Tumor monocyte content predicts immunochemotherapy outcomes in esophageal adenocarcinoma

For inoperable esophageal adenocarcinoma (EAC), identifying patients likely to benefit from recently approved immunochemotherapy (ICI+CTX) treatments remains a key challenge. We address this using a uniquely designed window-of-opportunity trial (LUD2015-005), in which 35 inoperable EAC patients received first-line immune checkpoint inhibitors for four weeks (ICI-4W), followed by ICI+CTX. Comprehensive biomarker profiling, including generation of a 65,000-cell single-cell RNA-sequencing atlas of esophageal cancer, as well as multi-timepoint transcriptomic profiling of EAC during ICI-4W, reveals a novel T cell inflammation signature (INCITE) whose upregulation correlates with ICI-induced tumor shrinkage. Deconvolution of pre-treatment gastro-esophageal cancer transcriptomes using our single-cell atlas identifies high tumor monocyte content (TMC) as an unexpected ICI+CTX-specific predictor of greater overall survival (OS) in LUD2015-005 patients and of ICI response in prevalent gastric cancer subtypes from independent cohorts. Tumor mutational burden is an additional independent and additive predictor of LUD2015-005 OS. TMC can improve patient selection for emerging ICI+CTX therapies in gastro-esophageal cancer.

Long-term outcomes from adding durvalumab to neoadjuvant treatment of operable gastroesophageal cancers: Results from a multicenter study LUD2015-005

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Background: Phase III studies have shown a survival benefit for the addition of immune checkpoint inhibitors to conventional chemotherapy for patients with gastroesophageal cancer (GEC). Large scale studies of chemoimmunotherapy prior to and after surgery are under way. We sought to characterise the effects of the PDL1 inhibitor durvalumab (D) with standard neo-adjuvant chemo(radio)therapy regimens in an open label phase I/II study in patients (pts) with operable GEC (LUD2015-005, NCT02735239, EudraCT 2015-005298-19). Methods: In pts identified as suitable for potentially curative surgery we gave D (750mg q2w) alongside their standard treatment. Pts had D only at first then Oxaliplatin and Capecitabine (CapOx) q3w or fluorouracil, leucovorin, oxaliplatin and taxotere (FLOT) starting with the third cycle of D. Chemotherapy and further D were given for 6 (CapOx) or 8 (FLOT) weeks before pts had surgery and for up to 12 further infusions of D after operation. Patients on FLOT could also have more chemotherapy. Pts suitable for chemoradiotherapy (CXRT, CROSS regimen) were offered two cycles of D before starting their treatment, and were able to have up to 12 further cycles after recovering from surgery. Participants were followed for toxicity, response and survival from the time of study enrolment until death, for 3 years or until June 2022 when the study ended. Results: 11 pts received D-CapOx, 9 D-FLOT and 15 D-CXRT. All were evaluable for safety and efficacy. Treatment side effects were as expected for the agents used with diarrhoea, nausea and fatigue the most commonly reported and no new safety signals. 156 of 160 planned pre-op D doses were given. Only 2 out of 35 patients did not have surgery, both due to progressive disease on D-CXRT. 23 of the 33 patients having surgery had post-operative treatment. Amongst 33 evaluable pts 2 (5.7%) and 6 (17.1%) had complete or partial pre-op responses (RECIST) and 3 (8.6%) progression prior to surgery. Tumor regression at surgery (Mandard 1-3) occurred in 24/33 pts. Median recurrence free survival was 25.4 months (mo) (D-CapOx), 32.0 mo (D-FLOT) and not reached (D-CXRT). 2 year survival was 81.8%, 77.8% and 77.8% respectively in the 3 arms. Conclusions: Adding D to standard neo-adjuvant regimens for GEC is well tolerated. Survival times and response rates exceeded those expected for the regimens used (2 year survivals with FLOT 68% and CROSS 67%) in this non-randomised multi-centre trial. Clinical trial information: NCT02735239 .

79 EXPERIENCES OF DIRECTORS OF NURSING IN RESIDENTIAL CARE OF OLDER PEOPLE DURING COVID 19

Background

COVID-19 was a global public health crisis and deaths in the over 65 age group represented a disproportionate number of deaths in older people. In particular, nursing homes experienced clusters of infection and high mortality rates. This paper discusses experiences of care homes’ Directors of Nursing/Persons in Charge (DoN) in their preparedness, management and control of care during COVID-19.

Methods

A mixed methods approach was used (survey- n=122) and semi-structured interviews (n=20) were conducted with DoNs in private and voluntary older person care homes in the Republic of Ireland. Survey data was analysed using descriptive and inferential statistics. Interviews were analysed using Braun & Clarke's thematic analysis.

Results

DoNs demonstrated an initial challenge in protecting residents from infection and also managing infection outbreak. However, over time they experienced more effectiveness in managing infection prevention and control as demanded at the level of a pandemic. Fifty percent of respondents experienced an infection outbreak and the data does not demonstrate any significant difference in preparedness and management in care homes which had outbreaks and those who had no outbreaks. Other challenges were related to financial sustainability of their facility while 47% of DoNs were either actively seeking other work, or thinking of leaving their post. In the interviews, the DoNs spoke of persistent concerns with the well-being of the staff and residents and a constant worry about meeting regulatory requirements and ensuring adequate staff cover for residents care needs. Moreover, the DoNs spoke of the difficulties when the media sensationalized poor care leading to a reduction of public confidence in the sector.

Conclusion

The DoNs were under constant alert and although had acclimatized to high level of infection control and prevention and managing emerging issues, the strain of the pandemic remained evident. Recommendations are given related to care homes and related to system level management for future public health crisis.

Abstract 1247: Comprehensive molecular profiling to predict first-line immunochemotherapy outcomes in inoperable esophageal adenocarcinoma

For patients with inoperable esophageal adenocarcinoma (EAC), prognosis on conventional chemotherapy (CTX) remains poor. In 2021, the FDA approved two αPD-1 immune checkpoint inhibitors (ICI) for addition to fluoropyrimidine/platinum-containing CTX in this first-line setting. As ICI+CTX enters the clinic, understanding ICI responses and predicting which patients will benefit from ICI addition are key challenges. To address these challenges, we assessed clinical and molecular profiles from the experimental LUD2015-005 trial (NCT02735239, EudraCT 2015-005298-19). Treatment consisted of an initial four-week ICI-only window with durvalumab (αPD-L1) with or without a single dose of tremelimumab (αCTLA-4), followed by 6 cycles of ICI+CTX (CapOx). 38 inoperable patients received treatment (35 EAC; 3 ESCC); median overall survival (OS) and progression-free survival (PFS) were 13.4 and 9.3 months, respectively. All patients reported at least one treatment emergent adverse event (TEAE), with 29 (76.3%) reporting grade 3 or higher TEAEs. EAC patients with available samples (n = 33) were taken forward for biomarker analysis, using tumor and adjacent normal biopsies collected at pre-treatment (PreTx), after four weeks of ICI-only (ICI-4W), and at the end of ICI+CTX (PostTx).

Transcriptomic comparison of paired PreTx and ICI-4W EAC biopsies (n = 28) revealed ICI-induced upregulation of a novel T-cell inflammation signature (termed INCITE). Stronger INCITE upregulation correlated with greater tumor shrinkage during the ICI-only window, and tumors with minimal INCITE upregulation showed markers of ICI resistance, including Innate PD-1 Resistance (IPRES). Despite correlation with ICI-only responses, INCITE changes were not associated with overall ICI+CTX outcomes.

To find predictive biomarkers of ICI+CTX outcomes, we conducted comprehensive genomic and transcriptomic profiling of PreTx EAC biopsies (n = 33). First, we generated a novel 65,000 cell scRNA-seq dataset and designed a deconvolution workflow to resolve tumor cell composition. Unexpectedly, monocyte composition was strongly linked with greater overall survival (OS) (HR: 0.40 [0.23-0.69]; p = 0.001; FDR = 0.047). Coding tumor mutational burden (TMB) was also associated with improved OS (HR: 0.50 [0.28-0.89]; p = 0.019). Multivariate modelling suggested monocyte composition and TMB were independent and complementary predictors of outcomes. Neither factor was associated with outcomes in a TCGA cohort of EAC patients not treated with ICI, suggesting these biomarkers may be specific to ICI or ICI+CTX.

Our findings suggest monocyte composition and TMB may identify EAC patients likely to benefit from ICI+CTX. INCITE upregulation may also serve as a useful monitor of ICI efficacy. These timely findings further our understanding of ICI response and resistance and may help inform patient selection for ICI+CTX.

