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.

Intestinal Stem Cell Marker ASCL2 is a Novel Prognostic Predictor in Esophageal Adenocarcinoma

Purpose

Intestinal stem cell markers play a significant role in esophageal adenocarcinoma carcinogenesis via Barrett’s esophagus; however, its utility as a prognostic biomarker has not been established.

Methods

We analyzed the immunohistochemical expression of intestinal stem cell markers, ASCL2 and LGR5, using whole slides (35 cases) and tissue microarray (TMA; 64 cases). On TMA slides, adjacent normal squamous epithelium, metaplastic glandular epithelium (Barrett's esophagus), and dysplastic glandular epithelium were inserted when applicable. Two pathologists semi-quantitatively scored stained slides independently, and the results were correlated with clinicopathologic factors and outcomes.

Results

In whole slides, 51% and 57% expressed high ASCL2 and high LGR5; in TMA, 69% and 88% expressed high ASCL2 and high LGR5, respectively. In TMA, high ASCL2 and low LGR5 expression significantly correlated to a higher number of involved lymph nodes (p=0.027 and p=0.0039), and LGR5 expression significantly correlated to the pathological stage (p=0.0032). Kaplan-Meier analysis showed a negative impact of high ASCL2 expression on overall survival (OS; WS p=0.0168, TMA p=0.0276) as well as progression-free survival (PFS; WS p=0.000638, TMA p=0.0466) but not LGR5. Multivariate Cox regression analysis revealed that ASCL2 expression is an independent prognostic factor for esophageal adenocarcinoma (OS; WS p=0.25, TMA p=0.011. PFS; WS p=0.012, TMA p=0.038). Analysis of the TCGA dataset showed that ASCL2 mRNA levels were correlated to nodal status but not overall survival.

Conclusion

High expression of the intestinal stem cell marker ASCL2 may predict unfavorable outcomes in surgically resected esophageal adenocarcinoma.

OUP accepted manuscript

BACKGROUND

We sought to identify variates correlating with overall survival (OS) in patients treated with surgery (S) plus adjuvant stereotactic radiosurgery (SRS) versus definitive SRS for large (&gt;4 cc) brain metastases (BrM).

METHODS

We used univariate (UVA) and multivariate analyses (MVA) to identify survival correlates among eligible patients identified from a prospective registry and compared definitive SRS to S+ adjuvant SRS cohorts using propensity score-matched analysis (PSMA). Secondary outcomes were measured using the cumulative incidence (CI) method.

RESULTS

We identified 364 patients; 127 and 237 were treated with S+SRS and definitive SRS, respectively. On UVA, SRS alone [HR1.73 (1.35,2.22) P &lt; .001), BrM quantity [HR 1.13 (1.06-1.22) (P &lt; .001)]; performance status (PS) [HR 2.78 (1.73-4.46) (P &lt; .001)]; extracranial disease (ECD) [HR 1.82 (1.37,2.40) (P &lt; .001)]; and receipt of systemic treatment after BrM therapy, [HR 0.58 (0.46-073) (P &lt; .001)] correlated with OS. On MVA, SRS alone [HR 1.81 (1.19,2.74) (P &lt; .0054)], SRS target volume [HR 1.03 (1.01,1.06) (P &lt; .0042)], and receipt of systemic treatment [HR 0.68 (0.50,0.93) (P &lt; .015)] correlated with OS. When PSMA was used to balance ECD, BrM quantity, PS, and SRS target volume, SRS alone remained correlated with worsened OS [HR 1.62 (1.20-2.19) (P = 0.0015)]. CI of local failure requiring resection at 12 months was 3% versus 7% for S+SRS and SRS cohorts, respectively [(HR 2.04 (0.89-4.69) (P = .091)]. CI of pachymeningeal failure at 12 months was 16% versus 0% for S+SRS and SRS.

CONCLUSION

SRS target volume, receipt of systemic therapies, and treatment with S+SRS instead of definitive SRS correlated with improved survival in patients with large BrM.

