Genomics-driven derivatization of the bioactive fungal sesterterpenoid variecolin: Creation of an unnatural analogue with improved anticancer properties

A biosynthetic gene cluster for the bioactive fungal sesterterpenoids variecolin (1) and variecolactone (2) was identified in Aspergillus aculeatus ATCC 16872. Heterologous production of 1 and 2 was achieved in Aspergillus oryzae by expressing the sesterterpene synthase VrcA and the cytochrome P450 VrcB. Intriguingly, the replacement of VrcB with homologous P450s from other fungal terpenoid pathways yielded three new variecolin analogues (5-7). Analysis of the compounds' anticancer activity in vitro and in vivo revealed that although 5 and 1 had comparable activities, 5 was associated with significantly reduced toxic side effects in cancer-bearing mice, indicating its potentially broader therapeutic window. Our study describes the first tests of variecolin and its analogues in animals and demonstrates the utility of synthetic biology for creating molecules with improved biological activities.

Coordination of Ru(II)-Arene Fragments to Dipyridophenazine Ligands Leads to the Modulation of Their In Vitro and In Vivo Anticancer Activity

Despite extensive research on the anticancer properties of Ru complexes with dipyrido[3,2-a:2',3'-c]phenazine (dppz) ligands, their in vivo efficacy is rarely investigated. Aiming to understand whether the coordination of certain half-sandwich Ru(II)-arene fragments might improve the therapeutic potential of dppz ligands, we prepared a series of Ru(II)-arene complexes with the general formula [(η⁶-arene)Ru(dppz-R)Cl]PF₆, where the arene fragment was benzene, toluene, or p-cymene and R was -NO₂, -Me, or -COOMe. All compounds were fully characterized by ¹H and ¹³C NMR spectroscopy and high-resolution ESI mass-spectrometry, and their purity was verified by elemental analysis. The electrochemical activity was investigated using cyclic voltammetry. The anticancer activity of dppz ligands and their respective Ru complexes was assessed against several cancer cell lines, and their selectivity toward cancer cells was assessed using healthy MRC5 lung fibroblasts. The substitution of benzene with a p-cymene fragment resulted in a more than 17-fold increase of anticancer activity and selectivity of Ru complexes and significantly enhanced DNA degradation in HCT116 cells. All Ru complexes were electrochemically active in the biologically accessible redox window and were shown to markedly induce the production of ROS in mitochondria. The lead Ru-dppz complex significantly reduced tumor burden in mice with colorectal cancers without inducing liver and kidney toxicity.

Abstract P4-09-02: A molecular classification system for basal-like breast cancer based on the tumor microenvironment is prognostic for survival

Recent advancements in molecular profiling have revealed distinct breast cancer subtypes, but many clinical NGS assays rely on gene panels, such as PAM50, limiting their clinical utility. Basal-like breast cancer (BLBC), one of the most aggressive subtypes, has highly variable molecular and clinical characteristics. Now, the tumor microenvironment (TME) is recognized as a vital participant in tumor progression and therapeutic response. The development of more refined classifications based on the TME, capable of accounting for tissue heterogeneity, may improve NGS clinical utility for BLBC. Here, we apply our transcriptomic-based approach, recently described by Bagaev et. al., to classify the BLBC TME into discrete immune portraits, to potentially improve clinical outcomes and facilitate therapeutic decisions. We collected a cohort of 1,708 BLBC samples based on the expression levels of 50 genes (PAM50) from 10 publicly available datasets, with clinical outcomes available (n = 819). Using methodology described by Bagaev et. al., 31 functional gene expression signatures (Fges) were selected, and unsupervised dense Louvain clustering was performed to identify TME subtypes. A novel RNA-seq deconvolution algorithm was used to determine the cell types within the TME. Validation of the histological features, including stroma, tumor infiltrating lymphocytes (TILs), and tertiary lymphoid structures (TLS), relative to gene expression patterns in the TME subtypes was performed by automated and manual annotation of BLBC H&E slides (n = 146) from an independent TCGA cohort. Overall survival (OS) analysis was performed using Kaplan-Meier and Cox regression methods.

