Early, precise, and safe clinical evaluation of the pharmacodynamic effects of novel agents in the intact human tumor microenvironment

Introduction: Drug development is systemically inefficient. Research and development costs for novel therapeutics average hundreds of millions to billions of dollars, with the overall likelihood of approval estimated to be as low as 6.7% for oncology drugs. Over half of these failures are due to a lack of drug efficacy. This pervasive and repeated low rate of success exemplifies how preclinical models fail to adequately replicate the complexity and heterogeneity of human cancer. Therefore, new methods of evaluation, early in the development trajectory, are essential both to rule-in and rule-out novel agents with more rigor and speed, but also to spare clinical trial patients from the potentially toxic sequelae (high risk) of testing investigational agents that have a low likelihood of producing a response (low benefit). Methods: The clinical in vivo oncology (CIVO®) platform was designed to change this drug development paradigm. CIVO precisely delivers microdose quantities of up to 8 drugs or combinations directly into patient tumors 4-96 h prior to planned surgical resection. Resected tissue is then analyzed for responses at each site of intratumoral drug exposure. Results: To date, CIVO has been used safely in 6 clinical trials, including 68 subjects, with 5 investigational and 17 approved agents. Resected tissues were analyzed initially using immunohistochemistry and in situ hybridization assays (115 biomarkers). As technology advanced, the platform was paired with spatial biology analysis platforms, to successfully track anti-neoplastic and immune-modulating activity of the injected agents in the intact tumor microenvironment. Discussion: Herein we provide a report of the use of CIVO technology in patients, a depiction of the robust analysis methods enabled by this platform, and a description of the operational and regulatory mechanisms used to deploy this approach in synergistic partnership with pharmaceutical partners. We further detail how use of the CIVO platform is a clinically safe and scientifically precise alternative or complement to preclinical efficacy modeling, with outputs that inform, streamline, and de-risk drug development.

Trackable Intratumor Microdosing and Spatial Profiling Provide Early Insights into Activity of Investigational Agents in the Intact Tumor Microenvironment

PURPOSE

Cancer drug development is currently limited by a paradigm of preclinical evaluation that does not adequately recapitulate the complexity of the intact human tumor microenvironment (TME). To overcome this, we combined trackable intratumor microdosing (CIVO) with spatial biology readouts to directly assess drug effects in patient tumors in situ.

EXPERIMENTAL DESIGN

In a first-of-its-kind phase 0 clinical trial, we explored the effects of an investigational stage SUMOylation-activating enzyme (SAE) inhibitor, subasumstat (TAK-981) in 12 patients with head and neck carcinoma (HNC). Patients scheduled for tumor resection received percutaneous intratumor injections of subasumstat and vehicle control 1 to 4 days before surgery, resulting in spatially localized and graded regions of drug exposure (∼1,000-2,000 μm in diameter). Drug-exposed (n = 214) and unexposed regions (n = 140) were compared by GeoMx Digital Spatial Profiler, with evaluation at single-cell resolution in a subset of these by CosMx Spatial Molecular Imager.

RESULTS

Localized regions of subasumstat exposure revealed SUMO pathway inhibition, elevation of type I IFN response, and inhibition of cell cycle across all tumor samples. Single-cell analysis by CosMx demonstrated cell-cycle inhibition specific to the tumor epithelium, and IFN pathway induction commensurate with a TME shift from immune-suppressive to immune-permissive.

CONCLUSIONS

Pairing CIVO with spatial profiling enabled detailed investigation of response to subasumstat across a diverse sampling of native and intact TME. We demonstrate that drug mechanism of action can be directly evaluated in a spatially precise manner in the most translationally relevant setting: an in situ human tumor.

Abstract 3476: TAK-243 increases tumor immunogenicity enhancing systemic anti-tumor immune response and tumor regression in combination with immune checkpoint inhibition in a syngeneic model of lymphoma

Agents that induce a shift in the activity state of the immune tumor microenvironment (TME) from “cold-to-hot” may increase response to immune checkpoint inhibitors. Here we examined whether TAK-243, a small molecule inhibitor of the ubiquitin activating enzyme (UAE), could heighten tumor immunogenicity and increase response to checkpoint inhibition. Our hypothesis was based on previous studies showing that TAK-243 induces ER stress (Hyer et al.) a phenomenon that can influence the status of the immune TME. While TAK-243 has previously shown anti-tumor potential, these studies were largely performed in immune-deficient models of cancer leaving potential influence on immune response in question. We first examined this potential using multiplexed trackable intratumor microdosing (CIVOTM, Presage Biosciences) to introduce TAK-243 alone or in combination with an anti-PD1 antibody (RPM1-14) to distinct localized positions within in a syngeneic model of lymphoma (A20). Response to localized drug exposure was then evaluated by immunohistochemistry and in situ hybridization biomarker analysis. TAK-243 induced elevation of multiple immune response biomarkers including 1) dendritic cell enrichment, 2) chemokine elevation, 3) TNFa elevation, and 4) CD8/Granzyme B elevation. We next examined whether TAK-243 could act as an “in situ vaccine” upon intratumor delivery and increase response to systemically delivered anti-PD1. Consistent with this potential, intratumor injection of TAK-243 resulted in greater regression of tumors in a dual flanked A20 xenograft model (ie one tumor on each flank of the host) when combined with systemically delivered anti-PD1 compared to either TAK-243 or anti-PD1 treatment alone. Importantly clear abscopal effects were induced as tumor regression was observed in both TAK-243 injected and non-injected tumors from subjects treated with the combination of TAK-243 and anti-PD1, 60% of which showed complete loss of tumor. Inhibition of the anti-tumor response was observed upon introduction of the drug combination with a CD8-depleting antibody. Furthermore, re-inoculation of subjects that exhibited complete regression of tumor masses with A20 cells showed no growth of new tumors. Taken together, these data suggest that intratumor injection of TAK-243 has potential to act as an in situ vaccine which increases anti-tumor immunogenicity and primes tumors for response to ICIs.

