Model-Based Prediction of Irinotecan-Induced Grade 4 Neutropenia in Cancer Patients: Influence of Incorporating Germline Genetic Factors in the Model

Neutropenia is the major dose-limiting toxicity of irinotecan-based therapy. The objective of this study was to assess whether inclusion of germline genetic variants into a population pharmacokinetic/pharmacodynamic model can improve prediction of irinotecan-induced grade 4 neutropenia and identify novel variants of clinical value. A semimechanistic population pharmacokinetic/pharmacodynamic model was used to predict neutrophil response over time in 197 patients receiving irinotecan. Covariate analysis was performed for demographic/clinical factors and 4,781 genetic variants in 84 drug response- and toxicity-related genes to identify covariates associated with neutrophil response. We evaluated the predictive value of the model for grade 4 neutropenia reflecting different clinical scenarios of available data on identified demographic/clinical covariates, baseline and post-treatment absolute neutrophil counts (ANCs), individual pharmacokinetics, and germline genetic variation. Adding 8 genetic identified covariates (rs10929302 (UGT1A1), rs1042482 (DPYD), rs2859101 (HLA-DQB3), rs61754806 (NR3C1), rs9266271 (HLA-B), rs7294 (VKORC1), rs1051713 (ALOX5), and ABCB1 rare variant burden) to a model using only baseline ANCs improved prediction of irinotecan-induced grade 4 neutropenia from area under the receiver operating characteristic curve (AUC-ROC) of 50-64% (95% confidence interval (CI), 54-74%). Individual pharmacokinetics further improved the prediction to 74% (95% CI, 64-84%). When weekly ANC was available, the identified covariates and individual pharmacokinetics yielded no additional contribution to the prediction. The model including only ANCs at baseline and at week 1 achieved an AUC-ROC of 78% (95% CI, 69-88%). Germline DNA genetic variants may contribute to the prediction of irinotecan-induced grade 4 neutropenia when incorporated into a population pharmacokinetic/pharmacodynamic model. This approach is generalizable to drugs that induce neutropenia and ultimately allows for personalized intervention to enhance patient safety.

Predictive value of CDC37 gene expression for targeted therapy in metastatic colorectal cancer

BACKGROUND

CDC37 is a key determinant of client kinase recruitment to the HSP90 chaperoning system. We hypothesized that kinase-specific dependency on CDC37 alters the efficacy of targeted therapies for metastatic colorectal cancer (mCRC).

MATERIAL AND METHODS

Two independent mCRC cohorts were analyzed to compare the survival outcomes between CDC37-high and CDC37-low patients (stratified by the median cutoff values): the CALGB/SWOG 80405 trial (226 and 207 patients receiving first-line bevacizumab- and cetuximab-containing chemotherapies, respectively) and Japanese retrospective (50 refractory patients receiving regorafenib) cohorts. A dataset of specimens submitted to a commercial CLIA-certified laboratory was utilized to characterize molecular profiles of CDC37-high (top quartile, N = 5055) and CDC37-low (bottom quartile, N = 5055) CRCs.

RESULTS

In the bevacizumab-treated group, CDC37-high patients showed significantly better progression-free survival (PFS) (median 13.3 vs 9.6 months, hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.44-0.79, p < 0.01) than CDC37-low patients. In the cetuximab-treated group, CDC37-high and CDC37-low patients had similar outcomes. In the regorafenib-treated group, CDC37-high patients showed significantly better overall survival (median 11.3 vs 6.0 months, HR 0.24, 95% CI 0.11-0.54, p < 0.01) and PFS (median 3.5 vs 1.9 months, HR 0.51, 95% CI 0.28-0.94, p = 0.03). Comprehensive molecular profiling revealed that CDC37-high CRCs were associated with higher VEGFA, FLT1, and KDR expressions and activated hypoxia signature.

CONCLUSIONS

CDC37-high mCRC patients derived more benefit from anti-VEGF therapies, including bevacizumab and regorafenib, but not from cetuximab. Molecular profiles suggested that such tumors were dependent on angiogenesis-relating pathways.

Germline cis variant determines epigenetic regulation of the anti-cancer drug metabolism gene dihydropyrimidine dehydrogenase ( DPYD )

Enhancers are critical for regulating tissue-specific gene expression, and genetic variants within enhancer regions have been suggested to contribute to various cancer-related processes, including therapeutic resistance. However, the precise mechanisms remain elusive. Using a well-defined drug-gene pair, we identified an enhancer region for dihydropyrimidine dehydrogenase (DPD, DPYD gene) expression that is relevant to the metabolism of the anti-cancer drug 5-fluorouracil (5-FU). Using reporter systems, CRISPR genome edited cell models, and human liver specimens, we demonstrated in vitro and in vivo that genotype status for the common germline variant (rs4294451; 27% global minor allele frequency) located within this novel enhancer controls DPYD transcription and alters resistance to 5-FU. The variant genotype increases recruitment of the transcription factor CEBPB to the enhancer and alters the level of direct interactions between the enhancer and DPYD promoter. Our data provide insight into the regulatory mechanisms controlling sensitivity and resistance to 5-FU.

Gene expression biomarkers differentiate overall survival of colorectal cancer upon targeted therapies

While monoclonal antibody-based targeted therapies have substantially improved progression-free survival in cancer patients, the variability in individual responses poses a significant challenge in patient care. Therefore, identifying cancer subtypes and their associated biomarkers is required for assigning effective treatment. In this study, we integrated genotype and pre-treatment tissue RNA-seq data and identified biomarkers causally associated with the overall survival (OS) of colorectal cancer (CRC) patients treated with either cetuximab or bevacizumab. We performed enrichment analysis for specific consensus molecular subtypes (CMS) of colorectal cancer and evaluated differential expression of identified genes using paired tumor and normal tissue from an external cohort. In addition, we replicated the causal effect of these genes on OS using validation cohort and assessed their association with the Cancer Genome Atlas Program data as an external cohort. One of the replicated findings was WDR62, whose overexpression shortened OS of patients treated with cetuximab. Enrichment of its over expression in CMS1 and low expression in CMS4 suggests that patients with CMS4 subtype may drive greater benefit from cetuximab. In summary, this study highlights the importance of integrating different omics data for identifying promising biomarkers specific to a treatment or a cancer subtype.

HER2 Gene Expression Levels Are Predictive and Prognostic in Patients With Metastatic Colorectal Cancer Enrolled in CALGB/SWOG 80405

PURPOSE

The phase III Cancer and Leukemia Group B (CALGB)/SWOG 80405 trial found no difference in overall survival (OS) in patients with metastatic colorectal cancer receiving first-line chemotherapy in combination with either bevacizumab or cetuximab. We investigated the potential prognostic and predictive value of HER2 amplification and gene expression using next-generation sequencing (NGS) and NanoString data.

PATIENTS AND METHODS

Primary tumor DNA from 559 patients was profiled for HER2 amplification by NGS (FoundationOne CDx). Tumor tissue from 925 patients was tested for NanoString gene expression using an 800-gene panel. OS and progression-free survival (PFS) were the time-to-event end points.

RESULTS

High HER2 expression (dichotomized at median) was associated with longer PFS (11.6 v 10 months, P = .012) and OS (32 v 25.3 months, P = .033), independent of treatment. An OS benefit for cetuximab versus bevacizumab was observed in the high HER2 expression group (P = .02), whereas a worse PFS for cetuximab was seen in the low-expression group (P = .019). When modeled as a continuous variable, increased HER2 expression was associated with longer OS (hazard ratio [HR], 0.83 [95% CI, 0.75 to 0.93]; adjusted P = .0007) and PFS (HR, 0.82 [95% CI, 0.74 to 0.91]; adjusted P = .0002), reaching a plateau effect after the median. In patients with HER2 expression lower than median, treatment with cetuximab was associated with worse PFS (HR, 1.38 [95% CI, 1.12 to 1.71]; adjusted P = .0027) and OS (HR, 1.28 [95% CI, 1.02 to 1.59]; adjusted P = .03) compared with that with bevacizumab. A significant interaction between HER2 expression and the treatment arm was observed for OS (Pintx = .017), PFS (Pintx = .048), and objective response rate (Pintx = .001).

CONCLUSION

HER2 gene expression was prognostic and predictive in CALGB/SWOG 80405. HER2 tumor expression may inform treatment selection for patients with low HER2 favoring bevacizumab- versus cetuximab-based therapies.

CALGB 80802 (Alliance): Impact of Sorafenib with and without Doxorubicin on Hepatitis C Infection in Patients with Advanced Hepatocellular Carcinoma

Sorafenib blocks nonstructural protein 5A (NS5A)-recruited c-Raf-mediated hepatitis C virus (HCV) replication and gene expression. Release of Raf-1-Ask-1 dimer and inhibition of Raf-1 via sorafenib putatively differ in the presence or absence of doxorubicin. Cancer and Leukemia Group B (CALGB) 80802 (Alliance) randomized phase III trial of doxorubicin plus sorafenib versus sorafenib in patients with advanced hepatocellular carcinoma (HCC), showed no improvement in median overall survival (OS). Whether HCV viral load impacts therapy and whether any correlation between HCV titers and outcome based on HCV was studied. In patients with HCV, HCV titer levels were evaluated at baseline and at multiple postbaseline timepoints until disease progression or treatment discontinuation. HCV titer levels were evaluated in relation to OS and progression-free survival (PFS). Among 53 patients with baseline HCV data, 12 patients had undetectable HCV (HCV-UN). Postbaseline HCV titer levels did not significantly differ between treatment arms. One patient in each arm went from detectable to HCV-UN with greater than 2 log-fold titer levels reduction. Aside from these 2 HCV-UN patients, HCV titers remained stable on treatment. Patients who had HCV-UN at baseline were 3.5 times more likely to progress and/or die from HCC compared with HCV detectable (HR = 3.51; 95% confidence interval: 1.58-7.78; P = 0.002). HCV titer levels remained unchanged, negating any sorafenib impact onto HCV titer levels. Although an overall negative phase III study, patients treated with doxorubicin plus sorafenib and sorafenib only, on CALGB 80802 had worse PFS if HCV-UN. Higher levels of HCV titers at baseline were associated with significantly improved PFS.

SIGNIFICANCE

Sorafenib therapy for HCC may impact HCV replication and viral gene expression. In HCV-positive patients accrued to CLAGB 80802 phase III study evaluating the addition of doxorubicin to sorafenib, HCV titer levels were evaluated at baseline and different timepoints. Sorafenib did not impact HCV titer levels. Despite an improved PFS in patients with detectable higher level HCV titers at baseline, no difference in OS was noted.

DNA Mutational Profiling in Patients With Colorectal Cancer Treated With Standard of Care Reveals Differences in Outcome and Racial Distribution of Mutations

PURPOSE

CALGB (Alliance)/SWOG 80405 was a randomized phase III trial that in first-line patients with metastatic colorectal cancer (mCRC) treated with bevacizumab or cetuximab with chemotherapy. We aimed to discover novel mutated genes associated with prognosis and differential response to therapy with the biologics.

METHODS

Primary tumor DNA from 548 patients was sequenced using FoundationOne. The effect of mutated genes and mutations on overall survival (OS) was tested adjusting for microsatellite instability status, BRAF V600E, all RAS mutations, arm, sex, and age.

RESULTS

The median number (lower-upper quartile) of mutated genes was 5 (3-7), 5 (3-6) in microsatellite stable and 12.5 (4.5-32) in microsatellite instability-high tumors. Mutated KRAS and APC were more frequent in Black (53% and 85%) than White (27% and 65%, respectively) patients while BRAF V600E was less frequent in Black (5%) than White (14%) patients. The median OS in patients with BRAF non-V600E (2.2% of patients) was 31.9 months (95% CI, 15.1 to not applicable [NA]) similar to that of BRAF wild-type (WT) patients (31.2 months [95% CI, 29.0 to 33.9]). Mutated LRP1B (10.7% of patients) was associated with improved OS compared with WT LRP1B (hazard ratio, 0.57 [95% CI, 0.40 to 0.80]). RNF43 (5.6% of patients) interacted with treatment arms as, in the cetuximab arm, patients with mutated RNF43 had a median OS of 11.5 (95% CI, 10.8 to NA) months compared with 30.1 (95% CI, 24.9 to 35.3) months in patients with WT RNF43, whereas in the bevacizumab arm, patients with mutated RNF43 had a median OS of 25.0 (95% CI, 14.2 to NA) months compared with 31.3 (95% CI, 29.0 to 34.3) months in patients with WT RNF43.

CONCLUSION

These results can provide new tools to predict patient outcome and improve therapeutic decisions and trial participation in patient minorities. The molecular alterations identified in this study may direct biomarker-driven studies.

CCR5 and CCL5 gene expression in colorectal cancer: comprehensive profiling and clinical value

BACKGROUND

The C-C motif chemokine receptor 5 (CCR5)/C-C motif chemokine ligand 5 (CCL5) axis plays a major role in colorectal cancer (CRC). We aimed to characterize the molecular features associated with CCR5/CCL5 expression in CRC and to determine whether CCR5/CCL5 levels could impact treatment outcomes.