We revealed 5 BLBC subtypes with distinct expression patterns: immune-enriched, non-fibrotic (IE, 19%), B-cell–enriched, TLS-like (TLS, 25.5%), granulocyte-enriched (G, 12.8%), fibrotic (F, 28%), and immune desert (D, 17.7%) (Table). IE tumors featured an active immune TME, with high immune checkpoint expression and T cell activity. The TLS subtype also had an immune-rich TME, presenting high levels of B cells, T helper cells, and TLS (p < 0.001). The TLS subtype exhibited the highest number of stromal TILs on TCGA H&E slides. The G subtype was characterized by high expression of granulocytes and granulocyte traffic molecules. In accordance with our findings, deconvolution predicted the highest percent of neutrophils in the G subtype (p < 0.001). The F subtype demonstrated the highest levels of angiogenesis, stromal Fges, and VEGFR1-3, FGFR1, and EGFR expression. By histological evaluation, 84% of F subtype samples demonstrated a medium or high level of fibrosis. The D subtype showed a high proliferation rate and low stromal and immune Fges. Indicative of proliferation rate, CCNB1 and cyclin B1 were highest in G, D, and IE subtypes. OS analysis revealed a significant association between TME subtypes (TLS = baseline; log HR G = 0.87, p < 0.05; IE = 0.39, p = 0.18; F = 0.99, p < 0.05; D = 1.21, p < 0.05), and survival outcomes. The immune-enriched subtypes, IE and TLS, demonstrated good prognosis and higher expression of immune checkpoint genes, while immune desert D and granulocyte-enriched G subtypes exhibited the worst OS.

Using our transcriptomic-based approach, BLBC was classified into 5 distinct subtypes, each with unique therapeutic vulnerabilities. Further investigation of these TME subtypes may lead to potential clinical utility as a prognostic tool to improve clinical decision making.

Table. Characteristics of Basal-like breast cancer (BLBC) tumor microenvironment (TME) subtypes. TLS - Tertiary lymphoid structures; CAF - cancer-associated fibroblasts

Citation Format: Svetlana Khorkova, Diana Shamsutdinova, Vladimir Kushnarev, Lev Popyvanov, Daniil Dymov, Anastasia Zotova, Ivan Valiev, Zoya Antysheva, Anna Love, Jessica H. Brown, Alexander Bagaev, Nikita Kotlov, Nathan Fowler. A molecular classification system for basal-like breast cancer based on the tumor microenvironment is prognostic for survival [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 P4-09-02.

Abstract P6-04-15: AI-based prediction of tertiary lymphoid structures and lymphocyte immune infiltration in breast carcinomas