Citation Format: Richard Klinghoffer, Connor Burns, Angela Merrell, Marc Grenley. TAK-243 increases tumor immunogenicity enhancing systemic anti-tumor immune response and tumor regression in combination with immune checkpoint inhibition in a syngeneic model of lymphoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3476.

Le Fort III fractures: An approach to resuscitation and management

Introduction

Le Fort fractures occur in approximately 20% of facial fractures and result from a high velocity/force mechanism of injury. In those rare 20% occurrences, the Le Fort III fractures are the least common and are highly associated with injuries of the cervical spine, intracranial, and internal neck structures.

Importance

This makes them difficult to manage and requiring a definitive sequence of resuscitation and thorough secondary and tertiary surveys thereafter. The morbidity and mortality of these severe fractures is high but with appropriate resuscitation and adequate stabilization of the fracture, this may be improved on and lowered.

Case presentation

A male sustaining multiple stabs to the face presents to a level one trauma emergency unit haemodynamically unstable/abnormal with a threatened airway and stridor. Discussion: This case report walks through step-by-step the management approaches at each stage thereby assessing and managing the outcomes of each diagnosis.

Conclusion

Le Fort III fractures are rare but critical injuries that require intensive resuscitation and a multidisciplinary approach to achieve wholistic and appropriate management of these patients. Adequate initial resuscitation and stabilization of fractures may improve the morbidity and mortality of these sever injuries.

•

Le Fort fractures result from a high velocity/force mechanism of injury, and those rare 20% occurrences, the Le Fort III fractures are the least common and are highly associated with injuries of the cervical spine, intracranial, and internal neck structures.

•

A male sustaining multiple stabs to the face presents haemodynamically unstable/abnormal with a threatened airway and stridor.

•

Le Fort III fractures require intensive resuscitation and a multidisciplinary approach to achieve wholistic and appropriate management of these patients through airway securing, CT scan, and theatre to plate the fractures.

Abstract CT139: Intratumoral (IT) microdosing of the investigational SUMOylation Inhibitor TAK-981 in a phase 0 CIVO trial demonstrates the reactivation of type I Interferon (IFN1) signaling in head and neck squamous cell carcinoma (HNSCC)

Purpose/Objectives: The human tumor microenvironment (TME) has a dramatic impact on cancer prognosis and therapeutic response, but accurate models of the native TME do not exist. The Comparative In Vivo Oncology (CIVO) platform was developed as a means to assess the effect of investigational agents on the native TME in a Phase 0 microdosing study. CIVO was clinically validated using approved agents and is used for the first time here to assess the impact of an investigational agent - the SUMOylation inhibitor TAK-981 - on the native human TME in HNSCC.

Materials/Methods: Eligible subjects have a confirmed HNSCC diagnosis, ECOG 0-2, and planned surgical resection. Injectable tumors were at the primary site or within cervical lymph nodes but had to be surface-accessible and ≥ 2cm. TAK-981 or control microdoses were simultaneously administered via a CIVO device and co-injected with a fluorescent tracking marker for injection site identification and visualization. Tumors were resected 24 or 72 hours after injection, processed, and then analyzed at a central site. Multiplexed biomarker staining and molecular profiling via GeoMx Digital Spatial Profiling were performed to capture pharmacodynamic responses in the native TME.

Results: As of January 2022, 8 subjects provided informed consent and were enrolled, and no adverse events associated with the injection procedure or microdoses have been reported. Biomarker analysis demonstrated TAK-981 distribution around the injection site accompanied by reduction of SUMOylation. Dose-dependent elevation of IFN1 signaling was also observed in TAK-981-exposed areas within the TME. Elevated IFN1 signaling was accompanied by TME reconfiguration, with increased macrophage M1 polarization and activation of dendritic cells, NK cells, and CD8+ T cells. TAK-981 exposure was also associated with upregulation of CXCL10, PD-L1, and an IFNγ gene expression signature predictive of response to immune checkpoint blockade.

Conclusion: IT microdosing with CIVO provided early insights into complex functional responses induced by the investigational agent TAK-981 that can only be accurately evaluated in the intact, native TME of a patient’s tumor. SUMO pathway inhibition in HNSCC tumors following TAK-981 exposure led to functional activation of multiple immune cell types, effectively shifting the local TME toward an inflamed “hot” state, highlighting TAK-981’s potential as an immune stimulating agent for treating patients with solid tumors. These data were generated while TAK-981 was still in Phase I dose escalation trials (via IV administration), highlighting CIVO’s ability to safely study investigational agents. Further evaluation of TAK-981 alone and in combination with other agents is ongoing in this Phase 0 CIVO microdosing trial.

