Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication

PURPOSE

Large hiatus hernias are relatively common and can be associated with adverse symptoms and serious complications. Operative repair is indicated in this patient group for symptom management and the prevention of morbidity. This study aimed to identify predictors of poor outcomes following laparoscopic hiatus hernia repair and fundoplication (LHHRaF) to aid in counselling potential surgical candidates.

METHODOLOGY

A retrospective analysis was performed from a prospectively maintained, multicentre database of patients who underwent LHHRaF between 2014 and 2020. Revision procedures were excluded. Hernia size was defined as the intraoperative percentage of intrathoracic stomach, estimated by the surgeon to the nearest 10%. Predictors of outcomes were determined using a prespecified multivariate logistic regression model.

RESULTS

625 patients underwent LHHRaF between 2014 and 2020 with 443 patients included. Median age was 65 years, 62.9% were female and 42.7% of patients had ≥ 50% intrathoracic stomach. In a multivariate regression model, intrathoracic stomach percentage was predictive of operative complications (P = 0.014, OR 1.05), post-operative complications (P = 0.026, OR 1.01) and higher comprehensive complication index score (P = 0.023, OR 1.04). At 12 months it was predictive of failure to improve symptomatic reflux (P = 0.008, OR 1.02) and persistent PPI requirement (P = 0.047, OR 1.02). Operative duration and blood loss were predicted by BMI (P = 0.004 and < 0.001), Type III/IV hernias (P = 0.045 and P = 0.005) and intrathoracic stomach percentage (P = 0.009 and P < 0.001). Post-operative length of stay was predicted by age (P < 0.001) and emergency presentation (P = 0.003).

CONCLUSION

In a multivariate regression model, intrathoracic stomach percentage was predictive of operative and post-operative morbidity, PPI use, and failure to improve reflux symptoms at 12 months.

Abstract 2709: TTI-622 (SIRPα-IgG4 Fc), a CD47-blocking innate immune checkpoint inhibitor, suppresses tumor growth and demonstrates enhanced efficacy in combination with antitumor antibodies in both hematologic and solid tumor models

Tumor cells frequently evade macrophage-mediated destruction by increasing cell surface expression of CD47, which delivers an anti-phagocytic (“do-not-eat”) signal by binding the inhibitory signal regulatory protein α (SIRPα) receptor on macrophages. Previous studies have shown that blockade of the CD47-SIRPα pathway using TTI-621, a soluble SIRPα-IgG1 Fc fusion protein, triggers macrophage phagocytosis of tumor cells in vitro, and potently inhibits tumor growth in vivo. In the current study, the in vitro and in vivo efficacy of TTI-622, a soluble SIRPα-Fc variant protein containing an IgG4 Fc tail, was evaluated in multiple model systems.

Unlike CD47-blocking antibodies, TTI-622 binds minimally to human erythrocytes, and does not induce hemagglutination in vitro. Therefore, it avoids a large circulating antigen sink, and is less likely to cause anemia in patients. Additionally, TTI-622 potently induces phagocytosis of a broad panel of tumor cells derived from patients with both hematological and solid tumors. Although in vitro phagocytosis of human platelets is also observed, TTI-622 preferentially induces phagocytosis of tumor cells over platelets in a competitive phagocytosis assay.

The in vivo efficacy of TTI-622 monotherapy and/or combination therapy was evaluated in different tumor models. In a DLBCL (Toledo) xenograft tumor model, both early and delayed treatments resulted in statistically significant decreases in tumor growth, and improved survival relative to treatment with control Fc. In the Burkitt lymphoma (Daudi) and multiple myeloma (MM.1S) xenograft tumor models, the potential of combining TTI-622 with daratumumab (anti-CD38 antibody) was also explored. In both models, TTI-622 monotherapy demonstrated partial tumor growth inhibition. However, the therapeutic efficacy was further enhanced when TTI-622 was combined with daratumumab. Intriguingly, a TTI-622 non-responsive head and neck cancer (FaDu) xenograft tumor model became responsive by combining TTI-622 with suboptimal doses of cetuximab (anti-EGFR antibody). The combination of TTI-622 with cetuximab resulted in a statistically significant decrease in tumor growth, and improved survival relative to monotherapy treatments.

