Lymphatic imaging to assess rheumatoid flare: mechanistic insights and biomarker potential

Proliferation of draining lymphatic vessels coupled with dynamic changes in lymph node volume and flow are characteristic features in rheumatoid arthritis (RA). Furthermore, impaired lymph egress from inflamed synovium is associated with joint flare in murine models of inflammatory-erosive arthritis. Unfortunately, advances towards a greater understanding of lymphatic changes in RA pathogenesis have been slow due to the absence of outcome measures to quantify lymphatic function in vivo. While lymphoscintigraphy is the current standard to assess lymphedema and sentinel lymph nodes in cancer patients, its sensitivity and specificity are inadequate to study lymphatics in RA. The emergence of high-resolution MRI, power Doppler ultrasound, and near-infrared imaging that permits real-time quantification of lymphatic function in animal models has been a major advance, and these techniques have produced a new paradigm of altered lymphatic function that underlies both acute arthritic flare and chronic inflammation. In acute flare, lymphatic drainage increases several fold, whereas no lymphatic contractions are detected in lymph vessels draining chronic arthritic joints. Moreover, these outcomes are now being adapted to study lymphatics in RA towards the development of novel biomarkers of arthritic flare and the discovery of new therapeutic targets. In particular, interventions that directly increase lymphatic egress from diseased joints by opening collateral lymphatic vessels, and that restore lymphatic vessel contractions, provide novel therapeutic approaches with potential for minimal toxicity and immunosuppression. To summarize the origins of this field, recent advances, and future directions, we herein review: current knowledge of lymphatics in RA based on classic literature; new in-vivo imaging modalities that have elucidated how lymphatics modulate acute versus chronic joint inflammation in murine models; and how these preclinical outcome measures are being translated to study lymphatic function in RA inflammation and how effective RA therapies alter lymphatic flow and lymph nodes draining flaring joints.

Trial registration: ClinicalTrials.gov NCT02680067. Registered 7 December 2015; ClinicalTrials.gov NCT01098201. Registered 30 March 2010; and ClinicalTrials.gov NCT01083563. Registered 8 March 2010.

Primary liver resection for patients with cirrhosis and hepatocellular carcinoma: the role of surgery in BCLC early (A) and intermediate stages (B)

AIM

This study aims to report the outcomes following primary liver resection (PLR) in patients with cirrhosis including stratification according to the Barcelona Clinic Liver Cancer (BCLC) classification.

METHODS

Patients with cirrhosis and hepatocellular carcinoma (HCC) who had PLR between 2000 and 2013 were examined. Overall survival (OS), disease-free survival (DFS) and recurrence rate (RR) were analysed. Management after recurrence was reviewed as well as comparison to a series of 116 patients listed directly for liver transplant.

RESULTS

Seventy-one patients underwent PLR. Median follow-up was 40 months. The 1-, 3- and 5-year OS and DFS for the series were 77, 69 and 61 % and 69, 39 and 28 % respectively. Overall recurrence was 59 % (44/71) and only 36 % (15/44) of those patients had a further potentially curative procedure. The 1-3-5-year OS and DFS in the BCLC-A (44 patients) were 86, 78 and 68 % and 78, 48 and 44 % respectively. The RR in BCLC-A was 45 % (20 patients) with half (11 patients) suitable for further treatment with curative intent. The 1-3-5-year OS and DFS in the BCLC-B (17 patients) were 81, 74 and 60 % and 58, 29 and 7 % respectively. The overall RR in BCLC-B was 76 % (13 patients).

CONCLUSION

Recurrence following PLR for HCC in patients with cirrhosis is high with only a third of patients suitable for further potentially curative procedures. For patients with BCLC-A (or within Milan criteria), PLR provided a 68 % 5-year OS with 44 % of them free of disease. Surgery can offer satisfactory OS in carefully selected patients in the BCLC-B stage.

