Patient understanding of genetic information influences reproductive decision making in retinoblastoma

BACKGROUND

Retinoblastoma is the most common malignant tumour of the eye in childhood, with nearly all bilateral tumours and around 17% to 18% of unilateral tumours due to an oncogenic mutation in the RB1 gene in the germline. Genetic testing enables accurate risk assessment and optimal clinical management for the affected individual, siblings, and future offspring.

MATERIAL AND METHODS

We carried out the first UK-wide audit of understanding of genetic testing in individuals with retinoblastoma. A total of 292 individuals aged 16 to 45 years were included.

RESULTS

Patients with bilateral disease were significantly more likely to understand the implications of retinoblastoma for siblings and children. There was a significant association between not knowing the results of genetic testing or not understanding the implications and not having children, particularly in women. Surprisingly, this was also true for individuals treated for unilateral disease with a low risk of retinoblastoma for their offspring.

CONCLUSION

We are concerned that individuals may be making life choices based on insufficient information regarding risks of retinoblastoma and reproductive options. We suggest that improvement in transition care is needed to enable individuals to make informed reproductive decisions and to ensure optimal care for children born at risk of retinoblastoma.

What are the priorities for improving cataract surgical outcomes in Africa? Results of a Delphi exercise

PURPOSE

The quality of cataract surgery delivered in sub-Saharan Africa (SSA) is a significant constraint to achieving the elimination of avoidable blindness. No published reports from routine SSA cataract services attain the WHO benchmarks for visual outcomes; poor outcomes (<6/60) often comprise 20% in published case series. This Delphi exercise aimed to identify and prioritise potential interventions for improving the quality of cataract surgery in SSA to guide research and eye health programme development.

METHODS

An initial email open-question survey created a ranked list of priorities for improving quality of surgical services. A second-round face-to-face discussion facilitated at a Vision 2020 Research Mentorship Workshop in Tanzania created a refined list for repeated ranking.

RESULTS

Seventeen factors were agreed that might form target interventions to promote quality of cataract services. Improved training of surgeons was the top-ranked item, followed by utilisation of biometry, surgical equipment availability, effective monitoring of outcomes of cataract surgery by the surgeon, and well-trained support staff for the cataract pathway (including nurses seeing post-operative cases).

CONCLUSION

Improving the quality of cataract surgery in SSA is a clinical, programmatic and public health priority. In the absence of other evidence, the collective expert opinion of those involved in ophthalmic services regarding the ranking of factors to promote quality improvement, refined through this Delphi exercise, provides us with candidate intervention areas to be evaluated.

Abstract B078: GoTCR: Inducible MyD88/CD40 (iMC) enhances proliferation and survival of tumor-specific TCR-modified T cells and improves antitumor efficacy in myeloma

Introduction: Use of T cells engineered to express antigen-specific T cell receptors (TCRs) has shown promise as a cancer immunotherapy treatment; however, durable responses have been limited by poor T cell persistence and expansion in vivo. Additionally, MHC class I downregulation on tumor cells further reduces therapeutic efficacy. Therefore, we co-expressed in human T cells a novel, small molecule dimerizer (rimiducid)-dependent T cell “activation switch”, called inducible MyD88/CD40 (iMC), along with tumor antigen-specific TCRs to regulate T cell activation and expansion, while upregulating MHC class I expression on tumor cells.

