Defining the Transcriptional Landscapes of the Tumor Microenvironment of Cervical and Vaginal Cancers at Single-Cell Resolution

PURPOSE/OBJECTIVE(S)

Malignancies found within vaginal tissue are often diagnosed as cancers of the cervix, vulva, or urethra and are clinically treated with similar modalities. However, the rarity of vaginal cancer may be an artifice of categorization; current treatment paradigms do not take into account tissue-specific mutations and differences in mechanistic pathways intracellularly. Understanding the shared and distinctly different transcriptional profiles of vaginal and cervical tumors at a single-cell resolution will provide insights in vaginal tumor biology and will open avenues for future clinical interventions.

MATERIALS/METHODS

Biopsies of tumor and adjacent normal tissue from 9 patients (3 adenocarcinomas (ADC), 3 squamous cell carcinomas (SCC) from the cervix, and 3 vaginal SCC) were collected and analyzed by single-cell RNA sequencing (scRNA-seq) to compare the tumor, immune, and stromal features of cervical and vaginal cancers.

RESULTS

Collectively, over 50,000 cells were analyzed by scRNA-seq in this study. We performed dimensionality reduction and clustering analysis of the single-cell transcriptomes to identify the major cell types composing the vaginal and cervical tumor tissues. Compared to Cervical SCC, Vaginal SCC tissues showed reduced fractions of macrophages (-2.7 log2-fold; padj < 0.02) and T cells (-3.7 log2-fold; padj < 0.02) by differential cell proportion analysis (RAISIN). Likewise, the vaginal SCC epithelial cell compartments showed downregulation of inflammatory pathways including TNF signaling via NFKB (NES = -5.7, padj = 5.0 × 10-19), IL2 STAT5 signaling (NES = -4.5, padj = 1.6 × 10-12), and interferon gamma response (NES = -4.3, padj = 9.4 × 10-12), among the Hallmark pathway collection. On the other hand, vaginal SCC epithelial cells showed significant upregulation of oxidative phosphorylation (NES = 4.8, padj = 1.7 × 10-17), p53 pathway (NES = 4.2, padj = 1.8 × 10-13), mTORC1 signaling (NES = 4.2, padj = 1.9 × 10-13), and estrogen early and late response (NES = 4.0, padj < 7.5 × 10-12) compared to cervical SCC.

CONCLUSION

These results highlight distinct differences in the cell type composition and cancer epithelial pathways in vaginal vs. cervical SCC. Among upregulated pathways in vaginal SCC, ER and mTORC1 pathway activation may represent targets for therapeutic intervention worthy of further investigation.

Improving Cancer Care by Incorporating the Patient's Voice in Symptom Management (IMPROVE): A Multicenter-Prospective Pilot Study

PURPOSE/OBJECTIVE(S)

IMPROVE is a prospective multicenter pilot study. It evaluates whether routine physician review of patient-reported outcomes measures (PROMs) during radiotherapy alters physicians' perception of cancer patients' treatment-related toxicity and influences symptom management.

MATERIALS/METHODS

We are enrolling patients with thoracic or gastrointestinal cancers amenable to conventional-fractionated radiotherapy. Patients may receive concurrent chemotherapy. Patients report (1) symptoms, using PRO-CTCAE measures, (2) the most burdensome symptom, and (3) how symptoms interfere with daily activities. Patients complete the measures before seeing their physician during each on-treatment visit. During weekly visits and before reviewing the patient's PROMs, physicians rate the symptom burden for each patient from 0 to 10, using available clinical data. These data include vital signs, lab work, physical exams, nursing assessments, and physicians' clinical judgment. After reviewing the patients' PROMs, physicians re-rate each patient's symptom burden and report any changes in recommended interventions. Changes could include (1) additional counseling, (2) new medications or interventions, (3) referrals to other services, or (4) further testing or evaluation. After each patient's course of radiotherapy, providers complete a Clinician Feedback Form about the impact of PROM review on symptom perception and management during treatment. This study commenced November 11, 2020 at a multi-site tertiary academic cancer center (using electronic or paper questionnaires) and July 21, 2021 at a multi-site community cancer center (using paper forms).

RESULTS

To be determined.

CONCLUSION

To be determined.