METHODS

7604 CRCs tested with NextGen Sequencing on DNA and RNA were analyzed. Molecular features were evaluated according to CCR5 and CCL5 tumor gene expression quartiles. The impact on treatment outcomes was assessed in two cohorts, including 6341 real-world patients and 429 patients from the Cancer and Leukemia Group B (CALGB)/SWOG 80405 trial.

RESULTS

CCR5/CCL5 expression was higher in right-sided versus left-sided tumors, and positively associated with consensus molecular subtypes 1 and 4. Higher CCR5/CCL5 expression was associated with higher tumor mutational burden, deficiency in mismatch repair and programmed cell death ligand 1 (PD-L1) levels. Additionally, high CCR5/CCL5 were associated with higher immune cell infiltration in the tumor microenvironment (TME) of MMR proficient tumors. Ingenuity pathway analysis revealed upregulation of the programmed cell death protein 1 (PD-1)/PD-L1 cancer immunotherapy pathway, phosphatase and tensin homolog (PTEN) and peroxisome proliferator-activated receptors (PPAR) signaling, and cytotoxic T-lymphocyte antigen 4 (CTLA-4) signaling in cytotoxic T lymphocytes, whereas several inflammation-related pathways were downregulated. Low CCR5/CCL5 expression was associated with increased benefit from cetuximab-FOLFOX treatment in the CALGB/SWOG 80405 trial, where significant treatment interaction was observed with biologic agents and chemotherapy backbone.

CONCLUSIONS

Our data show a strong association between CCR5/CCL5 gene expression and distinct molecular features, gene expression profiles, TME cell infiltration, and treatment benefit in CRC. Targeting the CCR5/CCL5 axis may have clinical applications in selected CRC subgroups and may play a key role in developing and deploying strategies to modulate the immune TME for CRC treatment.

Role of thyroid stimulating hormone in the maintenance and functioning of the human corpus luteum

PURPOSE

To evaluate the impact of high thyroid stimulating hormone (TSH) levels on human granulosa-luteal (hGL) cells.

METHODS

hGL cells were isolated from follicular aspirates derived from patients undergoing IVF treatment without any thyroid disorder (serum TSH 0.5-2 mU/L). Cells were cultured at 37 °C in DMEM, supplemented with 5% FBS. The cells were treated with 1 nM LH and increasing concentrations of TSH. At the end of culture, conditioned medium and cells were collected to analyze progesterone production, cell viability, and mRNA levels of genes involved in the steroidogenesis process. Human ovarian tissues were analyzed for TSH receptor (TSHR) expression by IHC.

RESULTS

The expression of TSHR was detected in human corpus luteum by IHC and in hGL by RT-PCR. In hGL cells, TSH treatment did not modulate progesterone production nor the expression of steroidogenic genes, such as p450scc and HSD3b 1/2. However, TSH induced a dose-dependent increase in cell death. Finally, TSH did not affect LH-induced p450scc and HSD3b1/2 expression while LH partially reverted TSH negative effect on cell death in hGL.

CONCLUSIONS

Elevated TSH levels in hypothyroid women may be associated with impaired CL functioning and maintenance. These findings open a new line of research for the importance of the treatment of women with thyroid dysfunction that could contribute to the onset of infertility.

Gene signatures derived from transcriptomic-causal networks stratified colorectal cancer patients for effective targeted therapy

Predictive and prognostic gene signatures derived from interconnectivity among genes can tailor clinical care to patients in cancer treatment. We identified gene interconnectivity as the transcriptomic-causal network by integrating germline genotyping and tumor RNA-seq data from 1,165 patients with metastatic colorectal cancer (CRC). The patients were enrolled in a clinical trial with randomized treatment, either cetuximab or bevacizumab in combination with chemotherapy. We linked the network to overall survival (OS) and detected novel biomarkers by controlling for confounding genes. Our data-driven approach discerned sets of genes, each set collectively stratify patients based on OS. Two signatures under the cetuximab treatment were related to wound healing and macrophages. The signature under the bevacizumab treatment was related to cytotoxicity and we replicated its effect on OS using an external cohort. We also showed that the genes influencing OS within the signatures are downregulated in CRC tumor vs. normal tissue using another external cohort. Furthermore, the corresponding proteins encoded by the genes within the signatures interact each other and are functionally related. In conclusion, this study identified a group of genes that collectively stratified patients based on OS and uncovered promising novel prognostic biomarkers for personalized treatment of CRC using transcriptomic causal networks.

Common variation in a long non-coding RNA gene modulates variation of circulating TGF-β2 levels in metastatic colorectal cancer patients (Alliance)

Background

Herein, we report results from a genome-wide study conducted to identify protein quantitative trait loci (pQTL) for circulating angiogenic and inflammatory protein markers in patients with metastatic colorectal cancer (mCRC).The study was conducted using genotype, protein marker, and baseline clinical and demographic data from CALGB/SWOG 80405 (Alliance), a randomized phase III study designed to assess outcomes of adding VEGF or EGFR inhibitors to systemic chemotherapy in mCRC patients. Germline DNA derived from blood was genotyped on whole-genome array platforms. The abundance of protein markers was quantified using a multiplex enzyme-linked immunosorbent assay from plasma derived from peripheral venous blood collected at baseline. A robust rank-based method was used to assess the statistical significance of each variant and protein pair against a strict genome-wide level. A given pQTL was tested for validation in two external datasets of prostate (CALGB 90401) and pancreatic cancer (CALGB 80303) patients. Bioinformatics analyses were conducted to further establish biological bases for these findings.

Results

The final analysis was carried out based on data from 540,021 common typed genetic variants and 23 protein markers from 869 genetically estimated European patients with mCRC. Correcting for multiple testing, the analysis discovered a novel cis-pQTL in LINC02869, a long non-coding RNA gene, for circulating TGF-β2 levels (rs11118119; AAF = 0.11; P-value < 1.4e-14). This finding was validated in a cohort of 538 prostate cancer patients from CALGB 90401 (AAF = 0.10, P-value < 3.3e-25). The analysis also validated a cis-pQTL we had previously reported for VEGF-A in advanced pancreatic cancer, and additionally identified trans-pQTLs for VEGF-R3, and cis-pQTLs for CD73.

Conclusions

This study has provided evidence of a novel cis germline genetic variant that regulates circulating TGF-β2 levels in plasma of patients with advanced mCRC and prostate cancer. Moreover, the validation of previously identified pQTLs for VEGF-A, CD73, and VEGF-R3, potentiates the validity of these associations.

Identification of Reduced ERAP2 Expression and a Novel HLA Allele as Components of a Risk Score for Susceptibility to Liver Injury Due to Amoxicillin-Clavulanate

BACKGROUND & AIMS

Drug-induced liver injury (DILI) due to amoxicillin-clavulanate (AC) has been associated with HLA-A∗02:01, HLA-DRB1∗15:01, and rs2476601, a missense variant in PTPN22. The aim of this study was to identify novel risk factors for AC-DILI and to construct a genetic risk score (GRS).

METHODS

Transcriptome-wide association study and genome-wide association study analyses were performed on 444 AC-DILI cases and 10,397 population-based controls of European descent. Associations were confirmed in a validation cohort (n = 133 cases and 17,836 population-based controls). Discovery and validation AC-DILI cases were also compared with 1358 and 403 non-AC-DILI cases.

RESULTS

Transcriptome-wide association study revealed a significant association of AC-DILI risk with reduced liver expression of ERAP2 (P = 3.7 × 10-7), coding for an aminopeptidase involved in antigen presentation. The lead eQTL single nucleotide polymorphism, rs1363907 (G), was associated with AC-DILI risk in the discovery (odds ratio [OR], 1.68; 95% CI, 1.23-1.66; P = 1.7 × 10-7) and validation cohorts (OR, 1.2; 95% CI, 1.04-2.05; P = .03), following a recessive model. We also identified HLA-B∗15:18 as a novel AC-DILI risk factor in both discovery (OR, 4.19; 95% CI, 2.09-8.36; P = 4.9 × 10-5) and validation (OR, 7.78; 95% CI, 2.75-21.99; P = .0001) cohorts. GRS, incorporating rs1363907, rs2476601, HLA-B∗15:18, HLA-A∗02:01, and HLA-DRB1∗15:01, was highly predictive of AC-DILI risk when cases were analyzed against both general population and non-AC-DILI control cohorts. GRS was the most significant predictor in a regression model containing known AC-DILI clinical risk characteristics and significantly improved the predictive model.

CONCLUSIONS

We identified novel associations of AC-DILI risk with ERAP2 low expression and with HLA-B∗15:18. GRS based on the 5 risk variants may assist AC-DILI causality assessment and risk management.

Sequencing of genes of drug response in tumor DNA and implications for precision medicine in cancer patients

Tumor DNA sequencing is becoming standard-of-care for patient treatment decisions. We evaluated genotype concordance between tumor DNA and genomic DNA from blood and catalogued functional effects of somatic mutations in 21 drug response genes in 752 solid tumor patients. Using a threshold of 10% difference between tumor and blood DNA variant allele fraction (VAF), concordance for heterogenous genotype calls was 78% and increased to 97.5% using a 30% VAF threshold. Somatic mutations were observed in all 21 drug response genes, and 44% of patients had at least one somatic mutation in these genes. In tumor DNA, eight patients had a frameshift mutation in CYP2C8, which metabolizes taxanes. Overall, somatic copy number losses were more frequent than gains, including for CYP2C19 and CYP2D6 which had the most frequent copy number losses. However, copy number gains in TPMT were more than four times as common as losses. Seven % of patients had copy number gains in ABCB1, a multidrug resistance transporter of anti-cancer agents. These results demonstrate tumor-only DNA sequencing might not be reliable to call germline genotypes of drug response variants.

Acquired Genomic Alterations on First-Line Chemotherapy With Cetuximab in Advanced Colorectal Cancer: Circulating Tumor DNA Analysis of the CALGB/SWOG-80405 Trial (Alliance)

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.Acquired genomic alterations (Acq-GAs), specifically RAS, BRAF, and EGFR-ectodomain mutations and ERBB2 and MET amplifications, are recognized as major mechanisms of resistance to later-line anti-EGFR-antibody therapy in metastatic colorectal cancer (mCRC). However, data regarding emergence of these Acq-GAs under the selective pressure of first-line anti-EGFR-chemotherapy are lacking. We performed next-generation sequencing (Guardant360) on circulating tumor DNA obtained from paired plasma samples (pretreatment and postprogression) from the CALGB/SWOG-80405 trial, which randomly assigned patients with mCRC between first-line chemotherapy with cetuximab (anti-EGFR-chemotherapy) or bevacizumab (anti-VEGF-chemotherapy). The primary objective was to determine the prevalence of Acq-GAs on anti-EGFR-chemotherapy and compare this to the prevalence with anti-VEGF-chemotherapy on trial and pooled estimates (N = 292) seen with later-line anti-EGFR-antibody therapy as reported in the literature. Among the 61 patients on anti-EGFR-chemotherapy, only four (6.6%) developed ≥ 1 Acq-GAs of interest compared with 10.1% (7) on anti-VEGF-chemotherapy (odds ratio, 0.62; 95% CI, 0.20 to 2.11) and 62.0% on anti-EGFR-antibody therapy in later lines (odds ratio, 0.09; 95% CI, 0.03 to 0.23). Acq-GAs, classically associated with anti-EGFR-antibody resistance in later lines (RAS, BRAF, and EGFR-ectodomain mutations; ERBB2 and MET amplifications), were rare with up-front use of anti-EGFR-chemotherapy indicating divergent resistance mechanisms. These findings have critical translational relevance to timing and value of circulating tumor DNA-guided anti-EGFR rechallenge in patients with mCRC, especially those treated with anti-EGFR therapy upfront.

KDR genetic predictor of toxicities induced by sorafenib and regorafenib

No biomarkers are available to predict toxicities induced by VEGFR TKIs. This study aimed to identify markers of toxicities induced by these drugs using a discovery-validation approach. The discovery set included 140 sorafenib-treated cancer patients (TARGET study) genotyped for SNPs in 56 genes. The most significant SNPs associated with grade ≥2 hypertension, diarrhea, dermatologic toxicities, and composite toxicity (any one of the toxicities) were tested for association with grade ≥2 toxicity in a validation set of 201 sorafenib-treated patients (Alliance/CALGB 80802). The validated SNP was tested for association with grade ≥2 toxicity in 107 (LCCC 1029) and 82 (Italian cohort) regorafenib-treated patients. SNP-toxicity associations were evaluated using logistic regression, and a meta-analysis between the studies was performed by inverse variance. Variant rs4864950 in KDR increased the risk of grade ≥2 composite toxicity in TARGET, Alliance/CALGB 80802, and the Italian cohort (meta-analysis p = 6.79 × 10^-4, OR = 2.01, 95% CI 1.34-3.01). We identified a predictor of toxicities induced by VEGFR TKIs. CLINICALTRIALS.GOV IDENTIFIER: NCT00073307 (TARGET), NCT01015833 (Alliance/CALGB 80802), and NCT01298570 (LCCC 1029).

