Indoximod-based chemo-immunotherapy for pediatric brain tumors: A first-in-children phase I trial

BACKGROUND

Recurrent brain tumors are the leading cause of cancer death in children. Indoleamine 2,3-dioxygenase (IDO) is a targetable metabolic checkpoint that, in preclinical models, inhibits anti-tumor immunity following chemotherapy.

METHODS

We conducted a phase I trial (NCT02502708) of the oral IDO-pathway inhibitor indoximod in children with recurrent brain tumors or newly diagnosed diffuse intrinsic pontine glioma (DIPG). Separate dose-finding arms were performed for indoximod in combination with oral temozolomide (200 mg/m2/day x 5 days in 28-day cycles), or with palliative conformal radiation. Blood samples were collected at baseline and monthly for single-cell RNA-sequencing with paired single-cell T cell receptor sequencing.

RESULTS

Eighty-one patients were treated with indoximod-based combination therapy. Median follow-up was 52 months (range 39-77 months). Maximum tolerated dose was not reached, and the pediatric dose of indoximod was determined as 19.2 mg/kg/dose, twice daily. Median overall survival was 13.3 months (n = 68, range 0.2-62.7) for all patients with recurrent disease and 14.4 months (n = 13, range 4.7-29.7) for DIPG. The subset of n = 26 patients who showed evidence of objective response (even a partial or mixed response) had over 3-fold longer median OS (25.2 months, range 5.4-61.9, p = 0.006) compared to n = 37 nonresponders (7.3 months, range 0.2-62.7). Four patients remain free of active disease longer than 36 months. Single-cell sequencing confirmed emergence of new circulating CD8 T cell clonotypes with late effector phenotype.

CONCLUSIONS

Indoximod was well tolerated and could be safely combined with chemotherapy and radiation. Encouraging preliminary evidence of efficacy supports advancing to Phase II/III trials for pediatric brain tumors.

Validity of 1% Hormonal Receptor Positivity Cutoff by the ASCO/College of American Pathologists Guidelines at the Georgia Cancer Center

PURPOSE

Treatment of breast cancer (BC) with borderline or low (1%-9%) estrogen and progesterone expression remains controversial, with recent data disputing ASCO/College of American Pathologists 2010 guidelines that lowered the threshold of receptor positivity from 10% to 1%. The objective of this retrospective study was to validate these guidelines at the Georgia Cancer Center with a high percentage of Black race.

METHODS

All female patients with invasive BC diagnosed between 2005 and 2010 at the Georgia Cancer Center were chart reviewed up to an 11-year follow-up with data cutoff at 2016. We used Cox regression to explore survival among three hormonal status (HS) groups (< 1%, 1%-9%, and ≥ 10%) adjusting for all known BC clinicopathologic variables. Fisher's exact test was used to evaluate response to endocrine therapy (ET).

RESULTS

Among 431 patients with mean age 59 years, 24.75% had HS < 1%, 17.5% HS 1%-9%, and 57.75% HS ≥ 10%. Race was 43.75% Black and 54% White. Disease stages were early (I-IIIA) in 84.4% and advanced (IIIB-IV) in 15.56%. Mortality in HS < 1% was significantly higher than that in HS ≥ 10% (hazard ratio [HR]: 1.8; 95% CI, 1.07 to 3.02), whereas no significant mortality difference between HS 1%-9% and HS ≥ 10% (HR: 1.05; 95% CI, 0.48 to 2.30) was observed. ET was protective, and treated patients had higher predicted survival than untreated patients in the 1%-9% group (HR: 0.10; 95% CI, 0.01 to 0.85). There was no significant mortality difference between ET-treated HS 1%-9% and ≥ 10% groups.

CONCLUSION

One percent cutoff predicted superior survival on treatment with ET compared with the other groups, and HS as low as 1%-9% was equiprognostic to HS ≥ 10%. Whether other factors such as lymphovascular invasion, grade, and other parameters change the behavior of the 1%-9% HS group remains to be explored.

