

Eccrine carcinomas are a rare tumor entity which originates from eccrine glands and comprise <0.01% of all cutaneous tumors. Eccrine carcinoma subtypes are classified based on their distinct histopathological pattern. Squamoid eccrine ductal carcinoma (SEDC) is a rare subtype, characterized by both squamous and adnexal ductal differentiation, and resembles squamous cell carcinoma on clinical examination. Given the rarity of these tumors, there remains a lack of clear diagnostic criteria or treatment guidelines for the management of SEDC. We report a rare case of SEDC with perineural invasion in an elderly gentleman who was treated with wide local excision.

Trichofolliculoma of the eyelid: systematic review

Background

Trichofolliculoma of the eyelid and periorbital region remains is rare, and there is limited evidence regarding surgical management, clinical and histological margins, and recurrence rate.

Objectives

We performed a systematic review of cases to date on diagnosis and management outcomes of eyelid trichofolliculoma.

Methods

Electronic databases were searched for cases reported on trichofolliculoma of the eyelid. The authors extracted and collated data from these studies, and outcomes were summarized descriptively.

Results

One hundred twenty citations were identified from database searching. The authors also report a case of eyelid trichofolliculoma. Fifteen studies reporting 19 cases of eyelid trichofolliculoma were finally included. Eighteen out of 19 (94.7%) cases were treated with surgical excision. Of 5 cases which were followed up over an average of 2 years, there was only 1 case of recurrence requiring wedge resection.

Conclusions

Recurrence rate in patients with eyelid trichofolliculoma excised with satisfactory margins appears to be low, and no cases of malignant transformation have been reported.

STEM-22. TARGETING PYRIMIDINE SYNTHESIS ACCENTUATES MOLECULAR THERAPY RESPONSE IN GLIOBLASTOMA STEM CELLS

Glioblastoma stem cells (GSCs) reprogram glucose metabolism by hijacking high-affinity glucose uptake to survive in a nutritionally dynamic microenvironment. Here, we trace metabolic aberrations in GSCs to link core genetic mutations in glioblastoma to dependency on de novo pyrimidine synthesis. Targeting the pyrimidine synthetic rate-limiting step enzyme carbamoyl-phosphate synthetase 2, aspartate transcarbamyolase, dihydroorotase (CAD) or the critical downstream enzyme, dihydroorotate dehydrogenase (DHODH) inhibited GSC survival, self-renewal, and in vivo tumor initiation through the depletion of the pyrimidine nucleotide supply in rodent models. Mutations in EGFR or PTEN generated distinct CAD phosphorylation patterns to activate carbon influx through pyrimidine synthesis. Simultaneous abrogation of tumor-specific driver mutations and DHODH activity with clinically approved inhibitors demonstrated sustained inhibition of metabolic activity of pyrimidine synthesis and GSC tumorigenic capacity. Higher expression of pyrimidine synthesis genes portend poor prognosis of glioblastoma patients. Collectively, our results demonstrate a therapeutic approach of precision medicine through targeting the nexus between driver mutations and metabolic reprogramming in cancer stem cells.

Ibrutinib inactivates BMX-STAT3 in glioma stem cells to impair malignant growth and radioresistance

Glioblastoma (GBM) is the most lethal primary brain tumor and is highly resistant to current treatments. GBM harbors glioma stem cells (GSCs) that not only initiate and maintain malignant growth but also promote therapeutic resistance including radioresistance. Thus, targeting GSCs is critical for overcoming the resistance to improve GBM treatment. Because the bone marrow and X-linked (BMX) nonreceptor tyrosine kinase is preferentially up-regulated in GSCs relative to nonstem tumor cells and the BMX-mediated activation of the signal transducer and activator of transcription 3 (STAT3) is required for maintaining GSC self-renewal and tumorigenic potential, pharmacological inhibition of BMX may suppress GBM growth and reduce therapeutic resistance. We demonstrate that BMX inhibition by ibrutinib potently disrupts GSCs, suppresses GBM malignant growth, and effectively combines with radiotherapy. Ibrutinib markedly disrupts the BMX-mediated STAT3 activation in GSCs but shows minimal effect on neural progenitor cells (NPCs) lacking BMX expression. Mechanistically, BMX bypasses the suppressor of cytokine signaling 3 (SOCS3)-mediated inhibition of Janus kinase 2 (JAK2), whereas NPCs dampen the JAK2-mediated STAT3 activation via the negative regulation by SOCS3, providing a molecular basis for targeting BMX by ibrutinib to specifically eliminate GSCs while preserving NPCs. Our preclinical data suggest that repurposing ibrutinib for targeting GSCs could effectively control GBM tumor growth both as monotherapy and as adjuvant with conventional therapies.