Collectively, these results demonstrate that TTI-622 induces potent, tumor-specific macrophage phagocytosis across a range of hematological and solid tumors, and is efficacious as a monotherapy agent in a DLBCL xenograft tumor model. Furthermore, TTI-622 potentiates the efficacy of daratumumab and cetuximab in hematological and solid xenograft tumor models, respectively. These data support the clinical evaluation of TTI-622 in combination with anti-tumor antibodies in cancer patients with both solid and hematological malignancies.

Citation Format: Gloria H. Y. Lin, Natasja N. Viller, Marilyse Chabonneau, Laura Brinen, Tapfuma Mutukura, Karen Dodge, Simone Helke, Vien Chai, Violetta House, Vivian Lee, Hui Chen, Alison O'Connor, Debbie Jin, Rene Figueredo, Saman Maleki Vareki, Mark Wong, Emma Linderoth, Lisa D. Johnson, Xinli Pang, James Koropatnick, Jeff Winston, Penka S. Petrova, Robert A. Uger. TTI-622 (SIRPα-IgG4 Fc), a CD47-blocking innate immune checkpoint inhibitor, suppresses tumor growth and demonstrates enhanced efficacy in combination with antitumor antibodies in both hematologic and solid tumor models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2709.

Abstract 2646: Intratumoral delivery of TTI-621 (SIRPαFc), a CD47-blocking immunotherapeutic, inhibits tumor growth and prolongs animal survival in a subcutaneous B cell lymphoma model

Tumor cells often evade macrophage-mediated destruction by increasing cell surface expression of CD47, which delivers an anti-phagocytic (“do-not-eat”) signal by binding the inhibitory signal-regulatory protein α (SIRPα) receptor on macrophages. We have previously shown that blockade of the CD47-SIRPα pathway using TTI-621, a soluble SIRPα-IgG1 Fc fusion protein, triggers macrophage phagocytosis of tumor cells in vitro as well as inhibits tumor growth in vivo when delivered systemically. In the current study, the efficacy of intratumoral delivery of TTI-621 was evaluated in a subcutaneous diffuse large B-cell lymphoma (Toledo) xenograft model.

Tumor bearing mice were randomized into treatment groups when tumor volumes reached approximately 120 mm3. Weekly intratumoral administration of TTI-621 at 10, 1 and 0.1 mg/kg dose levels resulted in statistically significant decreases in tumor growth and improved survival relative to vehicle control treatment. Notably, at day 50 post-tumor implantation 100% survival was achieved at the highest dose level (vs. 0% survival with vehicle control treatment). Moreover, weekly intratumoral administration of TTI-621 was efficacious even at a high tumor load setting in which the pre-dose volumes were approximately 300 mm3. Flow cytometry analysis of the dissociated tumor samples demonstrated no significant change in the numbers of M1 and M2 tumor-associated macrophages (TAMs) following intratumoral administration of TTI-621. Nevertheless, TTI-621 dramatically increased the phagocytosis of Toledo cells by both M1 and M2 TAMs to a similar extent ex vivo, suggesting that TTI-621 is efficacious in increasing the phagocytosis of tumor cells by a heterogeneous population of TAMs.

Collectively, these results demonstrate that TTI-621 is efficacious when delivered intratumorally and can increase the phagocytosis of tumor cells by both M1 and M2 TAM populations. These data support the evaluation of intratumoral administration of TTI-621 in cancer patients, and a Phase I study of intratumorally delivered TTI-621 in patients with percutaneously accessible solid tumors and mycosis fungoides is ongoing (NCT02890368).

Citation Format: Gloria H. Lin, Marilyse Charbonneau, Vien Chai, Alison M. O'Connor, Bolette Bossen, Hui Chen, Mark Wong, Natasja N. Viller, Emma Linderoth, Lisa D. Johnson, Xinli Pang, Jeffery Winston, Penka S. Petrova, Robert A. Uger. Intratumoral delivery of TTI-621 (SIRPαFc), a CD47-blocking immunotherapeutic, inhibits tumor growth and prolongs animal survival in a subcutaneous B cell lymphoma model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2646. doi:10.1158/1538-7445.AM2017-2646

TTI-621 (SIRPαFc): A CD47-Blocking Innate Immune Checkpoint Inhibitor with Broad Antitumor Activity and Minimal Erythrocyte Binding