Endovenous laser ablation of saphenous veins - favorable clinical results confirm theoretical advantages of the 1940nm diode laser

INTRODUCTION

Endovenous laser ablation (EVLA) is a recognized alternative to surgical treatment of varicose veins, although an optimal laser generator and its settings still remain a matter of debate. The aim of our study was to correlate clinical results with the theoretical advantage of the 1940nm diode laser characterized by high absorption of heat in a thin layer of coagulated tissue.

METHODS

From 1/2010 to 12/2021 EVLA was performed in a total of 3529 consecutive patients with varicose veins and ultrasonographically documented superficial venous reflux of lower extremities. Three types of laser were used successively with the wavelengths of 1064 nm, 1470 nm and 1940 nm, respectively. All patients were prospectively enrolled in our registry. An early postoperative followup visit was scheduled including an assessment of venous closure; additional visits were performed only in case of complications.

RESULTS

The success of venous closure did not differ (p=0.054) between the three laser types and was over 98%. The catheterbased method made it possible to perform multiple ablations in one procedure the trend was 1.08, 1.31 and 1.62. In 2021 the number of ablations per patient with the laser DL Tethys 1940 nm was 1.79. With this laser it was possible to reduce the total energy applied to one half (8 W, 5080 J/cm). The postoperative course of patients treated using the 1940nm laser was smoother - no other but the early followup visit was needed in 95.6% cases (p.

Assessing therapy response in patient-derived xenografts

[Figure: see text].

Antitumor efficacy of XPO1 inhibitor Selinexor in KRAS-mutant lung adenocarcinoma patient-derived xenografts

Gain-of-function Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations occur in 25% of lung adenocarcinomas, and these tumors are challenging to treat. Some preclinical work, largely based on cell lines, suggested KRASmut lung cancers are especially dependent on the nuclear export protein exportin-1 (XPO1), while other work supports XPO1 being a broader cancer dependency. To investigate the sensitivity of KRASmut lung cancers to XPO1 inhibition in models that more closely match clinical tumors, we treated 10 independently established lung cancer patient-derived tumor xenografts (PDXs) with the clinical XPO1 inhibitor, Selinexor. Monotherapy with Selinexor reduced tumor growth in all KRASmut PDXs, which included 4 different codon mutations, and was more effective than the clinical MEK1/2 inhibitor, Trametinib. Selinexor was equally effective in KRASG12C and KRASG12D tumors, with TP53 mutations being a biomarker for a weaker drug response. By mining genome-wide dropout datasets, we identified XPO1 as a universal cancer cell dependency and confirmed this functionally in two KRASWT PDX models harboring kinase drivers. However, targeted kinase inhibitors were more effective than Selinexor in these models. Our findings support continued investigation of XPO1 inhibitors in KRASmut lung adenocarcinoma, regardless of the codon alteration.

MLTI-06. Surgical resection plus stereotactic radiosurgery versus SRS alone for large brain metastases: a comparative study

Purpose

Large brain metastases (BRM) are challenging to manage. Therapeutic options include Stereotactic Radiosurgery (SRS) or surgery (S) with adjuvant SRS. We sought to compare overall survival (OS), radionecrosis (RN), local failure (LF), pachymeningeal (PMD) and leptomeningeal (LMD) disease in patients treated with SRS vs. S+SRS.

Methods

We reviewed a prospective registry database from 2009 to 2020 and identified all patients with BRM (≥4cc in volume) treated with SRS or S+SRS. WBRT or SRS re-targeting the index lesion were censoring events. Survival percentages were calculated using the Kaplan-Meier method. Differences between groups were tested using the Cox proportional hazards model.

Results

383 patients were identified, 128 and 255 were treated with S+SRS and SRS, respectively. Median ages in the S+SRS and SRS groups were 62.2 (23.6–98.5) and 60.2 (20.2–97.4) (P 0.33). OS at 12 and 24 months was 69% and 41% vs 55% and 20% for the S+SRS and SRS groups, respectively hazard ratio (HR) 1.64 (1.23–2.18) (P<0.001). LF requiring salvage surgery at 12 and 24 months were 3% and 5% vs 8% and 10% for S+SRS and SRS groups, respectively (P 0.067). RN at 12 and 24 months were 9% and 17% vs 15% and 21% for S+SRS and SRS groups, respectively 1.32 HR (0.77–2.29) (P =0.32). PMD disease at 12 and 24 months were 16% and 21% vs 3% and 7% for S+SRS and SRS groups, respectively HR 0.26(0.12–0.56) (P < 0.001). LMD at 12 and 24 months were 4% and 6% vs 2% and 4% for S+SRS and SRS groups, respectively HR 0.73(0.25–2.17) (P 0.57).