Trends of risk behaviors in adolescents: a 10-year study in a representative sample of Tuscany, Italy

Background

The aim of the study was to evaluate the trends of prevalence of several health risk behaviors (HRBs) and health conditions over a 10-years period in a representative sample of adolescents of Tuscany Region, Italy.

Methods

The study had a repeated cross-sectional design, data from the last four survey waves of EDIT surveillance (2008-2018) were used. EDIT surveillance investigates HRBs in a representative sample of students attending the upper secondary schools of Tuscany. Prevalence of 17 HRBs and health conditions were considered and analyzed by age, sex, and socioeconomic status (SES).

Results

A total of 21.943 students were surveyed from 2008 to 2018. Declining trends in the participation in smoking, cocaine use, driving under the influence of alcohol and drugs, and problem gambling were observed, while alcohol abuse and at-risk sexual behaviors remained unchanged or increased during the study period. During the most recent survey males resulted more frequently involved in most of the HRBs, while females more frequently reported physical inactivity, regular smoking and not using a condom. Female participation in smoking and alcohol abuse behaviors, fruit and vegetables consumption, and bullying worsened over the study period. Smoking, poor dietary habits, physical inactivity, high distress level, and obesity were more frequently observed in low SES students than in high SES students.

Conclusions

In conclusion findings showed various different tendencies in adolescent participation in HRBs over the course of the last decade; concerning trends in at-risk sexual behaviors and alcohol consumption and females’ risk-taking behavior on the rise require careful monitoring and intervention.

Key messages

• Distinct tendencies according to sex, socio-economic condition and specific health risk behavior were observed in adolescent participation in health risk behaviors over the course of the last decade.

• Health promotion and prevention interventions tailored on specific health risk behaviors and population groups are needed.

Stratification of patients admitted for SARS-CoV2 infection: prognostic scores in the first and second wave of the pandemic

To test the prognostic performance of different scores, both specifically designed for patients with COVID-19 and generic, in predicting in-hospital mortality and the need for mechanical ventilation (MV). We retrospectively collected clinical data of patients admitted to the Emergency Department of the University Hospital AOU Careggi, Florence, Italy, between February 2020 and January 2021, with a confirmed infection by SARS-CoV2. We calculated the following scores: Sequential Organ Failure Assessment (SOFA) score, CALL score, 4C Mortality score, QUICK score, CURB-65 and MuLBSTA score. The end-points were in-hospital mortality and the need for MV. We included 1208 patients, mean age 60 ± 17 years, 57% male sex. Compared to survivors, non-survivors showed significantly higher values of all the prognostic scores (4C: 13 [10-15] vs 8 [4-10]; CALL: 11 [10-12] vs 9 [7-11]; QUICK: 4 [1-6] vs 0 [0-3]; SOFA: 5 [4-6] vs 4 [4-5]; CURB: 2 [1-3] vs 1 [0-1]; MuLBSTA: 11 [9-13] vs 9 [7-11], all p < 0.001). Discriminative ability evaluated by the Receiver Operating Curve analysis showed the following values of the Area under the Curve: 0.83 for 4C, 0.74 for CALL, 0.70 for QUICK, 0.68 for SOFA, 0.76 for CURB and 0.64 for MuLBSTA. The mortality rate significantly increased in increasing quartiles of 4C and CALL score (respectively, 2, 8, 24 and 54% for the 4C score and 1, 17, 33 and 68% for the CALL score, both p < 0.001). 4C and CALL score allowed an early and good prognostic stratification of patients admitted for pneumonia induced by SARS-CoV2.

ARID1A mutations confer intrinsic and acquired resistance to cetuximab treatment in colorectal cancer

Most colorectal (CRC) tumors are dependent on EGFR/KRAS/BRAF/MAPK signaling activation. ARID1A is an epigenetic regulator mutated in approximately 5% of non-hypermutated CRC tumors. Here we show that anti-EGFR but not anti-VEGF treatment enriches for emerging ARID1A mutations in CRC patients. In addition, we find that patients with ARID1A mutations, at baseline, are associated with worse outcome when treated with cetuximab- but not bevacizumab-containing therapies; thus, this suggests that ARID1A mutations may provide both an acquired and intrinsic mechanism of resistance to anti-EGFR therapies. We find that, ARID1A and EGFR-pathway genetic alterations are mutually exclusive across lung and colorectal cancers, further supporting a functional connection between these pathways. Our results not only suggest that ARID1A could be potentially used as a predictive biomarker for cetuximab treatment decisions but also provide a rationale for exploring therapeutic MAPK inhibition in an unexpected but genetically defined segment of CRC patients.

ARID1A is an epigenetic regulator mutated in approximately 5% of non-hypermutated colorectal cancer tumors, however, its relationship with treatment response remains to be explored. Here, the authors suggest that ARID1A mutations may confer intrinsic and acquired resistance to cetuximab treatment.

Identification and single-base gene-editing functional validation of a cis-EPO variant as a genetic predictor for EPO-increasing therapies

Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are currently under clinical development for treating anemia in chronic kidney disease (CKD), but it is important to monitor their cardiovascular safety. Genetic variants can be used as predictors to help inform the potential risk of adverse effects associated with drug treatments. We therefore aimed to use human genetics to help assess the risk of adverse cardiovascular events associated with therapeutically altered EPO levels to help inform clinical trials studying the safety of HIF-PHIs. By performing a genome-wide association meta-analysis of EPO (n = 6,127), we identified a cis-EPO variant (rs1617640) lying in the EPO promoter region. We validated this variant as most likely causal in controlling EPO levels by using genetic and functional approaches, including single-base gene editing. Using this variant as a partial predictor for therapeutic modulation of EPO and large genome-wide association data in Mendelian randomization tests, we found no evidence (at p < 0.05) that genetically predicted long-term rises in endogenous EPO, equivalent to a 2.2-unit increase, increased risk of coronary artery disease (CAD, OR [95% CI] = 1.01 [0.93, 1.07]), myocardial infarction (MI, OR [95% CI] = 0.99 [0.87, 1.15]), or stroke (OR [95% CI] = 0.97 [0.87, 1.07]). We could exclude increased odds of 1.15 for cardiovascular disease for a 2.2-unit EPO increase. A combination of genetic and functional studies provides a powerful approach to investigate the potential therapeutic profile of EPO-increasing therapies for treating anemia in CKD.

Model-Based Prediction of Irinotecan-Induced Grade 4 Neutropenia in Advanced Cancer Patients: Influence of Demographic and Clinical Factors

Severe neutropenia is the major dose-liming toxicity of irinotecan-based chemotherapy. The objective was to assess to what extent a population pharmacokinetic/pharmacodynamic model including patient-specific demographic/clinical characteristics, individual pharmacokinetics, and absolute neutrophil counts (ANCs) can predict irinotecan-induced grade 4 neutropenia. A semimechanistic population pharmacokinetic/pharmacodynamic model was developed to describe neutrophil response over time in 197 patients with cancer receiving irinotecan. For covariate analysis, sex, race, age, pretreatment total bilirubin, and body surface area were evaluated to identify significant covariates on system-related parameters (mean transit time (MTT) and ɣ) and sensitivity to neutropenia effects of irinotecan and SN-38 (SLOPE). The model-based simulation was performed to assess the contribution of the identified covariates, individual pharmacokinetics, and baseline ANC alone or with incremental addition of weekly ANC up to 3 weeks on predicting irinotecan-induced grade 4 neutropenia. The time course of neutrophil response was described using the model assuming that irinotecan and SN-38 have toxic effects on bone marrow proliferating cells. Sex and pretreatment total bilirubin explained 10.5% of interindividual variability in MTT. No covariates were identified for SLOPE and γ. Incorporating sex and pretreatment total bilirubin (area under the receiver operating characteristic curve (AUC-ROC): 50%, 95% CI 50-50%) or with the addition of individual pharmacokinetics (AUC-ROC: 62%, 95% CI 53-71%) in the model did not result in accurate prediction of grade 4 neutropenia. However, incorporating ANC only at baseline and week 1 in the model achieved a good prediction (AUC-ROC: 78%, 95% CI 69-88%). These results demonstrate the potential applicability of a model-based approach to predict irinotecan-induced neutropenia, which ultimately allows for personalized intervention to maximize treatment outcomes.

Plasma Protein Biomarkers in Advanced or Metastatic Colorectal Cancer Patients Receiving Chemotherapy With Bevacizumab or Cetuximab: Results from CALGB 80405 (Alliance)

PURPOSE

CALGB 80405 compared the combination of first-line chemotherapy with cetuximab or bevacizumab in the treatment of advanced or metastatic colorectal cancer (mCRC). Although similar clinical outcomes were observed in the cetuximab-chemotherapy group and the bevacizumab-chemotherapy group, biomarkers could identify patients deriving more benefit from either biologic agent.

PATIENTS AND METHODS

In this exploratory analysis, the Angiome, a panel of 24 soluble protein biomarkers were measured in baseline plasma samples in CALGB 80405. Prognostic biomarkers were determined using univariate Cox proportional hazards models. Predictive biomarkers were identified using multivariable Cox regression models including interaction between biomarker level and treatment.

RESULTS

In the total population, high plasma levels of Ang-2, CD73, HGF, ICAM-1, IL6, OPN, TIMP-1, TSP-2, VCAM-1, and VEGF-R3 were identified as prognostic of worse progression-free survival (PFS) and overall survival (OS). PlGF was identified as predictive of lack of PFS benefit from bevacizumab [bevacizumab HR, 1.51; 95% confidence interval (CI), 1.10-2.06; cetuximab HR, 0.94; 95% CI, 0.71-1.25; Pinteraction = 0.0298] in the combined FOLFIRI/FOLFOX regimens. High levels of VEGF-D were predictive of lack of PFS benefit from bevacizumab in patients receiving FOLFOX regimen only (FOLFOX/bevacizumab HR, 1.70; 95% CI, 1.19-2.42; FOLFOX/cetuximab HR, 0.92; 95% CI, 0.68-1.24; Pinteraction = 0.0097).

CONCLUSIONS

In this exploratory, hypothesis-generating analysis, the Angiome identified multiple prognostic biomarkers and two potential predictive biomarkers for patients with mCRC enrolled in CALGB 80405. PlGF and VEGF-D predicted lack of benefit from bevacizumab in a chemo-dependent manner. See related commentaries by Mishkin and Kohn, p. 2722 and George and Bertagnolli, p. 2725.

Liposomal irinotecan (Onivyde): Exemplifying the benefits of nanotherapeutic drugs

Irinotecan is a topoisomerase inhibitor, widely used in treatment of malignancies including pancreatic ductal adenocarcinoma (PDAC) as part of the FOLFIRINOX regimen prescribed as a first-line treatment in several countries. However, irinotecan has not been successfully introduced as a second-line treatment for pancreatic cancer and few randomized clinical studies have evaluated its added value. Efficacy of liposomal irinotecan (nal-IRI) combined with 5-fluorouracil and leucovorin (5-FU/LV) was reported in the phase III NAPOLI-1 trial in metastatic PDAC following failure of gemcitabine-based therapy. Several features of nal-IRI pharmacokinetics (PK) could result in better outcomes versus nonliposomal irinotecan. Irinotecan is a prodrug that is converted to active SN-38 by carboxylesterase enzymes and inactivated by cytochrome P450 3A4/3A5. SN-38 is inactivated by UGT1A1 enzymes. Individual variations in their expression and activity could influence enhanced localized irinotecan activity and toxicity. Liposomal irinotecan exploits the enhanced permeability and retention effect in cancer, accumulating in tumor tissues. Liposomal irinotecan also has a longer half-life and higher area under the concentration-time curve (0-∞) than nonliposomal irinotecan, as the liposomal formulation protects cargo from premature metabolism in the plasma. This results in irinotecan activation in tumor tissue, leading to enhanced cytotoxicity. Importantly, despite the longer exposure, overall toxicity for nal-IRI is no worse than nonliposomal irinotecan. Liposomal irinotecan exemplifies how liposomal encapsulation of a chemotherapeutic agent can alter its PK properties, improving clinical outcomes for patients. Liposomal irinotecan is currently under investigation in other malignancies including biliary tract cancer (amongst other gastrointestinal cancers), brain tumors, and small-cell lung cancer.

P-189 Association between iDAScore v1.0, senior embryologists’ grading and euploidy in 546 blastocysts obtained during 189 PGT-A cycles

Study question

Is (intelligent data analysis) iDAScore v1.0 associated with euploidy at the blastocyst stage?

Summary answer

iDAScore v1.0 significantly correlated with euploidy (maternal age-adjusted OR:1.3 and AUC:0.72). Euploid blastocysts were ranked highest in ca.70% of the cohorts with both diagnoses.

What is known already

With machine learning and artificial intelligence (AI) implementation in IVF, several studies have been published mostly aimed at providing standardized and reproducible tools for gamete/embryo assessment and selection. Several of the proposed models might not be generally applicable due to their development on only a single center, small sample size and poor representation of the numerous clinical scenarios. Furthermore, the evidence has been rarely confirmed prospectively and/or in multicenter studies. Lately, the EmbryoScope+ has incorporated the iDAScore v1.0. This algorithm scores the chance of embryo implantation based on the video of blastocyst development and with no need for timing annotations.