IMMU-04. FIRST-IN-CHILDREN PHASE 1B STUDY USING THE IDO PATHWAY INHIBITOR INDOXIMOD IN COMBINATION WITH RADIATION AND CHEMOTHERAPY FOR CHILDREN WITH NEWLY DIAGNOSED DIPG (NCT02502708, NLG2105)

Background

Diffuse intrinsic pontine glioma (DIPG) is a uniformly fatal brain tumor with no available cure. Indoximod blocks the IDO (indoleamine 2,3-dioxygenase) pathway, thereby reversing IDO-mediated immune suppression in the tumor microenvironment.

Methods

Patients aged 3 to 21 years with treatment-naive DIPG were eligible for this phase 1b dose-confirmation study of indoximod. The treatment regimen comprised continuous oral indoximod (38.4 mg/kg/day divided twice daily) with conformal photon radiation (54 Gy in 30 fractions), followed by cycles of indoximod with temozolomide (200 mg/m2/day, days 1–5 in 28-day cycles).

Results

Thirteen patients (median age 9 years, range 5 to 20 years) with DIPG were treated. Median OS was 14.5 months (follow-up ranged 4.8 to 29.3 months), 12-month OS was 61.5% (8/13), and 18-month OS was 30.8% (4/13), with 1 patient remaining in follow-up at the data cutoff. This compared favorably to expected median OS of approximately 10.8 months, 12-month OS of 45.3%, and 18-month OS of 16.2% taken from published historical data from the Pediatric Brain Tumor Consortium. Two patients showed near-complete responses lasting until relapsing after 7.6 months and 13.3 months of study therapy, respectively. Many patients had increased circulating non-classical monocytes (nc-Monos, CD16+, CD14neg, CD33+, HLA-DR+) within the first 3 treatment cycles, and elevation of this early pharmacodynamic marker was predictive of subsequent OS. Patients with nc-Monos &gt;10% (n=7) had median OS of 19 months, whereas patients with nc-Monos below 10% (n=5) had median OS of 7 months (p=0.0047). No patients stopped therapy for toxicity. The most common indoximod-attributed adverse events were thrombocytopenia, neutropenia, nausea, vomiting, dizziness, and fatigue.

Conclusions

Adding indoximod immunotherapy to conventional radiation and chemotherapy for front-line treatment of pediatric patients with DIPG was well-tolerated. Improved outcomes were observed in patients having evidence of pharmacodynamic response. A follow-on phase 2 study is in progress (NCT04049669).

Financial Analysis of Free Lung Cancer Screening Program Shows Profitability Using Broader NCCN Guidelines

BACKGROUND

Lung cancer screening with low-dose computed tomography (LDCT) chest scans in high-risk populations has been established as an effective measure of preventive medicine by the National Lung Screening Trial. However, the sustainability of funding a program is still controversial. We present a 2.5-year profitability analysis of our screening program by using the broader National Comprehensive Cancer Network criteria.

METHODS

Retrospective chart review was performed on the initial 2.5-year data set of a free LDCT chest scan program that targeted the underserved Southeastern United States. Patients were selected by the National Comprehensive Cancer Network high-risk criteria, screening twice as many patients compared with Centers for Medicare and Medicaid Services criteria. LDCT scans were performed during the off-service hours of our positron emission tomography CT scanner. Analysis of fiscal years 2015 to 2017 was done to evaluate indirect cost, direct cost, and adjusted net margin per case after factoring downstream revenue from positive scans and other findings.

RESULTS

A total of 705 scans were performed with 418 patients referred for subsequent procedures or specialist evaluations. The mean overhead cost over total cost was 42.3%. The adjusted net margin per case was -$212 in the first year but turned positive to $177 in the third fiscal year. The total break-even point of adjusted net margin was between 6% and 7% of indirect cost as a function of charges. Of the 60 new patients introduced to the hospital system, a gross margin per case of $211 was found.

CONCLUSIONS

Free lung cancer screening can demonstrate profitability from downstream revenue with a lag time of 2 years.

