Richter's transformation: Transforming the clinical landscape

Richter transformation (RT) represents an aggressive histological transformation from chronic lymphocytic leukaemia, most often to a large B cell lymphoma. It is characterised by chemo-resistance and subsequent short survival. Drug development has struggled over recent years in light of the aggressive kinetics of the disease, lack of pivotal registrational trials and relative rarity of the phenomenon. In this review we will highlight the diagnostic and therapeutic challenges of managing patients with RT as well as taking a look to the future therapeutic landscape. Highly active therapies developed across B cell malignancies are starting to impact this field, with T-cell activation therapies (CAR-T, bispecific antibodies), antibody-drug conjugates, and novel small molecule inhibitor combinations (e.g. BTKi-BCL2i) being actively studied. We will highlight the data supporting these developments and look to the studies to come to provide hope for patients suffering from this devastating disease.

Esophageal Liposarcoma: A Case Report and Review of the Literature

Liposarcomas are extremely rare occurrences in the esophagus. Here, we present an unusual case of esophageal liposarcoma that contributed to a long history of dysphagia before a definitive diagnosis was reached. The case is that of a 61-year-old woman who complained of dysphagia and foreign body sensation in her throat and was found to have a large filling defect within the cervical esophagus on barium esophagogram. She underwent endoscopic resection of the mass and was diagnosed with a five-centimeter long, well-differentiated esophageal liposarcoma, confirmed with fluorescence in situ hybridization for MDM2 gene locus amplification. Subsequent laser ablation of the tumor bed was conducted with no recurrences noted to date. Proper histologic identification, alongside adjunctive cytogenetic and molecular diagnostics, followed by definitive surgical resection and extended follow-up, are emphasized as critical in optimizing outcomes for this disease. A review of the existing English-language medical literature relating to esophageal liposarcoma was performed and summarized.

Nrf2 Drives Hepatocellular Carcinoma Progression through Acetyl-CoA-Mediated Metabolic and Epigenetic Regulatory Networks

Correlations between the oxidative stress response and metabolic reprogramming have been observed during malignant tumor formation; however, the detailed mechanism remains elusive. The transcription factor Nrf2, a master regulator of the oxidative stress response, mediates metabolic reprogramming in multiple cancers. In a mouse model of hepatocellular carcinoma (HCC), through metabolic profiling, genome-wide gene expression, and chromatin structure analyses, we present new evidence showing that in addition to altering antioxidative stress response signaling, Nrf2 ablation impairs multiple metabolic pathways to reduce the generation of acetyl-CoA and suppress histone acetylation in tumors, but not in tumor-adjacent normal tissue. Nrf2 ablation and dysregulated histone acetylation impair transcription complex assembly on downstream target antioxidant and metabolic regulatory genes for expression regulation. Mechanistic studies indicate that the regulatory function of Nrf2 is low glucose dependent, the effect of which is demolished under energy refeeding. Together, our results implicate an unexpected effect of Nrf2 on acetyl-CoA generation, in addition to its classic antioxidative stress response regulatory activity, integrates metabolic and epigenetic programs to drive HCC progression.

IMPLICATIONS

This study highlights that Nrf2 integrates metabolic and epigenetic regulatory networks to dictate tumor progression and that Nrf2 targeting is therapeutically exploitable in HCC treatment.

Extravasation of Blood and Blood Toxicity Drives Tubular Injury from RBC Trapping in Ischemic AKI

Red blood cell (RBC) trapping is common in ischemic acute kidney injury (AKI) and presents as densely packed RBCs that accumulate within and engorge the kidney medullary circulation. In this study, we tested the hypothesis that "RBC trapping directly promotes tubular injury independent of extending ischemia time." Studies were performed on rats. Red blood cell congestion and tubular injury were compared between renal arterial clamping, venous clamping, and venous clamping of blood-free kidneys. Vessels were occluded for either 15 or 45 min with and without reperfusion. We found that RBC trapping in the medullary capillaries occurred rapidly following reperfusion from renal arterial clamping and that this was associated with extravasation of blood from congested vessels, uptake of blood proteins by the tubules, and marked tubular injury. To determine if this injury was due to blood toxicity or an extension of ischemia time, we compared renal venous and arterial clamping without reperfusion. Venous clamping resulted in RBC trapping and marked tubular injury within 45 min of ischemia. Conversely, despite the same ischemia time, RBC trapping and tubular injury were minimal following arterial clamping without reperfusion. Confirming the role of blood toward tubular injury, injury was markedly reduced in blood-free kidneys with venous clamping. Our data demonstrate that RBC trapping results in the rapid extravasation and uptake of blood components by tubular cells, causing toxic tubular injury. Tubular toxicity from extravasation of blood following RBC trapping appears to be a major component of tubular injury in ischemic AKI, which has not previously been recognized.

