Phase 1b study of vactosertib in combination with oxaliplatin with 5FU/LV (FOLFOX) in patients with metastatic pancreatic cancer who have failed first-line gemcitabine/nab-paclitaxel

e16299

Background: TGF-β is strongly involved in the tumor microenvironment of PDAC, and dysregulation of TGF-β signaling is a frequent molecular disturbance in pancreatic ductal adenocarcinoma (PDAC) progression and metastasis. Vactosertib is an orally bioavailable TGF-β signaling inhibitor that targets the TGF-β type I receptor kinase. In preclinical studies, vactosertib in combination with FOLFOX improves pancreatic cancer survival by suppressing cell migration, invasion, and epithelial-mesenchymal transition (EMT), highlighting a potential clinical application of this approach for PDAC patients. We performed a phase 1b study to determine the recommended phase 2 dose (RP2D) and to evaluate the safety of vactosertib in combination with FOLFOX in patients with metastatic PDAC who have failed first-line gemcitabine/ nab-paclitaxel. Methods: Eligible patients have histologically confirmed PDAC who have failed first-line gemcitabine/ nab-paclitaxel with adequate organ function and performance status. This study is composed of two parts; dose escalation and dose expansion. In the dose escalation part (phase 1b), different dose levels of vactosertib (50 mg bid, 100 mg bid, and 200 mg bid) for escalation were tested, starting with dose level 0 (DL 0, 100 mg bid) with 3 to 6 subjects recruited in each cohort. DL -1 was only planned to test when DL 0 was unacceptable. In the dose expansion part, an additional backfill cohort was planned to open for determination of the final RP2D. Patients in each cohort were planned to receive vactosertib 50-200 mg orally twice per day 1-5 & day 8-12 with oxaliplatin 85 mg/m2 on day 1, LV 200mg/m2 IV on day 1, 5FU 200mg/m2 bolus on day 1 and continuous 5-FU 2400mg/m2 infusion over 48 hours every 2 weeks. The primary endpoints were to determine RP2D and to evaluate safety of this combination. The key secondary endpoints were progression free survival (PFS), overall response rate (ORR), disease control rate (DCR) based on RECIST 1.1 and overall survival. Results: A total of 16 patients were enrolled, 3 in DL 0, 4 in DL 1 and 9 in DL 1 backfill cohort. No dose limiting toxicities (DLTs) were observed and the RP2D was established as vactosertib 200 mg orally twice per day 1-5 & day 8-12 with FOLFOX. The vactosertib related adverse events (AEs) of any grade included fatigue, nausea, vomiting and anorexia. Three of 13 patients (23.1%) had partial response and 5 (38.5%) stable disease as best response, with clinical benefit rate of 61.5 % in DL 1, while there were no PR or SD in DL 0. Median PFS was 5.6 months [95% confidence interval (CI), 2.27–8.93]. Conclusions: In this phase Ib study, we demonstrated the feasibility and safety of adding vactosertib to FOLFOX in 2nd line setting, which needs to be further investigated. Updated results, including PK analyses, safety profiles, ORR, PFS and overall survival, will be presented. Clinical trial information: NCT03666832.

Clinical characteristics and treatments of multi-system inflammatory syndrome in children: a systematic review

OBJECTIVE

Multisystem inflammatory syndrome in children (MIS-C) can occur in association with coronavirus disease 2019 (COVID-19). It is not easy to differentiate MIS-C from severe COVID-19 or Kawasaki disease based on symptoms. The aim of this study was to describe the clinical and laboratory characteristics of MIS-C.

PATIENTS AND METHODS

We searched PubMed/Medline for case series and reports of MIS-C published until June 20, 2020. From a total of nine articles involving 45 cases, various clinical and laboratory data were extracted. Each target case was evaluated by using different diagnostic criteria.

RESULTS

The average age at onset of MIS-C was 8.6 years. In 80% of cases, the age of patients ranged from 5 to 15 years. Fever (100%) and shock (82%) were the most common presenting symptoms. Sixty percent of cases met the diagnostic criteria for typical or atypical Kawasaki disease. Biomarkers indicative of inflammation, coagulopathy, or cardiac injury were characteristically elevated as follows: ferritin (mean: 1,061 ng/mL), CRP (217 mg/L), ESR (69 mm/hr), IL-6 (214.8 pg/mL), TNFα (63.4 pg/mL), D-dimer (3,220 ng/mL), PT (15.5 s), troponin I (1,006 ng/L), and BNP (12,150 pg/mL). Intravenous immunoglobulin was administered in all target cases, and inotropic agents were commonly used as well. No case of death was observed.

CONCLUSIONS

This study demonstrated that MIS-C is a serious condition that presents with fever, rash, as well as cardiovascular and gastrointestinal symptoms. Although it is challenging to differentiate MIS-C from Kawasaki disease or severe COVID-19, initiation of appropriate treatments through early diagnosis is warranted.

Combination therapy for treating drug-resistant multiple myeloma

Proteasome inhibitors (PIs) have remarkably improved the survival of multiple myeloma (MM) patients but dose-limiting toxicities and the development of drug resistance limit their long-term utility. Elevated TGF-β levels in MM patient sera correlate with chemoresistance, disease progression, metastasis and poor prognosis. Therefore, we evaluated the anti-MM therapeutic potential of a TGF-β type I receptor kinase inhibitor, Vactosertib. In vitro treatment of Vactosertib synergistically inhibited the growth of PI-resistant MM cells in combination with the ixazomib by suppressing TGF-β activation of Smad2/3 and expression of PSMB5, which encodes the proteasome 5 catalytic subunit targeted by PIs. Oral administration of Vactosertib as a single agent inhibited MM progression and induced a decrease in mortality and an increase in body weight of the mice bearing MM. Vactosertib alone also attenuated TGF-β activation of Smad2/3, reduced the expansion of CD11b+Gr-1+ myeloid derived suppressor cells (MDSCs) in bone marrow tumor microenvironment, and diminished the population of Foxp3+ regulatory T cells (Treg) in the spleen. Combination therapy of Vactosertib plus ixazomib was exhibited a synergistic anti-tumor effect when compared to either Vactosertib or ixazomib alone by greatly prolonged survival and significant a reduction in both MDSCs and Tregs. Taken together, our data provide the rationale for clinical evaluation of Vactosertib in MM and demonstrate proof-of-concept that combination of Vactosertib and PIs may overcome chemoresistance and enhance durable patient responses.