Free Lung Cancer Screening Trends Toward a Twofold Increase in Lung Cancer Prevalence in the Underserved Southeastern United States

OBJECTIVES

The National Lung Screening Trial (NLST) reported that the prevalence of lung cancer in individuals at high risk for the disease is 1%, and that screening these individuals using low-dose helical computed tomography of the chest saves lives. To increase screening accessibility in the underserved southeastern United States, we developed a free lung screening program, modeled after the Lahey Hospital & Medical Center Free Lung Screening Program, for individuals meeting National Comprehensive Cancer Network high-risk criteria.

METHODS

This was a chart review of 264 participants screened in the first year of our program. Participants were divided into categories based on the Lung Imaging Reporting and Diagnostic System. Categories three and four were considered positive findings, with demographic and disease criteria collected on these patients.

RESULTS

Of 264 participants screened, 28 (10.6%) were Lung Imaging Reporting and Diagnostic System category four, 23 (8.7%) were category three, 78 (29.5%) were category two, and 135 (51.1%) were category one. Eight of the 264 participants (3.0%) had lung cancer, with 75% detected in early stages.

CONCLUSIONS

We found a lung cancer prevalence in our high-risk screened population of 3.0% (8 of 264). After adjusting for patients who were symptomatic on clinical evaluation, we report a prevalence of cancer at 2.2% compared with 1.1% in the first year of the National Lung Screening Trial and a prevalence of 1.9% versus 0.6% compared with the National Comprehensive Cancer Network criteria in the first 10 months at Lahey Hospital & Medical Center. This study justifies low-dose helical computed tomography screening in high-risk regions because lung cancer treatment before symptoms appear is more effective, and the prevalence of disease in the detectable preclinical phase is high.

Validity of 1% hormonal positivity cutoff by American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines at Georgia Cancer Center

1094

Background: Hormone Receptor Status (HS) in breast cancer (BC) is a universally accepted biomarker. ASCO/CAP 2010 guidelines set the threshold of Estrogen and Progesterone Receptor positivity to 1 %. BC with 1-9% HS expression remains controversial with recent data disputing these guidelines. The objective of this retrospective study was to validate these guidelines at Georgia Cancer Center (GCC) with high percentage of black race. Methods: All female patients with invasive BC diagnosed between 2005-2010 at GCC (11y follow-up) were chart reviewed. We used Cox proportional hazards model to explore survival among three HS groups ( < 1%, 1-9%, ≥10%) adjusting for standard prognostic factors. Hazard ratios (HR) and 95% confidence intervals (CI) were also reported. 1-9 %, and ≥10% groups were further explored using same method to test survival difference with or without hormone therapy (HT). Fischer’s Exact test was used to evaluate response to HT in these groups. Results: 400 patients (all stages) with mean age of 59, were 24.75% HS < 1%, 17.5% HS1-9%, and 57.75% HS≥10%. Race was 43.75% Black, and 54% White. Disease stages were 84.4% early (I-IIIA) and 15.56% late (IIIB-IV). Grades were 51.42% low (1-2) and 48.58% high (3). The 2 groups (1-9%, ≥10%) received chemotherapy (42.86%, 39.83%), and HT (58.57%, 80.52%) respectively while 70.71% of < 1% HS group had chemotherapy. Mortality in HS < 1% was significantly higher than HS ≥10% (HR 1.8, 95% CI 1.07-3.02), while mortality between HS 1-9% and HS ≥10% was not different (HR 1.05, 95% CI 0.48-2.30). Treated (HT) subjects had lower mortality than untreated subjects in the 1-9% group (HR 0.10, 95% CI 0.01-0.85). 100% of HT group had no evidence of tumor at last follow up compared to 87.5% in non-treatment group (p = 0.048). There was no significant difference in mortality between treated (HT) 1-9% and ≥10% groups. Conclusions: Hormone receptor expression as low as 1-9% was found to be equi-prognostic to ≥10% expression. It also predicted response to hormonal therapy. Whether other factors as lympho-vascular invasion, grade, and other parameters change the behavior of the 1-9% HS group remain to be explored.

