Checkpoint inhibitor hepatotoxicity: pathogenesis and management

Immunotherapy, including immune checkpoint inhibitor (ICI) therapy, has been a paradigm shift in cancer therapeutics, producing durable cancer responses across a range of primary malignancies. ICI drugs increase immune activity against tumor cells, but may also reduce immune tolerance to self-antigens, resulting in immune-mediated tissue damage. ICI-associated hepatotoxicity usually manifests as hepatocellular enzyme elevation and may occur in 2%-25% of ICI-treated patients. Although ICI-associated hepatotoxicity is clinically and pathologically distinct from idiopathic autoimmune hepatitis, our understanding of its pathogenesis continues to evolve. Pending greater understanding of the pathophysiology, mainstay of management remains through treatment with high-dose corticosteroids. This approach works for many patients, but up to 30% of patients with high-grade hepatotoxicity may not respond to corticosteroids alone. Furthermore, atypical cholestatic presentations are increasingly recognized, and rare cases of fulminant hepatitis due to ICI hepatotoxicity have been reported. Optimal management for these challenging patients remains uncertain. Herein, we review the current understanding of pathogenesis of ICI-associated toxicities, with a focus on hepatotoxicity. Based on the existing literature, we propose evolving management approaches to incorporate strategies to limit excess corticosteroid exposure, and address rare but important presentations of cholestatic hepatitis and fulminant liver failure. Finally, as ICI hepatotoxicity frequently occurs in the context of treatment for advanced malignancy, we review the impact of hepatotoxicity and its treatment on cancer outcomes, and the overall safety of re-challenge with ICI, for patients who may have limited treatment options.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Toxicity and outcomes of melanoma brain metastases treated with stereotactic radiosurgery: the risk of subsequent symptomatic intralesional hemorrhage exceeds that of radiation necrosis

PURPOSE

We aimed to assess the outcomes and patterns of toxicity in patients with melanoma brain metastases (MBM) treated with stereotactic radiosurgery (SRS) with or without immunotherapy (IO).

METHODS

From a prospective registry, we reviewed MBM patients treated with single fraction Gamma Knife SRS between 2008 and 2021 at our center. We recorded all systemic therapies (chemotherapy, targeted therapy, or immunotherapy) administered before, during, or after SRS. Patients with prior brain surgery were excluded. We captured adverse events following SRS, including intralesional hemorrhage (IH), radiation necrosis (RN) and local failure (LF), as well as extracranial disease status. Distant brain failure (DBF), extracranial progression-free survival (PFS) and overall survival (OS) were determined using a cumulative Incidence function and the Kaplan-Meier method.

RESULTS

Our analysis included 165 patients with 570 SRS-treated MBM. Median OS for patients who received IO was 1.41 years versus 0.79 years in patients who did not (p = 0.04). Ipilimumab monotherapy was the most frequent IO regimen (30%). In the absence of IO, the cumulative incidence of symptomatic (grade 2 +) RN was 3% at 24 months and remained unchanged with respect to the type or timing of IO. The incidence of post-SRS g2 + IH in patients who did not receive systemic therapy was 19% at 1- and 2 years compared to 7% at 1- and 2 years among patients who did (HR: 0.33, 95% CI 0.11-0.98; p = 0.046). Overall, neither timing nor type of IO correlated to rates of DBF, OS, or LF. Among patients treated with IO, the median time to extracranial PFS was 5.4 months (95% IC 3.2 - 9.1).

CONCLUSION

The risk of g2 + IH exceeds that of g2 + RN in MBM patients undergoing SRS, with or without IO. IH should be considered a critical adverse event following MBM treatments.

Mesothelin-targeting T cell receptor fusion construct cell therapy in refractory solid tumors: phase 1/2 trial interim results

The T cell receptor fusion construct (TRuC) gavocabtagene autoleucel (gavo-cel) consists of single-domain anti-mesothelin antibody that integrates into the endogenous T cell receptor (TCR) and engages the signaling capacity of the entire TCR upon mesothelin binding. Here we describe phase 1 results from an ongoing phase1/2 trial of gavo-cel in patients with treatment-refractory mesothelin-expressing solid tumors. The primary objectives were to evaluate safety and determine the recommended phase 2 dose (RP2D). Secondary objectives included efficacy. Thirty-two patients received gavo-cel at increasing doses either as a single agent (n = 3) or after lymphodepletion (LD, n = 29). Dose-limiting toxicities of grade 3 pneumonitis and grade 5 bronchioalveolar hemorrhage were noted. The RP2D was determined as 1 × 108 cells per m2 after LD. Grade 3 or higher pneumonitis was seen in 16% of all patients and in none at the RP2D; grade 3 or higher cytokine release syndrome occurred in 25% of all patients and in 15% at the RP2D. In 30 evaluable patients, the overall response rate and disease control rate were 20% (13% confirmed) and 77%, respectively, and the 6-month overall survival rate was 70%. Gavo-cel warrants further study in patients with mesothelin-expressing cancers given its encouraging anti-tumor activity, but it may have a narrow therapeutic window. ClinicalTrials.gov identifier: NCT03907852 .

Use of digital measurement of medication adherence and lung function to guide the management of uncontrolled asthma (INCA Sun): a multicentre, single-blinded, randomised clinical trial

BACKGROUND

The clinical value of using digital tools to assess adherence and lung function in uncontrolled asthma is not known. We aimed to compare treatment decisions guided by digitally acquired data on adherence, inhaler technique, and peak flow with existing methods.

METHODS

A 32-week prospective, multicentre, single-blinded, parallel, randomly controlled trial was done in ten severe asthma clinics across Ireland, Northern Ireland, and England. Participants were 18 years or older, had uncontrolled asthma, asthma control test (ACT) score of 19 or less, despite treatment with high-dose inhaled corticosteroids, and had at least one severe exacerbation in the past year despite high-dose inhaled corticosteroids. Patients were randomly assigned in a 1:1 ratio to the active group or the control group, by means of a computer-generated randomisation sequence of permuted blocks of varying sizes (2, 4, and 6) stratified by fractional exhaled nitric oxide (FeNO) concentration and recruitment site. In the control group, participants were masked to their adherence and errors in inhaler technique data. A statistician masked to study allocation did the statistical analysis. After a 1-week run-in period, both groups attended three nurse-led education visits over 8 weeks (day 7, week 4, and week 8) and three physician-led treatment adjustment visits at weeks 8, 20, and 32. In the active group, treatment adjustments during the physician visits were informed by digital data on inhaler adherence, twice daily digital peak expiratory flow (ePEF), patient-reported asthma control, and exacerbation history. Treatment was adjusted in the control group on the basis of pharmacy refill rates (a measure of adherence), asthma control by ACT questionnaire, and history of exacerbations and visual management of inhaler technique. Both groups used a digitally enabled Inhaler Compliance Assessment (INCA) and PEF. The primary outcomes were asthma medication burden measured as proportion of patients who required a net increase in treatment at the end of 32 weeks and adherence rate measured in the last 12 weeks by area under the curve in the intention-to-treat population. The safety analyses included all patients who consented for the trial. The trial is registered with ClinicalTrials.gov, NCT02307669 and is complete.

FINDINGS

Between Oct 25, 2015, and Jan 26, 2020, of 425 patients assessed for eligibility, 220 consented to participate in the study, 213 were randomly assigned (n=108 in the active group; n=105 in the control group) and 200 completed the study (n=102 in the active group; n=98 in the control group). In the intention-to-treat analysis at week 32, 14 (14%) active and 31 (32%) control patients had a net increase in treatment compared with baseline (odds ratio [OR] 0·31 [95% CI 0·15-0·64], p=0·0015) and 11 (11%) active and 21 (21%) controls required add-on biological therapy (0·42 [0·19-0·95], p=0·038) adjusted for study site, age, sex, and baseline FeNO. Three (16%) of 19 active and 11 (44%) of 25 control patients increased their medication from fluticasone propionate 500 μg daily to 1000 μg daily (500 μg twice a day; adjusted OR 0·23 [0·06-0·87], p=0·026). 26 (31%) of 83 active and 13 (18%) of 73 controls reduced their medication from fluticasone propionate 1000 μg once daily to 500 μg once daily (adjusted OR 2·43 [1·13-5·20], p=0·022. Week 20-32 actual mean adherence was 64·9% (SD 23·5) in the active group and 55·5% (26·8) in the control group (between-group difference 11·1% [95% CI 4·4-17·9], p=0·0012). A total of 29 serious adverse events were recorded (16 [55%] in the active group, and 13 [45%] in the control group), 11 of which were confirmed as respiratory. None of the adverse events reported were causally linked to the study intervention, to the use of salmeterol-fluticasone inhalers, or the use of the digital PEF or INCA.

INTERPRETATION

Evidence-based care informed by digital data led to a modest improvement in medication adherence and a significantly lower treatment burden.

FUNDING

Health Research Board of Ireland, Medical Research Council, INTEREG Europe, and an investigator-initiated project grant from GlaxoSmithKline.

