The Journey to Improve the College of American Pathologists Cancer Biomarker Reporting Protocols

CONTEXT.—

Biomarker reporting has increasingly become a key component of pathology reporting, providing diagnostic, prognostic, and actionable therapeutic data for patient care.

OBJECTIVE.—

To expand and improve the College of American Pathologists (CAP) biomarker protocols.

DESIGN.—

We surveyed CAP members to better understand the limitations they experienced when reporting cancer biomarker results. A Biomarker Workgroup reviewed the survey results and developed a strategy to improve and standardize biomarker reporting. Drafts of new and revised biomarker protocols were reviewed in both print and electronic template formats during interactive webinars presented to the CAP House of Delegates. Feedback was collected, and appropriate revisions were made to finalize the protocols.

RESULTS.—

The first phase of the CAP Biomarker Workgroup saw the development of (1) a new stand-alone general Immunohistochemistry Biomarker Protocol that includes reporting for ER (estrogen receptor), PR (progesterone receptor), Ki-67, HER2 (human epidermal growth factor receptor 2), PD-L1 (programmed death ligand-1), and mismatch repair; (2) a new Head and Neck Biomarker Protocol that updates the prior 2017 paper-only version into an electronic template, adding new diagnostic and theranostic markers; (3) a major revision to the Lung Biomarker Protocol to streamline it and add in pan-cancer markers; and (4) a revision to the Colon and Rectum Biomarker Protocol to add HER2 reporting.

CONCLUSIONS.—

We have taken a multipronged approach to improving biomarker reporting in the CAP cancer protocols. We continue to review current biomarker reporting protocols to reduce and eliminate unnecessary methodologic details and update with new markers as needed. The biomarker templates will serve as standardized modular units that can be inserted into cancer-reporting protocols.

Genomic determinants of response and resistance to inotuzumab ozogamicin in B-cell ALL

Inotuzumab ozogamicin (InO) is an antibody-drug conjugate that delivers calicheamicin to CD22-expressing cells. In a retrospective cohort of InO treated patients with B-cell acute lymphoblastic leukemia, we sought to understand the genomic determinants of response to InO. Acquired CD22 mutations were observed in 11% (3/27) of post-InO relapsed tumor samples. There were multiple CD22 mutations per sample and the mechanisms of CD22 escape included protein truncation, protein destabilization, and epitope alteration. Hypermutation by error-prone DNA damage repair (alternative end-joining, mismatch repair deficiency) drove CD22 escape. Acquired loss-of-function mutations in TP53 , ATM and CDKN2A were observed, suggesting compromise of the G1/S DNA damage checkpoint as a mechanism of evading InO-induced apoptosis. In conclusion, genetic alterations modulating CD22 expression and DNA damage response influence InO efficacy. The escape strategies within and beyond antigen loss to CD22-targeted therapy elucidated in this study provide insights into improving therapeutic approaches and overcoming resistance.

KEY POINTS

We identified multiple mechanisms of CD22 antigen escape from inotuzumab ozogamicin, including protein truncation, protein destabilization, and epitope alteration.Hypermutation caused by error-prone DNA damage repair was a driver of CD22 mutation and escape.

VISUAL ABSTRACT

A Phase I study of Milademetan (DS3032b) in combination with low dose cytarabine with or without venetoclax in acute myeloid leukemia: Clinical safety, efficacy, and correlative analysis

In TP53 wild-type acute myeloid leukemia (AML), inhibition of MDM2 can enhance p53 protein expression and potentiate leukemic cell apoptosis. MDM2 inhibitor (MDM2i) monotherapy in AML has shown modest responses in clinical trials but combining options of MDM2i with other potent AML-directed agents like cytarabine and venetoclax could improve its efficacy. We conducted a phase I clinical trial (NCT03634228) to study the safety and efficacy of milademetan (an MDM2i) with low-dose cytarabine (LDAC)±venetoclax in adult patients with relapsed refractory (R/R) or newly diagnosed (ND; unfit) TP53 wild-type AML and performed comprehensive CyTOF analyses to interrogate multiple signaling pathways, the p53-MDM2 axis and the interplay between pro/anti-apoptotic molecules to identify factors that determine response and resistance to therapy. Sixteen patients (14 R/R, 2 N/D treated secondary AML) at a median age of 70 years (range, 23-80 years) were treated in this trial. Two patients (13%) achieved an overall response (complete remission with incomplete hematological recovery). Median cycles on trial were 1 (range 1-7) and at a median follow-up of 11 months, no patients remained on active therapy. Gastrointestinal toxicity was significant and dose-limiting (50% of patients ≥ grade 3). Single-cell proteomic analysis of the leukemia compartment revealed therapy-induced proteomic alterations and potential mechanisms of adaptive response to the MDM2i combination. The response was associated with immune cell abundance and induced the proteomic profiles of leukemia cells to disrupt survival pathways and significantly reduced MCL1 and YTHDF2 to potentiate leukemic cell death. The combination of milademetan, LDAC±venetoclax led to only modest responses with recognizable gastrointestinal toxicity. Treatment-induced reduction of MCL1 and YTHDF2 in an immune-rich milieu correlate with treatment response.

Clinicopathologic Features of Therapy-Related Myeloid Neoplasms in Patients with Myeloma in the Era of Novel Therapies

The development of therapy-related myeloid neoplasms (t-MN) is a rare complication that can occur in myeloma patients treated primarily with novel therapies. To better understand t-MNs in this context, we reviewed 66 such patients and compared them with a control group of patients who developed t-MN after cytotoxic therapies for other malignancies. The study group included 50 men and 16 women, with a median age of 68 years (range, 48-86 years). Therapies included proteasome inhibitors, immunomodulatory agents, and high-dose melphalan-based autologous stem cell transplantation (HDM-ASCT) in 64 (97%), 65 (98.5%), and 64 (97%) patients, respectively; 29 (43.9%) patients were exposed to other cytotoxic drugs besides HDM. The latency interval from therapy to t-MN was 4.9 years (range, 0.6-21.9 years). Patients who received HDM-ASCT in addition to other cytotoxic therapies had a longer latency period to t-MN compared with patients who only received HDM-ASCT (6.1 vs 4.7 years, P = .009). Notably, 11 patients developed t-MN within 2 years. Therapy-related myelodysplastic syndrome was the most common type of neoplasm (n = 60), followed by therapy-related acute myeloid leukemia (n = 4) and myelodysplastic syndrome/myeloproliferative neoplasm (n = 2). The most common cytogenetic aberrations included complex karyotypes (48.5%), del7q/-7 (43.9%), and/or del5q/-5 (40.9%). The most frequent molecular alteration was TP53 mutation, in 43 (67.2%) patients and the sole mutation in 20 patients. Other mutations included DNMT3A, 26.6%; TET2, 14.1%; RUNX1, 10.9%; ASXL1, 7.8%; and U2AF1, 7.8%. Other mutations in less than 5% of cases included SRSF2, EZH2, STAG2, NRAS, SETBP, SF3B1, SF3A1, and ASXL2. After a median follow-up of 15.3 months, 18 patients were alive and 48 died. The median overall survival after the diagnosis of t-MN in the study group was 18.4 months. Although the overall features are comparable to the control group, the short interval to t-MN (<2 years) underscores the unique vulnerable status of myeloma patients.