Introduction Tertiary lymphoid structures (TLSs) and tumor-infiltrating lymphocytes (TILs) in breast carcinomas are prognostic for survival and predictive of certain therapy responses. The presence of TLSs and TILs are identified by manual pathological examination; however, this method often lacks reproducibility, limiting its use in routine clinical practice. Here, we demonstrate that morphological evaluation of whole slide images (WSIs) using an artificial intelligence (AI)-based analytic workflow comprised of convolutional neural network (CNN) deep learning models that accurately and reproducibly characterizes TILs, measured as the lymphocyte immune-infiltrated area (LIIA), and TLSs in the tumor microenvironment (TME) of breast carcinomas. Methods We collected a cohort of 445 TCGA breast cancer H&E WSIs, including clinical and sequencing data, and divided this cohort into luminal invasive lobular carcinoma (ILC) (n = 192), HER2-enriched (n = 110), and basal-like (n = 143) molecular subtypes. After 55 samples were excluded due to artifacts or incomplete clinical annotation, a total of 390 samples were analyzed. A combination of CNN-based deep learning models was used to detect and classify the tumor area, TLSs present in the TME, TLS density (number of TLS per mm2 of tumor), and lymphocyte-rich regions. The LIIA was calculated as the area of the stromal and TIL components of the TME. Validation was performed by manually annotating 10 random WSIs from the dataset. Spatial model predictions of the tumor and TLSs were combined to identify TLS locations. Each model’s predictions were verified by univariate (Kaplan-Meier) and multivariate (Cox regression) survival analyses, and the log-rank test was used to calculate overall survival. Additionally, the relationship between TLSs and LIIAs with CD274 expression (PD-L1) and a high tumor mutational burden (TMB > 10) was analyzed. Statistical analyses included Spearman’s rank correlation and Mann-Whitney tests. Results TLS were detected in 53% (n = 207) of the samples, with a mean density of 26.02 TLS/mm2 (Q3 = 5.53 TLS/mm2). TLS density was higher in basal-like subtype samples compared to luminal and HER2-enriched subtypes. While LIIA and TMB-high samples exhibited a significant relationship (p = 0.00001), no significant association was found between TME and TLS quantities or density. PD-L1 gene expression exhibited weak to moderate correlations with predicted LIIA in basal-like (r = 0.38, p = 0.00001) and HER2-enriched subtypes (r = 0.38, p = 0.0001). The luminal subtype had no significant correlation between PD-L1 expression and predicted LIIA. As a result, LIIA and TLS were characterized as positive prognostic factors for the basal-like subtype. After adjusting for age, stage, and grade, the LIIA and TLS density were found to be significant independent positive prognostic overall survival factors for the basal-like subtype (LIIA HR: 0.02, p = 0.003; TLS-high group HR: 0.09, p = 0.002). For the HER2-enriched subtype, TLS density was also a significant predictor (HR: 0.05, p = 0.035), while LIIA was not a statistically significant prognostic factor (HR: 0.0002, p = 0.08). Associations were not observed between the TLSs and LIIA between the ILC subtypes and survival outcomes. The same result was observed for univariate analyses. Conclusion The developed analytic pipeline accurately identified the presence of LIIA and TLS on H&E slides, demonstrating the potential of CNN for automated characterization of the breast cancer TME. AI-based TLS and LIIA quantification can be a robust tool for pathology processes, offering additional information to help in clinical decision-making. This approach can be used to detect features of immune morphology biomarkers in other cancer types.

Citation Format: Vladimir Kushnarev, Daniil Dymov, Nadezhda Lukashevich, Lev Popyvanov, Anna Belozerova, Diana Shamsutdinova, Aida Akaeva, Yury Popov, Svetlana Khorkova, Ivan Valiev, Anastasia Zotova, Jessica H. Brown, Anna Love, Alexander Bagaev, Ekaterina Postovalova, Nathan Fowler. AI-based prediction of tertiary lymphoid structures and lymphocyte immune infiltration in breast carcinomas [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 P6-04-15.

Abstract 1227: Molecular-based tumor grade predictor for breast cancer, clear cell renal cell carcinoma, and lung adenocarcinoma