Citation Format: Jeffrey Houlton, Harrison Cash, Haodong Xu, Paul L. Swiecicki, Keith Casper, Steven B. Chinn, Daniel R. Clayburgh, Ryan J. Li, Robert J. Christian, Aaron Halfpenny, Annemieke van Zante, Beryl A. Hatton, Kimberly Sottero, Marc O. Grenley, Connor Burns, Jason Frazier, Jonathan Derry, Gloria Kung, Emily Beirne, Nathan J. Schauer, Atticus Turner, Wendy Jenkins, Kirsten Anderson, Richard A. Klinghoffer, Dennis Huszar, Allison Berger, Karuppiah Kannan. Intratumoral (IT) microdosing of the investigational SUMOylation Inhibitor TAK-981 in a phase 0 CIVO trial demonstrates the reactivation of type I Interferon (IFN1) signaling in head and neck squamous cell carcinoma (HNSCC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT139.

Reference Protocol to Assess Analytical Performance of Higher Order Structural Analysis Measurements: Results from an Interlaboratory Comparison

Measurements of protein higher order structure (HOS) provide important information on stability, potency, efficacy, immunogenicity, and biosimilarity of biopharmaceuticals, with a significant number of techniques and methods available to perform these measurements. The comparison of the analytical performance of HOS methods and the standardization of the results is, however, not a trivial task, due to the lack of reference protocols and reference measurement procedures. Here, we developed a protocol to structurally alter and compare samples of somatropin, a recombinant biotherapeutic, and describe the results obtained by using a number of techniques, methods and in different laboratories. This, with the final aim to provide tools and generate a pool of data to compare and benchmark analytical platforms and define method sensitivity to structural changes. Changes in somatropin HOS, induced by the presence of zinc at increasing concentrations, were observed, both globally and at more localized resolution, across many of the methods utilized in this study and with different sensitivities, suggesting the suitability of the protocol to improve understanding of inter- and cross-platform measurement comparability and assess analytical performance as appropriate.

OP0058-PARE MY SJÖGREN’S DIARY: AN ONLINE PATIENT PORTAL FOR PATIENT LED SJÖGREN’S SYNDROME RESEARCH

Background:

Sjögren’s Syndrome is a chronic autoimmune disease affecting the exocrine glands accompanied by variable extra-glandular manifestations. Symptom flares, including dry eyes, dry mouth, dry skin, fatigue, myalgia and arthralgia, are frequent. Many of these symptoms have a considerable impact on quality of life, but are variable, sensitive to external factors, and difficult to measure objectively.

Clinical research on Sjögren’s Syndrome is advancing with the help of patient registries: an array of clinical data is collected and available for approved studies. However, many of these registries focus on collecting clinical information and often fail to capture the diverse patient experience adequately. Thus, there is an unmet need for an online ‘patient portal’, secure and encrypted with the capability of interacting with existing registries, while also patient-facing to encourage active involvement in research and personal healthcare. Patient demand for this resource was highlighted in 2017 when the Cambridgeshire regional support group of the British Sjögren’s Syndrome Association (BSSA) contacted the Patient Led Research Hub (PLRH). The PLRH provides research expertise to co-produce research ideas with patient organisations1; the PLRH and Cambridgeshire group have since secured funding and initiated work on this project with the Cambridge Clinical Trials Unit.

Objectives:

Develop ‘My Sjögren’s Diary’ a cross-platform patient portal to:

1.Act as an interactive tool to help patients manage their healthcare needs and aid communication with healthcare providers.

2.Function as a research platform, enabling patients to consent to contact, as well as support home-based data entry, allowing real-time capture of symptom scores and ensuring ease of participation for patients. Link with the UK Primary Sjögren’s Syndrome Registry and NHS Digital to provide complementary clinical datasets.

Methods:

The PLRH has coordinated a team of rheumatologists, database programmers, patients and family members to develop My Sjögren’s Diary. Regular meetings, national surveys and correspondence with patients ensures the project remains relevant to patient needs, while collaborating with rheumatologists ensures the database is reliable, valid and of benefit to clinical care. Workshops hosted at key stages of database development have allowed both patients and rheumatologists to direct and refine My Sjögren’s Diary. A prototype was presented at the 2019 BSSA Annual Conference before further improvements and beta release.

Results:

A beta version of My Sjögren’s Diary enabling BSSA members to track their medication and symptoms is now active. Feedback will be incorporated into the final version before it is publicly available to Sjögren’s Syndrome patients. Further funding is required to develop the research platform.

Conclusion:

My Sjögren’s Diary encourages equal partnership between patients, clinicians and researchers. It presents a unique opportunity for comprehensive analysis of Sjögren’s Syndrome and associated health utilities. Research participation is not mandatory, encouraging all patients to have an active role in personal healthcare management.

References:

[1]Mader LB, Harris T, Kläger S, Wilkinson IB, Hiemstra TF. Inverting the patient involvement paradigm: defining patient led research.Research Involvement and Engagement4, 21 (2018).

