Practical resiliency training for healthcare workers during COVID-19: results from a randomised controlled trial testing the Community Resiliency Model for well-being support

Objective

To introduce the Community Resiliency Model (CRM) as mental well-being support for healthcare workers working through the height of the COVID-19 pandemic.

Design

Randomised controlled trial with a no treatment control group.

Setting

Two large urban health systems in the Southern United States between October 2020 and June 2021.

Participants

Eligible participants were currently employed as healthcare workers within the participating healthcare systems. 275 employees registered and consented electronically in response to email invitations. 253 participants completed the baseline survey necessary to be randomised and included in analyses.

Intervention

Participants were assigned 1:1 to the control or intervention group at the time of registration. Intervention participants were then invited to 1-hour virtual CRM class teaching skills to increase somatic awareness in the context of self and other care.

Main outcome measures

Self-reported data were collected rating somatic awareness, well-being, symptoms of stress, work engagement and interprofessional teamwork.

Results

Baseline data on the total sample of 275 (53% nurses) revealed higher symptoms of stress and lower well-being than the general population. The intervention participants who attended a CRM class (56) provided follow-up survey data at 1 week (44) and 3 months (36). Significant improvement for the intervention group at 3 months was reported for the well-being measures (WHO-5, p<0.0087, d=0.66; Warwick-Edinburgh Mental Well-Being Scale, p<0.0004, d=0.66), teamwork measure (p≤0.0002, d=0.41) and stress (Secondary Traumatic Stress Scale, p=0.0058, d=46).

Conclusion

Baseline results indicate mental health is a concern for healthcare workers. Post intervention findings suggest that CRM is a practical approach to support well-being for healthcare workers during a crisis such as this pandemic. The simple tools that comprise the model can serve as a starting point for or complement self-care strategies to enhance individual resilience and buffer the effects of working in an increasingly stressful work environment.

Management of Low-Grade Gliomas – Extent of Resection Matters But Not All Tumours Are Amenable to Surgery

AIMS

To present and review our experience in the management of low-grade gliomas.

METHOD

Retrospective case note review of all patients with WHO grade 2 glioma from 2011 to 2018 (based on WHO criteria at time of diagnosis). Data collected on demographics, presentation, location, initial management, histology, treatment, progression free (PFS) and overall survival (OS).

RESULTS

130 eligible patients. Median follow 4.6 years (up to 10.5). Median age 40 years (range: 18-83). There were 70 (53.8%) astrocytomas, 44 (33.8%) oligodenrogliomas, 16 (12.3%) oligoastrocytomas. 66%(n=86) presented with seizures, 10.7%(n=14) with sensory symptoms, 8.5%(n=11) with speech disturbance, 5.3%(n=4) with motor symptoms and 12.3%(n=16) were identified incidentally. 50.1%(n=65) were frontal, 27.7%(n=36) temporal and 9.2%(n=12) parietal. 1st line treatment was resection in 70.7%(n=92), biopsy in 23.8%(n=31) and observation in 4.6%(n=6). 15.4%(n=20) received adjuvant radiotherapy alone and 6.1%(n=8) received adjuvant radiotherapy followed by chemotherapy . At first recurrence, 31.6%(n=12) received further surgery and 95%(n=38) received radiotherapy and/or chemotherapy . Median PFS from 1st line treatment 66, 44 and 33 months for gross total resection (GRT), subtotal resection (STR), and biopsy respectively. Overall survival was 95.1%, 79.3% and 69.% for GTR, STR and biopsy respectively.

CONCLUSION

Management of low-grade gliomas remains challenging. Extent of resection impacts prognosis but not all patients have gliomas amenable to surgery. The effects of chemoradiotherapy will be presented in future meetings as this is an ongoing project.

Abstract ND02: MRTX0902: A SOS1 inhibitor for therapeutic intervention of KRAS-driven cancers

KRAS is the most frequently mutated oncogene in cancer and drives uncontrolled growth through hyperactivation of the MAPK pathway. Significant progress has been made in the past several years to directly target KRASG12C with the FDA approval of sotorasib and the reported clinical activity of adagrasib (MRTX849). Despite these remarkable breakthroughs, additional therapies that enhance the depth and duration of response to KRASG12C inhibitors provide the opportunity to build upon the initial progress. SOS proteins are guanine nucleotide exchange factors (GEFs) that transduce receptor tyrosine kinase (RTK) signaling from the cell surface and facilitate the activation of RAS family proteins. In addition, SOS1 is a target of negative feedback signaling following RAS-mediated activation of the RAF-MEK-ERK cascade. Thus, SOS proteins represent a significant therapeutic node that maintains RAS pathway equilibrium as well as oncogenic signaling dynamics. Here we highlight the discovery and preclinical evaluation of MRTX0902, a potent, selective, and orally bioavailable inhibitor of SOS1 presently in IND-enabling studies. A structure-based approach was used to identify a novel chemical series that disrupts the protein-protein interaction between SOS1 and KRAS, thereby preventing SOS1-mediated GTP-exchange on GDP-bound KRAS. Considering MRTX849 preferentially binds to inactive GDP-bound KRASG12C, targeting SOS1 in this genetic context increases the ability of MRTX849 to bind and inhibit KRASG12C. The combination of MRTX0902 with MRTX849 enhances the depth and durability of an anti-tumor response when compared to MRTX849 alone in pre-clinical KRASG12C tumor models. MRTX0902 augments additional targeted therapies across a variety of RAS-addicted tumors, indicating that SOS1 inhibition is effective against a broad spectrum of mutations within the MAPK pathway. Furthermore, drug-anchored CRISPR experiments with MRTX0902 and MRTX849 uncovered a previously underappreciated functional role of the SOS1 paralog, SOS2, in KRAS-addicted tumors. In addition to aiding in the understanding of SOS and RAS family signaling dynamics, these studies implicate SOS2 as a potential cancer drug target in the context of SOS1/KRASG12C inhibition. In summary, we have used a structure-based approach to discover a SOS1 inhibitor that augments the anti-tumor activity of MRTX849 and additional targeted MAPK pathway inhibitors. We anticipate our findings to translate into the clinic and make an impact in patients with RAS-addicted tumors.

Citation Format: John M. Ketcham, Shilpi Khare, Niranjan Sudhakar, David M. Briere, Larry Yan, Jade Laguer, Laura Vegar, Darin Vanderpool, Jill Hallin, Lauren Hargis, Vickie Bowcut, David Lawson, Robin J. Gunn, Anthony Ivetac, Nicole C. Thomas, Barbara Saechao, Natalie Nguyen, Jeffrey Clarine, Lisa Rahbaek, Christopher R. Smith, Aaron C. Burns, Matthew A. Marx, James G. Christensen, Peter Olson, Jacob R. Haling. MRTX0902: A SOS1 inhibitor for therapeutic intervention of KRAS-driven cancers [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 ND02.