Purpose: The ubiquitously expressed transmembrane glycoprotein CD47 delivers an anti-phagocytic (do not eat) signal by binding signal-regulatory protein α (SIRPα) on macrophages. CD47 is overexpressed in cancer cells and its expression is associated with poor clinical outcomes. TTI-621 (SIRPαFc) is a fully human recombinant fusion protein that blocks the CD47-SIRPα axis by binding to human CD47 and enhancing phagocytosis of malignant cells. Blockade of this inhibitory axis using TTI-621 has emerged as a promising therapeutic strategy to promote tumor cell eradication.Experimental Design: The ability of TTI-621 to promote macrophage-mediated phagocytosis of human tumor cells was assessed using both confocal microscopy and flow cytometry. In vivo antitumor efficacy was evaluated in xenograft and syngeneic models and the role of the Fc region in antitumor activity was evaluated using SIRPαFc constructs with different Fc tails.Results: TTI-621 enhanced macrophage-mediated phagocytosis of both hematologic and solid tumor cells, while sparing normal cells. In vivo, TTI-621 effectively controlled the growth of aggressive AML and B lymphoma xenografts and was efficacious in a syngeneic B lymphoma model. The IgG1 Fc tail of TTI-621 plays a critical role in its antitumor activity, presumably by engaging activating Fcγ receptors on macrophages. Finally, TTI-621 exhibits minimal binding to human erythrocytes, thereby differentiating it from CD47 blocking antibodies.Conclusions: These data indicate that TTI-621 is active across a broad range of human tumors. These results further establish CD47 as a critical regulator of innate immune surveillance and form the basis for clinical development of TTI-621 in multiple oncology indications. Clin Cancer Res; 23(4); 1068-79. ©2016 AACR.

Abstract 2345: SIRPαFc, a CD47-blocking cancer immunotherapeutic, triggers phagocytosis of lymphoma cells by both classically (M1) and alternatively (M2) activated macrophages

Macrophages are characterized by their heterogeneity and plasticity in response to the microenvironment. Although macrophages have the capacity to phagocytose cancer cells that express pro-phagocytic signals, tumor cells often evade macrophage-mediated destruction by increased cell surface expression of CD47, which delivers an anti-phagocytic (“do not eat”) signal by binding the inhibitory signal-regulatory protein α (SIRPα) receptor on the surface of macrophages. We have previously shown that soluble SIRPα-Fc fusion protein (SIRPαFc) neutralizes the suppressive effects of CD47 and promotes macrophage-mediated phagocytosis of tumor cells both in vitro and in vivo. In an attempt to recapitulate the functional and phenotypic heterogeneity of tumor infiltrating macrophages, we have examined the ability of SIRPαFc to trigger phagocytosis of lymphoma cells by six distinctly polarized macrophage populations.

We generated human monocyte-derived macrophages (MDMs) and polarized them into M0, M1, M2a, M2b and M2c subsets. These MDMs varied greatly in their expression of myeloid surface markers including CD14, CD11b, CD80, CD86, HLA-DR, CD206, CD200R and CD163; as well as in expression of the Fc gamma receptors (FcγRs) CD16, CD32 and CD64. Next, the ability of SIRPαFc to trigger MDM phagocytosis of lymphoma cells was examined using a flow cytometry-based assay. Blockade of CD47 on the tumor cells using SIRPαFc dramatically increased phagocytosis of tumor cells by all subsets, with M1 and M2c MDMs being superior at phagocytosis. Moreover, we found that M0, M2a and M2b MDMs, which exhibited slightly lower phagocytic capabilities, were remarkably plastic in nature and could readily be re-polarized into highly phagocytic MDMs using a variety of agents. This suggests that SIRPαFc will be efficacious in triggering the destruction of cancer cells by the diverse population of MDMs found in vivo.

To further understand what drives the phagocytic capacity of polarized MDMs, we analyzed FcγR expression and observed a positive correlation between MDM expression of the high-affinity FcγRI (CD64) and phagocytic activity following SIRPαFc treatment. Moreover, re-polarization of M0, M2a and M2b MDMs resulted in upregulation of FcγRs and enhanced tumor cell phagocytosis. Finally, by individually blocking CD16, CD32 and CD64 on MDMs prior to the phagocytosis assay, we found that the low-affinity FcγRs CD16 and CD32 also contribute to SIRPαFc-mediated phagocytosis of lymphoma cells.