Classifying tumors based on histological grade is used for many cancers to determine a patient’s prognosis and select the appropriate treatment. Although low grade (G1) and high grade (G3/G4) tumors have been shown to predict patient survival in many cancers, an intermediate histological grade (G2) does not have clear prognostic significance. Therefore, to allow a more accurate assessment of a patient’s risk, recent studies have focused on utilizing gene expression data to improve prognostic stratification of tumors into either a high-risk or low-risk group. Here, we present a molecular-based classifier that can use gene expression data from both RNA sequencing (RNA-seq) and microarray profiling to achieve accurate prediction of tumor grade for breast cancer (BRCA), lung adenocarcinoma (LUAD), and clear cell renal cell carcinoma (ccRCC). The tumor grade predictor was developed by training a machine-learning algorithm to classify tumors into categories of low (mG1) and high (mG3/mG4) molecular grades for each cancer type using rank transformation of gene expression data from multiple datasets. This resulted in the revealing of features of the mG3/mG4 groups not shown by histological methods (i.e., the Warburg effect, proliferation signaling pathways, inactivation of tumor suppressors, fibrotic and immunosuppressive microenvironment, and the loss of normal cell morphology), allowing for a more accurate stratification between the high- and low-grade groups. Importantly, by using rank transformation to analyze data from both RNA-seq and microarray profiling, the predictor functioned independent of various sources of batch effect, resulting in the ability to work with single samples and not only datasets. Validation of the tumor grade classifier with pathological classification of G1 and G3/G4 samples from RNA-seq and microarray expression data into mG1 and mG3/mG4 groups showed a more accurate performance than other gene expression-based methods, which was demonstrated by it’s sensitivity-specificity value (AUC scores: BRCA - 0.95, LUAD - 0.89, ccRCC - 0.83). Further, cox-regression analysis showed that prognostic value of mG1 and mG3 groups were comparable to histological grades (BRCA - 0.71 vs. 0.71; LUAD - 0.66 vs. 0.62; ccRCC - 0.74 vs. 0.71), demonstrating the ability of the classifiers to successfully split G2 histological samples into molecular grades. In conclusion, we developed a tumor grade predictor that utilizes expression data from multiple datasets to accurately classify tumors for three cancer types. The resulting prognostic ability of the molecular grades demonstrates their capability of assessing the levels of risk for G2 samples, suggesting the potential for molecular-based tumor grade classifiers to be used in future clinical application.

Citation Format: Zoya Antysheva, Maria V. Guryleva, Ivan Valiev, Nikita Kotlov, Viktor Svekolkin, Olga Gancharova, Vladimir Kushnarev, Yuriy Popov, Anna Belozerova, Dmitry Tabakov, Jessica H. Brown, Krystle Nomie, Alexander Bagaev, Nathan Fowler. Molecular-based tumor grade predictor for breast cancer, clear cell renal cell carcinoma, and lung adenocarcinoma [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 1227.

A digital imaging analysis (DIA) platform for identifying tertiary lymphoid structures (TLS) in lung adenocarcinoma (LUAD)

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Background: Previous studies of non-small cell lung cancer (NSCLC) have shown that TLS can be predictive of therapy response and a positive prognostic factor for survival. Currently, TLS identification is manually performed by pathologists with limited morphological criteria. Standardizing TLS detection with an automated DIA workflow could guide clinical trials in precision medicine by improving patient stratification. Here, we investigate the reproducibility and sensitivity of our DIA platform for evaluating TLS in LUAD using digital histopathology and machine learning. Methods: TLS were assessed by 3 pathologists on whole slide images (WSI) in a validation cohort of 22 LUAD samples using current TLS characterization criteria of dense lymphoid structures, the presence/absence of a germinal center, and high endothelial venules (HEVs). The intraclass correlation coefficient (ICC) was used to measure reproducibility between pathologists. The BostonGene DIA platform was used to train models for automated TLS detection. Quantitative measurements of area, lymphocyte number, and density of each TLS were obtained. A prospective cohort of 8 samples was used to compare pathologist and DIA identification of TLS. Normalized numbers of TLS in the tumor area were used for cohort stratification for overall survival (OS) analysis using the Kaplan-Meier method in an independent clinical cohort of 104 TCGA-LUAD patients. Results: A panel of 3 pathologists identified 326 unique TLS from 22 samples. Between-pathologist detection of TLS, independent of germinal center or HEV criteria, resulted in good reproducibility with an ICC of 0.77. Our DIA platform exhibited excellent reproducibility with an ICC of 0.94 when compared to validated prospective cohort annotation. In total, 155 and 189 TLS were identified by pathologists and our DIA platform, respectively. The DIA platform demonstrated a markedly improved sensitivity of 0.91 for TLS identification. Furthermore, OS analysis revealed that a TLS density greater than 0.94 TLS per mm2 of tumor assessed by DIA is a statistically significant independent biomarker of better OS in the LUAD cohort from TCGA. Conclusions: These results demonstrate the BostonGene DIA platform detects TLS in LUAD, with improved reproducibility and sensitivity over previous methods. Additionally, the DIA platform showed a TLS density greater than 0.94 TLS per mm2 of tumor is a positive prognostic marker for OS in LUAD. Standardized TLS DIA identification can be exploited in digital pathology applications for future clinical trials, informing clinicians of predictive and prognostic information during the decision-making process.