A tale of two vulvar angiomyxomas: Two cases and review of literature

Vulvar angiomyxomas are rare benign mesenchymal neoplasms. Superficial and Aggressive angiomyxomas are two distinct phenotypes that present similarly to other more common vulva-perineal pathologies. Albeit both angiomyxomas carry a risk of recurrence, especially in the setting of incomplete resection, simple excision is insufficient for Aggressive angiomyxoma. It requires wide local excision because of its unique potential for local invasion, infiltration of the paravaginal and pararectal tissue, and more distant metastasis. Here, we present a case of Superficial angiomyxoma and a case of Aggressive angiomyxoma to highlight the diagnostic challenges and management strategies of each tumor. In both cases, angiomyxomas were initially misdiagnosed because of their rarity and nonspecific presentation. Magnetic resonance imaging is the modality of choice for evaluation due to inherent higher spatial resolution of soft tissue anatomical details. Early diagnosis of Aggressive angiomyxoma can prevent incomplete excision and recurrence, spare additional surgery, and offer hormonal therapy options.

NADPH oxidase 1 in chronic pancreatitis-activated pancreatic stellate cells facilitates the progression of pancreatic cancer

Patients suffering from chronic pancreatitis (CP) have a higher risk of pancreatic ductal adenocarcinoma (PDAC) compared to the general population. For instance, the presence of an activated pancreatic stellate cell (PaSC)-rich stroma in CP has facilitated the progression of non-invasive pancreatic intraepithelial neoplasia (PanIN) lesions to invasive PDAC. We have previously found that in a mouse model of CP, NADPH oxidase 1 (Nox1) in activated PaSCs forms fibrotic tissue and up-regulates both matrix metalloproteinase (MMP) 9 and the transcription factor Twist1. Yet, the role and mechanism of Nox1 in activated PaSCs from mice with CP (CP-activated PaSCs) in the progression of PDAC is unknown. For that, we tested the ability of Nox1 in CP-activated PaSCs to facilitate the growth of pancreatic cancer cells, and the mechanisms involved in these effects by identifying proteins in the secretome of CP-activated PaSCs whose production were Nox1-dependent. We found that, in vitro, Nox1 evoked a pro-invasive and cancer-promoting phenotype in CP-activated PaSCs via Twist1/MMP-9 expression, causing changes in the extracellular matrix composition. In vivo, Nox1 in CP-activated PaSCs facilitated tumor growth and stromal expansion. Using mass spectrometry, we identified proteins protecting from endoplasmic reticulum, oxidative and metabolic stresses in the secretome of CP-activated PaSCs whose production was Nox1-dependent, including peroxiredoxins (Prdx1 and Prdx4), and thioredoxin reductase 1. In conclusion, inhibiting the Nox1 signaling in activated PaSCs from patients with CP at early stages can reduce the reorganization of extracellular matrix, and the protection of neoplastic cells from cellular stresses, ameliorating the progression of PDAC.

A Retrospective Analysis of Therapists' Coaching Behavior When Directing Parents to Conduct Behavioral Assessments and Treatments Via Telehealth

Research on the delivery of behavioral assessment and treatment via telehealth has focused largely on child outcomes and parent procedural fidelity. By contrast, the behavior of the therapists coaching parents to conduct assessment and treatment has garnered little research consideration. In this study, we conducted a retrospective analysis of behavior therapists' coaching behaviors when directing parents to conduct functional analysis (FA) and functional communication training (FCT) with their young children with autism via telehealth. Coaching behaviors for five experienced behavior therapists across seven parent-child dyads were scored using a combination of standardized and novel behavior codes. Therapists displayed more social engagement behaviors than any other type of behavior throughout the study, and rates of antecedent and consequence behaviors shifted across the FA and FCT phases. Results are discussed in relation to therapists' goals during behavioral assessment and treatment and the implications for training behavioral therapists to coach parents via telehealth.

Hepatic neddylation deficiency triggers fatal liver injury via inducing NF-κB-inducing kinase in mice

The conjugation of neural precursor cell expressed, developmentally downregulated 8 (NEDD8) to target proteins, termed neddylation, participates in many cellular processes and is aberrant in various pathological diseases. Its relevance to liver function and failure remains poorly understood. Herein, we show dysregulated expression of NAE1, a regulatory subunit of the only NEDD8 E1 enzyme, in human acute liver failure. Embryonic- and adult-onset deletion of NAE1 in hepatocytes causes hepatocyte death, inflammation, and fibrosis, culminating in fatal liver injury in mice. Hepatic neddylation deficiency triggers oxidative stress, mitochondrial dysfunction, and hepatocyte reprogramming, potentiating liver injury. Importantly, NF-κB-inducing kinase (NIK), a serine/Thr kinase, is a neddylation substrate. Neddylation of NIK promotes its ubiquitination and degradation. Inhibition of neddylation conversely causes aberrant NIK activation, accentuating hepatocyte damage and inflammation. Administration of N-acetylcysteine, a glutathione surrogate and antioxidant, mitigates liver failure caused by hepatic NAE1 deletion in adult male mice. Therefore, hepatic neddylation is important in maintaining postnatal and adult liver homeostasis, and the identified neddylation targets/pathways provide insights into therapeutically intervening acute liver failure.