Acknowledgments:

Thank you to Cambridgeshire and North Eastern BSSA regional support groups for ongoing review of the portal’s usability, function and design. Thank you to BSSA for project funding, and to the Cambridge Clinical Trials Unit and University of Cambridge Medical Library for providing workshop facilities.

Disclosure of Interests:

None declared

Assessment of methods for determination of glycan composition of erythropoietin

Erythropoietin (EPO) is a monomeric, highly glycosylated, protein hormone (molecular size around 30-35 kD), produced mainly in adult kidneys, which acts principally on red blood cell progenitors and precursors to promote red cell production. Therapeutic EPO products are widely used biotherapeutics. They are mainly produced by recombinant DNA technology in mammalian cells and their biological activity is closely linked to the degree of N-glycan sialylation. Determination of the sialic acids' content and complexity by glycan mapping therefore appears critical to ensure the quality and efficacy of the EPO therapeutic products. The European Directorate for the Quality of Medicines & HealthCare organised a study (BSP144) under the aegis of the Biological Standardisation Programme to assess N-glycan mapping tests with the aim of incorporating a standard method into the European Pharmacopoeia monograph 'Erythropoietin concentrated solution' (1316). The use of a 'reagent panel' consisting of six EPO preparations with a range of iso-electric properties facilitated comparison between laboratories and methodologies. Based on the study results, a robust and repeatable HPAEC-PAD chromatographic method was identified and work to introduce it in the monograph as an example method has been initiated.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

A modified gene trap approach for improved high-throughput cancer drug discovery

While advances in laboratory automation has dramatically increased throughout of compound screening efforts, development of robust cell-based assays in relevant disease models remain resource-intensive and time-consuming, presenting a bottleneck to drug discovery campaigns. To address this issue, we present a modified gene trap approach to efficiently generate pathway-specific reporters that result in a robust "on" signal when the pathway of interest is inhibited. In this proof-of-concept study, we used vemurafenib and trametinib to identify traps that specifically detect inhibition of the mitogen-activated protein kinase (MAPK) pathway in a model of BRAFV600E driven human malignant melanoma. We demonstrate that insertion of our trap into particular loci results in remarkably specific detection of MAPK pathway inhibitors over compounds targeting any other pathway or cellular function. The accuracy of our approach was highlighted in a pilot screen of ~6000 compounds where 40 actives were detected, including 18 MEK, 10 RAF, and 3 ERK inhibitors along with a few compounds representing previously under-characterized inhibitors of the MAPK pathway. One such compound, bafetinib, a second generation BCR/ABL inhibitor, reduced phosphorylation of ERK and when combined with trametinib, both in vitro and in vivo, reduced growth of vemurafenib resistant melanoma cells. While piloted in a model of BRAF-driven melanoma, our results set the stage for using this approach to rapidly generate reporters against any transcriptionally active pathway across a wide variety of disease-relevant cell-based models to expedite drug discovery efforts.

Modified tibial tuberosity advancement procedure with tuberosity advancement in excess of 12 mm in four large breed dogs with cranial cruciate ligament-deficient joints

Objective: To describe a modification of the tibial tuberosity advancement (TTA) procedure that required tuberosity advancement in excess of 12 mm for the stabilization of cranial cruciate ligament (CrCL) deficient stifle joints. Methods: Four large breed dogs with CrCL deficient stifle joints (one bilateral) underwent a modified TTA of 15 or 16 mm in order to obtain a patellar tendon angle of 90° to the tibial plateau slope or common tangent between femur and tibia in the extended limb position. The desired TTA was achieved by displacing a 12-mm cage distally; this displacement distance was calculated from two similar triangles formed within the planned osteotomy site. An allogenous cancellous bone block placed proximal to the cage provided buttress support; a corticocancellous allograft filled the remainder of the gap. Tibial tuberosity fixation was performed as previously described. Results: Healing of the osteotomy defects with incorporation of the cancellous block was observed at a mean of 8.6 weeks postoperatively. Normal return of limb function was reported in all of the dogs except for one dog that underwent revision surgery four months postoperatively for a continued lameness. Technical errors at the time of the original surgical procedure in this dog resulted in insufficient tuberosity advancement; additional advancement was performed, which resolved the lameness. Clinical significance: Results in this series suggest that our modification of the TTA, in order to advance the tuberosity in excess of 12 mm, could be successfully obtained using the currently available implants.

Abstract 4023: The SABRE platform: A novel, unbiased technology for drug discovery and prioritization