Citation Format: Thomas M. Carroll, Joseph A. Chadwick, Richard P. Owen, Michael J. White, Joseph Kaplinsky, Iliana Peneva, Anna Frangou, Jaeho Chang, Phil F. Xie, Andrew Roth, Bob Amess, Hantao Lou, Katy J. McCann, Georgina Berridge, Roman Fischer, Chansavath Phetsouphanh, Ayo O. Omiyale, Brittany-Amber Jacobs, David Ahern, Simon R. Lord, Stewart Norris-Bulpitt, Sam T. Dobbie, Lucinda Griffiths, Kristen Aufiero Ramirez, Toni Ricciardi, Mary J. Macri, Aileen Ryan, Ralph R. Venhaus, Benoit J. Van den Eynde, Ioannis Karydis, Benedikt M. Kessler, Benjamin Schuster-Böckler, Mark R. Middleton, Xin Lu. Comprehensive molecular profiling to predict first-line immunochemotherapy outcomes in inoperable esophageal 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 1247.

Circulating Immune Cell and Outcome Analysis from the Phase II Study of PD-L1 Blockade with Durvalumab for Newly Diagnosed and Recurrent Glioblastoma

PURPOSE

PD-L1 is upregulated in glioblastoma and supports immunosuppression. We evaluated PD-L1 blockade with durvalumab among glioblastoma cohorts and investigated potential biomarkers.

PATIENTS AND METHODS

MGMT unmethylated newly diagnosed patients received radiotherapy plus durvalumab (cohort A; n = 40). Bevacizumab-naïve, recurrent patients received durvalumab alone (cohort B; n = 31) or in combination with standard bevacizumab (cohort B2; n = 33) or low-dose bevacizumab (cohort B3; n = 33). Bevacizumab-refractory patients received durvalumab plus bevacizumab (cohort C; n = 22). Primary endpoints were: OS-12 (A), PFS-6 (B, B2, B3), and OS-6 (C). Exploratory biomarkers included: a systematic, quantitative, and phenotypic evaluation of circulating immune cells; tumor mutational burden (TMB); and tumor immune activation signature (IAS).

RESULTS

No cohort achieved the primary efficacy endpoint. Outcome was comparable among recurrent, bevacizumab-naïve cohorts. No unexpected toxicities were observed. A widespread reduction of effector immune cell subsets was noted among recurrent patients compared with newly diagnosed patients that was partially due to dexamethasone use. A trend of increased CD8+Ki67+ T cells at day 15 was noted among patients who achieved the primary endpoint and were not on dexamethasone. Neither TMB nor IAS predicted outcome.

CONCLUSIONS

Patients with recurrent glioblastoma have markedly lower baseline levels of multiple circulating immune cell subsets compared with newly diagnosed patients. An early increase in systemic Ki67+CD8+ cells may warrant further evaluation as a potential biomarker of therapeutic benefit among patients with glioblastoma undergoing checkpoint therapy. Dexamethasone decreased immune cell subsets. PD-L1 blockade and combination with standard or reduced dose bevacizumab was ineffective.

POS1138 PERSISTENCY OF DEPRESSIVE SYMPTOMS AND PHYSICAL PERFORMANCE IN KNEE OSTEOARTHRITIS

Background

Knee osteoarthritis (OA) is the most prevalent arthritic disorder, characterized by joint paint, which is exacerbated by chronic depressive episodes. Depression in knee OA is also associated with declines in physical activity level and greater disability; however, the impact of persistent depressive symptoms on physical performance remains unclear.

Objectives

To determine how the persistence of depressive symptoms affects functional capacity in knee OA.

Methods

Participants (n=2,212) were from the Osteoarthritis Initiative cohort and included individuals with radiographic disease (Kellgren-Lawrence grade ≥ 2) and complete data on study measures at baseline. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D; range 0-60) at baseline and the first three follow-up visits. Physical Performance was measured using 20-meter gait speed (meters per second) during follow-up at the first four annual visits. Persistency of depressive symptoms was operationalized as a cumulative exposure using average severity over time. Gait speed was standardized so that outcome estimates could be interpreted in standard deviations. Time-invariant confounders measured at study enrollment included demographic, socioeconomic, and lifestyle factors. Time-varying confounders assessed concurrent to CES-D scores were body mass index, analgesic medications, pain, and other knee OA signs and symptoms. Marginal structural models accounting for time-dependent confounding and selective attrition were the primary method of analysis. The outcome model included all potential statistical interactions between depressive symptoms and follow-up time indicators. Post-estimation linear combinations estimated time-specific effects of time-averaged CES-D scores on standardized gait speed and differences in physical performance between participants with (i.e., CES-D=16) and without (i.e., CES-D=0) depressive symptoms satisfying screening criteria for major depression.

Results

The interaction between depressive symptoms and time was statistically significant (P=<0.001). Time-specific associations indicated that the largest negative impact of depressive symptoms on physical performance was from baseline through year one (β = -0.0077; 95% CI: -0.0125, 0.0030). However, the effect of persistent depressive symptoms decreased over time and reversed in magnitude and directionality, evidenced by the time-specific associations between time-averaged CES-D scores from baseline through year one and year two and gait speed at year two (β = -0.0033; 95% CI: -0.0084, 0.0019) and year three (β = 0.0014; 95% CI: -0.0046, 0.0074), respectively. Consequently, the strongest negative affect of depressive symptoms on gait speed (β = -0.1232; 95% CI: -0.1998, -0.0473) between participants with and without depressive symptoms satisfying screening criteria for major depression was when depressive symptoms were first measured closest to the initial gait speed assessment.

Conclusion

In the contrast to the dose-dependent relationship between chronic depressive episodes and pain in knee OA, study findings imply that the negative effect of depressive symptoms on physical performance decreases over time with increasing depression persistency. These results may reflect diminishing marginal effects, where the largest impact on physical performance in knee OA is during the first depressive episode closest to initial gait speed assessment, especially when averaged against improvement in symptoms over the same duration.

Acknowledgements

The OAI is a public-private partnership comprised of five contracts (N01-AR-2-2258; N01-AR-2-2259; N01-AR-2-2260; N01-AR-2-2261; N01-AR-2-2262) funded by the National Institutes of Health, a branch of the Department of Health and Human Services, and conducted by the OAI Study Investigators. Private funding partners include Merck Research Laboratories; Novartis Pharmaceuticals Corporation, GlaxoSmithKline; and Pfizer, Inc. Private sector funding for the OAI is managed by the Foundation for the National Institutes of Health. This manuscript was prepared using an OAI public use data set and does not necessarily reflect the opinions or views of the OAI investigators, the NIH, or the private funding partners.

Disclosure of Interests

Rhea Mehta: None declared, Michelle Shardell: None declared, Alice Ryan: None declared, Yu Dong: None declared, Brock Beamer: None declared, Joseph Gallo: None declared, Elizabeth Stuart: None declared, Megan Schuler: None declared, Marc Hochberg Shareholder of: Dr. Marc C. Hochberg is the President of Rheumcon Corporation., Consultant of: Dr. Marc C. Hochberg receives consulting fees from Bioiberica SA, Bristol-Myers Squibb, Eli Lilly, EMD Serono, Galapagos, IBSA Biotechniq SA, Novartis Pharma AG, Pfizer, Plexxikon, Samumed LLC, Theralogix LLC, and TissueGene Inc., Alan Rathbun: None declared

Study to evaluate intraperitoneal (IP) ONCOS-102 with systemic durvalumab in patients with peritoneal disease who have epithelial ovarian (OC) or metastatic colorectal cancer (CRC): Phase 2 results