Supported by 1R03CA259901-01A1

Phase 1b study of vactosertib in combination with nal-IRI plus 5FU/LV in patients with metastatic pancreatic ductal adenocarcinoma who have failed first-line gemcitabine/nab-paclitaxel

TPS632

Background: Pancreatic ductal adenocarcinoma (PDAC) remains one of the most aggressive malignancies and the leading cause of cancer-related death in the world, although recent advances in chemotherapies for metastatic PDAC provide better clinical outcomes. TGF-β is strongly involved in the tumor microenvironment of PDAC, and dysregulation of TGF-β signaling is a frequent molecular disturbance in PDAC progression and metastasis. Vactosertib is an orally bioavailable TGF-β signaling inhibitor that targets the TGF-β type I receptor kinase. In in vivo studies, vactosertib reduces cancer cell migration, invasion, and metastasis of various cancers, and combination of vactosertib with nal-IRI/5-FU/LV improves pancreatic cancer survival by suppressing cell migration, invasion, and epithelial-mesenchymal transition (EMT), highlighting a potential clinical application of this approach for PDAC patients (Hong et al, 2020). Based on this preclinical study, we develop a phase 1b study to determine the recommended phase 2 dose (RP2D) and to evaluate the safety of vactosertib in combination with nal-IRI/5FU/LV in patients with metastatic PDAC who have failed first-line gemcitabine/ nab-paclitaxel. Methods: Eligible patients have histologically confirmed PDAC who have failed first-line gemcitabine/ nab-paclitaxel with adequate organ function and performance status. This study is composed of two parts; dose escalation and dose expansion. In the dose escalation part (phase 1b), different dose levels of vactosertib (100 mg bid, 200 mg bid, and 300 mg bid) for escalation will be tested, starting with dose level 0 (DL 0, 200 mg bid) with 3 to 6 subjects recruited in each cohort. DL -1 is only tested when DL 0 is unacceptable. In the dose expansion part, one or two additional backfill cohorts among DL -1 through DL 2 will be opened for determination of the final RP2D. For each cohort, a maximum of 12 patients can be enrolled including the dose escalation and dose expansion phase. Patients in each cohort will receive vactosertib 100-300 mg orally twice per day 1-5 & day 8-12 with nal-IRI 70mg/m2 intravenously day 1, LV 400mg/m2 IV day 1, and continuous 5-FU 2400mg/m2 infusion over 48 hours every 2 weeks. The primary endpoint is to determine RP2D and to evaluate safety of this combination. The key secondary endpoints are progression free survival, overall response rate, disease control rate based on RECIST 1.1 and overall survival. As of September 2021, 5 patients have been enrolled in DL 0 and 1 DLT has been reported in DL 0. This study is prospectively registered on ClinicalTrials.gov, NCT04258072. Clinical trial information: NCT04258072.

Serum Ceruloplasmin as a Potential Clinical Biomarker in Atopic Dermatitis

Background

Although the discovery of new biomarkers in atopic dermatitis (AD) is challenging, it is valuable in diagnosis, assessment of severity, and evaluation of treatment response.

Objective

This study was designed to identify and validate new candidate protein biomarkers of AD via proteomic analysis.

Methods

Comparison of protein expression in the patients’ serum before- and after-treatment and in patients without AD was performed via two-dimensional gel electrophoresis (2-DE), followed by image analysis. Spots showing differential expression in 2-DE image analysis were identified subsequently via nanoscale liquid chromatography-tandem mass spectrometry (LC-MS/MS) experiments. Blood tests were conducted to validate the results obtained by measuring the levels of candidate proteins.

Results

Based on LC-MS/MS analysis and database search, we identified ceruloplasmin (Cp) as a candidate protein. Serum Cp levels were significantly decreased in in pre-treated AD group than in control group. Additionally, the serum Cp level was higher in the mild group than in the moderate group of AD based on the Eczema Area and Severity Index (EASI) score.

Conclusion

Low serum Cp levels are associated with AD, suggesting the potential role of Cp as a biomarker for diagnosis and severity assessment of AD.

Anti-inflammatory and anti-fibrotic effects of modafinil in nonalcoholic liver disease

Small- and intermediate-conductance Ca²⁺-activated K⁺ channels, K_Ca2.3 and K_Ca3.1, are involved in cellular signaling processes associated with inflammation and fibrosis. K_Ca2.3 and K_Ca3.1 are upregulated by proinflammatory cytokines and profibrotic growth factors. Cyclic AMP, which downregulates K_Ca2.3 and K_Ca3.1, is elevated by modafinil in cells; accordingly, we investigated whether modafinil exerts anti-inflammatory and anti-fibrotic responses via K_Ca2.3- and K_Ca3.1-mediated pathways in high-fat diet (HFD)- or thioacetamide-induced liver disease models in mice. Modafinil was administered orally in the form of a racemate, (R)-isomer, or (S)-isomer. We also determined whether the treatment targeted the profibrotic activity of hepatic stellate cells using immortalized human hepatic stellate cells (LX-2 cells). Modafinil improved HFD- or thioacetamide-induced changes compared to the control, leading to a reduced inflammatory response, collagen deposition, and α-smooth muscle actin expression both in vivo and in vitro. However, modafinil did not relieve HFD-induced steatosis. There were no significant differences in the effects of the (R)- and (S)-isomers of modafinil. K_Ca2.3 and K_Ca3.1 were upregulated and catalase was downregulated in liver tissues from thioacetamide- or HFD-induced liver disease models or in TGF-β-treated LX-2 cells. TGF-β-induced upregulation of K_Ca2.3, K_Ca3.1, collagen, and α-smooth muscle actin and downregulation of catalase were reversed by modafinil, polyethylene glycol catalase, N-acetylcysteine, siRNA against K_Ca2.3 or K_Ca3.1, and Epac inhibitors. Our investigation revealed that modafinil attenuated inflammatory and fibrotic progression via K_Ca2.3- and K_Ca3.1-mediated pathways in nonalcoholic hepatitis, suggesting that inhibiting K_Ca2.3- and K_Ca3.1-mediated signaling may serve as a novel therapeutic approach for inflammatory and fibrotic liver diseases.