Targeted therapies designed to inhibit hyperactive oncogenic signaling have demonstrated some encouraging clinical responses. However, most of the time these responses are not durable as tumors “work around” pathway inhibition, often reactivating the inhibited pathway, leading to drug resistance and disease relapse. New technologies that enable more efficient discovery and development of “suites” of drugs that comprehensively inhibit multiple pathway nodes are needed. The SABRE (Splice Acceptor Brilliant Reporter) platform was developed to provide an unbiased method to screen large compound libraries and dramatically improve the speed and efficiency of which novel targeted therapeutics can be identified. SABRE is built off the premise that oncogenic output is exerted through changes in gene transcription and that such changes can be harnessed as powerful reporters of pathway activation status. SABRE utilizes the power of gene trap technology coupled with a drug selection process to isolate cells that generate a robust “off to on” signal in response to target or pathway inhibition. Via massively parallel comparative analysis, multiple traps let nature provide the best reporter for further analysis and drug discovery. In this proof-of-concept study, we employed the SABRE technology to identify insertion sites that are specifically regulated by the MAPK pathway. Experiments were performed using the human BRAFV600E mutant melanoma cell line A375. SABRE lentiviral transduced A375 cells were treated with trametinib, a MEK inhibitor, and clones were isolated that emitted a positive luciferase signal upon drug treatment. To determine if these reporters were MAPK pathway specific, the platform was miniaturized to a 1536 well format and used to screen a 6000+ compound library. Results from the screen found that 70% (28/40) of the top drug hits were known to directly modulate the MAPK pathway. Since drug resistance is a common occurrence in melanoma, we generated a “resistant” A375 SABRE reporter line to increasing concentrations of vemurafenib and interrogated the top drug candidates identified in the screen. As expected, the resistant SABRE line failed to respond to BRAFV600E specific inhibitors but continued to respond to downstream MEK inhibitors, which is helping to delineate the mechanism of resistance. We were also interested in the screening hits that were not previously known to influence the MAPK pathway including bafetinib and a Tie2 inhibitor. In follow-up testing, we found that these drugs induced robust and titratable reporter signals in both the SABRE A375 vemurafenib sensitive and resistant lines. In addition, treatment of either bafetinib or the Tie2 inhibitor reduced ERK phosphorylation in the vemurafenib resistant cells, suggesting that these drugs could be useful in the treatment of drug resistant melanomas. Studies are currently underway to determine the in vivo efficacy of these drugs in A375 SABRE reporter xenograft models.

Citation Format: Shelli M. Morris, Andrew J. Mhyre, Savanna S. Carmack, Connor Burns, Marc Ferrer, Wenjuan Ye, James M. Olson, Richard A. Klinghoffer. The SABRE platform: A novel, unbiased technology for drug discovery and prioritization [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4023. doi:10.1158/1538-7445.AM2017-4023

Coccidioidomycosis in pregnancy: Case report and literature review of associated placental lesions

BACKGROUND

Coccidioidomycosis is an endemic fungal infection found most commonly in the Southwestern United States, Northwestern Mexico, and parts of Central and South America. Although infection is relatively uncommon during pregnancy, it is imperative to have an index of suspicion in order to diagnose and begin timely treatment to prevent dissemination and dire consequences.

CASE REPORT

A 33-year-old Hispanic female was evaluated after she was involved in an automobile accident. Radiographic evaluation showed a 3.2 × 3.2 cm cavitary thick-walled lesion. A biopsy was negative for malignancy. Evaluation was positive for coccidioidomycosis by complement fixation reaction. Four months later, the patient presented 7 weeks into a pregnancy with massive hemoptysis. Bronchoscopy revealed bleeding from the right upper lobe and emergency embolization was performed. The patient had a spontaneous abortion 9 days after admission. The right upper and middle lobes of the lung were resected due to continuous bleeding. A subsequent pregnancy was un-eventful. Coccidioidomycosis titers remained negative throughout the second pregnancy.

DISCUSSION

This case demonstrates the potential for severe pulmonary coccidioidomycosis and vascular strain of pregnancy-associated vascular expansion in the first trimester of pregnancy and the possibility of a favorable pregnancy outcome in subsequent pregnancies after appropriate treatment. The route of feto-maternal transmission and placental lesions in coccidioidomycosis are discussed.

Establishment of the Ph. Eur. erythropoietin chemical reference substance batch 1

The Erythropoietin (EPO) European Pharmacopoeia (Ph. Eur.) Biological Reference Preparation (BRP) batch 3 was calibrated in 2006 by in vivo bioassay and was used as a reference preparation for these assays as well as for the physicochemical methods in the Ph. Eur. monograph Erythropoietin concentrated solution (1316). In order to avoid the frequent replacement of this standard and thus reduce the use of animals, a new EPO Chemical Reference Substance (CRS) was established to be used solely for the physicochemical methods. Here we report the outcome of a collaborative study aimed at demonstrating the suitability of the candidate CRS (cCRS) as a reference for the physicochemical methods in the Ph. Eur. monograph. Results from the study demonstrated that for the physicochemical methods currently required in the monograph (capillary zone electrophoresis (CZE), polyacrylamide gel electrophoresis (PAGE)/immunoblotting and peptide mapping), the cCRS is essentially identical to the existing BRP. However, data also indicated that, for the physicochemical methods under consideration for inclusion in a revised monograph (test for oxidised forms and glycan mapping), the suitability of the cCRS as a reference needs to be confirmed with additional work. Further to completion of the study, the Ph. Eur. Commission adopted the cCRS as "Erythropoietin for physicochemical tests CRS batch 1" to be used for CZE, PAGE/immunoblotting and peptide mapping.

