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Das A, Tabori U, Sambira Nahum LC, Collins NB, Deyell R, Dvir R, Faure-Conter C, Hassall TE, Minturn JE, Edwards M, Brookes E, Bianchi V, Levine A, Stone SC, Sudhaman S, Sanchez Ramirez S, Ercan AB, Stengs L, Chung J, Negm L, Getz G, Maruvka YE, Ertl-Wagner B, Ohashi PS, Pugh T, Hawkins C, Bouffet E, Morgenstern DA. Efficacy of Nivolumab in Pediatric Cancers with High Mutation Burden and Mismatch Repair Deficiency. Clin Cancer Res 2023; 29:4770-4783. [PMID: 37126021 PMCID: PMC10690097 DOI: 10.1158/1078-0432.ccr-23-0411] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/23/2023] [Accepted: 04/27/2023] [Indexed: 05/02/2023]
Abstract
PURPOSE Checkpoint inhibitors have limited efficacy for children with unselected solid and brain tumors. We report the first prospective pediatric trial (NCT02992964) using nivolumab exclusively for refractory nonhematologic cancers harboring tumor mutation burden (TMB) ≥5 mutations/megabase (mut/Mb) and/or mismatch repair deficiency (MMRD). PATIENTS AND METHODS Twenty patients were screened, and 10 were ultimately included in the response cohort of whom nine had TMB >10 mut/Mb (three initially eligible based on MMRD) and one patient had TMB between 5 and 10 mut/Mb. RESULTS Delayed immune responses contributed to best overall response of 50%, improving on initial objective responses (20%) and leading to 2-year overall survival (OS) of 50% [95% confidence interval (CI), 27-93]. Four children, including three with refractory malignant gliomas are in complete remission at a median follow-up of 37 months (range, 32.4-60), culminating in 2-year OS of 43% (95% CI, 18.2-100). Biomarker analyses confirmed benefit in children with germline MMRD, microsatellite instability, higher activated and lower regulatory circulating T cells. Stochastic mutation accumulation driven by underlying germline MMRD impacted the tumor microenvironment, contributing to delayed responses. No benefit was observed in the single patient with an MMR-proficient tumor and TMB 7.4 mut/Mb. CONCLUSIONS Nivolumab resulted in durable responses and prolonged survival for the first time in a pediatric trial of refractory hypermutated cancers including malignant gliomas. Novel biomarkers identified here need to be translated rapidly to clinical care to identify children who can benefit from checkpoint inhibitors, including upfront management of cancer. See related commentary by Mardis, p. 4701.
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Affiliation(s)
- Anirban Das
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Uri Tabori
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Lauren C. Sambira Nahum
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Natalie B. Collins
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | | | - Rina Dvir
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | - Jane E. Minturn
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa Edwards
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Elissa Brookes
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Vanessa Bianchi
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Adrian Levine
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Simone C. Stone
- Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario
| | - Sumedha Sudhaman
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Santiago Sanchez Ramirez
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Ayse B. Ercan
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Lucie Stengs
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Jill Chung
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Logine Negm
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Gad Getz
- Broad Institute of Harvard and MIT, Cambridge, Massachusetts
| | | | - Birgit Ertl-Wagner
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Pamela S. Ohashi
- Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario
| | - Trevor Pugh
- Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario
| | - Cynthia Hawkins
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Eric Bouffet
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Daniel A. Morgenstern
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario
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Predictive modeling of clinical trial terminations using feature engineering and embedding learning. Sci Rep 2021; 11:3446. [PMID: 33568706 PMCID: PMC7876037 DOI: 10.1038/s41598-021-82840-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 01/25/2021] [Indexed: 11/16/2022] Open
Abstract
In this study, we propose to use machine learning to understand terminated clinical trials. Our goal is to answer two fundamental questions: (1) what are common factors/markers associated to terminated clinical trials? and (2) how to accurately predict whether a clinical trial may be terminated or not? The answer to the first question provides effective ways to understand characteristics of terminated trials for stakeholders to better plan their trials; and the answer to the second question can direct estimate the chance of success of a clinical trial in order to minimize costs. By using 311,260 trials to build a testbed with 68,999 samples, we use feature engineering to create 640 features, reflecting clinical trial administration, eligibility, study information, criteria etc. Using feature ranking, a handful of features, such as trial eligibility, trial inclusion/exclusion criteria, sponsor types etc., are found to be related to the clinical trial termination. By using sampling and ensemble learning, we achieve over 67% Balanced Accuracy and over 0.73 AUC (Area Under the Curve) scores to correctly predict clinical trial termination, indicating that machine learning can help achieve satisfactory prediction results for clinical trial study.
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Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial. Lancet Gastroenterol Hepatol 2019; 4:599-610. [PMID: 31178342 DOI: 10.1016/s2468-1253(19)30174-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. METHODS A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485. FINDINGS Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% [95% CI 88·7-100] vs 71·7% [95% CI 60·1-83·3], hazard ratio 2·79 [95% CI 1·86-4·18]; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 [44%] of 66 patients vs 25 [39%] of 64, p=0·60; mortality: two [3%] vs four [6%], p=0·44). INTERPRETATION In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease). FUNDING Netherlands Organisation for Health Research and Development.
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Hage FG, AlJaroudi WA. Review of cardiovascular imaging in the Journal of Nuclear Cardiology in 2017. Part 2 of 2: Myocardial perfusion imaging. J Nucl Cardiol 2018; 25:1390-1399. [PMID: 29663117 DOI: 10.1007/s12350-018-1266-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 12/28/2022]
Abstract
In 2017, the Journal of Nuclear Cardiology published many high-quality articles. In this review, we will summarize a selection of these articles to provide a concise review of the main advancements that have recently occurred in the field. In the first article of this 2-part series, we focused on publications dealing with positron emission tomography, computed tomography, and magnetic resonance. This review will place emphasis on myocardial perfusion imaging using single-photon emission computed tomography summarizing advances in the field including prognosis, safety and tolerability, the impact of imaging on management, and the use of novel imaging protocols.
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Affiliation(s)
- Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Wael A AlJaroudi
- Division of Cardiovascular Medicine, Cardiovascular Imaging, Clemenceau Medical Center, P.O.Box 11-2555, Beirut, Lebanon
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