Conclusion

Surgical resection plus SRS correlated with improved OS and a trend towards a decreased incidence of LF compared to SRS alone. However, patients treated with S experienced an increased incidence of PMD.

SURG-13. Multiplicity does not affect outcomes in patients with surgically treated brain metastases

Background

Having multiple brain lesions has been considered a negative prognostic factor in patients with brain metastases. The role of surgery in the management of these patients remains a matter of debate.

Methods

We retrospectively reviewed our patients who underwent surgical resection of brain metastases from January 2018 to December 2019, and examined outcomes including overall survival (OS), progression free survival (PFS) and rates of local failure.

Results

We identified 130 patients who underwent surgical resection as the primary treatment modality of brain metastases. At the time of surgery, 117 patients harbored 1–3 lesions, 13 had more than 3 lesions. Overall survival at two years for our entire cohort was 46%. The difference in OS between patients with > 3 metastases (21%) and 1–3 metastases (49%) was not statistically significant (HR=1.34, 95% CI: 0.67–2.68, p=0.41). Similarly, 27% of patients had PFS at two years, with 25% in the multiple metastases group and 28% in the comparison group (HR=1.19, 95% CI: 0.63–2.23, p=0.59). Additionally, 32% of patients overall experienced local failure at two years and there was no significant difference between patients with >3 metastases (15%) and those with fewer (33%) (HR=0.68, 95% CI: 0.21–2.19, p=0.52). A multivariate regression model examining multiple preoperative features revealed large tumor volume to be the only independent predictor of limited OS (p = 0.017) and PFS (p = 0.023), and local failure (p = 0.031).

Conclusions

In carefully selected patients, surgical resection is a reasonable management option for patients with multiple brain metastases.

Schwartz A. P–654 What is the best luteal phase support in frozen-thawed embryo transfer cycle?

Study question

What is the best progesterone administration for luteal phase support (LPS) in frozen-thawed embryo transfer cycle?

Summary answer

Different modes of hormonal luteal phase support do not affect clinical pregnancy rate (CPR) or live birth rate (LBR) in frozen-thawed embryo transfer (FET) cycles.

What is known already

FET has increased substantially over the last years. To support implantation, endometrial and embryo maturities must be synchronized; therefore, endometrial and follicular maturation are monitored either within the artificial cycle. Estrogen and progesterone are sequentially administered. The optimal endometrial preparation strategy remains unclear; this study aims to compare the reproductive and pregnancy outcomes between five different regimens of hormonal LPS for FET treatment.

Study design, size, duration

Single centre retrospective cohort study conducted between 2013 and 2019. Included were women (N = 402) aged 18–45 years undergoing FET. After an optimal endometrial preparation and endometrial thickness, the LPS was started. Thereafter, five different progesterone applications were compared: (1) oral dydrogesterone (10mg tid), (2) vaginal progesterone gel (90mg/d), (3) dydrogesterone (10mg tid) plus vaginal progesterone gel (90mg/d), (4) vaginal progesterone capsules (200mg tid), or (5) subcutaneous injection of 25mg daily.

Participants/materials, setting, methods

An ultrasound was performed 14 days of estrogene ( &gt; =4mg/d) preparation. If the endometrial thickness was ≥7 mm and there was no dominant follicle, luteal support commenced four days before FET. Fourteen days after transformation, a serum beta-hCG test was performed. If positive (&gt; 50 IU/L), a transvaginal ultrasound was performed to confirm clinical pregnancy, defined as gestational sac with fetal heart movement. CPR was assessed and delivery reports for LBR were collected later.