Collaborative study for the establishment of erythropoietin BRP batch 4

The European Pharmacopoeia (Ph. Eur.) Biological Reference Preparation (BRP) for erythropoietin (EPO) is used as a working standard for potency determination of EPO preparations by in vivo bioassay as prescribed in the Ph. Eur. monograph Erythropoietin concentrated solution (1316). The BRP batch 3 was calibrated in 2006 and its stocks are depleted. The European Directorate for the Quality of Medicines & HealthCare (EDQM) thus initiated a project to calibrate a replacement batch in International Units against the WHO 3(rd) International Standard (IS) for Erythropoietin, recombinant, for bioassay (11/170). A Ph. Eur. Chemical Reference Substance (CRS) was established recently for use as reference in some of the physicochemical tests prescribed in the monograph. Therefore, the EPO BRP batch 4 was only calibrated for the normocythaemic and polycythaemic mouse in vivo bioassays described in the Assay section of the Ph. Eur. monograph (1316). The collaborative study involved seven laboratories from Europe, the USA and South America. The results confirmed that the candidate BRP (cBRP) is suitable for use as a reference preparation in the potency determination of EPO medicinal products by bioassay (using the normocythaemic or polycythaemic mouse methods). The outcome of the study enabled the Ph. Eur. Commission to establish the proposed standard as erythropoietin BRP batch 4 in November 2014 for use as a reference preparation solely for the polycythaemic and normocythaemic mouse bioassay, with an assigned potency of 13 000 IU/vial. Furthermore, the potency of BRP3 was confirmed during the study, thus warranting a good continuity of the IU.

Combination therapy with naltrexone and bupropion for obesity reduces total and visceral adiposity

The effects of combination naltrexone/bupropion therapy on body composition and visceral adipose tissue (VAT) mass were examined in a subset (n = 107) of obese subjects from a Phase 2 trial that compared the efficacy and safety of placebo, naltrexone monotherapy, bupropion monotherapy or one of three naltrexone/bupropion dose combinations for 24 weeks. Body composition data were obtained using dual-energy X-ray absorptiometry and computed tomography. Eighty subjects completed the substudy. Naltrexone/bupropion resulted in weight loss and a greater reduction in body fat (-14.0 ± 1.3%) than placebo (-4.0 ± 2.0%), naltrexone monotherapy (-3.2 ± 2.5%) and bupropion monotherapy (-4.1 ± 2.9%; all p < 0.01). Reduction in VAT mass was also greater with naltrexone/bupropion (-15.0 ± 1.8%) than placebo (-4.6 ± 2.7%), naltrexone monotherapy (-0.1 ± 3.5%) and bupropion monotherapy (-2.3 ± 4.2%; all p < 0.01). Reductions in body fat and VAT mass with naltrexone/bupropion were proportional with weight loss. Weight loss with naltrexone/bupropion was not associated with a greater relative reduction in lean mass than placebo or the monotherapies.

Monoclonal antibody TGN1412 trial failure explained by species differences in CD28 expression on CD4+ effector memory T-cells

BACKGROUND AND PURPOSE

In 2006, a life-threatening 'cytokine storm', not predicted by pre-clinical safety testing, rapidly occurred in all six healthy volunteers during the phase I clinical trial of the CD28 superagonist monoclonal antibody (mAb) TGN1412. To date, no unequivocal explanation for the failure of TGN1412 to stimulate profound cytokine release in vitro or in vivo in species used for pre-clinical safety testing has been established. Here, we have identified a species difference almost certainly responsible for this disparate immunopharmacology.

EXPERIMENTAL APPROACH

Polychromatic flow cytometry and intracellular cytokine staining were employed to dissect the in vitro immunopharmacology of TGN1412 and other therapeutic mAbs at the cellular level to identify differences between humans and species used for pre-clinical safety testing.

KEY RESULTS

In vitro IL-2 and IFN-γ release from CD4+ effector memory T-cells were key indicators of a TGN1412-type response. This mechanism of cytokine release differed from that of other therapeutic mAbs, which can cause adverse reactions, because these other mAbs stimulate cytokine release primarily from natural killer cells. In contrast to humans, CD28 is not expressed on the CD4+ effector memory T-cells of all species used for pre-clinical safety testing, so cannot be stimulated by TGN1412.

CONCLUSIONS AND IMPLICATIONS

It is likely that activation of CD4+ effector memory T-cells by TGN1412 was responsible for the cytokine storm. Lack of CD28 expression on the CD4+ effector memory T-cells of species used for pre-clinical safety testing of TGN1412 offers an explanation for the failure to predict a 'cytokine storm' in humans.

Delayed adjustable sutures: a multicentred clinical review

PURPOSE

To characterise the results of the largest patient series to date undergoing closed conjunctival delayed adjustable suture techniques.

METHODS

A multicentre retrospective review of 440 operations (patients aged 10-91 years) by five surgeons at four centres were evaluated for surgical outcomes associated with the delayed adjustable suture technique.

RESULTS

26% (116 of 440) of all patients required postoperative manipulation, with individual surgeon rates ranging from 13% to 56%. The majority of these patients did not complain of diplopia in target gaze and/or had satisfactory cosmetic improvement as evaluated at the 1-3 months follow-up visit (84%). Transient complications included dellen, poor conjunctival appearance, filamentary keratitis, infection, granuloma, exposed suture and corneal abrasion. Serious complications were rare.

CONCLUSIONS

This large multicentred series characterises the closed conjunctival delayed adjustable suture technique for the correction of strabismus. It may present some significant advantages to more traditional adjustable suture techniques.