Upregulation of the EGFR/MEK1/MAPK1/2 signaling axis as a mechanism of resistance to antiestrogen‑induced BimEL dependent apoptosis in ER+ breast cancer cells

The epidermal growth factor receptor (EGFR) is commonly upregulated in multiple cancer types, including breast cancer. In the present study, evidence is provided in support of the premise that upregulation of the EGFR/MEK1/MAPK1/2 signaling axis during antiestrogen treatment facilitates the escape of breast cancer cells from BimEL‑dependent apoptosis, conferring resistance to therapy. This conclusion is based on the findings that ectopic BimEL cDNA overexpression and confocal imaging studies confirm the pro‑apoptotic role of BimEL in ERα expressing breast cancer cells and that upregulated EGFR/MEK1/MAPK1/2 signaling blocks BimEL pro‑apoptotic action in an antiestrogen‑resistant breast cancer cell model. In addition, the present study identified a pro‑survival role for autophagy in antiestrogen resistance while EGFR inhibitor studies demonstrated that a significant percentage of antiestrogen‑resistant breast cancer cells survive EGFR targeting by pro‑survival autophagy. These pre‑clinical studies establish the possibility that targeting both the MEK1/MAPK1/2 signaling axis and pro‑survival autophagy may be required to eradicate breast cancer cell survival and prevent the development of antiestrogen resistance following hormone treatments. The present study uniquely identified EGFR upregulation as one of the mechanisms breast cancer cells utilize to evade the cytotoxic effects of antiestrogens mediated through BimEL‑dependent apoptosis.

Endoscope-assisted far lateral craniotomy for resection of posterior fossa neurocysticercosis: illustrative case

BACKGROUND

Neurocysticercosis is a parasitic infection that commonly affects the ventricles, subarachnoid spaces, and spinal cord of the central nervous system. The authors report an unusual manifestation of purely posterior fossa neurocysticercosis treated with endoscope-assisted open craniotomy for resection.

OBSERVATIONS

A 67-year-old male presented with 2 months of progressive dizziness, gait ataxia, headaches, decreased hearing, and memory impairment. Imaging revealed an extra-axial cystic lesion occupying the foramen magnum and left cerebellopontine angle with significant mass effect and evidence of early hydrocephalus. Gross-total resection was accomplished via a left far lateral craniotomy with open endoscopic assistance, and pathological findings were consistent with neurocysticercosis. Postoperatively, he was noted to have a sixth nerve palsy, and adjuvant therapy included albendazole. By 9 months postoperatively, he exhibited complete resolution of an immediate postoperative sixth nerve palsy in addition to all preoperative symptoms. His hydrocephalus resolved and did not require permanent cerebrospinal fluid (CSF) diversion.

LESSONS

When combined with traditional skull base approaches, open endoscopic techniques allow for enhanced visualization and resection of complex lesions otherwise inaccessible under the microscope alone. Recognition and obliteration of central nervous system neurocysticercosis can facilitate excellent neurological recovery without the need for CSF diversion.

Human Intestinal Spirochetosis: A Rare Case of Intermittent Bloating and Hematochezia

Human intestinal spirochetosis (HIS) is a condition where spirochetes, a group of spiral-shaped bacteria, attach to the apical membrane of the human colorectal epithelium. Although most findings of HIS are simply incidental discoveries found during screening colonoscopies, the ability to mimic the presentation of inflammatory bowel diseases should prompt consideration of this condition as part of a working differential diagnosis. Herein, we present the case of a 57-year-old bisexual, African American male with a medical history of Human Immunodeficiency Virus (HIV) on antiretroviral therapy (ART) with an undetectable viral load that presented for an elective, outpatient colonoscopy after experiencing four months of intermittent bloating and hematochezia. Histologic examination of colonic biopsies confirmed a diagnosis of HIS. The nonspecific clinical presentation in the setting of well-controlled HIV makes HIS a formidable diagnostic challenge that requires increased awareness.

Clinical and molecular assessment of an onco-immune signature with prognostic significance in patients with colorectal cancer

Understanding the complex tumor microenvironment is key to the development of personalized therapies for the treatment of cancer including colorectal cancer (CRC). In the past decade, significant advances in the field of immunotherapy have changed the paradigm of cancer treatment. Despite significant improvements, tumor heterogeneity and lack of appropriate classification tools for CRC have prevented accurate risk stratification and identification of a wider patient population that may potentially benefit from targeted therapies. To identify novel signatures for accurate prognostication of CRC, we quantified gene expression of 12 immune‐related genes using a medium‐throughput NanoString quantification platform in 93 CRC patients. Multivariate prognostic analysis identified a combined four‐gene prognostic signature (TGFB1, PTK2, RORC, and SOCS1) (HR: 1.76, 95% CI: 1.05–2.95, *p < 0.02). The survival trend was captured in an independent gene expression data set: GSE17536 (177 patients; HR: 3.31, 95% CI: 1.99–5.55, *p < 0.01) and GSE14333 (226 patients; HR: 2.47, 95% CI: 1.35–4.53, *p < 0.01). Further, gene set enrichment analysis of the TCGA data set associated higher prognostic scores with epithelial–mesenchymal transition (EMT) and inflammatory pathways. Comparatively, a lower prognostic score was correlated with oxidative phosphorylation and MYC and E2F targets. Analysis of immune parameters identified infiltration of T‐reg cells, CD8⁺ T cells, M2 macrophages, and B cells in high‐risk patient groups along with upregulation of immune exhaustion genes. This molecular study has identified a novel prognostic gene signature with clinical utility in CRC. Therefore, along with prognostic features, characterization of immune cell infiltrates and immunosuppression provides actionable information that should be considered while employing personalized medicine.