The use of transcutaneous electrical nerve stimulation along with functional tasks for immediate pain relief in individuals with knee osteoarthritis

BACKGROUND

Knee pain is the major complaint in individuals with knee osteoarthritis (OA), and the effects of transcutaneous electrical nerve stimulation (TENS) on knee pain are controversial. The present study applied TENS along with functional tests to investigate its effect on pain level in individuals with mild to moderate knee OA.

METHODS

Twenty volunteers with knee OA classification of graded 2-3 performed four functional tests (stair climb test - SCT, timed up and go test - TUG, 6-minute walk test - 6MWT, knee extensor strength test - KES, and 2-step test from the locomotive syndrome risk test - LSR_2ST) while wearing either an active or inactive TENS. Knee pain level before and after each test was self-accessed by the visual analog scale (VAS). The effect of TENS (active vs. inactive) on pain level was submitted to statistical analyses.

RESULTS

Knee pain during SCT, TUG, and LSR_2ST tests was significantly lower when subjects used the active TENS, compared to using the inactive unit. The effect of the active TENS on pain level was also more significant in subjects with no anxiety or depression.

CONCLUSIONS

The results provided evidence of immediate pain relief in individuals with mild to moderate knee OA when TENS is applied along with functional activities, that usually induced pain in people with knee OA.

Correlates of financial toxicity in adult cancer patients and their informal caregivers

BACKGROUND

Financial toxicity is commonly reported by cancer patients, but few studies have assessed caregiver perceptions. We aimed to validate the modified Comprehensive Score for Financial Toxicity (COST) in cancer caregivers, identify factors associated with financial toxicity in both patients and caregivers, and assess the association of caregiver financial toxicity with patient and caregiver outcomes.

METHODS

Using a convenience sampling method, 100 dyads of adult cancer patients and a primary caregiver visiting outpatient oncology clinics (Jan-Sep 2019) were recruited. We assessed the internal consistency and convergent and divergent validity of the modified COST. Multivariable analyses identified correlates of financial toxicity. Association of financial toxicity with care non-adherence, lifestyle-altering behaviors (e.g., home refinance/sale, retirement/saving account withdrawal), and quality of life (QOL) was investigated.

RESULTS

Recruited patient vs. caregiver characteristics were as follows: mean age: 60.6 vs. 56.5; 34% vs. 46.4% female; 79% vs. 81.4% white. The caregiver COST measure demonstrated high internal consistency (Cronbach α = 0.91). In patients, older age (B, 0.3 [95% CI, 0.1-0.4]) and higher annual household income (B, 14.3 [95% CI, 9.3-19.4]) correlated with lower financial toxicity (P < 0.05). In caregivers, lower patient financial toxicity (B, 0.4 [95% CI, 0.2-0.6]) and cancer stages 1-3 (compared to stage 4) (B, 4.6 [95% CI, 0.4-8.8]) correlated with lower financial toxicity (P < 0.05). Increased caregiver financial toxicity correlated with higher care non-adherence in patients, increased lifestyle-altering behaviors, and lower QOL in patients and caregivers (P < 0.05).

CONCLUSION

The COST measure can also be used to assess caregiver financial toxicity. Caregivers' financial toxicity was associated with negative outcomes for both dyad members.

Evaluation of a 'drop box' doorstep assessment service to aid remote assessments for COVID-19 in general practice

The COVID-19 is an established threat whose clinical features and epidemiology continues to evolve. In an effort to contain the disease, the National Health Service has adopted a digital first approach in UK general practice resulting in a significant shift away from face-to-face consultations. Consequently, more consultations are being completed without obtaining objective recording of vital signs and face-to-face examination. Some regions have formed hot hubs to facilitate the review of suspected COVID-19 cases and keep their practice site 'clean' including the use of doorstep observations in avoiding the risk of face-to-face examination. To support the safe, effective and efficient remote assessment of suspected and confirmed patients with COVID-19, we established a doorstep assessment service to compliment telephone and video consultations. This allows physiological parameters such as temperature, pulse, blood pressure and oxygen saturation to be obtained to guide further triage. Quality improvement methods were used to integrate and optimise the doorstep assessment and measure the improvements made. The introduction of a doorstep assessment service increased the proportion of assessments for patients with suspected COVID-19 in routine care over weeks. At the same time we were able to dramatically reduce face-to-face assessment over a 6-week period by optimising through a range of measures including the introduction of a digital stethoscope. The majority of patients were managed by their own general practitioner following assessment supporting continuity of care. There were no adverse events during the period of observation; no staff absences related to COVID-19. Quality improvement methods have facilitated the successful integration of doorstep assessments into clinical care.

Melanoma Cell Intrinsic GABAA Receptor Enhancement Potentiates Radiation and Immune Checkpoint Inhibitor Response by Promoting Direct and T Cell-Mediated Antitumor Activity

PURPOSE

Most patients with metastatic melanoma show variable responses to radiation therapy and do not benefit from immune checkpoint inhibitors. Improved strategies for combination therapy that leverage potential benefits from radiation therapy and immune checkpoint inhibitors are critical.

METHODS AND MATERIALS

We analyzed metastatic melanoma tumors in the TCGA cohort for expression of genes coding for subunits of type A γ-aminobutyric acid (GABA) receptor (GABA_AR), a chloride ion channel and major inhibitory neurotransmitter receptor. Electrophysiology was used to determine whether melanoma cells possess intrinsic GABA_AR activity. Melanoma cell viability studies were conducted to test whether enhancing GABA_AR mediated chloride transport using benzodiazepine-impaired viability. A syngeneic melanoma mouse model was used to assay the effect of benzodiazepine on tumor volume and its ability to potentiate radiation therapy or immunotherapy. Treated tumors were analyzed for changes in gene expression by RNA sequencing and presence of tumor-infiltrating lymphocytes by flow cytometry.

RESULTS

Genes coding for subunits of GABA_ARs express functional GABA_ARs in melanoma cells. By enhancing GABA_AR-mediated anion transport, benzodiazepines depolarize melanoma cells and impair their viability. In vivo, benzodiazepine alone reduces tumor growth and potentiates radiation therapy and α-PD-L1 antitumor activity. The combination of benzodiazepine, radiation therapy, and α-PD-L1 results in near complete regression of treated tumors and a potent abscopal effect, mediated by increased infiltration of polyfunctional CD8⁺ T cells. Treated tumors show expression of cytokine-cytokine receptor interactions and overrepresentation of p53 signaling.

CONCLUSIONS

This study identifies an antitumor strategy combining radiation and/or an immune checkpoint inhibitor with modulation of GABA_ARs in melanoma using benzodiazepine.