Case Report: Multiple Causes of Cardiac Death After the First Infusion of Atezolizumab: Histopathological and Immunohistochemical Findings

Immune checkpoint inhibitors are promising agents for anticancer therapy. But despite their high efficacy in the treatment of solid tumors, there is still a problem with immune-related adverse events, especially cardiovascular complications with a very high mortality rate. Myocarditis or ischemic heart disease progression is not the only possible cause of cardiovascular death in patients treated with checkpoint inhibitors. We report a case of a patient with mucinous carcinoma of the lung, with a previous history of hypertension and moderate left ventricular dysfunction. The patient was prescribed atezolizumab, but the first atezolizumab infusion resulted in the patient cardiovascular death. Postmortem histopathological evaluation of myocardium revealed several possible reasons for hemodynamic instability: tumor embolism of the coronary arteries, micrometastases of mucinous carcinoma in the myocardium, and myocarditis diagnosed by both Dallas and immunohistochemistry criteria. In addition, testing for expression of PD-L1 detected the high levels of membranous and cytoplasmic PD-L1 protein even in the myocardium area free from tumor cells. The present clinical case demonstrates a problem of cardiovascular death in patients treated with checkpoint inhibitors and actualizes the need for future research of potential risk factors for cardiovascular complications.

Abstract P3-18-09: Refusal of breast surgery in breast cancer patients with clinical complete response (cCR) after neoadjuvant systemic therapy and vacuum-assisted biopsy (VAB) and sentinel lymph node biopsy (SLNB) confirmed pathological complete response (pCR). A first report of the prospective non-randomized trial results. NCT04293796

