Surveillance imaging with FDG-PET/CT in the post-operative follow-up of stage 3 melanoma

Background

As early detection of recurrent melanoma maximizes treatment options, patients usually undergo post-operative imaging surveillance, increasingly with FDG-PET/CT (PET). To assess this, we evaluated stage 3 melanoma patients who underwent prospectively applied and sub-stage-specific schedules of PET surveillance.

Patients and methods

From 2009, patients with stage 3 melanoma routinely underwent PET +/- MRI brain scans via defined schedules based on sub-stage-specific relapse probabilities. Data were collected regarding patient characteristics and outcomes. Contingency analyses were carried out of imaging outcomes.

Results

One hundred and seventy patients (stage 3A: 34; 3B: 93; 3C: 43) underwent radiological surveillance. Relapses were identified in 65 (38%) patients, of which 45 (69%) were asymptomatic. False-positive imaging findings occurred in 7%, and 6% had treatable second (non-melanoma) malignancies. Positive predictive values (PPV) of individual scans were 56%-83%. Negative scans had predictive values of 89%-96% for true non-recurrence [negative predictive values (NPV)] until the next scan. A negative PET at 18 months had NPVs of 80%-84% for true non-recurrence at any time in the 47-month (median) follow-up period. Sensitivity and specificity of the overall approach of sub-stage-specific PET surveillance were 70% and 87%, respectively. Of relapsed patients, 33 (52%) underwent potentially curative resection and 10 (16%) remained disease-free after 24 months (median).

Conclusions

Application of sub-stage-specific PET in stage 3 melanoma enables asymptomatic detection of most recurrences, has high NPVs that may provide patient reassurance, and is associated with a high rate of detection of resectable and potentially curable disease at relapse.

Impact of Tumour Hypoxia on Evofosfamide Sensitivity in Head and Neck Squamous Cell Carcinoma Patient-Derived Xenograft Models

Tumour hypoxia is a marker of poor prognosis and failure of chemoradiotherapy in head and neck squamous cell carcinoma (HNSCC), providing a strategy for therapeutic intervention in this setting. To evaluate the utility of the hypoxia-activated prodrug evofosfamide (TH-302) in HNSCC, we established ten early passage patient-derived xenograft (PDX) models of HNSCC that were characterised by their histopathology, hypoxia status, gene expression, and sensitivity to evofosfamide. All PDX models closely resembled the histology of the patient tumours they were derived from. Pimonidazole-positive tumour hypoxic fractions ranged from 1.7-7.9% in line with reported HNSCC clinical values, while mRNA expression of the Toustrup hypoxia gene signature showed close correlations between PDX and matched patient tumours, together suggesting the PDX models may accurately model clinical tumour hypoxia. Evofosfamide as a single agent (50 mg/kg IP, qd × 5 for three weeks) demonstrated antitumour efficacy that was variable across the PDX models, ranging from complete regressions in one p16-positive PDX model to lack of significant activity in the three most resistant models. Despite all PDX models showing evidence of tumour hypoxia, and hypoxia being essential for activation of evofosfamide, the antitumour activity of evofosfamide only weakly correlated with tumour hypoxia status determined by pimonidazole immunohistochemistry. Other candidate evofosfamide sensitivity genes-MKI67, POR, and SLFN11-did not strongly influence evofosfamide sensitivity in univariate analyses, although a weak significant relationship with MKI67 was observed, while SLFN11 expression was lost in PDX tumours. Overall, these data confirm that evofosfamide has antitumour activity in clinically-relevant PDX tumour models of HNSCC and support further clinical evaluation of this drug in HNSCC patients. Further research is required to identify those factors that, alongside hypoxia, can influence sensitivity to evofosfamide and could act as predictive biomarkers to support its use in precision medicine therapy of HNSCC.