Mini-hyper-CVD plus inotuzumab ozogamicin, with or without blinatumomab, in the subgroup of older patients with newly diagnosed Philadelphia chromosome-negative B-cell acute lymphocytic leukaemia: long-term results of an open-label phase 2 trial

BACKGROUND

The outcome of older patients with B-cell acute lymphocytic leukaemia is inferior to that in younger patients due to the adverse disease biology and their inability to tolerate intensive therapy. We aimed to study the long-term outcomes of inotuzumab ozogamicin with or without blinatumomab in combination with low-intensity chemotherapy in these patients.

METHODS

For this open-label phase 2 trial, patients aged 60 years or older with newly diagnosed, Philadelphia-chromosome negative, B-cell acute lymphocytic leukaemia, and an ECOG performance status of 3 or lower were eligible. This study was conducted at the University of Texas MD Anderson Cancer Center. The induction chemotherapy consisted of mini-hyper-CVD and has been published before; inotuzumab ozogamicin was administered intravenously on day 3 of the first four cycles at a dose of 1·3-1·8 mg/m² in cycle 1, followed by 1·0-1·3 mg/m² in subsequent cycles (cycles 2-4). Maintenance therapy with dose-reduced POMP (6-mercaptopurine, vincristine, methotrexate, and prednisone) was given for 3 years. From patient 50 onwards, the study protocol was amended to fractionate inotuzumab ozogamicin to a maximum cumulative dose of 2·7 mg/m² (0·9 mg/m² during cycle 1 fractionated into 0·6 mg/m² on day 2 and 0·3 mg/m² on day 8 of cycle 1, and 0·6 mg/m² in cycles 2-4 fractionated into 0·3 mg/m² on day 2 and 0·3 mg/m² on day 8) followed by blinatumomab for four cycles (cycles 5-8). POMP maintenance was shortened to 12 cycles with one cycle of blinatumomab administered by continuous infusion after every three cycles of POMP. The primary endpoint was progression-free survival and was analysed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov (NCT01371630) and the present data is from the newly diagnosed, older subgroup of patients treated on the phase 2 portion of this trial; the trial is still enrolling patients.

RESULTS

Between Nov 11, 2011, and March 31, 2022, 80 patients were enrolled and treated (32 female and 48 male patients; median age 68 years [IQR 63-72]), 31 of whom were treated after the protocol amendment. With a median follow-up of 92·8 months (IQR 8·8-67·4), the 2-year progression-free survival was 58·2% (95% CI 46·7-68·2) and 5-year progression-free survival was 44·0% (31·2-54·3). At a median follow-up of 104·4 months (IQR 6·6-89·2) for the patients treated before the protocol amendment and 29·7 months (8·8-41·0) for those treated after the protocol amendment, median progression-free survival did not differ significantly between the two groups (34·7 months [95% CI 15·0-68·3] vs 56·4 months [11·3-69·7]; p=0·77). The most common grade 3-4 events were thrombocytopenia in 62 (78%) patients and febrile neutropenia in 26 (32%) patients. Six (8%) patients developed hepatic sinusoidal obstruction syndrome. There were eight (10%) deaths due to infectious complications, nine (11%) from complications related to secondary myeloid malignancy, and four (5%) from sinusoidal obstruction syndrome.

INTERPRETATION

Inotuzumab ozogamicin with or without blinatumomab added to low-intensity chemotherapy showed promising activity in terms of progression-free survival in older patients with B-cell acute lymphocytic leukaemia. Further attenuation of the chemotherapy regimen might improve tolerability while maintaining efficacy in older patients.

FUNDING

Pfizer and Amgen.

Injuries Common to the Brazilian Jiu-Jitsu Practitioner

BACKGROUND

Brazilian jiu-jitsu (BJJ) is a martial art that focuses on ground combat, emphasizing skill over strength and submission over striking. The purpose of this study is to evaluate the nature of injuries affecting practitioners of BJJ in the settings of competition, training, and conditioning.

METHODS

An online survey was created to collect demographic and injury-specific information. This survey was distributed to the 234 schools in the United States registered with the International Brazilian Jiu-Jitsu Federation (IBJJF). The survey was also distributed to local BJJ schools and at local tournaments in the Greater New York City area. Data from a total of N=56 participants were recorded for this survey.

RESULTS

The majority of participants were male (n=44, 78.6%) and amateur competitors (n=29, 51.8%) with an average duration of BJJ training of 6.9 ± 5.9 years. The majority of participants (82.1%) train at least six hours per week and compete in an average of 4.6 ± 2.5 competitions per year. The most common injuries were to the finger/hand (78.6%) and knee (61.5%). The most commonly reported fracture was of the hand/fingers (n=6). Of the 156 total injuries reported, 133 (85.3%) occurred during practice or training rather than in competition and 76 (48.7%) required medical attention. Few injuries required surgical intervention.

CONCLUSIONS

This study provides novel information regarding injury characteristics of BJJ practitioners with respect to the level of training and use of protective equipment that can guide expectations and management for this unique group of athletes. Amateur BJJ practitioners are the most commonly injured, and largely experience injuries of the upper extremities during training or conditioning rather than during competition.

Abstract P5-06-01: A Multi-center Clinical Study to Harvest and Characterize Circulating Tumor Cells from Patients with Metastatic Breast Cancer Using the Parsortix® PC1 System in support of FDA clearance

Background: Circulating tumor cells (CTCs) captured from the blood of cancer patients may serve as a non-invasive surrogate source of tumor material to investigate tumor characteristics in real-time. However, the only FDA-cleared CTC assay is limited to the enumeration of surface marker-defined epithelial cells and not designed for further characterization of the CTCs identified. The Parsortix® PC1 system is a semi-automated microfluidic device capable of capturing and harvesting CTCs from peripheral blood based on cell size and deformability, making it cell-surface marker agnostic. Here, we demonstrate that the Parsortix® PC1 system enables the enrichment and capture of CTCs from the blood of patients with metastatic breast cancer (MBC) and their interrogation using evaluation techniques commonly available in clinical laboratories. Methods: As part of a multicenter clinical trial (NCT03427450), peripheral blood samples from 216 patients with MBC and 205 healthy volunteers (HVs) were prospectively collected at four different clinical sites located throughout the United States. Each subject provided two separate blood samples collected into K2EDTA Vacutainer® tubes to be processed using the Parsortix® PC1 system on the same day. The cells harvested from one of the blood samples collected from each subject by the Parsortix® PC1 system were deposited onto cytology slides using a cytocentrifugation method and stained with Wright-Giemsa reagents using an automated stainer. The stained slides were subjected to cytopathological evaluation by a board-certified pathologist to enumerate CTCs. As proof of principle, cells harvested from the second blood sample were evaluated using one of three additional techniques: molecular profiling by qRT-PCR, RNA sequencing, or cytogenetic analysis of HER2 amplification by FISH. Results: Cytologic examination identified one or more cells as a CTC in 48.5% (95% CI of 41.5 – 55.4%) of the 194 patients with MBC and 9.9% (95% CI of 6.4 – 14.9%) of the 192 HVs. The results from the qRT-PCR evaluation (102 HVs and 74 MBC patients) showed differential expression of cancer-related genes (KRT19, EPCAM, and TWIST1) in the patients with MBC compared to the HVs. Results from the RNA sequencing (53 HVs and 16 MBC patients) showed differential expression of several genes involved in the Kegg Cancer Pathway in the patients with MBC compared to the HVs. The results from the HER2 FISH evaluation (38 HVs and 101 MBC patients) showed that while the majority of the CTC identified had normal HER2/CEP17 ratios, detection of HER2 amplification was possible. Conclusions: The Parsortix PC1 system is capable of capturing and harvesting CTCs from the peripheral blood of patients with MBC. Harvested cells can be evaluated using standard orthogonal methodologies such as gene expression and FISH to identify and characterize CTCs. Based in part on the above results, the FDA granted a De Novo classification request (DEN200062) for the Parsortix PC1 device in May of 2022.