Main results and the role of chance

In total, 402 patients on an artificial cycle were included (mean age, 35 years (y); range, 26–46 y; standard deviation, 4.1 y). No differences in endometrial thickness and cause of infertility were found between groups. Multivariate logistic regression analysis revealed that the odds ratios (ORs) with 95% confidence intervals (CIs) for the CPR was significantly higher in the dydrogesterone only group (OR, 3.25; 95% CI, 1.7–6.2; p &lt; 0.001) and in the combined group (3) (OR, 7.55; 95% CI, 2.7–21.10; p &lt; 0.001). Statistically significant differences in live birth rate could not be found between the five groups; they were 33%, 54%, 8.3%, 4%, 0% for groups 1, 2, 3, 4, and 5 respectively. Overall satisfaction and tolerability were significantly higher in oral dydrogesterone compared to the vaginal progesterone.

Limitations, reasons for caution

This is a retrospective single-center study. Also, potentially confounding variables like ethnicity, parity, BMI were not accounted for, possibly contributing to bias. Further prospective randomized studies are needed.

Wider implications of the findings: Oral dydrogesterone was found to be effective with equal CPR and LBR. Benefit is well-tolerated and accepted among patients; however we did not observe significant differences in the rates of live birth between the five regimens for used for LPS in women undergoing frozen-thawed embryo transfers.

Trial registration number

BASEC Switzerland 2020–01527

Limited-stage small cell lung cancer: Outcomes associated with prophylactic cranial irradiation over a 20-year period at the Princess Margaret Cancer Centre

•

Prophylactic cranial irradiation (PCI) was more commonly used in younger patients.

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PCI utilization rates did not change throughout our 20-year institutional experience.

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PCI was associated with improved OS and lower brain metastasis risk, independent of MRI follow-up or era of treatment.

•

For LS-SCLC patients with good thoracic response, PCI remains the standard-of-care.

Background & purpose

Prophylactic cranial irradiation (PCI) is recommended for limited-stage small-cell lung cancer (LS-SCLC) patients with good response to concurrent chemoradiation. We report our institution’s 20-year experience with this patient population and associated clinical outcomes.

Materials & methods

A retrospective cohort of consecutive LS-SCLC patients treated with curative intent chemoradiation at our institution (1997–2018) was reviewed. Overall survival (OS) was calculated using the Kaplan-Meier method, and significant covariates determined by the Cox proportional hazards model. Covariates predictive of PCI were determined using Fisher's exact test and the Mann-Whitney test. Brain failure risk (BFR) was calculated using the cumulative incidence method treating death as a competing event. Treatment cohorts (historic vs. contemporary) were stratified by the median year of diagnosis (2005).

Results

A total of 369 patients with LS-SCLC were identified, of which 278 patients were notionally PCI eligible. PCI was given to 196 patients (71%). Younger age was associated with PCI utilization (p < 0.001). PCI utilization rates did not change between the historic and contemporary treatment era (p = 0.11), whereas magnetic resonance imaging (MRI) use at baseline and follow-up became more prevalent in the contemporary era (p = <0.001). On multivariable analysis, PCI utilization was associated with improved OS (HR 1.88, 95% CI 1.32–2.69) and decreased BFR (HR 4.66, 95% CI 2.58–8.40). Patients who had MRI follow-up had a higher incidence of BFR (HR 0.35, 95% CI 0.18–0.66) in multivariable analyses.

Conclusions

For LS-SCLC patients at our institution, PCI is more frequently utilized in younger patients, and the utilization rate did not change significantly over the past 20 years. PCI was independently associated with improved OS and lower BFR. Omission of PCI in LS-SCLC patients should not be routinely practiced in the absence of further prospective data.

Pain relief and local tumour control following percutaneous image-guided cryoablation for spine metastasis: a 12-year single-centre experience

AIM

To assess pain relief and local tumour control retrospectively in spinal metastases undergoing cryoablation.

MATERIALS AND METHODS

Between May 2008 and September 2020, 46 metastases in 41 consecutive patients (mean age 59.7±4.4 [SD] years; range 27-84) were treated with cryoablation in 42 interventional sessions. Patient demographics, procedural data, complications, pain, and local tumour control were analysed retrospectively.