Phase 1 study to determine the safety and dosing of autologous PBMCs modified to present HPV16 antigens (SQZ-PBMC-HPV) in HLA-A*02+ patients with HPV16+ solid tumors

We conducted a dose escalation Phase 1 study of autologous PBMCs loaded by microfluidic squeezing (Cell Squeeze® technology) with HPV16 E6 and E7 antigens (SQZ-PBMC-HPV), in HLA-A*02+ patients with advanced/metastatic HPV16+ cancers. Preclinical studies in murine models had shown such cells resulted in stimulation and proliferation of antigen specific CD8+ cells, and demonstrated antitumor activity. Administration of SQZ-PBMC-HPV was every 3 weeks. Enrollment followed a modified 3+3 design with primary objectives to define safety, tolerability, and the recommended Phase 2 dose. Secondary and exploratory objectives were antitumor activity, manufacturing feasibility, and pharmacodynamic evaluation of immune responses. Eighteen patients were enrolled at doses ranging from 0.5 × 106 to 5.0 × 106 live cells/kg. Manufacture proved feasible and required < 24 h within the overall vein-to-vein time of 1 - 2 weeks; at the highest dose, a median of 4 doses were administered. No DLTs were observed. Most related TEAEs were Grade 1 - 2, and one Grade 2 cytokine release syndrome SAE was reported. Tumor biopsies in three patients showed 2 to 8-fold increases in CD8+ tissue infiltrating lymphocytes, including a case that exhibited increased MHC-I+ and PD-L1+ cell densities and reduced numbers of HPV+ cells. Clinical benefit was documented for the latter case. SQZ-PBMC-HPV was well tolerated; 5.0 × 106 live cells/kg with double priming was chosen as the recommended Phase 2 dose. Multiple participants exhibited pharmacodynamic changes consistent with immune responses supporting the proposed mechanism of action for SQZ-PBMC-HPV, including patients previously refractory to checkpoint inhibitors.

Oncologist-led germline genetic testing for uveal melanoma

PURPOSE

To report the genotype and phenotype of a cohort of unselected uveal melanoma (UM) patients who had germline multi-gene panel genetic testing, including the BAP1 gene, from a large multi-ethnic cancer centre. We describe the central role of the medical genetics clinic in collaboration with oncologists in a mainstreaming model to facilitate genetic testing, counselling and streamlining of patients with hereditary cancer predisposition.

METHODS

A retrospective chart review of clinical and genetic findings of unselected UM patients who had germline genetic testing between December 2019 and October 2021 was conducted. Extracted DNA from peripheral blood samples were analyzed with a multi-gene panel that included at least six genes associated with hereditary melanoma. The correlation between the genotype and the phenotype of the cohort was evaluated. Statistical analysis comprised descriptive and comparative statistics with significance assigned at p < .05. The genetics clinic streamlined patients among the relevant oncology clinics for cancer screening in germline BAP1 positive individuals.

RESULTS

In unselected UM patients, 3.5% (4/114) tested positive for a BAP1 pathogenic variant. Germline BAP1 status was associated with a family history of mesothelioma (p = .0015) and metastatic disease (p = .017). There were no other significant associations between the patient- or tumour-related characteristics and germline BAP1 results.

CONCLUSION

A germline BAP1 mutation was detected in 3.5% of unselected UM patients. The oncologist-initiated and genetics-led mainstreaming model is a straightforward process and can be utilized for offering genetic testing to all UM patients.

A242 DELAYED STEROID TAPER MAY REDUCE RISK OF RELAPSE IN PATIENTS WITH IMMUNE CHECKPOINT INHIBITOR ASSOCIATED HEPATOTOXICIT

Background

Immune checkpoint inhibitors (ICI) have become the cornerstone of treatment of certain malignancies. However, they can result in systemic toxicities including hepatitis. Societal guidelines recommend initial management with high dose steroids, then a slow taper as hepatitis resolves. However, there is significant variation in steroid response with some patients experiencing a relapse of hepatitis as steroid doses are tapered (“steroid relapse”).

Purpose

Identify clinical features that predict relapse, and to explore variations in steroid management, in patients with ICI hepatotoxicity.

Method

Patients receiving ICI in early phase clinical trials at Princess Margaret Cancer Centre, or treated at the Toronto Centre for Liver Disease for ICI hepatotoxicity, were included. Patients with CTCAE Grade (G)3 ICI hepatotoxicity (ALT >5 x ULN) were identified and clinical records reviewed for management and outcomes. Patients with an alternate cause for ALT elevation; who did not receive corticosteroids; or with HCC or viral hepatitis, were excluded.

Result(s)

Between August 2012 and December 2021, 36 patients with G3 ICI hepatotoxicity were identified. Most (23; 64%) had metastatic melanoma. Thirteen received anti-CTLA-4/PD-1; 18 anti-PD-1 or anti-PD-L1, and 5 anti-CTLA-4 monotherapy. All patients initially received corticosteroids (1-2mg/kg/day methylprednisone equivalent). Thirteen patients (36%) were steroid relapsers. Consistent steroid response was seen in 18 (50%). Age, sex, liver metastases, prior ICI exposure, peak ALT or starting dose of steroids (≤1.5 vs >1.5mg/kg/day methylprednisolone equivalents) did not predict relapse, although relapsers were more likely to have been treated with combination anti-CTLA-4/PD-1 (7 (54%) relapsers, vs 3 (16%) responders, p = 0.02). Relapse occurred after a median of 14.5 days (range 8-111), and after taper to median 54% (5-100) of initial steroid dose. In responders, ALT normalisation occurred after median 14 days (range 3-56). In 27 patients where sufficient data were available, societal guidelines on ALT thresholds to initiate steroid taper were followed in 13 (48%; 6 relapsers and 7 responders). However, initiation of steroid taper was delayed in responders compared to relapsers (after median 7 days (2-15) in responders vs 4 days (range 2-9) in relapsers, p = 0.04). Overall, 5 relapsers responded to re-escalation of steroids. Eight required additional treatment with MMF, and 4 required 3^rd line therapy with Tacrolimus. Ultimately, hepatitis resolved in all patients.

Conclusion(s)

In patients with ICI hepatotoxicity, combination ICI therapy confers a higher risk of steroid relapse than monotherapy. There is significant heterogeneity in management of steroid dosing in patients with ICI hepatotoxicity. Delayed initiation of steroid taper may be associated with a reduced risk of relapse and warrants prospective evaluation as part of a standardised management algorithm.

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Disclosure of Interest

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Promoting Self-management and Patient Activation Through eHealth: Protocol for a Systematic Literature Review and Meta-analysis

BACKGROUND

Major advances in different cancer treatment modalities have been made, and people are now living longer with cancer. However, patients with cancer experience a range of physical and psychological symptoms during and beyond cancer treatment. New models of care are needed to combat this rising challenge. A growing body of evidence supports the effectiveness of eHealth interventions in the delivery of supportive care to people living with the complexities of chronic health conditions. However, reviews on the effects of eHealth interventions are scarce in the field of cancer-supportive care, particularly for interventions with the aim of empowering patients to manage cancer treatment-related symptoms. For this reason, this protocol has been developed to guide a systematic review and meta-analysis to assess the effectiveness of eHealth interventions for supporting patients with cancer in managing cancer-related symptoms.

OBJECTIVE

This systematic review with meta-analysis is conducted with the aim of identifying eHealth-based self-management intervention studies for adult patients with cancer and evaluating the efficacy of eHealth-based self-management tools and platforms in order to synthesize the empirical evidence on self-management and patient activation through eHealth.

METHODS

A systematic review with meta-analysis and methodological critique of randomized controlled trials is conducted following Cochrane Collaboration methods. Multiple data sources are used to identify all potential research sources for inclusion in the systematic review: (1) electronic databases such as MEDLINE, (2) forward reference searching, and (3) gray literature. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for conducting the review were followed. The PICOS (Population, Interventions, Comparators, Outcomes, and Study Design) framework is used to identify relevant studies.

RESULTS

The literature search yielded 10,202 publications. The title and abstract screening were completed in May 2022. Data will be summarized, and if possible, meta-analyses will be performed. It is expected to finalize this review by Winter 2023.

CONCLUSIONS

The results of this systematic review will provide the latest data on leveraging eHealth interventions and offering effective and sustainable eHealth care, both of which have the potential to improve quality and efficiency in cancer-related symptoms.

TRIAL REGISTRATION

PROSPERO 325582; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325582.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38758.

Combined autologous blood patch-immediate patient rollover does not reduce the pneumothorax or chest drain rate following CT-guided lung biopsy compared to immediate patient rollover alone

PUPROSE

The purpose of this study was to evaluate a combined autologous blood-patch (ABP)-immediate patient rollover (IPR) technique compared with the IPR technique alone on the incidence of pneumothorax and chest drainage following CT-guided lung biopsy.

METHODS

In this interventional cohort study of both prospectively and retrospectively acquired data, 652 patients underwent CT-guided lung biopsy. Patient demographics, lesion characteristics and technical biopsy variables including the combined ABP-IPR versus IPR alone were evaluated as predictors of pneumothorax and chest drain rates using regression analysis.

RESULTS

The combined ABP-IPR technique was performed in 259 (39.7 %) patients whilst 393 (60.3 %) underwent IPR alone. There was no significant difference in pneumothorax rate or chest drains required between the combined ABP-IPR vs IPR groups (p =.08, p =.60 respectively). Predictors of pneumothorax adjusted for the combined ABP-IPR and IPR alone groups included age (p =.02), lesion size (p =.01), location (p =.005), patient position (p =.008), emphysema along the needle track (p =.005) and lesion distance from the pleura (p =.02). Adjusted predictors of chest drain insertion included lesion location (p =.09), patient position (p =.002), bullae crossed (p =.02) and lesion distance from the pleura (p =.02).

CONCLUSION

The combined ABP-IPR technique does not reduce the pneumothorax or chest drain rate compared to the IPR technique alone. Utilising IPR without an ABP following CT-guided lung biopsy results in similar pneumothorax and chest drain rates while minimising the potential risk of systemic air embolism.

Metamorphosis Imposes Variable Constraints on Genome Expansion through Effects on Development

Genome size varies ∼100,000-fold across eukaryotes and has long been hypothesized to be influenced by metamorphosis in animals. Transposable element accumulation has been identified as a major driver of increase, but the nature of constraints limiting the size of genomes has remained unclear, even as traits such as cell size and rate of development co-vary strongly with genome size. Salamanders, which possess diverse metamorphic and non-metamorphic life histories, join the lungfish in having the largest vertebrate genomes-3 to 40 times that of humans-as well as the largest range of variation in genome size. We tested 13 biologically-inspired hypotheses exploring how the form of metamorphosis imposes varying constraints on genome expansion in a broadly representative phylogeny containing 118 species of salamanders. We show that metamorphosis during which animals undergo the most extensive and synchronous remodeling imposes the most severe constraint against genome expansion, with the severity of constraint decreasing with reduced extent and synchronicity of remodeling. More generally, our work demonstrates the potential for broader interpretation of phylogenetic comparative analysis in exploring the balance of multiple evolutionary pressures shaping phenotypic evolution.