Evofosfamide for the treatment of human papillomavirus-negative head and neck squamous cell carcinoma

Evofosfamide (TH-302) is a clinical-stage hypoxia-activated prodrug of a DNA-crosslinking nitrogen mustard that has potential utility for human papillomavirus (HPV) negative head and neck squamous cell carcinoma (HNSCC), in which tumor hypoxia limits treatment outcome. We report the preclinical efficacy, target engagement, preliminary predictive biomarkers and initial clinical activity of evofosfamide for HPV-negative HNSCC. Evofosfamide was assessed in 22 genomically characterized cell lines and 7 cell line-derived xenograft (CDX), patient-derived xenograft (PDX), orthotopic, and syngeneic tumor models. Biomarker analysis used RNA sequencing, whole-exome sequencing, and whole-genome CRISPR knockout screens. Five advanced/metastatic HNSCC patients received evofosfamide monotherapy (480 mg/m2 qw × 3 each month) in a phase 2 study. Evofosfamide was potent and highly selective for hypoxic HNSCC cells. Proliferative rate was a predominant evofosfamide sensitivity determinant and a proliferation metagene correlated with activity in CDX models. Evofosfamide showed efficacy as monotherapy and with radiotherapy in PDX models, augmented CTLA-4 blockade in syngeneic tumors, and reduced hypoxia in nodes disseminated from an orthotopic model. Of 5 advanced HNSCC patients treated with evofosfamide, 2 showed partial responses while 3 had stable disease. In conclusion, evofosfamide shows promising efficacy in aggressive HPV-negative HNSCC, with predictive biomarkers in development to support further clinical evaluation in this indication.

Abstract 169: Preclinical efficacy and sensitivity determinants of evofosfamide in molecularly defined models of head and neck squamous cell carcinoma

Tumor hypoxia is prevalent in head and neck squamous cell carcinoma (HNSCC), where it limits radiotherapy outcomes. Hypoxia-activated prodrugs (HAPs) have been developed to target hypoxic regions of tumors. These agents undergo oxygen-sensitive reductive activation, thereby delivering cytotoxic species within hypoxic cells. This study investigated the efficacy and sensitivity determinants of the clinical-stage HAP evofosfamide (TH-302) using molecularly-characterized models of HNSCC. We deployed a collection of 27 HPV-negative HNSCC cell lines derived from lesions of varying TNM stages and primary, nodal or recurrent sites. The collection was characterized for gene expression by RNA-seq, from which somatic variants were also called. Their transcriptomic features were investigated in the context of pan-cancer TCGA data by hierarchical clustering. The potency and hypoxic selectivity of 3 HAPs - evofosfamide, PR-104A and SN30000 - were assessed by antiproliferative assay in 22 lines and compared to bromo-isophosphoramide mustard (Br-IPM), cisplatin and 5-FU. The antitumor activity of evofosfamide (50 mg/kg qdx5 for 2-3 cycles with or without a single 10 Gy dose of radiation on day 5 of cycle 1) was evaluated in HNSCC xenografts in addition to a PDX isolated from an SCC of the glottic larynx. The hypoxic fraction at baseline and after 5 days of treatment was quantified by pimonidazole staining. Genetic modifiers of sensitivity to evofosfamide and its cytotoxic metabolite Br-IPM were explored through whole-genome CRISPR-Cas9 screens using the GeCKO v2 library. High-throughput screens with a custom shRNA pool were performed in one HNSCC and two pancreatic ductal adenocarcinoma cell lines to identify reductases responsible for the activation of evofosfamide in hypoxic cells. Evofosfamide was more potent and more selective for hypoxic HNSCC cells in vitro than PR-104A or SN30000. Cell line sensitivity to evofosfamide was correlated with Br-IPM and cisplatin but not with PR-104A, SN30000 or 5-FU, indicating distinct sensitivity determinants. Evidence of antitumor activity with evofosfamide was observed in vivo. CRISPR screens identified potential evofosfamide sensitivity genes that were reproducibly enriched following drug exposure. Reductase-focused RNA interference screens defined a cluster of sensitivity genes that mapped to mitochondrial electron transport, whereas shRNA’s targeted against presumed activating enzymes such as POR were not enriched. Concentration-dependent oxidation of cytochrome a and decreased respiration was observed in cells exposed to evofosfamide, suggesting reduction by mitochondrial complexes. This study provides a rationale for the clinical evaluation of evofosfamide with radiotherapy in genetically defined subsets of HNSCC patients.