Tumor-draining lymph node is important for a robust abscopal effect stimulated by radiotherapy

Background

Radiotherapy (RT) has been shown to stimulate an antitumor immune response in irradiated tumors as well as unirradiated distant sites (abscopal effect). Previous studies have demonstrated a role for the tumor-draining lymph node (LN) in mediating an anti-programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) stimulated antitumor immune response. Here, we investigated whether the LN is also important in mediating a RT alone stimulated abscopal response.

Methods

We used a subcutaneous modified B16F10 flank tumor model injected bilaterally. Our B16F10 cell line has an inserted viral glycoprotein which facilitated identification of tumor-specific T-cells. RT was directed at one flank tumor alone or one flank tumor and the tumor-draining LN. We evaluated response by tumor growth measurements and flow cytometry of both tumor-infiltrating and LN T-cells.

Results

We show that local tumor irradiation improves distant tumor control (abscopal effect). Depletion of CD8⁺ T-cells significantly reduced this abscopal response. We have previously shown, in a chronic lymphocytic choriomeningitis virus (LCMV) infection, that the T-cell proliferative burst following blockade of PD-1/L1 is provided by a ‘stem-like’ CD8⁺ T-cell subset which then differentiate into terminally differentiated effectors. These terminally differentiated effectors have the potential to kill virally infected or tumor cells following PD-1/L1 blockade. In the chronic LCMV infection, stem-like CD8⁺ T-cells were found exclusively in secondary lymphoid organs. Similarly, here we found these cells at high frequencies in the tumor-draining LN, but at low frequencies within the tumor. The effect of RT on this T-cell subset in unknown. Interestingly, tumor irradiation stimulated total CD8⁺ and stem-like CD8⁺ T-cell proliferation in the LN. When the LN and the tumor were then targeted with RT, the abscopal effect was reduced, and we found a concomitant reduction in the number of total tumor-specific CD8⁺ T-cells and stem-like CD8⁺ T-cells in both the irradiated and unirradiated tumor.

Conclusions

These correlative results suggest the tumor-draining LN may be an important mediator of the abscopal effect by serving as a stem-like CD8⁺ T-cell reservoir, a site for stem-like T-cell expansion, and a site from which they can populate the tumor.

20. MELANOMA CELL INTRINSIC GABAA RECEPTOR ENHANCEMENT POTENTIATES RADIATION AND IMMUNE CHECKPOINT INHIBITOR RESPONSE BY PROMOTING DIRECT AND T CELL-MEDIATED ANTI-TUMOR ACTIVITY

Most metastatic melanoma patients exhibit poor and variable response to radiotherapy and targeted therapies, including immune checkpoint inhibitors. There is a need for therapeutics that can potentiate existing treatments to positively impact clinical outcomes of metastatic melanoma patients. We reanalyzed melanoma TCGA transcriptomes and identified, as linked to previously defined molecular subgroups, enhanced expression of genes coding for subunits of the Type A GABA receptor (GABA_AR), a chloride ion channel and major inhibitory neurotransmitter receptor. Using whole-cell patch clamp electrophysiology, we find that melanoma cells possess GABA_ARs that control membrane permeability to anions. Select benzodiazepines, by enhancing GABA_AR mediated anion transport, depolarize melanoma cell mitochondrial membrane potential and impair cell viability in vitro. Using a syngeneic melanoma mouse model, we find that a benzodiazepine promotes reduction in tumor volume when administered alone and potentiated radiation or immune checkpoint inhibitor α-PD-L1. When a benzodiazepine is combined with concurrent α-PD-L1 and a sub-lethal radiation dose, there is near complete loss of tumor, beyond what is observed for benzodiazepine with radiation or α-PD-L1. Mechanistically, benzodiazepine with radiation or α-PD-L1 results in ipsilateral and an abscopal tumor volume reduction commensurate with enhanced infiltration into the tumor milieu of polyfunctional CD8 T-cells. There is also an increased expression of genes with roles in the cytokine-cytokine receptor and p53 signaling pathways. This study provides evidence for melanoma cell GABA_ARs as a therapeutic vulnerability with benzodiazepines promoting both direct and immune-mediated anti-tumor activity.

Impact of Sequencing Radiation Therapy and Immune Checkpoint Inhibitors in the Treatment of Melanoma Brain Metastases

PURPOSE

Melanoma brain metastases (MBM) occur in ∼50% of melanoma patients. Although both radiation therapy (RT) and immune checkpoint inhibitor (ICI) are used alone or in combination for MBM treatment, the role of this combination and how these treatments could best be sequenced remains unclear.

METHODS AND MATERIALS

We conducted a retrospective analysis of patients with resected MBM who underwent treatment with RT, ICI, or a combination of RT and ICI. Among the latter, we specifically investigated the differential gene expression via RNA-sequencing between patients who received RT first then ICI (RT → ICI) versus ICI first then RT (ICI → RT). We used a glycoprotein-transduced syngeneic melanoma mouse model for validation experiments.

RESULTS

We found that for patients with resected MBM, a combination of RT and ICI confers superior survival compared with RT alone. Specifically, we found that RT → ICI was superior compared with ICI → RT. Transcriptome analysis of resected MBM revealed that the RT → ICI cohort demonstrated deregulation of genes involved in apoptotic signaling and key modulators of inflammation that are most implicated in nuclear factor kappa-light-chain-enhancer of activated B cells signaling. In a preclinical model, we showed that RT followed by anti-programmed death-ligand 1 therapy was superior to the reverse sequence of therapy, supporting the observations we made in patients with MBM.

CONCLUSIONS

Our study provides initial insights into the optimal sequence of RT and ICI in the treatment of MBM after surgical resection. Prospective studies examining the best sequence of RT and ICI are necessary, and our study contributes to the rationale to pursue these.

Chemokine receptor 4 targeted protein MRI contrast agent for early detection of liver metastases

Liver metastases often progress from primary cancers including uveal melanoma (UM), breast, and colon cancer. Molecular biomarker imaging is a new non-invasive approach for detecting early stage tumors. Here, we report the elevated expression of chemokine receptor 4 (CXCR4) in liver metastases in UM patients and metastatic UM mouse models, and development of a CXCR4-targeted MRI contrast agent, ProCA32.CXCR4, for sensitive MRI detection of UM liver metastases. ProCA32.CXCR4 exhibits high relaxivities (r ₁ = 30.9 mM^-1 s^-1, r ₂ = 43.2 mM^-1 s^-1, 1.5 T; r ₁ = 23.5 mM^-1 s^-1, r ₂ = 98.6 mM^-1 s^-1, 7.0 T), strong CXCR4 binding (K _d = 1.10 ± 0.18 μM), CXCR4 molecular imaging capability in metastatic and intrahepatic xenotransplantation UM mouse models. ProCA32.CXCR4 enables detecting UM liver metastases as small as 0.1 mm³. Further development of the CXCR4-targeted imaging agent should have strong translation potential for early detection, surveillance, and treatment stratification of liver metastases patients.