Citation Format: Evan Cohen, Gitanjali Jayachandran, Richard Moore, Massimo Cristofanilli, Julie E. Lang, Joseph Khoury, Michael F. Press, Heather McBride, Kyu Kwang Kim, Negar Khazan, Qiang Zhang, Youbin Zhang, Roberta Guzman, Michael C. Miller, James Reuben, Naoto T. Ueno. A Multi-center Clinical Study to Harvest and Characterize Circulating Tumor Cells from Patients with Metastatic Breast Cancer Using the Parsortix® PC1 System in support of FDA clearance [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-06-01.

Prediction of survival with intensive chemotherapy in acute myeloid leukemia

Progress with intensive chemotherapy and supportive care measures has improved survival in newly diagnosed acute myeloid leukemia (AML). Predicting outcome helps in treatment decision making. We analyzed survival as the treatment endpoint in 3728 patients with newly diagnosed AML treated with intensive chemotherapy from 1980 to 2021. We divided the total study group (3:1 basis) into a training (n = 2790) and a validation group (n = 938). The associations between survival and 27 characteristics were investigated. In the training cohort, the multivariate analysis identified 12 consistent adverse prognostic variables independently associated with worse survival: older age, therapy-related myeloid neoplasm, worse performance status, cardiac comorbidity, leukocytosis, anemia, thrombocytopenia, elevated creatinine and lactate dehydrogenase, cytogenetic abnormalities, and the presence of infection at diagnosis except fever of unknown origin. We categorized patients into four prognostic groups, favorable (7%), intermediate (43%), poor (39%), and very poor (11%) with estimated 5-year survival rates of 69%, 36%, 13%, and 3% respectively (p < .001). The predictive model was validated in an independent cohort. In a subset of patients with molecular mutation profiles, adding the mutation profiles after accounting for the effects of previous factors identified NPM1 (favorable), PTPN11, and TP53 (both unfavorable) mutations as molecular prognostic factors. The new proposed predictive model for survival with intensive chemotherapy in patients with AML is robust and can be used to advise patients regarding their prognosis, to modify therapy in remission (e.g., proposing allogeneic stem cell transplantation in first remission), and to compare outcome and benefits on future investigational therapies.

Accelerated neutral atom beam (ANAB) modified polyethylene for decreased wear and reduced bacteria colonization: An in vitro study

Ultra-high molecular weight polyethylene (UHMWPE) model implants were modified using accelerated neutral atom beam (ANAB) technology and tested for in vitro wear properties and bacteria colonization. Material characterization studies using atomic force microscopy (AFM), surface energy, and in vitro protein adsorption events were also conducted to better understand the mechanism behind such wear properties and bacteria colonization. ANAB modified UHMWPE showed significantly reduced wear properties compared to controls due to nanostructured features, greater surface energy, and improved adsorption of lubricin, a synovial fluid lubricating protein. There was significantly greater adsorption of proteins known to reduce bacteria colonization (specifically, mucin, casein, and lubricin) after 4 h on UHMWPE after ANAB treatment. Such changes in initial protein events led to significantly decreased bacteria (including methicillin resistant Staph. aureus (or MRSA), Staph. aureus, E. coli, multi-drug resistant E. coli, Pseudomonas aeruginosa and Staph. epidermidis) colonization after 24 h without resorting to antibiotic use.

Accelerated Neutral Atom Beam (ANAB) Modified Poly-Ether-Ether-Ketone for Increasing In Vitro Bone Cell Functions and Reducing Bacteria Colonization Without Drugs or Antibiotics

Poly-ether-ether-ketone (PEEK) has become the spinal implant material of choice due to its radiolucency, low elastic modulus, manufacturability, and mechanical durability. However, studies have highlighted less that optimal cytocompatibility properties of conventional PEEK leading to decreased bone growth and/or extensive bacteria infection. In order to improve the surface properties of PEEK for orthopedic applications, here, Accelerated Neutral Atom Beam (ANAB) technology was used to modify PEEK and such samples were tested In Vitro for osteoblast (bone-forming cell) functions and bacterial colonization. Results showed significantly improved osteoblast responses (such as deposition of calcium containing mineral as well as alkaline phosphatase, osteocalcin, osteopontin, and osteonectin synthesis) on ANAB modified PEEK compared to controls due to optimized surface energy from nanostructured features and greater exposure of PEEK chemistry. ANAB treatment enhanced protein absorption (specifically, mucin, casein, and lubricin) to the PEEK surface and consequently significantly reduced bacterial (including methicillin resistant Staph. aureus (or MRSA), E. coli, and Staph. epidermidis) colonization. Collectively, this study introduces ANAB treated PEEK as a novel material that should be further studied for a wide range of improved orthopedic applications.

Accelerated Neutral Atom Beam (ANAB) Modified Polypropylene for Reducing Bacteria Colonization Without Antibiotics

For this first time, this study utilized Accelerated Neutral Atom Beam (ANAB) technology to modify polypropylene to inhibit bacteria colonization in vitro after 24 hours without the use of drugs or antibiotics. Specifically, ANAB was designed and used to increase the surface energy of polypropylene to be closer to that of two critical proteins (mucin and casein) contained in bodily fluids that if adsorbed to a material surface can decreased bacteria colonization. Materials were characterized using atomic force microscopy demonstrating an expected greater surface roughness and surface area for the ANAB-treated samples compared to controls. A wide range of gram-positive, gram-negative, and antibiotic resistant bacteria were tested here (including Staph. epidermidis, Staph. aureus, MRSA, multi-drug resistant E. coli, and Pseudomonas aeruginosa) and demonstrated on average an over a 3-log reduction in bacteria after 24 hours. Further, this study confirmed a greater adsorption of mucin and casein on ANAB-treated polypropylene as the mechanism to decrease bacteria colonization. Lastly, this study utilized an aggressive cleaning procedure and showed strong durability of the ABAN-treated surfaces. This study is important as it demonstrates a way to potentially decrease polypropylene based implant infections using ANAB modification without using antibiotics.

Safety and efficacy of teriparatide treatment for severe osteoporosis in patients with Duchenne muscular dystrophy

Osteoporosis is a major concern in patients with Duchenne muscular dystrophy. In this novel study of teriparatide treatment in 6 patients with severe osteoporosis, bone health (fractures, vertebral morphometry, and DXA) remained stable, with no adverse events. These findings will help inform future osteoporosis research in this challenging population.