Citation Format: Francis W. Hunter, Avik Shome, Dan Li, Way W. Wong, Peter Tsai, Nooriyah Poonawala, Purvi M. Kakadiya, Troy M. Ketelä, Maria K. Kondratyev, Courtney R. Lynch, Tet-Woo Lee, Khanh B. Tran, Jules B. Devaux, Rachel Zussman, Cho R. Hong, Dennis Kee, Andrew M. Macann, Anthony J. Hickey, Stefan K. Bohlander, Cristin G. Print, William R. Wilson, Bradly G. Wouters, Stephen M. Jamieson. Preclinical efficacy and sensitivity determinants of evofosfamide in molecularly defined models of head and neck squamous cell carcinoma [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 169. doi:10.1158/1538-7445.AM2017-169

EZN-2968, a novel hypoxia-inducible factor-1α (HIF-1α) messenger ribonucleic acid (mRNA) antagonist: Results of a phase I, pharmacokinetic (PK), dose-escalation study of daily administration in patients (pts) with advanced malignancies

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Background: HIF-1 is a transcription factor that regulates expression of many key genes, notably those switching cell metabolism to anaerobic glycolysis and inducing neovascularization in response to hypoxia. Increased HIF-1α levels are associated with poor prognosis in several neoplasms. EZN-2968 is a potent locked nucleic acid antisense oligonucleotide suppressing HIF-1α mRNA translation in vitro (IC50 ∼1–5 nM). Methods: This study was designed to determine the safety, tolerability, PK, maximum tolerated dose, recommended dose, and preliminary evidence of antitumor activity of EZN-2968. Pts with advanced malignancies were treated with EZN-2968 administered as a daily 2-hr IV infusion x 5 days every 4 weeks using a 3+3 dose-escalating design. Dose escalation was based on toxicities observed during Cycle 1. Results: 19 pts (11 men; median age = 60 y [47–79 y]) were treated with EZN-2968 doses of 0.5 (3 pts), 0.8 (3 pts), 1.2 (3 pts), 1.8 (4 pts), 2.7 (3 pts), and 4.1 (3 pts) mg/kg/day. Tumor types included colorectal cancer (7 pts); renal cancer (4 pts); soft-tissue sarcoma (STS; 2 pts); angiosarcoma (1 pt); melanoma (1 pt); and breast, ovarian, pancreatic, and prostate cancers (1 pt each). No dose-limiting toxicities were observed. The most common adverse events (Aes) were vomiting (32%); fatigue (26%); and anemia, diarrhea, nausea, and tumor pain (each 21%). Most Aes were Grade 1 or 2. Plasma PK for Day 1 is tabulated below. Stable disease was observed for 1 pt with angiosarcoma (28 wks) and 1 pt with renal cancer (12 wks). Conclusions: EZN-2968 was well tolerated in previously treated pts with advanced malignancies. PK data do not show accumulation of EZN-2968. Dose escalation is ongoing; final results will be presented at the meeting. Durable stable disease has been observed.

[Table: see text]

[Table: see text]

LUBA: an assessment technique for postural loading on the upper body based on joint motion discomfort and maximum holding time

This paper presents a technique for postural loading on the upper body assessment (LUBA). The proposed method is based on the new experimental data for composite index of perceived discomfort (ratio values) for a set of joint motions, including the hand, arm, neck and back, and the corresponding maximum holding times in static postures. Twenty male subjects participated in the experiment designed to measure perceived joint discomforts. The free modulus technique of the magnitude estimation method was employed to obtain subjects' discomforts for varying joint motions. The developed postural classification scheme was based on the angular deviation levels from the neutral position for each joint motion. These were divided into groups with the same degree of discomforts based on the statistical analysis. Each group was assigned a numerical discomfort score relative to the perceived discomfort value of elbow flexion, which exhibited the lowest level among all joint motions investigated in this study, and, therefore, was set as a reference point. The criteria for evaluating stresses of working postures were proposed based on the four distinct action categories, in order to enable practitioners to apply appropriate corrective actions. The proposed scheme can be used for evaluating and redesigning static working postures in industry.