EXTH-12. RADIATION ENHANCES MELANOMA RESPONSE TO IMMUNOTHERAPY AND SYNERGIZES WITH BENZODIAZEPINES TO PROMOTE ANTI-TUMOR ACTIVITY

Melanoma brain metastases (MBM) occur in ~50% of advanced melanoma patients. It is unclear if systemic therapies synergize with radiotherapy (RT) and what the impact of RT timing has on efficacy. We find that RT followed by ICI (immune checkpoint inhibitors) (RTàICI) improves MBM patient survival compared to other combination strategies, also shown here in a murine melanoma model. RNA-seq of MBM tumors in the RTàICI group exhibit overrepresentation of genes implicated in NFKB signaling. There is also expression of GABAA receptor subunits across both treatment groups. We show that melanoma cells express functional GABAA receptors and that benzodiazepines impair tumor growth. Combination of sub-lethal RT doses with benzodiazepine results in significant ipsilateral and out of field abscopal anti-tumor activity, which is associated with enhanced tumor infiltration with poly-functional CD8 T-cells. This study provides evidence that RT enhances MBM response to ICI and synergizes with benzodiazepines to promote anti-tumor activity.

RARE-50. PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA – OUTCOMES IN THE ‘HAEMATOLOGY ERA’

BACKGROUND

Primary CNS lymphoma (PCNSL) requires a biopsy for diagnosis. Administration of corticosteroids can lead to inconclusive results and delay diagnosis. The aim of this study was to compare outcomes of patients treated under haematology compared to radiation oncologists.

METHODS

Retrospective case review of patients treated under radiation oncology (2006–2010) and haematology (2011–2016).

RESULTS

121 cases were identified (median age 63 years; range 19–84). Median WHO performance status (PS) was 1. Fourteen patients (11.6%) required repeat biopsy. 10 patients were managed palliatively due to poor PS. 67 cases were managed under haematology. Median symptom duration was 28 days (range 2–540). Median time from MRI to diagnosis was 18 days (range 6–232). 66 patients received chemotherapy, 1 received radiotherapy. Median overall survival (OS) was 8 months (95%CI:0.7–15.3), 5-year OS was 22.4%. 44 cases were managed under radiation oncology. Median symptom duration was 28 days (range 2–365). Median time from MRI to diagnosis was 16 days (range 6–309). 34 patients received radiotherapy first-line, 10 received chemotherapy. Median OS was 7 months (95%CI:0–21.5), 5-year OS was 15.9%. Multivariate analysis demonstrated PS (HR 2.02 (95%CI: 1.08–3.76)) and symptom duration (HR 0.63 (95%CI: 0.41–0.96)) to be significant prognostic indicators for OS.

CONCLUSION

The outcomes from the ‘haematology era’ are similar to those achieved by radiation oncologists. Delay in diagnosis leads to worse outcomes and highlights the ongoing need to streamline the patient pathway to improve outcomes.

Primary Central Nervous System Lymphoma – Management and Outcome in the ‘haematology era’

Introduction

Primary CNS lymphoma (PCNSL) requires a biopsy for diagnosis but can be inconclusive when steroids are administered. Without treatment median survival is 1.5–3.3 months, improving to 10–20 months with oncological treatment. This study aimed to compare outcomes of PCNSL treated under haematology to those of clinical oncologists.

Methods

Retrospective casenote review of patients with PCNSL treated under oncologists (2006–2010) and haematologists (2011–2016).

Results

121 cases were identified (median age 63 years; range 19–84). Median WHO performance status (PS) was 1. 11.6% required repeat biopsy.

10 patients were managed palliatively due to poor PS.

67 cases were managed under haematology. Median symptom duration was 28 days (range 2–540). Median time from MRI to diagnosis was 18 days (range 6–232). 66 patients received chemotherapy, 1 received radiotherapy. Median overall survival (OS) was 8 months (95%CI: 0.7–15.3), 5-year OS was 22.4%.

44 cases were managed under oncology. Median symptom duration was 28 days (range 2–365). Median time from MRI to diagnosis was 16 days (range 6–309). 34 patients received radiotherapy first-line, 10 received chemotherapy. Median OS was 7 months (95%CI: 0–21.5), 5-year OS was 15.9%.

Multivariate analysis demonstrated PS (HR 2.02 (95%CI: 1.08–3.76)) and symptom duration (HR 0.63 (95%CI: 0.41–0.96)) to be significant prognostic indicators for OS.

Discussion

PCNSL carries poor prognosis and outcomes from the ‘haematology era’ are similar to those achieved by clinical oncologists. Delay in diagnosis leads to worse outcomes and highlights the ongoing need to streamline current clinical services to improve outcomes.

Management and outcomes of meningiomas secondary to childhood and adolescent radiation treatment

Background

With the increased rate of childhood cancer survivors, a marked rise in the incidence of secondary intracranial meningiomas has been established.

Objective

Determine the outcomes of patients diagnosed with radiation-induced meningiomas (RIM).

Methods

Single-centre retrospective cohort study of patients with new or recurrent RIM (2007–2018).

Results

47 patients were identified (21 females). Mean age at radiation was 15 years (SD=14) and the most common indications were leukaemia (n=8) and childhood brain tumours (n=35; medulloblastoma and pilocytic astrocytoma (n=7 each)). 93 de-novo meningiomas were identified. The median latency period between radiation and diagnosis was 28.5 years (IQR 22–37). 61% were asymptomatic whilst the remainder manifested headache (20%), focal neurological deficit (12%) and epilepsy (5%). 32 operated de-novo RIM revealed WHO grade I (n=19; 59%), WHO grade II (n=11; 34%) and 2 intraosseous meningiomas (n=2; 6%). After a median of 5 years (IQR 3–10), 9 (28%) operated RIM recurred/progressed. At recurrence, 5 were operated (3 WHO grade I, 2 WHO grade II and 1 WHO grade III), 2 patients were palliated and 2 remain under active observation. By the end of the study period, 20 patients were harbouring multiple meningiomas and 8 patients were deceased.

Conclusion

Radiation-induced meningioma should be monitored until symptomatic. Operated RIMs have a high recurrence rate. Further radiotherapy is not effective. Further clinical and genetic analyses as part of an international multi-centre collaboration are planned.

Glioblastoma multiforme in patients over 65 – should we operate?

Aim

Current standard of care for glioblastoma is maximum safe resection followed by radio chemotherapy with Temozolomide. Older patients are less likely to receive the full treatment. The aim was to determine treatment and outcomes in glioblastoma patients >65 years.

