Utility and limitations of multiplex ligation-dependent probe amplification technique in the detection of cytogenetic abnormalities in products of conception

Background and Introduction: Chromosomal abnormality is found in about half of first-trimester abortions. Karyotype is the gold standard to detect chromosomal abnormalities. Multiplex ligation-dependent probe amplification (MLPA) offers advantage over karyotype in terms of lower failure rate, faster turnaround time, and much higher resolution than conventional karyotyping and found to be 98% concordant with conventional karyotype.

AIM

We performed this study to look for the utility of MLPA in diagnosing chromosomal abnormalities in first-trimester abortions.

MATERIALS AND METHODS

MLPA using subtelomeric SALSA probe sets (P036 and P070) was used to detect cytogenetic abnormalities in products of conception in missed/spontaneous abortions.

RESULTS

A total of ninety abortus samples were analyzed by MLPA. Successful results were provided in (67) 74.4% of the cases while no conclusion could be drawn in 25.6% (23) of the cases. Fifty-five (82.1%) cases were cytogenetically normal and 17.9% (12) had some abnormality. Aneuploidy was detected in 8 (66.7%) cases, 3 (25%) had double-segment imbalance, and one (8.3%) had partial aneuploidy.

CONCLUSION

We suggest that MLPA is a good substitute to traditional karyotype.

RAGE Enhances TLR Responses through Binding and Internalization of RNA

Nucleic acid recognition is an important mechanism that enables the innate immune system to detect microbial infection and tissue damage. To minimize the recognition of self-derived nucleic acids, all nucleic acid-sensing signaling receptors are sequestered away from the cell surface and are activated in the cytoplasm or in endosomes. Nucleic acid sensing in endosomes relies on members of the TLR family. The receptor for advanced glycation end-products (RAGE) was recently shown to bind DNA at the cell surface, facilitating DNA internalization and subsequent recognition by TLR9. In this article, we show that RAGE binds RNA molecules in a sequence-independent manner and enhances cellular RNA uptake into endosomes. Gain- and loss-of-function studies demonstrate that RAGE increases the sensitivity of all ssRNA-sensing TLRs (TLR7, TLR8, TLR13), suggesting that RAGE is an integral part of the endosomal nucleic acid-sensing system.

Unusual case of failure to thrive: Type III Bartter syndrome

Bartter syndrome Type III is a rare autosomal recessive disorder resulting from an inherited defect in the thick ascending limb of the loop of henle of the nephrons in kidney. The typical clinical manifestations in childhood are failure to thrive and recurrent episodes of vomiting. Typical laboratory findings which help in the diagnosis are hypokalemic metabolic alkalosis, hypomagnesemia and hypercalciuria. We report a case of Type III Bartter syndrome not responding to repeated conventional treatment of failure to thrive.

Anesthetic Management of a Patient with Myasthenia Gravis for Meningioma Surgery - A Case Report

Myasthenia gravis is a disease of great challenge to the anesthesiologist, because it affects the neuromuscular junction. Anesthetic management involves either muscle relaxant or non-muscle relaxant techniques. This case report documents the safe use of fentanyl, propofol and sevoflurane combination guided by bispectral index, without the use of muscle relaxants in a patient with myasthenia gravis who presented for meningioma surgery.

Abstract 3847: Creating the tumor microenvironment for effective immunotherapy: Antitumor activity of intratumoral IMO-2125, a TLR9 agonist is further enhanced by inhibition of indoleamine-pyrrole 2,3-dioxygenase (IDO)

In recent years, understanding of tumor immunology has led to significant advances in cancer immunotherapy. New approaches include selective blockade of checkpoints, harnessing tumor infiltrating lymphocytes (TILs) and use of intratumoral oncolytic viruses. Evolving data has continued to provide evidence that the tumor microenvironment (TME) is critical for effective immunotherapy. In preclinical studies, intratumoral delivery (i.t.) of the Toll-like receptor (TLR) 9 agonist IMO-2125 resulted in increased IFNα, IL-12, Th1 responses, TIL infiltration and dose-dependent antitumor activity against treated and distant tumors. However, gene expression analysis of the treated tumors showed that levels of IDO1 was increased, thereby hampering the optimal TME. We hypothesized that combination of i.t. IMO-2125 and an IDO1 inhibitor would lead to modulation of the TME and more potent antitumor activity versus either agent alone.