Heterogeneity in the use of biologics for severe asthma in Europe: a SHARP ERS study

Introduction

Treatment with biologics for severe asthma is informed by international and national guidelines and defined by national regulating bodies, but how these drugs are used in real-life is unknown.

Materials and methods

The European Respiratory Society (ERS) SHARP Clinical Research Collaboration conducted a three-step survey collecting information on asthma biologics use in Europe. Five geographically distant countries defined the survey questions, focusing on seven end-points: biologics availability and financial issues, prescription and administration modalities, inclusion criteria, continuation criteria, switching biologics, combining biologics and evaluation of corticosteroid toxicity. The survey was then sent to SHARP National Leads of 28 European countries. Finally, selected questions were submitted to a broad group of 263 asthma experts identified by national societies.

Results

Availability of biologics varied between countries, with 17 out of 28 countries having all five existing biologics. Authorised prescribers (pulmonologists and other specialists) also differed. In-hospital administration was the preferred deliverance modality. While exacerbation rate was used as an inclusion criterion in all countries, forced expiratory volume in 1 s was used in 46%. Blood eosinophils were an inclusion criterion in all countries for interleukin-5 (IL-5)-targeted and IL-4/IL-13-targeted biologics, with varying thresholds. There were no formally established criteria for continuing biologics. Reduction in exacerbations represented the most important benchmark, followed by improvement in asthma control and quality of life. Only 73% (191 out of 263) of surveyed clinicians assessed their patients for corticosteroid-induced toxicity.

Conclusion

Our study reveals important heterogeneity in the use of asthma biologics across Europe. To what extent this impacts on clinical outcomes relevant to patients and healthcare services needs further investigation.

This study, based on a three-step survey among 28 European countries, has demonstrated some similarities but also great disparities in the availability and use of biologics for severe asthma in Europehttps://bit.ly/3pqwlC5

Abstract LB001: Identifying MAGE-A4-positive tumors for SPEAR T-cell therapies in HLA-A*02-eligible patients

Autologous T-cells engineered with T-cell receptors (TCRs) targeting tumor antigens are promising therapies for metastatic solid cancers.1 Specific peptide enhanced affinity receptor (SPEAR) T-cell therapies are T-cells with engineered HLA-restricted TCRs that precisely target tumor cells with specific antigens, such as MAGE-A4 (a cancer testis antigen), presented on the surface by HLA molecules. In SPEAR T-cell clinical trials targeting MAGE-A4, a 2-step prescreen is done before enrolment. 1) Patients undergo HLA typing via a high-resolution (allelic, 4-digit) sequence-based assay, and those who are positive for the inclusion alleles (HLA-A*02:01P, 02:02P, 02:03P, 02:06P) and not positive for the exclusion allele A*02:05P are eligible. 2) Tumor MAGE-A4 testing is done via an immunohistochemical clinical trial assay (MAGE-A4+ cutoff: ≥30% tumor cell staining at ≥2+ intensity) in HLA-eligible patients. A screening protocol (NCT02636855) has been used in Phase 1 trials of first- and next-generation SPEAR T-cells targeting MAGE-A4 (NCT03132922, NCT04044859) with responses in multiple MAGE-A4+ tumors. As of November 19, 2021, 6,168 patients with 9 solid tumor types were screened at 32 sites across North America and Europe in this screening protocol; among which, 2,744 were HLA-eligible (eligibility rate: 45%, range per tumor type: 42%-55%). HLA-A*02:01 was the most frequent HLA-A*02 allele. Of these HLA-eligible patients, 1,549 had tumor tissues evaluable for MAGE-A4 expression; among which, 313 were MAGE-A4+ (MAGE-A4+ rate: 20%, range: 8%-54%) (Table). MAGE-A4 showed highest prevalence in synovial sarcoma and myxoid/round cell liposarcoma but was seen across all tumor types investigated. Our results will be discussed in the context of tumor histopathology, disease status, and demography. HLA and MAGE-A4 biomarker data will inform the therapeutic opportunities for SPEAR T-cells targeting MAGE-A4 in metastatic solid cancers. 1. D’Angelo et al. Cancer Discov. 2018;8:944.

HLA eligibility and MAGE-A4 prevalence in a screening protocol (NCT02636855) Indication Esophageal cancer Esophagogastric junction cancer Gastric cancer Head and neck squamous cell carcinoma Non-small cell lung cancer Melanoma Ovarian cancer Urothelial cancer Synovial sarcoma and myxoid/round cell liposarcoma HLA screened (N) 284 228 271 601 3189 668 539 270 118 HLA eligible (%) 46 45 43 42 43 50 49 43 55 MAGE-A4 evaluable (N) 104 91 73 200 457 245 225 93 61 MAGE-A4 positive (%) 22 25 8 22 14 16 24 32 54

Citation Format: Tianjiao Wang, Jean-Marc Navenot, Stavros Rafail, Mark Carroll, Ruoxi Wang, Cheryl McAlpine, Swethajit Biswas, Francine Brophy, Erica Elefant, Paige Bayer, Sandra McGuigan, Dennis Williams, George Blumenschein, Marcus Butler, Jeffrey M. Clarke, Justin F. Gainor, Ramaswamy Govindan, Victor Moreno, Janet Tu, David S. Hong. Identifying MAGE-A4-positive tumors for SPEAR T-cell therapies in HLA-A*02-eligible patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB001.

Recommended first-line management of brain metastases from melanoma: A multicenter survey of clinical practice

BACKGROUND

Radiotherapy (RT) and surgery (Sx) are effective in treating brain metastases. However, immune checkpoint inhibitors (ICI) have shown activity against asymptomatic melanoma brain metastases (MBM). BRAF/MEK inhibitors can be used to treat BRAF V600 mutation positive (BRAF+) MBM.

METHOD

We conducted an international survey among experts from medical oncology (MO), clinical oncology (CO), radiation oncology (RO), and neurosurgery (NS) about treatment recommendations for patients with asymptomatic BRAF+ or BRAF mutation negative (BRAF-) MBM. Eighteen specific clinical scenarios were presented and a total of 267 responses were collected. Answers were grouped and compared using Fisher's exact test.

RESULTS

In most MBM scenarios, survey respondents, regardless of specialty, favored RT in addition to systemic therapy. However, for patients with BRAF+ MBM, MO and CO were significantly more likely than RO and NS to recommend BRAF/MEK inhibitors alone, without the addition of RT, including the majority of MO (51%) for patients with 1-3 MBM, all <2cm. Likewise, for BRAF- MBM, MO and CO more commonly recommended single or dual agent ICI only and dual agent ICI therapy alone was the most common recommendation from MO or CO for MBM <2cm. When at least 1 of 3 MBM (BRAF+ or BRAF-) was >2cm, upfront Sx was recommended by all groups with the exception that MO and RO recommended RT for BRAF- MBM.

CONCLUSIONS

In most clinical settings involving asymptomatic MBM, experts recommended RT in addition to systemic therapy. However, recommendations varied significantly according to specialty, with MO and CO more commonly recommending dual systemic therapy alone for up to 9 BRAF- MBM <2cm.

Aligning tumor mutational burden (TMB) quantification across diagnostic platforms: phase II of the Friends of Cancer Research TMB Harmonization Project

BACKGROUND

Tumor mutational burden (TMB) measurements aid in identifying patients who are likely to benefit from immunotherapy; however, there is empirical variability across panel assays and factors contributing to this variability have not been comprehensively investigated. Identifying sources of variability can help facilitate comparability across different panel assays, which may aid in broader adoption of panel assays and development of clinical applications.

MATERIALS AND METHODS

Twenty-nine tumor samples and 10 human-derived cell lines were processed and distributed to 16 laboratories; each used their own bioinformatics pipelines to calculate TMB and compare to whole exome results. Additionally, theoretical positive percent agreement (PPA) and negative percent agreement (NPA) of TMB were estimated. The impact of filtering pathogenic and germline variants on TMB estimates was assessed. Calibration curves specific to each panel assay were developed to facilitate translation of panel TMB values to whole exome sequencing (WES) TMB values.

RESULTS

Panel sizes >667 Kb are necessary to maintain adequate PPA and NPA for calling TMB high versus TMB low across the range of cut-offs used in practice. Failure to filter out pathogenic variants when estimating panel TMB resulted in overestimating TMB relative to WES for all assays. Filtering out potential germline variants at >0% population minor allele frequency resulted in the strongest correlation to WES TMB. Application of a calibration approach derived from The Cancer Genome Atlas data, tailored to each panel assay, reduced the spread of panel TMB values around the WES TMB as reflected in lower root mean squared error (RMSE) for 26/29 (90%) of the clinical samples.

CONCLUSIONS

Estimation of TMB varies across different panels, with panel size, gene content, and bioinformatics pipelines contributing to empirical variability. Statistical calibration can achieve more consistent results across panels and allows for comparison of TMB values across various panel assays. To promote reproducibility and comparability across assays, a software tool was developed and made publicly available.

Airborne protection for staff is associated with reduced hospital-acquired COVID-19 in English NHS Trusts

Introduction

The rate of hospital-acquired coronavirus disease 2019 has reduced from 14.3% to 4.2% over the last year, but substantial differences still exist between English National Health Service (NHS) hospital trusts.