Study design, size, duration

Interim analysis of a prospective study. Between April-December 2021, 189 preimplantation-genetic-testing (PGT) cycles (maternal age:38.4±4yr) with ≥1 blastocyst (N = 546 blastocysts, mean±SD:2.9±1.8, range:1-13) were included. We aimed at blindly analyzing the correlation between iDAScore v1.0 and (i) blastocyst quality estimated by senior embryologists, (ii) day of blastocyst full-expansion, (iii) chromosomal constitution diagnosed by NGS on a trophectoderm biopsy, (iv) the blastocyst to prioritize for transfer within cohorts with ≥2 blastocysts.

Participants/materials, setting, methods

Undisturbed culture was conducted in the EmbryoScope+. Assisted hatching was not performed and only fully-expanded blastocysts were biopsied. Morphology was assessed by 2 senior embryologists based on Gardner criteria. Average iDAScores were reported for the following groups: (i)excellent (AA)/good (AB,BA)/average (BB,AC,CA)/poor-quality (CC,BC,CB) blastocysts, (ii)day5/6/7 blastocysts, (iii)euploid/aneuploid/complex aneuploid blastocysts. Lastly, we reported how often the highest iDAScore corresponded to the highest ranked morphology (N = 143 cycles with ≥2 blastocysts) and/or euploid blastocysts (N = 79 cycles with both diagnoses).

Main results and the role of chance

In the study period, 546 blastocysts (iDAScore: 6.9±2.0, 2-9.7) were biopsied. The iDAScore was significantly different (Kruskal-Wallis&lt;0.01) across blastocysts graded excellent (N = 256,46.9%; 8.1±1.3, 2.5-9.7), good (N = 97,17.7%; 6.9±1.6, 2.3-9.5), average (N = 75,13.9%; 5.8±1.4, 2.9-8.7) and poor (N = 118,21.5%; 4.8±1.6, 2-8.8). A significant difference (Kruskal-Wallis&lt;0.01) was also found for the day of full-expansion (day5: N = 184,33.9%, 8.8±0.8, 4.3-9.7; day6: N = 324,59.1%, 6.0±1.6, 2.2-9.1; day7: N = 38,6.9%, 4.6±1.6, 2-7.8). Euploid blastocysts (N = 178,32.6%) had a significantly higher (Kruskal-Wallis&lt;0.01) iDAScore (7.5±1.7, 2.4-9.6) than both simple (N = 209,38.3%, 6.7±2.1, 2.1-9.7) and complex aneuploid blastocysts (N = 159,29.1%, 6.3±2.0, 2-9.4). The logistic regression adjusted for maternal age highlighted a multivariate-OR 1.3, 95%CI 1.18-1.45, adjusted-p&lt;0.01 for the association between iDAScore v1.0 and euploidy. The Receiver-Operating-Characteristic (ROC) curves outlined similar performance in predicting euploidy among the models encompassing iDAScore v1.0 adjusted for maternal age (AUC: 0.72, 95%CI 0.67-0.76, p &lt; 0.01) or blastocyst quality (defined by senior embryologists) plus day of biopsy also adjusted for maternal age (AUC: 0.73, 95%CI 0.69-0.78, p &lt; 0.01). iDAScore v1.0 and embryologists ranked the same blastocyst highest in 123 of 143 cycles with ≥2 blastocysts (86%). The highest ranked blastocyst according to iDAScore was a euploid blastocyst in 54 of the 79 cycles (68%) containing both euploid and aneuploid blastocysts.

Limitations, reasons for caution

The main purpose of iDAScore v1.0, for which the algorithm was trained, is implantation prediction of untested blastocysts. Thus, once the sample size of this blinded prospective study will be large enough, we will also examine the association between iDAScore v1.0 and the implantation of euploid blastocysts.

Wider implications of the findings

The similar predictivity on euploidy reported between subjective senior embryologists’ grading and objective AI-powered iDAscores is promising in view of IVF automation and standardization. This is especially relevant since iDAScore v1.0 has not been trained yet to specifically predict euploidy, and its future versions could be fine-tuned accordingly.

Trial registration number

Not Applicable

P-773 Assessment of the putative impact of culture strategies, oocyte/embryo manipulations, and operators: a retrospective analysis of 3705 blastocyst culture cycles and 2604 single blastocyst transfers

Study question

Do the culture strategies, oocyte/embryo manipulations, and operators impact blastulation-rates per cohort of metaphase-II oocytes (BR per MII-oocytes) and/or live-birth-rates per single-embryo-transfer (LBR per SET)?

Summary answer

Undisturbed culture improved the BR per MII-oocytes, while culture drop volumes ≥80ml in the well-of-the-well system were associated with increased LBR per untested/euploid blastocyst SET.

What is known already

IVF lab performance is critical to achieve success in IVF. Yet, while a consensus exists on the main key-performance-indicators (KPIs), namely BR and LBR, and their inherent benchmark values, the strategies to fulfil them are still poorly standardized. The plasticity of human embryos along with the disparities in the patient populations might mask even largely different outcomes across clinics. Therefore, clear guidelines shall outline which procedures to standardize and carefully monitor in IVF laboratories. Here we investigated different embryo culture strategies, manipulations, and operators for their effect on BR and LBR per SET, adjusting the results for all main confounders.

Study design, size, duration

Retrospective analysis of 3705 cycles with ≥1 MII-oocyte and 2604 SETs (January2019-March2021). BR per MII-oocytes and LBR per SET were the main outcomes. Embryo-twinning was also assessed. The putative impact of culture strategies, manipulations, and operators’ expertise (0-5yr,6-11yr or &gt; 12yr) was determined via regression analyses adjusted for possible confounders (autologous/donated oocytes, age, primary/secondary infertility and duration, sperm factor; for SET: also endometrial preparation, age at transfer, number of consecutive transfer, untested/euploid blastocyst, quality, and day).

Participants/materials, setting, methods

In donation cycles, only vitrified oocytes were used. In Preimplantation-Genetic-Testing (PGT) cycles, no assisted-hatching was performed and only euploid non-mosaic vitrified-warmed blastocysts were transferred. The culture strategies assessed were undisturbed (Embryoscope, Geri and Embryoscope-plus)/disturbed (KSystems), volume and approach (drops ≤30ml with single-culture or ≥ 80ml with well-of-the-well approaches), humidified/non-humidified atmosphere and media refreshed/not-refreshed. The manipulations assessed were oocyte/blastocyst vitrification (performed/not-performed), oocyte retrieval and denudation performed with oil overlay (yes/not), laser-assisted artificial-shrinkage (performed/not-performed), trophectoderm biopsy (performed/not-performed).

Main results and the role of chance

The only confounders on BR per MII-oocytes (overall:39.1±26.6%) were sperm factor and oocyte age. The linear regressions showed benefits for humidified atmosphere (unstandardized B-coefficient:+2.9%, p = 0.01), manipulations with oil overlay (+3.9%, p = 0.03) and drops≥80ml with a well-of-the-well approach (+4.3%, p &lt; 0.01). However, only the positive effect of undisturbed incubators was significant when adjusting for confounders [41.7±27.8% (N = 1440 cycles) versus 37.5±25.7% in a disturbed incubator (N = 2265 cycles); unstandardized B-coefficient:+5.6%, 95%CI +3.9% to + 7.3%, standardized beta-coefficient:-0.103,p&lt;0.01].

The main confounders on LBR per SET (overall: N = 1044/2604, 40.1%) were oocyte age, number of consecutive transfer, blastocyst chromosomal status (untested/euploid), quality and day. The univariate logistic regressions showed a benefit for undisturbed incubators (OR:1.3, 95%CI 1.1-1.5, p &lt; 0.01), humidified atmosphere (OR:1.4, 95%CI 1.1-1.7, p &lt; 0.01) and media refresh (OR:1.3, 95% 1.01-1.8, p = 0.05). However, only the use of drops ≥80ml with a well-of-the-well approach rather than drops ≤30ml with a single-culture approach involved an improvement when adjusting for confounders (untested SETs: N = 71/171, 41.5% versus N = 434/1284, 33.8%; euploid SETs: N = 170/316, 53.8% versus N = 369/833, 44.3%; multivariate-OR:1.33, 95%CI 1.12-1.58, adjusted p-value&lt;0.01). This result was confirmed in a sub-analysis across only first patients’ SETs.

Lastly, no feature under investigation was associated with embryo-twinning (overall: N = 23/1243, 1.9% and N = 14/1044, 1.3% per pregnancy and delivery, respectively).

Limitations, reasons for caution

Retrospective single center study. Only ICSI cycles and continuous culture media were assessed. Cleavage stage SETs were excluded. All operators had at least 3yr of experience. Perinatal and gestational outcomes were not evaluated.

Wider implications of the findings

Real-life data adjusted for confounders may unveil fluctuations in critical KPIs mainly imputable to culture strategies. An impact seldom derives from oocyte/embryo manipulations if experienced operators adopt validated protocols. An accurate interpretation of these evidence shall lead to properly designed studies with problem-solving/progress-building purposes, and guidelines to standardize culture practices.

Trial registration number

Not applicable

O-101 Elucidation of blastocyst collapse and its consequences: a comprehensive artificial intelligence-powered analysis of 1943 embryos from 643 couples

Study question

What are the causes and consequences of blastocyst collapse?

Summary answer

∼50% of blastocysts collapsed, especially if they are aneuploid and/or morphologically-poor. Yet, no impact on the live-birth-rate (LBR) per vitrified-warmed euploid single-embryo-transfer (SET) was reported.

What is known already

Time-lapse-microscopy (TLM) is a powerful tool to describe the peculiar dynamics of preimplantation development. Lately, artificial intelligence (AI) has been also implemented to automatize and standardize such description. Here, we adopted AI to comprehensively portray blastocyst collapse, namely the phenomenon of embryo contraction with an efflux of blastocoel fluid and the detachment of the trophectoderm (TE) from the Zona Pellucida (ZP). Although, the causes of this event are still undetermined, small blastocyst contractions have been reported beneficial for the hatching process, while a full collapse has been associated with lower competence.

Study design, size, duration

Observational study including 1943 blastocysts from 643 couples cultured in the Embryoscope between January-2013 and December-2020. TE biopsy without day3 ZP drilling and comprehensive-chromosome-testing were performed. The Fairtility® software automatically registered: (i)time of starting-blastulation (tSB), (ii)starting and ending time of each collapse (tSC and tEC), (iii)blastocysts’ areas, (iv)shrinkage% [(area at SC – area at EC)/area at SC)], (v)embryo:ZP ratio at EC (area of the collapsed embryo/area of the ZP), and (vi)time of biopsy (t-biopsy).

Participants/materials, setting, methods

Blastocyst quality was defined according to Istanbul Consensus (11, excellent; 12-21, good; 22-13-31, average; 33-23-32, poor) and with the Fairtility implantation score (IS) as well, i.e., a continuous variable from 0 to 1 generated by the KID+ software based on the TLM videos of preimplantation development. The main outcome was the LBR per euploid SET adjusted for confounders through logistic regressions. All couple and embryo features were also investigated for their association with blastocyst collapse.

Main results and the role of chance

47.3% of the blastocysts collapsed 1- to 9-times (interval between collapses: 4-8hr), and 73% of the couples had ≥1 collapsed blastocyst (1.8±1.1, range:1-8). No couple feature, though, was associated with blastocyst collapse. The longest collapses lasted 1.5±1.1 (0.13-5.1)hr, while the largest shrinkage% and embryo:ZP ratio at EC were 35±14% (10-78%) and 81±9% (33-90%), respectively. In ∼50-60% of collapses a 20-40% blastocyst volume reduction was registered, 40-60% or 20-40% in ∼15-30%, 60-80% in 0-4%. In case of multiple collapses, the first three involved smaller shrinkages. Blastocysts undergoing ≥1 collapse showed similar tSB as not-collapsing blastocysts, but progressively longer tEB and t-biopsy. The earlier the first event, the more the consecutive collapses. Notably, the poorer the morphology, the higher the risk (excellent, good, average, and poor not-collapsing blastocysts were 64%,50%,44% and 37%), number (e.g.,≥4 collapses were 0.4%,2%,4% and 8%) and duration (1.2±1.0,1.4±1.0,1.6±1.1 and 1.9±1.3hr) of blastocyst collapse. Collapsing blastocysts were significantly less euploid than non-collapsing (35% vs 47%; multivariate-OR:0.75,95%CI 0.6-0.92,p&lt;0.01); conversely, their LBR per euploid SET (39% vs 46%) and miscarriage rate per clinical pregnancy (17% vs 11%), were not significantly different (adjusted-OR:1.0,95%CI 0.69-1.48,p=0.96 and adjusted-OR:1.65,95%CI 0.79-3.42,p=0.18, respectively). All data were confirmed also by defining blastocyst quality through the Fairtility IS.