74 Tumor microenvironment based on PD-L1 and CD8 T-cell infiltration correlated with the response of MSS mCRC patients treated vactosertib in combination with pembrolizumab

Background

The expression of PD-L1 and tumor-infiltrating CD8 T cells were reported to have a decisive effect on the immunotherapy response (PMID: 26819449). Microsatellite stable (MSS) metastatic colorectal cancer (mCRC) shows a limited clinical benefit to immunotherapy alone known to be having an ‘immune-cold’ microenvironment. To understand the basis of the clinical responses to anti-PD-1 and TGF-β inhibitor combination therapy in MSS mCRC, we conducted a comprehensive analysis of survival outcome, whole transcriptome sequencing (WTS) data, and multiplex immunohistochemistry (mIHC) data from a combination treatment of vactosertib and pembrolizumab.

Methods

Clinical outcomes were evaluated by RECIST v1.1 and iRECIST. Tumor tissue biopsy samples for WTS and mIHC were obtained in screening and cycle 2 post-treatment time point. CD274(PD-L1) and CD8A expression cut-off were calculated as a median value in the merged data set of TCGA Pan-cancer and MP-VAC-204 study. Having over median value defined as a high group and under median value as a low group. Tumor immune status by a combination of gene expression (high or low) was classified into four subtypes (1: CD274 high, CD8A high; 2: CD274 low, CD8A low; 3: CD274 high, CD8A low; 4: CD274 low, CD8A high). Tumor tissue slides stained with PD-L1, CD8, and granzyme B (GZB) in tumor nest and stroma.

Results

Among 43 patients whose WTS data are available, thus included in the analysis, 9 patients were responders (7 PRs and 2 iPRs). Subtype 2 showed a major proportion in the MP-VAC-204 CRC patients (1: 14%, 2: 58%, 3: 12%, 4: 16%). Responders were observed in subtype 2 and 4 (24% and 14%, RECIST). The CD8A expression and median overall survival (mOS) showed a significantly positive correlation (**P=0.0028) and there was no significance in the correlation of CD274 and mOS. mOS was significantly longer in high expression of CD8A patients (*P=0.0083, Not reached vs 9.9 months, hazard ratio 8.812 [95% CI 3.19–24.31]). After the combination treatment, CD8 and GZB positive T cells were increased significantly in both tumor nest and stroma.

Conclusions

Our study suggests a high level of CD8 T cells, even in the case of low PD-L1 expression, is significantly correlated with the improved clinical outcomes in MSS mCRC patients treated with vactosertib and pembrolizumab. The increases in CD8 T cells both in tumor nest and stroma after the combined inhibition of PD-1 and TGF-β pathway may contribute to the survival benefit. Further clinical investigations are warranted. (Clinical trial information: NCT03724851)

823 Spatial analysis of tumor-infiltrating lymphocytes correlates with the response of metastatic colorectal cancer patients treated with vactosertib in combination with pembrolizumab

Background

Previously, we presented a promising anti-tumor efficacy (ORR: 16%, mOS: 15.8 months, RECIST) of the combination of vactosertib, a potent and selective TGF-β receptor I, and pembrolizumab (vac+pem) in patients with microsatellite stable metastatic colorectal cancer (MSS mCRC, MP-VAC-204 study). Recent reports showed immune-excluded TIL located in stroma would be closely related to TGF-β signature, which may harbor the primary resistance of pembrolizumab. In this study, we performed an exploratory biomarker analysis of TIL resided in either intra-tumoral or stromal area in pathology slides, and we hypothesized that spatial features of TIL would correlate with the response of vac+pem.

Methods

Pathology slides stained with H&E were obtained from 31 patients at baseline and 14 patients at cycle 2 in MSS mCRC patients in MP-VAC-204 study. For spatial TIL analysis, we applied an artificial intelligence -powered H&E analyzer, named Lunit SCOPE IO, which automatically detects TIL, tumor and stroma. It calculates the proportion of immune phenotype consists of inflamed, as high TIL density inside tumor area, or immune-excluded, as high TIL density in stroma in whole-slide images. Additionally, PD-L1 and CD8 were stained using multiplex immunohistochemistry to validate immune phenotype assessed by Lunit SCOPE IO.

Results

At baseline, the proportion of immune-excluded area (immune-excluded score, IES) was positively correlated with the density of CD8-positive cells in stroma area measured by mIHC (coefficient = 0.349), but it was not related to the density of PD-L1-positive cells (coefficient = -0.226). Area under receiver operating characteristics to predict the responder as partial response by RECIST v1.1 by IES and PD-L1 were 0.741 and 0.528. The overall response rate of vac+pem in the patients with high IES > 42.3% was 25% (4 out of 16), while no response was observed in those with low IES (0 out of 15). Overall survival (OS) of vac+pem was significantly prolonged in those with high IES > 42.3% compared to low IES (median OS: not reached versus 6.8 months, P = 0.0097), but it was not different according to PD-L1 level. After treatment of vac+pem, while IES was decreased regardless of treatment response, the proportion of inflamed area was increased in the responders (N=3) but decreased in the non-responders (N=11).

Conclusions

Immune-excluded score which reflects TGF-β-driven TIL exclusion into stroma is correlated with anti-tumor response of vac+pem in MSS mCRC. Further investigation on spatial TIL analysis as a potential biomarker should be warranted. (Clinical trial information: NCT03724851)

Characteristics and outcomes of emergency department patients with a foreign body that entered through the ear, nose or mouth: a 10-year retrospective analysis

BACKGROUND

Foreign bodies in the ear, nose and throat commonly necessitate emergency department visits.

METHOD

This retrospective study was conducted on emergency department visits from January 2010 to December 2019 to determine characteristics and clinical prognoses of ENT patients. Patients were divided into three groups according to foreign-body entry route; patient characteristics and clinical findings were compared between groups.