Breast cancer molecular subtypes association with clinical outcomes and race

e12575

Background: Breast Cancer (BC) has been classified into four subtypes: Luminal A (LABC), Luminal B (LBBC), Triple negative (TNBC) and HER2-enriched (HER2e). BC mortality in Black women is significantly higher than in Whites and Asians. BC in Blacks has been characterized by higher grade and later stage. Causes of the Black-White BC survival disparity have been investigated, including differences in: diagnostic stage, socioeconomics, and comorbidities. These have led researchers to investigate the differences in tumor molecular subtype and their association with clinical outcomes and races. Methods: This study used the Surveillance, Epidemiology, and End Results – 18 (SEER-18) Registries research data between 2010 and 2013 that included over 212,000 patients. Descriptive statistics, Odds ratios (OR) and 95%Confidence intervals (CI) were used to study the association between BC stage, grade, and mortality and BC molecular subtypes across different races. We employed Cox regression models to explore the race disparity in BC mortality before and after controlling for BC molecular subtype and other clinical and social factors. Results: TNBC had more high grade cancer compared to HER2e subtype (OR, 1.5; CI, 1.3 - 1.8), LBBC (OR, 4.5; CI, 4.0 - 5.0) and LABC (OR, 12.2; CI, 11.2 – 13.3) for Black. BC mortality was higher in TNBC subtype compared to HER2e subtype (OR, 1.3; CI, 1.1 - 1.6), LBBC (OR, 2.4; CI, 2.0 - 2.9), and LABC (OR, 2.8; CI, 2.4 – 3.2) for Blacks. Results are consistent for all races. HER2e subtype had more late cancer stage compare to LBBC (OR, 1.2; CI, 1.0 - 1.4), TNBC (OR, 1.4; CI, 1.2 - 1.6) and LABC (OR, 2.1; CI, 1.8 - 2.4) in Blacks with similar results in all races. BC mortality in Blacks was higher compare with Whites (HR, 1.9; CI, 1.8 - 2.0) and Asian (HR, 2.7; CI, 2.5 - 3.0). After controlling for cancer subtype and other factors in the Cox regression model, the corresponding HRs ware significantly decreased to 1.2 (CI, 1.1 -1.3) and 1.6 (9CI, 1.5 -1.8). Blacks have heighst percent in stage IV and grade higer grade of disease. Conclusions: Molecular subtypes of BC contribute differently to risks of late cancer stage, high cancer grade and BC specific mortality. These differences are consistent in all races. The molecular subtypes and other social and clinical factors may explain part of the BC mortality race disparity.

Impact of support group participation in women with gynecologic cancer

252

Background: Unlike breast cancer support group literature, there is no data in women with gynecologic cancer who have different perspectives about their disease and therapy. We have a well-established, grass root level support group unique to women with gynecologic cancers that meets monthly. Our goal was to investigate perceived benefits of support group participation. Methods: We developed an original questionnaire to evaluate the CSRA Gynecologic Oncology Support Group (CGOSG) participant’s perceived effects of attending the group on their side effects and disease status which was distributed to patients attending CGOSG meetings. 47 surveys were collected for analysis; Wilcox rank sum test was used as appropriate. Patients were also administered the validated FACT-G questionnaire addressing physical well-being (PWB), emotional well-being (EWB), social well-being (SWB), and functional well-being (FWB). 33 surveys were collected, and t-tests were conducted using FACIT SAS scoring program. Results: In the original questionnaire, the 2 top reasons that patients attended CGOSG were physician driven (28%) and to meet other women with the same diagnosis (26%). The most concerning physical side effect from their cancer or therapy was fatigue (21%), and patients with more than 5 visits reported that CGOSG participation improved their fatigue with a median score of 7.5 ± 4 out of 10. The most concerning emotional side effect was fear of recurrence (26%), and patients reported the CGOSG improved their fear of recurrence with a median score of 9 ± 2 out of 10. Patients with more than one visit, not on treatment reported a higher quality of life score (p = 0.001) and perceived a positive impact on cancer therapy (p = 0.02) compared to patients on treatment. Among patients who took the validated FACT-G questionnaire, those on active treatment had a lower PWB than patients not on therapy (p = 0.01). The mean subscale scores were PWB 21.99, SWB 24.26, EWB 20.08, FWB 20.92 with patients faring best in social well-being. Conclusions: This is a first of a kind attempt to understand the impact of a well-organized support group on women with gynecological cancers which indicates that these women struggle with fear of recurrence but are able to find some solace.