In the present study, we evaluated the antitumor activity of i.t. IMO-2125 in combination with an IDO1 inhibitor in a murine syngeneic colon carcinoma CT26 model. Each BALB/c mouse was implanted with two tumors: subcutaneous solid tumor and lung metastatic tumor by s.c. (1×107) and i.v. (3×106) inoculation with CT26 cells. Treatment was initiated when tumor nodules reached 100-200 mm3 with 2.5 mg/kg intratumoral IMO-2125 and 75 mg/kg oral IDO1 inhibitor. All treatments were well tolerated. In the placebo-treated group, the tumor volume was 1039 ± 262 mm3 (mean ± SD). In groups treated with IMO-2125 and IDO1 inhibitor, the tumor volume was 369 ± 216 mm3 (64% tumor growth inhibition, TGI) and 745 ± 252 mm3 (27% TGI), respectively. In the group treated with the combination of IMO-2125 and IDO1 inhibitor, the tumor volume was 45 ± 75 mm3, showing 95% tumor growth inhibition. Similar treatment-related results were observed in the lung nodules, with the combination group showing a 76% reduction in the number of lung tumor nodules over PBS control. Tumors treated with IMO-2125 alone showed 90-fold increase in IDO1 expression which was inhibited 47% in tumors treated with a combination of IMO-2125 and IDO1 inhibitor. The inhibition of IDO1 in combination with i.t. IMO-2125 also resulted in increased TILs.

Overall, these preclinical data showed that combination of i.t. IMO-2125 and an IDO1 inhibitor stimulated systemic immune responses and primed the TME to enable potent antitumor activity. In previous preclinical studies IMO-2125 has shown potent antitumor activity in multiple tumor models in combination with anti-CTLA4 and anti-PD1 agents.

Citation Format: Daqing Wang, Wayne Jiang, Bhagat Lakshmi, Jillian DiMuzio, Fugang Zhu, Sudhir Agrawal. Creating the tumor microenvironment for effective immunotherapy: Antitumor activity of intratumoral IMO-2125, a TLR9 agonist is further enhanced by inhibition of indoleamine-pyrrole 2,3-dioxygenase (IDO). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3847.

Outcomes Following a Moderately Hypofractionated Adjuvant Radiation (START B Type) Schedule for Breast Cancer in an Unscreened Non-Caucasian Population

AIMS

Breast cancer is the most common cancer in women. Western data have confirmed hypofractionated radiation therapy to be safe and effective in the adjuvant radiation therapy of breast cancers. We report the disease-related outcomes in a non-Caucasian, unscreened population treated with hypofractionated radiation.

MATERIALS AND METHODS

Unselected case notes of patients presenting to a tertiary cancer centre between June 2011 and December 2013 were reviewed from the electronic hospital case records. Patients with a diagnosis of non-metastatic invasive non-sarcomatous breast cancer were identified. Demographic information, oestrogen receptor (ER), progesterone receptor (PR), HER2 status, pathological tumour, nodal stage at diagnosis and outcomes of treatment, including systemic therapies, surgery and hypofractionated radiation, were documented. Local recurrence rates, disease-free survival (DFS) and overall survival were calculated.

RESULTS

Overall 925 patents were identified, median age 53.0 years (interquartile range 45-61), 330 of whom had neoadjuvant chemotherapy. The median follow-up time was 22.6 months and 23.5 months for overall and neoadjuvant chemotherapy groups, respectively. ER, PR and HER2 status was available in 788 patients, 77.2% of whom were ER/PR positive, 14.7% had triple negative disease, while 9.5% were HER2 rich. Overall, 34.2% (113 patients) underwent breast conservation surgery; 744 (80.4%) patients were treated with systemic chemotherapy and 878 (94.9%) patients received adjuvant radiation therapy, of whom 407 (44.0%) received supraclavicular-fossa radiotherapy. Overall survival, DFS and locoregional recurrence-free survival (LRRFS) for the overall group were 93%, 86.9% and 97.1%, respectively. LRRFS in the breast conservation surgery versus mastectomy groups were 99% versus 95.5% (P=0.003), with more node-positive patients in the mastectomy group. Stage N0/1 had better LRRFS compared with N2/2 (99.1% versus 95.7%); 94.3% versus 82.3%; P=0.005, 0.000. Grade 3 (53.8%) tumours had worse overall survival compared with grade 1 or grade 2 disease (89.6% versus 100% and 96.4%; P<0.001) although the LRRFS was not significantly different between the groups (98.9% versus 97.8%; P=0.37). There was no difference in LRRFS based on molecular subtypes.