Methods

This study assessed rates of hospital-acquired infection (HAI), comparing NHS hospital trusts using airborne respiratory protection (e.g. FFP3 masks) for all staff, as a marker of measures to reduce airborne spread, with NHS hospital trusts using mainly droplet precautions (e.g. surgical masks).

Results/discussion

The use of respiratory protective equipment was associated with a 33% reduction in the odds of HAI in the Delta wave, and a 21% reduction in the odds of HAI in the Alpha wave (P<0.00001). It is recommended that all hospitals should prioritize airborne mitigation.

383 Durable responses with intratumoral electroporation of plasmid interleukin 12 plus pembrolizumab in patients with advanced melanoma progressing on an anti-PD-1 antibody: updated data from keynote 695

Background

Electroporated plasmid interleukin-12 (pIL-12-EP; tavokinogene telseplasmid; TAVO) induces sustained intratumoral expression of IL-12, a cytokine that is integral for response to anti-PD-1 antibodies. Here, we present updated safety and response duration data from KEYNOTE 695, a Phase 2, multicenter, open-label trial of pIL-12-EP in combination with pembrolizumab in patients with stage III/IV melanoma immediately following confirmed progression on an anti-PD-1 antibody.

Methods

Patients with confirmed disease progression after ≥12 weeks‘ treatment with an anti-PD-1 antibody alone or in combination were eligible. Patients received intratumoral pIL-12-EP on days 1, 5 and 8 every 6 weeks and pembrolizumab 200 mg every 3 weeks. Responses were assessed by the investigator at 12-week intervals using RECIST v1.1; overall survival (OS) and duration of response (DoR) assessments were conducted using the Kaplan-Meier method.

Results

Of the first 56 patients treated, 50% had visceral disease (M1b-d), 80% had received 1–2 and 20% ≥3 prior lines of therapy, 27% had prior ipilimumab and 21% prior BRAF/MEK inhibitors. 61% of patients were primary refractory to anti-PD-1. 54 patients were efficacy evaluable, defined as patients who had at least one post-treatment scan. The investigator-assessed objective response rate (ORR) per RECIST was 27.8% (4 CR, 11 PR); ORR per iRECIST was 29.6%. In patients with M1b-d staging, ORR was 33.3% (n=9/27), and in those receiving prior ipilimumab, ORR was 33.3% (n=5/15). Seven patients had 100% reduction in target lesions, and regression was observed in non-injected lesions. The median DoR had not been reached. With a median follow up of 19.3 months, the median OS (95% CI) was 24.5 (14.4, NR) months (figure 1). The study is now fully enrolled. In 105 patients with safety data, there were no Grade 4/5 treatment-related adverse events (TRAEs) reported. Grade 3 TRAEs occurred in 5.7% and comprised cellulitis in two patients and arthralgia, pneumonitis, enteritis, keratoacanthoma, lichen planus and musculoskeletal chest pain in one patient each. The Grade 1/2 TRAEs in ≥10% patients were fatigue (27.6%), procedural pain (20.0%), diarrhea (17.1%), nausea (10.5%) and pruritus (10.5%). ORR by blinded independent central review has commenced and a global phase 3 trial is planned.

Abstract 383 Figure 1

Overall survival in patients treated with pIL-12-EP in combination with pembrolizumab. Dark grey bars: time on study treatment, light grey bars: end of treatment to death or censoring

Conclusions

Patients with anti-PD-1 therapy refractory advanced melanoma can achieve deep, durable responses in both injected and non-injected lesions with pIL-12-EP plus pembrolizumab. Intratumoral pIL-12-EP in combination with pembrolizumab was generally well tolerated, with minimal Grade 3 and no Grade 4/5 TRAEs.

Trial Registration

NCT03132675

Ethics Approval

The study was approved by a central IRB and/or local institutional IRB/Ethics Committee as required for each participating institution.

Consent

Written informed consent was obtained from the patients participating in the trial; the current abstract does not include information requiring additional consent

538 Updated survival of patients with previously treated metastatic uveal melanoma who received tebentafusp

Background

Tebentafusp, a bispecific fusion protein consisting of an affinity-enhanced T cell receptor fused to an anti-CD3 effector that can redirect T cells to target gp100+ cells, has shown an overall survival benefit for patients with untreated metastatic uveal melanoma (mUM) in a Ph3 trial (NCT03070392). Metastatic uveal melanoma (mUM) is a historically treatment-refractory tumor with 1-year (yr), 2-yr and 3-yr OS rates of 37%, 15% and 9%, respectively, and median OS of 7.8 months in 2L+ patients.1 In the primary analysis of the phase 2 IMCgp100–102 study (NCT02570308) enrolling patients with previously treated mUM, the 1-year overall survival (OS) rate was 62% with median OS of 16.8 months.2 We present updated OS and safety after 2-year follow-up.

Methods

127 HLA-A*02:01+ 2L+ mUM patients were dosed weekly with tebentafusp following intra-patient dose escalation: 20mcg dose 1, 30mcg dose 2 and 68mcg dose 3+. Primary objective was ORR and secondary objectives included safety, OS and PFS. Here we present the updated OS and safety (data cut-off 31 Mar 2021).

Results

Median follow-up was 29.9 mos (range 1.8 – 59.9 mos). With extended follow-up, the 1-yr, 2-yr and 3-yr OS rates were 61%, 37% and 24%, respectively (figure 1). Median OS remained unchanged at 16.8 mos (95% CI, 12.8 – 22.5 mos).Mean and median duration of treatment were 9.5 mos and 5.6 mos (0 – 47.4 mos), respectively. As previously reported, most treatment-related AEs (TRAEs) occurred early on treatment. Beyond 6 months, no TRAE led to treatment discontinuation. No new safety signals, changes in the type or treatment-related deaths were reported. Beyond 12 months, there were a total of 7 Grade (G) 3 or 4 events in 3 (7%) patients, all were temporally related to tumor progression and majority included lab abnormalities. Episodes of rash, a common tebentafusp-related AE early on-treatment, were infrequent after 6 months, with no Grade 3 or 4 events.

Abstract 538 Figure 1

Kaplan-Meier estimate of overall survival at 2-yr follow-up of IMCgp100-102

Conclusions

This study provides the longest follow-up of OS and safety of a soluble TCR therapeutic to date. Tebentafusp continued to show promising survival for 2L+ mUM patients with estimated 2-yr OS rate of 37%. Tebentafusp’s safety profile was as expected and consistent with primary analysis showing that most adverse events occur early on treatment with incidence and severity decreasing with prolonged exposure.

Trial Registration

NCT02570308

References

Rantala ES, Hernberg M, Kivela TT. Overall survival after treatment for metastatic uveal melanoma: a systematic review and meta-analysis. Melanoma Res 2019;29:561–568.

Sacco JJ, Carvajal R, Butler MO, et al. A phase (ph) II, multi-center study of the safety and efficacy of tebentafusp (tebe) (IMCgp100) in patients (pts) with metastatic uveal melanoma (mUM). Ann Oncol 2020;31: S1442–S1143.

Ethics Approval

The institutional review board or independent ethics committee at each center approved the trial. The trial was conducted in accordance with the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines.

Reduced activity in a liaison psychiatry service during the peak of the COVID-19 pandemic: Comparison with 2019 data and characterisation of the SARS-COV-2 positive cohort

Introduction

The COVID-19 pandemic led to changes in how healthcare was accessed and delivered. It was suggested that COVID-19 will lead to an increased delirium burden in its acute phase, with variable effect on mental health in the longer term. Despite this, there are limited data on the direct effects of the pandemic on psychiatric care.

Objectives

1) describe the mental health presentations of a diverse acute inpatient population, 2) compare findings with the same period in 2019, 3) characterise the SARS-CoV-2 positive cohort of patients.

Methods

We present a descriptive summary of the referrals to a UK psychiatric liaison department during the exponential phase of the pandemic, and compare this to the same period in 2019.

Results

show a 40.3% reduction in the number of referrals in 2020, with an increase in the proportion of referrals for delirium and psychosis. One third (28%) of referred patients tested positive for COVID-19 during their admission, with 39.7% of these presenting with delirium as a consequence of their COVID-19 illness. Our data indicate decreased clinical activity for our service during the pandemic’s peak. There was a marked increase in delirium, though in no other psychiatric presentations.

Conclusions

In preparation for further exponential rises in COVID-19 cases, we would expect seamless integration of liaison psychiatry teams in general hospital wards to optimise delirium management in patients with COVID-19. Further consideration should be given to adequate staffing of community and crisis mental health teams to safely manage the potentially increasing number of people reluctant to visit the emergency department.

Management of acute disturbance: The intravenous route

Introduction

The intravenous (IV) is one of the main parenteral routes for drug administration. Rapid onset of action, precise titration, patient-specific dosing and bypass of liver metabolism are a few of its advantages, while hypersensitivity reactions, adverse effects, infection risk and a higher overall cost some of its most debated downsides. Unlike other areas of Medicine, IV has been significantly under-utilized in Psychiatry.

Objectives

This systematic review analyzed the evidence for effectiveness and safety behind the use of IV medication used for the management of acute disturbance.

Methods

APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible studies. Studies were included if they used IV medication to treat acute disturbance, in English language, had participants aged >18. The quality of the included studies was assessed using the National Institutes of Health quality checklist.

Results

17 studies were deemed eligible. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly between each study. Findings showed strong evidence for efficacy and safety of dexmedetomidine, droperidol, midazolam, and olanzapine. These medications displayed a short time to sedation, reduction in agitation levels, or large percentage of patients adequately sedated with a low number of adverse events. Results did not provide enough evidence for the use of IV ketamine, haloperidol, diazepam, lorazepam, and promethazine.

Conclusions

This review supports dexmedetomidine, droperidol, midazolam, and olanzapine as safe and efficacious options for managing acute disturbance via the intravenous route, particularly in special clinical settings where trained staff, optimal monitoring, resuscitation equipment and ventilators are all at hand.