Methods: Human T cells were activated with anti-CD3/CD28 and transduced with γ-retroviruses encoding TCR α and β chains recognizing either the cancer-testes antigen PRAME (HLA-A*201-restricted SLLQHLIGL) or the B cell-specific transcriptional co-activator, Bob1/OBF-1 (HLA-B*702-restricted APAPTAVVL). Parallel “GoTCR” vectors co-expressed the αβ TCR and iMC, comprising signaling domains from MyD88 and CD40 fused in frame with tandem rimiducid-binding FKBP12v36 domains. Proliferation, cytokine production and cytotoxicity of modified T cells was assessed using peptide-pulsed EGFPluc-expressing T2 cells (PRAME only) or PRAME+/Bob1+, HLA-A2+ HLA-B7+ EGFPluc-expressing U266 myeloma cells ± rimiducid (10 nM). MHC class I upregulation on tumor cells was measured using transwell assays and flow cytometry. In vitro tumor killing and T cell proliferation were analyzed using T cell and tumor coculture assays by either measuring loss of luciferase activity overnight or by flow cytometry over a period of 4-7 days. Finally, in vivo efficacy was determined using immune-deficient NSG mice engrafted i.v. with U266 cells and treated i.v. with 5×106-1×107 transduced T cells. iMC was activated in vivo by weekly or biweekly i.p. rimiducid injections (1-5 mg/kg). Tumor size and T cell expansion was measured using in vivo bioluminescence imaging and flow cytometry, respectively.

Results: All vectors efficiently (∼85%) transduced activated T cells and showed antigen-specific IFN-γ production and cytolytic function against peptide-pulsed T2 cells and/or PRAME+Bob1+ U266 myeloma cells. However, both TCR ligation and rimiducid-dependent iMC costimulation were required for IL-2 production against PRAME peptide-pulsed T2 cells. Coculture assays against U266 cells showed that tumor elimination was optimized with concurrent rimiducid-driven iMC activation in both “GoPRAME” and “GoBob1” constructs, and this was accompanied by greatly increased IL-2 secretion and robust T cell proliferation (∼ 50-fold vs PRAME or Bob1-specific TCRs alone). Further, iMC activation produced IFN-γ independently of TCR ligation, which significantly increased MHC class I expression on tumor cells (∼ 7-fold) relative to PRAME TCR-transduced T cells. In NSG mice engrafted with PRAME+ U266 myeloma tumors, GoPRAME TCR-modified T cells persisted for 81 days post-injection and prevented tumor growth, unlike any of the other T cell groups. Importantly, weekly rimiducid injection dramatically expanded iMC-PRAME TCR-expressing T cell numbers by ∼1000-fold on day 81 post-injection compared to T cells expressing only the PRAME TCR (p &lt; 0.001).

Summary: iMC is a novel “Go” switch that utilizes rimiducid, a small molecule dimerizer, to provide costimulation to PRAME and Bob1-specific TCR-engineered T cells while sensitizing tumors to TCR-mediated recognition via cytokine-induced MHC I upregulation. These iMC-enhanced TCRs are prototypes of novel “GoTCR” engineered T cell therapies that may increase efficacy, safety and durability of adoptive T cell therapies.

Citation Format: Tsvetelina Pentcheva-Hoang, David Torres, Tania Rodriguez, Ana Korngold, An Lu, Jeannette Crisostomo, Annemarie Moseley, Lorenz Jahn, Mirjam H.M. Heemskerk, Kevin Slawin, David Spencer, Aaron Foster. GoTCR: Inducible MyD88/CD40 (iMC) enhances proliferation and survival of tumor-specific TCR-modified T cells and improves antitumor efficacy in myeloma [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr B078.

Abstract LB-084: Go-TCR™: Inducible MyD88/CD40 (iMC) enhances proliferation and survival of tumor-specific TCR-modified T cells, increasing anti-tumor efficacy

Introduction: Use of tumor antigen-specific T cell receptors (TCRs) to refocus T cell killing has shown tantalizing clinical efficacy; however, durable responses have been limited by poor T cell persistence and expansion in vivo. Also, MHC class I downregulation in tumors further reduces therapeutic efficacy. Therefore, we co-expressed in human T cells a small molecule dimerizer (rimiducid)-dependent “activation switch”, called inducible MyD88/CD40 (iMC), along with tumor-targeted TCRs to regulate T cell expansion and activation, while affecting upregulation of MHC class I on tumors.