INTRODUCTION

Despite standard therapy with vitamin D and bisphosphonates (BP), many patients with Duchenne muscular dystrophy (DMD) continue to sustain fragility fractures due to long-term glucocorticoid treatment and limited mobility. We aimed to evaluate the safety and efficacy of teriparatide for the treatment of severe osteoporosis in adolescent and young adult patients with DMD.

METHODS

We prospectively treated 6 patients with DMD who had severe osteoporosis with teriparatide 20 mcg subcutaneously daily for 1-2 years. Inclusion criteria were long-term glucocorticoid therapy, and severe osteoporosis despite treatment with BP, or intolerance to BP. We examined long bone and vertebral fracture outcomes, including vertebral morphometry measures, bone mineral density and content, bone formation markers, safety indices, and adverse events.

RESULTS

The mean age at teriparatide start was 17.9 years (range 13.9-22.1 years). All 6 patients were on daily glucocorticoids (mean ± SD; duration 10.9 ± 2.5 years) and 5 were non-ambulatory. Five patients had been treated with BP for 7.9 ± 4.2 years. All had vertebral and a history of long bone fragility fractures at baseline. Vertebral heights and Genant fracture grading remained stable. Long bone fracture rate appeared to decrease (from 0.84/year to 0.09/year); one patient sustained a long bone fracture at 6 months of treatment. Trajectories for change in bone mineral density and content were not different post- vs. pre-teriparatide. Procollagen type 1 amino-terminal propeptide (P1NP) increased, while laboratory safety indices remained stable and non-concerning. No adverse events were observed.

CONCLUSION

In six patients with DMD treated with teriparatide for severe osteoporosis, we observed stable bone health and modest increases in P1NP, without safety concerns. Further studies are needed to better understand teriparatide efficacy for treatment of osteoporosis in patients with DMD.

Abstract PO-35: Prognostic significance of MYC, BCL2, and BCL6 colocalization at single-cell resolution in DLBCL

MYC, BCL2, and BCL6 are commonly used markers for immunohistochemistry of Diffuse large B-cell lymphomas (DLBCL). Coexpression of MYC and BCL2 in particular constitutes a subgroup of “double expressor lymphomas” (DEL) with a distinct poor clinical outcome. However, it is not known if MYC and BCL2/BCL6 coexpression occurs in the same cell or in different cells within the tumor, as traditional immunohistochemistry (IHC) is limited by the number of markers that can be simultaneously assessed within formalin-fixed, paraffin-embedded (FFPE) samples. We set out to discover the clinical significance of MYC, BCL2, and BCL6 colocalization at single-cell resolution using multiplexed quantitative immunofluorescence (qIF) based on sequential OPAL-TSA staining and spectral microscopy on the Vectra platform. The initial discovery cohort comprised 90 cases of DLBCL from NUH Singapore with adequate clinical follow-up after R-CHOP therapy. We stratified each DLBCL tumor into 8 “clonal fractions” based on the possible permutations of MYC (M), BCL2 (2), and BCL6 (6) colocalization: M+2+6+, M+2+6-, M+2-6+, M+2-6-, M-2+6+, M-2-6+, M-2+6-, and M-2-6-. Interestingly, even within cases that fit traditional IHC criteria for “positivity” of MYC, BCL2, and BCL6, only a subset of cells within each case expressed multiple markers concurrently. Using the fraction of each of these clones as a continuous variable, Cox regression analysis revealed that the percentage of M+2+6- cells in a case was most predictive of poor survival. Importantly, the same clonal fraction (M+2+6-) was a significant poor prognostic feature in 2 smaller validation cohorts from SGH Singapore (n=41) and MD Anderson Cancer Centre USA (n=36). The single-cell staining pattern of these markers revealed a stark contrast between healthy tonsil tissue and DLBCL tissue. In the tonsil, colocalization of each marker was nonrandom (mutually exclusive BCL2 positivity in B cells outside the germinal center and BCL6 positivity inside the germinal center), whereas in DLBCL samples the mutual exclusivity pattern noted in the tonsil was lost, leading to a random distribution of colocalization of MYC, BCL2, and BCL6. The random nature of this colocalization allowed us to mathematically predict the “extent” of these 8 subclones from any data set with quantitative data of each single marker (MYC, BCL2, and BCL6). We therefore attempted to evaluate this model in RNA expression datasets of DLBCL cases with clinically annotated data. Remarkably, in concordance with our IF data, the “predicted” M+2+ 6- subgroup consistently was associated with an unfavorable prognosis in 3 independent mRNA datasets (GSE10846 n=233, GSE117556 n=469, GSE32918 n=140). In summary, we have for the first time assessed the expression of MYC, BCL2, and BCL6 at the single-cell level in DLBCL. These results may explain the apparent protective function of BCL6 expression in prior cohort studies of DEL, and provide a quantitative tool for the identification of DLBCL cases with poor survival on R-CHOP.

Citation Format: Michal Hoppe, Shuangyi Fan, Patrick Jaynes, Phuong Mai Hoang, Liu Xin, Sanjay De Mel, Li Mei Poon, Esther Chan, Joanne Lee, Yen Lin Chee, Choon Kiat Ong, Tiffany Tang, Soon Thye Lim, Nicholas Francis Grigoropoulos, Sheng-Tsung Chang, Shih-Sung Chuang, Joseph Khoury, Hyungwon Choi, Wee Joo Chng, Siok-Bian Ng, Claudio Tripodo, Anand D. Jeyasekharan. Prognostic significance of MYC, BCL2, and BCL6 colocalization at single-cell resolution in DLBCL [abstract]. In: Proceedings of the AACR Virtual Meeting: Advances in Malignant Lymphoma; 2020 Aug 17-19. Philadelphia (PA): AACR; Blood Cancer Discov 2020;1(3_Suppl):Abstract nr PO-35.

Valve surgery for infective endocarditis complicated by stroke: surgical timing and perioperative neurological complications

BACKGROUND AND PURPOSE

Ischaemic and hemorrhagic strokes are dreaded complications of infective endocarditis (IE). The timing of valve surgery for IE patients with stroke remains uncertain. The aim was to study perioperative neurological complications in relation to surgical timing.

METHODS

The study cohort consisted of patients diagnosed with acute IE from January 2010 to December 2016. Early surgery was defined as valve surgery within 14 days of IE diagnosis, and late surgery as after 14 days. Neurological complications that occurred within 14 days post-surgery were considered perioperative and classified as new ischaemic stroke or hemorrhagic stroke, expansion of an existing intracranial hemorrhage and new-onset seizures. Perioperative neurological complications were compared by surgical timing and other variables, including pre-surgical imaging.

RESULTS

Overall, 183 patients underwent valve surgery: 92 had early surgery at a median of 8 days (interquartile range 6-11); 91 had late surgery at a median of 28 days (interquartile range 19-50). Twenty patients (10.9%) had 24 complications: 11 ischaemic, six intraparenchymal hemorrhages, three subarachnoid hemorrhages (SAHs) and four new-onset seizures. Rates of neurological complications were similar for early and late surgery groups (10.9% vs. 11%). Enterococcal IE was more common amongst patients with perioperative neurological complications (35% vs. 12.3%, P < 0.01). An acute infarct was present on pre-surgical magnetic resonance imaging of 134 patients (74%) and was not associated with perioperative neurological complications. Thirty-five patients (19.3%) had intracranial hemorrhage on pre-surgical imaging. SAH on pre-surgical imaging was associated with developing SAH perioperatively (66.7% vs. 13.5%, P < 0.01).