Teaching Hardy-Weinberg Equilibrium using Population-Level Punnett Squares: Facilitating Calculation for Students with Math Anxiety

Hardy-Weinberg (HW) equilibrium and its accompanying equations are widely taught in introductory biology courses, but high math anxiety and low math proficiency have been suggested as two barriers to student success. Population-level Punnett squares have been presented as a potential tool for HW equilibrium, but actual data from classrooms have not yet validated their use. We used a quasi-experimental design to test the effectiveness of Punnett squares over 2 days of instruction in an introductory biology course. After 1 day of instruction, students who used Punnett squares outperformed those who learned the equations. After learning both methods, high math anxiety was predictive of Punnett square use, but only for students who learned equations first. Using Punnett squares also predicted increased calculation proficiency for high-anxiety students. Thus, teaching population Punnett squares as a calculation aid is likely to trigger less math anxiety and help level the playing field for students with high math anxiety. Learning Punnett squares before the equations was predictive of correct derivation of equations for a three-allele system. Thus, regardless of math anxiety, using Punnett squares before learning the equations seems to increase student understanding of equation derivation, enabling them to derive more complex equations on their own.

It's the Bloody Gallbladder! Spontaneous Gallbladder Hemorrhage Following Factor Xa Inhibition

Spontaneous gallbladder hemorrhage (SGBH) is a rare diagnosis related to trauma, malignancy or vascular abnormalities, associated with significant morbidity and mortality. We present a case of SGBH in a 55-year-old patient with right upper quadrant (RUQ) pain following initiation of apixaban for deep vein thrombosis post recent kidney transplant. Multiple imaging studies revealed a distended gallbladder with heterogeneous hyperdense material in the lumen and cystic duct obstruction. Surgery revealed a gallbladder with chronic cholecystitis, hemorrhage and hematoma. This case highlights a rare adverse event of anticoagulation, and SGBH should be considered when acute RUQ pain occurs in this setting.

Beyond Squamous Cell Carcinoma: Basaloid Squamous Cell Carcinoma of the Esophagus

Basaloid squamous cell carcinoma (BSCC) is a poorly differentiated variant of squamous cell carcinoma (SCC) with distinct morphologic characteristics. Yet, there are no clearly defined guidelines established for management. BSCC in the esophagus is a very rare entity, with the proportion of esophageal BSCC ranging from 0.068% to 11%. This wide range is thought to be secondary to difficulty making the diagnosis on small biopsy specimens and the lack of a universally defined proportion of BSCC components necessary to make the diagnosis. We present the case of a 57-year-old African American female, who underwent esophagogastroduodenoscopy (EGD) after an abnormal barium swallow in the setting of two months history of dysphagia and weight loss and was diagnosed with BSCC of the esophagus on histopathology.

Performance in practice; exploring trainer and trainee experiences of user-designed formative assessment tools

INTRODUCTION

General Practice training in Ireland currently has various methods of formative assessment and feedback delivered to trainees. In 2018 the Irish College of General Practitioners commissioned the generation of two new user-designed formative feedback tools that would allow trainee feedback to drive learning. These tools became known as the Performance in Practice (PiP) tools.

AIMS

To explore the experiences of General Practice (GP) trainers and trainees having completed a pilot of using the PiP tools for 4 months.

METHODS

An explorative phenomenological approach was taken to understand the experiences of trainers and trainees. One to one interviews were conducted, and the transcripts analysed for themes and sub-theme via Template analysis.

RESULTS

User experiences focused on two main areas; educational value and acceptability. In relation to educational value, the PiP tools were seen as an improvement over established forms of formative feedback, as they were centred around the curriculum and therefore reflected the unique multifaceted requirements of an independently practising GP. Acceptability primarily focused around data governance and structures, as well as practical issues such as ease of software use.

CONCLUSIONS

Overall, the experience of using the PiP tools was positive for both trainers and trainees. Future plans to further explore implementation of the PiP tools have been significantly informed by this research.

Disseminated Histoplasmosis Presenting as Weight Loss and Hypercalcemia in a Renal Transplant Patient With Prior History of Subtotal Parathyroidectomy

Hypercalcemia and weight loss in a renal transplant patient especially with history of parathyroidectomy raises concern for an underlying malignancy, fungal infections or granulomatous disease. We present a case of 45-year-old male with history of subtotal parathyroidectomy presented with severe persistent hypercalcemia, acute kidney injury (AKI) and significant weight loss. An extensive workup revealed disseminated histoplasmosis. Hypercalcemia (which was refractory to initial medical management) and other symptoms resolved after a few weeks of initiating the antifungal treatment.