Methods: Human T cells were CD3/CD28-activated and transduced with αβTCR-encoding γ-retroviruses recognizing either the CT antigen, PRAME (HLA-A*02:01/SLLQHLIGL), or the B-cell-specific transcriptional co-activator, Bob1/OBF-1 (HLA-B*07:02/APAPTAVVL). Parallel “Go-TCR” vectors co-expressed iMC, comprising MyD88 and CD40 signaling domains along with rimiducid-binding FKBP12-V36. Proliferation, cytokine production and cytotoxicity of modified T cells was assessed using peptide-pulsed T2 cells (PRAME only) or against PRAME+/Bob1+, HLA-A2+ -B7+ U266 myeloma cells +/- 10 nM rimiducid. MHC class I induction was measured using transwell assays and flow cytometry. In vitro tumor killing was analyzed by T cell and tumor coculture assays at various effector to target ratios over a 7-day period. Finally, in vivo efficacy was determined using immune-deficient NSG mice engrafted i.v. with U266 cells and treated i.v. with 1×107 transduced T cells. iMC was activated in vivo by weekly i.p. rimiducid injections (1-5 mg/kg). Tumor size and T cell expansion was measured using in vivo BLI imaging and flow cytometry.

Results: All vectors efficiently (∼85%) transduced activated T cells and showed antigen-specific IFN-γ production and cytotoxicity against peptide-pulsed T2 cells and/or PRAME+Bob1+ U266 cells. However, both iMC signaling and TCR ligation of PRAME peptide-pulsed T2 Cells were required for IL-2 production. Coculture assays with U266 cells showed that tumor elimination, IL-2 secretion and robust (∼ 50-fold) T cell proliferation (vs TCR signaling alone) was optimized with concurrent rimiducid-driven iMC activation in both “Go-PRAME” and “Go-Bob1” constructs. Further, iMC activation produced TCR-independent IFN-γ that increased (∼100-fold) MHC class I expression on tumor cells. In NSG mice engrafted with U266 tumors, iMC-PRAME TCR-modified T cells persisted for at least 81 days post-injection and prevented tumor growth, unlike other T cell groups. Importantly, weekly rimiducid injection dramatically expanded iMC-PRAME TCR-expressing T cell numbers by ∼1000-fold on day 81 post-injection vs T cells expressing only the PRAME TCR (p &lt; 0.001).

Summary: The novel rimiducid-regulated “Go” switch, iMC, greatly augments activation and expansion of TCR-engineered T cells while sensitizing tumors to T cells via cytokine-induced MHC class I upregulation. iMC-enhanced TCRs are prototypes of novel “Go-TCR” engineered T cell therapies that increase efficacy, safety and durability of adoptive T cell therapies.

Citation Format: David M. Spencer, Tsvetelina P. Hoang, Aaron Foster, Tania Rodriguez, David Torres, An Lu, Jeannette Crisostomo, Lorenz Jahn, Mirjam H.M. Heemskerk. Go-TCR™: Inducible MyD88/CD40 (iMC) enhances proliferation and survival of tumor-specific TCR-modified T cells, increasing anti-tumor efficacy. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-084.

The use of ultrasonography and digital mammography in women under 40 years with symptomatic breast cancer: a 7-year Irish experience

BACKGROUND

Breast cancer in women under 40 years of age is rare and typically presents symptomatically. The optimal imaging modality for this patient group is controversial. Most women undergo ultrasonography with/without mammography. Young women typically have dense breasts, which can obscure the features of malignancy on film mammography, however, initial studies have suggested that digital mammography may have a more accurate diagnostic performance in younger women. Ultrasound generally performs well in this age group, although it is poor at detecting carcinoma in situ (DCIS).

AIMS

To evaluate the comparative diagnostic performance of ultrasonography and digital mammography in the initial diagnostic evaluation of women under 40 years of age with symptomatic breast cancer.

METHODS

Retrospective review of all women under the age of 40 years managed at our symptomatic breast cancer unit from January 2009 to December 2015.

RESULTS

There were 120 patients that met the inclusion criteria for this study. The sensitivity of ultrasonography and digital mammography for breast cancer in this patient group was 95.8 and 87.5 %, respectively. The patients with a false negative mammographic examination were more likely to have dense breasts (p < 0.01). Five patients had a false negative ultrasonographic examination, withal of whom were diagnosed with DCIS detected by mammography.