CONCLUSION

Early valve surgery for patients with IE complicated by stroke was not associated with perioperative neurological complications.

Phase 2 study of hyper-CMAD with liposomal vincristine for patients with newly diagnosed acute lymphoblastic leukemia

Liposomal vincristine is designed to reduce neurotoxicity and increase dose intensity delivery, and has been approved as salvage therapy in relapsed/refractory acute lymphoblastic leukemia (ALL). Our aim was to evaluate the response rate, toxicities, and outcome of adults with newly diagnosed ALL who received liposomal vincristine, rather than regular vincristine in combination with intensive chemotherapy (Hyper-CMAD). In a single-center, phase 2 study, patients ≥18 years with newly-diagnosed B-cell ALL were eligible to receive hyper-CMAD alternating with high-dose methotrexate and cytarabine. Rituximab was administered in CD20 positive ALL. Tyrosine kinase inhibitors (imatinib or dasatinib) were added in Philadelphia chromosome-positive (Ph-positive) ALL. Thirty-one patients were enrolled, median follow-up of 59 months (0.3-70). Thirteen patients (42%) had CD20 positive ALL, and 21 (68%) had Ph-positive ALL. Thirty (97%) achieved complete remission (CR). All 26 patients with abnormal karyotype achieved complete cytogenetic response (CCyR), and 27/30 (90%) achieved negative minimal residual disease status by multicolor flow cytometry. Of 20 evaluable Ph-positive ALL patients, major molecular response (MMR) was achieved in 19 patients (95%); complete molecular response (CMR) in 14 (70%). Grade 3/4 peripheral neuropathy was observed in five (16%) with all grade peripheral neuropathy in 21 (68%). With a median follow-up of 59 months, 21 (68%) patients are alive. The 5-year CR duration and survival rates were 73% and 61%, respectively. Ten (32%) patients died: one, sepsis on C1D10; four, unknown; one, post-transplant complications; four, relapse. Hyper-CMAD with liposomal vincristine is safe and demonstrated high response and survival rates in newly diagnosed ALL.

Genome-wide analysis of acute leukemia and clonally related histiocytic sarcoma in a series of three pediatric patients

Pediatric histiocytic sarcoma (HS) clonally related to anteceding leukemia is a rare malignancy with poor outcome. We performed a molecular characterization of HS and the corresponding leukemia by methylation arrays and whole-exome sequencing and found a variety of aberrations in both entities with deletions of CDKN2A/B as a recurrent finding. Furthermore, data from genome-wide mutation analysis from one patient allowed the reconstruction of a sequence of tumorigenesis of leukemia and HS lesions including the acquisition of a putatively activating KRAS frameshift deletion (p.A66fs). Our results provide an insight into the genetic landscape of pediatric HS clonally related to anteceding leukemia.

Features of non-activation dendritic state and immune deficiency in blastic plasmacytoid dendritic cell neoplasm (BPDCN)

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare, male-predominant hematologic malignancy with poor outcomes and with just one recently approved agent (tagraxofusp). It is characterized by the abnormal proliferation of precursor plasmacytoid dendritic cells (pDCs) with morphologic and molecular similarities to acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS)/chronic myelomonocytic leukemia (CMML) in its presentation within the bone marrow and peripheral blood. To identify disease-specific molecular features of BPDCN, we profiled the bone marrow, peripheral blood, and serum samples from primary patient samples using an in-house hematologic malignancy panel ("T300" panel), transcriptome microarray, and serum multiplex immunoassays. TET2 mutations (5/8, 63%) were the most prevalent in our cohort. Using the transcriptome microarray, genes specific to pDCs (LAMP5, CCDC50) were more highly expressed in BPDCN than in AML specimens. Finally, the serum cytokine profile analysis showed significantly elevated levels of eosinophil chemoattractants eotaxin and RANTES in BPDCN as compared with AML. Along with the high levels of PTPRS and dendritic nature of the tumor cells, these findings suggest a possible pre-inflammatory context of this disease, in which BPDCN features nonactivated pDCs.

NAVA-synchronized compared to nonsynchronized noninvasive ventilation for apnea, bradycardia, and desaturation events in VLBW infants

Neurally adjusted ventilatory assistance (NAVA) can overcome technical difficulties with synchronizing noninvasive ventilation breaths with the patient, a modality often used in very low birthweight infants (VLBW) with apnea of prematurity (AOP). This study is a retrospective single-center investigation into whether NAVA-synchronized noninvasive (niNAVA) ventilation is better than nonsynchronized (nasal intermittent positive pressure ventilation [nIPPV]) for symptomatic apnea in VLBW infants. Nursing records of apnea, bradycardia, and/or desaturations were abstracted from the electronic medical records of 108 VLBW infants admitted to the neonatal intensive care unit (NICU) from 2015 to 2017 who received either of the two modalities, 61 epochs of niNAVA totaling 488 days and 103 epochs of nIPPV totaling 886.5 days. niNAVA was associated with a significant reduction in the number of isolated bradycardic events/day (0.48 ± 0.14 vs 1.35 ± 0.27; P = .019) and overall bradycardias/day (2.42 ± 0.47 vs 4.02 ± 0.53; P = .042) and there were more epochs with no events with niNAVA compared with nIPPV (23.0% vs 6.8%; P = .004). These results justify a prospective trial of NAVA-synchronized noninvasive ventilation for VLBW infants with caffeine-resistant AOP.

Results from ongoing phase 1/2 clinical trial of tagraxofusp (SL-401) in patients with intermediate or high risk relapsed/refractory myelofibrosis