RESULTS

Of 676 142 emergency department visits, 10 454 were because of ENT-related foreign bodies. The mean (± standard deviation) age of subjects was 24.0 (± 23.4) years, and 5176 patients were male (49.5 per cent). The most common entry route was the mouth (74.5 per cent). Most patients (97.1 per cent) were discharged after emergency treatment. Intensive care and in-hospital mortality occurred only in the mouth group.

CONCLUSION

Clinical findings differ depending on foreign-body entry route. After emergency treatment, most patients were discharged; some cases presented serious complications.

T Cell-Mediated Antitumor Immunity Cooperatively Induced By TGFβR1 Antagonism and Gemcitabine Counteracts Reformation of the Stromal Barrier in Pancreatic Cancer

The desmoplastic stroma of pancreatic cancers forms a physical barrier that impedes intratumoral drug delivery. Attempts to modulate the desmoplastic stroma to increase delivery of administered chemotherapy have not shown positive clinical results thus far, and preclinical reports in which chemotherapeutic drugs were coadministered with antistromal therapies did not universally demonstrate increased genotoxicity despite increased intratumoral drug levels. In this study, we tested whether TGFβ antagonism can break the stromal barrier, enhance perfusion and tumoral drug delivery, and interrogated cellular and molecular mechanisms by which the tumor prevents synergism with coadministered gemcitabine. TGFβ inhibition in genetically engineered murine models (GEMM) of pancreas cancer enhanced tumoral perfusion and increased intratumoral gemcitabine levels. However, tumors rapidly adapted to TGFβ-dependent stromal modulation, and intratumoral perfusion returned to pre-treatment levels upon extended TGFβ inhibition. Perfusion was governed by the phenotypic identity and distribution of cancer-associated fibroblasts (CAF) with the myelofibroblastic phenotype (myCAFs), and myCAFs which harbored unique genomic signatures rapidly escaped the restricting effects of TGFβ inhibition. Despite the reformation of the stromal barrier and reversal of initially increased intratumoral exposure levels, TGFβ inhibition in cooperation with gemcitabine effectively suppressed tumor growth via cooperative reprogramming of T regulatory cells and stimulation of CD8 T cell-mediated antitumor activity. The antitumor activity was further improved by the addition of anti-PD-L1 immune checkpoint blockade to offset adaptive PD-L1 upregulation induced by TGFβ inhibition. These findings support the development of combined antistroma anticancer therapies capable of impacting the tumor beyond the disruption of the desmoplastic stroma as a physical barrier to improve drug delivery.

Penetration Cascade of Size Switchable Nanosystem in Desmoplastic Stroma for Improved Pancreatic Cancer Therapy

Pancreatic ductal adenocarcinoma (PDAC) cells are surrounded by a dense extracellular matrix (ECM), which greatly restricts the access of therapeutic agents, resulting in poor clinical response to chemotherapy. Transforming growth factor-β1 (TGF-β1) signaling plays a crucial role in construction of the desmoplastic stroma and provides potential targets for PDAC therapy. To surmount the pathological obstacle, we developed a size switchable nanosystem based on PEG-PLGA nanospheres encapsulated within liposomes for the combined delivery of vactosertib (VAC), a TGF-β1 receptor kinase inhibitor, and the cytotoxic drug paclitaxel (TAX). By surface modification of the liposomes with a peptide, APT_EDB, the nanosystem can be anchored to abundant tumor-associated fibronectin in PDAC stroma and decreases its size by releasing encapsulated TAX-loaded nanospheres, as well as VAC after collapse of the liposomes. The inhibition of ECM hyperplasia by VAC allows TAX more ready access to the cancer cells in addition to its small size, thereby shrinking pancreatic tumor xenografts more effectively than a combination of the free drugs. This size switchable nanosystem enables sequential delivery of drugs at a fixed dose combination with simplified administration and provides an encouraging cascade approach of drug penetration for enhanced chemotherapy in cancers with a dense desmoplastic stroma.

Metastasis Risk Assessment Using BAG2 Expression by Cancer-Associated Fibroblast and Tumor Cells in Patients with Breast Cancer

Simple Summary

Cancer-associated fibroblasts (CAFs) promote tumor progression and play an important role in evading immune surveillance. The previous study showed that BAG2 could be elevated in cancer associated fibroblasts (CAFs). Here, we evaluated BAG2 expression of CAF and tumor cells and assessed metastasis risk in patients with breast cancer. We found that patients with either BAG2-high or BAG2(+) CAF had significantly worse distant metastasis-free survival than those with BAG2-double negative. Evaluation of BAG2 expression on both CAFs and tumor cells could be helpful to estimate the risk of metastasis in breast cancer.

Abstract

Few studies have examined the role of BAG2 in malignancies. We investigated the prognostic value of BAG2-expression in cancer-associated fibroblasts (CAFs) and tumor cells in predicting metastasis-free survival in patients with breast cancer. Tissue-microarray was constructed using human breast cancer tissues obtained by surgical resection between 1992 and 2015. BAG2 expression was evaluated by immunohistochemistry in CAFs or the tumor cells. BAG2 expression in the CAFs and cytoplasm of tumor cells was classified as positive and negative, and low and high, respectively. BAG2-CAF was evaluated in 310 patients and was positive in 67 (21.6%) patients. Kaplan–Meier plots showed that distant metastasis-free survival (DMFS) was lesser in patients with BAG2(+) CAF than in patients with BAG2(−) CAF (p = 0.039). Additionally, we classified the 310 patients into two groups: 109 in either BAG2-high or BAG2(+) CAF and 201 in BAG2-low and BAG2(−) CAF. DMFS was significantly reduced in patients with either BAG2-high or BAG2(+) CAF than in the patients of the other group (p = 0.005). Multivariable analysis demonstrated that DMFS was prolonged in patients with BAG2(−) CAF or BAG2-low. Evaluation of BAG2 expression on both CAFs and tumor cells could help in determining the risk of metastasis in breast cancer.