CONCLUSION

Local recurrence rates following hypofractionated radiation in our population were comparable with those reported by the START trialists and were found to be safe in the medium term for patients irrespective of breast conservation surgery/mastectomy or radiotherapy to the supraclavicular field. Molecular group frequencies were comparable with Western populations but did not affect LRRFS.

Visual outcomes in patients with zonular dialysis following cataract surgery

PurposeTo evaluate the visual outcomes of patients with zonular dialysis following cataract surgery.Patients and methodsMedical records of all patients with documented zonular dialysis, either pre- or peri-operatively, undergoing cataract surgery between 2004-2010 at Queen Alexandra Hospital, Portsmouth, were retrospectively reviewed. Baseline demographics and biometry were analysed, and ocular co-morbidities documented. Intraoperative complications and the use of a capsular tension ring (CTR) were identified. Early and late best-corrected visual acuity (BCVA) post surgery were determined using LogMar values. Univariate and multivariate linear regression analysis was performed to determine associations with BCVA post surgery, and further subgroup analysis performed in groups determined by CTR use.ResultsThe records of 22 312 consecutive eyes undergoing cataract surgery were reviewed. The incidence of zonular dialysis was 0.50% (111 eyes). A CTR was inserted in 46 eyes. Using a multivariate linear regression model, better initial pre-operative BCVA (P=0.019), the use of a CTR (P=0.014), and the absence of vitreous loss during surgery (P=0.008, β 0.45) were associated with improved early postoperative BCVA (mean follow-up 6.6 weeks). Better medium-term postoperative BCVA was significantly associated with preoperative BCVA (P=0.002) and the use of a CTR during surgery (P=0.004, β -0.41).ConclusionsThe overall incidence of zonular dialysis is low. CTR use intra-operatively suggests improved early and medium-term BCVA and should be considered in all cases of zonular dialysis.

Pioglitazone Enhances the Beneficial Effects of Glucocorticoids in Experimental Nephrotic Syndrome

Glucocorticoids are the primary therapy for nephrotic syndrome (NS), but have serious side effects and are ineffective in ~20-50% of patients. Thiazolidinediones have recently been suggested to be renoprotective, and to modulate podocyte glucocorticoid-mediated nuclear receptor signaling. We hypothesized that thiazolidinediones could enhance glucocorticoid efficacy in NS. We found that puromycin aminonucleoside-induced proteinuria in rats was significantly reduced by both high-dose glucocorticoids (79%) and pioglitazone (61%), but not low-dose glucocorticoids (25%). Remarkably, pioglitazone + low-dose glucocorticoids also reduced proteinuria (63%) comparably to high-dose glucocorticoids, whereas pioglitazone + high-dose glucocorticoids reduced proteinuria to almost control levels (97%). Molecular analysis revealed that both glucocorticoids and pioglitazone enhanced glomerular synaptopodin and nephrin expression, and reduced COX-2 expression, after injury. Furthermore, the glomerular phosphorylation of glucocorticoid receptor and Akt, but not PPARγ, correlated with treatment-induced reductions in proteinuria. Notably, clinical translation of these findings to a child with refractory NS by the addition of pioglitazone to the treatment correlated with marked reductions in both proteinuria (80%) and overall immunosuppression (64%). These findings together suggest that repurposing pioglitazone could potentially enhance the proteinuria-reducing effects of glucocorticoids during NS treatment.

A clinico-histopathological study on skin appendageal tumors

Background: Skin Appendageal tumors are a large and diverse group of tumors that are commonly classified according to their state of appendageal differentiation: follicular, sebaceous, eccrine and apocrine. Objectives of this study were to study the clinic-epidemiological profile of skin appendageal tumors and to correlate the clinico-histopathological diagnosis.Materials and Methods: This was a retrospective and prospective study which included all cases of skin adnexal tumours diagnosed histologically during the period of f