Systematic review and meta-analysis of internet-delivered interventions providing personalized feedback for weight loss in overweight and obese adults

BACKGROUND

Obesity levels continue to rise annually. Face-to-face weight loss consultations have previously identified mixed effectiveness and face high demand with limited resources. Therefore, alternative interventions, such as internet-delivered interventions, warrant further investigation. The aim was to assess whether internet-delivered weight loss interventions providing personalized feedback were more effective for weight loss in overweight and obese adults in comparison with control groups receiving no personalized feedback.

METHOD

Nine databases were searched, and 12 studies were identified that met all inclusion criteria.

RESULTS

Meta-analysis, identified participants receiving personalized feedback via internet-delivered interventions, had 2.13 kg mean difference (SMD) greater weight loss (and BMI change, waist circumference change and 5% weight loss) in comparison with control groups providing no personalized feedback. This was also true for results at 3 and 6-month time points but not for studies where interventions lasted ≥12 months.

CONCLUSION

This suggests that personalized feedback may be an important behaviour change technique (BCT) to incorporate within internet-delivered weight loss interventions. However, meta-analysis results revealed no differences between internet-delivered weight loss interventions with personalized feedback and control interventions ≥12 months. Further investigation into longer term internet-delivered interventions is required to examine how weight loss could be maintained. Future research examining which BCTs are most effective for internet-delivered weight loss interventions is suggested.

Impact of parenchymal preserving surgery on survival and recurrence after liver resection for colorectal liver metastasis

BACKGROUND

This study aimed to investigate the impact of non-anatomical liver resection (NAR) versus anatomical resection (AR) in patients with colorectal liver metastasis (CRLM), with regard to perioperative and long-term outcomes.

METHODS

Analysis of prospectively collected data for patients with CRLM who underwent either AR or NAR between January 1993 and August 2011 was performed. The impact of AR and NAR on morbidity, mortality, margin positivity, redo liver resections, overall survival (OS) and disease free survival (DFS) was analysed.

RESULTS

A total of 1574 resections for CRLM were performed. A total of 249 were redo resections and 334 patients underwent combined AR and NAR, hence, 583 were excluded. In total, 582 AR and 409 NAR were performed. The median age was 66 years (range 23.8-91.8). Median follow up was 32.2 months (interquartile range 17.5-56.9). The need for postoperative transfusion (11.6% versus 2.2%, P = <0.0001), overall complications (25% versus 10.7%, P < 0.0001) and 90-day mortality (4.9% versus 1.2%, P < 0.0001) was higher in the AR group. R0 and R1 resection rates (AR 26.2% NAR 25%, P = 0.69) and number of patients with intrahepatic recurrence was similar between the two groups (AR 17.5% NAR 22%, P = 0.08). However, the need for redo liver surgery was higher in NAR group 15.4% versus 8.7% (P < 0.001). The OS (NAR 34.1 months versus AR 31.4 months, P = 0.002) and DFS were longer in the NAR group (NAR 18.8 months versus AR 16.9 months, P = 0.031).

CONCLUSIONS

A parenchymal preserving surgery (NAR) is associated with lower complication rates and better OS and DFS when compared with AR without compromising margin status. However, NAR increases the need for repeat liver resections.

Hormone receptor positive, HER2 negative metastatic breast cancer: Future treatment landscape

Endocrine therapy is an established and effective treatment strategy for hormone receptor positive metastatic breast cancer. The clinical utility of endocrine therapy is lost over time due to evolving changes in tumor biology and the development of endocrine resistance. Many agents targeting the intracellular signaling pathways associated with endocrine resistance are in development. Encouraging early results have been seen for agents which directly target the estrogen receptor (ER), inhibitors of co-signaling pathways, inhibitors of ER chaperones, ER antagonists able to inhibit mutated or otherwise activated ERs, and modulators of histone acetylation restoring synthesis of ER signaling components. Following our systematic review of treatments with established benefits in this supplement, we review some of the more promising new strategies for overcoming endocrine resistance, looking at the impact on disease control and quality of life for women with hormone receptor positive, HER2 negative breast cancer. We also examine the biomarkers that may guide selection of the best therapy for the individual.