Methods

Single centre retrospective study from 2001–2016. Eligible patients had: (i) diagnosis of glioblastoma (ii) undergone biopsy or resection with radiotherapy ± adjuvant chemotherapy. Age at diagnosis, type of surgery, performance status, complications, adjuvant therapy and median survival (MS) were recorded. Patients were assigned to group A (age <65), B (age 65–69 years) or C (age >/= 70 years).

Results

637 patients met the eligibility criteria and 403 had complete records for analysis. Age distribution of the cohort was 17.9 – 91.6 years.

In the group A (n=259), those who had undergone resection had significantly longer MS compared to biopsy: 17.2 vs 13.2 months (P<0.05 CI: 444.043 – 561.957). 70 patients developed complications.

In the group B (n=79), those who had undergone resection had significantly longer MS compared to biopsy: 12.3 vs 5.1 months (P<0.05 CI: 194.354 – 335.646). 17 patients developed complications.

In the group C (n=64), analysis did not show statistically significant difference (P=0.066 CI: 220.476 – 321.524). Clinically, patients who had resection had longer MS (10.5 months vs 3.5 months). Furthermore, there was no significant difference in the rate of complications between resection and biopsy (Fisher’s exact test, P=0.755).

Conclusion

i) Patients >65 should be treated as per the Stupp protocol ii) In patients >70 surgical resection should be considered.:

Abstract 526: Tumor-draining lymph node irradiation reduces tumor-infiltrating stem-like CD8+T-cells and abrogates the abscopal effect

Purpose: PD-1 and PD-L1 antagonists are efficacious because cancer induces T-cell exhaustion via upregulation of PD-L1 and persistent antigen exposure. Our lab, has shown that the proliferative burst following αPD-L1 therapy of exhausted CD8+PD-1+T-cells is restricted to a “stem-like” CD8+T-cell subset in a murine chronic viral infection model. The role of these stem-like CD8+T-cells in malignancies and whether these cells respond to other immuno-stimulation including radiotherapy (RT) is unknown. RT’s immuno-stimulation includes acting as an in-situ vaccine by liberating cryptic tumor neo-antigens, generating a potent anti-tumor CD8+T-cell response, synergizing with αPD-1/L1 and leading to control at distant sites of disease outside the radiation field (abscopal effect). In initial studies, we found these stem-like CD8+T-cells in B16F10 tumors and at high frequencies in the tumor-draining lymph nodes (TDLN) of immunocompetent mice. Here, we investigated: (1) the impact of tumor-directed RT on this stem-like CD8+T-cell population in the tumor and TDLN in the context of an abscopal response, and (2) due to the high frequency of stem-like CD8+T-cells in the TDLN, whether depletion of lymphocytes from the TDLN via RT influenced the abscopal effect.

Experimental Design: We developed a preclinical model of oligo-metastatic melanoma to evaluate the role of stem-like CD8+ T-cells and the TDLN in the abscopal effect. This was done with unilateral tumor-directed RT with or without TDLN-directed RT. This was also done in the presence and absence of αPD-L1.

Results: Tumor-directed RT improved local tumor control and induced an abscopal response with a concomitant increase in tumor infiltrating tumor-specific stem-like CD8+T-cells. Tumor-specific stem-like CD8+T-cells were also observed in the TDLN of tumors on both sides. Importantly, the tumor-directed RT increased tumor-specific T-cell proliferation in the TDLNs bilaterally despite only being targeted at one tumor. Given this robust proliferative response and the high frequency of stem-like CD8+T-cells in the TDLN, we next evaluated the role of the TDLN in mediating the abscopal effect. We found that the abscopal effect is impaired if the TDLN is lymphocyte depleted with TDLN-directed RT in the presence or absence of αPD-L1. Additionally, the tumor-directed RT mediated increase in stem-like T-cells in the irradiated and unirradiated tumor was abrogated with TDLN-directed RT.

Conclusion: Our results demonstrate slowed distant tumor growth following irradiation of a local site and that this correlates with an increase in tumor-infiltrating stem-like CD8+T-cells which is reduced with TDLN-directed RT. These data suggest a critical role for both the stem-like CD8+T-cells and the TDLN in mediating the abscopal effect.

Citation Format: Zachary S. Buchwald, Tahseen H. Nasti, Christiane S. Eberhardt, Andreas Wieland, David Lawson, Walter Curran, Rafi Ahmed, Mohammad K. Khan. Tumor-draining lymph node irradiation reduces tumor-infiltrating stem-like CD8+T-cells and abrogates the abscopal effect [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 526.

Abstract 247: Identification of the GABAA receptor in melanoma brain metastases patient tumors and demonstration that it is a viable drug target using benzodiazepine-derivatives

Primary cutaneous melanoma is often successfully treated in early stages in patients with regional disease. While distant metastatic disease, including brain metastasis, that develops in most stage IV melanoma patients, carries a particularly poor prognosis with median overall survival of only 4-5 months. Standard-of-care treatment of brain metastases includes surgery, radiation, and chemotherapy. The fact that melanoma is a radio-resistant cancer, significantly limits treatment options for melanoma that has metastasized to the brain. There is clearly a significant demand for new therapeutic approaches. We have conducted a whole transcriptomic analysis of melanoma brain metastases to provide insight into molecular changes that may contribute to metastasis as well as to identify potential therapeutic targets in the metastasized cancer. Total RNA was extracted from 29 formalin-fixed paraffin-embedded (FFPE) melanoma brain metastatic samples, libraries constructed and enriched for transcript fragments with coding regions. Libraries were subjected to Transcriptome Capture (TCap) targeting 21,415 genes, which represents more than 98% of the total RefSeq exome. Sequencing was performed on the Illumina HiSeq platform. Gene expression analysis of melanoma brain metastatic samples reveals high expression levels of ion channels, including subunits of the ligand-gated neurotransmitter GABAA receptors. We will present differential expression analysis between recent melanoma transcriptomic studies [1, 2] and melanoma brain metastases samples. More than 20% of FDA approved drugs target ion channels. We report that repurposing of one such class of drugs targeting GABAA receptors can impair melanoma cell viability in vitro and reduce tumor volume in vivo. GABAA receptors can serve as a potential therapeutic target for treatment brain metastasis.

References 1. Akbani, et al. (The Cancer Genome Atlas Network, TCGA). Genome classification of cutaneous melanoma. Cell 2015; 161(7): 1681-1696. 2. Tirosh, et al. Dissecting the multicellular ecosystem of metastatic melanoma by single-cell RNA-seq. Science 2016; 352 (6282): 189-196.