Understanding Of Nepalese Patients With Vitiligo About Their Disease

Introduction: Vitiligo, a pigmentary disorder, may influence considerably patients’ health-related quality of life (QoL) and psychological wellbeing. Previous reports indicated that the patients' illness understandings influence adherence behaviors and actions in various chronic dermatological conditions. Objectives: To know the understanding of Nepalese patients with vitiligo about their disease by using illness perception questionnaire and also to investigate the potential factors that might influence it. Material and Methods: The illness perception questionnaire consisting of 25 questions about causes, timeline, consequences and control of disease were given to 154 patients with vitiligo of 13 years or more age attending the dermatology OPD. Results: A total of 146 patients completed the questionnaire. The belief about the causes of vitiligo was considered as “germs or virus” by 64.4% patients while half of the patients believed that vitiligo was due to “chance or fate”. Vitiligo was considered to be a serious condition (83.6%) and have had serious consequences on their life (63%). Approximately half of the patients believed that their disease had serious economic and financial consequences more so in female patients and in those with generalized disease. Although 43.8% patients believed that their illness was likely to be permanent rather than temporary, 75% patients believed that vitiligo would improve with the time and their treatments were effective (75.3%). However, females felt that there were very little that could be done to improve their vitiligo. Conclusion: The knowledge about vitiligo is unsatisfactory and needs accessible, accurate, community based education about the natural history of vitiligo and the effectiveness of treatment. DOI: http://dx.doi.org/10.3126/njdvl.v12i1.10590 Nepal Journal of Dermatology, Venereology & Leprology Vol.12(1) 2014 pp.7-13 

Abstract B159: Modulation of checkpoint expression in tumor microenvironment by intratumoral administration of a novel TLR9 agonist: Rationale for combination therapy

Recent advances in the understanding of immune tolerance has led to the targeting of various checkpoints for the treatment of cancer. Several independent clinical studies have pointed out a strong correlation between the clinical activity of checkpoint inhibitors and tumor checkpoint expression. These findings highlight an opportunity to improve cancer immunotherapy by combining checkpoint inhibitors with an immunostimulatory agent that modulates the tumor microenvironment.

Our objective was to modulate the tumor microenvironment by activating Toll-like receptor (TLR) 9, a pathogen-associated molecular pattern recognition receptor. In preclinical studies, administration of IMO-2125, a novel TLR9 agonist, led to maturation of dendritic cells and induction of IFN-alpha. We hypothesized that immune activation by a TLR9 agonist administered intratumorally (i.t.) will lead to modulation of immune checkpoints in the tumor microenvironment, allowing these tumors to be targeted with a checkpoint inhibitor.

To evaluate the potential of i.t. IMO-2125 therapy and its effect on checkpoint gene expression, we employed three different tumor models: CT26 colon carcinoma, A20 lymphoma, and B16 melanoma mouse models. IMO-2125 was administered at a dose of 50 mcg per treatment, either as a single dose or as multiple doses into a targeted tumor nodule. Blood samples were collected post-dosing for analysis of the cytokine profile. Anti-tumor activity was evaluated by measuring the growth of the injected tumor as well as the distant tumor. Tumor nodules were homogenized to analyze gene expression of selected checkpoints by qPCR.

Results showed that a single i.t. injection of IMO-2125 in a CT26 colon carcinoma model induced systemic Th1 type cytokines, and resulted in tumor growth inhibition. Two days post IMO-2125 administration, analysis of gene expression of the treated tumor showed upregulation of IDO1 (13 fold) and PDL1 (2.7 fold), and no changes in expression of PD1 and OX40. Increased IDO1 gene expression correlated with increased IDO protein levels in the treated tumor nodules. In contrast, subcutaneous administration of IMO-2125 showed no substantial anti-tumor effect and no significant changes in checkpoint gene expression despite an induction of similar levels of systemic cytokines as the i.t. treatment. Multiple i.t. injections of IMO-2125 led to inhibition of tumor growth of the injected tumor and the distant tumor in all three tumor models. Tumor growth was correlated with increased CD3+ cells in treated as well as distant tumors. Analysis of the checkpoint gene expression at treated and distant tumor sites was conducted at 1-2 weeks post treatment. There was a significant upregulation of IDO1 and PDL1 gene expression in the treated tumors as well as in distant tumors. In addition to IDO1 and PDL1, depending on the tumor model, other immune checkpoints, including PD1, TIM3, BTLA, LAG3, OX40, and CTLA4, were also modulated.

In conclusion, IMO-2125 i.t. treatment led to modulation of the tumor microenvironment by inducing local and systemic Th1 type immune responses, which impacted the levels of checkpoint gene expression. Increased expression of some of these checkpoints may allow tumors to be targeted broadly by checkpoint inhibitor therapy.