Prospective study to evaluate impact of support group participation in women with gynecological cancer

243

Background: Unlike breast cancer support group literature, there is no data in women with gynecologic cancers who have different perspective about their disease and therapy. We have a well-established (10 years old) active grass root level support group unique to women with gynecologic cancers that meets monthly. Our goal was to investigate perceived benefits of support group participation. Methods: We developed a prospective questionnaire to evaluate the CSRA Gynecologic Oncology Support Group (CGOSG) participant’s perceived effects of attending the group on their side effects and disease status. The questionnaire was distributed to patients attending CGOSG meetings over a 4 month period. 47 surveys were collected for analysis; Wilcox rank sum test was used as appropriate. Results: The common cancers were 52% ovarian, 26% endometrial and 62% were currently on therapy. The 3 top reasons that patients attended CGOSG were physician driven (28%), to meet other women with the same diagnosis (26%) and to learn more about their cancer (22%). The top 3 expectations of patients were emotional support (28%), bonding/companionship (21%), and cancer education (14%). The top 3 concerning physical side effects from their cancer or therapy were fatigue (21%), memory loss (14%), and peripheral neuropathy (14%). Patients with more than 5 visits reported that CGOSG participation improved their most concerning physical side effect (fatigue) with a median score of 7.5 ± 4 out of 10. The top 3 concerning emotional side effects identified were fear of recurrence (26%), living with uncertainty (20%) and defining a new sense of normal (15%). Patients reported the CGOSG improved their most concerning emotional side effect (fear of recurrence) with a median score of 9 ± 2 out of 10. Patients with more than one visit, not on treatment reported a higher quality of life score (p = 0.001) and perceived a positive impact on cancer therapy (p = 0.02) compared to patients on treatment. Conclusions: This is a first of a kind attempt to understand the impact of a well-organized support group on women with gynecological cancers which indicates that these women struggle with fear of recurrence and uncertainty, but are able to find some solace.

Rates and Risk Factors for Condition-Specific Hospitalizations in HIV-Infected and Uninfected Women

BACKGROUND

The rates and risk factors for overall and medical condition-specific hospitalizations in HIV-positive women have not been examined in detail or compared with rates in risk factor-matched HIV-negative women.

OBJECTIVE

To determine the rates and risk factors for overall and condition-specific hospitalizations.

METHODS

Prospective cohort study of 885 HIV-positive women and 425 HIV-negative women followed for semiannual research visits between 1993 and 2000 in 4 urban locations in the United States. Outcome measures were hospitalization diagnoses with diabetes mellitus, nonacute renal conditions, cardiovascular conditions, liver conditions, AIDS defining conditions, and overall hospitalizations. Clinical and laboratory risk factors were assessed at research visits every 6 months, and effects of risk factors on hospitalization rates were calculated using generalized estimating equations and Poisson regression.

RESULTS

Renal laboratory abnormalities, hypertension, and clinical AIDS were each associated with 3 of the 5 condition-specific hospitalization rates. Over time, diabetes-, nonacute renal-, and cardiovascular-related rates were flat or slightly increased and liver-related rates were significantly increased in HIV-positive women. Hospitalization rates with an AIDS-defining condition declined sharply in the latter half of the study period.

CONCLUSIONS

In this population of largely African-American, inner-city, HIV-infected women, renal abnormalities, hypertension, and hepatitis C virus infection were common. Rate ratios indicated that "non-AIDS" risk factors were important predictors of hospitalization. In the highly active antiretroviral therapy era, clinicians must pay attention to these risk factors for morbidity and should closely monitor renal abnormalities, hypertension, and hepatitis status.