Abstract S1-01: Analysis of molecular prognostic factors associated with tumor immune and stromal microenvironment in BEATRICE, an open-label phase 3 trial in early triple-negative breast cancer (eTNBC)

Background: TNBC is a mutationally complex heterogeneous breast cancer subtype. In BEATRICE, adding bevacizumab to standard adjuvant chemotherapy for eTNBC improved neither invasive disease-free survival (IDFS; primary endpoint) nor overall survival (OS) [Cameron 2013; Bell SABCS 2014]. We explored prognostic effects of tumor-associated immune and stromal gene signatures.

Methods: Gene expression (RNA) was assessed in pretreatment archival tumor tissue using an 800-gene nanostring platform. Given the low event rates and lack of bevacizumab effect in BEATRICE, treatment arms were pooled. The biomarker-evaluable population (BEP; all patients with an evaluable biomarker sample and ≥1 postbaseline efficacy assessment) was dichotomized using median gene expression level as the cutoff. Prognostic associations between IDFS/OS and prespecified candidate gene sets/de novo identified clusters were assessed using univariate Cox proportional hazards models.

Results: Baseline characteristics and efficacy were similar in the BEP (988/2591 randomized pts; 38%) and the overall study population. In hierarchical cluster analysis based exclusively on immune gene expression, immune genes were enriched in 33% of samples, intermediate in 38%, and weak in 28%. Further characterization suggested differential prognostic value of distinct immune and stromal cell gene sets (Table). A significant prognostic effect for IDFS and OS was seen for CD8 effector T cell (Teff) and regulatory T cell (Treg) gene signatures, but not for the Teff:Treg ratio. A less pronounced positive prognostic effect was seen for other gene sets representing immune cells, including macrophages, CD4 T cells, and B cells (data not shown). Activated T helper (Th)-1 cell-derived chemokines and negative immune modulators of T cell activity (eg PD-L1) were highly prognostic for IDFS and OS. Both the cytokine IL-8 and ESM1 (target of VEGF-A pathway activation) were associated with worse IDFS and OS. No association was seen between outcome and markers for classic microvasculature (CD31, CD34), cancer-associated fibroblasts (FAP, BGN, DCN), VEGF-A, or VEGF-C.

 IDFSOSGene signatureHR (95% CI)Interaction p-valueHR (95% CI)Interaction p-valueTeff0.40 (0.28-0.57)7.2x10-70.29 (0.17-0.49)4.2x10-6Treg0.38 (0.26-0.54)1.6x10-70.23 (0.13-0.40)2.9x10-7Teff:Treg ratio0.80 (0.58-1.12)0.20.89 (0.57-1.39)0.6Th10.45 (0.31-0.64)8.1x10-60.43 (0.27-0.70)5.8x10-4PD-L10.42 (0.29-0.60)1.8x10-60.24 (0.14-0.41)3.4x10-7IL-81.48 (1.06-2.08)0.0221.89 (1.18-3.01)0.0076ESM11.73 (1.23-2.43)0.00172.22 (1.38-3.58)0.001

Conclusions: These molecular gene signature analyses in eTNBC confirm that markers of cytotoxic CD8 T cells are associated with good prognosis. This is the first report of a positive prognostic effect of regulatory T cell markers, immune checkpoint modulators, and macrophage-associated markers in the adjuvant TNBC setting. High VEGF-A activity, but not its expression, was associated with worse prognosis. The strong prognostic effect of immune checkpoint modulators suggests equilibrium between cytotoxic T cells and their inhibitors in eTNBC, supporting further exploration of immune checkpoint inhibitors in this therapeutic context.

Citation Format: Molinero L, Yu J, Li C, Deurloo R, Dent RA, Bell R, Brown J, Parmar M, Toi M, Suter T, Steger G, Pivot X, Mackey J, Jackisch C, Hall P, Hegde P, Bais C, Cameron D. Analysis of molecular prognostic factors associated with tumor immune and stromal microenvironment in BEATRICE, an open-label phase 3 trial in early triple-negative breast cancer (eTNBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S1-01.