POS0057 INDUCIBLE REGULATORY SYNOVIAL MACROPHAGES: A PROOF-OF-CONCEPT STUDY FOR A CELL-BASED TARGETED THERAPY FOR RHEUMATOID ARTHRITIS

Background

Infiltration of monocyte-derived macrophages into the synovial tissue (ST) is a hallmark of rheumatoid arthritis (RA) pathology. These macrophages promote inflammation, local joint effusion, and joint damage via the release of cytokines, oxygen reactive species, and tissue damaging enzymes. However, balancing these, are the ‘regulatory’ macrophages with inflammation-resolving properties, characterised by expression of CD206 and MerTK, dominant within the ST of healthy individuals as well as RA patients in remission (1). Indeed, these cells are believed to actively contribute to the maintenance of remission.

Macrophages are known to exhibit remarkable phenotypic plasticity and understanding the role of this characteristic in regulating inflammation and pathology remains a major challenge, as does the characterization of factors in the microenvironment such as the synovium that control such macrophage characteristics. Importantly, whether the infiltrating, inflammatory macrophages of the RA ST similarly exhibit such phenotypic plasticity, and whether this occurs during the process of reaching remission, remains to be studied.

Objectives

We investigated the phenotypic plasticity of inflammatory synovial macrophages from patients with RA in vitro, investigating their ability to convert from an inflammatory macrophage population into ‘regulatory’ CD206+MerTK+ macrophages. These findings will provide a proof-of-concept as to the utility of these macrophage for a cell-based therapy in resolving inflammation in patients with RA, and will likely extend our understanding of the mechanisms of action of currently used therapeutics.

Methods

Synovial fluid (SF) mononuclear cells were obtained from patients with active early RA (<1 year; fulfilling 2010 ACR/EULAR classification criteria). Cryopreserved SFMCs were cultured for 48hr in the presence of 10 ng/mL interferon(IFN)γ, 50 ng/mL dexamethasone, 10 μg/mL Infliximab, or diluent. Following culture, cells were immunostained and analysed using a Beckman Coulter CytoFLEX flow cytometer and FlowJo software. SF macrophages were characterised by expression of CD14, CD45, CD68 (Figure 1A), and proportions of CD206+ MerTK+ macrophages measured.

Figure 1.

Synovial fluid CD68+macrophage plasticity in vitro. (A) Gating strategy depicting CD68+ CD45+CD14+ SF macrophage determination. (B) Proportions of CD206 and MerTK-expressing SF macrophages after 48hr culture in the presence of 10 ng/mL IFNγ, 50 ng/mL dexamethasone or 10 µg/mL Infliximab, or absence. Data are representative of 5 individual experiments. Data were analysed by two-way ANOVA followed by Dunnett’s multiple comparison test, *p<0.05.

Results

Prior to culture, the CD68+ macrophage populations present in SF were found to be predominantly CD206-MerTK-. After 48 hours of culture, in the absence of any stimulus, there was an increase in proportions of CD206+MerTK+ macrophages. Treatment with either dexamethasone or anti-TNF (Infliximab) resulted in a further increase in proportions of CD206+ MerTK+, M2-like macrophages. In contrast, culture with IFNγ induced a reduction in this population. Importantly, we found that the generated CD206+MerTK+ macrophages were phenotypically stable in culture following removal of these differentiating agents.

Conclusion

Our findings demonstrate that inflammatory SF cells are indeed able to polarise to regulatory, CD206+MerTK+ macrophages in vitro. The findings provide further mechanistic insights into the basis for the therapeutic benefits of glucocorticoids and TNF inhibitors, as well as providing initial proof-of-concept in the use of regulatory macrophages as a cellular-based therapy or therapeutic target for patients with RA.

References

[1]Alivernini S, MacDonald L, Elmesmari A, et al., Distinct synovial tissue macrophage subsets regulate inflammation and remission in rheumatoid arthritis. Nature Medicine. 2020;26(8):1295-306 10.1038/s41591-020-0939-8.

Disclosure of Interests

None declared

What are the essential components of antenatal care? A systematic review of the literature and development of signal functions to guide monitoring and evaluation

BACKGROUND

Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity.

OBJECTIVES

To identify the essential components of ANC and develop signal functions.

SEARCH STRATEGY

MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science.

SELECTION CRITERIA

Papers and reports on content of ANC published from 2000 to 2020.

DATA COLLECTION AND ANALYSIS

Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

MAIN RESULTS

A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions address monitoring of fetal growth and wellbeing, and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC.