Introduction The aim of the study was to prove efficacy and safety of refusal of traditional breast surgery in BC patients who develop cCR after neoadjuvant chemotherapy. Refusal of surgery was offered to exceptional responders after vacuum-assisted tumor bed biopsy and sentinel lymph node biopsy confirmed absence of residual disease (pCR). Materials and methods A single-center prospective study was run in the NMRC n.a. N.N. Petrov. Starting from August of 2020 20 patients with early сT1-2N0-1M0 (stage Ia-IIb) triple-negative and HER2-positive (both ER+ and ER-) unifocal tumours without in situ component in core-biopsy specimen enrolled in the study. Primary lesions were marked with a single clip in the centre. In cases with nodal involvement (cN1) the affected lymph nodes were also clipped. Patients with triple-negative breast cancer received 4 cycles of AC q21d followed by 12 cycles of weekly paclitaxel and carboplatinum AUC 2.0. HER2-positive patients received 4 cycles of AC followed by 4 cycles of docetaxel combined with trastuzumab and pertuzumab q21d. Breast US, mammography and SPECT were used at baseline and at response evaluation. Vacuum-assisted biopsy was performed with 7G needle and US-guidance in the OR simultaneously with the SLNB under general anesthesia. VAB protocol included retrieval of the tumor clip as first stage. Subsequently surrounding tissues were sampled, and markers were placed to guide radiotherapy. In case residual tumor was found patients received standard breast-conserving surgery. In case the sentinel lymph nodes were found to be positive, standard level II axillary clearance was performed. HER2-positive patients with pCR confirmed by VAB and SLNB received adjuvant trastuzumab up to one year. HER2-positive patients with residual breast or nodal involvement received trastuzumab-emtanzine up to one year. In case ER-positive, all patients received appropriate endocrine-therapy. In case of residual in-breast or nodal involvement patients with triple-negative breast cancer received 6 cycles of capecitabine. Results cCR was achieved in 8 of 10 patients in the HER2-positive group. VAB and SLNB were performed in 7 cases and confirmed pCR in 5 patients. 2 had residual in-breast disease with <10% cellularity. One patient with cCR requested standard surgical approach that confirmed pCR. 2 patients failed to obtain cCR. Both received standard surgery. In one of the cases no residual disease was found, in another one - a residual in-breast tumor was found at section. All HER2-positive patients were found to be sn ypN0. In the triple-negative group cCR was achieved in 6 of 10 patients. 4 patients went on to receive VAB and SLNB. After VAB and SLNB pCR was confirmed in three of them. 1 patient had residual tumor with less than 5% cellularity. Two patients with cCR after NAT opted for standard surgery. In both cases pCR was confirmed. 4 patients with clinically detectable residual in-breast tumor received standard surgery. All turned out to have pCR. All the patients in the TNBC group were also found to be sn ypN0.ConclusionVisualization modalities fail to provide reliable information on the true rate of pCR. Contemporary systemic therapy regimens provide the rate of pCR up to 60-70%. In all cases of NAT tumor bed marking at baseline is an essential procedure to guide future interventions and confirm their success. Discrepancies between radiologic assessment and true rates of pCR are a substrate for further search for the techniques that would challenge the role of surgery in exceptional responders developing cCR. The trial continues to enrol patients.

Citation Format: Petr Krivorotko, Sergey Yerechshenko, Alexander Emelyanov, Ekaterina Busko, Alexander Bessonov, Viktoriya Gukova, Alexander Komyahov, Elena Zhiltsova, Kirill Nikolaev, Tengiz Tabagua, Larisa Gigolaeva, Roman Pesotsky, Sergey Novikov, Zhanna Bryantseva, Anna Artemyeva, Viktoriya Smirnova, Vladimir Kushnarev, Alexey Belyaev, Tatiana Semiglazova, Vladimir Semiglazov. Refusal of breast surgery in breast cancer patients with clinical complete response (cCR) after neoadjuvant systemic therapy and vacuum-assisted biopsy (VAB) and sentinel lymph node biopsy (SLNB) confirmed pathological complete response (pCR). A first report of the prospective non-randomized trial results. NCT04293796 [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-09.

Myocardial PD-L1 Expression in Patients With Ischemic and Non-ischemic Heart Failure

Objective: Immune checkpoints inhibitors are promising and wide-spread agents in anti-cancer therapy. However, despite their efficacy, these agents could cause cardiotoxicity, a rare but life-threatening event. In addition, there are still no well-described predictive factors for the development of immune-related adverse events and information on high risk groups. According to known experimental studies we hypothesized that cardiovascular diseases may increase myocardial PD-L1 expression, which could be an extra target for Checkpoint inhibitors and a potential basis for complications development.

Methods: We studied patterns of myocardial PD-L1 expression in non-cancer-related cardiovascular diseases, particularly ischemic heart disease (n = 12) and dilated cardiomyopathy (n = 7), compared to patients without known cardiovascular diseases (n = 10) using mouse monoclonal anti-PD-L1 antibody (clone 22C3, 1:50, Dako). Correlation between immunohistochemical data and echocardiographic parameters was assessed. Statistical analyses were performed using R Statistical Software—R studio version 1.3.1093.