Transcriptional analysis of metastatic uveal melanoma survival nominates NRP1 as a therapeutic target

Uveal melanoma is a rare form of melanoma with particularly poor outcomes in the metastatic setting. In contrast with cutaneous melanoma, uveal melanoma lacks BRAF mutations and demonstrates very low response rates to immune-checkpoint blockade. Our objectives were to study the transcriptomics of metastatic uveal melanoma with the intent of assessing gene pathways and potential molecular characteristics that might be nominated for further exploration as therapeutic targets. We initially analyzed transcriptional data from The Cancer Genome Atlas suggesting PI3K/mTOR and glycolysis as well as IL6 associating with poor survival. From tumor samples collected in a prospective phase II trial (A091201), we performed a transcriptional analysis of human metastatic uveal melanoma observing a novel role for epithelial-mesenchymal transition associating with survival. Specifically, we nominate and describe initial functional validation of neuropillin-1 from uveal melanoma cells as associated with poor survival and as a mediator of proliferation and migration for uveal melanoma in vitro. These results immediately nominate potential next steps in clinical research for patients with metastatic uveal melanoma.

285 Phase I clinical trial evaluating the safety of ADP-A2M10 in patients with MAGE-A10+ head and neck, melanoma, or urothelial tumors

Background

ADP-A2M10 SPEAR T-cells are genetically engineered autologous T-cells that express a high affinity MAGE-A10-specific T-cell receptor targeting MAGE-A10+tumors in the context of HLA A*02. This trial is no longer enrolling (NCT02989064).

Methods

This ADP-A2M10 dose escalation trial utilized a modified 3+3 design to evaluate safety and antitumor activity. Patients (pts) with advanced head and neck squamous cell carcinoma (HNSCC), melanoma, or urothelial cancer (UC) were enrolled. Pts were HLA A*02+ with tumors expressing MAGE A10. Pts underwent apheresis; T cells were isolated, transduced with a lentiviral vector containing the MAGE-A10 TCR, and expanded. Eligible pts underwent lymphodepletion with fludarabine and cyclophosphamide prior to receiving ADP-A2M10. ADP-A2M10 was administered at Dose Level (DL) 1 = 0.1 × 109, DL2 = >1.2 - 6×109, and Expansion = 1.2–15×109 transduced cells.

Results

As of January 10, 2020, 10 pts (8 male and 2 female) with HNSCC (4), melanoma (3), and UC (3) cancers were treated. Three pts each were treated at DL1 and DL2 and 4 pts were treated in Expansion. The most frequently reported adverse events ≥ Grade 3 were lymphopenia (10 pts), neutropenia (10), anemia (8), leukopenia (7), and thrombocytopenia (5). Two pts reported CRS (1 Grade 1, 1 Grade 3) with resolution. Responses included: 3 pts - stable disease, 5 pts – progressive disease, 1 pt – not evaluable, and 1 pt too early to determine. ADP-A2M10 SPEAR T-cells were detectable in peripheral blood from pts at each dose level and in tumor tissues from several pts at Expansion.

Conclusions

There was no evidence of on- or off-target toxicity. Given the minimal antitumor activity and the discovery that MAGE-A10 expression frequently overlaps with MAGE-A4 expression, the clinical program has closed. Several trials with SPEAR T-cells targeting MAGE-A4 are ongoing (https://bit.ly/35htsZK).

Trial Registration

NCT02989064

Ethics Approval

The trial was conducted in accordance with the principles of the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines and was approved by local authorities. An independent ethics committee or institutional review board approved the clinical protocol at each participating center. All the patients provided written informed consent before study entry.

Differentiating combined pulmonary fibrosis and emphysema from pure emphysema: utility of late gadolinium-enhanced MRI

Background

Differentiating combined pulmonary fibrosis with emphysema (CPFE) from pure emphysema can be challenging on high-resolution computed tomography (HRCT). This has antifibrotic therapy implications.

Methods

Twenty patients with suspected CPFE underwent late gadolinium-enhanced (LGE) thoracic magnetic resonance imaging (LGE-MRI) and HRCT. Data from twelve healthy control subjects from a previous study who underwent thoracic LGE-MRI were included for comparison. Quantitative LGE signal intensity (SI) was retrospectively compared in regions of fibrosis and emphysema in CPFE patients to similar lung regions in controls. Qualitative comparisons for the presence/extent of reticulation, honeycombing, and traction bronchiectasis between LGE-MRI and HRCT were assessed by two readers in consensus.

Results

There were significant quantitative differences in fibrosis SI compared to emphysema SI in CPFE patients (25.8, IQR 18.4–31.0 versus 5.3, IQR 5.0–8.1, p < 0.001). Significant differences were found between LGE-MRI and HRCT in the extent of reticulation (12.5, IQR 5.0–20.0 versus 25.0, IQR 15.0–26.3, p = 0.038) and honeycombing (5.0, IQR 0.0–10.0 versus 20.0, IQR 10.6–20.0, p = 0.001) but not traction bronchiectasis (10.0, IQR 5–15 versus 15.0, IQR 5–15, p = 0.878). Receiver operator curve analysis of fibrosis SI compared to similarly located regions in control subjects showed an area under the curve of 0.82 (p = 0.002). A SI cutoff of 19 yielded a sensitivity of 75% and specificity of 86% in differentiating fibrosis from similarly located regions in control subjects.

Conclusion

LGE-MRI can differentiate CPFE from pure emphysema and may be a useful adjunct test to HRCT in patients with suspected CPFE.

Estimated population prevalence of cardiac transthyretin amyloidosis in elderly men derived from incidental cardiac uptake from routine bone scans – “we're going to need a bigger boat”

Background/Introduction

Transthyretin amyloidosis (TTR) is a cause of restrictive cardiomyopathy and heart failure predominantly in elderly men. Two main factors have moved TTR amyloidosis from super-specialist centres into mainstream cardiology:

We aimed to determine the potential magnitude of referrals to our embryonic cardiac TTR service from patients having routine bone scans for non-cardiac reasons. We planned to estimate the prevalence of cardiac TTR in our local over 65 male population to plan service provision.

Methods

All HDP bone scans performed at a teaching and research hospital in the UK from the 2017/18 financial year were reviewed (n=1530). Our hospital is the only provider of these scans locally. Of these, 1399 were for oncological and musculoskeletal (oncology/MSK) indications and 37 were referred to specifically “exclude amyloidosis”. We excluded paediatric and duplicate follow-up imaging. There are approximately 140,000 people over aged 65 living within our catchment region. We have assumed approximately 50% are male.

Results

Myocardial uptake was present in 7/1399 of the oncology/MSK group and 3/7 (43%) of these already had features of heart failure. In these 7 patients bone scans were performed to investigate bony metastases in 6 (1 oesophageal cancer and 5 for prostate cancer) and 1 following an orthopaedic procedure. Cardiac uptake was present in 10/37 of the “exclude amyloid” group. In those with cardiac uptake across both groups (17) 94% were male with a mean age of 83 (sd ±6.59) and 41% were from the oncology/musculoskeletal group. Incidental cardiac uptake was seen in 1:200 routine HDP scans. When looking at males &gt;65 specifically the uptake rate increases to (6 out of 701 scans) i.e. 1:117. Assuming there is no increased risk of TTR in patients with prostate or oesophageal cancer, then an estimate of cardiac TTR in the 75,000 males over the age of 65 locally would be approximately 640 men.

Conclusions

Bone scans account for 41% of all HDP scans with incidental cardiac uptake and therefore represents a significant potential referral source for a cardiac amyloid service. Our data suggests a potential prevalence of cardiac amyloidosis in 1:117 men over 65 with 43% already having heart failure symptoms and signs. Our age and sex specific prevalence suggests cardiac TTR is neither a rare nor unusual diagnosis. We will use our prevalence estimate to ensure our cardiac TTR service is resourced appropriately. We suggest that cardiac amyloid and cardio-oncology services should include pathways incorporating rapid access routes for suitable patients with incidental cardiac uptake on bone scans performed by non-cardiologists.

Funding Acknowledgement

Type of funding source: None

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Sara Alert: An enduring national resource to support public health monitoring & disease containment

Background

Public health agencies had to respond swiftly to the novel coronavirus that emerged in 2019 (COVID-19) to try to contain the virus, which requires early identification of new cases. Monitoring exposed individuals is labor intensive and available tools are often limited. MITRE, a company that operates federally funded research and development centers for the U.S. government, rapidly developed a configurable monitoring tool that allows public health authorities to monitor potentially exposed individuals in their jurisdictions.

Methods

A team, including public health leaders, field epidemiologists, software engineers, and health communication specialists, was quickly assembled to design and develop an open source, disease-independent monitoring tool called Sara Alert. Outreach to key public health stakeholders, including partner organizations and local and state health departments, was conducted early for requirements gathering and to validate assumptions. Public health law experts were consulted regarding data privacy and security.

Results

By four weeks, a minimally viable monitoring tool was available for testing by public health partners. Exposed individuals can be enrolled and reminded daily to enter a temperature and any symptoms by web or mobile interface, SMS messaging or phone. Public health officials monitor and can quickly take action if symptoms consistent with COVID-19 are reported of if there is failure to report within a configurable time frame. Dashboards provide insight into aggregated data appropriate to level of view.

Conclusions

Sara Alert serves as a force multiplier that supports disease containment and allows resources to be directed where they are most needed. Successful development was possible because key stakeholders across public health practice were consulted early. Sara Alert is available, free, to state and local public health departments and serves as an enduring resource easily configured for the next public health emergency.

Key messages

Sara Alert serves as a force multiplier that supports disease containment and allows resources to be directed where they are most needed.

Sara Alert serves as an enduring resource easily configured for the next public health emergency.