Combination of Limosilactobacillus fermentum MG4231 and MG4244 attenuates lipid accumulation in high-fat diet-fed obese mice

We investigated the anti-obesity effect and the underlying mechanisms of action of human-derived Limosilactobacillus fermentum MG4231, MG4244, and their combination, in high-fat diet-induced obese mice. Administration of the Limosilactobacillus strains decreased body weight gain, liver and adipose tissue weight, and glucose tolerance. Serum levels of total cholesterol, low-density lipoprotein-cholesterol, and leptin were reduced, while adiponectin increased. The administration of Limosilactobacillus strains improved the histopathological features of liver tissue, such as hepatic atrophy and inflammatory penetration, and significantly reduced the content of triglyceride in the liver. Limosilactobacillus administration discovered a significant reduction in the size of the adipocytes in the epididymal tissue. Limosilactobacillus treatment significantly reduced the expression of important regulators in lipid metabolism, including peroxisome proliferator-activated receptor γ, CCAAT/enhancer-binding protein α, fatty acid synthase (FAS), adipocyte-protein 2, and lipoprotein lipase in the epididymal tissue. Also, Limosilactobacillus lowered sterol regulatory element-binding protein 1-c and FAS in the liver tissue. Such changes in the expression of these regulators in both liver and epididymis tissue were caused by Limosilactobacillus upregulating phosphorylation of AMP-activated protein kinase and acetyl-CoA carboxylase. Therefore, we suggest that the use of the combination of L. fermentum MG4231 and MG4244, as probiotics could effectively inhibit adipogenesis and lipogenesis from preventing obesity.

3 Epidemiology of running-related injuries in the Korean population: a cross-sectional survey of 1046 runners

Aims

Running is the oldest form of exercise in human history and the most popular exercise in the world.1 While running can improve physical fitness and reduce chronic health problems such as obesity and cardiovascular disease, it is also associated with injuries in lower extremities.2 However, because there was no consensus definition of running-related injury, the prevalence and incidence of running-related injuries had been reported to vary between 19% and 92%.3 Moreover, epidemiology of running-related injuries in Asian populations has been rarely investigated. Therefore, this study was first to use the consensus definition of running-related injuries published in 20153 and investigated the epidemiology of running-related injuries in the Korean population.

Methods

In cross-sectional design, an online survey was circulated among various running communities in Korea. The questionnaire contained information on presence and location of pain attributed to running, demographic characteristics, weekly running mileage, training intensity, running pace, type of shoes, foot strike, reason for running, and exercise experience prior to running.

Results

Among 1046 runners (male=624, female 422) who responded, 94.7% experienced some kind of pain while running, but only 37% were categorized to have running-related injuries. The most common site of injury was the knee followed by ankle. Exercise experience prior to running (OR 1.57 95% CI 1.13–2.21), setting of specific running goals (OR 1.57 95% CI 1.08–2.27), and mileage increases from 20–30 km to 30–40 km (OR 1.66 95% CI 1.06–2.63) were associated with significant increases in running-related injuries.

Conclusion

In order to avoid running-related injuries, runners should be careful in increasing weekly mileage. Moreover, runners with previous exercise experience may need to approach running more cautiously. Setting goals may be motivating but at the same time can increase the risk of running-related injuries.

References

Videbæk S, Bueno AM, Nielsen RO, Rasmussen S. Incidence of running-related injuries per 1000 h of running in different types of runners: a systematic review and meta-analysis. Sports medicine 2015;45(7):1017–26.

Van Gent R, Siem D, van Middelkoop M, Van Os A, Bierma-Zeinstra S, Koes B. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine 2007;41(8):469–80.

Yamato TP, Saragiotto BT, Lopes AD. A consensus definition of running-related injury in recreational runners: a modified Delphi approach. Journal of orthopaedic & sports physical therapy 2015;45(5):375–80.

Phytochemicals in Cancer Immune Checkpoint Inhibitor Therapy

The interaction of immune checkpoint molecules in the tumor microenvironment reduces the anti-tumor immune response by suppressing the recognition of T cells to tumor cells. Immune checkpoint inhibitor (ICI) therapy is emerging as a promising therapeutic option for cancer treatment. However, modulating the immune system with ICIs still faces obstacles with severe immunogenic side effects and a lack of response against many cancer types. Plant-derived natural compounds offer regulation on various signaling cascades and have been applied for the treatment of multiple diseases, including cancer. Accumulated evidence provides the possibility of efficacy of phytochemicals in combinational with other therapeutic agents of ICIs, effectively modulating immune checkpoint-related signaling molecules. Recently, several phytochemicals have been reported to show the modulatory effects of immune checkpoints in various cancers in in vivo or in vitro models. This review summarizes druggable immune checkpoints and their regulatory factors. In addition, phytochemicals that are capable of suppressing PD-1/PD-L1 binding, the best-studied target of ICI therapy, were comprehensively summarized and classified according to chemical structure subgroups. It may help extend further research on phytochemicals as candidates of combinational adjuvants. Future clinical trials may validate the synergetic effects of preclinically investigated phytochemicals with ICI therapy.

Abstract 1749: DRAK1 suppresses inflammation-induced cervical cancer progression by targeting TRAF6 protein

Cervical cancer is a major cause of mortality in women worldwide and strongly associated with persistent infection with high-risk (HR) human papillomavirus (HPV), mainly HPV16 and HPV18. Most HPV viruses can be cleared by the immune system, and a preventive and effective vaccine against HPV infection decreases the development of cervical cancer. The adaptor protein TNF receptor-associated factor 6 (TRAF6) is a key mediator in inflammation. However, the molecular mechanisms controlling its activity and stability in cancer progression remain unclear. Here we show that death-associated protein kinase-related apoptosis-inducing kinase 1 (DRAK1) specifically decreases the stability of the TRAF6 protein via an autophagy-mediated degradation pathway by interfering with the homo-oligomerization of TRAF6, eventually suppressing tumor growth and metastasis in inflammation-associated advanced cervical cancer cells. DRAK1 bounds directly to the TRAF domain of TRAF6, preventing its autoubiquitination by interfering homo-oligomerization, eventually leading to autophagy-mediated degradation of TRAF6. Depletion of DRAK1 in cervical cancer cells resulted in markedly increased levels of TRAF6 protein, promoting activation of the IL1β signaling-associated pathway and pro-inflammatory cytokine production. DRAK1 knockdown accelerated cervical cancer tumorigenesis and metastasis whereas DRAK1 overexpression suppressed that phenomenon. DRAK1 was specifically underexpressed in metastatic cervical cancers and inversely correlated with TRAF6 expression in mouse xenograft model tumor tissues and human cervical tumor tissues. Collectively, our findings highlight DRAK1 as a novel potential biomarker and novel therapeutic target for treatment of TRAF6-associated advanced cervical cancers. [This work was supported by National R&D Program for Cancer Control, Ministry for Health and Welfare, Republic of Korea (HA17C0037).]