Improved stability of long-duration sitting in spatial neglect after a single session of prism adaptation

Spatial neglect after right brain stroke affects balance, and improvements in sitting balance after prism adaptation have been demonstrated using short-duration center of pressure (CoP) data. We present long-duration (5 min) CoP and trunk muscles electromyography recordings of a 61-year-old man with left-sided spatial neglect, before and after a single session of prism adaptation. His CoP-derived measures showed improved balance and postural stability in both the anterior-posterior and medial-lateral directions after prism adaptation. Concurrently, asymmetry in neuromuscular activations was reduced. The findings suggest that improved sitting balance may be associated with more symmetrical activation of trunk muscles after prism adaptation.

Genomic Signatures Predict the Immunogenicity of BRCA-Deficient Breast Cancer

PURPOSE

Breast cancers with BRCA1/2 alterations have a relatively high mutational load, suggesting that immune checkpoint blockade may be a potential treatment option. However, the degree of immune cell infiltration varies widely, and molecular features contributing to this variability remain unknown.

EXPERIMENTAL DESIGN

We hypothesized that genomic signatures might predict immunogenicity in BRCA1/2 breast cancers. Using The Cancer Genome Atlas (TCGA) genomic data, we compared breast cancers with (89) and without (770) either germline or somatic BRCA1/2 alterations. We also studied 35 breast cancers with germline BRCA1/2 mutations from Penn using WES and IHC.

RESULTS

We found that homologous recombination deficiency (HRD) scores were negatively associated with expression-based immune indices [cytolytic index (P = 0.04), immune ESTIMATE (P = 0.002), type II IFN signaling (P = 0.002)] despite being associated with a higher mutational/neoantigen burden, in BRCA1/2 mutant breast cancers. Further, absence of allele-specific loss of heterozygosity (LOH negative; P = 0.01) or subclonality (P = 0.003) of germline and somatic BRCA1/2 mutations, respectively, predicted for heightened cytolytic activity. Gene set analysis found that multiple innate and adaptive immune pathways that converge on NF-κB may contribute to this heightened immunogenicity. IHC of Penn breast cancers demonstrated increased CD45⁺ (P = 0.039) and CD8⁺ infiltrates (P = 0.037) and increased PDL1 expression (P = 0.012) in HRD-low or LOH-negative cancers. Triple-negative cancers with low HRD had far greater CD8⁺ T cells (P = 0.0011) and Perforin 1 expression (P = 0.014) compared with hormone receptor-positive HRD-high cancers.

CONCLUSIONS

HRD scores and hormone receptor subtype are predictive of immunogenicity in BRCA1/2 breast cancers and may inform the design of optimal immune therapeutic strategies.

Thrombospondin-2 regulates extracellular matrix production, LOX levels, and cross-linking via downregulation of miR-29

Collagen fibrillogenesis and crosslinking have long been implicated in extracellular matrix (ECM)-dependent processes such as fibrosis and scarring. However, the extent to which matricellular proteins influence ECM protein production and fibrillar collagen crosslinking has yet to be determined. Here we show that thrombospondin 2 (TSP2), an anti-angiogenic matricellular protein, is an important modulator of ECM homeostasis. Specifically, through a fractionated quantitative proteomics approach, we show that loss of TSP2 leads to a unique ECM phenotype characterized by a significant decrease in fibrillar collagen, matricellular, and structural ECM protein production in the skin of TSP2 KO mice. Additionally, TSP2 KO skin displays decreased lysyl oxidase (LOX), which manifests as an increase in fibrillar collagen solubility and decreased levels of LOX-mediated fibrillar collagen crosslinking. We show that these changes are indirectly mediated by miR-29, a major regulator of ECM proteins and LOX, as miR-29 expression is increased in the TSP2 KO. Altogether, these findings indicate that TSP2 contributes to ECM production and assembly by regulating miR-29 and LOX.

Fecal Host Transcriptomics for Non-Invasive Human Mucosal Immune Profiling: Proof of Concept in Clostridium Difficile Infection

Background:

Host factors play an important role in pathogenesis and disease outcome in Clostridium difficile infection (CDI), and characterization of these responses could uncover potential host biomarkers to complement existing microbe-based diagnostics.

Methods:

We extracted RNA from fecal samples of patients with CDI and profiled human mRNA using amplicon-based next-generation sequencing (NGS). We compared the fecal host mRNA transcript expression profiles of patients with CDI to controls with non-CDI diarrhea.

Results:

We found that the ratio of human actin gamma 1 (ACTG1) to 16S ribosomal RNA (rRNA) was highly correlated with NGS quality as measured by percentage of reads on target. Patients with CDI could be differentiated from those with non-CDI diarrhea based on their fecal mRNA expression profiles using principal component analysis. Among the most differentially expressed genes were ones related to immune response (IL23A, IL34) and actin-cytoskeleton function (TNNT1, MYL4, SMTN, MYBPC3, all adjusted P-values < 1 x 10^-3).

Conclusions:

In this proof-of-concept study, we used host fecal transcriptomics for non-invasive profiling of the mucosal immune response in CDI. We identified differentially expressed genes with biological plausibility based on animal and cell culture models. This demonstrates the potential of fecal transcriptomics to uncover host-based biomarkers for enteric infections.