The First International Standard For Insulin-like Growth Factor-1 (IGF-1) for immunoassay: preparation and calibration in an international collaborative study

The World Health Organization (WHO) Expert Committee on Biological Standardization (ECBS) has recognized the need for an International Standard for Insulin-like Growth Factor-1 (IGF-1) for the calibration of immunoassays and for the monitoring of the content of therapeutic products. The objective of the study reported here was the characterization of a candidate standard for IGF-1 in an international collaborative study carried out by 18 laboratories in nine countries, by comparison with (i) a primary calibrant characterized by amino acid analysis and UV spectroscopy, and (ii) the existing International Reference Reagent coded 87/518 by HPLC, immunoassay and bioassay. The study was designed as follows: Phase I involved the establishment of a primary calibrant of rhIGF-1, containing approximately 1.0mg rhIGF-1 per vial. A defined value was assigned to the primary calibrant by amino acid analysis (AAA) and UV spectroscopy. Phase II involved calibration of the candidate standard in terms of the primary calibrant by HPLC, with confirmatory data from immunoassay and bioassay. Results from Phase I confirmed the primary calibrant as containing 1.045 mg per vial. Although there was some variability among laboratory estimates of IGF-1 in the proposed standard using the different methods in Phase II, the estimates by the various methods were in broad agreement. On the basis of the results reported here, the World Health Organization (WHO) has established the preparation coded 02/254 as the First International Standard for Insulin-like Growth Factor-1, human, recombinant, for immunoassay with an assigned content of 8.50 microg per ampoule. Details of how to order the standard can be found at www.nibsc.ac.uk.

Over and undernutrition in the children of Australian immigrants: Assessing the influence of birthplace of primary carer and English language use at home on the nutritional status of 4-5-year-olds

OBJECTIVE

To document the relationship between childhood nutrition status and ethnicity (defined as the birthplace of primary carer and English language use at home) using a nationally representative sample of 4- to 5-year-old children.

DESIGN AND PARTICIPANTS

Cross-sectional population survey of 4 983 4- to 5-year-old children (2 537 boys and 2 446 girls) as part of Wave 1 (2004) of the Longitudinal Study of Australian Children.

MAIN OUTCOME MEASURES

Overweight/obesity and thinness using the newly published body mass index cut-off points of Cole (2007).

RESULTS

In total, 20.6% (95%CI 19.5, 21.7) of children aged 4 to 5 years were estimated to be overweight or obese, while 1.0% (95%CI 0.8, 1.3) was thin. Unadjusted analyses showed a significant relationship between childhood overweight/obesity and primary carer's country of birth (chi2=15.9, p<0.01), but the significance became minimal after adjusting for socio-economic and demographic factors. The adjusted model suggests that boys of primary carer's born in Europe (excluding UK and Ireland) were less likely to be overweight/obese than boys whose primary carers were born in Australia, but the overall effect size was negligible. No difference was found for girls. In addition, boys who mainly spoke English at home were less likely to be overweight/obese (OR=0.49; 95%CI 0.27, 0.88; p=0.017) and thin (OR=0.27; 95%CI 0.12, 0.62; p=0.002) than boys who spoke a language other than English at home. No difference was found for girls.

CONCLUSIONS

There is a relationship between main language spoken at home and nutritional status in 4-5-year-old boys but not girls. The use of English language at home may be a protective factor for normal weight in young boys. After adjustment for socio-economic and demographics characteristics, there was a negligible relationship between overweight/obesity in children and their primary carer's country of birth.

Defining distinct caregiver subpopulations by intensity of end-of-life care provided

Interventions designed to assist informal caregivers who serve individuals at or near the end of life have predominantly focused on caregiving spouses. Can we define other caregiver subpopulations--by intensity of care provided--so as to enable better a) identification of caregiver needs and b) targeting of support to caregivers? The Health Omnibus Survey, an annual face-to-face survey in South Australia, collects health-related data from a representative sample of 4400 households. Piloted questions included in the 2001-2005 Health Omnibus surveys addressed death of a loved one, caregiving provided, impact of caregiving and caregiver characteristics. Of 18,224 respondents, 5302 reported a loved one's death due to terminal illness in the previous 5 years. In all, 502 (10%) provided daily care [5-7 days/week], 619 (12%) provided intermittent care [2-4 days/week] and 425 (8%) provided rare care. Active (daily plus intermittent) caregivers, compared with non-active (rare) caregivers, were more often women (63% vs 50%; P < 0.0001). Daily caregivers were distinguishable from intermittent; daily caregivers were more often widowed (95% vs 7%; P < 0.0001) and >or=60 years (80% vs 64%; P < 0.0001); intermittent caregivers were more commonly children/parents (35%), other relatives (33%), or friends (26%; P < 0.0001) and were better educated, more active in paid work and wealthier. Financial burden, experience at time of death, ability to move on after the death and need for grief support also differed by intensity of caregiving. Caregiver subpopulations can be defined according to intensity of caregiving with distinct demographic features helping to distinguish them.