RESULTS

Thirty-one patients (36 spine metastases; 32 sessions) were treated for pain relief and 10 (10 metastases; 10 sessions) for local tumour control. Clinical success was reached in 30/32 (93.8%) interventional palliative sessions. Mean pre-procedural numerical pain rate scale was 6.2±1.7 (SD), and dropped significantly to 3.5±1.8 (SD), 1.9±1.7 (SD), and 1.9±1.8 (SD) at 24-h, 1-month and at the last available follow-up (median 16.5±23.2 [SD] months), respectively. For patients requiring local tumour control, primary clinical success was reached in 6/10 (60%) spinal metastases at median 25-months follow-up. The overall complication rate was 8%, with no secondary fractures or iatrogenic thermal-mediated nerve injuries reported.

CONCLUSION

Percutaneous image-guided cryoablation of spinal metastases is safe and effective in achieving pain relief and local tumour control.

Elderly patients with unresectable stage 3 NSCLC treated with definitive chemoradiation with or without durvalumab: Safety and outcomes

8547

Background: Recently, it has been demonstrated that the addition of durvalumab after chemoradiation (CRT) in unresectable stage 3 non-small cell lung cancer (NSCLC) significantly improves overall survival (OS). The benefit of CRT in elderly patients is considered controversial given its increased toxicity. As such, CRT followed by durvalumab in elderly patients may be underutilized despite its demonstrated superiority. The practice pattern at our center is to offer curative treatment unless clearly contraindicated. We sought to investigate the outcomes of elderly patients treated with CRT +/- durvalumab at our center. Methods: We conducted a review of all stage 3 NSCLC patients treated with CRT between 2018 and 2020. Patients were analyzed based on age: < 70 years, ≥70 years. Endpoints evaluated were treatment patterns, toxicity, progression free survival (PFS) and overall survival (OS). Results: We identified 115 stage 3 patients: 44 patients ≥70 years (70-89) and 71 patients < 70 years (34-69). Patients were fit: ECOG 0-1 (98%/97%), mean Charlson comorbidity index (CCI) (1.1/0.9) in elderly vs young patients; p > 0.05. All other baseline characteristics including PD-L1 expression were similar. The chemotherapy regimens (platinum in combination with etoposide, paclitaxel or pemetrexed), dose intensity (97% vs 97%) and percentage of planned cycles received (91% vs 96%) were similar. There were 2 treatment related deaths from CRT among the younger cohort and none in the elderly patients. At the completion of CRT, 75% of elderly and 72% of young patients received durvalumab. Clinician/patient preference was the most common reason for not receiving consolidation durvalumab in older patients (55% vs 25%). The median time to starting durvalumab was 43 days in the elderly and 37 days in young patients (p = 0.19). Durvalumab was well tolerated in the elderly and incidence of grade ≥3 immune-related adverse events was 9% compared to 6% in young patients; p = 0.68. The durvalumab completion rates were 30% in elderly and 24% in young patients; p = 0.22. Median PFS was similar between elderly and young patients (17.9 vs 10.6 months respectively; p = 0.07), even after adjusting for the CCI (HR 0.60; p = 0.07). The 24- and OS rates are also similar (p = 0.93): 77% in elderly and 77% in young patients. Conclusions: Definitive CRT followed by durvalumab can be safely delivered in elderly patients ≥70 years with comparable outcomes. The non-significant trend towards better PFS in elderly patients suggests that only select fit patients are being referred for treatment. In conclusion, all patients should undergo comprehensive oncologic assessment to determine if curative intent treatment can be delivered to avoid undertreatment of elderly patients.