Citation Format: Kyoungwha Pang, Jihee Lee, Jinah Park, Akira Ooshima, Kyung-Min Yang, Seong-Jin Kim. DRAK1 suppresses inflammation-induced cervical cancer progression by targeting TRAF6 protein [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1749.

Abstract 989: Tetraarsenic hexoxide enhances generation of mitochondrial ROS to promote pyroptosis by inducing the activation of caspase-3/GSDME in triple-negative breast cancer cells

Modified arsenic derivative compounds such as arsenic trioxide (As2O3), arsenic trisulfide (As2S3), and tetraarsenic hexoxide (As4O6) have been known to be one of the potent anti-cytotoxic effects in various cancer cells, including leukemia, glioma, colon, breast, and cervix cancer cells. Particularly, tetraarsenic hexoxide was developed as a chemotherapeutic agent for patients with advanced cancers. Although anti-cancer effect of tetraarsenic hexoxide has been extensively studied in various cancer cells, the molecular basis of its tumor inhibitory activity remains poorly understood. In this study, we suggest a mechanism of tetraarsenic hexoxide induces pyroptosis through the increase of mitochondrial ROS by targeting phosphorylation of mitochondrial STAT3, subsequently activating caspase-3/GSDME that eventually leads to suppression of cancer progression of TNBC cells. Interestingly, we first found that tetraarsenic hexoxide markedly induced pyroptotic cell death through caspase-3 in releading N-terminal fragments of GSDME in TNBC cells. Indeed, tetraarsenic hexoxide-treated TNBC cells exhibited pyroptotic cell death and the release of LDH. Supporting this observation, inhibition of active caspase-3 attenuated tetraarsenic hexoxide-induced pyroptotic features by blocking the cleavage of GSDME. In conclusion, our results suggest a mechanism of tetraarsenic hexoxide by inducing pyroptosis through the increase of mitochondrial ROS by targeting phosphorylation of mitochondrial STAT3, subsequently activating caspase-3/GSDME that eventually leads to suppression of cancer progression of TNBC cells. Also, given that traditional chemotherapeutic agents, tetraarsenic hexoxide may be useful for aggressive TNBC cells showing resistance to apoptosis as a new GSDME-targeted therapeutic strategy.

Citation Format: Haein An, Jin Sun Heo, Akira Ooshima, Zhaoyan Wu, Seong-Jin Kim, ILLJU BAE, Kyung-Min Yang. Tetraarsenic hexoxide enhances generation of mitochondrial ROS to promote pyroptosis by inducing the activation of caspase-3/GSDME in triple-negative breast cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 989.

Pikeienuella piscinae gen. nov., sp. nov., a novel genus in the family Rhodobacteraceae

A novel bacterium, designated strain RR4-56T, was isolated from a biofilter of a seawater recirculating aquaculture system. The 16S rRNA gene sequence analysis showed that the isolate was closely related to Halovulum dunhuangense YYQ-30T (92.6%), Albimonas donghaensis DS2T (91.3%), Pontivivens insulae GYSW-23T (91.3%), and Monaibacterium marinum C7T (90.9%), belonging to the family Rhodobacteraceae. The strain was aerobic, Gram-negative, rod-shaped, oxidase-positive, and catalase-negative. Its optimum temperature, pH, and salinity for growth were 25-30°C, pH 8.5, and 2-3% NaCl (w/v), respectively. Its growth occurred at 15-35°C, pH 5.0-9.5, and 0-7% NaCl (w/v). It contained ubiquinone-10 (Q-10), a respiratory quinone, and the major cellular fatty acids were 11-methyl C18:1 ω7c (31.9%), C18:1 ω6c (30.4%), and C19:0 cyclo ω8c (16.1%). The polar lipids present in the strain were phosphatidylglycerol, an unidentified phospholipid, and an unidentified aminolipid. The strain had one 4,373,045 bp circular chromosome with G + C contents of 65.9 mol% including 4,169 genes, 4,118 coding sequences (CDSs), 3 rRNAs, and 45 tRNAs. Genome annotation predicted some gene clusters related to the degradation of several types of organic matter such as protocatechuate, catechol, and phthalate. Based on the polyphasic characteristics, RR4-56T represents a novel genus and species in the family Rhodobacteraceae, for which the name Pikeienuella piscinae gen. nov., sp. nov. was proposed. The type strain is RR4-56T (= KCTC 52648T = DSM 107918T).

Prognostic Utility of Disproportionately Enlarged Subarachnoid Space Hydrocephalus in Idiopathic Normal Pressure Hydrocephalus Treated with Ventriculoperitoneal Shunt Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Disproportionately enlarged subarachnoid space hydrocephalus is a specific radiologic marker for idiopathic normal pressure hydrocephalus. However, controversy exists regarding the prognostic utility of disproportionately enlarged subarachnoid space hydrocephalus.

PURPOSE

Our aim was to evaluate the prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and its predictive utility regarding prognosis in patients treated with ventriculoperitoneal shunt surgery.

DATA SOURCES

We used MEDLINE and EMBASE databases.

STUDY SELECTION

We searched for studies that reported the prevalence or the diagnostic performance of disproportionately enlarged subarachnoid space hydrocephalus in predicting treatment response.

