A Nationwide Evaluation of Bevacizumab-based Treatments in Paediatric Low-Grade Glioma in the UK: Safety. Efficacy, Visual Morbidity and Outcomes

BACKGROUND

Bevacizumab is increasingly used in children with Paediatric Low-Grade Glioma (PLGG) despite limited evidence. A nationwide UK service evaluation was conducted to provide larger cohort 'real life' safety and efficacy data including functional visual outcomes.

METHODS

Children receiving Bevacizumab-based treatments (BBT) for PLGG (2009-2020) from 11 centres were included. Standardised neuro-radiological (RANO-LGG) and visual (logMAR visual acuity) criteria were used to assess clinical-radiological correlation, survival outcomes and multivariate prognostic analysis.

RESULTS

Eighty-eight children with PLGG received BBT either as 3 rd line with Irinotecan (85%) or alongside 1 st/2 nd line chemotherapies (15%). Toxicity was limited and minimal. Partial response (PR, 40%), stable disease (SD, 49%), and progressive disease (PD, 11%) were seen during BBT. However, 65% progressed at 8 months (median) from BBT cessation, leading to a radiology-based 3yr-progression-free survival (PFS) of 29%. Diencephalic syndrome (p= 0.03) was associated with adverse PFS. Pre-existing visual morbidity included unilateral (25%) or bilateral (11%) blindness. Improvement (29%) or stabilisation (49%) of visual acuity were achieved, more often in patients' best eyes. Vision deteriorated during BBT in 14 (22%), with 3-year visual-PFS of 53%; more often in patients' worst eyes. A superior visual outcome (p=0.023) was seen in Neurofibromatosis type 1-associated Optic Pathway Glioma (OPG). Concordance between visual and radiological responses was 36%; optimised to 48% using only best eye responses.

CONCLUSIONS

BBTs provide effective short-term PLGG control and delay further progression, with a better sustained visual (best >worst eye) than radiological response. Further research could optimise the role of BBTs towards a potentially sight-saving strategy in OPG.

LGG-09. A Nationwide Service Evaluation of Safety, Radiologic and Visual Outcome Refining Bevacizumab-based Treatments in Children with Progressive Low-Grade Glioma

INTRODUCTION: Bevacizumab/Irinotecan is currently 3rd-line treatment in the UK for progressive Paediatric Low-Grade Glioma (PLGG) based on limited evidence. A nationwide service evaluation was conducted to review its safety and efficacy amongst a larger cohort.

METHODS: Data from children with PLGG receiving Bevacizumab-based Treatments (BBT) from 11 UK Centres (2009-2020) were reviewed. Radiological and visual outcomes were based on standardized measurements. Clinical-radiological correlation was investigated. Time to progression from BBT stop, progression free-survival (PFS) curves and multivariate analysis of prognostic factors (p 0.05) were performed.

RESULTS: 88 children with PLGG (88% OPG, 24% NF1) had BBT for radiological (43%), visual (20%) or combined (27%) progression, after 40 months (median) from diagnosis. Amongst OPG cases, visual acuity (VA) per eye (better/worse) before BBT was logMAR 0.0-0.3 (23/7) 0.3 - 1.0 (27/20), > 1.0 (14/18) and LP/NLP (8/27), with 19/8 children respectively blind (LP/NLP) in one or both eyes. Bevacizumab 10 mg/kg every 14 days (median 24 doses) was given as 3rd line+ with Irinotecan (85%) or alongside 1st/2nd line chemo (15%) leading to remarkable radiological (88%) and visual (74%) responses (stable or improved) within 3-6 months, with limited toxicity. 12% progressed on treatment, and 8% died unrelated to BBT. After initial response 65% progressed at a median of 8 months (4 - 23) after BBT, resulting in 3-year-all-causes-PFS of 16% and 3-yr-visual-PFS of 45% from start of BBT. Visual concordance with MRI was poor (36%) but increases (47%) when better-eye determines visual outcome. Lack of NF1 and diencephalic syndrome (DS) at presentation were independent negative prognostic factors for PFS.

CONCLUSIONS: A remarkable but transient effect of BBT has been confirmed. Visual > radiological responses can be sustained after BBT. Variations in current BBT strategies justifies further research, including the potential upfront use alongside conventional first-line chemotherapy as sight-saving strategy.