Intravenous ribavirin for hantavirus pulmonary syndrome: safety and tolerance during 1 year of open-label experience. Ribavirin Study Group

Intravenous ribavirin was provided non-selectively for investigational open-label use among persons with suspected hantavirus pulmonary syndrome (HPS) in the United States between 4 June 1993 and 1 September 1994. Therapy was initiated prior to laboratory confirmation of hantavirus infection because most deaths from HPS occur within 48 h of hospitalization. Thirty patients with confirmed HPS, 105 patients without HPS and 5 patients without adequate diagnostic testing for HPS were enrolled. This observational study arguably provides the most complete information available on ribavirin-associated adverse effects. Although ribavirin was generally well tolerated, 71% of recipients became anaemic and 19% underwent transfusion. An apparent excess of hyperamylasaemia/pancreatitis was either therapy-associated or due to enrollment bias. The 30 enrolled HPS patients had a case-fatality rate of 47% (14/30). It is not possible to assess efficacy with this study design. However, comparison of survival curves for the 30 enrolled HPS patients and 34 patients who developed HPS during the same time period but were not enrolled did not suggest an appreciable drug effect. A randomized, placebo-controlled trial that enrolls patients during the prodrome phase would be necessary to assess the efficacy and further define the safety of intravenous ribavirin for HPS.

Ebola hemorrhagic fever, Democratic Republic of the Congo, 1995: determinants of survival

In May 1995, an international team characterized and contained an outbreak of Ebola hemorrhagic fever in Kikwit, Democratic Republic of the Congo. This study reports the descriptive features of this outbreak along with a statistical analysis of the outbreak data. Proportional hazards analysis was used to examine the effect of age, phase of the outbreak, and sex on the risk of death, and a conditional probability analysis was used to examine the effectiveness of whole blood transfusion from convalescent patients on survival. Two hundred fifty case-patients (80.7%) died. The main predictor of survival in the proportional hazards model was age. No statistical evidence of a survival benefit of transfusion of blood from convalescent patients was evident after adjusting for age, sex, and the days since onset of symptoms (P = .1713).

Human immunodeficiency virus type 2 (HIV-2) seroprevalence and characterization of a distinct HIV-2 genetic subtype from the natural range of simian immunodeficiency virus-infected sooty mangabeys

The extent of zoonotic infections in rural Sierra Leone, where both feral and pet sooty mangabeys harbor divergent members of the human immunodeficiency virus type 2 (HIV-2)-sooty mangabey simian immunodeficiency virus (SIVsm) family, was tested in blood samples collected from 9,309 human subjects in 1993. Using HIV-1- and HIV-2-specific enzyme immunoassays and confirmatory Western blot analysis to test for antibodies to SIVsm-related lentiviruses, we found only nine subjects (0.096%) who tested positive for HIV: seven tested positive for HIV-1 and two tested positive for HIV-2. Compared with other rural West African communities, Sierra Leone displayed the lowest seroprevalence (0.021%) of HIV-2 infection yet reported, much lower than the previously reported seroprevalence in SIVsm-infected feral and household pet sooty mangabeys. Heteroduplex analysis demonstrated that two of the newly found HIV-1 strains belonged to subtype A, the most common HIV-1 subtype in Africa, but this is the first report of subtype A in Sierra Leone. The two HIV-2-infected individuals harbored two distinct HIV-2 strains, designated 93SL1 and 93SL2. Phylogenetic analysis indicated that HIV-2 93SL1 is a member of HIV-2 subtype A, the first strain of this HIV-2 subtype found in Sierra Leone. In contrast, HIV-2 93SL2 belongs to none of the five previously characterized HIV-2 subtypes (A to E) but is a new subtype, herein designated F, having the most divergent transmembrane sequences yet reported for HIV-2. The fact that both of the two most divergent HIV-2 subtypes known, E and F, are rare and found as single occurrences in persons from Sierra Leone may be related to the fact that this small region of West Africa also contains free-living and household pet sooty mangabeys with highly divergent variants of SIVsm. This finding provides support for the hypotheses that new HIV-2 subtypes result from independent cross-species transmission of SIVsm to the human population and that these single-occurrence transmission events had not spread widely into the population by 1993.