The boundaries for joint angles of isocomfort for sitting and standing males based on perceived comfort of static joint postures

This study presents data for the joint angles of isocomfort (JAI) in sitting and standing males based on perceived comfort ratings for static joint postures maintained for 60 s. The JAI value was defined as a boundary indicating joint deviation (an angle) from neutral posture, within which the perceived comfort for different body joint postures is expected to be the same. An experiment for quantifying perceived comfort ratings was conducted using the free modulus method of magnitude estimation. Based on experimental results, regression equations were derived for each joint posture, to represent the relationships between different levels of joint deviation/joint posture and corresponding normalized comfort scores. The JAI values were developed for nine verbal categories of joint comfort. The JAIs with the marginal comfort levels, one of the nine verbal categories used, for most joint postures around the wrist, elbow, neck and ankle were similar to the maximum range of motion (ROM) values for these joints. However, the JAIs with the marginal comfort category for back and hip postures were much smaller than the maximum ROM values for these joints. There were no significant differences in JAI expressed in terms of the percentage of the corresponding maximum ROM values between sitting and standing postures. The relative 'marginal comfort index', defined as the percentage of JAIs for the marginal comfort relative to the corresponding maximum ROM values, for the hip was the smallest among all joints. This was followed, in an increasing order of the marginal comfort index, by the lower back and shoulder, while the marginal comfort index for the elbow joint was the largest. The results of this study suggest that static postures maintained for 60 s cause greater discomfort for the hip joint than for the other joints studied, and less discomfort for the elbow than for the other joints. The data about JAIs can be used as guidelines for enhancing postural comfort when designing a variety of human-machine tasks where static postures cannot be eliminated.

Comparison of prediction models for the compression force on the lumbosacral disc

The main objective of this research was to compare three representative methods of predicting the compressive forces on the lumbosacral disc: LP-based model, double LP-based model, and EMG-assisted model. Two subjects simulated lifting tasks that are frequently performed in the refractories industry of Korea, in which vertical and lateral distances, and weight of load were varied. To calculate the L5/S1 compressive forces, EMG signals from six trunk muscles were measured, and postural data and locations of load were recorded using the Motion Analysis System. The EMG-assisted model was shown to reflect well all three factors considered here, whereas the compressive forces from the two LP-based models were only significantly affected by weight of load. In addition, low lifting index (LI) values were observed for relatively high L5/S1 compressive forces from the EMG-assisted model, suggesting that the 1991 NIOSH lifting equations may not fully evaluate the risk of dynamic asymmetric lifting tasks.

Adaptive rate pacing controlled by the right ventricular preejection interval: clinical experience with a physiological pacing system

In the Precept pacing system, the right ventricular intracardiac impedance waveform is used to evaluate either of two indicators of metabolic demand relative right ventricular stroke volume and preejection interval (PEI). PEI is known to reliably parallel contractility changes, which is reflective of physical and emotional stress. The stability and dynamic behavior of PEI were tested in ten patients with a Precept pacing system under various forms of exercise and during postural changes. Although significant patient-to-patient variability of the sensor values was observed, reflecting individual physiological differences, the chronic stability of PEI was excellent in the total device experience of 147 months. In all patients, PEI shortened significantly during bicycle ergometry from a mean value of 137.7 +/- 17.8 (range 96-162) to a mean value of 103.0 +/- 21.6 (range 92-109) (P less than 0.05). Low level bicycle exercise of short duration resulted in a prompt decrease in PEI and increase in pacing rate in all patients. There were no uniform postural responses overall, although some posture related rate changes were observed in two patients. We conclude that the first generation of a PEI based pacing system holds promise for adaptive rate pacing.