CONCLUSIONS

New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Feeding forage or concentrates early in life influences rumen fermentation, metabolic response, immune function and growth of Wagyu × Friesian calves

Context Early life nutrition of calves influences their performance later in life. There is limited literature demonstrating the effects of rearing dairy calves in early life on milk with either exclusively forage or concentrate starter diets on metabolic and immune function and post-weaning growth and body composition on a pasture only diet. Aim This study evaluated the effects of feeding Wagyu × Holstein Friesian calves a forage starter (FS) or a concentrate starter (CS) for the first 14 weeks of rearing on rumen fermentation, blood metabolites, immune function, growth and body composition to Week 41. Methods Group-housed calves (Wagyu × Friesian, 10 calves per group, three groups per treatment) were fed milk (2 L per calf twice daily) until Week 7, then transitioned to once a day milk feeding until weaning by Week 9, with ad libitum access to either FS or CS. All calves were transferred to graze ryegrass pastures a week after transitioning to once daily milk feeding, with starter feeds removed gradually by Week 14. Thereafter, calves were reared together on pasture until Week 41. Results Solid feed intake was lower in FS than CS calves during the first 7 weeks. Total short chain fatty acids were lower, but acetate to propionate ratio and rumen pH were higher in FS than CS calves at Week 7, with no differences observed at Week 12 or 30. Plasma β-hydroxybutyrate an indicator of ketogenic ability of the rumen in developing calves was higher in FS vs CS calves at weaning. Further, FS calves had lower concentrations of circulating non-esterified fatty acids compared with CS calves at weaning. Compared with CS calves, FS calves grew slower for the first 14 weeks which was associated with lower plasma IGF-1 levels. However, FS calves had greater average daily gain after 14 weeks when on pasture and had similar plasma IGF-1 at 30 weeks and similar body weight and body composition (muscle and subcutaneous fat deposition) by Week 41 compared to CS calves. Conclusions These results indicate that offering a FS starter has better prepared calves for weaning onto pasture and potentially improved utilisation of forage post-weaning to achieve similar muscle and fat deposition and overall liveweight in both groups by 41 weeks. Implications Dairy beef calves can be successfully reared using forage as the only solid feed source without affecting their growth performance on pasture until 10 months of age. Rearing calves using forage will contribute to reducing the usage of concentrate feeds in pastoral dairy-beef production systems and provide an opportunity to fulfil the market requirements and standards for grain-free beef production.

End-of-life care in intellectual disability: a retrospective cross-sectional study

Background

Adults with intellectual disability (ID) experience inequality in access to healthcare that is considered to extend to end-of-life care. Their experiences of healthcare at the end of life and how these compare with the general population are unknown.

Aim

To describe the end-of-life care outcomes for adults with ID living in residential care in the UK using the VOICES-SF questionnaire and compare these with the general population.

Design

Nationwide population-based postbereavement survey.

Participants

38 ID care providers took part in the study. The supported over 13 000 people with ID. Over the 18-month period of data collection, 222 deaths were reported. The survey was completed, by care staff, for 157 (70.7%) of those deaths.

Results

Decedents had complex health, functional and behavioural needs. Death was unanticipated in a high proportion of cases. Quality of care provided across care settings was generally well rated. However, hospital care and care provided at the time of was less well rated, particularly in comparison with the general population. Respondents reported low levels of involvement in care and awareness of approaching death among adults with ID, and lower than in the general population.

Conclusions

Access to end-of-life care for adults with ID may be constrained by a failure to identify approaching the end of life. The high proportion of unexpected deaths in this population warrants further study. There is a need to increase and support the involvement of adults with ID to be active partners in planning care at the end of their lives.

Effect of weaning age on growth, mammary gland development, and immune function in Holstein Friesian calves fed conserved alfalfa (FiberStart)

