The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Facile one pot synthesis and Li-cycling properties of MnO2

MnO₂ compounds prepared by a molten salt method (MSM) using three different Mn-salts and studied for its electrochemical properties.

Sodium-ion diffusion mechanisms in the low cost high voltage cathode material Na2+δFe2−δ/2(SO4)3

Bond-valence site energy modelling, molecular dynamics and DFT simulations jointly clarify Na⁺-ion migration in Na_2+δFe_2−δ/2(SO₄)₃, a promising high voltage cathode material for sodium-ion batteries, and the role of Fe²⁺ vacancies therein.

Comparison of the effects of active, passive and mixed warm ups on swimming performance

AIM

The aim of this paper was to compare the effects of an active (AWU), passive (PWU) and mixed warm up (MWU) on swimming performance.

METHODS

Eight male competitive swimmers completed each type of WU and, following a 20-minute rest, performed a maximum 100m test on their specialised stroke. The order of WUs was randomized and there was a 7-day period between subsequent testing sessions. The time taken to complete the 100m trial was the performance measure. The rating of perceived exertion (RPE) was measured immediately post WU, while heart rate (HR) was measured pre and post WU and pre and post the maximum swim. During the 20-minute rest, the swimmers' psychological state was assessed with the CSAI-2 questionnaire.

RESULTS

Post WU HR and RPE had the lowest values following the AWU and the highest values following the PWU (P<0.01). No other significant differences were found in any variables. Pre performance HR increased significantly relative to pre WU HR for all conditions (P≤0.01). Swimmers had relatively low levels of anxiety and modest to high levels of self confidence for all conditions.

CONCLUSIONS

No WU appeared to be superior to the others with respect to swimming performance. The MWU produced nearly identical values to the AWU for most variables, and was therefore found to be an appropriate alternative WU type that swimmers may use before competition. The PWU also seemed to be appropriate, but the somewhat worse performance and lower cognitive anxiety and self confidence scores recorded, albeit non-significant, suggested that more swimmers and distances are tested before any firm conclusions regarding its effectiveness can be drawn.

Efficacy, safety and usability of secukinumab administration by autoinjector/pen in psoriasis: a randomized, controlled trial (JUNCTURE)

BACKGROUND

Secukinumab is a fully human anti-interleukin-17A monoclonal antibody.

OBJECTIVE

Determine the efficacy, safety and usability of secukinumab administered via autoinjector/pen.

METHODS

This phase III trial randomized subjects with moderate to severe plaque psoriasis to secukinumab 300 mg, 150 mg or placebo self-injection once weekly to Week 4, then every 4 weeks. Co-primary end points at Week 12 were ≥75% improvement in Psoriasis Area and Severity Index (PASI 75) and clear/almost clear skin by investigator's global assessment 2011 modified version (IGA mod 2011 0/1). Secondary end points included autoinjector usability, assessed by successful, hazard-free self-injection and subject-reported acceptability on Self-Injection Assessment Questionnaire.

RESULTS

Week 12 PASI 75 and IGA mod 2011 0/1 responses were superior with secukinumab 300 mg (86.7% and 73.3%, respectively) and 150 mg (71.7% and 53.3%, respectively) vs. placebo (3.3% and 0%, respectively) (P < 0.0001 for all). All subjects successfully self-administered treatment at Week 1, without critical use-related hazards. Subject acceptability of autoinjector was high throughout 12 weeks. Adverse events were higher with secukinumab (300 mg, 70.0%; 150 mg, 63.9%) vs. placebo (54.1%), with differences largely driven by mild/moderate nasopharyngitis.

CONCLUSION

Secukinumab delivered by autoinjector/pen is efficacious, well-tolerated and associated with high usability in moderate to severe plaque psoriasis.

The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Big Data in Healthcare - Defining the Digital Persona through User Contexts from the Micro to the Macro. Contribution of the IMIA Organizational and Social Issues WG

OBJECTIVES

While big data offers enormous potential for improving healthcare delivery, many of the existing claims concerning big data in healthcare are based on anecdotal reports and theoretical vision papers, rather than scientific evidence based on empirical research. Historically, the implementation of health information technology has resulted in unintended consequences at the individual, organizational and social levels, but these unintended consequences of collecting data have remained unaddressed in the literature on big data. The objective of this paper is to provide insights into big data from the perspective of people, social and organizational considerations.