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Background: Patients with myelofibrosis (MF) who fail or are intolerant to JAK inhibitors (JAKi) have no standard treatment options. CD123 is expressed on a variety of malignancies, including MF. CD123+ plasmacytoid dendritic cells (pDCs), in the MPN microenvironment, including chronic myelomonocytic leukemia and MF, may be tumor-promoting. Monocytosis in MF associated with rapid disease progression and short survival, suggesting an accelerated disease phase. Notably, monocytes share a common precursor with CD123+ pDCs. Tagraxofusp, a novel CD123 targeted therapy, demonstrated high activity in patients with BPDCN, an aggressive hematologic malignancy derived from CD123+ pDCs, and is FDA approved in BPDCN. As such, tagraxofusp may offer a novel therapeutic approach in MF. Methods: Multicenter, 2-stage Ph 1/2 trial enrolling patients (pts) with MF relapsed, refractory, or intolerant to JAKi. Objectives: determine optimal dose, evaluate safety and efficacy. Stage 1 dose escalation: IV tagraxofusp (7, 9, and 12 mcg/kg/day) dosed daily days 1-3 every 21 days (C1-4), 28 days (C5-7), and 42 days (C8+). Stage 2 (ongoing): pts receive optimal S1 dose (12 mcg/kg/day; no MTD). Results: 23 r/r pts treated. Median age 69 (55-81); 57% female. DIPSS Plus: 4% INT-1, 55% INT-2, 41% high. Baseline platelets: median 59 K/uL (15-579); 70% (16/23) <100 K/uL, 8 pts <50 K/uL. 87% (20/23) baseline splenomegaly (palpable ≥5 cm below left costal margin by physical exam). Most common TRAEs: headache (22%), hypoalbuminaemia (22%), ALT incr. (17%) and thrombocytopenia (17%). Most common ≥Gr3 TRAE thrombocytopenia (2%). Capillary leak syndrome in 1 pt (4%; Gr3). 57% (8/14) of pts with baseline spleen ≥5cm BCM spleen responses: 43% (6/14) had ≥29% and 21% (3/14) had ≥45% reduction. 100% of pts with baseline spleen ≥5cm and monocytosis splenomegaly reductions: 80% (4/5) had ≥29% and 40% (2/5) had ≥45%. 6 pts (3 monocytosis pts and 5 pts platelets <100 K/uL) had 6 mos+ duration, 9 pts ongoing. Conclusions: Tagraxofusp demonstrated single agent activity (reduction in splenomegaly) and manageable safety in R/R MF, including pts with monocytosis, an unmet medical need. Given the presence of CD123+ pDCs, tagraxofusp may offer a novel targeted approach in MF. Updated data to be presented. Registrational designs are being evaluated. Clinical trial information: NCT02268253.

Results from ongoing phase 1/2 clinical trial of tagraxofusp (SL-401) in patients with relapsed/refractory chronic myelomonocytic leukemia (CMML)

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Background: Patients with chronic myelomonocytic leukemia (CMML) have historically poor outcomes, with ~6-7 mos median OS in relapsed/refractory (r/r) setting. Splenomegaly is a poor prognostic factor and potential target in CMML. CD123 is detected on blasts, monocytes, and neoplastic microenvironmental plasmacytoid dendritic cell (pDC) infiltrates part of the CMML malignant clone (Solary, et al). Tagraxofusp, a novel CD123 targeted therapy, demonstrated high levels of activity in BPDCN, an aggressive hematologic malignancy derived from CD123-expressing pDCs, and is FDA approved in BPDCN. As such, tagraxofusp may offer a novel approach in CMML. Methods: Multicenter, 2-stage Ph1/2 enrolling patients (pts) with r/r CMML. Objectives: determine optimal dose, evaluate safety and efficacy. Stage 1 dose escalation: IV tagraxofusp (7, 9, and 12 mcg/kg/day) dosed on days 1-3 every 21 days (C1-4), 28 days (C5-7), and 42 days (C8+). Stage 2 (ongoing), pts receive optimal S1 dose (12 mcg/kg/day; no MTD). Results: 20 pts (12 CMML-1; 8 CMML-2) enrolled. 18 pts 2nd-line (2 pts in 1L), HMAs most common prior therapy. Median age 69 (43-80); 81% male. 11 (52%) had baseline splenomegaly (spleen palpable below left costal margin by physical exam) of 2-27 cm. Most common TRAEs: hypoalbuminaemia (35%), thrombocytopenia (35%), nausea (30%), vomiting (30%), and fatigue (20%). Most common ≥Gr3 TRAEs were thrombocytopenia (35%) and nausea (5%). Capillary leak syndrome in 3 pts (15%; all Gr1&2). 100% (10/10) of pts with splenomegaly had spleen response: 80% (8/10) had reductions ≥50% and 67% (4/6) with spleen size ≥5 cm had reductions ≥50%. 3 pts achieved bone marrow complete responses, including 1 pt bridged to SCT in remission. Conclusions: Tagraxofusp demonstrated single agent activity in CMML as 80% of pts showed ≥50% reduction in splenomegaly by palpation. Splenomegaly in CMML, as in myelofibrosis, is a major cause of morbidity and associated with poor prognosis and impaired QoL. Targeting splenomegaly in myeloid neoplasms with proliferative features may be an important therapeutic goal. Given CD123 expression on CMML blasts, monocytes, and malignant pDCs, tagraxofusp may offer a targeted approach, especially in pts with splenomegaly. Updated safety and efficacy data to be presented. Registrational trial planned. Clinical trial information: NCT02268253.

Surface bioactivation of PEEK by neutral atom beam technology

Polyetheretherketone (PEEK) is an alternative to metallic implants and a material of choice in many applications, including orthopedic, spinal, trauma, and dental. While titanium (Ti) and Ti-alloys are widely used in many intraosseous implants due to its biocompatibility and ability to osseointegrate, negatives include stiffness which contributes to shear stress, radio-opacity, and Ti-sensitivity. Many surgeons prefer to use PEEK due to its biocompatibility, similar elasticity to bone, and radiolucency, however, due to its inert properties, it fails to fully integrate with bone. Accelerated Neutral Atom Beam (ANAB) technology has been successfully employed to demonstrate enhanced bioactivity of PEEK both in vitro and in vivo. In this study, we further characterize surfaces of PEEK modified by ANAB as well as elucidate attachment and genetic effects of dental pulp stem cells (DPSC) exposed to these surfaces. ANAB modification resulted in decreased contact angle at 72.9 ± 4.5° as compared to 92.4 ± 8.5° for control (p < 0.01) and a decreased average surface roughness, however with a nano-textured surface profile. ANAB treatment also increased the ability of DPSC attachment and proliferation with considerable genetic differences showing earlier progression towards osteogenic differentiation. This surface modification is achieved without adding a coating or changing the chemical composition of the PEEK material. Taken together, we show that ANAB processing of PEEK surface enhances the bioactivity of implantable medical devices without an additive or a coating.

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PEEK is a material of choice for biomaterials except that it is inert and does not integrate with bone.

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Neutral atom beam technology (ANAB) is a surface modification technique that modifies the surface at a nano-scale level and makes the surface more hydrophilic.

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Increased cell attachment and proliferation is seen on ANAB-treated PEEK.

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Dental pulp stem cells differentiate towards osteoblast when grown on ANAB-treated PEEK.

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ANAB makes PEEK bioactive.

Neonatal Resuscitation and Adaptation Score vs Apgar: newborn assessment and predictive ability

OBJECTIVE

To test the non-inferiority of an alternative to the Apgar score.

STUDY DESIGN

The Neonatal Resuscitation and Adaptation Score (NRAS) was recorded in parallel to the Apgar score by a resuscitation team at deliveries. Correlation between the systems was assessed, as well as the predictive ability of NRAS and Apgar scores for mortality or short-term morbidities.

RESULTS

A total of 340 infants were in the study group. The two scores correlated strongly (r = 0.87 and 0.83 at 1 and 5 min, respectively). Those needing ventilation at 48 h of life had a 5-min NRAS < 7 in 23/26 vs Apgar < 7 (23/36, p = 0.001). A low (0-3) 1-min NRAS score was more predictive of death, 53% vs 17%, p = 0.0065.

CONCLUSIONS

NRAS correlates with Apgar status assessment, and identifies newborns who die or may require further care better than the Apgar score.