Limitations, reasons for caution

Gestational and perinatal outcomes were not assessed. Other culture strategies and media shall be assessed for their association with blastocyst collapse. Perhaps, future studies from other groups and with a larger sample size might unveil a significant impact on the clinical outcomes.

Wider implications of the findings

Collapse is common and delays blastocyst full-expansion. Moreover, poor morphology and aneuploidies involve a higher risk of collapse(s); however, no impact was reported on the clinical outcomes after euploid SET. AI appears to increase the throughput of the analysis, but additional data are required to research the causes of collapse.

Trial registration number

Not applicable

O-072 Can preimplantation genetic testing for monogenic conditions represent an indication for DuoStim? A multicenter case series

Study question

Is double stimulation in the same ovarian cycle (DuoStim) a valuable strategy to improve the chance of success in couples carrier of monogenic conditions?

Summary answer

DuoStim is advantageous in patients indicated for preimplantation genetic testing for monogenic diseases and aneuploidy testing (PGT-M/-A) and obtaining ≤5 blastocysts after the I-stimulation.

What is known already

PGT-M is a well-established strategy to identify unaffected blastocysts in a cohort of embryos produced from couples carrier of single gene disorders. When PGT-M is conducted in poor prognosis and/or advanced maternal age (POR/AMA) patients, also aneuploidy-testing among unaffected blastocysts is suggested on a single biopsy. The Poseidon group stated that retrieving an adequate number of oocytes to produce ≥1 euploid blastocyst should be considered the main goal of controlled-ovarian-stimulation (COS). This task is even more complex when PGT-M is required in POR/AMA patients. Therefore, lately we started suggesting DuoStim to these couples to maximize their chance of success.

Study design, size, duration

Multicenter case series (2016-2021). Comprehensive description of IVF outcomes derived from DuoStim application in POR/AMA patients undergoing PGT-M. Aneuploidy-testing was also conducted on unaffected blastocysts. All results were compared between the two stimulations in the same ovarian cycle, and we reported the contribution of II-stimulations to higher chances of success.

Participants/materials, setting, methods

GnRH-antagonist COS was performed with recombinant-gonadotrophins and agonist-trigger. Based on the expected risk each embryo would be affected-aneuploid, DuoStim was suggested to all patients obtaining ≤5 blastocysts (day5-7 from I-retrieval). 61 patients accepted and underwent II-stimulations with the same protocol. Only ICSI, trophectoderm-biopsy, qPCR, and vitrified-warmed unaffected-euploid single-blastocyst-transfer(s) were conducted.

Main results and the role of chance

90 patients (36.7±3.7yr) indicated to PGT-M/-A and obtaining ≤5 blastocysts after I-stimulations were suggested starting a II-stimulation in the same ovarian cycle. Among them, 61 accepted (67%). 7.2±4.4 and 7.4±4.2 cumulus-oocyte-complexes were retrieved after I- and II-stimulations, respectively (p = 0.7). 5.1±3.0 and 5.8±3.4 were metaphase-II oocytes (p = 0.2), resulting in 75±21% and 77±25% maturation-rates (p = 0.6). 3.6±2.1 and 4.6±2.9 2PN-zygotes were obtained (p = 0.04), resulting in 75±27% and 81±20% fertilization-rates (p = 0.19). 1.6±1.3 and 2.2±1.8 blastocysts were obtained (p = 0.04), resulting in 43±32% and 46±32% blastulation-rates (p = 0.6). Lastly, 0.5±0.7 and 0.7±1.0 blastocysts were diagnosed unaffected-euploid (p = 0.3), resulting in 35±40% and 30±36% transferable blastocyst rates per biopsied embryo, respectively (p = 0.53), and identical 10±16% transferable blastocyst rates per metaphase-II oocyte in both groups (p = 0.9). 23 (38%) and 24 (39%) patients obtained ≥1 transferable blastocyst after the I- and II-simulation, respectively. Overall, 36 (59%) patients obtained ≥1 transferable blastocyst thanks to DuoStim. To date, 57 (93%) cycles were concluded, and the cumulative live birth rate (CLBR) was 37% (N = 21/57). The patients with a LB have 1.7 surplus transferable blastocysts, and 3 patients already delivered 2 singleton healthy-LBs. The CLBR among patients undergoing the conventional strategy was 21%, no surplus transferable blastocyst is available, and no patient delivered &gt;1 LB.

Limitations, reasons for caution

Observational case series based on real-life data. Of note, the adoption of DuoStim (or any other oocyte/embryo accumulation strategy) in PGT-M/-A is valuable also to amortize the costs of PGT-M set-up and genetic testing through a larger number of blastocysts. In this context, cost-effectiveness analyses in different settings are desirable.

Wider implications of the findings

DuoStim is a fully-personalized strategy advisable any time lower chance of success and higher treatment costs could be balanced by a larger number of blastocysts produced in a short time-frame. Adopting GnRH-antagonist protocols in these patients allows to suggest DuoStim even in progress, based on the embryological outcomes after I-stimulations.

Trial registration number

Not applicable

O-121 Uncovering the value of day 7 blastocysts using artificial intelligence on time lapse videos

Study question

Which is the clinical value of day 7 blastocysts?

Summary answer

Ending embryo culture at 144 hours-post-insemination (hpi) would involve7.3%- and 4.4%-relative reductions in the patients obtaining euploid blastocysts and live birth(s)(LBs), respectively.

What is known already

Many studies showed that day 7 blastocysts are clinically valuable although less euploid and less competent than faster growing embryos. Nevertheless, a large variability exists in: (i) the definition of “day 7”; (ii) the criteria to culture embryos to day 7; (iii)the clinical setting; (iv) the local regulation; and/or (v) the culture strategies and incubators. Here,we aimed at ironing out these differences and portray day 7 blastocysts with the lowest possible risk of bias. To this end, we have also adopted an artificial intelligence (AI)-powered software to automatize developmental timings annotations and standardize embryo morphological assessment.

Study design, size, duration

Observational study including 1966 blastocysts obtained from 681 patients cultured in a time lapse incubator between January 2013 and December 2020 at a private Italian IVF center.

Participants/materials, setting, methods

Trophectoderm biopsy without hatching and comprehensive-chromosome-testing were performed. Blastocysts were clustered in six groups based on the time-of-biopsy every 12hr from &lt;120hpi (control) to &gt; 168hpi. Blastocyst quality, time-of-expanding-blastocyst (tEB) and duration of expansion were annotated through AI and confirmed manually. The main outcomes were euploidy-rate and LB-rate (LBR) per transfer. Lastly, patients obtaining (euploid) blastocysts, LBs, and supernumerary blastocysts, were reported based on a hypothetical 144hpi cut-off, and all relative reductions calculated.

Main results and the role of chance

14.6% of the blastocysts reached full expansionbeyond 144hpi (5.9% between 144-156hpi, 7.9% between 156-168hpi, and 0.8% &gt;168hpi). Slower blastocysts were of a worse quality based on the evaluation of both embryologists and AI. Both longer tEB and a longer duration of expansion concurred to day7 development, quite independently of embryo quality. The lower euploidy rate among day7 blastocysts is due to their worse morphology and more advanced oocyte age, rather than to a slower development per se. Conversely, the lower LBR was significant even after adjusting for confounders, with a first relevant decrease for blastocysts biopsied in the range 132-144hpi (N = 76/208, 36.5% versus N = 114/215, 53.0% in the control, multivariate-OR: 0.61, 95%CI 0.40-0.92, adjusted-p=0.02), and a second step for blastocysts biopsied in the range 156-168hpi (N = 3/21, 14.3%, multivariate-OR:0.24, 95%CI 0.07-0.88, adjusted-p=0.03). Nevertheless, when the cut-off was set at 144hpi, no significant difference was reported. In this patient population, ending embryo culture at 144hpi would have caused 10.6%-, 7.3%-, 4.4%-, 13.7%-, and 5.2%-relative reductions in the number ofpatients obtaining blastocysts, euploid blastocysts, LBs, supernumerary blastocysts without a LB and after a LB, respectively.

Limitations, reasons for caution

Gestational and perinatal outcomes were not assessed, and a cost-effectiveness analysis was not performed. We encourage the production of these data in other clinical settings and regulatory contexts.

Wider implications of the findings

Day7 culture shall be supported following a careful case-by-case evaluation. Patients shall be aware of their lower competence, yet day7 blastocysts are valuable for poor-prognosis couples, couples less compliant towards other attempts in case of failures, and couples wishing for second children. AI may improve the generalizability of these evidence.

Trial registration number

Not applicable

Abstract 5420: DPYD enhancer variant confers increased risk of severe toxicity in 5-FU chemotherapy

Genetic variants in the DPYD gene that are deleterious to dihydropyrimidine dehydrogenase (DPD) enzyme function have demonstrated clinical validity as predictive biomarkers for severe (i.e., CTCAE grade ≥3) and potentially lethal toxicity to fluorouracil (5-FU) and capecitabine chemotherapies. Variants within the coding region only explain 5-10% of 5-FU-related toxicities; and GWAS approaches have been unable to identify validated predictive biomarkers to date. Our previous studies demonstrated that DPD expression was controlled by multiple epigenetic processes; considerable variation was also noted in liver DPYD/DPD levels. Using CRISPR-interference (CRISPRi) and CRISPR-activation (CRISPRa), we identified functional enhancer regions within liver tissues and cells. Epigenetic status at these regions was shown to correlate with DPYD expression in cell models and human liver tissues. Chromosome conformation capture (3C) confirmed direct promoter-enhancer interactions. A multi-omics analysis of &gt;1000 human liver specimens identified a proximal eQTL for DPYD expression within an enhancer, with a global minor allele frequency of 27%. This variant was subsequently shown to directly alter DPYD expression in knock-in cell line models. The variant disrupts transcription factor binding at the DPYD enhancer, leading to reduced enhancer-promoter interaction, reduced DPD expression, and increased cellular sensitivity to 5-FU. Collectively, our data suggest that the variant could represent a novel predictive biomarker for severe 5-FU toxicity. The evaluation of this marker in the clinical setting is currently underway.

Citation Format: Ting Zhang, Alisa Ambrodji, Huixing Huang, Kelly Bouchonville, Amy Etheridge, Remington Schmidt, Jose Cardiel Nunez, Zoey Temesgen, Federico Innocenti, Robert Diasio, Carlo Largiadèr, Steven M. Offer. DPYD enhancer variant confers increased risk of severe toxicity in 5-FU chemotherapy [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 5420.

Predictive value of CDC37 gene expression for targeted therapy in metastatic colorectal cancer (mCRC)

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Background: HSP90 mediated chaperoning is a well-conserved biological mechanism for stabilization and activation of kinases. More than 60% of human kinases including VEGFR, CRAF, CSF1R, and FGFR are target of HSP90 (client kinases), whereas EGFR is non-client. CDC37 is a specific co-chaperone determining selectivity of client kinases recognized by HSP90. We hypothesized that gene expression levels of CDC37 have predictive values for anti-angiogenic therapies in mCRC. Methods: The subjects of this study were mCRC patients treated with regorafenib (REGO, Japanese retrospective cohort) and those treated with bevacizumab (BEV) or cetuximab (CET) in combination with first-line chemotherapy (CALGB/SWOG 80405 trial cohort). CDC37 expression levels were measured using RNA isolated from FFPE samples by nCounter gene expression profiling (Nanostring) and HiSeq 2500 (Illumina) in the Japanese and CALGB/SWOG 80405 cohorts, respectively. Overall survival (OS) and progression-free survival (PFS) were compared between patients with high CDC37 expression ( CDC37-H) and those with low expression ( CDC37-L), grouped by median cutoff value in each cohort. Results: In total, 484 patients were included (50 treated with REGO, 227 treated with BEV, and 207 treated with CET). In REGO-treated patients, CDC37-H showed significantly better OS (median 11.3 vs 6.0 months, adjusted hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.11-0.54, p <0.01) and PFS (median 3.5 vs 1.9 months, adjusted HR 0.51, 95% CI 0.28-0.94, p = 0.03) compared to CDC37-L. Similarly, in BEV-treated patients, CDC37-H showed significantly better PFS (median 13.5 vs 9.6 months, adjusted HR 0.59, 95% CI 0.43-0.79, p <0.01) and numerically better OS (median 34.1 vs 29.4 months, adjusted HR 0.81, 95% CI 0.60-1.11, p = 0.20) compared to CDC37-L. However, in CET-treated patients, CDC37-H and CDC37-L patients showed similar OS (median 33.7 vs 26.1 months, adjusted HR 1.00, 95% CI 0.73-1.38, p = 0.98) and PFS (median 11.3 vs 11.0 months, adjusted HR 1.08, 95% CI 0.81-1.45, p = 0.60). Significant interaction was observed between CDC37 expression and treatment in terms of PFS in the CALGB/SWOG 80405 cohort ( p = 0.01). Conclusions: Our results suggest patients with CDC37-dependent ( CDC37-H) tumors may derive more benefit from REGO and BEV both of which target HSP90 client kinases or signaling pathways, but not from CET which target HSP90 non-client kinase. Further validation studies are warranted to develop a novel personalized approach for targeted therapies based on CDC37 expression in mCRC patients. Support: U10CA180821, U10CA180888; Pfizer, Genentech; https://acknowledgments.alliancefound.org. ClinicalTrials.gov Identifier: NCT00265850.