METHOD

We draw upon the concept of persona to define the digital persona as the intersection of data, tasks and context for different user groups. We then describe how the digital persona can serve as a framework to understanding sociotechnical considerations of big data implementation. We then discuss the digital persona in the context of micro, meso and macro user groups across the 3 Vs of big data.

RESULTS

We provide insights into the potential benefits and challenges of applying big data approaches to healthcare as well as how to position these approaches to achieve health system objectives such as patient safety or patient-engaged care delivery. We also provide a framework for defining the digital persona at a micro, meso and macro level to help understand the user contexts of big data solutions.

CONCLUSION

While big data provides great potential for improving healthcare delivery, it is essential that we consider the individual, social and organizational contexts of data use when implementing big data solutions.

Abstract OT2-1-02: Novel combination of toll-like receptor (TLR)-7 agonist imiquimod and local radiotherapy in the treatment of breast cancer chest wall recurrences or skin metastases

Background/Rationale: To assess the immune and systemic anti-tumor effects of the novel combination of local radiotherapy combined with imiquimod applied topically to breast cancer metastatic to skin. Breast cancer is the most common tumor, excluding melanoma, to metastasize to the skin in women. Chest wall recurrence is debilitating for patients, substantially affecting quality of life. Current treatment modalities for unresectable lesions are rarely curative and patients ultimately die of visceral metastases, indicating the need for more effective therapies. Imiquimod (IMQ), a synthetic TLR-7 agonist has immunomodulatory activity with profound effects on the tumor environment and can lead to tumor regression of cutaneous breast cancer metastases (Adams et al, Clin Ca Res, Dec 15, 2012). Accumulating evidence indicates that the potential of local radiotherapy to convert the tumor into an in-situ vaccine can be enhanced by combination with immunotherapy to achieve a therapeutic synergy. We have previously shown in a mouse model of cutaneous breast cancer that topical IMQ synergizes with local RT to induce complete tumor regression (REF). Importantly, this approach used a local treatment to generate anti-tumor immune responses with ability to control the tumor systemically (Dewan et al, Clin Ca Res Dec 15, 2012). This trial was designed to test the feasibility of translating this therapeutic synergy in the clinic (clinicaltrials.gov NCT01421017).

Methods: Eligibility includes patients with biopsy-confirmed breast cancer, measurable disease and skin metastases, ECOG PS 0-2 and adequate organ/marrow function. Radiation therapy is delivered to one area of skin metastases in five fractions of 6 Gy (days 1,3,5,8,10). IMQ 5% cream is applied topically to skin metastases overnight for 5 days/week for 8 weeks, beginning the evening of the first radiotherapy. Continuous imiquimod to all skin metastases even after completion of RT is based on our preclinical evidence of an improved effector phase of the immune response. Additional treatment cycles with IMQ/RT are permitted. Following a brief phase I portion to allow dose optimization in the event of unanticipated adverse events (3-3 design), the phase II study evaluates efficacy with a planned additional 25 patients. Primary endpoint is the response rate in untreated metastases, assessed by immune-related response criteria. Furthermore, the local tumor responses and safety of the combination will be determined; tumor FNA biopsies will be obtained to investigate signatures of immune-mediated rejection as recently described with IMQ mediated rejection of basal cell carcinomas; and peripheral lymphocytes will be examined for the induction/boosting of selected tumor antigen-specific T and B cell responses.

The phase I portion has been successfully completed with 6 patients without DLT. Enrollment into the phase II portion has begun. At present, a total of 11 patients have been enrolled.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-1-02.

Isn't it time for a cadaver skin bank in South Africa?

Improvements in comprehensive burn care, as practiced in dedicated burns units, have reduced mortality and morbidity rates significantly. Strategies deemed most important include the application of fluid resuscitation and nutrition protocols, intensive care and antimicrobial dressings, as well as early excision and grafting. Autografting is limited, however, by availability in very extensive burns, despite the use of expanded (meshed) skin. Alternatives have therefore been required, and deceased donor allograft is considered the gold standard. Fresh allograft use is limited by supply, and legislative and cultural restrictions have significantly influenced availability, despite evidence of its efficacy. This necessitates the establishment of a deceased donor skin bank in South Africa, with a mandate to procure and store allograft for distribution to burns units when required.