In conclusion, SIRPαFc triggered phagocytosis of lymphoma cells by a diverse panel of polarized MDMs, which required MDM expression of FcγRs. These data support the evaluation of SIRPαFc in cancer patients and a clinical study of SIRPαFc in patients with lymphoma and other hematological malignancies is currently in progress.

Citation Format: Gloria H. Y. Lin, Vien Chai, Vivian Lee, Karen Dodge, Tran Truong, Mark Wong, Lisa D. S. Johnson, Xinli Pang, Penka S. Petrova, Robert A. Uger, Natasja N. Viller. SIRPαFc, a CD47-blocking cancer immunotherapeutic, triggers phagocytosis of lymphoma cells by both classically (M1) and alternatively (M2) activated macrophages. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2345.

Abstract 4271: Lack of CD47 membrane mobility contributes to the poor erythrocyte binding of SIRPαFc, a novel CD47-blocking cancer immunotherapeutic

CD47 binds to SIRPα on the surface of macrophages and delivers a “do not eat” signal that suppresses phagocytosis. There is strong evidence that many liquid and solid tumors exploit the CD47-SIRPα pathway to escape macrophage-mediated destruction. Blockade of CD47 using a soluble SIRPα-Fc fusion protein (SIRPαFc) has emerged as a promising strategy to neutralize the suppressive effects of CD47 and promote the eradication of tumor cells. We have previously reported data demonstrating that human SIRPαFc binds strongly to tumor cells but very poorly to human red blood cells (RBCs), despite abundant surface expression of CD47 on RBCs and strong reactivity with CD47-specific antibodies. Here we expand upon these early findings and assess inter-species differences in RBC binding.

Our results, based on a panel of 43 human donors, clearly show that SIRPαFc binds very poorly to human RBCs regardless of gender, ABO blood group or Rh antigen status. Consistent with this finding, SIRPαFc was unable to induce agglutination of RBCs in vitro, although hemagglutination was triggered by CD47-blocking antibodies. Curiously, although the binding affinity of human SIRPαFc to cynomolgus macaque CD47 is approximately 10-fold lower than the binding to the human target, it binds strongly to cyno RBCs. This indicates that affinity alone does not predict the ability to bind erythrocytes. Instead, we hypothesized that the mobility of CD47 in the RBC membrane is a key determinant of SIRPαFc binding and thus compared the detergent solubilization profile of CD47 in human and cyno RBCs. CD47 was observed to segregate largely into the detergent-soluble fraction in monkey erythrocytes but was localized primarily to the insoluble pellet fraction in human RBCs, suggesting greater membrane mobility in cyno compared to human RBCs. This finding is consistent with a model in which CD47 mobility is required to form high affinity clusters with SIRPαFc, and indeed we have previously observed that pre-clustering CD47 with a non-blocking antibody converts human RBCs into strong SIRPαFc binders. Finally, the consequences of cyno RBC binding were assessed in vivo. Significant depletion of RBCs was evident following intravenous infusions of SIRPαFc in cyno monkeys. We speculate that similar anemia is likely to occur in humans treated with CD47-blocking antibodies that bind to human erythrocytes, but not with a low RBC-binding SIRPαFc therapeutic.

In conclusion, human SIRPαFc binds very poorly to human RBCs but is highly reactive with cyno erythrocytes. This unusual pattern of species cross-reactivity may result from species-specific differences in CD47 membrane mobility and is consistent with a model in which SIRPαFc binding requires mobile CD47 to form high affinity clusters. We predict that anemia, which occurs in monkeys following SIRPαFc administration, is not likely to occur in human patients where significant RBC binding is absent.

Citation Format: Penka S. Petrova, Karen Dodge, Tanya Prasolava, Vien Chai, Xinli Pang, Robert A. Uger. Lack of CD47 membrane mobility contributes to the poor erythrocyte binding of SIRPαFc, a novel CD47-blocking cancer immunotherapeutic. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4271. doi:10.1158/1538-7445.AM2015-4271