ALK-positive anaplastic large cell lymphoma with a monomorphic small-cell pattern masquerading as inflammatory gastric lesions

INTRODUCTION

Anaplastic lymphoma kinase-positive (ALK+) anaplastic large cell lymphoma (ALCL) with a non-common pattern can be diagnostic challenging. Pathologists can be unavoidably and unintentionally blind to non-descript tumor cells in a lymphohistiocytic- (LH) or small-cell (SC)-pattern. We report a case of primary systemic ALK+ ALCL with a SC pattern that presented as secondary gastric lesions with a mixed LH and SC pattern that was masqueraded as inflammatory lesions.

CASE REPORT

A 34-year-old woman with intractable epigastric pain was referred to have repeated endoscopy with biopsy. She was found to multiple gastric erosions and nodules that were diagnosed as inflammatory lesions both endoscopically and histologically. Meanwhile, she developed an acute onset of severe back pain associated with a pathologic compression fracture in the T3 thoracic vertebral body. Imaging studies disclosed a disseminated systemic disease involving abdominopelvic lymph nodes and cervical and thoracic vertebral bodies. The needle biopsy of the pelvic lymph node disclosed diffuse proliferation of monomorphic small round cells that were diffusely positive for CD30 and ALK. A diagnosis of ALK+ ALCL with a monomorphic SC pattern was rendered.

DISCUSSION

A retrospective review of the gastric biopsies with the aid of immunohistochemistry enabled us to recognise the presence of lymphomatous infiltrates with a mixed LH and SC pattern in every piece of gastric biopsies that were repeatedly misdiagnosed as inflammatory lesions. This case illustrates a significant diagnostic pitfall of the LH- and SC-patterns in ALK+ ALCL, in which the tumour cells featuring lymphoid, plasmacytoid or histiocytoid appearance can be masqueraded as inflammatory cells.

[VALUE OF METALPROTEINASES OF BLOOD IN PATHOGENESIS OF EPITELIAL SKIN TUMORS AND THE POSSIBILITY OF THEIR SURGICAL CORRECTION]

Research objective - to carry out studying of changes of metalproteinases of blood at patients with epitelial cancer of skin in the postoperative period. Changes of TIMP-1 and MMP-2, MMP-7 and MMP-9 of blood it has been studied at 98 patients with various cancer of skin whose age was 55±3 years. From them bazalnokletochny cancer of skin - at 39 people, planocellular cancer is skin - at 39 patients. Researches were conducted before expeditious treatment, in the first postoperative days, for the fifth, seventh, tenth postoperative days and in 18 months after the undergone operation. For comparison at 20 patients operated with skin fibroma. Studying of indicators was carried out for the same days. At all patients the diagnosis is confirmed morphologically before performing expeditious treatment. Expeditious treatment was carried out under local anesthesia, at cancer broad excision of education was carried out, at fibroma - education excision. The conducted researches of indicators of inhibitor of metalproteinases-1, matriksny metalproteinases of blood at patients with various skin tumors show that in pathogenesis of development of a tumor of epitelialny tumors the great value is given to increase in inhibitor of metalproteinases-1, matriksny metalproteinases of blood. So, it is established that prior to expeditious treatment in all groups, both malignant, and good-quality increase in all studied indicators has been registered. It should be noted that increase in these indicators depended on malignancy of a tumor. So, in group with good-quality formations of skin this increase was minimum, and in group with planocellular cancer of skin - maximum. It is possible to assume that each tumor produces in TIMP-1, MMP-2, MMP-7 and MMP-9 blood, and this quantity depends on the nature of malignancy of a tumor. Besides, in the course of the research it has been established that performance of surgical treatment at benign tumors is led to correction of this indicator that it is shown by normalization of these indicators. At the same time at bazalnokletochny cancer of skin only to partial decrease in an indicator, and at planocellular cancer of skin these indicators didn't change. From this it is possible to make the conclusion that surgical treatment doesn't lead to correction of these indicators at malignant new growths of skin.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Zoonotic origin and transmission of Middle East respiratory syndrome coronavirus in the UAE