DATA ANALYSIS

The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was obtained. Pooled sensitivity, specificity, and area under the curve of disproportionately enlarged subarachnoid space hydrocephalus to predict treatment response were obtained. Subgroup and sensitivity analyses were performed to explain heterogeneity among the studies.

DATA SYNTHESIS

Ten articles with 812 patients were included. The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus was 44% (95% CI, 34%-54%). The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was higher in the studies using the second edition of the Japanese Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus compared with the studies using the international guidelines without statistical significance (52% versus 43%, P = .38). The pooled sensitivity and specificity of disproportionately enlarged subarachnoid space hydrocephalus for prediction of treatment response were 59% (95% CI, 38%-77%) and 66% (95% CI, 57%-74%), respectively, with an area under the curve of 0.67 (95% CI, 0.63-0.71).

LIMITATIONS

The lack of an established method for assessing disproportionately enlarged subarachnoid space hydrocephalus using brain MR imaging served as an important cause of the heterogeneity.

CONCLUSIONS

Our meta-analysis demonstrated a relatively low prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and a poor diagnostic performance for treatment response.

Efficacy and safety of vactosertib and pembrolizumab combination in patients with previously treated microsatellite stable metastatic colorectal cancer

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Background: Microsatellite stable metastatic colorectal cancer (MSS mCRC) represents a high unmet need since there are currently no approved immunotherapy options. Since the inhibition of the transforming growth factor-β (TGF-β) pathway is known to contribute to the enhancement of immunotherapy efficacy, here, we report the results of vactosertib, a potent and selective TGF-β receptor I kinase inhibitor, combined with pembrolizumab in patients with MSS mCRC. Methods: In this phase 2, open label trial, patients have received vactosertib (300 mg BID, 5 days on / 2 days off) and pembrolizumab (200 mg, every 3 weeks) until confirmed progressive disease (PD), unacceptable toxicity or consent withdrawal. Patients with histologically confirmed mCRC who had disease progression after treatment with all available therapies including fluoropyrimidine and oxaliplatin or irinotecan were enrolled. Eligible patients were ≥19 years old, had ECOG status ≤1, and had no prior exposure to immunotherapy. The objectives were to evaluate the safety and efficacy (objective response rate (ORR) per RECIST v1.1). Results: Thirty-three patients with MSS mCRC were enrolled. Median age was 60 (range 33-72), 55% were male, median number of previous lines of chemotherapy was 3 (range 1-7), and 82% were consensus molecular subtype (CMS) 4. The ORR was 15.2% including 5 partial responses (PRs), 7 stable diseases, and 17 PDs as best overall responses; 12 patients remain on treatment. Among 5 patients with PR, 3 patients had confirmed PR and median duration of response was not reached yet. As of 04 Jan 2021, the most common treatment related adverse events (AEs) were increased amylase (21.2%), pruritus (21.2%), rash (21.2%), and increased lipase (18.2%). There were 3 treatment-related SAEs reported; drug induced pneumonitis (3%), nausea (3%), and vomiting (3%). Conclusions: The combination treatment with vactosertib and pembrolizumab showed favorable safety profile with promising efficacy in patients with MSS mCRC. Updated data including pharmacodynamic markers will be presented at the meeting. Clinical trial information: NCT03724851.

Identification of susceptibility loci for cardiovascular disease in adults with hypertension, diabetes, and dyslipidemia

BACKGROUND

Hypertension (HTN), diabetes mellitus (DM), and dyslipidemia (DL) are well-known risk factors of cardiovascular disease (CVD), but not all patients develop CVDs. Studies have been limited investigating genetic risk of CVDs specific to individuals with metabolic diseases. This study aimed to identify disease-specific and/or common genetic loci associated with CVD susceptibility in chronic metabolic disease patients.

METHODS

We conducted a genome-wide association study (GWAS) of a multiple case-control design with data from the City Cohort within Health EXAminees subcohort of the Korean Genome and Epidemiology Study (KoGES_HEXA). KoGES_HEXA is a population-based prospective cohort of 173,357 urban Korean adults that had health examinations at medical centers. 42,393 participants (16,309 HTN; 5,314 DM; 20,770 DL) were analyzed, and each metabolic disease group was divided into three CVD case-controls: coronary artery disease (CAD), ischemic stroke (IS), and cardio-cerebrovascular disease (CCD). GWASs were conducted for each case-control group with 7,975,321 imputed single nucleotide polymorphisms using the Phase 3 Asian panel from 1000 Genomes Project, by logistic regression and controlled for confounding variables. Genome-wide significant levels were implemented to identify important susceptibility loci.

RESULTS

Totaling 42,393 individuals, this study included 16,309 HTN (mean age [SD], 57.28 [7.45]; 816 CAD, 398 IS, and 1,185 CCD cases), 5,314 DM (57.79 [7.39]; 361 CAD, 153 IS, and 497 CCD cases), and 20,770 DL patients (55.34 [7.63]; 768 CAD, 295 IS, and 1,039 CCD cases). Six genome-wide significant CVD risk loci were identified, with relatively large effect sizes: 1 locus in HTN (HTN-CAD: 17q25.3/CBX8-CBX4 [OR, 2.607; P = 6.37 × 10^-9]), 2 in DM (DM-IS: 4q32.3/MARCH1-LINC01207 [OR, 5.587; P = 1.34 × 10^-8], and DM-CCD: 17q25.3/RPTOR [OR, 3.511; P = 1.99 × 10^-8]), and 3 in DL (DL-CAD: 9q22.2/UNQ6494-LOC101927847 [OR, 2.282; P = 7.78 × 10^-9], DL-IS: 3p22.1/ULK4 [OR, 2.162; P = 2.97 × 10^-8], and DL-CCD: 2p22.2/CYP1B1-CYP1B1-AS1 [OR, 2.027; P = 4.24 × 10^-8]).

CONCLUSIONS

This study identified 6 susceptibility loci and positional candidate genes for CVDs in HTN, DM, and DL patients using an unprecedented study design. 1 locus (17q25.3) was commonly associated with CAD. These associations warrant validation in additional studies for potential therapeutic applications.