Patient-derived tumor xenograft and organoid models established from resected pancreatic, duodenal and biliary cancers

Patient-derived xenograft (PDX) and their xenograft-derived organoid (XDO) models that recapitulate the genotypic and phenotypic landscape of patient cancers could help to advance research and lead to improved clinical management. PDX models were established from 276 pancreato-duodenal and biliary cancer resections. Initial, passage 0 (P0) engraftment rates were 59% (118/199) for pancreatic, 86% (25/29) for duodenal, and 35% (17/48) for biliary ductal tumors. Pancreatic ductal adenocarcinoma (PDAC), had a P0 engraftment rate of 62% (105/169). KRAS mutant and wild-type PDAC models were molecularly profiled, and XDO models were generated to perform initial drug response evaluations. Subsets of PDAC PDX models showed global copy number variants and gene expression profiles that were retained with serial passaging, and they showed a spectrum of somatic mutations represented in patient tumors. PDAC XDO models were established, with a success rate of 71% (10/14). Pathway activation of KRAS-MAPK in PDXs was independent of KRAS mutational status. Four wild-type KRAS models were characterized by one with EGFR (L747-P753 del), two with BRAF alterations (N486_P490del or V600E), and one with triple negative KRAS/EGFR/BRAF. Model OCIP256, characterized by BRAF (N486-P490 del), had activated phospho-ERK. A combination treatment of a pan-RAF inhibitor (LY3009120) and a MEK inhibitor (trametinib) effectively suppressed phospho-ERK and inhibited growth of OCIP256 XDO and PDX models. PDAC/duodenal adenocarcinoma have high success rates forming PDX/organoid and retaining their phenotypic and genotypic features. These models may be effective tools to evaluate novel drug combination therapies.

Prevalence and Heterogeneity of PD-L1 Expression by 22C3 Assay in Routine Population-Based and Reflexive Clinical Testing in Lung Cancer

INTRODUCTION

Programmed death-ligand 1 (PD-L1) is used as a biomarker for anti-programmed cell death protein-1 (PD-1) or anti-PD-L1 immunotherapies in NSCLC. We report here the results of population-based PD-L1 testing using the 22C3 IHC pharmDx Assay (Agilent Technologies) in a large Canadian regional reference pathology laboratory.

METHODS

Testing was conducted reflexively on biopsies and resections for NSCLC during an 8-month period. Tumor proportion score (TPS) cutoffs for low and high expression were 1% and 50%, respectively.

RESULTS

Altogether, 2031 PD-L1 tests were performed on specimens from 1795 patients, with 107 inconclusive results (5.3%). Excluding cases with inconclusive/missing data, proportions for the remaining 1713 patients were 41.6% for TPS less than 1%, 28.6% for TPS 1% to 49%, and 29.8% for TPS greater than or equal to 50%. Higher PD-L1 expression rates were noted in EGFR wild-type versus mutant tumors (p < 0.001), squamous versus adenocarcinoma (p < 0.001), and metastatic versus primary tumors (p < 0.001). PD-L1 among 103 patients with paired biopsy and resection specimens revealed moderate concordance (κ = 0.67). A total of 52% (25 of 48) of biopsies with TPS less than 1% had TPS greater than 1% in resection, whereas 84.6% (22 of 26) of biopsies with TPS greater than or equal to 50% were concordant in resected tumors. Discordance rates between biopsy and resection were 71.4% for biopsies with less than 8 mm² total area, compared with 33.3% for biopsies with greater than or equal to 8 mm² area (p < 0.026). Concordance among 27 patients with paired primary lung and metastatic tumor biopsies revealed only weak concordance (κ = 0.48).

CONCLUSIONS

Intratumoral heterogeneity of PD-L1 expression may result in misclassification of PD-L1 status in a substantial proportion of PD-L1-negative small biopsy samples. Biopsy of metastatic site may increase proportion of patients with high PD-L1 expression.

Effects of Aerobic Exercise Training on Daily Psychological Processes in Family Caregivers: Secondary Analyses of a Randomized Controlled Trial

The aim of this study was to examine the effects of a 24-week aerobic exercise training program on daily psychological processes and occurrence of stressors in a group of previously physically underactive family caregivers of patients with dementia. As part of the Fitness, Aging, and STress (FAST) randomized controlled trial, 68 participants (F = 55; M = 13) were randomized to either a staff-supported, 24-week aerobic training (N = 34) program or waitlist control (N = 34) group. Approximately 2 weeks prior to randomization, ecological momentary assessments were completed 6 times per day for 7 days and again in the 24th week of the trial to assess exposure to levels of momentary positive affect, negative affect, rumination, control, and the occurrence of stressors throughout the day. These secondary analyses with data from 56 of the participants revealed that the intervention group showed a significantly larger increase in daily positive affect and perceptions of control compared to control participants over the course of the intervention. A treatment effect was also found for negative affect and rumination, whereby both decreased to a greater extent in the intervention group when compared with participants in the control condition. The 24-week aerobic training program had significant impacts on daily psychological processes in family caregivers, deepening our understanding of the robust effects of exercise on mental health.