Eosinophilic esophagitis in children with esophageal atresia

Eosinophilic esophagitis (EoE) has only rarely been reported in esophageal atresia (EA) patients. A retrospective case analysis of all EA patients born at our center between January 1999 and April 2012 was performed. A total of 113 of patients were identified; 10 patients were excluded as a result of inadequate data. Eighteen patients (17%) were diagnosed with EoE. The average number of eosinophilis was 30/high-power field (HPF) (19/HPF-80/HPF). The median age for diagnosis of EoE was 1 year and 6 months (8 months-8 years and 7 months). Children with EoE had a significantly greater incidence of reflux symptoms, dysphagia, tracheomalacia, and 'hypoxic spells' (P < 0.05). EoE patients also underwent significantly more surgery including fundoplication and aortopexy when compared with those without EoE (P < 0.0001). Although the incidence of gastrostomy was greater in the EoE group (33% vs. 13%), this was not statistically significant. Half of the EoE patients had a coexisting atopic condition at time of diagnosis. The commonest condition was asthma 7/18 (38%) followed by specific food allergy 6/18 (33%). EoE was treated in 11 patients with either swallowed fluticasone or budesonide slurry. All improved clinically. Histologically, five had complete resolution and six had partial improvement. Six children with EoE were treated with acid suppression alone. All improved clinically, and 5/6 had subsequent histological resolution. One child who received acid suppression and an exclusion diet also improved. Seven patients (38%) had an esophageal stricture at time of EoE diagnosis. Five were dilated at time of the initial endoscopy, prior to the diagnosis of EoE being available. Two patients had resolution of their strictures on medical treatment of their EoE alone and did not require further dilatation. EoE was seen in 17% of children with EA in this study. EoE should be considered in EA patients with persistent symptoms on standard reflux treatment, increasing dysphagia, and recurrent strictures.

Tracheostomy in the critically ill: the myth of dead space

Benefits and advantages of tracheostomy have been vigorously debated. There is a lack of consensus as to whether perceived clinical improvement is attributable to fundamental changes in respiratory dynamics. We compare the effect of tracheostomy versus endotracheal tube on dead space, airway resistance and other lung parameters in critically ill ventilated patients. Data collected included patients who were admitted to surgical, burn and neurosurgical intensive care units at the University of North Carolina. Twenty-four intubated patients were included in our analysis with various aetiologies of respiratory failure. Tracheostomy was deemed necessary either for severe neurological devastation or failure to wean from the ventilator. The diameter of the endotracheal tubes ranged from 6-8 mm and the tracheostomy tube diameters were from 6.4-8.9 mm. Internal diameters between endotracheal tube and tracheostomy tubes, ventilator settings and sedation were kept consistent throughout the study. Respiratory parameters were measured using the Respironics' non-invasive cardiac output 2 device (Phillips, Andover, MA) immediately prior to tracheostomy and repeated within 24 hours of tracheostomy. Only two (8%) of the patients had slight improvement (>6% decrease in dead space). The average dead space of endotracheal versus tracheostomy tubes was 41±12.6% and 40±14.6%, respectively (P=0.75). The remaining 22 patients (92%) had no significant change in dead space, compliance or other respiratory parameters. This study shows that there is no significant difference in respiratory mechanics and dead space with a tracheostomy versus endotracheal tube.

Plaque triclosan concentration and antimicrobial efficacy of a new calcium carbonate toothpaste with 0.3% triclosan compared to a marketed 0.3% triclosan toothpaste

OBJECTIVE

To compare the delivery and retention of triclosan in dental plaque, and to compare the antibacterial efficacy of a newly developed toothpaste to a marketed calcium carbonate toothpaste.

METHODS

Two clinical delivery/retention studies were carried out to determine the concentration of triclosan in plaque 10 minutes, and two and four hours after brushing with a new triclosan-containing toothpaste with magnesium aluminium silicate or a marketed triclosan-containing toothpaste. Both studies had a double-blind, randomized, complete cross-over design. Supragingival plaque samples (minimum 2 microg) were taken from smooth surfaces of all teeth (1-7) in all four quadrants for the 10-minute plaque measurements and in two randomly allocated quadrants at the two- and four-hour time points. Triclosan concentration was measured by HPLC. Antibacterial efficacy was evaluated in vitro using a biofilm formation approach. Three replicate experiments were carried out to check for repeatability and consistency of the assay. Toothpaste slurries were prepared by stirring one part by weight of each toothpaste with two parts by weight of deionized water. An overnight culture suspension of Streptococcus mutans (ATCC 25175) was prepared and then adjusted to give a bacterial count of approximately 10(7) CFU/ml. Sterile HAP discs were used as substrate and treated with the toothpaste slurry before inoculation with the standardized culture suspension of S. mutans. Following incubation in brain heart infusion (BHI) broth containing 2% sucrose for four hours, standard Total Viable Count (TVC) procedures were carried out and colonies counted (log10 values).