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Background: Locoregional treatment with oncolytic viruses may be used to improve the efficacy of immune checkpoint inhibitors at both treated and distant tumor sites. This study evaluated the combination of IP-administered ONCOS-102, an oncolytic adenovirus encoding for granulocyte macrophage colony stimulating factor (GM-CSF), with systemic durvalumab (durva) in patients (pts) with advanced OC or CRC who have failed prior chemotherapy. Methods: This open-label study (NCT02963831) evaluated ONCOS-102 (IP 3 x 1011 VP in 500ml saline [recommended phase 2 dose] weekly x 6) + durva (IV 1500 mg every 4 weeks x 12). One dose of cyclophosphamide was given prior to first ONCOS-102 dose. Phase 2 evaluated the activity of the combination using Simon’s 2-stage MINIMAX design. In MINIMAX stage 1, if ≥ 5 of 18 OC pts or ≥ 1 of 13 CRC pts met the efficacy criteria (progression free at end of week 24), 15 additional OC pts or 14 additional CRC pts were to be enrolled in stage 2. The efficacy endpoint would be met if ≥ 11 OC pts or ≥ 4 CRC pts remained progression free at 24 weeks. Safety, response rate and progression-free survival (PFS) by RECIST 1.1, overall survival (OS), and immunologic effects in tumors were evaluated. ITT population = all pts who received at least one dose of durva or ONCOS-102; per protocol (PP) population = all pts who received at least 60% of ONCOS-102 doses and at least 1 durva dose in the first 2 cycles. Results: In MINIMAX stage 1, the OC cohort did not meet the efficacy criteria and was closed. For CRC, stage 1 efficacy criteria were achieved and the cohort was opened for stage 2. As of the 14 Dec 2021 cutoff, CRC enrollment was complete, and all pts were followed for 24 weeks or until progression or off study. Two pts were progression free at 24 weeks (see table). Treatment-related adverse events (TRAEs) occurring in > 30% pts were vomiting, nausea, fatigue, chills, and pyrexia. There were no grade 4 or 5 TRAEs. Grade 3 TRAEs were reported in 8 pts, 2 in the OC cohort and 6 in CRC. All grade 3 TRAEs occurred in no more than 1 pt for each AE except abdominal pain, which occurred in 2 pts. Conclusions: The combination of IP ONCOS-102 and durva was well tolerated. The study did not meet its efficacy endpoint. Evaluation of pre- and on-therapy translational parameters is ongoing. Clinical trial information: NCT02963831. [Table: see text]

Application of an electrocardiography device (iECG) for heart rhythm analysis after exercise in Thoroughbred horses

AliveCor is a smartphone electrocardiography device (iECG) providing automated heart rate (HR) and rhythm determination. Atrial fibrillation (AF) in horses often is paroxysmal and rapid ECG acquisition is needed for diagnostic confirmation. iECGs were collected post-race from 15 horses with AF and 64 horses in sinus rhythm (SR). Results of manual assessment were compared to 3 commercial algorithms for HR and rhythm. Agreement between manually derived HR (HR_M ) and HR derived by the AliveECG Vet (HR_VET ) and Kardia version-1 (K_V1 HR) and Kardia advanced (K_ADV HR) algorithms was quantified by the Bland-Altman limits of agreement test. Agreement between manual rhythm classification and K_V1 and K_ADV algorithms for AF and SR was calculated by the Kappa statistical coefficient. The agreement (bias, 95% limits), between HR_M and HR_VET was 7.1 BPM (-29 to 43) in AF and -4.2 BPM (-38 to 30) in SR, between HR_M and K_V1 HR, was -0.3 BPM (-31 to 30) in AF and 0.2 BPM (-3 to 4) in SR, and between HR_M and K_ADV HR was 7.0 BPM (-29 to 43) in AF and 0.2 BPM (-3.9 to 4.2) in SR. Agreement between manual rhythm classification and K_V1 was 0.36 (0.13-0.59), and K_ADV was 0.84 (0.68-0.99). Sensitivity and specificity for identification of AF and SR of the K_V1 algorithm were 60, 100% and 83, 100%, respectively, and of K_ADV was 87, 100% and 93, 100% respectively. The Kardia algorithms improved precision for HR determination in SR but not AF. The advanced algorithm accurately distinguished between AF and SR. The iECG is suitable for recording episodes of AF following exercise.

337 Intratumoral immune therapy for recurrent breast cancer with polyICLC, and tremelimumab combined with systemic durvalumab

Background

Intratumoral (IT) cancer therapies may enhance T cell activation and tumor infiltration when combined with systemic checkpoint blockade. This approach may improve treatment of advanced breast cancer, which is commonly resistant to immune therapy.

Methods

A multicenter basket-style trial (NCT02643303) was performed in patients with advanced solid tumors, who received polyICLC IT 1mg x 6, then intramuscular (IM) x 3, combined with intravenous (IV) durvalumab 1500 mg q4W. Most were assigned to cohorts also receiving tremelimumab: 10 mg IT or 75 mg IV. Goals were to assess tolerability and clinical activity. Treated tumors were evaluated for immune infiltrates on days (d) 0, 15, and 29 by multiparameter immunofluorescence histology. A strong signal for clinical response was in breast cancer patients; thus, an expansion cohort was enrolled. We report analysis of that breast cancer subgroup.

Results

Nineteen participants with treatment-refractory recurrent breast cancer with median 4 prior lines of therapy were enrolled and treated with IV durvalumab and IT/IM polyICLC. Seventeen also received tremelimumab (15 IT, 2 IV). Common treatment-related AEs were fatigue, injection site pain, and chills. There was one dose-limiting toxicity in a participant who received tremelimumab IV, and died with severe hyponatremia (DLT) and progressive disease. Objective clinical responses (1 complete; 4 partial (1 unconfirmed)) were observed in 5 (26%), including 2/9 patients with triple-negative breast cancer (TNBC) and 3/10 with non-TNBC. Median OS was longer for those with CR, PR, or SD (not reached) vs. those with PD or not evaluable (5 months): two responders remain alive at 34+ and 40+ months. In injected tumors, there were significant increases from d0 to d29 in numbers/mm2 of CD8+ T cells, CD20+ B cells, mature dendritic cells (DC), macrophages, and CD56+ NK cells, and in CD8+ cells with antigen-experience (CD45RO), cytotoxic function (granzyme B), activation (ICOS1), or proliferation (Ki67). CD8+ cells expressing LAG3 and TIM3 increased, as did PDL1+ tumor cells and stromal cells. There were no differences in cells expressing IDO, ARG1, CD39, or CD73. Among patients with objective response, vs. all others, proportions of intratumoral CD8+ cells expressing Ki67 increased (p < 0.04).

Conclusions

IT tremelimumab and polyICLC plus systemic durvalumab is safe and has clinical activity in patients with advanced TNBC and non-TNBC. The therapy enhances intratumoral immune effectors and markers of T cell function in hypothesis-generating data that warrant confirmatory studies. Clinical response was associated with longer survival and increased CD8 T cell proliferation.

Trial Registration

NCT02643303

Ethics Approval

The study has been performed with approval of the institutional review boards of each participating institution (Roswell Park Cancer Institute: STUDY 00000121/I291016; Mount Sinai School of Medicine: IRB-17-01692; University of Virginia: IRB # 19276; Cleveland Clinic: 18-694; Toledo: 300176; Dartmouth: STUDY00031630; Emory: IRB00099445). All participants give informed consent before enrolling and participating. The study was also performed with approval from the FDA

Protection of bone mineral density in heart failure patients:audit on current clinical practice in a busy tertiary care hospital cardiology department in Ireland

Background

The strong association between heart failure (HF) and osteoporosis is well recognised. Heart failure, due to its multiple risk factors and common pathogenesis with osteoporosis can lead to low bone mineral density (BMD) and increase the risk of fragility fractures. The mortality of HF patients following these fractures is high. Current National Osteoporosis Foundation Guidelines recommend that pharmacological therapy should be reserved for postmenopausal women and men aged 50 years or older who present with a hip or vertebral fracture, where the vertebral fractures may be clinical or identified on a radiograph alone.

Methods

Most HF patients have frequent chest radiographs over their course years. We aimed to audit the prevalence of osteoporosis and current practice of prescribing BMD-protection in patients attending the HF clinic in a busy tertiary care hospital in Ireland. 100 patients attending the clinic in the last one year were randomly selected and clinical, medication and chest radiograph information on this cohort was collected via the hospital electronic information system. All those patients with Radiologist confirmed vertebral compression fractures (VCF) on their plain chest radiographs were audited regarding osteoporosis screening and bone protection prescription.

Results

Due to limited penetration,18 out of 100 chest radiographs were inconclusive,reducing the sample size to 82. 9 out of the remaining 82 patients had radiologist confirmed VCF on their plain chest radiographs whereas 2 patients had VCF incidentally picked up on their lumbar spine x-rays. All patients were aged more than 50. 4 were female and 7 male. Median ejection fraction calculated was 35%. 3 out of 11 were smokers,8 had atrial fibrillation and were on anticoagulation,4 had DM-II and 2 had CKD. 10 were on loop diuretics. Of note,4 patients were on calcium and vitamin D supplements but only 1 patient was on antiresorptive therapy for osteoporosis.

Conclusion

Despite its strong association with heart failure,Osteoporosis remains undertreated in this patient cohort.Due to the significant mortality and morbidity associated with major osteoporotic fractures, doctors should carefully assess and screen heart failure patients for osteoporosis and initiate specific therapy where indicated.

Funding Acknowledgement

Type of funding sources: None.