Results: In the myocardium of cardiac patients, we found membranous, cytoplasmic, and endothelial expression of PD-L1 compared to control group. In samples from patients with a history of myocardial infarction, PD-L1 membrane and endothelial expression was more prominent and frequent, and cytoplasmic and intercalated discs staining was more localized. In contrast, samples from patients with dilated cardiomyopathy displayed very faint endothelial staining, negative membrane staining, and more diffuse PD-L1 expression in the cytoplasm and intercalated discs. In samples from the non-cardiac patients, no convincing PD-L1 expression was observed. Moreover, we discovered a significant negative correlation between PD-L1 expression level and left ventricular ejection fraction and a positive correlation between PD-L1 expression level and left ventricular end-diastolic volume.

Conclusions: The present findings lay the groundwork for future experimental and clinical studies of the role of the PD-1/PD-L1 pathway in cardiovascular diseases. Further studies are required to find patients at potentially high risk of cardiovascular adverse events associated with immune checkpoint inhibitors therapy.

Interfering with Metabolic Profile of Triple-Negative Breast Cancers Using Rationally Designed Metformin Prodrugs

Triple-negative breast cancer (TNBC) is the most aggressive subtype of breast cancer, characterized by an aberrant metabolic phenotype with high metastatic capacity, resulting in poor patient prognoses and low survival rates. We designed a series of novel Au^III cyclometalated prodrugs of energy-disrupting Type II antidiabetic drugs namely, metformin and phenformin. Prodrug activation and release of the metformin ligand was achieved by tuning the cyclometalated Au^III fragment. The lead complex 3met was 6000-fold more cytotoxic compared to uncoordinated metformin and significantly reduced tumor burden in mice with aggressive breast cancers with lymphocytic infiltration into tumor tissues. These effects was ascribed to 3met interfering with energy production in TNBCs and inhibiting associated pro-survival responses to induce deadly metabolic catastrophe.

Impact of Oscillating Positive Expiratory Pressure Device Use on Post-Discharge Hospitalizations: A Retrospective Cohort Study Comparing Patients with COPD or Chronic Bronchitis Using the Aerobika® and Acapella® Devices

Purpose

Managing and preventing disease exacerbations are key goals of COPD care. Oscillating positive expiratory pressure (OPEP) devices have been shown to improve clinical outcomes when added to COPD standard of care. This retrospective database study compared real-world resource use and disease exacerbation among patients with COPD or chronic bronchitis prescribed either of two commonly used OPEP devices.

Patients and methods

Patients using the Aerobika^® (Trudell Medical International, London, ON, Canada) or Acapella^® (Smiths Medical, Wampsville, New York, USA) OPEP device for COPD or chronic bronchitis were identified from hospital claims linked to medical and prescription claims between September 2013 and April 2018; the index date was the first hospital visit with an OPEP device. Severe disease exacerbation, defined as an inpatient visit with a COPD or chronic bronchitis diagnosis, and all-cause healthcare resource utilization over 30 days and 12 months post-discharge were compared in propensity score (PS)-matched Aerobika device and Acapella device users.

Results

In total, 619 Aerobika device and 1857 Acapella device users remained after PS matching. After discharge from the index visit, Aerobika device users were less likely to have ≥1 severe exacerbation within 30 days (12.0% vs 17.4%, p=0.01) and/or 12 months (39.6% vs 45.3%, p=0.01) and had fewer 12-month severe exacerbations (mean, 0.7 vs 0.9 per patient per year, p=0.01), with significantly longer time to first severe exacerbation than Acapella users (log-rank p=0.01). Aerobika device users were also less likely to have ≥1 all-cause inpatient visit within 30 days (13.9% vs 20.3%, p<0.001) and 12 months (44.9% vs 51.8%, p=0.003) than Acapella users.

Conclusion

Patients receiving the Aerobika OPEP device, compared to the Acapella device, had lower rates of subsequent severe disease exacerbation and all-cause inpatient admission. This suggests that Aerobika OPEP device may be a beneficial add-on to usual care and that OPEP devices may vary in clinical effectiveness.