0377 A Strengths-Based Approach to Examine Obstructive Sleep Apnea in Black and White Patients

Introduction

The majority of studies on race/ethnic disparities in OSA are derived from a deficit-based perspective (i.e. &gt;BMI, non-adherence to PAP). It would prove useful to identify which aspects are protective to inform potential treatment approaches. We focused on two potential factors: resilience and social support, in patients newly diagnosed with OSA. Given the high prevalence of insomnia complaints in patients with OSA, insomnia was our outcome of interest.

Methods

91 patients newly diagnosed with OSA provided demographic and socioeconomic status, sleep measures (Epworth, DBAS), resilience (Connor Davidson Resiliency Scale), social support (MOS Social Support Scale) and completed the Insomnia Severity Index. The cross-sectional associations between ISI, race/ethnicity, resilience, social support and their interaction effects were examined using linear regression models with covariate adjustment for participant age, sex and BMI. We ascertained total ISI score and individual items.

Results

The sample was 34.1% black (n=31), mean age of 57.6 years, SD=13.6, 64.8% male (n=59), and mean BMI of 32.4, SD=7.04. Mean sleep duration (as reported by sleep diary) was 6.64, SD=1.35. Black, white differences were not observed for sleepiness (M=8.60; 10.43, p=0.11) or DBAS (M=4.61; M=5.04, p=0.30). Blacks, reported clinically significant insomnia (M=15.00, SD=7.17) compared to whites (M=12.02, SD=6.83, p=0.05). On the individual ISI items, blacks were significantly more likely to endorse difficulty falling asleep (M=1.58, SD=1.54; M=0.75, SD=0.93,p=0.002) and waking up too early (M=2.09, SD=1.26; M=1.45, SD=0.93,p=0.021) compared to whites. Resilience (M=30.04, SD=6.42) and social support scores (M=74.13, SD=21.36) did not differ by race/ethnicity. In adjusted linear analysis, resilience had significant effect on ISI score (b=-0.36, SE=0.12, p=0.003) but not social support (b=-0.06, SE=0.08, p=0.31).

Conclusion

In this study we did not observe race/ethnic differences for sleepiness and dysfunctional beliefs about sleep. With respect to the protective factors, race/ethnic differences were not observed. Resilience, not social support, was related to insomnia complaints. Future studies should examine a variety of factors that may serve black and other racial/ethnic groups with OSA, and help elucidate protective processes.

Support

K23HL125939

Guillain-Barré Syndrome following a series of novel therapies adapting the gold-standard in the era of immune priming

Over the past two decades, there has been a fundamental shift away from traditional cytotoxic chemotherapy towards the identification, and subsequent suppression of specific oncogenes. Immunotherapy and targeted therapy prime the immune system, potentially leading to deleterious side effects. The following case of Guillain-Barré Syndrome (GBS) emphasizes the importance of considering every agent when iatrogenic toxicity is suspected. We underline the possibility of immune priming by checkpoint inhibitors. An optimal understanding of the pathogenesis and toxicity of targeted therapy is key in an era where the prognosis of melanoma is revolutionized by the use of novel agents. Our case emphasizes the importance of considering every agent in the context of toxicity induced by combined novel therapies.

A systematic review and meta-analysis of patient data from the West Africa (2013-16) Ebola virus disease epidemic

BACKGROUND

Over 28 000 individuals were infected with Ebola virus during the West Africa (2013-2016) epidemic, yet there has been criticism of the lack of robust clinical descriptions of Ebola virus disease (EVD) illness from that outbreak.

OBJECTIVES

To perform a meta-analysis of published data from the epidemic to describe the clinical presentation, evolution of disease, and predictors of mortality in individuals with EVD. To assess the quality and utility of published data for clinical and public health decision-making.

DATA SOURCES

Primary articles available in PubMed and published between January 2014 and May 2017.

ELIGIBILITY

Studies that sequentially enrolled individuals hospitalized for EVD and that reported acute clinical outcomes.

METHODS

We performed meta-analyses using random-effect models and assessed heterogeneity using the I2 method. We assessed data representativeness by comparing meta-analysis estimates with WHO aggregate data. We examined data utility by examining the availability and compatibility of data sets.

RESULTS

In all, 3653 articles were screened and 34 articles were included, representing 16 independent cohorts of patients (18 overlapping cohorts) and at least 6168 individuals. The pooled estimate for case fatality rate was 51% (95% CI 46%-56%). However, pooling of estimates for clinical presentation, progression, and predictors of mortality in individuals with EVD were hampered by significant heterogeneity, and inadequate data on clinical progression. Our assessment of data quality found that heterogeneity was largely unexplained, and data availability and compatibility were poor.

CONCLUSIONS

We have quantified a missed opportunity to generate reliable estimates of the clinical manifestations of EVD during the West Africa epidemic. Clinical data standards and data capture platforms are urgently needed.

Evaluating steady-state resting energy expenditure using indirect calorimetry in adults with overweight and obesity

BACKGROUND

Determining a period of steady state (SS) is recommended when estimating resting energy expenditure (REE) using a metabolic cart. However, this practice may be unnecessarily burdensome and time-consuming in the research setting.

AIM

The aim of the study was to evaluate the use of SS criteria, and compare it to alternative approaches in adults with overweight and obesity.

METHODS

In this cross-sectional, ancillary analysis, participants enrolled in a bariatric (study 1; n = 13) and lifestyle (study 2; n = 51) weight loss intervention were included. Indirect calorimetry was performed during baseline measurements using a metabolic cart for 25 min, including a 5-min stabilization period at the start. SS was defined as the first 5-min period with a coefficient of variation (CV) ≤10% for both VO₂ and VCO₂ (hereafter REE_5-SS). Body composition was measured using bioelectrical impedance analysis in study 2 participants only. REE_5-SS was compared against the lowest CV (REE_CV-lowest), 5-min time intervals (REE_6-10, REE_11-15, REE_16-20, REE_21-25), 4-min and 3-min SS intervals (REE_4-SS and REE_3-SS), and time intervals of 6-15, 6-20 and 6-25 min (REE_6-15, REE_6-20, and REE_6-25) using repeated measures ANOVA and Bland-Altman analysis to test for bias, limits of agreement and accuracy (±6% measured REE).

RESULTS

Participants were 54 ± 13 years old, mostly women (75%) and had a BMI of 35 ± 5 kg/m². Overall, 54/63 (84%) of participants reached REE_5-SS, often (47/54, 87%) within the first 10-min (6-15 min). Alternative approaches to estimating REE had a relatively low bias (-16 to 13 kcals), narrow limits of agreement and high accuracy (83-98%) when compared to REE_5-SS, in particular, outperforming standard prediction equations (e.g., Mifflin St. Joer).

CONCLUSION

Indirect calorimetry measurements that utilize the 5-min SS approach to estimate REE are considered the gold-standard. Under circumstances of non-SS, it appears 4-min and 3-min SS periods, or fixed time intervals of atleast 5 min are accurate and practical alternatives for estimating REE in adults with overweight and obesity. However, future trials should validate alternative methods in similar populations to confirm these findings.

RADI-08. A SURVEY BASED STUDY OF BRAIN METASTASES MANAGEMENT FOR PATIENTS WITH NON-SMALL CELL LUNG CANCERS OR MELANOMA

INTRODUCTION: The standard of care for 1–4 brain metastases (BrM) is stereotactic radiosurgery (SRS), whereas whole brain radiation remains the standard treatment for extensive BrM, and surgical resection is appropriate in certain scenarios. Some newer systemic therapies such as tyrosine kinase inhibitors and immunotherapy have impressive CNS activity and are used by some practitioners either alone or in combination with other modalities as first-line treatment for BrM. We conducted a survey to ascertain current real-world practices for the treatment of BrM from NSCLC and melanoma. OBJECTIVES: Our study aimed to assess practice patterns of oncologists who treat BrM from NSCLC or melanoma. We also investigated the extent to which various clinical factors influence decision making. METHODOLOGY: We created 2 sets of surveys: one for Medical-/Clinical-/Neuro- oncologists and another for Radiation oncologists/Neurosurgeons. Surveys were conducted online or on-line. Following administration, data was tabulated and analyzed. Statistical analyses were performed using Fisher’s exact test. RESULTS: Of 361 respondents, 250 were Radiation oncologists/Neurosurgeons, and 111 were Medical-/Clinical-/Neuro- oncologists. For patients with 1–3 brain lesions, all < 2cm, 34% of respondents recommended systemic therapy alone as first-line treatment. In contrast, only 15% recommend systemic therapy alone for >9 lesions, at least one > 2cm. Medical-/Clinical-/Neuro- oncologists were more likely to recommend systemic therapy alone compared to Radiation oncologists/ Neurosurgeons for 1–3 lesions, all < 2cm (53% vs. 28%, p< .0001). For patients with > 9 BrM, one >2cm diameter, Medical-/Clinical-/Neuro- oncologists were not significantly more likely to recommend systemic therapy alone (20% vs 13%, p=.11). DISCUSSION: Our results reveal that significant numbers of physicians recommend systemic therapy alone as first-line therapy in BrM and that management decisions correlate with a physician’s type of practice. These findings underscore the need for prospective clinical trials to direct appropriate BrM management.

Dose-Ranging and Cohort-Expansion Study of Monalizumab (IPH2201) in Patients with Advanced Gynecologic Malignancies: A Trial of the Canadian Cancer Trials Group (CCTG): IND221

PURPOSE

Monalizumab binds CD94/NKG2A, preventing HLA-E inhibition of tumor lymphocytes. A dose-ranging/cohort expansion trial of monalizumab for recurrent gynecologic malignancies was conducted to determine the recommended phase II dose (RP2D) and to explore clinical activity, pharmacokinetics, pharmacodynamics, safety, and immunogenicity.