Predictive value of MAOB gene expression for targeted therapy in patients (pts) with metastatic colorectal cancer (mCRC) enrolled in CALGB (Alliance)/SWOG 80405

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Background: Monoamine oxidases (MAOs), including MAOA and MAOB, are mitochondrial enzymes responsible for catalyzing monoamine oxidation. Increased expression of MAOs were found in several cancer types and high MAOB was associated with worse disease stage and poorer survival in CRC. Positive and negative correlations of MAOB expression with mesenchymal type and epithelial type gene expressions, respectively, have been reported. Hence, we investigated whether MAOB expression is predictive for targeted therapies in mCRC. Methods: 430 mCRC pts treated with either bevacizumab (BEV, n = 224) or cetuximab (CET, n = 206) in combination with first-line chemotherapy within the CALGB/SWOG 80405 trial were included in the analysis. MAOB RNA was isolated from FFPE tumor samples and sequenced on the HiSeq 2500 (Illumina). Overall survival (OS) and progression-free survival (PFS) were compared between groups of pts categorized by tertiles of MAOB expression into high (H), medium (M) and low (L). Hazard ratios (HR) and 95% confidence intervals (CI) were computed from multivariable Cox proportional hazards model, adjusting for age, sex, location, number of metastases, KRAS, MSI status, and treatment with FOLFOX or FOLFIRI. Sensitivity analyses were conducted after stratifying by sex. Logrank P-values describe differences without adjustment for patient characteristics. Results: In CET-treated pts, MAOB-L showed significantly longer OS (median 39.2 vs 30.9 vs 15.9 months, logrank P = 4.7E-05, L vs H (as reference) adjusted HR 0.42, 95% CI [0.27, 0.65]) and PFS (median 13.2 vs 11.8 vs 7.6 months, logrank P = 0.006, L vs H adjusted HR 0.59 [0.40, 0.88]) compared to MAOB-M and MAOB-H, respectively. Similar results were observed when evaluating MAOB expression as a continuous variable. In BEV-treated pts, no significant differences were observed when comparing MAOB expression tertiles; however, pts with lower MAOB expression had significantly better OS, but not PFS, when evaluating MAOB as a continuous variable (Cox LRT P = 0.015, covariate adjusted). In CET-treated pts, the effect of MAOB expression was observed in male but not female pts (OS: median 40.3 vs 30.9 vs 16.1 months by MAOB-L, M, H, respectively, logrank P = 6.8E-05, L vs H adjusted HR 0.33 [0.19, 0.59]; PFS: median 13.8 vs 12.6 vs 7.9 months, logrank P = 0.001, L vs H adjusted HR 0.46 [0.28, 0.79]). A significant interaction was observed between MAOB expression and treatment for OS ( P = 0.010) in males and females combined, but only in males ( P = 0.018) when stratified by sex. Conclusions: Our results suggest that pts with MAOB-L tumors may have greater benefit from CET-based treatment and that targeting MAOB may be a promising strategy to improve patient outcomes. Further validation studies are warranted to develop a novel personalized approach based on MAOB expression in mCRC pts. Clinical trial information: NCT00265850.

Polygenic Risk Scores for Blood Pressure to Assess the Risk of Severe Bevacizumab-Induced Hypertension in Cancer Patients (Alliance)

Hypertension is a common bevacizumab-induced toxicity. No markers are available to predict patients at risk of developing hypertension. We hypothesized that genetic risk of essential hypertension, as measured by a blood pressure polygenic risk score (PRS), would be associated with risk of severe bevacizumab-induced hypertension. PRSs were calculated for 1,027 bevacizumab-treated patients of European descent with cancer from four clinical trials (Alliance for Clinical Trials in Oncology (Alliance) / Cancer and Leukemia Group B (CALGB) 80303, 40503, 90401, 40502) using summary systolic blood pressure (SBP) and diastolic blood pressure (DBP) genome-wide association results obtained from 757,601 individuals of European descent. The association between PRS and grade 3 bevacizumab-induced hypertension (Common Toxicity Criteria for Adverse Events version 3) in each trial was performed by multivariable logistic regression. Fixed-effect meta-analyses odds ratios (ORs) per standard deviation (SD) of the association of PRS (quantitative) and hypertension across trials were estimated by inverse-variance weighting. PRSs were additionally stratified into quintiles, with the bottom quintile as the referent group. The OR of the association between hypertension and each quintile vs. the referent group was determined by logistic regression. The most significant PRS (quantitative)-hypertension association included up to 67 single-nucleotide variants (SNPs) associated with SBP (P = 0.0077, OR per SD = 1.31, 95% confidence interval (CI), 1.07-1.60), and up to 53 SNPs associated with DBP (P = 0.0209, OR per SD = 1.27, 95% CI, 1.04-1.56). Patients in the top quintile had a higher risk of developing bevacizumab-induced hypertension compared with patients in the bottom quintile using SNPs associated with SBP (P = 4.75 × 10^-4 , OR = 3.72, 95% CI, 1.84-8.16) and DBP (P = 0.076, OR = 1.83, 95% CI, 0.95-3.64). Genetic variants associated with essential hypertension, mainly SBP, increase the risk of severe bevacizumab-induced hypertension.

Age and comorbidity association with survival outcomes in metastatic colorectal cancer: CALGB 80405 analysis

BACKGROUND

Little is known about the interaction of comorbidities and age on survival outcomes in colorectal cancer (mCRC), nor how comorbidities impact treatment tolerance.

METHODS

We utilized a cohort of 1345 mCRC patients enrolled in CALGB/SWOG 80405, a multicenter phase III trial of fluorouracil/leucovorin + oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) plus bevacizumab, cetuximab or both. Endpoints were overall survival (OS), progression-free survival (PFS), and grade ≥ 3 toxicities assessed using NCI CTCAE v.3.0. Participants completed a questionnaire, including a modified Charlson Comorbidity Index. Adjusted Cox and logistic regression models tested associations of comorbidities and age on the endpoints.

RESULTS

In CALGB/SWOG 80405, 1095 (81%) subjects were < 70 years and >70 250 (19%). Presence of ≥1 comorbidity was not significantly associated with either OS (HR 1.10, 95% CI 0.96-1.25) or PFS (HR 1.03, 95% CI 0.91-1.16). Compared to subjects <70 with no comorbidities, OS was non-significantly inferior for ≥70 with no comorbidities (HR 1.21, 95% CI 0.98-1.49) and significantly inferior for ≥70 with at least one comorbidity (HR 1.51, 95% CI 1.22-1.86). There were no significant associations or interactions between age or comorbidity with PFS. Comorbidities were not associated with treatment-related toxicities. Age ≥ 70 was associated with greater risk of grade ≥ 3 toxicities (OR 2.15, 95% CI 1.50-3.09, p < 0.001).

CONCLUSIONS

Among participants in a clinical trial of combination chemotherapy for mCRC, presence of older age with comorbidities was associated with worse OS but not PFS. The association of age with toxicity suggests additional factors of care should be measured in clinical trials.

Plasma levels of VEGF-A and VCAM-1 as predictors of drug-induced hypertension in patients treated with VEGF-pathway inhibitors

BACKGROUND AND PURPOSE

Hypertension is a common toxicity induced by vascular endothelial growth factor (VEGF)-pathway inhibitors. There are no validated markers of hypertension induced by these drugs.

EXPERIMENTAL APPROACH

We previously discovered that cancer patients with lower plasma levels of angiopoietin-2, VCAM-1, and VEGF-A are at high risk of developing severe hypertension when treated with bevacizumab. This study aimed to validate the predictive value of these markers in pretreatment plasma samples of an additional cohort of 101 colorectal cancer patients treated with regorafenib. The levels of angiopoietin-2, VCAM-1, and VEGF-A were measured by ELISA. The association between proteins and grade ≥2 regorafenib-induced hypertension was performed by calculating the odds ratio (OR) from logistic regression. Using the optimal cut-point of each protein, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for hypertension were estimated.

KEY RESULTS

Lower levels of VCAM-1 (p=0.015, OR=3.11, 95% CI 1.27-8.08) and VEGF-A (p=0.007, OR=3.47, 95% CI 1.40-8.75) were associated with a higher risk of hypertension. Levels of angiopoietin-2 were not associated with hypertension. The multivariable model indicates an independent effect of VCAM-1 (p=0.018, OR=3.18, 95% CI 1.25-8.68) and VEGF-A (p=0.008, OR=3.77, 95% CI 1.44-10.21). The presence of low levels of both VCAM-1 and VEGF-A had an OR of 9.46 (95% CI 3.08-33.26, p=1.70x10^-4 ) for the risk of hypertension (sensitivity of 41.4%, specificity of 93.1%, PPV of 70.6% and NPV of 79.8%).

CONCLUSION AND IMPLICATIONS

This study confirmed the value of VCAM-1 and VEGF-A levels in predicting hypertension induced by regorafenib, another VEGF-pathway inhibitor.

Tumor Immunogenomic Features Determine Outcomes in Patients with Metastatic Colorectal Cancer Treated with Standard-of-Care Combinations of Bevacizumab and Cetuximab

PURPOSE

CALGB/SWOG 80405 was a randomized phase III trial in first-line patients with metastatic colorectal cancer treated with bevacizumab, cetuximab, or both, plus chemotherapy. We tested the effect of tumor immune features on overall survival (OS).

EXPERIMENTAL DESIGN

Primary tumors (N = 554) were profiled by RNA sequencing. Immune signatures of macrophages, lymphocytes, TGFβ, IFNγ, wound healing, and cytotoxicity were measured. CIBERSORTx scores of naive and memory B cells, plasma cells, CD8+ T cells, resting and activated memory CD4+ T cells, M0 and M2 macrophages, and activated mast cells were measured.

RESULTS

Increased M2 macrophage score [HR, 6.30; 95% confidence interval (CI), 3.0-12.15] and TGFβ signature expression (HR, 1.35; 95% CI, 1.05-1.77) were associated with shorter OS. Increased scores of plasma cells (HR, 0.55; 95% CI, 0.38-0.87) and activated memory CD4+ T cells (HR, 0.34; 95% CI, 0.16-0.65) were associated with longer OS. Using optimal cutoffs from these four features, patients were categorized as having either 4, 3, 2, or 0-1 beneficial features associated with longer OS, and the median (95% CI) OS decreased from 42.5 (35.8-47.8) to 31.0 (28.8-34.4), 25.2 (20.6-27.9), and 17.7 (13.5-20.4) months respectively (P = 3.48e-11).

CONCLUSIONS

New immune features can be further evaluated to improve patient response. They provide the rationale for more effective immunotherapy strategies.

Evaluation of methylated DCR1 as a biomarker for response to adjuvant irinotecan-based therapy in stage III colon cancer: cancer and leukaemia Group B 89803 (Alliance)

Aberrantly methylated genes contribute to the landscape of epigenetic alterations in colorectal adenocarcinoma. The global CpG Island methylator phenotype (CIMP) and individually methylated genes are potential prognostic/predictive biomarkers. Research suggests an association between methylated DCR1 (mDCR1) and lack of benefit with irinotecan (IFL) treatment. We assessed the association between DCR1 methylation status and survival in patients receiving adjuvant fluorouracil/ leucovorin (5-FU/LV) or IFL. We analysed data from patients with stage III colon adenocarcinoma randomly assigned to adjuvant 5-FU/LV or IFL in CALGB 89803 (Alliance). The primary endpoint was overall survival (OS), and the secondary endpoint was disease-free survival (DFS). Using tumour sample DNA, we evaluated the association between survival, DCR1 methylation status, and molecular subgroups (BRAF, KRAS, mismatch repair status, CIMP status) using Kaplan-Meier estimator and Cox proportional hazard model. mDCR1 was observed in 221/400 (55%) colon cancers. Histopathologic features were similar between mDCR1 and unmethylated DCR1 (unDCR1) colon cancers. There was no difference in OS (p = 0.83) or DFS (p = 0.85) based on DCR1 methylation status. There was no association between methylation status and response to IFL . In patients with unDCR1 and KRAS-wildtype tumours, those who received IFL had a nearly two-fold worse DFS compared to patients who received 5-FU/LV (HR = 1.85, 95% CI (0.97-3.53, p = 0.06). This relationship was not notable among other subgroups. In stage III colon cancer patients, mDCR1 status did not associate with response to irinotecan. Larger studies may suggest an association between the iridocene response and molecular subgroups.

Survival in Young-Onset Metastatic Colorectal Cancer: Findings From Cancer and Leukemia Group B (Alliance)/SWOG 80405

BACKGROUND

The incidence of young-onset colorectal cancer (yoCRC) is increasing. It is unknown if there are survival differences between young and older patients with metastatic colorectal cancer (mCRC).