A Functional Respiratory Imaging Approach to the Effect of an Oscillating Positive Expiratory Pressure Device in Chronic Obstructive Pulmonary Disease

Purpose

Chronic obstructive pulmonary disease (COPD) patients are prone to suffer from chronic bronchitis, which ultimately affects their quality of life and overall prognosis. Oscillating positive expiratory pressure (oPEP) devices are designed to aid in the mucus clearance by generating positive pressure pulses in the airways. The main aim of this study was to analyze the impact of a specific oPEP device - Aerobika^® - on top of standard of care medication in COPD patients' lung dynamics and drug deposition.

Patients and Methods

In this single-arm pilot study, patients were assessed using standard spirometry tests and functional respiratory imaging (FRI) before and after a period of 15±3 days of using the oPEP device twice daily (before their standard medication).

Results

The utilization of the oPEP device led to a significant increase of 2.88% in specific airway volume after two weeks (1.44 (SE: 0.18) vs 1.48 (SE: 0.19); 95% CI = [0.03%,5.81%]; p=0.048). Moreover, the internal airflow distribution (IAD) was affected by the treatment: patients' changes ranged from -6.74% to 4.51%. Furthermore, IAD changes at the lower lobes were also directly correlated with variations in forced expiratory volume in one second and peak expiratory flow; conversely, IAD changes at the upper lobes were inversely correlated with these clinical parameters. Interestingly, this change in IAD was significantly correlated with changes in lobar drug deposition (r ²=0.30, p<0.001).

Conclusion

Our results support that the Aerobika device utilization leads to an improved airflow, which in turn causes a shift in IAD and impacts the drug deposition patterns of the concomitant medication in patients with COPD.

A Real-World Evidence Study Assessing the Impact of Adding the Aerobika Oscillating Positive Expiratory Pressure Device to Standard of Care Upon Healthcare Resource Utilization and Costs in Post-Operative Patients

INTRODUCTION

The aim of this real-world study was to measure the benefit of the Aerobika oscillating positive expiratory pressure (OPEP) device when added to standard of care (defined as incentive spirometry [IS]) for post-operative patients.

METHODS

Adults aged ≥ 18 years who were hospitalized for cardiac, thoracic or upper abdominal surgery between 1 September 2013 and 30 April 2017 were identified from IQVIA's Hospital Charge Detail Master (CDM) database; the index date was the date of the first hospitalization for surgery. The control cohort (IS) included patients who had ≥ 1 CDM record within 12 months prior to the index date and ≥ 1 record after discharge, evidence of IS use during index hospitalization and no evidence of use of a PEP or OPEP device at any time during the study period. The Aerobika OPEP cohort was selected in a similar manner, except that patients were required to have evidence of Aerobika OPEP use during the index hospitalization. Aerobika OPEP patients were 1:1 matched to IS patients using propensity score (PS) matching. Hospital readmissions and costs were measured at 30 days post-discharge from the index hospitalization.

RESULTS

After PS matching, 144 patients were included in each cohort. At 30 days post-discharge, compared to the control (IS) cohort there were significantly fewer patients in the Aerobika OPEP cohort with ≥ 1 all-cause re-hospitalizations (13.9 vs. 22.9%; p = 0.042). The patients in the Aerobika OPEP cohort also had a shorter mean length of stay (± standard deviation) (1.25 ± 4.04 vs. 2.60 ± 8.24 days; p = 0.047) and lower total unadjusted mean all-cause cost per patient ($3670 ± $13,894 vs. $13,775 ± $84,238; p = 0.057). Adjusted analyses suggested that hospitalization costs were 80% lower for the Aerobika OPEP cohort versus the IS cohort (p = 0.001).

CONCLUSION

Our results suggest that the addition of the Aerobika OPEP device to standard of care (IS) is beneficial in the post-operative setting.

FUNDING

Trudell Medical International.