PATIENTS AND METHODS

Participants (and part 2 expansion cohorts) included (i) platinum-sensitive ovarian, (ii) platinum-resistant ovarian, (iii) squamous cervical (CX), and (iv) epithelial endometrial (END) carcinomas. Part 1 assessed monalizumab at 1, 4, or 10 mg/kg every 2 weeks. In part 2, ≥4 patients/cohort underwent pre- and on-treatment tumor biopsies. Preset criteria determined cohort expansion.

RESULTS

A total of 58 participants were evaluable. The RP2D was 10 mg/kg i.v. every 2 weeks. Dose proportionality and 100% NKG2A saturation were observed. Related adverse events were mild: headache, abdominal pain, fatigue, nausea, and vomiting. Grade 3 related adverse events were nausea (1), vomiting (1), dehydration (1), fatigue (2), anorexia (1), dyspnea (1), and proctitis (1). Dose-limiting toxicities were not observed. Hematologic and biochemical changes were mild and not dose related. Best response was SD: part 1, 7 of 18 (39%) [3.4 months (1.4-5.5)], and part 2, 7 of 39 (18%) [1.7 months (CX) to 14.8 months (END)]. Neither a predictive biomarker for SD nor evidence of pharmacodynamic effects was identified. There was a trend to significance between a reduction in lymphocyte HLA-E total score and pharmacodynamics.

CONCLUSIONS

Monalizumab 10 mg/kg i.v. every 2 week is well tolerated in patients with pretreated gynecologic cancers. Short-term disease stabilization was observed. Future studies should assess combinations with other agents, including immunotherapeutics.

Abstract 3141: The relationship between BRAF/NRAS/KIT genomic driver mutations and anti-PD1 immunotherapy responses in patients with advanced melanoma

Background: Anti-PD1 immunotherapy, when used alone or in combination (combo) with anti-CTLA4, prolongs overall (OS) and progression-free survival (PFS) of patients (pts) with advanced melanoma, compared to single-agent (SA) anti-CTLA4. Combo immunotherapy is more toxic than SA anti-PD1, therefore it is of interest to identify patients most likely benefit from SA anti-PD1 to spare these pts the toxicity of combo immunotherapy. We asked whether genomic driver mutations (mts) in BRAF, NRAS or KIT could predict anti-PD1 responses in melanoma pts.

Methods: We preformed a single-center retrospective analysis of 292 melanoma pts who received SA or combo anti-PD1 immunotherapy at Princess Margaret Hospital between 2012-17. BRAF/NRAS/KIT mts and other covariates were abstracted from chart review. Multivariable Cox models were used to assess differences in OS/PFS.

Results: We identified 209 and 83 melanoma patients who received SA-anti-PD1 or combo immunotherapy, respectively. Pt characteristics were: mean age 59 yrs; 56% male; 77% cutaneous/unknown primary 23% uveal or mucosal; 17% brain metastases; 34% stage M0/M1a/M1b, 66% stage M1c/M1d, 51% BRAF/NRAS/KIT mt. Among pts receiving SA anti-PD1, presence of a BRAF, NRAS, or KIT mt was an independent predictor of poor PFS (HR 1.84; 95% CI 1.21-2.81) and OS (HR 1.93; 95% CI 1.17-3.22) in multivariate models. Other negative predictors of poor survival were: elevated LDH, multiple previous lines of therapy, 3 or more sites of metastasis, and uveal or mucosal histology. Combo immunotherapy was independently associated with longer OS compared to SA anti-PD1 in BRAF/NRAS/KIT mt pts (HR 0.43; 95% CI 0.20-0.90), but not in BRAF/NRAS/KIT wild-type pts (HR 1.34; 95% CI 0.46-3.90).

Conclusions: In this retrospective study, the presence of a BRAF NRAS or KIT mt was an independent predictor of poor PFS/OS in melanoma pts treated with SA anti-PD1. Combo immunotherapy prolonged survival vs SA anti-PD1 in BRAF/NRAS/KIT mt melanoma, but not in BRAF/NRAS/KIT wild-type melanoma. These data suggest that BRAF/NRAS/KIT wild-type melanoma pts may derive less added benefit from combo immunotherapy (vs single agent anti-PD1) compared to pts with BRAF/NRAS/KIT mutations. Validation analyses are on-going.

Citation Format: April A.N. Rose, Susan M. Armstrong, David Hogg, Marcus Butler, Anthony M. Joshua, Danny Ghazarian, Suzanne Kamel-Reid, Ayman Al Habeeb, Mary Anne Chappell, Kendra Ross, Eitan Amir, Phillippe L. Bedard, Lillian Siu, Anna Spreafico. The relationship between BRAF/NRAS/KIT genomic driver mutations and anti-PD1 immunotherapy responses in patients with advanced melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3141.

An analysis of nivolumab-mediated adverse events and association with clinical efficacy in resected stage III or IV melanoma (CheckMate 238)

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Background: In both previous 18- and 24-month follow-up reports from CheckMate 238, NIVO demonstrated significantly longer recurrence-free survival (RFS) than ipilimumab (IPI) in patients (pts) with resected stage IIIB/C or stage IV melanoma. Here we provide a more comprehensive analysis of treatment-related adverse events (TRAEs) for NIVO over discrete follow-up intervals and an investigation of the association of these AEs with efficacy (RFS). Methods: Eligible pts were aged ≥15 years and underwent complete resection of stage IIIB/C or IV melanoma. A total of 453 pts were treated with NIVO 3 mg/kg Q2W for up to 1 year. The primary endpoint was RFS. Pts were followed for safety for up to 100 days following their last dose; as of the previous 18-month database lock, all pts had been off study drug for > 100 days. Here safety data were analyzed within discrete time intervals: months 0–3 of treatment (0–3), months 3–12 of treatment (3–12), and from last dose to 100 days after last dose (+100). In addition, the association of TRAEs with RFS was investigated using the 24-month efficacy dataset, accounting for time-delay bias within the first 12 weeks after randomization. Results: The incidence of the first onset of TRAEs reported in ≥5% of pts was highest in the 0–3 time frame; the most common TRAEs with NIVO were fatigue (28% for 0–3 vs 6% for 3–12 vs 2% for +100), pruritus (16% vs 7% vs 1%), and diarrhea (15% vs 7% vs 2%). Most TRAEs with NIVO resolved within 3 months of occurrence, except for endocrine AEs, which could have required hormone supplementation, and skin AEs (median overall resolution time of 48 and 22 weeks, respectively). Similar results were observed in an analysis taking into account repeat occurrences of TRAEs over time. Analyses investigating the association of TRAEs with RFS are ongoing and will be presented. Conclusions: These results in pts with resected stage IIIB/C or IV melanoma are consistent with the established safety profile of NIVO. Based on the time periods analyzed, the majority of TRAEs with adjuvant NIVO occurred early during treatment, and patients had a reduced frequency of TRAEs after the treatment course. The majority of select TRAEs resolved within 3 months. Clinical trial information: NCT02388906.

Computer-assisted image analysis of the tumor microenvironment on an oral tongue squamous cell carcinoma tissue microarray

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Tissue segmentation can be achieved using a spatially registered cytokeratin mask.

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Automated and manual cell counts and stain intensities were highly correlated.

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Smokers had significantly stronger PD-L1 stain intensity and higher numbers TILs.

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After radiotherapy, greater CD8+ TILs was associated with inferior survival.

Oral tongue squamous cell carcinoma (OTSCC) displays variable levels of immune cells within the tumor microenvironment. The quantity and localization of tumor infiltrating lymphocytes (TILs), specific functional TIL subsets (e.g., CD8+), and biomarker-expressing cells (e.g., PD-L1+) may have prognostic and predictive value. The purpose of this study was to evaluate the robustness and utility of computer-assisted image analysis tools to quantify and localize immunohistochemistry-based biomarkers within the tumor microenvironment on a tissue microarray (TMA). We stained a 91-patient OTSCC TMA with antibodies targeting CD3, CD4, CD8, FOXP3, IDO, and PD-L1. Cell populations were segmented into epithelial (tumor) or stromal compartments according to a mask derived from a pan-cytokeratin stain. Definiens Tissue Studio was used to enumerate marker-positive cells or to quantify the staining intensity. Automated methods were validated against manual tissue segmentation, cell count, and stain intensity quantification. Univariate associations of cell count and stain intensity with smoking status, stage, overall survival (OS), and disease-free survival (DFS) were determined. Our results revealed that the accuracy of automated tissue segmentation was dependent on the distance of the tissue section from the cytokeratin mask and the proportion of the tissue containing tumor vs. stroma. Automated and manual cell counts and stain intensities were highly correlated (Pearson coefficient range: 0.46–0.90; p < 0.001). Within this OTSCC cohort, smokers had significantly stronger PD-L1 stain intensity and higher numbers of CD3+, CD4+ and FOXP3+ TILs. In the subset of patients who had received adjuvant radiotherapy, a higher number of CD8+ TILs was associated with inferior OS and DFS. Taken together, this proof-of-principle study demonstrates the robustness and utility of computer-assisted image analysis for high-throughput assessment of multiple IHC markers on TMAs, with potential implications for studies on prognostic and predictive biomarkers.

Validation of CyTOF Against Flow Cytometry for Immunological Studies and Monitoring of Human Cancer Clinical Trials

Flow cytometry is a widely applied approach for exploratory immune profiling and biomarker discovery in cancer and other diseases. However, flow cytometry is limited by the number of parameters that can be simultaneously analyzed, severely restricting its utility. Recently, the advent of mass cytometry (CyTOF) has enabled high dimensional and unbiased examination of the immune system, allowing simultaneous interrogation of a large number of parameters. This is important for deep interrogation of immune responses and particularly when sample sizes are limited (such as in tumors). Our goal was to compare the accuracy and reproducibility of CyTOF against flow cytometry as a reliable analytic tool for human PBMC and tumor tissues for cancer clinical trials. We developed a 40+ parameter CyTOF panel and demonstrate that compared to flow cytometry, CyTOF yields analogous quantification of cell lineages in conjunction with markers of cell differentiation, function, activation, and exhaustion for use with fresh and viably frozen PBMC or tumor tissues. Further, we provide a protocol that enables reliable quantification by CyTOF down to low numbers of input human cells, an approach that is particularly important when cell numbers are limiting. Thus, we validate CyTOF as an accurate approach to perform high dimensional analysis in human tumor tissue and to utilize low cell numbers for subsequent immunologic studies and cancer clinical trials.