CONCLUSION

This study demonstrates the superior sensitivity of ultrasound for breast cancer in women under the age of 40 years, however, the results show that digital mammography has an important complimentary role in the comprehensive assessment of these patients, particularly in the diagnosis of DCIS.

Histological Features and Tissue Microarray Taxonomy of Nigerian Breast Cancer Reveal Predominance of the High-Grade Triple-Negative Phenotype

INTRODUCTION

Little is known about the biology, molecular profile and hence optimal treatment of African Nigerian breast cancer. The aim of this work, therefore, was to characterize the histology and molecular profile of Nigerian breast cancer.

METHODS

Breast carcinomas from women at 6 centres of similar tribal origin in Nigeria were reviewed and assembled into tissue microarrays (TMAs), and sections were stained for hormone receptors, i.e. estrogen receptor (ER)α, ERβ1, ERβ progesterone receptor (PR) and androgen receptor, cyclin D, HER2, Ki67 and cytokeratins (CKs), i.e. CK5/6 and CK14 (basal) and CK18 and 19 (luminal).

RESULTS

A total of 835 tumours were analysed. The mean age at diagnosis was 48.62 ± 12.41 years. The most common histological subtype was ductal NST (no-special-type) carcinoma (87.3%). Over 90% of the tumours were grade 2 or 3. The predominant molecular phenotype was the non-basal, triple-negative type (47.65%) followed by the HER2-positive group (19.6%). The percentage of ER-, PR- and HER2-positive tumours was 22.4, 18.9 and 18.8%, respectively.

CONCLUSION

Nigerian breast cancer predominantly has a high-grade, triple-negative profile. It occurs at a younger age and bears similarities at the molecular level to pre-menopausal breast cancer in white women, with remarkably lower levels of ERβ expression. The early presentation and histological and molecular phenotype may explain the poor prognosis, and tailoring treatment strategies to target this unique profile are required.

Freeze-thaw cycles have minimal effect on the mineralisation of low molecular weight, dissolved organic carbon in Arctic soils

Warmer winters in Arctic regions may melt insulating snow cover and subject soils to more freeze–thaw cycles. The effect of freeze–thaw cycles on the microbial use of low molecular weight, dissolved organic carbon (LMW-DOC) is poorly understood. In this study, soils from the Arctic heath tundra, Arctic meadow tundra and a temperate grassland were frozen to −7.5 °C and thawed once and three times. Subsequently, the mineralisation of 3 LMW-DOC substrates types (sugars, amino acids and peptides) was measured over an 8-day period and compared to controls which had not been frozen. This allowed the comparison of freeze–thaw effects between Arctic and temperate soil and between different substrates. The results showed that freeze–thaw cycles had no significant effect on C mineralisation in the Arctic tundra soils. In contrast, for the same intensity freeze–thaw cycles, a significant effect on C mineralisation was observed for all substrate types in the temperate soil although the response was substrate specific. Peptide and amino acid mineralisation were similarly affected by FT, whilst glucose had a different response. Further work is required to fully understand microbial use of LMW-DOC after freeze–thaw, yet these results suggest that relatively short freeze–thaw cycles have little effect on microbial use of LMW-DOC in Arctic tundra soils after thaw.

The Value of Tranexamic Acid in Reducing Blood Loss following Hip Reconstruction in Children with Cerebral Palsy

This is a retrospective study of 51 consecutive hip reconstructions in children with cerebral palsy performed between 2011 and 2013. Tranexamic acid (TXA) was used in 14 hip reconstructions only. Transfusion rate was higher, postoperative Hb was lower, and patients stayed longer in the TXA group. This did not reach a statistical significance (P = 0.75, 0.5, and 0.71, resp.). More than half of the patients who had TXA underwent bilateral hip reconstructions in comparison with 27% only in the non-TXA group. Bilateral hip reconstructions mean more surgery, more blood loss, and more blood transfusion. The patients who had TXA were significantly more disabled as evident by the higher proportions of patient with worse GMFCS levels. Although we have not been able to demonstrate the value of TXA in reducing blood loss and transfusion rate in children with CP who underwent hip reconstruction, it is hoped that an interest in exploring the value of TXA in paediatric orthopaedic surgery is generated. Ideally this should be explored further in an adequately powered, randomised controlled trial where risk of bias is minimized.