Correction: Neonatal Resuscitation and Adaptation Score vs Apgar: newborn assessment and predictive ability

Since the publication of the above article, the authors have noted that the name of the first Item in the NRAS scoring system in Figure 1 was omitted. It is Heart Rate (C1). The authors apologise for any inconvenience caused by this error. The html and online pdf versions have now been rectified and carry the corrected Figure.

Chemoimmunotherapy with inotuzumab ozogamicin combined with mini-hyper-CVD, with or without blinatumomab, is highly effective in patients with Philadelphia chromosome-negative acute lymphoblastic leukemia in first salvage

BACKGROUND

The outcomes of patients with relapsed or refractory (R-R) acute lymphoblastic leukemia (ALL) are poor. Inotuzumab ozogamicin and blinatumomab have single-agent activity in R-R ALL. Their addition to low-intensity chemotherapy may further improve the outcomes of patients with ALL in their first relapse.

METHODS

The chemotherapy was lower in intensity than conventional hyperfractionated cyclophosphamide, vincristine, adriamycin, and dexamethasone and was called mini-hyperfractionated cyclophosphamide, vincristine, and dexamethasone (or mini-HCVD). Inotuzumab was given on day 3 of each of the first 4 cycles at 1.8 to 1.3 mg/m² for cycle 1, and this was followed by 1.3 to 1.0 mg/m² for subsequent cycles. From patient 39 onward, the inotuzumab dose was reduced and fractionated into weekly doses (0.6 and 0.3 mg/m² during cycle 1 and 0.3 and 0.3 mg/m² during subsequent cycles), and blinatumomab was administered for up to 4 cycles after inotuzumab therapy.

RESULTS

Forty-eight patients with Philadelphia chromosome-negative ALL with a median age of 39 years were treated during their first relapse. Overall, 44 patients (92%) responded, with 35 of them (73%) achieving a complete response. The overall minimal residual disease negativity rate among the responders was 93%. Twenty-four patients (50%) underwent allogeneic stem cell transplantation (ASCT). Veno-occlusive disease of any grade occurred in 5 patients (10%). With a median follow-up of 31 months, the median progression-free survival (PFS) and the median overall survival (OS) were 11 and 25 months, respectively. The 2-year PFS and OS rates were 42% and 54%, respectively. Of the 24 patients (50%) who underwent ASCT, 14 patients were alive at the last follow-up (13 [54%] in remission). Of the remaining 20 responding patients who did not undergo subsequent ASCT, 6 (30%) remained in remission at the last follow-up. According to propensity score matching, the combination of mini-HCVD and inotuzumab with or without blinatumomab conferred better outcomes than intensive salvage chemotherapy or inotuzumab alone.

CONCLUSIONS

The combination of inotuzumab and low-intensity mini-HCVD chemotherapy with or without blinatumomab shows encouraging results in patients with ALL in first salvage.

Theoretical open-loop model of respiratory mechanics in the extremely preterm infant

Non-invasive ventilation is increasingly used for respiratory support in preterm infants, and is associated with a lower risk of chronic lung disease. However, this mode is often not successful in the extremely preterm infant in part due to their markedly increased chest wall compliance that does not provide enough structure against which the forces of inhalation can generate sufficient pressure. To address the continued challenge of studying treatments in this fragile population, we developed a nonlinear lumped-parameter respiratory system mechanics model of the extremely preterm infant that incorporates nonlinear lung and chest wall compliances and lung volume parameters tuned to this population. In particular we developed a novel empirical representation of progressive volume loss based on compensatory alveolar pressure increase resulting from collapsed alveoli. The model demonstrates increased rate of volume loss related to high chest wall compliance, and simulates laryngeal braking for elevation of end-expiratory lung volume and constant positive airway pressure (CPAP). The model predicts that low chest wall compliance (chest stiffening) in addition to laryngeal braking and CPAP enhance breathing and delay lung volume loss. These results motivate future data collection strategies and investigation into treatments for chest wall stiffening.

Cerebral microbleeds predict infectious intracranial aneurysm in infective endocarditis

BACKGROUND AND PURPOSE

Magnetic resonance imaging (MRI) features such as cerebral microbleeds and sulcal susceptibility-weighted imaging (SWI) or gradient-echo T2* lesions in infective endocarditis (IE) have been associated with the presence of infectious intracranial aneurysm (IIA). Our aim was to validate these MRI predictors for IIA in order to better assist in assessing the appropriate indications for digital subtraction angiography (DSA).

METHODS

The derivation cohort comprised IE patients with neurological evaluation, MRI and DSA at a single tertiary referral center from January 2015 to July 2016. Validation was performed in a cohort of IE patients who underwent MRI and DSA at the same center from 2010 to 2014.

RESULTS

Of 62 patients in the derivation cohort, 10 (16%) had IIAs. Of 129 in the validation cohort, 19 (15%) IIAs were identified. The MRI predictors for IIA consist of (i) contrast enhancement with microbleeds, (ii) cerebral microbleeds >5 mm or sulcal SWI lesions and (iii) any MRI hemorrhages. The sensitivity for the presence of IIA in each group of the derivation cohort was 90%, 80% and 100%, respectively. The sensitivity in the validation cohort was 47%, 68% and 94% respectively. The specificity in the derivation cohort was 87%, 85% and 18%. In the validation cohort, the specificity was similar at 87%, 75% and 27%.

CONCLUSIONS

The absence of MRI hemorrhages may not necessitate the need for DSA.

Opening Wedge Osteotomy for the Correction of Adolescent Tibia Vara

BACKGROUND

Tibia vara, or Blount's disease, is a pathologic angular deformity of upper tibial physis causing a bow leg deformity. Adolescent Blount's disease may be unilateral or bilateral and is diagnosed during or just before the adolescent growth spurt. In addition to predisposing genetic factors, biomechanical overload of the proximal tibial physis causes asymmetric growth leading to a varus deformity.Surgical intervention is usually required for adolescent Blount's disease. Hemiepiphysiodesis has had some success in arresting or correcting the deformity. Tibial osteotomy can achieve correction acutely with internal or external fixation or gradually with external fixation.This article reports the outcomes of correcting adolescent tibia vara with a proximal opening wedge osteotomy (POWO) and internal fixation in nine patients with a primary diagnosis of Adolescent Blount's Disease.

METHODS

We conducted a retrospective review of patients treated with POWO between April 2007 and July 2015. Fifty charts were selected using ICD9 codes for tibia vara and CPT codes for osteotomy. Nine patients (11 tibia) meeting eligibility criteria were identified. In addition to pre-operative data; operative factors, such as blood loss; and post-operative outcomes such as radiographic accuracy of correction, time to healing, time to full weight-bearing, number of office visits and complication rates were collected.

RESULTS

Pre-operative radiographic measurements showed the varus deformity was primarily tibial. Post-operative correction demonstrated a mean correction of 17.64° (range, 7°-26°). Patients returned to full weight bearing status around 67 days after surgery and required very few follow-up visits during the course of treatment. Three of nine patients experienced complications including seroma requiring drainage, metallosis mistaken for infection leading to hardware removal, and a wound abscess treated with antibiotics (one patient each). No patients lost correction, experienced nerve palsy, compartment syndrome nor complained of leg length discrepancy.