EXTH-46. ARTIFICIAL INTELLIGENCE-BASED IDENTIFICATION OF COMBINED VANDETANIB AND EVEROLIMUS IN THE TREATMENT OF ACVR1-MUTANT DIFFUSE INTRINSIC PONTINE GLIOMA

Somatic mutations in ACVR1, encoding the serine/threonine kinase ALK2 receptor, are found in a quarter of children with the currently incurable brain tumour diffuse intrinsic pontine glioma (DIPG). Treatment of ACVR1-mutant DIPG patient-derived models with multiple inhibitor chemotypes leads to a reduction in cell viability in vitro and extended survival in orthotopic xenografts in vivo, though there are currently no specific ACVR1 inhibitors licensed for DIPG. Using an Artificial Intelligence-based platform to search for approved compounds which could be used to treat ACVR1-mutant DIPG, the combination of vandetanib and everolimus was identified as a possible therapeutic approach. Vandetanib, an approved inhibitor of VEGFR/RET/EGFR, was found to target ACVR1 (Kd=150nM) and reduce DIPG cell viability in vitro, but has been trialed in DIPG patients with limited success, in part due to an inability to cross the blood-brain-barrier. In addition to mTOR, everolimus inhibits both ABCG2 (BCRP) and ABCB1 (P-gp) transporter, and was synergistic in DIPG cells when combined with vandetanib in vitro. This combination is well-tolerated in vivo, and significantly extended survival and reduced tumour burden in an orthotopic ACVR1-mutant patient-derived DIPG xenograft model. Based on these preclinical data, three patients with ACVR1-mutant DIPG were treated with vandetanib and everolimus. These cases may inform on the dosing and the toxicity profile of this combination for future clinical studies. This bench-to-bedside approach represents a rapidly translatable therapeutic strategy in children with ACVR1 mutant DIPG.

Evaluating vehicle inspection/maintenance programs using on-road emissions data. The Atlanta Reference Method

On-road remote sensing data is an increasingly popular source of evaluation information for vehicle inspection/maintenance (I/M) programs. This article conducts one such remote sensing data evaluation for the Atlanta, Georgia, I/M program. The reference method involves comparing emissions differences in I/M and non-I/M fleet vehicles with those predicted by a regulatory computer model. Assuming that on-road emissions differences represent observed effectiveness and model-predicted emissions differences represent effectiveness goals, the Atlanta enhanced I/M program appears to be achieving 83% of its targeted emissions reductions. The method compares favorably with other remote sensing evaluation methods in its ability to be applied over time and its relatively small sample size requirement. The chief limitation to the approach is its reliance on a representative non-I/M fleet, which may differ in characteristics for which controls are difficult to locate. Such potential confounding factors include discrepancies in maintenance trends, socioeconomic conditions, and vehicle quality.

A plasmid vector for isolation of strong promoters in Escherichia coli

In order to isolate very strong promoters from bacteria and bacteriophage a plasmid named pProm was constructed. It possesses an origin (ORI) for replication in Gram-negative bacteria, an ORI for replication in Gram-positive bacteria, a promoterless ampicillin resistance gene with a multiple cloning site (MCS) in the position formerly occupied by the ampicillin promoter, a tetracycline resistance gene for selection in Gram-negative bacteria and a chloramphenicol resistance gene for selection in Gram-positive bacteria. Insertion in the MCS of DNA fragments of Staphylococcus aureus bacteriophages resulted in isolation of several clones very resistant to ampicillin. The DNA fragments inserted in these recombinant plasmids were sequenced and all of them contained putative promoter motifs. Direct measurement of the penicillinase activity indicated that one of the isolated promoters could be included within a group of the stronger known prokaryotic promoters. According to these results pProm is a powerful tool to perform studies on promoter strength and for industrial applications.

Specialists achieve better outcomes than generalists for lung cancer surgery

OBJECTIVE

A push toward care provided by generalists as opposed to specialists has occurred in the health-care marketplace despite a lack of provider specific outcome data. The objective of this study was to determine whether the outcome of patients undergoing lung cancer surgery is different between general surgeons (GSs) and thoracic surgeons (TSs).

DESIGN

Examination of data from a state-wide severity-adjusted administrative hospital discharge database.

SETTING/PARTICIPANTS

Patients undergoing lung cancer resection in all nonfederal acute care hospitals within South Carolina.

MAIN OUTCOME MEASURES

Mortality by specialty adjusted for case mix.

RESULTS

From 1991 to 1995, 1,720 resections for lung cancer were performed in South Carolina. One hundred thirty-seven cases were excluded because surgeons did not meet the predefined criteria for board certification, leaving 1,583 resections for analysis. One-half of lobectomies and nearly 60% of pneumonectomies were performed by GSs. Patients were similar in age, sex, gender, race, and the proportion in each severity of illness subclass. Mortality was significantly higher in patients who underwent lobectomy by GSs vs TSs (5.3% vs 3.0%; p<0.05) and in patients with extreme comorbidities (43.6% vs 25.4%; p=0.03) or age >65 years (7.4% vs 3.5%; p<0.05). Seventy percent of TSs performed > 10 cases in the series, whereas 75% of GSs performed <10 (p=0.05). Logistic regression analysis failed to identify any significant variable that might explain the mortality differences between TSs and GSs.