Systemic Inflammatory Markers of Survival in Epidermal Growth Factor-Mutated Non-Small-Cell Lung Cancer: Single-Institution Analysis, Systematic Review, and Meta-analysis

BACKGROUND

Systemic inflammatory response (SIR) may influence prognosis in epidermal growth factor receptor (EGFR)-mutated (m) non-small-cell lung cancer (NSCLC). Pretreatment SIR markers (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio [LMR], lactate dehydrogenase [LDH], and lung immune prognostic index [LIPI]) were assessed as prognostic factors in NSCLC survival.

PATIENTS AND METHODS

Retrospective survival analysis (overall survival [OS] and progression-free survival [PFS]) of EGFR-mutated NSCLC patients at Princess Margaret Cancer Centre were performed separately for early (I-IIIa) and late (IIIb-IV) stage disease for individual SIR variables, dichotomized by optimal cutoff points by Kaplan-Meier survival analysis and multivariable Cox proportional hazard modeling. A systematic review and meta-analysis of known SIR studies in patients with late-stage EGFR-mutated were also performed.

RESULTS

From 2012 to 2019, in 530 patients, significant adjusted hazard ratios (aHR) for OS comparing high versus low NLR were 2.12 for early stage and 1.79 for late stage disease. Additionally, late stage cohorts had significant associations, as follows: high versus low derived NLR, aHR = 1.53; LMR, aHR = 0.62; LDH, aHR = 2.04; and LIPI, aHR = 2.04. Similar patterns were found for PFS in early stage NLR (aHR = 1.96) and late stage NLR (aHR = 1.46), while for PFS, only late stage derived NLR (aHR = 1.34), LDH (aHR = 1.75), and LIPI (aHR = 1.66) were significant. A meta-analysis confirmed that NLR, LMR, LDH, and LIPI were all significantly associated with OS and PFS in the late stage.

CONCLUSION

This primary study and meta-analysis demonstrated that LMR and LDH were significantly associated with late stage EGFR-mutated NSCLC outcomes, and the LIPI scoring system was prognostic. NLR remained an independent prognostic factor across all stages and could represent an early marker of immuno-oncology interactions.

Group Virtual Mindfulness-Based Intervention for Parents of Autistic Adolescents and Adults

Mindfulness-based approaches have been shown to be effective in improving the mental health of parents of youth and adults with autism and other developmental disabilities, but prior work suggests that geography and caregiving demands can make in-person attendance challenging. The purpose of this study was to evaluate the feasibility, acceptability and preliminary outcomes of a mindfulness-based group intervention delivered to parents virtually. It was feasible to deliver this manualized intervention. Twenty-one of 39 parents completed the intervention and completers reported high satisfaction ratings. Parents reported reduced levels of distress, maintained at 3-month follow-up, and increased mindfulness. Changes reported following intervention were similar to changes reported in a prior study of parents competing an in person mindfulness group.