Abstract A22: Homologous recombination deficiency negatively predicts for immune infiltration and antitumor immune activity in breast tumors with BRCA1/2 alterations

Tumors with germline or somatic BRCA1 or BRCA2 alterations are sensitive to DNA-damaging agents but often develop therapeutic resistance. Breast cancers associated with BRCA1/2 alterations have a relatively high mutational load, defined as the number of nonsynonymous single nucleotide mutations, relative to BRCA1/2 wild-type tumors, leading to suggestions that patients with BRCA1/2 mutations are possible candidates for immune checkpoint blockade. However, immune infiltration can range widely in tumors with BRCA1/2 alterations, and molecular determinants that account for this variability remain unclear. Our goal was to delineate the molecular features associated with immunogenicity in breast cancers associated with germline or somatic BRCA1/2 alterations through genetic/genomic and histopathologic analyses in 115 tumors from the TCGA (n=89) and Penn (n=26). In the TCGA dataset, we found that the level of homologous recombination deficiency (HRD), as measured by the copy number-based HRD score (high vs. low, dichotomized by median), correlated positively with neoantigen load in BRCA1/2 tumors (p=0.02), but unexpectedly inversely with immunogenicity as measured by cytolytic index (p=0.04) (geometric mean of PRF1 and GZMA expression) and immune ESTIMATE (p=0.002), an RNA-seq-based measure of immune cell infiltration. In prior studies, we had found that a surprisingly high percentage of BRCA1 and BRCA2 germline mutation-associated breast cancers lacked allele-specific loss of heterozygosity (LOH), 10% and 46%, respectively. We thus evaluated whether allele-specific LOH of germline BRCA2 mutations and somatic BRCA1/2 mutation clonality were drivers of the negative association between HRD level and cytolytic index/immune ESTIMATE. We found that allele-specific LOH was associated with higher HRD score (p=0.015) but lower enrichment of the Type II IFN signaling immune metagene (p=0.01), lower cytolytic index (p=0.04), and lower immune ESTIMATE score (p=0.01); tumors with clonal somatic BRCA1/2 mutations had significantly higher HRD score (p=2.4E-07) and mutational burden (p=0.05) but lower cytolytic index (p=0.003) and immune ESTIMATE scores (p=5E-05) than tumors with subclonal somatic BRCA1/2 mutations. Stratifying by both hormone receptor expression and median HRD score, we found that triple-negative breast cancers with low HRD were the most immunogenic and hormone receptor-positive tumors with high HRD the least (p=0.001). We confirmed these TCGA findings by histopathology in tumors associated with germline mutations in BRCA1/2 from Penn. We found that CD45+ leukocyte (p=0.03) and CD8+ cytotoxic T-cell infiltration (p=0.03) as well as expression of the immune effector PRF1 (p=0.048) were significantly lower with high HRD. Further, tumors with allele-specific LOH of the germline BRCA1/2 mutation had significantly lower PRF1 staining (p=0.004), lower membrane levels of the immune checkpoint protein PDL1 (p=0.05), and lower CD8+ (p=0.001), FoxP3+ (p=0.03), and CD20+ (p=0.04) immune cells, suggesting an immunosuppressive role for allele-specific LOH leading to high HRD. These data are consistent with a prior pan-TCGA analysis demonstrating that increased tumor chromosome/arm level copy number alterations suppress immunogenicity. We have found, for the first time, that genomic instability in BRCA1/2 tumors is associated with lower antitumor immune activity, and that the immunogenicity of BRCA1/2 mutation-associated breast cancers is directly related to their HRD level (driven by allele-specific LOH and clonality) and receptor status, both clinically evaluable biomarkers. These findings have immediate implications for the stratification of patients with BRCA1/2 mutation-associated breast cancer for checkpoint blockade therapy.

Citation Format: Adam A. Kraya, Kara N. Maxwell, Bradley Wubbenhorst, Brandon M. Wenz, John Pluta, Andrew J. Rech, Nicole Lunceford, Amanda Barrett, Nandita Mitra, Jennifer J.D. Morrissette, Anupma Nayak, Michael Feldman, Susan M. Domchek, Robert H. Vonderheide, Katherine L. Nathanson. Homologous recombination deficiency negatively predicts for immune infiltration and antitumor immune activity in breast tumors with BRCA1/2 alterations [abstract]. In: Proceedings of the AACR Special Conference: Advances in Breast Cancer Research; 2017 Oct 7-10; Hollywood, CA. Philadelphia (PA): AACR; Mol Cancer Res 2018;16(8_Suppl):Abstract nr A22.