METHODS

We studied the association of age with survival in 2326 mCRC patients enrolled in the Cancer and Leukemia Group B and SWOG 80405 trial, a multicenter, randomized trial of first-line chemotherapy plus biologics. The primary and secondary outcomes of this study were overall survival (OS) and progression-free survival (PFS), respectively, which were assessed by Kaplan-Meier method and compared among younger vs older patients with the log-rank test. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated based on Cox proportional hazards modeling, adjusting for known prognostic variables. All statistical tests were 2-sided.

RESULTS

Of 2326 eligible subjects, 514 (22.1%) were younger than age 50 years at study entry (yoCRC cohort). The median age of yoCRC patients was 44.3 vs 62.5 years in patients aged 50 years and older. There was no statistically significant difference in OS between yoCRC vs older-onset patients (median = 27.07 vs 26.12 months; adjusted HR = 0.98, 95% CI = 0.88 to 1.10; P = .78). The median PFS was also similar in yoCRC vs older patients (10.87 vs 10.55 months) with an adjusted hazard ratio of 1.02 (95% CI = 0.92 to 1.13; P = .67). Patients younger than age 35 years had the shortest OS with median OS of 21.95 vs 26.12 months in older-onset patients with an adjusted hazard ratio of 1.08 (95% CI = 0.81 to 1.44; Ptrend = .93).

CONCLUSION

In this large study of mCRC patients, there were no statistically significant differences in survival between patients with yoCRC and CRC patients aged 50 years and older.

Bevacizumab-induced hypertension and proteinuria: a genome-wide study of more than 1000 patients

BACKGROUND

Hypertension and proteinuria are common bevacizumab-induced toxicities. No validated biomarkers are available for identifying patients at risk of these toxicities.

METHODS

A genome-wide association study (GWAS) meta-analysis was performed in 1039 bevacizumab-treated patients of European ancestry in four clinical trials (CALGB 40502, 40503, 80303, 90401). Grade ≥2 hypertension and proteinuria were recorded (CTCAE v.3.0). Single-nucleotide polymorphism (SNP)-toxicity associations were determined using a cause-specific Cox model adjusting for age and sex.

RESULTS

The most significant SNP associated with hypertension with concordant effect in three out of the four studies (p-value <0.05 for each study) was rs6770663 (A > G) in KCNAB1, with the G allele increasing the risk of hypertension (p-value = 4.16 × 10-6). The effect of the G allele was replicated in ECOG-ACRIN E5103 in 582 patients (p-value = 0.005). The meta-analysis of all five studies for rs6770663 led to p-value = 7.73 × 10-8, close to genome-wide significance. The most significant SNP associated with proteinuria was rs339947 (C > A, between DNAH5 and TRIO), with the A allele increasing the risk of proteinuria (p-value = 1.58 × 10-7).

CONCLUSIONS

The results from the largest study of bevacizumab toxicity provide new markers of drug safety for further evaluations. SNP in KCNAB1 validated in an independent dataset provides evidence toward its clinical applicability to predict bevacizumab-induced hypertension. ClinicalTrials.gov Identifier: NCT00785291 (CALGB 40502); NCT00601900 (CALGB 40503); NCT00088894 (CALGB 80303) and NCT00110214 (CALGB 90401).

PIK3R5 genetic predictors of hypertension induced by VEGF-pathway inhibitors

No biomarkers are available to predict patients at risk of developing hypertension induced by VEGF-pathway inhibitors. This study aimed to identify predictive biomarkers of hypertension induced by these drugs using a discovery-replication approach. The discovery set included 140 sorafenib-treated patients (TARGET study) genotyped for 973 SNPs in 56 genes. The most statistically significant SNPs associated with grade ≥2 hypertension were tested for association with grade ≥2 hypertension in the replication set of a GWAS of 1039 bevacizumab-treated patients from four clinical trials (CALGB/Alliance). In the discovery set, rs444904 (G > A) in PIK3R5 was associated with an increased risk of sorafenib-induced hypertension (p = 0.006, OR = 3.88 95% CI 1.54-9.81). In the replication set, rs427554 (G > A) in PIK3R5 (in complete linkage disequilibrium with rs444904) was associated with an increased risk of bevacizumab-induced hypertension (p = 0.008, OR = 1.39, 95% CI 1.09-1.78). This study identified a predictive marker of drug-induced hypertension that should be evaluated for other VEGF-pathway inhibitors.ClinicalTrials.gov Identifier:NCT00073307 (TARGET).

Circulating tumor DNA dynamics on front-line chemotherapy with bevacizumab or cetuximab in metastatic colorectal cancer: A biomarker analysis for acquired genomic alterations in CALGB/SWOG 80405 (Alliance) randomized trial

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Background: Enhanced understanding of the evolving clonal architecture under treatment stress is crucial to optimizing care and developing effective therapies in metastatic colorectal cancer (mCRC). Emergence of genomic alterations (GAs) [mutations (muts) and amplifications (amps)] in RAS, BRAF, EGFR, ERBB2, and MET have been recognized as key resistance mechanisms to anti-EGFR therapy in later lines in mCRC. Data regarding occurrence of these GAs under selective pressure in the first line setting is lacking. Methods: CALGB/SWOG 80405 was a randomized trial of bevacizumab (bev) vs cetuximab (cet) in first line mCRC. Patients (pts) with paired plasma samples (pre-treatment and post-progression) available for circulating tumor DNA (ctDNA) testing were included in this substudy. Sequencing of ctDNA was performed by Guardant360 assay in a CLIA-certified environment to detect GAs in 73 genes. RAS/BRAF status [mut vs. wild type (wt)] was based on clonal muts [pre-defined cutoff of relative MAF (rMAF) ≥ 25%] in ctDNA. Only samples with ≥1 GA were analyzed to minimize false negatives. The primary objective was to determine and compare prevalence of acquired GAs between study arms: bev (anti-VEGF) and cet (anti-EGFR). Descriptive statistics and Fisher’s exact test were used. Results: Baseline characteristics of ctDNA cohort were similar to the 80405 population. Among 133 randomized RAS/BRAF wt pts, 11 (15.3%) and 5 (8.2%) developed acquired GAs (OR 2.0, P = 0.29), in bev and cet arm, respectively. Key comparative data for pts with regard to acquired pathogenic GAs are shown in the table. Conclusions: In this randomized mCRC cohort, the ctDNA profile of acquired GAs with front line anti-EGFR chemotherapy appears to be strikingly distinct from that seen with later lines of therapy. Acquisition of GAs, classically associated with EGFR resistance in later line, was not only rare with upfront cet-chemotherapy but also comparable to bev-containing (anti-VEGF) regimen. The mechanisms of acquired resistance appear to differ when anti-EGFR therapy is administered in combination with highly active first line chemotherapy. Our findings have critical translational relevance to the timing and value of ctDNA-guided anti-EGFR rechallenge in mCRC pts, especially in those treated with anti-EGFR therapy upfront.[Table: see text]

Genome-wide association studies of survival in 1520 cancer patients treated with bevacizumab-containing regimens

Germline variants might predict cancer progression. Bevacizumab improves overall survival (OS) in patients with advanced cancers. No biomarkers are available to identify patients that benefit from bevacizumab. A meta-analysis of genome-wide association studies (GWAS) was conducted in 1,520 patients from Phase III trials (CALGB 80303, 40503, 80405 and ICON7), where bevacizumab was randomized to treatment without bevacizumab. We aimed to identify genes and single nucleotide polymorphisms (SNPs) associated with survival independently of bevacizumab treatment or through interaction with bevacizumab. A cause-specific Cox model was used to test the SNP-OS association in both arms combined (prognostic), and the effect of SNPs-bevacizumab interaction on OS (predictive) in each study. The SNP effects across studies were combined using inverse variance. Findings were tested for replication in advanced colorectal and ovarian cancer patients from The Cancer Genome Atlas (TGCA). In the GWAS meta-analysis, patients with rs680949 in PRUNE2 experienced shorter OS compared to patients without it (P = 1.02 × 10^-7 , hazard ratio [HR] = 1.57, 95% confidence interval [CI] 1.33-1.86), as well as in TCGA (P = .0219, HR = 1.58, 95% CI 1.07-2.35). In the GWAS meta-analysis, patients with rs16852804 in BARD1 experienced shorter OS compared to patients without it (P = 1.40 × 10^-5 , HR = 1.51, 95% CI 1.25-1.82) as well as in TCGA (P = 1.39 × 10^-4 , HR = 3.09, 95% CI 1.73-5.51). Patients with rs3795897 in AGAP1 experienced shorter OS in the bevacizumab arm compared to the nonbevacizumab arm (P = 1.43 × 10^-5 ). The largest GWAS meta-analysis of bevacizumab treated patients identified PRUNE2 and BARD1 (tumor suppressor genes) as prognostic genes of colorectal and ovarian cancer, respectively, and AGAP1 as a potentially predictive gene that interacts with bevacizumab with respect to patient survival.

All You Need to Know About UGT1A1 Genetic Testing for Patients Treated With Irinotecan: A Practitioner-Friendly Guide

Irinotecan is an anticancer agent widely used for the treatment of solid tumors, including colorectal and pancreatic cancers. Severe neutropenia and diarrhea are common dose-limiting toxicities of irinotecan-based therapy, and UGT1A1 polymorphisms are one of the major risk factors of these toxicities. In 2005, the US Food and Drug Administration revised the drug label to indicate that patients with UGT1A1*28 homozygous genotype should receive a decreased dose of irinotecan. However, UGT1A1*28 testing is not routinely used in the clinic, and specific reasons include lack of access to concise information on this wide issue as well as mixed recommendations by regulatory and professional entities. To assist oncologists in assessing whether and when to use UGT1A1 genetic testing in patients receiving irinotecan-based therapies, this article provided (1) essential knowledge of UGT1A1 polymorphisms; (2) an update on the impact of UGT1A1 polymorphisms on efficacy and toxicity of contemporary irinotecan-based regimens; (3) dosing adjustments based upon the UGT1A1 genotypes, and (4) recommendations from currently available guidelines from the US and international scientific consortia and major oncology societies.

Genome-Wide Meta-analysis Identifies Genetic Variants Associated With Glycemic Response to Sulfonylureas

OBJECTIVE

Sulfonylureas, the first available drugs for the management of type 2 diabetes, remain widely prescribed today. However, there exists significant variability in glycemic response to treatment. We aimed to establish heritability of sulfonylurea response and identify genetic variants and interacting treatments associated with HbA1c reduction.

RESEARCH DESIGN AND METHODS

As an initiative of the Metformin Genetics Plus Consortium (MetGen Plus) and the DIabetes REsearCh on patient straTification (DIRECT) consortium, 5,485 White Europeans with type 2 diabetes treated with sulfonylureas were recruited from six referral centers in Europe and North America. We first estimated heritability using the generalized restricted maximum likelihood approach and then undertook genome-wide association studies of glycemic response to sulfonylureas measured as HbA1c reduction after 12 months of therapy followed by meta-analysis. These results were supported by acute glipizide challenge in humans who were naïve to type 2 diabetes medications, cis expression quantitative trait loci (eQTL), and functional validation in cellular models. Finally, we examined for possible drug-drug-gene interactions.

RESULTS

After establishing that sulfonylurea response is heritable (mean ± SEM 37 ± 11%), we identified two independent loci near the GXYLT1 and SLCO1B1 genes associated with HbA1c reduction at a genome-wide scale (P < 5 × 10-8). The C allele at rs1234032, near GXYLT1, was associated with 0.14% (1.5 mmol/mol), P = 2.39 × 10-8), lower reduction in HbA1c. Similarly, the C allele was associated with higher glucose trough levels (β = 1.61, P = 0.005) in healthy volunteers in the SUGAR-MGH given glipizide (N = 857). In 3,029 human whole blood samples, the C allele is a cis eQTL for increased expression of GXYLT1 (β = 0.21, P = 2.04 × 10-58). The C allele of rs10770791, in an intronic region of SLCO1B1, was associated with 0.11% (1.2 mmol/mol) greater reduction in HbA1c (P = 4.80 × 10-8). In 1,183 human liver samples, the C allele at rs10770791 is a cis eQTL for reduced SLCO1B1 expression (P = 1.61 × 10-7), which, together with functional studies in cells expressing SLCO1B1, supports a key role for hepatic SLCO1B1 (encoding OATP1B1) in regulation of sulfonylurea transport. Further, a significant interaction between statin use and SLCO1B1 genotype was observed (P = 0.001). In statin nonusers, C allele homozygotes at rs10770791 had a large absolute reduction in HbA1c (0.48 ± 0.12% [5.2 ± 1.26 mmol/mol]), equivalent to that associated with initiation of a dipeptidyl peptidase 4 inhibitor.

CONCLUSIONS

We have identified clinically important genetic effects at genome-wide levels of significance, and important drug-drug-gene interactions, which include commonly prescribed statins. With increasing availability of genetic data embedded in clinical records these findings will be important in prescribing glucose-lowering drugs.