Citation Format: Wayne Jiang, Daqing Wang, Fugang Zhu, Lakshmi Bhagat, Jillian DiMuzio, Sudhir Agrawal. Modulation of checkpoint expression in tumor microenvironment by intratumoral administration of a novel TLR9 agonist: Rationale for combination therapy. [abstract]. In: Proceedings of the CRI-CIMT-EATI-AACR Inaugural International Cancer Immunotherapy Conference: Translating Science into Survival; September 16-19, 2015; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(1 Suppl):Abstract nr B159.

Abstract B094: Intratumoral administration of IMO-2125, a novel TLR9 agonist, modulates the tumor microenvironment and exerts systemic antitumor activity alone and in combination with an anti-CTLA-4 mAb

Cancer immunotherapy aims to stimulate host antitumor immune responses or break tumor-related immune tolerance or both with the potential of curative treatment. Potential immunotherapy targets include Toll-like receptors (TLRs), which are key receptors of the innate immune system and play an important role in regulating adaptive immune responses. IMO-2125 is a potent and selective agonist of endosomal TLR9 which significantly induces IFN-α, and the maturation of dendritic cells (DC). In the setting of cancer immunotherapy, we hypothesize that intratumoral (i.t.) administration of IMO-2125 has the potential to stimulate DC maturation and T-cell activation in the tumor microenvironment, leading to increased local and systemic antitumor immune responses and tumor regression, and may potentiate the activity of checkpoint inhibitors.

In the present study, we evaluated the antitumor immune activity of i.t. IMO-2125 in murine syngeneic colon carcinoma models. BALB/c mice were s.c. implanted with 3 x 106 CT26 and CT26.CL25 cells, a subclone of CT26 expressing a model antigen beta-galactosidase (beta-gal), on the right and left flanks, respectively. Treatment was initiated when tumor nodules reached 200 mm3. Treated mice received IMO-2125 at doses of 10, 50 and 100 µg per injection, placebo, or a control compound (n=8 each), by i.t. injection only in the CT26 tumor implanted in the right flank twice weekly for two weeks. To evaluate IMO-2125 in combination with an anti-CTLA-4 mAb, 50 µg IMO-2125 and 10 µg anti-mouse CTLA-4 mAb were co-injected into the right tumor. Over two weeks, IMO-2125 was administered five times and the anti-mouse CTLA-4 mAb was administered four times.

Results showed that i.t. IMO-2125 treatment led to dose-dependent inhibition of both treated and distant tumor growth. In mice treated with 100 µg, there were reductions in tumor volume of 95.2% (p = 0.0058) and 91.2% (p = 0.0048) in the treated and distant tumors, respectively. At this dose, there was complete tumor regression in 5 out 8 mice (63%). Control compound showed no anti-tumor activity. Antitumor activity was correlated with increased CD8+ T cell infiltration into both treated and distant tumors. In vivo depletion of T cells showed that IMO-2125 i.t mediated antitumor effects depended on CD8+ T cells, while depletion of CD4+ T cells enhanced IMO-2125 mediated tumor regression through elimination of Tregs. Furthermore, treatment elicited tumor-specific cytotoxic T cells not only to CT26 associated antigen AH1 in the injected tumor and also to beta-gal presented only in distant CT26.CL25 tumors. The mice with complete regression were rechallenged with CT26/CT26.CL25 and rejected the implantation; however, they were not protected from rechallenge with A20 lymphoma, indicating IMO-2125 i.t. treatment resulted in persistent tumor memory. Treatment with a combination of i.t. IMO-2125 and i.t. anti CTLA-4 mAb resulted in more potent antitumor activity than either agent alone.

In conclusion, i.t. administration of IMO-2125 changes the local tumor microenvironment by inducing Th1 type cytokines, thereby modulating levels of immune checkpoint expression, and exerting potent local and systemic antitumor activity. In addition, IMO-2125 treatment in combination with an anti-CTLA-4 mAb demonstrated more potent antitumor activity compared to either agent alone. IMO-2125 has been well tolerated and showed induction of systemic IFN-α in a human trial. Planning for a clinical trial of a combination of i.t. IMO-2125 and ipilumimab is ongoing.

Citation Format: Daqing Wang, Fugang Zhu, Xianzhi Mao, Sudhir Agrawal. Intratumoral administration of IMO-2125, a novel TLR9 agonist, modulates the tumor microenvironment and exerts systemic antitumor activity alone and in combination with an anti-CTLA-4 mAb. [abstract]. In: Proceedings of the CRI-CIMT-EATI-AACR Inaugural International Cancer Immunotherapy Conference: Translating Science into Survival; September 16-19, 2015; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(1 Suppl):Abstract nr B094.