A phase 1 study of NY-ESO-1 vaccine + anti-CTLA4 antibody Ipilimumab (IPI) in patients with unresectable or metastatic melanoma

Ipilimumab (IPI) can enhance immunity to the cancer-testis antigen NY-ESO-1. A clinical trial was designed to assess safety, immunogenicity, and clinical responses with IPI + NY-ESO-1 vaccines and effects on the tumor microenvironment (TME). Patients with measurable NY-ESO-1⁺ tumors were enrolled among three arms: A) IPI + NY-ESO-1 protein + poly-ICLC (pICLC) + incomplete Freund’s adjuvant (IFA); B) IPI + NY-ESO-1 overlapping long peptides (OLP) + pICLC + IFA; and C) IPI + NY-ESO-1 OLP + pICLC. Clinical responses were assessed by irRC. T cell and Ab responses were assessed by ex vivo IFN-gamma ELIspot and ELISA. Tumor biopsies pre- and post-treatment were evaluated for immune infiltrates. Eight patients were enrolled: 5, 2, and 1 in Arms A-C, respectively. There were no DLTs. Best clinical responses were SD (4) and PD (4). T-cell and antibody (Ab) responses to NY-ESO-1 were detected in 6 (75%) and 7 (88%) patients, respectively, and were associated with SD. The breadth of Ab responses was greater for patients with SD than PD (p = .036). For five patients evaluable in the TME, treatment was associated with increases in proliferating (Ki67⁺) CD8⁺ T cells and decreases in RORγt⁺ CD4⁺ T cells. T cell densities increased for those with SD. Detection of T cell responses to NY-ESO-1 ex vivo in most patients suggests that IPI may have enhanced those responses. Proliferating intratumoral CD8⁺ T cells increased after vaccination plus IPI suggesting favorable impact of IPI plus NY-ESO-1 vaccines on the TME.

List of Abbreviations: Ab = antibody; CTCAE = NCI Common Terminology Criteria for Adverse Events; DHFR/DHRP = dihydrofolate reductase; DLT = Dose-limiting toxicity; ELISA = enzyme-linked immunosorbent assay; IFA = incomplete Freund’s adjuvant (Montanide ISA-51); IFNγ = Interferon gamma; IPI = Ipilimumab; irRC = immune-related response criteria; mIFH = multispectral immunofluorescence histology; OLP = NY-ESO-1 overlapping long peptides; PBMC = peripheral blood mononuclear cells; PD = Progressive disease; pICLC = poly-ICLC (Hiltonol), a TLR3/MDA-5 agonist; RLT = Regimen-limiting Toxicity; ROI = regions of interest; RT = room temperature; SAE = serious adverse event; SD = stable disease; TEAE = treatment-emergent adverse events; TLR = toll-like receptor; TME = tumor microenvironment; TRAE = treatment-related adverse events.

Radioprotective effects of induced astronaut torpor and advanced propulsion systems during deep space travel

BACKGROUND

Human metabolic suppression is not a new concept, with 1950s scientific literature and movies demonstrating its potential use for deep space travel (Hock, 1960). An artificially induced state of metabolic suppression in the form of torpor would improve the amount of supplies required and therefore lessen weight and fuel required for missions to Mars and beyond (Choukèr et al., 2019). Transfer habitats for human stasis to Mars have been conceived (Bradford et al., 2018). Evidence suggests that animals, when hibernating, demonstrate relative radioprotection compared to their awake state. Experiments have also demonstrated relative radioprotection in conditions of hypothermia as well as during sleep (Bellesi et al., 2016 and Andersen et al., 2009). Circadian rhythm disrupted cells also appear to be more susceptible to radiation damage compared to those that are under a rhythmic control (Dakup et al., 2018). An induced torpor state for astronauts on deep space missions may provide a biological radioprotective state due to a decreased metabolism and hypothermic conditions. A regular enforced circadian rhythm might further limit DNA damage from radiation. The As Low As Reasonably Achievable (A.L.A.R.A.) radiation protection concept defines time, distance and shielding as ways to decrease radiation exposure. Whilst distance cannot be altered in space and shielding either passively or actively may be beneficial, time of exposure may be drastically decreased with improved propulsion systems. Whilst chemical propulsion systems have superior thrust to other systems, they lack high changes in velocity and fuel efficiency which can be achieved with nuclear or electric based propulsion systems. Radiation toxicity could be limited by reduced transit times, combined with the radioprotective effects of enforced circadian rhythms during a state of torpor or hibernation.

OBJECTIVES

1. Investigate how the circadian clock and body temperature may contribute to radioprotection during human torpor on deep space missions. 2. Estimate radiation dose received by astronauts during a transit to Mars with varying propulsion systems.

METHODS

We simulated three types of conditions to investigate the potential radioprotective effect of the circadian clock and decreased temperature on cells being exposed to radiation such that may be the case during astronaut torpor. These conditions were: - Circadian clock strength: strong vs weak. - Light exposure: dark-dark vs light-dark cycle - Body temperature: 37C vs hypothermia vs torpor. We estimated transit times for a mission to Mars from Earth utilizing chemical, nuclear and electrical propulsion systems. Transit times were generated using the General Mission Analysis Tool (GMAT) and Matlab. These times were then input into the National Aeronautics and Space Administration (NASA) Online Tool for the Assessment of Radiation In Space (OLTARIS) computer simulator to estimate doses received by an astronaut for the three propulsion methods.

RESULTS

Our simulation demonstrated an increase in radioprotection with decreasing temperature. The greatest degree of radioprotection was shown in cells that maintained a strong circadian clock during torpor. This was in contrast to relatively lower radioprotection in cells with a weak clock during normothermia. We were also able to demonstrate that if torpor weakened the circadian clock, a protective effect could be partially restored by an external drive such as lighting schedules to aid entrainment i.e.: Blue light exposure for periods of awake and no light for rest times For the propulsion simulation, estimated transit times from Earth to Mars were 258 days for chemical propulsion with 165.9mSv received, 209 days for nuclear propulsion with 134.4mSv received and 80 days for electrical propulsion with 51.4mSv received.

CONCLUSION

A state of torpor for astronauts on deep space missions may not only improve weight, fuel and storage requirements but also provide a potential biological radiation protection strategy. Moreover, maintaining a controlled circadian rhythm during torpor conditions may aid radioprotection. In the not too distant future, propulsion techniques will be improved to limit transit time and hence decrease radiation dose to astronauts. Limiting exposure time and enhancing physiological radioprotection during transit could provide superior radioprotection benefits compared with active and passive radiation shielding strategies alone.

Serial endometrial thickness and risk of non-endometrial hormone-dependent cancers in postmenopausal women in UK Collaborative Trial of Ovarian Cancer Screening

OBJECTIVE

Estrogen is a well-established risk factor for various cancers. It causes endometrial proliferation, which is assessed routinely as endometrial thickness (ET) using transvaginal ultrasound (TVS). Only one previous study, restricted to endometrial and breast cancer, has considered ET and the risk of non-endometrial cancer. The aim of this study was to explore the association between baseline and serial ET measurements and nine non-endometrial hormone-sensitive cancers, in postmenopausal women, using contemporary statistical methodology that attempts to minimize the biases typical of endogenous serial data.

METHODS

This was a cohort study nested within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). In the ultrasound arm of UKCTOCS, 50639 postmenopausal women, aged 50-74, underwent annual TVS examination, of whom 38 105 had a valid ET measurement, no prior hysterectomy and complete covariate data, and were included in this study. All women were followed up through linkage to national cancer registries. The effect of ET on the risk of six estrogen-dependent cancers (breast, ovarian, colorectal, bladder, lung and pancreatic) was assessed using joint models for longitudinal biomarker and time-to-event data, and Cox models were used to assess the association between baseline ET measurement and these six cancers in addition to liver cancer, gastric cancer and non-Hodgkin's lymphoma (NHL). All models were adjusted for current hormone-replacement therapy (HRT) use, body mass index, age at last menstrual period, parity and oral contraceptive pill use.

RESULTS

The 38 105 included women had a combined total of 267 567 (median, 8; interquartile range, 5-9) valid ET measurements. During a combined total of 407 838 (median, 10.9) years of follow-up, 1398 breast, 351 endometrial, 381 lung, 495 colorectal, 222 ovarian, 94 pancreatic, 79 bladder, 62 gastric, 38 liver cancers and 52 NHLs were registered. Using joint models, a doubling of ET increased significantly the risk of breast (hazard ratio (HR), 1.21; 95% CI, 1.09-1.36; P = 0.001), ovarian (HR, 1.39; 95% CI, 1.06-1.82; P = 0.018) and lung (HR, 1.25; 95% CI, 1.02-1.54; P = 0.036) cancers. There were no statistically significant associations between ET and the remaining six cancers.