Racial differences in survival and response to therapy in patients with metastatic colorectal cancer: A secondary analysis of CALGB/SWOG 80405 (Alliance A151931)

BACKGROUND

The objective of this study was to evaluate the association between self-identified race and overall survival (OS), progression-free survival (PFS), and response to therapy among patients enrolled in the randomized Cancer and Leukemia Group B (CALGB)/SWOG 80405 trial.

METHODS

Patients with advanced or metastatic colorectal cancer who were enrolled in the CALGB/SWOG 80405 trial were identified by race. On the basis of covariates (treatment arm, KRAS status, sex, age, and body mass index), each Black patient was exact matched with a White patient. The association between race and OS and PFS was examined using a marginal Cox proportional hazard model for matched pairs. The interaction between KRAS status and race was tested in the model. The association between race and response to therapy and adverse events were examined using a marginal logistic regression model.

RESULTS

In total, 392 patients were matched and included in the final data set. No difference in OS (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.73-1.16), PFS (HR, 0.97; 95% CI, 0.78-1.20), or response to therapy (odds ratio [OR], 1.00; 95% CI, 0.65-1.52) was observed between Black and White patients. Patients with KRAS mutant status (HR, 1.31; 95% CI, 1.02-1.67), a performance statusscore of 1 (reference, a performance status of 0; HR, 1.49; 95% CI, 1.18-1.88), or ≥3 metastatic sites (reference, 1 metastatic site; HR, 1.67; 95% CI, 1.22-2.28) experienced worse OS. Black patients experienced lower rates and risk of grade ≥3 fatigue (6.6% vs 13.3%; OR, 0.46; 95% CI, 0.24-0.91) but were equally likely to be treated with a dose reduction (OR, 1.09; 95% CI, 0.72-1.65).

CONCLUSIONS

No difference in OS, PFS, or response to therapy was observed between Black patients and White patients in an equal treatment setting of the CALGB/SWOG 80405 randomized controlled trial.

LAY SUMMARY

Despite improvements in screening and treatment, studies have demonstrated worse outcomes in Black patients with colorectal cancer. The purpose of this study was to determine whether there was a difference in cancer-specific outcomes among Black and White patients receiving equivalent treatment on the CALGB/SWOG 80405 randomized clinical trial. In this study, there was no difference in overall survival, progression-free survival, or response to therapy between Black and White patients treated on a clinical trial. These findings suggest that access to care and differences in treatment may be responsible for racial disparities in colorectal cancer.

P–783 Clinical, obstetric and perinatal outcomes after vitrified-warmed euploid blastocyst transfer are independent of cryo-storage duration

Study question

Is cryo-storage duration associated with the outcomes after vitrified-warmed euploid single blastocyst transfer?

Summary answer

Lower live-birth-rates from blastocysts cryo-stored for periods longer than 3-months are mostly imputable to the worse quality of the embryos being warmed across sequential transfers.

What is known already

Blastocyst vitrification is crucial in modern IVF. Given its widespread application, a constant comprehensive monitoring of its effect on reproductive outcomes is pivotal. For instance, the effect of cryo-storage duration on embryo implantation potential, gestational and perinatal outcomes is object of a still ongoing investigation. The evidence in this regard are contrasting especially with regard to similar or decreased live birth rates among blastocysts subject to long-term cryo-storage. When investigating the neonatal outcomes, instead, no impact of blastocyst cryo-storage duration has ever been reported to date. Yet, data on euploid blastocysts and adjusted for quality and full-blastulation day are needed.

Study design, size, duration

Retrospective observational study. We included 2688 vitrified-warmed euploid single blastocyst transfers. The primary outcome was the live-birth-rates (LBR) according to cryo-storage duration clustered as ≤ 60, 61–90, 91–180, 181–360, 361–720, 721–1080 and &gt;1080-days. The secondary outcomes were the miscarriage rate, the rates of gestational and perinatal issues among the deliveries, and the mean gestational age and birthweight among the babies born. All data were adjusted for confounders through linear or logistic regression analyses. Participants/materials, setting, methods: We included all vitrified-warmed transfers (range:1–8) conducted between May–2013 and March–2020 by 1884 patients (age:38±3yr) undergoing one blastocyst stage PGT-A cycle and obtaining ≥1 euploid embryo at our private clinic. Among putative confounders, only the number of sequential transfer from the same patient, blastocyst quality (Gardner’s scheme) and full-blastulation day (5–7) significantly associated with the LBR through univariate regressions. No association was reported for sperm factor, maternal age, incubator, and culture media.

Main results and the role of chance

The LBR of euploid blastocysts cryo-stored for ≤60-days was 49.4% (N = 319/646) versus 48.7% (N = 292/599; OR:0.98,95%CI:0.78–1.21,p=0.82) between 61–90-days, 42.9% (N = 291/679; OR:0.77,95%CI:0.62–0.96,p=0.02) between 91–180-days, 41.7% (N = 169/405; OR:0.73,95%CI:0.57–0.94,p=0.02) between 181–360-days, 34.7% (N = 50/144; OR:0.55,95%CI:0.37–0.79,p&lt;0.01) between 361–720-days, 53.4% (N = 63/118; OR:1.17,95%CI:0.79–1.74,p=0.42) between 721–1080-days, and 50.5% (N = 49/97; OR:1.05,95%CI:0.68–1.60,p=0.83) for &gt;1080-days. However, when these data were adjusted for blastocyst quality and full-blastulation day, all the multivariate-OR were not-significant. Indeed, the longer the cryo-storage period the worse the quality of the euploid blastocysts transferred (e.g. AA-blastocysts were 74% among embryos cryo-stored for ≤90-days, but always &lt;70% for embryos cryo-stored for longer periods, p &lt; 0.01; similarly, day5-blastocysts were ∼50% among embryos cryo-stored for ≤90-days, but always &lt;50% for embryos cryo-stored for longer periods, p = 0.02). The miscarriage-rate (overall 14%, ranging 7–18%) was not associated with cryo-storage duration already from univariate regressions. Also the gestational (overall 6%, ranging 0–8%) and perinatal issues rates (overall 3%, ranging 0–5%) were not associated with cryo-storage duration already from the univariate regressions. Neither the gestational age nor the birthweight showed significant associations with cryo-storage duration, as confirmed by linear regressions. In fact the rate of newborns whose weight was normal-for-gestational-age was similar across all cryo-storage duration groups (overall 81%, ranging 80–83%).

Limitations, reasons for caution

The prevalence of first transfers decreases from ≥95% for procedures conducted ≤90-days from vitrification to 71%, 39%, 22% and 4% for procedures conducted between 91–180, 181–360, 361–720 and &gt;720-days, respectively. However, also the sequential number of transfer was not associated with the LBR when adjusted for blastocyst-quality and full-blastulation day.

Wider implications of the findings: Cryo-storage by vitrification is confirmed safe in the hands of experienced operators, and its duration does not impact any outcome. This information is valuable for freeze-all cycles, but also for women cryo-preserving surplus embryos for second pregnancies; in this regard, 6.8% of the patients in this study delivered ≥2 LBs.

Trial registration number

Not applicable

P–210 Abnormal cleavage patterns during embryo preimplantation development and their effect on blastulation: an overview from IVF patients with multiple IVF cycles in a time-lapse incubator

Study question

How common abnormal cleavage patterns (ACP) are in IVF and what are their consequences on embryo developmental competence?

Summary answer

ACP might affect up to 25% of the 2PN-zygotes, independently from patients’/cycles’ characteristics, and mostly cause embryo developmental arrest around the 4-to–8-cell transition.

What is known already

Since its implementation in IVF, time-lapse-microscopy (TLM) allowed the standardization of embryo culture within undisturbed incubators, but it has not improved embryo selection especially if blastocyst transfer is performed. Nevertheless, TLM holds the potential for boosting our knowledge of embryo preimplantation development. In particular, a continuous observation of embryo morpho-dynamics unveiled peculiar blastomere cleavage patterns previously unidentifiable with a static morphological assessment. These events are possibly associated with massive mitotic errors, affecting both chromosomes and cytoskeletal components, as well as downstream metabolic imbalances. Still, the causes of ACP and their consequences on embryo developmental/reproductive competence require further investigation.

Study design, size, duration

Observational study including 75 patients (age:38.6±3.7yr, FSH:8.8±3.6IU/l, AMH:1.7±1.3ng/ml; BMI:21.4±2.4) who conducted multiple IVF cycles (N = 160; 8.7±5.0 cumulus-oocyte-complexes and 6.3±3.6 metaphase-II collected; 201±245 days between first and second cycles) in a time-lapse incubator between 2014–2020. All annotations were performed blindly by two operators and confirmed by a third in case of discordance. The outcomes were the blastulation rate after any ACP, their association between each other and with patients’/cycles’ characteristics.

Participants/materials, setting, methods

We included only ICSI-cycles after ovarian-stimulation with blastocyst culture conducted in the Embryoscope. Overall, 981 metaphase-II were inseminated and 677 2PN-zygotes annotated. The ACP investigated were: (i)cytokinesis-failure, formation of cytoplasmic septa without cell division; (ii)Chaotic-cleavage, disordered and uneven cleavages; (iii)Direct-unequal-cleavage (DUC), cleavage of zygotes or single blastomeres directly into 3; (iv)Rapid-cleavage, t3-t2&lt;5hr; (v)Reverse-cleavage, fusion of 2 blastomeres into 1; (vi)Fragmentation, presence of numerous non-nucleated fragments; (vii)Blastomeres’ exclusion/extrusion, nucleated cells excluded/extruded from the morula.

Main results and the role of chance

Among the 2PN-zygotes, the prevalence of cytokinesis-failure was 5.9% (N = 40/677), 15.7% for chaotic-cleavage (N = 106/677), 18.6% for DUC (N = 126/677), 4.1% for rapid-cleavage (N = 28/677), 3.5% for reverse-cleavage (N = 24/677) and 24.1% for fragmentation (N = 163/677). Among the morulae, the prevalence of blastomere exclusion/extrusion was 27% (N = 109/410;1.5±1.2 excluded/extruded cells,range:1–7). The risk for reverse-cleavage was higher among 2PN-zygotes facing failed-cytokinesis (N = 8/40,20% versus N = 16/637,2.5%, OR:9.7,95%CI:3.9–24.3,p&lt;0.01). Fragmentation was instead higher among 2PN-zygotes undergoing chaotic cleavage (N = 47/106,44.3% versus N = 116/571,20.3%, OR:3.1,95%CI:2–4.8,p&lt;0.01) or DUC (N = 46/126,36.5% versus N = 117/551,21.2%, OR:2.1,95%CI:1.4–3.2,p&lt;0.01). Lastly, higher prevalence of blastomeres’ exclusion/extrusion were reported among morulae obtained after chaotic-cleavage (N = 17/29,58.6% versus N = 92/381,24.1%, OR:4.4,95%CI:2–9.7,p&lt;0.01), DUC (N = 26/37,70.3% versus N = 83/373,22.3%, OR:8.3,95%CI:3.9–17.4,p&lt;0.01) and in presence of fragmentation (N = 79/195,75.2% versus N = 30/305,9.8%, OR:27.8,95%CI:15.6–49.8,p&lt;0.01); only a higher trend after rapid-/reverse-cleavage.

No predictive factor of ACP was identified among patients’ and cycles’ characteristics, except for higher risks of fragmentation (OR:2.6,95%CI:1.1–6.3,p= 0.04) and blastomeres’ exclusion/extrusion (OR:2.7,95%CI:1.1–7.2,p=0.04) among patients with previous experience with these events.

The viable-blastocyst rate per 2PN-zygote was 45.1% (N = 305/677). It was lower in case of failed-cytokinesis (N = 12/40,30% versus N = 293/637,46%, OR:0.5,95%CI:0.25–0.99,p=0.05), chaotic cleavage (N = 20/106,18.9% versus N = 285/571,49.9%, OR:0.23,95%CI:0.14–0.39,p&lt;0.01), DUC (N = 27/126,21.4% versus N = 278/551,50.5%, OR:0.27,95%CI:0.17–0.42,p&lt;0.01), rapid-cleavage (N = 6/22,21.4% versus N = 299/649,46.1%, OR:0.32,95%CI:0.13–0.8,p=0.02), and reverse-cleavage (N = 5/19,20.8% versus N = 300/653,45.9%, OR:0.31, 95%CI:0.11–0.84,p=0.02). No difference was instead shown in case of fragmentation and/or blastomeres’ exclusion/extrusion.

Limitations, reasons for caution

The patients included were poor-prognosis women undergoing ≥2 cycles. We are expanding the sample size to account for all cycles conducted in time-lapse incubators. Larger sample size will provide also statistical-power to investigate the effect of ACP on blastocysts’ chromosomal and implantation competence, and more visualizations of rapid-/reverse-cleavage events.

Wider implications of the findings: After ACP,developmental-arrest mostly occurs around the 4-to–8-cell transition (50–70% versus ∼30%), when embryonic-genome-activation takes place. Surviving embryos often fragment and/or exclude/extrude blastomeres at morulation, without further impact on blastulation-rates. Moreover, ACP seem independent from patients’/cycles’ characteristics. These evidence incite future Research on the biological/genetic mechanisms triggering ACP and their consequences.

Trial registration number

None