RESULTS

Brushing with the new calcium carbonate/triclosan toothpaste resulted in a higher triclosan concentration in plaque after 10 minutes, and two and four hours compared to a marketed triclosan toothpaste. The increase ranged from 14% to 35% and was statistically significant (p < 0.05). The antibacterial efficacy of the new calcium carbonate/triclosan toothpaste, measured four hours after application, was greater than that of a marketed toothpaste with 0.3% triclosan. The difference was statistically significant (p < 0.05).

CONCLUSION

The new calcium carbonate toothpaste with 0.3% triclosan and magnesium aluminium silicate demonstrated significantly greater efficacy four hours post-brushing both in terms of in vivo delivery and in vitro antibacterial action compared to a marketed calcium carbonate toothpaste with 0.3% triclosan.

Abstract P5-20-05: A Phase 2 trial of RAD 001 and Carboplatin in patients with triple negative metastatic breast cancer

BACKGROUND: RAD001 is an oral mTOR inhibitor that has exhibited activity in breast cancer. Triple negative breast cancer cells are unable to repair double stranded DNA breaks and hence have sensitivity to platinum agents that cause interstrand cross-links. Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in at least two different breast cancer cell lines (including ER/PR negative cell lines). We propose that combination RAD001 and carboplatin may have activity in triple-negative breast cancer.

MATERIALS AND METHODS: The primary objective of the study is to determine clinical benefit (complete remission (CR) + partial remission (PR) + stable disease (SD more than 6 months)) and the toxicity of this combination in triple negative metastatic breast cancer who have had 0–3 prior chemotherapy regimens for metastatic disease. Twenty-five subjects were to be entered in this Phase II study. This design has greater than 80% power to test the null hypothesis that the clinical benefit rate is less than or equal to 10% versus the alternative hypothesis that clinical benefit rate is greater than or equal to 30%. Prior carboplatin is allowed. Women with treated brain metastasis are eligible. Secondary objectives are to determine progression free survival and relationship between pretreatment sensitivity (biopsy at baseline) and clinical response (biopsy post 2 cycles) using IHC staining for abundance of key proteins in the Akt-mTOR pathway and their activity using surrogate phosphorylation site-specific antibodies. According to the original study plan, carboplatin AUC 6, was to be given intravenously every three weeks. Five mg of RAD001 was to be given daily with a 3 patient run-in and then 10 mg daily if there were no dose-limiting toxicities. Due to a surprising amount of thrombocytopenia with this combination the dose of carboplatin was first amended to AUC 5 and most recently to AUC 4 with 5 mg of RAD001 (and no plan to escalate to 10 mg).

RESULTS: 23 patients of a planned 25 have been recruited thus far. Median age is 59. Of the 20 patients assessable for response at this time, there have been 1 CR, 5 PRs, 8 SDs and 6 PDs. One SD was achieved in a patient progressing on single agent Carboplatin at study entry. Median duration of CR+ SD +PR thus far is 13 weeks (range: 6–74 weeks). 5 of 22 patients assessable for toxicity had grade 3/4 thrombocytopenia and 4 patients had grade 3 neutropenia (no febrile neutropenia). 13 out of eighteen patients have had treatment held and/or dose reductions secondary to hematological toxicity, however, since amendment for starting dose of Carboplatin to AUC 4 the regimen has been very well tolerated with only 1 out of eleven patients with grade 3 neutropenia and grade 3 thrombocytopenia. 1 patient suffered from grade 3 dehydration. The estimated clinical benefit rate is 45% (95% confidence interval: 23%, 67%). Median time to progression or death is 85 days from start of treatment.

CONCLUSIONS: Our study has met the primary end point of demonstrating clinical benefit in triple negative metastatic breast cancer. Dose limiting thrombocytopenia was an unexpected side effect requiring protocol amendment. We continue to accrue study subjects at the amended dosing.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-20-05.