Citation Format: Milota Kaluzova, Tahseen Nasti, Hiao-Rong Chen, Lindsey Lowder, Robert Press, Havi Rosen, Manali Rupji, Laura Kallay, Rikesh Patel, Andre Burnham, Maxwell Xu, Alexandra Ross, Havva Keskin, Erin Connelly, Benjamin Izar, Cory Adamson, Jeffrey Olson, Jing Su, Walter Curran, Ragini Kudchadkar, Matthew Schniederjan, Stewart Neill, David Lawson, Michael Chan, Jeanne Kowalski, Mohammad Khan, Daniel Pomeranz Krummel, Soma Sengupta. Identification of the GABAA receptor in melanoma brain metastases patient tumors and demonstration that it is a viable drug target using benzodiazepine-derivatives [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 247.

Abstract B176: Sequential immunotherapy and association with clinical outcomes in advanced-stage cancer patients

Background: There are now six approved immune checkpoint inhibitors for several different malignancies including melanoma, head and neck cancer, lung cancer, and renal cell carcinoma. Given the increased number of available immunotherapeutic agents, more patients are presenting in clinic as candidates for sequential immunotherapy. However, the efficacy of sequential immunotherapy in a trial setting is unknown. We investigated the association between prior treatment with immune checkpoint inhibitors and clinical outcomes in patients treated with subsequent immunotherapy in a phase 1 clinical trial. Methods: We conducted a retrospective review of 90 advanced stage cancer patients treated on immunotherapy-based phase 1 clinical trials at Winship Cancer Institute between 2009 and 2017. We included 49 patients with an immune checkpoint-indicated histology (melanoma, lung cancer, head and neck cancer, and bladder cancer). Patients were then analyzed based on whether they had received at least one immune checkpoint inhibitor prior to enrollment. Overall survival (OS) and progression-free survival (PFS) were calculated in months from immunotherapy initiation on trial to date of death and clinical or radiographic progression, respectively. Clinical benefit (CB) was defined as a best response of complete response (CR), partial response (PR), or stable disease (SD). Univariate analysis (UVA) and multivariate analysis (MVA) were carried out using Cox proportional hazard or logistic regression model. Covariates included age, presence of liver metastases, number of prior lines of systemic therapy, histology, and Royal Marsden Hospital (RMH) risk group. Results: The median age was 67 years and most patients (78%) were men. The most common histologies were melanoma (61%) and lung/head and neck cancers (37%). The majority (81%) of patients were RMH good risk. More than half of patients (n=27, 55%) had received at least one immune checkpoint inhibitor prior to trial enrollment: ten received anti-PD-1, two received anti-CTLA-4, five received anti-PD-1/CTLA-4 combination therapy, and ten received multiple immune checkpoint inhibitors. In MVA, patients who had not received a prior immune checkpoint inhibitor had significantly longer OS (HR: 0.22, CI: 0.07-0.70, p=0.010). These patients also trended towards longer PFS (HR: 0.86, CI: 0.39-1.87, p=0.699) and higher chance of CB (HR: 2.52, CI: 0.49-12.97, p=0.268). Immunotherapy-naïve patients had substantially longer OS (24.3 vs 10.9 months) and PFS (5.1 vs. 2.8 months) than patients who had prior immunotherapy per Kaplan-Meier estimation. Conclusion: Optimal treatment options for oncology patients who progress on immune checkpoint inhibitors are lacking. In this study, patients who received at least one prior immune checkpoint inhibitor had worse clinical outcomes on immunotherapy-based phase 1 clinical trials than immune checkpoint-naïve patients. This suggests that further development of immunotherapy combination therapies is needed to improve clinical outcomes of these patients. The results from this study should be validated in a larger, prospective study.

Citation Format: Mehmet Bilen, Dylan Martini, Yuan Liu, Colleen Lewis, Hannah Collins, Julie Shabto, Mehmet Akce, Haydn Kissick, Bradley Carthon, Walid Shaib, Olatunji Alese, Rathi Pillai, Conor Steuer, Christina Wu, David Lawson, Ragini Kudchadkar, Bassel El-Rayes, Viraj Master, Suresh Ramalingam, Taofeek Owonikoko, R. Donald Harvey. Sequential immunotherapy and association with clinical outcomes in advanced-stage cancer patients [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B176.

Inflammatory demyelinating polyneuropathy versus leptomeningeal disease following Ipilimumab

Background

Ipilimumab is an FDA-approved anti-CTLA-4 monoclonal antibody used in treatment of metastatic melanoma. We present an unusual neurological complication of Ipilimumab therapy and the diagnostic dilemma it caused.

Case presentation

A 42 year old male with Stage IV metastatic melanoma developed lower extremity weakness and sensory neuropathy following three doses of Ipilimumab. MRI of the lumbar spine was initially interpreted as diffuse leptomeningeal disease, and patient began Dexamethasone and radiation with improvement in symptoms. However, subsequent completion imaging revealed smooth nerve root involvement with sparing of the spinal cord, findings more compatible with inflammatory demyelinating polyneuropathy. The absence of malignant cells in the cerebrospinal fluid (CSF) and nerve conduction study (NCS) showing lumbar polyradiculoneuropathy with axonal involvement and demyelinating features supported the diagnosis of inflammatory demyelinating polyneuropathy. Later in the course of his disease, the patient developed frank leptomeningeal melanoma.

Conclusion

Ipilimumab immune-related toxicity presented as inflammatory demyelinating polyneuropathy, which was difficult to distinguish from leptomeningeal disease, a common complication of melanoma.

The Emergence of Stimulus Relations: Human and Computer Learning

Traditionally, investigations in the area of stimulus equivalence have employed humans as experimental participants. Recently, however, artificial neural network models (often referred to as connectionist models [CMs]) have been developed to simulate performances seen among human participants when training various types of stimulus relations. Two types of neural network models have shown particular promise in recent years. RELNET has demonstrated its capacity to approximate human acquisition of stimulus relations using simulated matching-to-sample (MTS) procedures (e.g., Lyddy & Barnes-Holmes Journal of Speech and Language Pathology and Applied Behavior Analysis, 2, 14-24, 2007). Other newly developed connectionist algorithms train stimulus relations by way of compound stimuli (e.g., Tovar & Chavez The Psychological Record, 62, 747-762, 2012; Vernucio & Debert The Psychological Record, 66, 439-449, 2016). What makes all of these CMs interesting to many behavioral researchers is their apparent ability to simulate the acquisition of diversified stimulus relations as an analogue to human learning; that is, neural networks learn over a series of training epochs such that these models become capable of deriving novel or untrained stimulus relations. With the goal of explaining these quickly evolving approaches to practical and experimental endeavors in behavior analysis, we offer an overview of existing CMs as they apply to behavior-analytic theory and practice. We provide a brief overview of derived stimulus relations as applied to human academic remediation, and we argue that human and simulated human investigations have symbiotic experimental potential. Additionally, we provide a working example of a neural network referred to as emergent virtual analytics (EVA). This model demonstrates a process by which artificial neural networks can be employed by behavior-analytic researchers to understand, simulate, and predict derived stimulus relations made by human participants.