CONCLUSION

Postmenopausal women with high/increasing ET on TVS are at increased risk of breast, ovarian and lung cancer. It is important that clinicians are aware of these risks, as TVS is a common investigation. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Phase I/II study to evaluate systemic durvalumab + intraperitoneal (IP) ONCOS-102 in patients with peritoneal disease who have epithelial ovarian (OC) or metastatic colorectal cancer (CRC): Interim phase I clinical and translational results

3017

Background: Metastasis to the peritoneal cavity is associated with end-stage disease in many cancers, including OC and CRC, both of which exhibit poor responses to checkpoint inhibitors. Locoregional treatment with oncolytic viruses may be used to improve the efficacy of checkpoint inhibitors at both treated and distant tumor sites. This study evaluates the combination of IP-administered ONCOS-102, an oncolytic adenovirus encoding for granulocyte macrophage colony stimulating factor (GMCSF), with systemic durvalumab, an anti PD-L1 antibody, in patients with peritoneal disease who have histologically confirmed OC or metastatic CRC and have failed prior standard therapies. Methods: This ongoing Phase 1/2, open-label study (NCT02963831) evaluates safety and antitumor/biologic activity of durvalumab (1500 mg IV, every 4 weeks x 12) + ONCOS-102 (IP, weekly x 6); cyclophosphamide is given pre first ONCOS-102 dose. Phase 1 uses a 3+3 design to evaluate the ONCOS-102 dose (1 or 3 x 1011 VP) to be given with durvalumab. Phase 2 evaluates the activity of the combination using Simon’s 2-stage MINIMAX design. Safety, response rate by RECIST 1.1, and immunological effects in tumors were evaluated for Phase 1; the current abstract reports on the phase 1 results. Results: Enrollment opened 7 Sep 2017; data cutoff, 1 Nov 2019. There were 17 patients treated in Phase 1: 8 CRC, 9 ovarian; 94% female; median age, 56 [37-77] years; ECOG PS0, 47%; ECOG PS1, 53%. There were no DLTs. Grade 3 treatment-related AEs included hypokalemia (n = 2); anemia, myocarditis, increased GGT, and influenza like illness (n = 1 each). There were 4 deaths due to PD. One patient had durable confirmed partial response and remains on treatment > 1 year; 4 patients had stable disease as best overall response. Two patients remained on treatment at data cutoff. Analysis of pre- and on-treatment tumor biopsies revealed changes in the tumor-infiltrating immune cells and PD-L1 expression, including an increase in tumor-infiltrating CD8 T cells in 5 of 11 evaluable patients. Conclusions: Combination of durvalumab and IP ONCOS-102 was safe, and no DLTs were observed. Preliminary analyses demonstrate evidence of biologic and clinical activity. Phase 2 enrollment is ongoing. Clinical trial information: NCT02963831 .

A Prospective, Phase 1 Trial of Nivolumab, Ipilimumab, and Radiotherapy in Patients with Advanced Melanoma

PURPOSE

Preclinical data suggest that radiotherapy (RT) is beneficial in combination with immune checkpoint blockade. Clinical trials have explored RT with single-agent immune checkpoint blockade, but no trials have reported RT with the combination of nivolumab and ipilimumab.

PATIENTS AND METHODS

We conducted a phase 1 study of patients with stage IV melanoma receiving nivolumab and ipilimumab with two different dose-fractionation schemes of RT. Patients had at least one melanoma metastasis that would benefit from palliative RT and one metastasis that would not be irradiated. Nivolumab 1 mg/kg + ipilimumab 3 mg/kg and extracranial RT with a dose of 30 Gy in 10 fractions was administered in Cohort A, and then 27 Gy in 3 fractions was administered in Cohort B. The primary outcome was safety.

RESULTS

Twenty patients were treated (10 in each cohort). The rates of treatment-related grade 3-4 adverse events in Cohort A and B were 40% and 30%, respectively. There were no grade ≥3 adverse events attributed to RT. Patients responded to treatment outside of the irradiated volume (Cohort A 5/10; Cohort B 1/9). No evaluable patients had progression of irradiated metastases. Immunologic changes were seen in the peripheral blood with increases in T-cell receptor diversity in some responding patients.

CONCLUSIONS

RT with nivolumab and ipilimumab was safe compared with historical data of nivolumab and ipilimumab alone. Immunologic effects were observed in the peripheral blood. Randomized studies are ongoing to assess whether RT increases the efficacy of nivolumab and ipilimumab.

Investigation of a foodborne outbreak of Shigella sonnei in Ireland and Northern Ireland, December 2016: the benefits of cross-border collaboration and commercial sales data

OBJECTIVES

To describe a cross-border foodborne outbreak of Shigella sonnei that occurred in Ireland and Northern Ireland (NI) in December 2016 whilst also highlighting the valuable roles of sales data and international collaboration in the investigation and control of this outbreak.

STUDY DESIGN

A cross-border outbreak control team was established to investigate the outbreak.

METHODS

Epidemiological, microbiological, and environmental investigations were undertaken. Traditional analytical epidemiological studies were not feasible in this investigation. The restaurant chain provided sales data, which allowed assessment of a possible increased risk of illness associated with exposure to a particular type of heated food product (product A).

RESULTS

Confirmed cases demonstrated sole trimethoprim resistance: an atypical antibiogram for Shigella isolates in Ireland. Early communication and the sharing of information within the outbreak control team facilitated the early detection of the international dimension of this outbreak. A joint international alert using the European Centre for Disease Control's confidential Epidemic Intelligence Information System for Food- and Waterborne Diseases and Zoonoses (EPIS-FWD) did not reveal further cases outside of the island of Ireland. The outbreak investigation identified that nine of thirteen primary case individuals had consumed product A from one of multiple branches of a restaurant chain located throughout the island of Ireland. Product A was made specifically for this chain in a food production facility in NI. S. sonnei was not detected in food samples from the food production facility. Strong statistical associations were observed between visiting a branch of this restaurant chain between 5 and 9 December 2016 and eating product A and developing shigellosis.

CONCLUSIONS

This outbreak investigation highlights the importance of international collaboration in the efficient identification of cross-border foodborne outbreaks and the value of using sales data as the analytical component of such studies.

Phase II study to evaluate safety and efficacy of MEDI4736 (durvalumab) + radiotherapy in patients with newly diagnosed unmethylated MGMT glioblastoma (new unmeth GBM)

2032

Background: Durvalumab (durva), a human IgG1 monoclonal Ab against PD-L1, is FDA-approved for selected patients with bladder and non-small cell lung cancers. PD-L1 is expressed by some GBM tumors, while GBM infiltrating T lymphocytes often express PD-1. Radiation induced cell death releases tumor antigens and could potentiate anti-PD-(L)1 therapy. Methods: This ongoing Phase 2 open-label study (NCT02336165) evaluates the safety and efficacy of durva (10 mg/kg every 2 weeks) in 5 GBM cohorts. Results are presented for Cohort A, which evaluates durva + standard radiotherapy (RT, 60 Gy over 30 fractions) followed by durva monotherapy in patients with new unmeth GBM after maximum safe resection. The primary efficacy endpoint for Cohort A is overall survival at 12 months (OS12); secondary endpoints include safety/tolerability, tumor response rate, and progression-free survival (PFS). Historical benchmarks of median OS and OS12 for patients with new unmeth GBM following standard therapy are 12.7 months and 50%, respectively (EORTC 26981-22981/NCIC CE.3). Results: Median follow-up of 40 enrolled patients is 24.5 months (data cutoff = 05 Nov 2018). Baseline characteristics: male, 70%; median age, 57.0 [22 to 77] years; ECOG PS0, 60.0%; ECOG PS1, 40.0%; measurable disease, 80.0%; and dexamethasone use, 32.5%. Treatment-related adverse events with maximum CTCAE grade ≥ 3 occurred in 14 (35.0%) patients; the most common were asymptomatic increased lipase (n = 6) and increased amylase (n = 2). Twenty-four of 40 patients were alive at 12 months (Kaplan-Meier for OS12, 60.0% [90% CI: 46.1, 71.4]). Median OS was 15.1 (95% CI: 12.0, 18.4) months. As of 05 Nov 2018, 8 (20%) patients remain alive, with ongoing survival ranging from 15.7 to 34.9 months. Tumor immunocorrelative and systemic studies are pending. Conclusions: This is the first study report of anti-PD-L1 for new GBM. Durva was well tolerated when combined with RT and seemed to have efficacy among patients with new unmeth GBM. Further studies may be warranted. Clinical trial information: NCT02336165.