Abstract PD8-07: Does resection of cavity shave margins result in lower positive margin and re-excision rates in patients with stage 0-III breast cancer? Results from a prospective multicenter randomized controlled trial

INTRODUCTION: Routine resection of cavity shave margins has been shown in single center studies to result in a significant reduction in positive margin and re-excision rates. In this prospective multicenter randomized controlled trial, we sought to validate these findings across practice settings.

METHODS: Nine centers across the United States, varying in practice setting and patient population, participated in this clinical trial of 398 stage 0-III breast cancer patients undergoing partial mastectomy (with or without resection of selective cavity margins). Participants were stratified by clinical stage and randomized 1:1 to either have routine cavity shave margins resected (“shave”) or not (“no shave”). Randomization group was revealed to the surgeon intraoperatively, after they had completed their standard partial mastectomy and were ready to close. Positive margins were defined as “tumor at ink” for invasive cancer or within 2 mm for ductal carcinoma in situ (DCIS). Adverse events were defined as seromas requiring percutaneous drainage, and/or hematomas or abscesses requiring operative intervention.

RESULTS: Median patient age was 65 (range; 29-94). 116 patients had invasive disease, 74 had DCIS, 179 had both, and 29 had no residual cancer at the time of partial mastectomy. The median invasive cancer size was 1.2 cm (range; 0.05-8.00 cm); the median extent of DCIS was 0.9 cm (range; 0.05-6.40 cm). The “shave” and “no shave” groups were well matched at baseline for clinicopathologic and demographic factors.

FactorShave (n=197)No Shave (n=201)p-valueAge (years); median (range)67 (36-94)64 (29-89)0.585Race  0.062-- White173 (87.8%)164 (81.6%) -- Black20 (10.2%)33 (16.4%) -- Asian2 (1.0%)2 (1.0%) -- Native American0 (0%)2 (1.0%) -- Unknown/Declined2 (1.0%)0 (0%) Hispanic ethnicity28 (14.2%)32 (15.9%)0.806Invasive tumor size (cm); median (range)1.30 (0.09-8.00)1.20 (0.05-7.50)0.282DCIS extent (cm); median (range)0.80 (0.10-6.40)1.00 (0.05-5.50)0.906Invasive histology  0.556-- Ductal177 (89.8%)186 (92.5%) -- Lobular16 (8.1%)13 (6.5%) -- Mucinous3 (1.5%)2 (1.0%) -- Other1 (0.5%)0 (0%) Neoadjuvant therapy15 (7.6%)19 (9.5%)0.592Palpable tumor57 (28.9%)56 (27.9%)0.825Node positive*24 (16.3%)16 (10.6%)0.175*Of the 298 patients who had lymph nodes evaluated

Prior to randomization, positive margin rates were similar in the “shave” and “no shave” groups (38.1% vs. 37.3%, respectively, p=0.918). After randomization, however, those in the “shave” group were significantly less likely than those in the “no shave” group to have positive margins (8.6% vs. 37.3%, respectively, p&lt;0.001). They were also less likely to require re-excision or mastectomy for margin clearance (8.6% vs. 23.9%, p&lt;0.001). There were no significant differences between the two groups in terms of adverse events (p=0.280). Rates of seroma (1.5% vs. 0.5%, p=0.368), hematoma (0.5% vs. 0.5%, p=1.000) and abscess (0.3% vs. 0%, p=0.495) were similar between the “shave” and “no shave” groups, respectively.

CONCLUSION: Resection of cavity shave margins significantly reduces positive margin and re-excision rates in patients with stage 0-III breast cancer undergoing partial mastectomy.

Citation Format: Chagpar AB, Tsangaris T, Garcia-Cantu C, Howard-McNatt M, Chiba A, Berger AC, Levine E, Gass JS, Gallagher K, Lum SS, Martinez RD, Willis AI, Pandya SV, Brown EA, Fenton A, Mendiola A, Murray M, Haddad V, Solomon NL, Senthil M, Bansil H, Ollila D, Snyder SK, Edmonson D, Lazar M, Namm JP, Li F, Butler M, McGowan NE, Herrera ME, Avitan YP, Yoder B, Dupont E. Does resection of cavity shave margins result in lower positive margin and re-excision rates in patients with stage 0-III breast cancer? Results from a prospective multicenter randomized controlled trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-07.

Safety and efficacy of durvalumab in patients with head and neck squamous cell carcinoma: results from a phase I/II expansion cohort

INTRODUCTION

Durvalumab selectively blocks programmed cell death ligand-1 (PD-L1) binding to programmed cell death-1. Encouraging clinical activity and manageable safety were reported in urothelial carcinoma, non-small-cell lung cancer (NSCLC), hepatocellular carcinoma (HC) and small-cell lung cancer (SCLC) in a multicenter phase I/II study. Safety and clinical activity in recurrent/metastatic head and neck squamous cell carcinoma (HNSCC) were evaluated in the expansion phase.

METHODS

Patients received 10 mg/kg of durvalumab intravenously every 2 weeks for 12 months or until confirmed progressive disease or unacceptable toxicity. The primary objective was safety; clinical activity was a secondary objective.

RESULTS

Sixty-two patients were enrolled and evaluable (received first dose ≥24 weeks before data cutoff). Median age was 57 years; 40.3% were human papillomavirus (HPV)-positive; 32.3% had tumour cell PD-L1 expression ≥25%, and 62.9% were current/former smokers. They had a median of 2 prior systemic treatments (range, 1-13). All-causality adverse events (AEs) occurred in 98.4%; drug-related AEs occurred in 59.7% and were grade III-IV in 9.7%. There were no drug-related discontinuations or deaths. Objective response rate (blinded independent central review) was 6.5% (15.0% for PD-L1 ≥25%, 2.6% for <25%). Median time to response was 2.7 months (range, 1.2-5.5); median duration was 12.4 months (range, 3.5-20.5+). Median progression-free survival was 1.4 months; median overall survival (OS) was 8.4 months. OS rate was 62% at 6 months and 38% at 12 months (42% for PD-L1 ≥25%, 36% for <25%).

CONCLUSIONS

Durvalumab safety in HNSCC was manageable and consistent with other cohorts of the study. Early, durable responses in these heavily pretreated patients warrant further investigation; phase III monotherapy and combination therapy studies are ongoing. CLINICAL TRIAL REGISTRY: clinicaltrials.gov NCT01693562; MedImmune study 1108.

Arthroscopic subtalar arthrodesis through the sinus tarsi portal approach: A series of 77 cases

BACKGROUND

Subtalar arthrodesis through an open approach carries significant risk of complications. An arthroscopic approach aims to minimise damage to the soft tissue envelope to improve recovery, union and complication rates. A two portal approach through the sinus tarsi was used.

METHODS

A retrospective review of all patients undergoing isolated arthroscopic arthrodesis was performed.

RESULTS

Seventy-seven procedures were performed. Successful arthrodesis was achieved in 75 (97.4%). Two patients underwent successful revision arthrodesis for aseptic nonunion. There was one (1.3%) superficial infection and one (1.3%) partial sural nerve injury.

CONCLUSIONS

Two-portal sinus tarsi arthroscopic subtalar arthrodesis is safe and effective. Advantages over other arthroscopic approaches are the access to all three facets of the joint, avoidance of a posterolateral portal in order to minimise risk to the sural nerve, and the ability to use the same approach to arthrodese the entire triple hindfoot joint complex. Technical tips and pitfalls are discussed.

Current landscape of immunotherapy in the treatment of solid tumours, with future opportunities and challenges

Immunotherapy has emerged as a new standard of care, showing survival benefit for solid tumours in multiple disease sites and indications. The survival improvements seen in diseases that were highly resistant to traditional therapies, with a poor prognosis, are unprecedented. Although the benefits observed in clinical trials are undeniable, not all patients derive those benefits, leading to emerging combination strategies and an ongoing quest for biomarker selection. Here, we summarize the current evidence for immunotherapy in the treatment of solid tumours, and we discuss emerging strategies at the forefront of research. We discuss future challenges that will be encountered as experience and knowledge continue to expand in this rapidly emerging field.

Antitumour activity of pembrolizumab in advanced mucosal melanoma: a post-hoc analysis of KEYNOTE-001, 002, 006

Background

Mucosal melanoma is an aggressive melanoma with poor prognosis. We assessed efficacy of pembrolizumab in patients with advanced mucosal melanoma in KEYNOTE-001 (NCT01295827), −002 (NCT01704287), and −006 (NCT01866319).

Methods

Patients received pembrolizumab 2 mg/kg every 3 weeks (Q3W) or 10 mg/kg Q2W or Q3W. Response was assessed by independent central review per RECIST v1.1.

Results

1567 patients were treated and 84 (5%) had mucosal melanoma. Fifty-one of 84 were ipilimumab-naive. In patients with mucosal melanoma, the objective response rate (ORR) was 19% (95% CI 11–29%), with median duration of response (DOR) of 27.6 months (range 1.1 + to 27.6). Median progression-free survival (PFS) was 2.8 months (95% CI 2.7–2.8), with median overall survival (OS) of 11.3 months (7.7–16.6). ORR was 22% (95% CI 11–35%) and 15% (95% CI 5–32%) in ipilimumab-naive and ipilimumab-treated patients.

Conclusion

Pembrolizumab provides durable antitumour activity in patients with advanced mucosal melanoma regardless of prior ipilimumab.