New Antarctic Gravity Anomaly Grid for Enhanced Geodetic and Geophysical Studies in Antarctica

Gravity surveying is challenging in Antarctica because of its hostile environment and inaccessibility. Nevertheless, many ground-based, airborne and shipborne gravity campaigns have been completed by the geophysical and geodetic communities since the 1980s. We present the first modern Antarctic-wide gravity data compilation derived from 13 million data points covering an area of 10 million km², which corresponds to 73% coverage of the continent. The remove-compute-restore technique was applied for gridding, which facilitated levelling of the different gravity datasets with respect to an Earth Gravity Model derived from satellite data alone. The resulting free-air and Bouguer gravity anomaly grids of 10 km resolution are publicly available. These grids will enable new high-resolution combined Earth Gravity Models to be derived and represent a major step forward towards solving the geodetic polar data gap problem. They provide a new tool to investigate continental-scale lithospheric structure and geological evolution of Antarctica.

Characterizing and quantifying the effects of breast cancer therapy using mathematical modeling

We designed a mathematical model to describe and quantify the mechanisms and dynamics of tumor growth, cell-kill and resistance as they affect durations of benefit after cancer treatment. Our aim was to explore how treatment efficacy may be related to primary tumor characteristics, with the potential to guide future trial design and appropriate selection of therapy. Assuming a log-normal distribution of both resistant disease and tumor doubling times generates disease-free survival (DFS) or invasive DFS curves with specific shapes. Using a multivariate mathematical model, both treatment and tumor characteristics are related to quantified resistant disease and tumor regrowth rates by allowing different mean values for the influence of different treatments or clinical subtypes on these two log-normal distributions. Application of the model to the CALGB 9741 adjuvant breast cancer trial showed that dose-dense therapy was estimated to achieve an extra 3/4 log of cell-kill compared to standard therapy, but only in patients with more rapidly growing ER-negative tumors. Application of the model to the AZURE trial of adjuvant bisphosphonate treatment suggested that the 5-year duration of zoledronic acid was adequate for ER-negative tumors, but may not be so for ER-positive cases, with increased recurrences after ceasing the intervention. Mathematical models can identify different effects of treatment by subgroup and may aid in treatment design, trial analysis, and appropriate selection of therapy. They may provide a more appropriate and insightful tool than the conventional Cox model for the statistical analysis of response durations.

Neck length and mean arterial pressure in the sauropod dinosaurs

How blood was able to reach the heads of the long-necked sauropod dinosaurs has long been a matter of debate and several hypotheses have been presented. For example, it has been proposed that sauropods either had exceptionally large hearts, multiple ‘normal’ sized hearts spaced at regular intervals up the neck, held their necks horizontal, or the siphon effect was in operation. By means of an experimental model, we demonstrate that the siphon principle is able to explain how blood was able to adequately perfuse the sauropod brain. The return venous circulation may have been protected from complete collapse by a structure akin to the vertebral venous plexus. We derive an equation relating neck height and mean arterial pressure, which indicates that with a mean arterial pressure similar to the giraffe, the maximum safe vertical distance between heart and head would have been about 12 m. A hypothesis is presented that the maximum neck length in the fossil record is due to the siphon height limit. The equation indicates that to migrate over high ground, sauropods would either have had to significantly increase their mean arterial pressure or keep their necks below a certain height dependent on altitude.

Trastuzumab re-treatment following adjuvant trastuzumab and the importance of distant disease-free interval: the HERA trial experience

This retrospective analysis conducted using data from patients enrolled onto the Herceptin Adjuvant has two objectives: The first is to evaluate the impact of the time interval between the end of adjuvant trastuzumab and distant recurrence (TDRI) upon overall survival (OS). The second is to describe the duration of trastuzumab-based regimens in the metastatic setting for patients previously treated with adjuvant trastuzumab. The first objective included 187 patients treated with adjuvant trastuzumab and diagnosed with distant recurrence at 4-year median follow-up. The second objective included data from questionnaires sent to investigators retreating patients with trastuzumab upon distant recurrence: 144 of 156 questionnaires were returned (93 %), and 90 patients were selected based on available clinical information and consent for subsequent studies. There was no statistically significant relationship between TDRI following 1 year of adjuvant trastuzumab and OS from distant recurrence: hazard ratio 0.991, p = 0.46. The median OS from distant recurrence was numerically longer among patients with a TDRI of ≥12 months (n = 103) than <12 months (n = 84) but not statistically significant (23.7 vs. 17.8 months, p = 0.47). The median duration of first-line trastuzumab-based regimens for patients previously treated with adjuvant trastuzumab and diagnosed with distant disease recurrence was 8.8 months (n = 88). This retrospective, exploratory study suggests that TDRI did not impact on OS measured from distant recurrence. We argue that prospective collection of treatment information beyond disease progression should be included in future clinical studies.