Predictors for 1-year mortality following hip fracture: a retrospective review of 465 consecutive patients

INTRODUCTION

In Europe, trauma admissions and in particular hip fractures are on the rise. In recent years, health care systems have placed particular emphasis, including financial incentives, on delivering patients quickly and safely to surgery. At our unit, we have observed that hip fracture patients appear to be at significant risk of mortality even up to a year following injury. This study reviews a consecutive population of hip fracture patients to identify predictors of excess risk.

MATERIALS AND METHODS

Four hundred and sixty-five consecutive patients were treated over a 2-year period at our district general hospital with no ward-based orthogeriatricians. Follow-up was for 1 year following hip fracture admission. Statistical analysis of variables and their influence on 1-year mortality were performed by calculating odd's ratio (OR) using a logistic regression model and a p value <0.05 was considered statistically significant.

RESULTS

Four patients were lost to follow-up, 18 patients (4.1 %) were managed conservatively, 16 were too unwell for surgery and their mortality rate at 1 year was 50 %. Following hip fracture, we found an overall 1-year mortality rate of 15.1 %. Patients with a time to surgery ≥36 h were at significantly increased risk of mortality even up to 1 year. We did not identify a further reduction in mortality in those operated on within 24 h. Raised ORs (p > 0.05) were found with increasing comorbidity, surgery type, independence on discharge, alcohol ingestion, history of smoking, readmission and several biochemical markers.

CONCLUSION

Minimising mortality risk, even over the longer term, should begin on admission with prompt optimisation of any acute medical or biochemical abnormalities, followed by early surgery and intensive rehabilitation to maintain patients' functional independence.

A Rare Case of BRCA2-Associated Breast Cancer in Pregnancy

A 30-year old woman was referred to our department with symptomatic breast cancer at 35 weeks gestation. Genetic testing revealed a pathogenic BRCA2 mutation. Labour was induced at 38 weeks. Mastectomy and axillary clearance were performed with a view to adjuvant chemotherapy, radiation and hormonal therapy. Multidisciplinary involvement is crucial for management of BRCA-associated breast cancer, especially in the context of pregnancy. Bilateral mastectomy may be indicated given the increased risk of ipsilateral and contralateral breast cancers. Tamoxifen may lower contralateral breast cancer risk in those in whom risk-reducing surgery is not performed.

BARRIERS TO AN EFFECTIVE DIABETIC RETINOPATHY SERVICE IN IBADAN, NIGERIA (SUB -SAHARAN AFRICA) - A PILOT QUALITATIVE STUDY

BACKGROUND

Diabetic retinopathy is an increasing cause of blindness. The prevalence of retinopathy in hospital attending diabetics in Ibadan is reported to be 42 %. This study assessed the barriers identified by patients and service providers to delivering good services for diabetic retinopathy in Ibadan, Nigeria, Sub-Saharan Africa.

METHODS

A qualitative survey using non-participatory observation, in-depth interviews (patients and healthcare providers), and focus group discussion for diabetic patients in the eye clinic in University College Hospital, Ibadan was done. Semistructured interview and topic guides were used to evaluate the barriers to effective service. The participants were selected using a non-probability, purposive sampling strategy. Twenty participants were involved in the pilot study. There were ten in-depth interviews of patients and two focus group discussions of patients (3 in each group). Four healthcare providers were interviewed (a retinal surgeon, a senior registrar, an endocrinologist and a public health nurse).

RESULTS

Lack of awareness that diabetes causes irreversible blindness was identified as a major barrier by both patients and providers. Cost of treatment of diabetes and treatment of retinopathy was also an important barrier. The long waiting time before consultation, staff attitudes to patients and appointment scheduling problems deterred patients from using the service.

CONCLUSIONS

More diabetic patients can be encouraged to use eye service by providing more detailed information/counselling and making clinic attendance less costly and more convenient.