Lack of evidence for expression and function of IL-39 in human immune cells

Members of the IL-6/IL-12 cytokine family are critical regulators of innate and adaptive immunity and have emerged as key players controlling inflammatory and autoimmune disorders. This cytokine family comprises of IL-12, IL-23, IL-27, and IL-35, each consisting of distinct α- and β-cytokine subunits that form heterodimers. A new member of this family, IL-39, was identified in the murine species and was shown to consist of the IL-23p19 and Epstein-Barr Virus-induced 3 (EBI3) subunits. Subsequently, it was shown that IL-39 was implicated in the immunopathogenesis of murine experimental lupus erythematosus. The existence of IL-39 in the human system has yet to be confirmed. Based on the clinical success of IL-23p19 neutralizing approaches in moderate-to-severe psoriasis, anti-IL-23p19 antibodies in the clinic may not only neutralize IL-23, but additionally IL-39, implying that IL-39 might also contribute to the pathogenesis of psoriasis. It is therefore pivotal to demonstrate IL-39 expression and to characterize its function in the human system. In this study, we provided evidence for the existence of secreted heterodimeric p19 and EBI3 complexes in supernatants originating from p19 and EBI3 transfected HEK293FT cells. We attempted to detect IL-39 expression from stimulated human primary B cells, human keratinocytes and in vitro polarized human macrophages. Whereas, the expression of p19 and EBI3 mRNA was elevated, we failed to detect p19 and EBI3 heterodimers. Functional assays were conducted with conditioned media containing human IL-39 or with a human recombinant IL-39 Fc protein. Immune cells targeted by IL-39 in mouse, such as neutrophils and PBMCs, did not respond to human IL-39 stimulation and IL-39 failed to activate STAT3 in a reporter cell line. These results suggest that, while the secretion of p19/EBI3 complexes can be forced in human cells, it is secreted below the lower quantity of detection or it has no functional role.

BIOM-02. IDENTIFYING MGMT ALTERATIONS AS BIOMARKERS OF SURVIVAL IN LUNG ADENOCARCINOMA WITH BRAIN METASTASES

EGFR-mutant lung adenocarcinomas (EGFRm-LUAD) have a higher risk of developing brain metastases (BM) compared to non-EGFR-mutant tumors. BM development has significant prognostic impact and leads to poorer patient survival. MGMT promoter methylation is known to determine response to therapy in other cancer types including intracranial gliomas but has not been investigated in EGFRm-LUAD BM. This work aims to assess whether MGMT promoter methylation predicts patient survival or BM development in EGFRm-LUAD patients. A large cohort of 90 primary EGFRm-LUAD tumors, of which 33 (37%) developed BM, were profiled using the Illumina Infinium MethylationEPIC Bead chip. Using the previously reported MGMT-STP27 approach that uses two CpG sites to predict MGMT methylation status, Cox modeling was performed to assess whether MGMT methylation status correlates with overall survival independent of other clinical factors. MGMT methylation significantly predicted poorer survival in EGFRm-LUAD patients that developed BM (p=0.0003) and did not develop BM (p=0.003). A multivariate cox analysis, adjusting for cancer stage and smoking status as potential confounders, showed that MGMT methylation (HR=6.2, 95%CI:2.2–17.4, p=0.0005) and BM development (HR=2.6, 95%CI:1.3–5.3, p=0.007) were both independently predictive of worse overall survival in EGFRm-LUAD patients. This finding of poorer survival in MGMT methylated EGFRm-LUAD is validated in an independent LUAD patient cohort. Total mutation burden, calculated by the number of mutations per megabase of DNA, was substantially higher in MGMT methylated tumours with an interquartile range (IQR) of 58 (30–71) compared to MGMT unmethylated tumours with the IQR of 5.5 (4.3–6.1) resulting p-value of 0.01 for this comparison. Overall, this work shows that MGMT promoter methylation status is an important prognostic biomarker in LUAD patients. MGMT promoter methylation status in EGFRm–LUAD patients with BM may be used to guide patient treatment with potentially a greater extent of treatment for high-risk patients.

Variety of scaling behaviors in nanocrystalline plasticity

We address the question of why larger, high-symmetry crystals are mostly weak, ductile, and statistically subcritical, while smaller crystals with the same symmetry are strong, brittle and supercritical. We link it to another question of why intermittent elasto-plastic deformation of submicron crystals features highly unusual size sensitivity of scaling exponents. We use a minimal integer-valued automaton model of crystal plasticity to show that with growing variance of quenched disorder, which can serve in this case as a proxy for increasing size, submicron crystals undergo a crossover from spin-glass marginality to criticality characterizing the second order brittle-to-ductile (BD) transition. We argue that this crossover is behind the nonuniversality of scaling exponents observed in physical and numerical experiments. The nonuniversality emerges only if the quenched disorder is elastically incompatible, and it disappears if the disorder is compatible.