This study aimed to evaluate intake, body growth, and the development of the rumen, mammary gland, and immune system in Holstein Friesian calves reared for 100 d on the commercially available feed FiberStart (conserved alfalfa, Medicago sativa; Fiber Fresh Feeds Ltd., Reporoa, New Zealand) and fed calf milk replacer (CMR) for either 56 or 91 d. Eighty calves (40 bulls and 40 heifer calves) were reared indoors in groups (n = 5 of the same sex/pen). All calves were fed 4 L of CMR/d (175 g/L of CMR) in 2 feeds/d for the first 10 d and then 1 feed/d until d 49 or 84. The calves were gradually weaned by d 56 (earlier weaned; n = 8 pens) and d 91 (later weaned; n = 8 pens). All calves were fed FiberStart ad libitum as the only solid feed source from d 1 to 100 of the study. Irrespective of treatment, all calves had similar body weights at d 0 (40.9 ± 3.0 kg) and d 49 (74.2 ± 5.1 kg) of the study. Calf sex had no effect on intake, growth, blood, and immune system parameters. Earlier-weaned calves consumed 18% more solid feed dry matter but had 16% lower body weight gain (28.9 vs. 38.5 kg, respectively) from d 56 to 100 relative to later-weaned calves, resulting in different body weight at 100 d (104 vs. 121 ± 1.3 kg). Although earlier-weaned calves could compensate for the loss of CMR dry matter and crude protein intake from d 56 to 100 by increasing forage intake, they were unable to compensate for the loss of energy from the CMR by increasing solid feed consumption. Plasma β-hydroxybutyrate concentrations were 52% greater in earlier-weaned calves than in later-weaned calves at d 84, indicating greater metabolic activity of the rumen wall. The duration of CMR feeding had no influence on humoral or cell-mediated immune functions of the calves, as evidenced by a lack of effect on antivaccine antibody responses as well as on immune gene expression. Earlier- versus later-weaned heifer calves had 5% lower mammary gland mass, indicating that greater energy supply increased mammary mass. The results of this experiment demonstrate the ability to artificially rear dairy calves on a conserved alfalfa as the only solid feed. Furthermore, earlier weaning off CMR promotes solid feed intake and an associated increase in blood β-hydroxybutyrate, an indicator of rumen development, but increasing the duration of CMR feeding improves growth and mammary gland mass by d 100. The implications of these findings on lifetime growth, health, and milk production in dairy heifers warrant further investigation.

Neuroleptic prescribing in an adolescent psychiatric in-patient unit

The Royal College of Psychiatrists' consensus statement suggests that prescribing high dose antipsychotic medication in children and adolescents should rarely be necessary. Our objective was to study the prescribing of antipsychotic medication in a regional adolescent unit during a three-year period. We found that antipsychotic prescribing on this unit is common in psychotic disorders and often high closes are required. This is not in keeping with the recommendations of the consensus statement. Review of clinical practice on other adolescent units is needed, together with a more comprehensive evaluation of the outcome of psychotic disorders in this age group.

Milk production and composition, nitrogen utilization, and grazing behavior of late-lactation dairy cows as affected by time of allocation of a fresh strip of pasture

Eighty late-lactation dairy cows were used to examine the effects of allocating a new pasture strip of a sward based on ryegrass (Lolium perenne L.) in the morning (a.m.; ∼0730 h) or in the afternoon (p.m.; ∼1530 h) on milk production and composition, nitrogen (N) utilization, and grazing behavior. Cows grazed the same pasture strips for 24 h and were offered the same daily herbage allowance. Herbage composition differed among treatments; p.m. herbage had greater dry matter (DM; 22.7 vs. 19.9%), organic matter (OM; 89.5 vs. 88.9%), and water-soluble carbohydrate (10.9 vs. 7.6%) concentrations and lesser crude protein (20.5 vs. 22.2%) and neutral detergent fiber (48.8 vs. 50.4%) concentrations compared with a.m. herbage. Total fatty acids (FA), α-linolenic acid, and polyunsaturated FA (PUFA) were greater in a.m. herbage, whereas monounsaturated FA were greater in p.m. herbage. Estimates of herbage DM intake did not differ among treatments. Daily milk yields and milk fat and milk protein concentrations were similar among treatments, whereas milk fat (684 vs. 627 g/cow), milk protein (545 vs. 505 g/cow), and milk solids (milk fat + milk protein) yields (1,228 vs. 1,132 g/cow) tended to be greater for cows on p.m. herbage. Rumenic acid and total PUFA in milk were greater for cows on a.m. herbage, whereas oleic acid was greater for cows on p.m. herbage. Estimates of urinary N excretion (g/d) did not differ among treatments, but urinary N concentrations were greater for cows on a.m. herbage (5.85 vs. 5.36 g/L). Initial herbage mass (HM) available (kg of DM/ha) and instantaneous HM disappearance rates (kg of DM/ha and kg of DM/h) did not differ, but fractional disappearance rates (0.56 vs. 0.74 per hour for a.m. vs. p.m., respectively) differed. Under the current conditions, timing of pasture strip allocation altered the herbage nutrient supply to cows; allocating a fresh strip of pasture later in the day resulted in moderate increases in milk and milk solids yields in late-lactation dairy cows. Conversely, a greater concentration of precursor FA in a.m. herbage resulted in a greater concentration of beneficial FA in milk, compared with cows on p.m. herbage.