Abstract 3691: Analysis of germline BRCA1/2 mutation associated breast and ovarian tumors reveals distinct pathways of immunosuppression

BRCA1 and BRCA2 are essential homologous recombination (HR) repair proteins; germline mutations confer elevated risk for breast and ovarian cancer. Defects in BRCA can lead to immune-related effects including depletion of peripheral T-cell pools and increased somatic mutational burden. We investigated the immunophenotypic properties of breast and ovarian cancers associated with germline BRCA1/2 mutations. We determined neoantigen load in 16 breast and 26 ovarian tumors with germline BRCA1/2 mutations and 50 non-BRCA tumors for each disease using whole exome sequencing data from the TCGA. Although neoantigen load (IC50 &lt;500 nM) was variable across tumors, it did not differ between BRCA1/2 mutant and non-BRCA tumors. Leveraging RNAseq data from the TCGA, we investigated immune-related transcriptomic features within each disease. Cytolytic index, a measure of PRF1 and GZMA expression, was higher in non-BRCA tumors than BRCA1/2 mutant for breast (p&lt;0.01) tumors and correlated more closely with neoantigen load than in non-BRCA tumors (Breast: BRCA r2=-0.15, non-BRCA r2=0.237). Class I HLA expression also correlated with cytolytic index (p&lt;0.05) in non-BRCA tumors but not BRCA1/2 mutation associated tumors for both breast and ovarian cancers, suggesting more robust antigen-driven adaptive immunity in non-BRCA tumors. HLA expression was significantly lower (p&lt;0.01) among BRCA mutant breast tumors, indicating immune escape by HLA down-regulation. We classified non-BRCA breast tumors by their level of HR deficiency (HRD score), as HRD by both BRCA and non-BRCA mediated mechanisms can lead to increased somatic mutational burden. Non-BRCA breast tumors irrespective of HRD score exhibited evidence of a more inflamed phenotype than BRCA1/2 mutant tumors, indicated by higher inferred immune cell infiltration, immune checkpoint expression, and chemokine expression (all p&lt;0.01). To investigate potential mechanisms of immune escape in BRCA1/2 vs non-BRCA tumors, we compared canonical gene sets (MsigDb) across the two cohorts. Expression of extracellular matrix (ECM) proteins was higher in BRCA1/2 breast and ovarian tumors (q&lt;0.02), suggesting that BRCA1/2 tumors may exclude immune cells via a dense ECM as observed for colorectal cancer and melanoma. Among Penn BRCA1/2 tumors (19 breast, 20 ovarian), neoantigen load did not differ from TCGA BRCA1/2 tumors. We directly measured immune cell infiltration via tumor immunohistochemistry in 12 breast and 14 ovarian Penn BRCA1/2 tumors. We found that CD3+ and CD8+ T cell infiltration was significantly lower in BRCA1/2 tumors with PTEN deletion (p&lt;0.05), a known correlate of ECM remodeling in breast and ovarian cancer. Our work provides early evidence that BRCA1/2 breast and ovarian tumors mitigate intratumoral adaptive immunity by T-cell exclusion, so that despite higher mutational burden, they may not respond to checkpoint blockade.

Citation Format: Adam Kraya, Kara N. Maxwell, Brandon M. Wenz, Bradley Wubbenhorst, Nicole Lunceford, Amanda Barrett, Jennifer J. Morrissette, Michael D. Feldman, Susan M. Domchek, Robert H. Vonderheide, Katherine L. Nathanson. Analysis of germline BRCA1/2 mutation associated breast and ovarian tumors reveals distinct pathways of immunosuppression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3691. doi:10.1158/1538-7445.AM2017-3691

Abstract A12: Analysis of tumor immunogenicity in germline BRCA1/2 mutation associated breast and ovarian cancers

Germline mutations in BRCA1 or BRCA 2 can lead to increased genomic instability and mutational burden in mutation-associated breast and ovarian cancer. Given the association of tumor neoepitope load and clinical response to immune checkpoint therapy, we used whole exome sequencing (WES) to predict missense mutational burden and potential neoepitope expression in 34 breast and 71 ovarian tumors with germline BRCA1/2 mutations (combining Penn and TCGA cohorts). Analysis of WES data found that tumors from patients with BRCA1/2 mutations had significantly higher mutational burden than non-BRCA1/2 tumors (p&lt;0.01). Based on a novel bioinformatics pipeline for human leukocyte antigen (HLA) genotyping and MHC class I neoantigen prediction, we found that neoantigen load (predicted IC50 &lt;500 nM) varied across patients (breast: mean - 147, std. dev. – 127; ovarian: mean – 126, std. dev. – 96). While higher neoantigen load promotes cytotoxic CD8+ T-cell responses in a number of cancers, we found among the BRCA1/2 subset that neoantigen load did not correlate with cytolytic signature, an RNA-based metric of anti-tumor immune response. From TCGA RNA-seq data, immune pathways (q&lt;0.01) including PD-1 signaling, reflective of counter-regulatory responses often observed in response to immune pressure, positively correlated with cytolytic signature. Neoantigen load, however, correlated only with GPCR signaling and extracellular matrix (ECM) proteins (q&lt;0.01). By contrast, the expression of genes involved in ECM and angiogenesis, which are involved in tumor immune escape and suppression of immune cell infiltration, negatively correlated with cytolytic signature (q&lt;0.01). Increased PDL1 and PDL2 (p&lt;0.05) expression associated with copy number loss in PTEN. These data were confirmed by tissue microarray analysis, which found that levels of T cell infiltration did not associate with neoantigen load, whereas PTEN loss was associated with decreased T cell infiltration (p&lt;0.05). Our work demonstrates that neoantigen load alone is not sufficient to induce T-cell infiltration and cytotoxicity in tumors from patients with BRCA1/2 mutations, but rather points to tumor intrinsic pathways involving PTEN copy alterations and a dense extracellular matrix as determinants of tumor immunity, both of which may lead to novel opportunities for combination immune therapy in these cancers.