Since the emergence of Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012, there have been a number of clusters of human-to-human transmission. These cases of human-to-human transmission involve close contact and have occurred primarily in healthcare settings, and they are suspected to result from repeated zoonotic introductions. In this study, we sequenced whole MERS-CoV genomes directly from respiratory samples collected from 23 confirmed MERS cases in the United Arab Emirates (UAE). These samples included cases from three nosocomial and three household clusters. The sequences were analysed for changes and relatedness with regard to the collected epidemiological data and other available MERS-CoV genomic data. Sequence analysis supports the epidemiological data within the clusters, and further, suggests that these clusters emerged independently. To understand how and when these clusters emerged, respiratory samples were taken from dromedary camels, a known host of MERS-CoV, in the same geographic regions as the human clusters. Middle East respiratory syndrome coronavirus genomes from six virus-positive animals were sequenced, and these genomes were nearly identical to those found in human patients from corresponding regions. These data demonstrate a genetic link for each of these clusters to a camel and support the hypothesis that human MERS-CoV diversity results from multiple zoonotic introductions.

Therapeutic targeting of ependymoma as informed by oncogenic enhancer profiling

Genomic sequencing has driven precision-based oncology therapy; however, genetic drivers remain unknown or non-targetable for many malignancies, demanding alternative approaches to identify therapeutic leads. Ependymomas are chemotherapy-resistant brain tumours, which, despite genomic sequencing, lack effective molecular targets. Intracranial ependymomas are segregated based on anatomical location – supratentorial region (ST) or posterior fossa (PF) – and further divided into distinct molecular subgroups that reflect differences in age of onset, gender predominance, and response to therapy^1–3. The most common and aggressive subgroup, Posterior Fossa Ependymoma Group A (PF-EPN-A), occurs in young children and appears to lack recurrent somatic mutations². Conversely, Posterior Fossa Ependymoma Group B (PF-EPN-B) tumours display frequent large-scale copy number gains and losses yet favourable clinical outcomes^1,3. Greater than 70% of supratentorial ependymomas are defined by highly recurrent gene fusions in the NFκB subunit RELA (ST-EPN-RELA), and less frequently involve fusion of the gene encoding the transcriptional activator YAP1 (ST-EPN-YAP1).^1,3,4 Subependymomas, a distinct histologic variant, can also be found within the ST and PF compartments accounting for the majority of tumours in the molecular subgroups ST-EPN-SE and PF-EPN-SE, respectively¹. Here, we mapped active chromatin landscapes in 42 primary ependymomas in two non-overlapping primary ependymoma cohorts with the goal of identifying essential super enhancer associated genes on which tumour cells were dependent. Enhancer regions revealed putative oncogenes, molecular targets, and pathways, which when subjected to small molecule inhibitor or shRNA treatment, diminished proliferation of patient-derived neurospheres and increased survival in mouse models of ependymomas. Through profiling of transcriptional enhancers, our study provides a framework for target and drug discovery in other cancers recalcitrant to therapeutic development because of their lack of known genetic drivers.

High-quality cell block preparation from scraping of conventional cytology slide: a technical report on a modified cytoscrape cell block technique

BACKGROUND

Immunocytochemistry (ICC) on formalin-fixed paraffin embedded cell blocks is an ancillary tool commonly recruited for differential diagnoses of fine needle aspiration cytology (FNAC) samples. However, the quality of conventional cell blocks in terms of adequate cellularity and evenness of distribution of cytologic material is not always satisfactory for ICC. We introduce a modified agarose-based cytoscrape cell block (CCB) technique that can be effectively used for the preparation of cell blocks from scrapings of conventional FNAC slides.

METHODS

A decoverslipped FNAC slide was mounted with a small amount of water. The cytological material was scraped off the slide into a tissue mold by scraping with a cell scraper. The cytoscrape material was pelleted by centrifugation and pre-embedded in ultra-low gelling temperature agarose and then re-embedded in conventional agarose. The final agarose gel disk was processed and embedded in paraffin.