Adults with intellectual disabilities and challenging behaviour: the costs and outcomes of in- and out-of-area placements

BACKGROUND

People with severe challenging behaviour are vulnerable to exclusion from local services and removal to out-of-area placements if locally available supported accommodation is insufficient to meet their needs. There are concerns about the high costs and potentially poorer outcomes of out-of-area placements but relatively little is known about how costs and outcomes compare with provision for a similar population placed locally.

METHODS

Costs, quality of care and a wide range of quality of life outcomes for 38 people with intellectual disabilities and challenging behaviour living in-area and 38 similar people living out-of-area were compared. The two groups were matched as far as possible on risk factors for out-of-area placement. The out-of-area group represented two-thirds of the total number of people who originated from the territory served by the largest specialist health service in Wales and were placed in residential settings at least 10 miles beyond its boundaries.

RESULTS

There was a mixed pattern of quality of care and quality of outcome advantages between the two types of setting, although in-area placements had a greater number of advantages than out-of-area placements. Unexpectedly, out-of-area placements had lower total costs, accommodation costs and daytime activity costs.

CONCLUSIONS

No overall conclusion could be reached about cost-effectiveness. A number of potential reasons for the differences in cost were identified. Although additional resources may be needed to provide in-area services for those currently placed out-of-area, government policy to provide comprehensively for those who want to live locally, irrespective of their needs, appears to be attainable.

Abstract P4-09-05: Long Term Follow-Up of Breast Cancer Patients of the Swedish Cancer Institute Breast Cancer Research Registry

Background: Since 1990 the Swedish Cancer Institute Breast Cancer Research Registry has accrued over 10,900 cases with a 92% follow-up rate. We analyzed the incidence of recurrence over time to evaluate the appropriate duration of our long term follow-up. Methods:

Patients with stages 1-3 disease were selected for study. Stages 0 and 4 disease, and neo-adjuvant treatment patients were excluded. The incidence and time to recurrence was compared with tumor grade [Bloom Richardson (BR) score], hormone receptor, HER2 status, stage, number of positive lymph nodes, surgery, radiation therapy, chemotherapy, hormone therapy and menopausal status. Results:

The recurrence rate was 7.8% (740/9455) of which 68% (500) occurred in the first 5 years, 24% (179) occurred between 5 and 10 years, and 8% (61) occurred after 10 years. Factors that had a significant (P&lt;0.05) relationship with the incidence of and time to recurrence were: stage, grade, hormone receptor status, number of positive lymph nodes, hormone therapy and radiation therapy. In the hormone receptor negative group, 15% (181/1205) recurred - 86% within 5 years, 12% between 5 and 10 years and 1.7% over 10 years. In the hormone receptor positive group, 7.3% (522/7201) recurred - 62% within 5 years, 28% between 5 and 10 years and 10% over 10 years. Of the patients with negative nodes, 4.7% (255/5405) recurred - 65% within 5 years, 27% within 5 to 10 years and 7.5% over 10 years. For the patients with 1 - 3 nodes positive, 12.6% (222/1769) recurred - 67% within 5 years, 24% between 5 and 10 years and 10% over 10 years. For 4-9 nodes positive, 25.3% (121/478) recurred - 79% within 5 years, 20% between 5 and 10 years and 6.6% over10 years. For greater than 10 nodes positive, 40.9% (92/225) recurred - 75% within the first 5 years, 20% between 5 and 10 years and 5.4% over 10 years. A BR score of 3-5 resulted in 2.0% (32/1574) recurrences - 63% within 5 years, 25% between 5 and 10 years and 13% over 10 years. A BR score of 6-7 resulted in 5.1% (131/2559) recurrences - 73% within 5 years, 26% between 5 and 10 years and 1.5% over 10 years. A BR score of 8-9 resulted in 11.3% (179/1581) recurrences - 89% within 5 years, 10% between 5 and 10 years and 0.6% over 10 years. Conclusion:

The incidence of recurrence and the rate of recurrence of breast cancer was greatest for tumors that were hormone receptor negative, had a high number of positive lymph nodes and were high grade (BR 8-9). The incidence of recurrence after 10 years was under 0.5% overall and under 1.0% for most groups. The exception was patients with over 10 nodes positive (2.2%). However, patients with low grade (BR 3-5), hormone receptor positive or 1-3 positive lymph nodes, or patients treated with total mastectomy without irradiation or hormone therapy had over 10% of their recurrences occur after 10 years. The old adage that after ten years one is cured does not apply to these low risk patients. Nor does it apply to the high risk patients although their outlook is markedly improved by 10 years.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-05.