The Banff 2007 working classification of skin-containing composite tissue allograft pathology

Composite tissue allotransplantation (CTA) is a recently introduced option for limb replacement and reconstruction of tissue defects. As with other allografts, CTA can undergo immune-mediated rejection; therefore standardized criteria are required for characterizing and reporting severity and types of rejection. This article documents the conclusions of a symposium on CTA rejection held at the Ninth Banff Conference on Allograft Pathology in La-Coruna, Spain, on 26 June 2007, and proposes a working classification, the Banff CTA-07, for the categorization of CTA rejection. This classification was derived from a consensus discussion session attended by the first authors of three published classification systems, pathologists and researchers from international centers where clinical CTA has been performed. It was open to all attendees to the Banff conference. To the extent possible, the format followed the established National Institutes of Health (NIH) guidelines on Consensus Development Programs. By consensus, the defining features to diagnose acute skin rejection include inflammatory cell infiltration with involvement of epidermis and/or adnexal structures, epithelial apoptosis, dyskeratosis and necrosis. Five grades of severity of rejection are defined. This classification refines proposed schemas, represents international consensus on this topic, and establishes a working collective classification system for CTA reporting of rejection in skin-containing CTAs.

Maintenance of traditional cultural orientation is associated with lower rates of obesity and sedentary behaviours among African migrant children to Australia

BACKGROUND

Migrants from developing to developed countries rapidly develop more obesity than the host population. While the effects of socio-economic status on obesity are well established, the influence of cultural factors, including acculturation, is not known.

OBJECTIVE

To examine the association between acculturation and obesity and its risk factors among African migrant children in Australia.

DESIGN AND PARTICIPANTS

A cross-sectional study using a non-probability sample of 3- to 12-year-old sub-Saharan African migrant children. A bidimensional model of strength of affiliation with African and Australian cultures was used to divide the sample into four cultural orientations: traditional (African), assimilated (Australian), integrated (both) and marginalized (neither).

MAIN OUTCOME MEASURES

Body mass index (BMI), leisure-time physical activity (PA) and sedentary behaviours (SBs) and energy density of food.

RESULTS

In all, 18.4% (95% confidence interval (CI): 14-23%) were overweight and 8.6% (95% CI: 6-12%) were obese. After adjustment for confounders, integrated (beta=1.1; P<0.05) and marginalized (beta=1.4; P<0.01) children had higher BMI than traditional children. However, integrated children had significantly higher time engaged in both PA (beta=46.9, P<0.01) and SBs (beta=43.0, P<0.05) than their traditional counterparts. In comparison with traditional children, assimilated children were more sedentary (beta=57.5, P<0.01) while marginalization was associated with increased consumption of energy-dense foods (beta=42.0, P<0.05).

CONCLUSIONS

Maintenance of traditional orientation was associated with lower rates of obesity and SBs. Health promotion programs and frameworks need to be rooted in traditional values and habits to maintain and reinforce traditional dietary and PA habits, as well as identify the marginalized clusters and address their needs.

Collaborative study for the establishment of erythropoietin BRP batch 3

The European Pharmacopoeia (Ph. Eur.) monograph on Erythropoietin concentrated solution (1316) specifies that identification and assay are performed using pharmacopoeial methods requiring the use of a reference preparation. To replace the current erythropoietin Biological Reference Preparation (BRP) of Ph. Eur., in 2006, the European Directorate for the Quality of Medicines undertook a collaborative study designed to establish a replacement batch. In order to guarantee continuity, the formulation of the candidate batch was similar to that of previous batches (1 and 2). The methods chosen to qualify the new standard were those included in the current monograph. The study was defined to allow calibration of the candidate by in vivo bioassay in terms of the current World Health Organization (WHO) International Standard (IS) and to assign a unitage. The suitability of the candidate preparation to serve as a reference standard for the other pharmacopoeial analytical procedures was also investigated. The collaborative study involved 16 laboratories from Europe, Australia, Canada, China, Japan, South Korea and the United States of America. Participants carried out biological and physicochemical assays on the candidate erythropoietin BRP batch 3 (cBRP3), using batch 2 (BRP2) and where necessary the 2nd World Health Organization International Standard (WHO 2nd IS) for recombinant erythropoietin as the reference standards. It was demonstrated that the replacement batch is appropriate for use as erythropoietin BRP in the context of the control of erythropoietin concentrated solutions according to the Ph. Eur. monograph (1316). However as regards the potency of BRP2 and cBRP3 in the mouse bioassay unexpected observations were made. Direct calibration of BRP2 against the WHO 2nd IS yielded, in all laboratories, results that were systematically higher than the potency of 32,500 IU/vial assigned by direct calibration against the WHO 2nd IS in the former study. It was therefore recommended to assign the potency of cBRP3 against BRP2, using the average of all results that were not considered as outlying obtained in the collaborative study, in order to guarantee continuity of unitage between the successive BRP batches. The outcome of the study enabled the Ph. Eur. Commission to establish the proposed standard as 'erythropoeitin BRP batch 3' (BRP3). BRP3 was established in June 2007 for use as a reference preparation for the polycythaemic and normocythaemic mouse bioassay, with an assigned potency of 35,280 IU/vial, the identification by capillary zone electrophoresis, by polyacrylamide gel electrophoresis, immunoblotting and peptide mapping and as a reference for checking the system suitability of size-exclusion chromatographic procedures used in the test for dimers and related substances of higher molecular mass in the Ph. Eur. monograph (1316).