Artery first approach to pancreatoduodenectomy: current status

BACKGROUND

The need for an early determination of resectability and before an irreversible step is taken during pancreatoduodenectomy promoted the development of an 'artery first approach' (AFA). The aim of this study was to review the current evidence related to this approach, with particular reference to margins and survival.

METHODS

An electronic search was performed in MEDLINE, EMBASE and PubMed databases from 1960 to 2015 using both subject headings (MeSH) and truncated word searches to identify all published related articles to this topic.

RESULTS

Six different AFAs have been published. Four studies evaluated the impact of AFA on perioperative outcomes and survival. Three studies showed no difference in the perioperative outcomes, margin status, lymph node yield and survival while one study showed improved margin status and survival comparing AFA with standard resection.

CONCLUSION

The current evidence regarding the benefits of AFA in relation to decreasing margin positivity or increasing survival is sparse. Further larger studies and randomized controlled trails are needed to ascertain the benefits of AFA.

Serum cardiac troponin I concentrations decrease following treatment of primary immune-mediated haemolytic anaemia

OBJECTIVES

The measurement of serum cardiac troponin I concentrations in dogs with a range of non-primary cardiac illnesses suggests that cardiac myocyte damage is commonplace. Dogs with primary immune-mediated haemolytic anaemia have increased serum cardiac troponin I concentrations at the time of diagnosis. However, it is unclear whether biochemical evidence of cardiac myocyte damage improves following successful treatment of anaemia.

METHODS

A haematology profile was performed and serum cardiac troponin I concentrations were measured in 19 dogs with primary immune-mediated haemolytic anaemia before and after treatment.

RESULTS

The haematocrit increased significantly (P = 0 · 0001) following treatment of primary IMHA (median pre: 0 · 13 L/L, median post: 0 · 33 L/L). The serum cardiac troponin I concentrations decreased significantly (P < 0 · 05) after treatment (median pre: 0 · 26 ng/mL, median post: 0 · 16 ng/mL).

CLINICAL SIGNIFICANCE

Serum cardiac troponin I concentration decreases following successful treatment of primary immune-mediated haemolytic anaemia. The clinical and prognostic significance of serum cardiac troponin I concentrations before and after treatment in dogs with primary immune-mediated haemolytic anaemia merits further investigation.

Red Kidney: Kidney Transplant From a Deceased Donor Who Received Massive Blood Transfusion During Cardiopulmonary Bypass

Here, we present a case of a deceased-donor kidney transplant. The brain-dead donor had received a massive blood transfusion during cardiopulmonary bypass, which lead to hemolysis, hemoglobinuria, acute kidney injury, and renal replacement therapy. The kidney appeared red after in situ flush. Postoperatively, the recipient developed delayed graft function. Protocol biopsy during the postoperative period revealed the widespread deposition of heme pigment in the renal tubules. Massive blood transfusion and cardiopulmonary bypass surgery are associated with hemolysis and heme pigment deposition in the renal tubules, which subsequently lead to acute kidney injury. Kidneys from such donors appear red and, while this does not preclude transplant, are likely to develop delayed graft function.