Abstract 5001: High dose IL-2 (HDIL-2) results in increased PD-1 expression on CD45RA-CCR7-CD8+ and CD45RA-CCR7-CD4+ T cells in melanoma patients

Introduction: HDIL-2 is associated with long-term remissions in Stage IV melanoma in less than 10% of patients. We hypothesized that HDIL-2 alters the expression of PD-1 on T cell subsets in melanoma patients.

Methods: Samples were collected after written consent under an IRB approved protocol. Peripheral blood was collected at baseline and serially post-treatment at 24, 48, 72, and 96 hours from 6 patients with advanced stage melanoma undergoing HDIL-2. All patients were treatment naïve with regards to anti-PD-1 and anti-CTLA4 therapies. PBMCs were isolated and underwent intracellular cytokine and extracellular receptor staining. Co-signaling molecule expression was analyzed via flow cytometry. Statistical analysis was performed using paired t tests via Prism 6.0e software.

Results: HDIL-2 was associated with a preferential loss of effector memory (TEM; CD45RA-CCR7-) CD4+ and CD8+ T cells and a relative enrichment of naïve (CD45RA+CCR7+) CD4+ and CD8+ T cells in the blood during the first 3 days of treatment. On day 4, frequencies of CD4+ and CD8+ TEM had returned to baseline. Importantly, PD-1 expression was significantly increased on day 4 post-treatment on CD8+ TEM relative to baseline (22.1% +/- 13.2% on day 4 compared to 13.4% +/- 7.4% at baseline; p = 0.04). This finding was also true for CD4+ TEM (11.4% +/- 6.1% on day 4 compared to 6.1% +/- 3.7% at baseline, p = 0.04). PD-1 expression was not statistically different within the other CD4+ and CD8+ memory T cell subsets including: naïve, central memory (CD45RA-CCR7+), or TEMRA (CD45RA+CCR7-) lymphocytes.

Conclusion: These results demonstrate that HDIL-2 is associated with an increase in expression of PD-1 on TEM cells in patients with advanced melanoma suggesting a possible mechanism contributing to the limited efficacy of HDIL-2 in most patients. It is known that TEM cells function by migrating to peripheral tissues, and that CD8+ TEM cells are found specifically in metastatic melanoma lesions. Importantly, our findings illustrate a potential synergistic effect between HDIL-2 and PD-1 blockade. Upregulation of PD-1 and the chronologic pattern in which its expression changes under the effects of HDIL-2 provide a mechanistic rationale for testing the combination of HDIL-2 and anti-PD-1 therapy in patients with advanced melanoma.

Citation Format: Maggie L. Diller, Susan Maio, Cabell E. Eysmans, David Lawson, Keith A. Delman, Ragini R. Kudchadkar, Mandy L. Ford. High dose IL-2 (HDIL-2) results in increased PD-1 expression on CD45RA-CCR7-CD8+ and CD45RA-CCR7-CD4+ T cells in melanoma patients. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5001. doi:10.1158/1538-7445.AM2015-5001

Gene expression profiling for molecular staging of cutaneous melanoma in patients undergoing sentinel lymph node biopsy

BACKGROUND

A gene expression profile (GEP) test able to accurately identify risk of metastasis for patients with cutaneous melanoma has been clinically validated.

OBJECTIVE

We aimed for assessment of the prognostic accuracy of GEP and sentinel lymph node biopsy (SLNB) tests, independently and in combination, in a multicenter cohort of 217 patients.

METHODS

Reverse transcription polymerase chain reaction (RT-PCR) was performed to assess the expression of 31 genes from primary melanoma tumors, and SLNB outcome was determined from clinical data. Prognostic accuracy of each test was determined using Kaplan-Meier and Cox regression analysis of disease-free, distant metastasis-free, and overall survivals.

RESULTS

GEP outcome was a more significant and better predictor of each end point in univariate and multivariate regression analysis, compared with SLNB (P < .0001 for all). In combination with SLNB, GEP improved prognostication. For patients with a GEP high-risk outcome and a negative SLNB result, Kaplan-Meier 5-year disease-free, distant metastasis-free, and overall survivals were 35%, 49%, and 54%, respectively.

LIMITATIONS

Within the SLNB-negative cohort of patients, overall risk of metastatic events was higher (∼30%) than commonly found in the general population of patients with melanoma.

CONCLUSIONS

In this study cohort, GEP was an objective tool that accurately predicted metastatic risk in SLNB-eligible patients.

Ipilimumab administration for advanced melanoma in patients with pre-existing Hepatitis B or C infection: a multicenter, retrospective case series

Ipilimumab is a fully human, monoclonal antibody directed against Cytotoxic T Lymphocyte Antigen-4 (CTLA-4) that has demonstrated a survival benefit and durable disease control in patients with advanced melanoma. Ipilimumab is associated with potentially serious immune-related adverse events, including autoimmune hepatitis. Because clinical trials of ipilimumab excluded patients with pre-existing hepatitis B or C infection, there is a paucity of data on the safety of ipilimumab administration to that patient population. Here, we report the largest case series to date of patients with hepatitis B or C who received ipilimumab for advanced melanoma. Two of the nine patients described in this case series experienced fluctuations in their liver function tests (LFTs) and were subsequently treated with corticosteroids. Although this is a small series, the rate of hepatotoxicity appears similar to what has been seen in the general population treated with ipilimumab, and the ability to administer ipilimumab did not appear to be affected by concomitant hepatitis B or C infection. The use of ipilimumab in patients with metastatic melanoma who have pre-existing hepatitis can be considered among other therapeutic options.

Engineered fusokine GIFT4 licenses the ability of B cells to trigger a tumoricidal T-cell response

Engineered chimeric cytokines can generate gain-of-function activity in immune cells. Here, we report potent antitumor activity for a novel fusion cytokine generated by N-terminal coupling of GM-CSF to IL4, generating a fusokine termed GIFT4. B cells treated with GIFT4 clustered GM-CSF and IL4 receptors on the cell surface and displayed a pan-STAT hyperphosphorylation associated with acquisition of a distinct phenotype and function described to date. In C57BL/6J mice, administration of GIFT4 expanded endogenous B cells and suppressed the growth of B16F0 melanoma cells. Furthermore, B16F0 melanoma cells engineered to secrete GIFT4 were rejected immunologically in a B-cell-dependent manner. This effect was abolished when GIFT4-expressing B16F0 cells were implanted in B-cell-deficient mice, confirming a B-cell-dependent antitumor effect. Human GIFT4-licensed B cells primed cytotoxic T cells and specifically killed melanoma cells in vitro and in vivo. Taken together, our results demonstrated that GIFT4 could mediate expansion of B cells with potent antigen-specific effector function. GIFT4 may offer a novel immunotherapeutic tool and define a previously unrecognized potential for B cells in melanoma immunotherapy.