CONCLUSIONS

Proximal opening wedge osteotomy (POWO) is a reproducible, safe and effective technique for correction of adolescent tibia vara, with potential advantages of fewer return visits and sooner return to weight bearing than external fixation. In select patients, it is a useful alternative to external fixation or closing wedge osteotomy.Level of Evidence: IV.

Evidence for in vitro antiophidian properties of aqueous buds extract of Eucalyptus against Montivipera bornmuelleri venom

Because snake venoms are complex mixtures of bioactive molecules, snake bites produce a large panel of symptoms which cannot be totally prevented by current antivenoms. Thus investigating plant extracts for antivenomics therapy approaches seemed relevant. Here, we evaluated the potency of the aqueous Buds extract of Eucalyptus (ABEE) to counteract the main enzymatic activities of Montivipera bornmuelleri venom. We showed that ABEE efficiently counteracts the proteolytic, Phospholipases A2 (PLA2), and L-aminoacid oxidase activities (LAAO) of M. bornmuelleri venom. ABEE was found to inhibit Acetylcholine esterase (AChE) and to exhibit a potent antioxidant activity. In addition, M. bornmuelleri venom displays antibacterial properties against Staphylococcus aureus, which were not inhibited by ABEE. We also showed that of M. bornmuelleri venom lacks AChE, either anti-AChE activities. ABEE represents a promising natural source of antivenomics compounds against the deleterious effects of M. bornmuelleri or other Vipera species bites.

Synthesis of N-Aryl and N-Heteroaryl γ-, δ-, and ε-Lactams Using Deprotometalation–Iodination and N-Arylation, and Properties Thereof

Xanthone, thioxanthone, fluorenone, benzophenone, 2-benzoylpyridine, dibenzofuran, and dibenzothiophene were deprotonated using a base prepared in situ from MCl2·TMEDA (M = Zn or Cd; TMEDA = N,N,N′,N′-tetramethylethylenediamine) and lithium 2,2,6,6-tetramethylpiperidide in a 1:3 ratio, as demonstrated by subsequent iodolysis. The different aryl halides were involved as partners in the N-arylation of pyrrolidin-2-one. In the presence of copper(I) iodide and tripotassium phosphate, and using dimethyl sulfoxide as solvent, the reactions could be performed in yields ranging from 40 to 70%. Most of the products were tested for their antimicrobial, antifungal, antioxidant, and cytotoxic (MCF-7) activity.

Differential impact of minimal residual disease negativity according to the salvage status in patients with relapsed/refractory B-cell acute lymphoblastic leukemia

BACKGROUND

Minimal residual disease (MRD) assessment predicts survival for patients with newly diagnosed acute lymphoblastic leukemia (ALL). Its significance in relapsed/refractory ALL is less clear.

METHODS

This study identified 78 patients with relapsed/refractory B-cell ALL who achieved a morphologic response with inotuzumab ozogamicin (n = 41), blinatumomab (n = 11), or mini-hyperfractionated cyclophosphamide, vincristine, and doxorubicin plus inotuzumab (n = 26) during either salvage 1 (S1; n = 46) or salvage 2 (S2; n = 32) and had undergone an MRD assessment by multiparameter flow cytometry at the time of remission.

RESULTS

MRD negativity was achieved in 41 patients overall (53%). The MRD negativity rate was 57% in S1 and 47% in S2. Among patients in S1, achieving MRD negativity was associated with longer event-free survival (EFS; median, 18 vs 7 months; 2-year EFS rate, 46% vs 17%; P = .06) and overall survival (OS; median, 27 vs 9 months; 2-year OS, 52% vs 36%; P = .15). EFS and OS were similar in S2, regardless of the MRD response. Among MRD-negative patients who underwent allogeneic stem cell transplantation (SCT), EFS and OS were superior for those who underwent SCT in S1 rather than S2 (P = .003 and P = .04, respectively). Patients in S1 who achieved MRD negativity and subsequently underwent SCT had the best outcomes with a 2-year OS rate of 65%.

CONCLUSIONS

Patients with relapsed/refractory ALL who achieve MRD negativity in S1 can have long-term survival. Patients in S2 generally have poor outcomes, regardless of their MRD status. Cancer 2017;123:294-302. © 2016 American Cancer Society.

Pros and cons of circumcision: an evidence-based overview

Based on three large randomized controlled trials (RCTs) conducted in Africa, it can clearly be stated that circumcision lowers the risk of infection with the human immunodeficiency virus (HIV) and some sexually transmitted infections (STIs) among males in settings of high HIV and STI endemicity. Similar effects on STI risk may exist for females, although this may result from an indirect effect of decreasing risk of infection among male partners. It is unknown whether circumcision prevents HIV acquisition in men who have sex with men (MSM), although there might be a protective effect for men who engage mainly in insertive anal intercourse. When the effects of adult circumcision on sexual function and satisfaction of men are examined, high-quality evidence strongly supports lack of harm. Whether circumcision alters sexual satisfaction of female partners is not known as fewer and smaller studies reported conflicting results. Circumcision rarely causes serious complications if practiced by trained practitioners, in a sterile setting, and with a proper follow-up. These conclusions are limited by the lack of high-quality data from areas outside of Africa. RCTs have not been conducted to assess the effects of circumcising infants or MSM. Circumcision has well-proven benefits for people residing in areas with high prevalence of STIs, including HIV, and is not unethical for those who choose to be circumcised or have their children circumcised on religious, social, or cultural grounds. For many others, a definite pro or con recommendation, based on a risk-benefit ratio, cannot be made.

Stress Physiology in Infancy and Early Childhood: Cortisol Flexibility, Attunement and Coordination

Research on stress physiology in infancy has assumed increasing importance due to its lifelong implications. In this review, we focus on measurement of hypothalamic-pituitary-adrenal (HPA) function, in particular, and on complementary autonomic processes. We suggest that the measure of HPA function has been overly exclusive, focusing on individual reactivity to single, pragmatically selected laboratory challenges. We advocate use of multiple, strategically chosen challenges and within-subject designs. By administering one challenge that typically does not provoke reactivity and another that does, it is possible to represent allostatic load in terms of "flexibility," the capacity to titrate response to challenge. We also recommend assessing infant reactivity in the context of the primary caregiver's physiological function. Infant-mother "attunement" is central to developmental psychology, permeating diverse developmental domains with varied consequences. A review of adrenocortical attunement suggests that attunement is a reliable process, manifest across varied populations. However, attunement appears stronger in the context of more highly stressful circumstances, such that administration of multiple, selected challenges may help evaluate the degree to which individuals titrate attunement to challenge and determine the correlates of this differential attunement. Finally, we advocate studying the "coordination" of HPA function with other aspects of stress physiology and variation in the degree of this coordination. The use of multiple stressors is important here because each stress system is differentially sensitive to different types of challenge. Therefore, use of single stressors in between-subject designs impedes full recognition of the role played by each system. Overall, we recommend measure of flexibility, attunement, and coordination in the context of multiple challenges to capture allostasis in environmental and physiological context. The simultaneous use of such inclusive and integrative metrics may yield more reliable findings than has hitherto been the case. The interrelation of these metrics can be understood in the context of the adaptive calibration model..