Abstract P5-15-06: Potential Medicare beneficiary out-of-pocket cost reductions through use of biosimilar filgrastim-sndz over reference filgrastim among breast cancer patients: A simulation model analysis

Rationale & Objective: Granulocyte colony-stimulating factors (G-CSFs) are utilized to decrease the incidence of febrile neutropenia (FN) in patients with cancers undergoing chemotherapy treatments. In 2015 biosimilar filgrastim-sndz was the first biosimilar to be approved and launched in the US market. Limited data exists in ascertaining the impact of biosimilars on patient out-of-pocket (OOP) expenditures. The objective of this simulation model was to estimate potential OOP cost savings through use of filgrastim-sndz over reference filgrastim from a Medicare breast cancer patient perspective.

Methods: An Excel simulation analysis was conducted among breast cancer patients treated with biosimilar filgrastim-sndz or the branded reference filgrastim (identified through HCPCS codes). Data from the 2016 Medicare Limited Data Set (5% sample of the carrier file) was used to populate the model. The payment calculation worksheet within the Medicare carrier file was used to calculate the average Medicare payment to the provider and the average beneficiary OOP responsibility per claim of either filgrastim-sndz or reference filgrastim. The average OOP reduction per claim for a filgrastim-sndz beneficiary relative to a reference filgrastim beneficiary was multiplied to a hypothetical FN prevalent population of 100,000 beneficiaries (average of 10 claims per beneficiary) to estimate the potential OOP savings.

Results: Data for 616 filgrastim-sndz and 1,064 reference filgrastim claims were used to populate the model. The average Medicare allowed charge amount per claim for a filgrastim-sndz beneficiary was $362.8 versus $406.9 for a reference filgrastim beneficiary, while corresponding average Medicare payments to the provider were $284.1 and $316.9, respectively. On an average, OOP responsibility for a filgrastim-sndz beneficiary was lower compared to a reference filgrastim beneficiary ($72.9 versus $82.5) leading to a cost saving per claim of $9.60. When extrapolated to 100,000 beneficiaries (1,000,000 claims), the overall cost saving was projected to be around $9.6 million.

Conclusions: Our simulation model estimated a potential OOP Medicare breast cancer beneficiary saving of around $9.6 million, based on a hypothetical population of 100,000 FN beneficiaries, with the use of biosimilar filgrastim-sndz over reference filgrastim. Further real-world analyses are required to evaluate the true cost saving potential from a breast cancer patient perspective with the use of biosimilars over reference biologics.

Citation Format: Puckrein G, Xu L, Ryan A, Campbell K, Balu S. Potential Medicare beneficiary out-of-pocket cost reductions through use of biosimilar filgrastim-sndz over reference filgrastim among breast cancer patients: A simulation model analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-06.

Abstract A006: Phase 1 study to evaluate the safety and tolerability of MEDI4736 (durvalumab, durva) + tremelimumab (treme) in patients with advanced solid tumors

Durvalumab (durva) is a human IgG1 monoclonal antibody (mAb) that blocks programmed cell death ligand-1 (PD-L1). Tremelimumab (treme) is a human IgG2 mAb inhibitor of cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4). Blocking these checkpoints can result in antitumor activity in some solid tumors. The targets for durva and treme are non-redundant, providing sound rationale for clinical testing of the combination.This is an ongoing phase 1, multicenter, open-label study (NCT01975831) with a dose escalation (3+3 design) and subsequent expansion phase. Patients with renal cell carcinoma (RCC), cervical (CC), colorectal (CRC), non-triple-negative breast (NTNBC), or ovarian (OC) cancer are included in the expansion phase. The protocol excludes patients who had prior exposure to anti-CTLA-4 or anti-PD-1/PD-L1 antibodies. Primary objectives are safety/tolerability and identification of maximum tolerated dose (MTD) of the combination. Secondary objectives include tumor response, progression-free survival (PFS), and overall survival (OS). The intent-to treat (ITT) analysis set includes all patients who received at least one dose of durva or treme and had the baseline and at least one post-baseline tumor assessment.As of 11 May 2018, 104 patients were treated (73.1% female; median age: 56 (30 to 80) years. Durva 1500 mg every 4 weeks (Q4W) X 12 and treme 75 mg Q4W X 4 was the regimen used for opening the expansion phase (n = 82 patients). The majority of treatment-related adverse events (TRAEs) for all patients were Grades 1 and 2. TRAEs ≥ Grade 3 were reported in 17 (16.3%) patients; the majority were diarrhea/colitis (n = 6) and abnormal liver function tests (n = 4) and responded to established treatment algorithms. There was 1 Grade 5 TRAE: multi-organ failure. Fifteen (14.4%) patients experienced TRAEs leading to treatment discontinuation; the majority were diarrhea/colitis (n = 6) and abnormal liver function tests (n = 5). No new toxicities were identified. Tumor response by immune-related Response Criteria (irRC) was assessed by tumor type in the ITT analysis set for all cohorts included in the expansion phase; the follow-up period was at least 12 months. Best overall responses (complete response (irCR), partial response (irPR) and stable disease (irSD)) are presented by tumor type. For OC (n = 27): irCR = 0, irPR = 2 (7.4%), irSD = 10 (37%); for CRC (n = 18): irCR = 1 (5.6%), irPR = 1 (5.6%), irSD = 2 (11.1%); for NTNBC (n = 16): irCR = 0, irPR = 1 (6.3%), irSD = 2 (12.5%); for RCC (n = 19): irCR = 0, irPR = 3 (15.8%), irSD = 11 (57.9%); and for CC (n = 16): irCR = 1 (6.3%), irPR = 3 (18.8%), irSD = 4 (25%) patients. PD-L1 status is not yet available. MSI status was collected retrospectively for patients with CRC; in this group, the patient with irPR had MSI-high status, and the MSI status of the patient with irCR is unknown. PFS and OS rates will be presented at the meeting. In conclusion, the durva and treme combination has a manageable safety profile, with evidence of clinical activity. These data support continued study of the combination therapy.

Citation Format: Margaret K. Callahan, Kunle Odunsi, Mario Sznol, John Nemunaitis, Patrick A. Ott, Patrick Dillon, Reva Schneider, Andrew Park, Paul Schwarzenberger, Toni Ricciardi, Mary Macri, Aileen Ryan, Ralph Venhaus, Jedd D. Wolchok. Phase 1 study to evaluate the safety and tolerability of MEDI4736 (durvalumab, durva) + tremelimumab (treme) in patients with advanced solid tumors [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr A006.

Abstract B209: Phase 1/2 study of mRNA vaccine therapy + durvalumab (durva) ± tremelimumab (treme) in patients with metastatic non-small cell lung cancer (NSCLC)

Vaccine therapies stimulate the immune system to attack cancer cells (active immunotherapy), whereas checkpoint inhibitors block immune inhibition (passive immunotherapy). BI 1361849 (formerly CV9202) is a cancer vaccine comprising 6 mRNA constituents, each of which encodes for one of the non-small cell lung cancer (NSCLC) associated antigens: MUC1, survivin, NY-ESO-1, 5T4, MAGE-C2, and MAGE-C1. Durvalumab (durva) is a checkpoint inhibitor that blocks programmed cell death ligand-1 (PD-L1) binding to programmed cell death-1 (PD-1). Several PD-1 and PD-L1 blocking antibodies are approved for NSCLC. Tremelimumab (treme) is an anti-cytotoxic T-lymphocyte-associated antigen-4 (anti-CTLA-4) blocking antibody. Targeting both the CTLA-4 and PD-1 checkpoint pathways provides the potential for additive or synergistic effects. This study combines active and passive immunotherapies to determine if the addition of a mRNA vaccine, BI 1361849, can enhance the activity of checkpoint blockade. This ongoing phase 1/2, open-label study (NCT03164772) evaluates the safety and efficacy of BI 1361849 when administered with durva (Arm A) or durva + treme (Arm B) in patients with NSCLC. In Arm A, an initial dose evaluation phase follows a 3+3 design to confirm the dose of durva (full dose 1500 mg or de-escalated 750 mg, if needed) to be given with the vaccine. Arm B uses the dose established in Arm A, with the addition of 75 mg treme. In the expansion phase, 20 patients are treated in each arm. To aid in the evaluation of immune responses, there is an additional control group (n=10), in which patients receive the checkpoint inhibitor(s) only. Study treatment is administered over 12 cycles (28 days each). Durva (x 12 doses) and treme (x 4 doses, Arm B only) are administered intravenously every 28 days. The vaccine is administered as a total of 14 doses (of the 6 components) during the 12 cycles, using a device that provides a needle-free intradermal administration. The primary endpoint is assessment of safety and tolerability, including evaluation of dose-limiting toxicities. Secondary endpoints include progression-free survival and objective response rate at 8 and 24 weeks, disease control rate, response duration, and overall survival, with tumor response evaluated by RECIST 1.1 and immune-related RECIST. Exploratory objectives include effects on tumor microenvironment and evaluation of immune responses. Enrollment opened 20 December 2017. As of 27 June 2018, 2 patients are enrolled; enrollment is ongoing.