Delayed exercise promotes remodeling in sub-rupture fatigue damaged tendons

Tendinopathy is a common musculoskeletal injury whose treatment is limited by ineffective therapeutic interventions. Previously we have shown that tendons ineffectively repair early sub-rupture fatigue damage. In contrast, physiological exercise has been shown to promote remodeling of healthy tendons but its utility as a therapeutic to promote repair of fatigue damaged tendons remains unknown. Therefore, the objective of this study was to assess the utility of exercise initiated 1 and 14 days after onset of fatigue damage to promote structural repair in fatigue damaged tendons. We hypothesized that exercise initiated 14 days after fatigue loading would promote remodeling as indicated by a decrease in area of collagen matrix damage, increased procollagen I and decorin, while decreasing proteins indicative of tendinopathy. Rats engaged in 6-week exercise for 30 min/day or 60 min/day starting 1 or 14 days after fatigue loading. Initiating exercise 1-day after onset of fatigue injury led to exacerbation of matrix damage, particularly at the tendon insertion. Initiating exercise 14 days after onset of fatigue injury led to remodeling of damaged regions in the midsubstance and collagen synthesis at the insertion. Physiological exercise applied after the initial biological response to injury has dampened can potentially promote remodeling of damaged tendons.

Abstract PD2-2: Final efficacy results of the randomized phase III BEATRICE trial evaluating adjuvant bevacizumab-containing therapy in triple-negative early breast cancer

Background: In the metastatic and neoadjuvant settings, bevacizumab (BEV) significantly improves progression-free survival and pathologic complete response rates, respectively, when combined with chemotherapy (CT) for breast cancer. In contrast, accumulating phase III data in the adjuvant setting in both colon and breast cancers have not shown a benefit from the addition of 1 year of BEV to standard therapy. Primary efficacy results from the BEATRICE trial in early triple-negative breast cancer (TNBC) showed no significant difference in invasive disease-free survival (IDFS; primary outcome measure) between adjuvant BEV and non-BEV regimens after events in 393 (15%) of the 2591 randomized patients (stratified hazard ratio 0.87 [95% CI 0.72–1.07]) [Cameron et al. Lancet Oncol 2013]. The low number of events at the prespecified primary analysis of BEATRICE, the largest prospective trial in patients with centrally confirmed early TNBC, suggested that the prognosis for patients with TNBC was better than previously thought. This observation, together with data from retrospective series suggesting that most recurrences occur within 3–5 years of TNBC diagnosis [Dent et al. 2007], makes longer follow-up important to fully understand outcomes in this patient population and the natural history of TNBC. We now report extended follow-up data from the prespecified overall survival (OS) analysis of BEATRICE.

Methods: Eligible patients in the open-label randomized multinational phase III BEATRICE trial had centrally confirmed triple-negative and/or basal-like operable primary invasive breast cancer (pT1a-pT3). CT (anthracycline and/or taxane based) was selected by the investigator for each patient. After definitive surgery, patients were randomized 1:1 to receive ≥4 cycles of either CT alone or the same CT + 1 year of BEV (5 mg/kg/wk equivalent). Stratification factors were nodal status (0 vs 1-3 vs ≥4 involved nodes), selected CT backbone (anthracycline vs taxane vs both), hormone receptor status (negative vs low), and surgery (breast conserving vs mastectomy). Secondary outcome measures were OS, breast cancer-free interval, disease-free survival (DFS), distant DFS, and safety (NCI CTCAE v3.0). The prespecified final OS analysis will be performed approximately 52 months after randomization of the last patient into the study.

Results: The planned clinical cut-off date is June 30, 2014, when the duration of follow-up will be 4.3–6.5 years in those who have not died or been lost to follow-up. OS (with at least 284 events; 11%), updated IDFS with longer follow-up, and long-term safety results will be analyzed and reported.

Citation Format: Richard Bell, Julia Brown, Mahesh Parmar, Mark Toi, Thomas Suter, Guenther Steger, Xavier Pivot, John Mackey, Christian Jackisch, Rebecca Dent, Peter Hall, Almut Mecke, Leilani Morales, Louise Provencher, Elzbieta Staroslawska, Roberto Hegg, Laurence Vanlemmens, Andreas Kirsch, Andreas Schneeweiss, Norikazu Masuda, Friedrich Overkamp, David Cameron. Final efficacy results of the randomized phase III BEATRICE trial evaluating adjuvant bevacizumab-containing therapy in triple-negative early breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr PD2-2.