RESULTS

The quality of the ICC on the CCB sections was identical to that of the immunohistochemical stains on histological sections. By scrapping and harvesting the entirety of the cytological material off the cytology slide into a compact agarose cell button, we could avoid the risk of losing diagnostic material during the CCB preparation.

CONCLUSION

This modified CCB technique enables concentration and focusing of minute material while maintaining the entire amount of the cytoscrape material on the viewing spot of the CCB sections. We believe this technique can be effectively used to improve the level of confidence in diagnosis of FNAC especially when the FNAC slides are the only sample available.

Abstract A064: IDO1 expression stratifies glioblastoma patient survival and correlates with dominantly immunosuppressive pathways

Purpose: The objective of this study was to evaluate the prognostic significance of the immunosuppressive molecule indoleamine 2, 3-dioxygenase (IDO1) mRNA expression in patients with low-grade glioma (LGG) and glioblastoma (GBM).

Experimental Design: Hi-RNA-seq. Illumina data mined from the cancer genome atlas (TCGA) reflecting 475 LGG (WHO grade II and III) and 172 GBM patients were utilized to characterize the pattern of IDO1 mRNA expression. Kaplan-Meier (KM) survival analysis and multivariate Cox proportional hazards regression were conducted to evaluate the significance of IDO1 expression as a stratification marker in glioma patients. mRNA expression of proinflammatory and immunosuppressive factor genes were also investigated for their correlation with IDO1 mRNA expression. Ivy GAP analysis was further utilized to localize IDO1 mRNA within different GBM anatomic niches.

Results: Expression profiling of the TCGA revealed a distinct pattern of progressively increasing IDO1 mRNA levels correlating with decreased survival both in LGG and GBM patients. In grade III LGG and GBM, IDO1 mRNA expression was significantly decreased when mutant isocitrate dehydrogenase 1 and 2 (mIDH1/2) was coincidently expressed when compared to samples with wild-type IDH1/2 expression (mean difference = 1.51, P &lt; 0.0001 in grade III; mean difference = 2.15, P &lt; 0.01 in GBM). KM analysis and multivariate Cox regression analysis found IDO1 mRNA expression levels to be an independent prognostic factor for survival among LGG (P = 0.0115; HR = 1.68) and GBM (P = 0.0076; HR = 1.82) patients. Pearson's correlation analysis identified significant associations among GBM between IDO1 and the genes encoding immunosuppressive factors including PD-L1 (r = 0.2993, P &lt; 0.0001), PD-L2 (r = 0.4871, P &lt; 0.0001), PD-1 (r = 0.3416, P &lt; 0.0001), CTLA-4 (r = 0.3534, P &lt; 0.0001), STAT3 (r = 0.2366, P = 0.0018), CD39 (r = 0.2691, P = 0.0004), BTLA (r = 0.2981, P &lt; 0.0001), Lag3 (r = 0.2567, P = 0.0007), FoxP3 (r = 0.1865, P &lt; 0.0143) and FGL2 (r = 0.4267, P &lt; 0.0001). Notably, IDO1 mRNA levels were higher in the cellular (1.398 ± 0.1257, mean ± SEM) and necrotic (1.543 ± 0.1489) GBM zones, when compared to infiltrating (0.9303 ± 0.0786) and leading margins (0.9064 ± 0.1224). Additionally, for the IDO1 paralog genes IDO2 and TDO2, which encodes indoleamine 2, 3-dioxygenase 2 and tryptophan dioxygenase respectively, no overall differential expression pattern were observed between different pathological grades nor a significant stratification in LGG and GBM patient survival.

Conclusions: Our data show for the first time that IDO1 mRNA levels can be used as an independent prognostic variable for patients with LGG and/or GBM. Given that ongoing IDO1-targeted immunotherapy clinical trials aim to inhibit enzymatic activity in malignant glioma, our data suggest that targeted subject enrollment may result in a better clinical response to therapy.

Citation Format: Lijie Zhai, Matthew Genet, Erik Ladomersky, Kristen Lauing, Meijing Wu, David Binder, Leo Kim, Jeremy Rich, Craig Horbinski, C. David James, Jeffrey A. Sosman, Orin Bloch, Derek A. Wainwright. IDO1 expression stratifies glioblastoma patient survival and correlates with dominantly immunosuppressive pathways [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A064.