CONCLUSION

Mortality is lower for lung cancer resection when the surgery is performed by a TS.

Evidence of genetic heterogeneity in a BALB/c mouse colony as determined by DNA fingerprinting

A genetic monitoring of the BALB/c mouse foundation colony in our animal facility was carried out. The techniques of choice were skin grafting, coat colour test, flow cytometric analysis for H2 antigens (loci H2-D and H2-A), electrophoretic analysis of isoenzymes (loci Idh1, Pep3, Es3 and Mod1), PCR-amplified microsatellites (loci Igh-V, Ngfg, Plau, Crp, Igh, D16Mit5, D3Mit49 and D17Mit16) and DNA fingerprinting (multilocus probes 33.6, 33.15 and (CAC)5). No evidence of genetic contamination was found, ruling out the possibility of an outcross with AKR, the other albino strain maintained at the facility. Nevertheless, DNA fingerprint patterns revealed evidence of genetic heterogeneity in four out of nine lines of the nucleus colony, interpreted as minisatellite mutations favoured for a single line system with more than 40 generations of separation from the ancestral pair. These mice are mainly used in cancer and immunological research within the institute.

Papillomaviruses in human skin warts and their incidence in an Argentine population

Human papillomavirus genomic types present in human warts of an Argentine population were studied. HPV DNA from single warts was obtained using an alkaline extraction procedure that resulted in a clean DNA preparation, which could be analyzed with several endonucleases. This method was used to isolate and insert the HPV DNAs of two genomic types into the Bam HI site of the pBR322 plasmid. Restriction maps of both HPV DNAs were constructed. According to these maps, one of the genomic variations was identical to HPV1a and the other to HPV2a. The incidence of HPV2 and of HPV1 in different types of skin warts was studied by a dot blot hybridization assay. Twenty-two out of 28 common warts were positive for HPV2 and negative for HPV1; four were positive for HPV1 and negative for HPV2 and two were negative for both. Five out of six plantar warts were positive for HPV1, and one was negative for both. Three out of seven filiform warts were positive for HPV2, three were positive for both probes, and one was negative for both. Southern blot analysis of HPV2 positive samples indicated that 80% were HPV2a and 20% another subtype not yet characterized. All plantar warts contained HPV1a. Msp I/Hpa II restriction analysis confirms previous results indicating that HPV1a DNA is partially methylated, while no evidence of methylation was found for HPV2a DNA.

The effect of organic solvents on the activation and the activity of spinach chloroplast fructose-1,6-bisphosphatase

A two-stage assay was used to study the effect of organic solvents on the activation of and the catalysis by chloroplast fructose-1,6-bisphosphatase. Irrespective of chemical structure, all the organic solvents tested had a dual effect on the enzyme. In the activation they stimulated and inhibited at low and high concentrations, respectively, in a process that required dithiothreitol, fructose 1,6-bisphosphate, and Ca2+. Conversely, organic solvents inhibited catalysis. The enhancement in fructose-1,6-bisphosphatase activity did not arise from a change in the molecular weight of the enzyme and correlated positively with the hydrophobic character of the organic solvent. In the presence of 2-propanol, all the activation constants for modulators (fructose 1,6-bisphosphate, a2+, thioredoxin-f) were lower than in a strictly aqueous medium. Monothiols were also functional in the activation of chloroplast fructose-1,6-bisphosphatase, although they were less effective than dithiols. Sulfhydryl compounds decreased the concentration of fructose 1,6-bisphosphate required for the activation of the enzyme, and 2-propanol lowered this requirement further. Arrhenius plots were nonlinear for the enzyme activation and linear for the hydrolytic step. The anomalous temperature dependence of the chloroplast fructose-1,6-bisphosphatase activation was indicative of a cooperative process. The data obtained in this study indicate that the concerted activation of chloroplast fructose-1,6-bisphosphatase is favored in a medium less polar than water.

Regulation of the activation of chloroplast fructose-1,6-bisphosphatase: inhibition by spermidine and spermine

The activation of chloroplast fructose-1,6-bisphosphatase by fructose-1,6-bisphosphate, Ca2+, DTT and chloroplast thioredoxin-f is prevented by either spermidine or spermine; on the contrary, other amino compounds do not replace polyamines in this reversible effect. On the other hand, neither spermidine nor spermine modify the catalysis of chloroplast fructose-1,6-bisphosphatase. The effect of spermidine, but not the effect of spermine, is reversed by increasing the concentration of Ca2+ in the activation; higher concentrations of Fructose-1,6-bisphosphate or thioredoxin-f do not restore the control activity. The present results suggest that other regulatory mechanisms may control the activation of fructose-1,6-bisphosphatase in chloroplasts.