Citation Format: Joshua Sabari, Kristen Aufiero Ramirez, Paul Schwarzenberger, Toni Ricciardi, Mary Macri, Aileen Ryan, Ralph Venhaus. Phase 1/2 study of mRNA vaccine therapy + durvalumab (durva) ± tremelimumab (treme) in patients with metastatic non-small cell lung cancer (NSCLC) [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B209.

Abstract A022: Phase 1/2 study to evaluate systemic durvalumab (durva) + intraperitoneal ONCOS-102 in patients with peritoneal disease who have epithelial ovarian (OC) or metastatic colorectal cancer (CRC)

Metastasis to the peritoneal cavity is associated with end-stage disease in many cancers, including epithelial ovarian cancer (OC) and colorectal cancer (CRC), both of which exhibit poor responses to checkpoint inhibitors. Oncolytic viruses may promote tumor recognition by the immune system. Evidence suggests that locoregional treatment with oncolytic viruses can be used to improve the efficacy of checkpoint inhibitors at both treated and distant tumor sites. ONCOS-102 is an oncolytic adenovirus encoding for granulocyte-macrophage colony stimulating factor (GMCSF). Durvalumab (durva), a checkpoint inhibitor, is a human IgG1 monoclonal antibody against programmed cell death ligand-1 (PD L1). This study evaluates the combination of intraperitoneally administered ONCOS-102 with systemic durva in patients with peritoneal disease who have histologically confirmed OC or metastatic CRC and have failed prior standard therapies.This ongoing phase 1/2, open-label study (NCT02963831) evaluates the safety and antitumor/biologic activity of durva (1500 mg intravenous, every 4 weeks x 12) + ONCOS-102 (intraperitoneal, weekly x 6); cyclophosphamide is given before the first ONCOS-102 dose. Phase 1 will follow a 3+3 design to evaluate the ONCOS 102 dose to be given with durva. Phase 2 will evaluate the activity of the combination using Simon’s 2-stage MINIMAX design. In Stage 1, the OC and CRC cohorts will enroll 18 and 13 patients, respectively. If ≥ 5 patients in the OC cohort or ≥ 1 patient in the CRC cohort are progression free at the end of Week 24 (PFS24W), then Stage 2 will enroll 15 and 14 additional patients in the OC and CRC cohorts for a total n of 33 and 27, respectively. The null/alternative hypotheses for PFS24W are 20/40% for OC and 5/20% for CRC. The null hypothesis will be rejected if ≥ 11 patients in the OC cohort or ≥ 4 patients in the CRC cohort experience PFS24W. The primary endpoints are safety/tolerability per Common Terminology Criteria for Adverse Events (CTCAE) for phase 1 and PFS24W rate by RECIST 1.1 for phase 2. Secondary endpoints are safety and tolerability, response rate at 8 and 24 weeks, progression-free survival, and overall survival. Exploratory endpoints are immunologic effects in tumors and peripheral blood. Enrollment opened 07 September 2017. As of 27 June 2018, 4 patients are enrolled; enrollment is ongoing.

Citation Format: Dmitriy Zamarin, Kunle Odunsi, Brian Slomovitz, Vanessa M. Hubbard-Lucey, Danielle McCabe, Lisa Shohara, Paul Schwarzenberger, Toni Ricciardi, Mary Macri, Aileen Ryan, Anne-Kirsti Aksnes, Lukasz Kuryk, Ralph Venhaus. Phase 1/2 study to evaluate systemic durvalumab (durva) + intraperitoneal ONCOS-102 in patients with peritoneal disease who have epithelial ovarian (OC) or metastatic colorectal cancer (CRC) [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr A022.

Fetal fraction-based risk algorithm for non-invasive prenatal testing: screening for trisomies 13 and 18 and triploidy in women with low cell-free fetal DNA

OBJECTIVE

To identify pregnancies at increased risk for trisomy 13, trisomy 18 or triploidy attributable to low fetal fraction (FF).

METHODS

A FF-based risk (FFBR) model was built using data from more than 165 000 singleton pregnancies referred for single-nucleotide polymorphism (SNP)-based non-invasive prenatal testing (NIPT). Based on maternal weight and gestational age (GA), FF distributions for normal, trisomy 13, trisomy 18 and triploid pregnancies were constructed and used to adjust prior risks for these abnormalities. A risk cut-off of ≥ 1% was chosen to define pregnancies at high risk for trisomy 13, trisomy 18 or triploidy (high FFBR score). The model was evaluated on an independent blinded set of pregnancies for which SNP-based NIPT did not return a result, and for which pregnancy outcome information was gathered retrospectively.

RESULTS

The evaluation cohort comprised 1148 cases, of which approximately half received a high FFBR score. Compared with rates expected based on maternal age (MA) and GA, cases with a high FFBR score had a significantly increased rate of trisomy 13, trisomy 18 or triploidy combined (5.7% vs 0.7%; P < 0.001) and also of unexplained pregnancy loss (14.7% vs 10.4%; P < 0.001). For cases that did not receive a high FFBR score, the incidence of a chromosomal abnormality or pregnancy loss was not significantly different from that expected based on MA and GA. In this study cohort, the sensitivity of the FFBR model for detection of trisomy 13, trisomy 18 or triploidy was 91.4% (95% CI, 76.9-98.2%) with a positive predictive value of 5.7% (32/564; 95% CI, 3.9-7.9%).

CONCLUSIONS

For pregnancies with a FF too low to receive a result on standard NIPT, the FFBR algorithm identified a subset of cases at increased risk for trisomy 13, trisomy 18 or triploidy. For the remainder of cases, the risk of a fetal chromosomal abnormality was unchanged from that expected based on MA and GA. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Association of plasma nitrite levels with obesity and metabolic syndrome in the Old Order Amish

OBJECTIVES

Plasma nitrite is a metabolite of nitric oxide and reflects endogenous nitric oxide synthase (NOS) activity. Although plasma nitrites were previously linked with obesity and metabolic syndrome (MetS), the direction of association remains inconsistent, possibly due to sample heterogeneity. In a relatively homogeneous population, we hypothesized that nitrite levels will be positively associated with overweight/obesity and MetS.

METHODS

Fasting nitrite levels were measured in 116 Old Order Amish (78% women). We performed age-and-sex-adjusted ancovas to compare nitrite levels between three groups (a) overweight/obese(-)MetS(-), (b) overweight/obese(+)MetS(-) and (c) overweight/obese(+)MetS)(+). Multivariate linear regressions were conducted on nitrite associations with continuous metabolic variables, with successive adjustments for demographics, body mass index, C-reactive protein and neopterin.

RESULTS

Nitrite levels were higher in the obese/overweight(+)MetS(+) group than in the other two groups (p < 0.001). Nitrites were positively associated with levels of triglycerides (p < 0.0001), total cholesterol (p = 0.048), high-density lipoprotein/cholesterol ratio (p < 0.0001) and fasting glucose (p < 0.0001), and negatively correlated with high-density lipoprotein-cholesterol (p < 0.0001). These associations were robust to adjustments for body mass index and inflammatory markers.

CONCLUSION

Further investigation of the connection between obesity/MetS and plasma nitrite levels may lead to novel dietary and pharmacological approaches that ultimately may contribute to reducing the increasing burden of obesity, MetS and cardiovascular morbidity and mortality.

Association between skirt size and chronic liver disease in post-menopausal women: a prospective cohort study within the United Kingdom Trial of Ovarian Cancer Screening (UKCTOCS)

Background

We investigated the association between self-reported skirt size (SS) and change in SS, and incidence of chronic liver disease (CLD) in a prospective cohort study of women recruited to the UKCTOCS trial.

Methods

Women recruited to UKCTOCS in England without documented CLD self-reported their current UK SS during trial participation and were asked to recall their SS when aged in 20s (via completion of a questionnaire 3–5 years after recruitment). Participants were followed up via electronic health record linkage and hazard ratios (HR) calculated for incident liver-related events (LRE).