Tetraarsenic hexoxide enhances generation of mitochondrial ROS to promote pyroptosis by inducing the activation of caspase-3/GSDME in triple-negative breast cancer cells

Although tetraarsenic hexoxide is known to exert an anti-tumor effect by inducing apoptosis in various cancer cells, its effect on other forms of regulated cell death remains unclear. Here, we show that tetraarsenic hexoxide induces the pyroptotic cell death through activation of mitochondrial reactive oxygen species (ROS)-mediated caspase-3/gasdermin E (GSDME) pathway, thereby suppressing tumor growth and metastasis of triple-negative breast cancer (TNBC) cells. Interestingly, tetraarsenic hexoxide-treated TNBC cells exhibited specific pyroptotic characteristics, including cell swelling, balloon-like bubbling, and LDH releases through pore formation in the plasma membrane, eventually suppressing tumor formation and lung metastasis of TNBC cells. Mechanistically, tetraarsenic hexoxide markedly enhanced the production of mitochondrial ROS by inhibiting phosphorylation of mitochondrial STAT3, subsequently inducing caspase-3-dependent cleavage of GSDME, which consequently promoted pyroptotic cell death in TNBC cells. Collectively, our findings highlight tetraarsenic hexoxide-induced pyroptosis as a new therapeutic strategy that may inhibit cancer progression of TNBC cells.

Understanding the genetic architecture of the metabolically unhealthy normal weight and metabolically healthy obese phenotypes in a Korean population

Understanding the mechanisms underlying the metabolically unhealthy normal weight (MUHNW) and metabolically healthy obese (MHO) phenotypes is important for developing strategies to prevent cardiometabolic diseases. Here, we conducted genome-wide association studies (GWASs) to identify the MUHNW and MHO genetic indices. The study dataset comprised genome-wide single-nucleotide polymorphism genotypes and epidemiological data from 49,915 subjects categorised into four phenotypes-metabolically healthy normal weight (MHNW), MUHNW, MHO, and metabolically unhealthy obese (MUHO). We conducted two GWASs using logistic regression analyses and adjustments for confounding variables (model 1: MHNW versus MUHNW and model 2: MHO versus MUHO). GCKR, ABCB11, CDKAL1, LPL, CDKN2B, NT5C2, APOA5, CETP, and APOC1 were associated with metabolically unhealthy phenotypes among normal weight individuals (model 1). LPL, APOA5, and CETP were associated with metabolically unhealthy phenotypes among obese individuals (model 2). The genes common to both models are related to lipid metabolism (LPL, APOA5, and CETP), and those associated with model 1 are related to insulin or glucose metabolism (GCKR, CDKAL1, and CDKN2B). This study reveals the genetic architecture of the MUHNW and MHO phenotypes in a Korean population-based cohort. These findings could help identify individuals at a high metabolic risk in normal weight and obese populations and provide potential novel targets for the management of metabolically unhealthy phenotypes.

ROS-Induced SIRT2 Upregulation Contributes to Cisplatin Sensitivity in Ovarian Cancer

Cisplatin resistance remains a significant obstacle for improving the clinical outcome of ovarian cancer patients. Recent studies have demonstrated that cisplatin is an important inducer of intracellullar reactive oxygen species (ROS), triggering cancer cell death. Sirtuin 2 (SIRT2), a member of class III NAD⁺ dependent histone deacetylases (HDACs), has been reported to be involved in regulating cancer hallmarks including drug response. In this study, we aimed to identify the role of SIRT2 in oxidative stress and cisplatin response in cancer. Two ovarian cancer cell lines featuring different sensitivities to cisplatin were used in this study. We found different expression patterns of SIRT2 in cisplatin-sensitive (A2780/S) and cisplatin-resistant (A2780/CP) cancer cells with cisplatin treatment, where SIRT2 expression was augmented only in A2780/S cells. Furthermore, cisplatin-induced ROS generation was responsible for the upregulation of SIRT2 in A2780/S cells, whereas overexpression of SIRT2 significantly enhanced the sensitivity of cisplatin-resistant counterpart cells to cisplatin. Our study proposes that targeting SIRT2 may provide new strategies to potentiate platinum-based chemotherapy in ovarian cancer patients.

Development and Validation of a Deep Learning-Based Automatic Brain Segmentation and Classification Algorithm for Alzheimer Disease Using 3D T1-Weighted Volumetric Images

BACKGROUND AND PURPOSE

Limited evidence has suggested that a deep learning automatic brain segmentation and classification method, based on T1-weighted brain MR images, can predict Alzheimer disease. Our aim was to develop and validate a deep learning-based automatic brain segmentation and classification algorithm for the diagnosis of Alzheimer disease using 3D T1-weighted brain MR images.

MATERIALS AND METHODS

A deep learning-based algorithm was developed using a dataset of T1-weighted brain MR images in consecutive patients with Alzheimer disease and mild cognitive impairment. We developed a 2-step algorithm using a convolutional neural network to perform brain parcellation followed by 3 classifier techniques including XGBoost for disease prediction. All classification experiments were performed using 5-fold cross-validation. The diagnostic performance of the XGBoost method was compared with logistic regression and a linear Support Vector Machine by calculating their areas under the curve for differentiating Alzheimer disease from mild cognitive impairment and mild cognitive impairment from healthy controls.

RESULTS

In a total of 4 datasets, 1099, 212, 711, and 705 eligible patients were included. Compared with the linear Support Vector Machine and logistic regression, XGBoost significantly improved the prediction of Alzheimer disease (P < .001). In terms of differentiating Alzheimer disease from mild cognitive impairment, the 3 algorithms resulted in areas under the curve of 0.758-0.825. XGBoost had a sensitivity of 68% and a specificity of 70%. In terms of differentiating mild cognitive impairment from the healthy control group, the 3 algorithms resulted in areas under the curve of 0.668-0.870. XGBoost had a sensitivity of 79% and a specificity of 80%.

CONCLUSIONS

The deep learning-based automatic brain segmentation and classification algorithm allowed an accurate diagnosis of Alzheimer disease using T1-weighted brain MR images. The widespread availability of T1-weighted brain MR imaging suggests that this algorithm is a promising and widely applicable method for predicting Alzheimer disease.