Effects of a complex housing environment on heart rate and blood pressure of rats at rest and after stressful challenges

Housing enrichment for rodents continues to be a discussion topic within the animal care community. The objective of this study was to determine the extent to which a complex housing environment affects heart rate, blood pressure, and activity of rats when undisturbed and after exposure to stressful challenges and whether autonomic controls of heart rate would be affected. Male and female Sprague-Dawley and Wistar rats with radiotelemetry transmitters were evaluated under nonenriched single-housing conditions and after acclimation to a complex environment of dim light and cohabitation with 3 conspecifics in large cages with hiding, food foraging, and nesting items. Telemetry data were collected when rats were undisturbed, after acute challenges (cage change, intraperitoneal injections, restraint), during a forced running protocol, and after cholinergic or adrenergic blockade. The complex environment reduced heart rate and increased activity in undisturbed rats but did not affect blood pressure. Heart rate responses to challenges were unaffected, decreased, or increased by complex housing, depending on the stock and sex of rats. Forced running was either unaffected or decreased, depending on the stock and sex of rats. Heart rate responses to cholinergic or β1-adrenergic blockade were not affected. We conclude that the complex housing did not reduce indices of stress (for example, heart rate) as compared with simpler housing. However, the possibility that some environmental elements interact negatively with each other must be considered in future studies.

The Society for Immunotherapy of Cancer consensus statement on tumour immunotherapy for the treatment of cutaneous melanoma

Immunotherapy is associated with durable clinical benefit in patients with melanoma. The goal of this article is to provide evidence-based consensus recommendations for the use of immunotherapy in the clinical management of patients with high-risk and advanced-stage melanoma in the USA. To achieve this goal, the Society for Immunotherapy of Cancer sponsored a panel of melanoma experts--including physicians, nurses, and patient advocates--to develop a consensus for the clinical application of tumour immunotherapy for patients with melanoma. The Institute of Medicine clinical practice guidelines were used as a basis for this consensus development. A systematic literature search was performed for high-impact studies in English between 1992 and 2012 and was supplemented as appropriate by the panel. This consensus report focuses on issues related to patient selection, toxicity management, clinical end points and sequencing or combination of therapy. The literature review and consensus panel voting and discussion were used to generate recommendations for the use of immunotherapy in patients with melanoma, and to assess and rate the strength of the supporting evidence. From the peer-reviewed literature the consensus panel identified a role for interferon-α2b, pegylated-interferon-α2b, interleukin-2 (IL-2) and ipilimumab in the clinical management of melanoma. Expert recommendations for how to incorporate these agents into the therapeutic approach to melanoma are provided in this consensus statement. Tumour immunotherapy is a useful therapeutic strategy in the management of patients with melanoma and evidence-based consensus recommendations for clinical integration are provided and will be updated as warranted.

Fatty aldehydes in cyanobacteria are a metabolically flexible precursor for a diversity of biofuel products

We describe how pathway engineering can be used to convert a single intermediate derived from lipid biosynthesis, fatty aldehydes, into a variety of biofuel precursors including alkanes, free fatty acids and wax esters. In cyanobacteria, long-chain acyl-ACPs can be reduced to fatty aldehydes, and then decarbonylated to alkanes. We discovered a cyanobacteria class-3 aldehyde-dehydrogenase, AldE, that was necessary and sufficient to instead oxidize fatty aldehyde precursors into fatty acids. Overexpression of enzymes in this pathway resulted in production of 50 to 100 fold more fatty acids than alkanes, and the fatty acids were secreted from the cell. Co-expression of acyl-ACP reductase, an alcohol-dehydrogenase and a wax-ester-synthase resulted in a third fate for fatty aldehydes: conversion to wax esters, which accumulated as intracellular lipid bodies. Conversion of acyl-ACP to fatty acids using endogenous cyanobacterial enzymes may allow biofuel production without transgenesis.

Spontaneous extradural aerocele following cardiopulmonary resuscitation - an unrecognised complication

We present a case report of a 61-year-old gentleman who had a cardiac arrest and was delivered cardiopulmonary resuscitation (CPR) by a bystander. After resuscitation, he regained cardiac output and was breathing spontaneously. CT scan of the head showed spontaneous right frontal extradural aerocele with fracture of the posterior wall of the frontal sinus with no sign of head injury. We discuss the pathophysiology of this unrecognised complication due to CPR.

Laboratory based experiments to assess the use of green and food based compost to improve water quality in a Sustainable Drainage (SUDS) device such as a swale

Many tonnes of compost are generated per year due to door step composting of both garden and kitchen waste. Whilst there are commercial outlets for the finer grade of compost (<10mm) in plant nurseries, there is little demand for the coarser material (>25 mm). This paper reports part of a WRAP-sponsored (Waste Resources Action Programme) study which investigated the potential for green (GC) and mixed green and food (MC) composts to be incorporated into Sustainable Drainage (SUDS) devices such as swales, and replace the topsoil (TS) onto which turf is laid or grass seed distributed. However, it is not known whether compost can replace TS in terms of pollutant remediation, both the trapping of polluted particulates and in dealing with hydrocarbons such as oil, but also from a biofilm development and activity perspective. Using laboratory based experiments utilising leaching columns and an investigation of microbiological development in the composts studied, it was found that many of the differences in performance between MC and GC were insignificant, whilst both composts performed better in terms of pollutant retention than TS. Mixed compost in particular could be used in devices where there may be oil spillages, such as the lorry park of a Motorway Service Area due to its efficiency in degrading oil. Samples of GC and MC were found to contain many of the bacteria and fungi necessary for an active and efficient biofilm which would be an argument in their favour for replacement of TS and incorporation in swales.

The Use of Preventive Strategies for Bone Loss

Osteoporosis is a worldwide problem that is increasing significantly as the global population both increases and ages. While osteoporosis has been extensively studied in recent years, the utilization of traditional Chinese medicine (TCM) for the diagnosis, prevention and treatment of this condition has seldom been examined. This paper examines the theories and the literature that relate to diagnosis, prevention and treatment of bone loss at the time of menopause according to the principles of TCM. It also considers practical developments in these areas as illustrated by the authors' research findings in recent studies. TCM diagnosis attributes a number of different underlying patterns to menopausal bone loss. A very common pattern in this situation is a Kidney qi and yin deficiency pattern. TCM analysis can be used as an early determinant of those persons who are potentially at risk of bone loss. Acupuncture, herbal medicine and Tai Ji exercise can then be applied to prevent and treat osteoporosis. These treatments can be effective, if they are applied correctly. The therapies may also be used in the treatment and prevention of osteoporosis, as well as the general maintenance of women's health during menopause.