Results

Three hundred twenty-two (0.3%) of 94,124 women experienced a first LRE. Compared to SS ≤ 16, rates of LRE were higher in the SS ≥ 18 groups (both when aged in 20s and at questionnaire completion). Event rates were higher if there was no change in SS or an increase in SS, compared to a decrease in SS.

In the models adjusted for potential confounders, HRs for LRE were higher in the groups of women reporting SS ≥ 18 both when aged in 20s (HR = 1.39 (95% CI; 0.87–2.23)) and at questionnaire completion (HR = 1.37 (95% CI; 1.07–1.75)). Compared to a decrease in SS, HRs were higher in the no change (HR = 1.78 (95% CI; 0.95–3.34)) and increase (HR = 1.80 (95% CI; 1.01–3.21)) groups.

Conclusion

CLD is associated with high SS and an increase in SS over time. These data suggest SS can be used in simple public health messages about communicating the risk of liver disease.

Trial Registration

UKCTOCS is registered as an International Standard Randomised Controlled Trial, number ISRCTN22488978. Registered 06/04/2000.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5308-x) contains supplementary material, which is available to authorized users.

Sonographers' self-reported visualization of normal postmenopausal ovaries on transvaginal ultrasound is not reliable: results of expert review of archived images from UKCTOCS

OBJECTIVE

In the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), self-reported visualization rate (VR) of the ovaries by the sonographer on annual transvaginal sonographic (TVS) examinations was a key quality control (QC) metric. The objective of this study was to assess self-reported VR using expert review of a random sample of archived images of TVS examinations from UKCTOCS, and then to develop software for measuring VR automatically.

METHODS

A single expert reviewed images archived from 1000 TVS examinations selected randomly from 68 931 TVS scans performed in UKCTOCS between 2008 and 2011 with ovaries reported as 'seen and normal'. Software was developed to identify the exact images used by the sonographer to measure the ovaries. This was achieved by measuring caliper dimensions in the image and matching them to those recorded by the sonographer. A logistic regression classifier to determine visualization was trained and validated using ovarian dimensions and visualization data reported by the expert.

RESULTS

The expert reviewer confirmed visualization of both ovaries (VR-Both) in 50.2% (502/1000) of the examinations. The software identified the measurement image in 534 exams, which were split 2:1:1 providing training, validation and test data. Classifier mean accuracy on validation data was 70.9% (95% CI, 70.0-71.8%). Analysis of test data (133 exams) provided a sensitivity of 90.5% (95% CI, 80.9-95.8%) and specificity of 47.5% (95% CI, 34.5-60.8%) in detecting expert confirmed visualization of both ovaries.

CONCLUSIONS

Our results suggest that, in a significant proportion of TVS annual screens, the sonographers may have mistaken other structures for normal ovaries. It is uncertain whether or not this affected the sensitivity and stage at detection of ovarian cancer in the ultrasound arm of UKCTOCS, but we conclude that QC metrics based on self-reported visualization of normal ovaries are unreliable. The classifier shows some potential for addressing this problem, though further research is needed. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Clinical experience with a single-nucleotide polymorphism-based non-invasive prenatal test for five clinically significant microdeletions

Single-nucleotide polymorphism (SNP)-based non-invasive prenatal testing (NIPT) can currently predict a subset of submicroscopic abnormalities associated with severe clinical manifestations. We retrospectively analyzed the performance of SNP-based NIPT in 80 449 referrals for 22q11.2 deletion syndrome and 42 326 referrals for 1p36, cri-du-chat, Prader-Willi, and Angelman microdeletion syndromes over a 1-year period, and compared the original screening protocol with a revision that reflexively sequenced high-risk calls at a higher depth of read. The prevalence of these microdeletion syndromes was also estimated in the referral population. The positive predictive value of the original test was 15.7% for 22q11.2 deletion syndrome, and 5.2% for the other 4 disorders combined. With the revised protocol, these values increased to 44.2% for 22q11.2 and 31.7% for the others. The 0.33% false-positive rate (FPR) for 22q11.2 deletion syndrome decreased to 0.07% with the revised protocol. Similarly, the FPR for the other 4 disorders combined decreased from 0.56% to 0.07%. Minimal prevalences were estimated to be 1 in 1255 for 22q11.2 deletion syndrome and 1 in 1464 for 1p36, cri-du-chat, and Angelman syndromes combined. Our results show that these microdeletions are relatively common in the referral population, and that the performance of SNP-based NIPT is improved with high-depth resequencing.

Prevalence and predictors of complementary and alternative medicine/non-pharmacological interventions use for menopausal symptoms within the UK Collaborative Trial of Ovarian Cancer Screening

OBJECTIVES

The negative publicity about menopausal hormone therapy (MHT) has led to increased use of complementary and alternative medicines (CAM) and non-pharmacological interventions (NPI) for menopausal symptom relief. We report on the prevalence and predictors of CAM/NPI among UK postmenopausal women.

METHOD

Postmenopausal women aged 50-74 years were invited to participate in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). A total of 202 638 women were recruited and completed a baseline questionnaire. Of these, 136 020 were sent a postal follow-up-questionnaire between September 2006 and May 2009 which included ever-use of CAM/NPI for menopausal symptom relief. Both questionnaires included MHT use.

RESULTS

A total of 88 430 (65.0%) women returned a completed follow-up-questionnaire; 22 206 (25.1%) reported ever-use of one or more CAM/NPI. Highest use was reported for herbal therapies (43.8%; 9725/22 206), vitamins (42.6%; 9458/22 206), lifestyle approaches (32.1%; 7137/22 206) and phytoestrogens (21.6%; 4802/22 206). Older women reported less ever-use of herbal therapies, vitamins and phytoestrogens. Lifestyle approaches, aromatherapy/reflexology/acupuncture and homeopathy were similar across age groups. Higher education, Black ethnicity, MHT or previous oral contraceptive pill use were associated with higher CAM/NPI use. Women assessed as being less hopeful about their future were less likely to use CAM/NPI.

CONCLUSION

One in four postmenopausal women reported ever-use of CAM therapies/NPI for menopausal symptom relief, with lower use reported by older women. Higher levels of education and previous MHT use were positive predictors of CAM/NPI use. UKCTOCS Trial registration: ISRCTN22488978.

Phase 1/2 study of in situ vaccination with tremelimumab + intravenous (IV) durvalumab + poly-ICLC in patients with select relapsed, advanced cancers with measurable, biopsy-accessible tumors

TPS3106

Background: Immunotherapy has demonstrated promising antitumor activity in various advanced cancers. Combined tumor targeting from multiple drugs with unique mechanisms may provide further improved outcomes. Tremelimumab (TRE) is a CTLA-4 antibody and durvalumab (DUR) blocks PD-L1. Poly-ICLC is a toll-like receptor 3 agonist. Intratumoral (intra-T) injection of poly-ICLC directly alters the tumor microenvironment (TME), and by creating an in situ vaccination, may trigger a clinically effective systemic anti-tumor response when also combined with DUR and TRE. Methods: This is an ongoing Phase 1/2, open-label, multicenter study (NCT02643303). The study evaluates the use of intra-T administration of TRE and IV DUR + poly-ICLC (intra-T and intramuscular [IM]) to determine the safety, preliminary efficacy and immune activity of this regimen in patients with advanced, measurable, biopsy-accessible tumors: head and neck squamous cell carcinoma, breast cancer, sarcoma, merkel cell carcinoma, cutaneous T-cell lymphoma, melanoma, genitourinary cancer, and other solid tumors. Phase 1 determines the recommended combination dosing (RCD) for the regimen with dose de-escalation based on dose limiting toxicities (DLTs) and standard 3 + 3 rules. Starting doses are: DUR, 1500 mg IV; TRE, 75 mg IV; TRE, 10 mg intra-T; poly-ICLC, 1 mg intra-T/IM. Phase 1 starts with Cohort 1A (DUR + poly-ICLC). Upon demonstration of tolerability, enrollment proceeds with Cohort 1B (DUR + IV TRE + poly-ICLC) and Cohort 1C (DUR + intra-T TRE + poly-ICLC). The RCD is the highest dose at which < 2/6 patients have DLTs. In Phase 2, up to 66 evaluable patients are treated using the RCD regimen, with enrollment of 6 patients per tumor type initially, and enrollment of 6 additional patients per 3 tumor types contingent upon at least 1 response among the initial 6 patients. Study endpoints are RCD and safety, objective response rate, progression-free survival, and overall survival. Exploratory endpoints are biological activity, including effects on the TME and immunological responses. Enrollment opened on 28 Dec 2016. Clinical trial information: NCT02643303.