Citation Format: Adam Kraya, Kara N. Maxwell, Brandon M. Wenz, Bradley Wubbenhorst, Daniel De Sloover, Nicole Lunceford, Amanda Barrett, Jennifer D. Morrissette, Michael Feldman, Robert H. Vonderheide, Susan M. Domcheck, Katherine L. Nathanson. Analysis of tumor immunogenicity in germline BRCA1/2 mutation associated breast and ovarian cancers. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr A12.

Malnutrition in Hospitalised Older Adults: A Multicentre Observational Study of Prevalence, Associations and Outcomes

BACKGROUND

Malnutrition is common in older adults and is associated with high costs and adverse outcomes. The prevalence, predictors and outcomes of malnutrition on admission to hospital are not clear for this population.

DESIGN

Prospective Cohort Study.

SETTING

Six hospital sites (five public, one private).

PARTICIPANTS

In total, 606 older adults aged 70+ were included. All elective and acute admissions to any speciality were eligible. Day-case admissions and those moribund on admission were excluded.

MEASUREMENTS

Socio-demographic and clinical data, including nutritional status (Mini-Nutritional Assessment - short form), was collected within 36 hours of admission. Outcome data was collected prospectively on length of stay, in-hospital mortality and new institutionalisation.

RESULTS

The mean age was 79.7; 51% were female; 29% were elective admissions; 67% were admitted to a medical specialty. Nutrition scores were available for 602/606; 37% had a 'normal' status, 45% were 'at-risk', and 18% were 'malnourished'. Malnutrition was more common in females, acute admissions, older patients and those who were widowed/ separated. Dementia, functional dependency, comorbidity and frailty independently predicted a) malnutrition and b) being at-risk of malnutrition, compared to normal status (p < .001). Malnutrition was associated with outcomes including an increased length of stay (p < .001), new institutionalisation (p =<0.001) and in-hospital mortality (p < .001).

CONCLUSIONS

These findings support the prioritisation of nutritional screening in clinical practice and public health policy, for all patients ≥70 on admission to hospital, and in particular for people with dementia, increased functional dependency and/or multi-morbidity, and those who are frail.

Pre-hospital notification is associated with improved stroke thrombolysis timing

Intravenous thrombolysis increases disability-free survival after acute ischaemic stroke in a time-dependent fashion. We aimed to determine whether pre-hospital notification, introduction of a CT scanner near to assessment site and introduction of out-of-hours thrombolysis services affect thrombolysis timing. Methods Timings related to thrombolysis were collected between May 2012 and June 2014 at a single hospital site; these included time to stroke physician assessment, time to cranial CT imaging and door to needle time. All thrombolysed ischaemic stroke patients admitted via the emergency department were included. Ambulance services were asked to pre-notify the emergency department of any suspected stroke patient during this period. Results We studied 182 patients (48% female; mean age 74 years; 59% pre-notified). Pre-hospital notification was associated with a significantly higher rate of CT scanning within 25 minutes (60% vs 24%, odds ratio [OR] 4.7, 95% confidence interval [CI] 2.4-9.0; p<0.001), earlier stroke physician assessment (median 6 vs 32 minutes; p<0.001) and receiving thrombolysis within 60 minutes (89% vs 49%, OR 8.0, 95% CI 3.8-16.9; p<0.001). Being treated outside normal working hours did not alter thrombolysis timing. Logistic regression identified the introduction of a near-site CT scanner (OR 4.6 [95% CI 1.7-12.5]) and pre-hospital notification (OR 4.7, [95% CI 2.3-9.6]) as independent predictors of door to CT time less than or equal to 25 minutes, and pre-hospital notification (OR 11.6, [95% CI 4.9-30.3]) and stroke severity (OR 1.15 per point of NIHSS scale, [95% CI 1.08-1.23]) as predictors of door to thrombolysis time less than or equal to 60 minutes. The most common perceived timing delays were radiology-related (33%), the need to acutely lower blood pressure (15%) and obtaining consent (12%). Conclusion Pre-hospital notification is associated with earlier stroke physician review, CT imaging and delivery of thrombolysis. Referral to an out of hours thrombolysis service was not associated with additional delay.

The wealth, health and wellbeing of Ireland's older people before and during the economic crisis

The economic crisis of 2008/9 was felt more acutely in Ireland relative to elsewhere and culminated in the international bailout in 2010. Given the economic collapse, Ireland provides an ideal case-study of the link between wealth collapses and movements in variables such as health and well-being. Using nationally-representative samples of older people collected before and during the crisis, we show that mean net assets fell by 45 percent between 2006/7 and 2012/13. In spite of this massive fall in wealth, measures of health and well-being remained broadly unchanged. However, expectations about future living standards became less optimistic. The results tend to support the findings of other recent studies that recessions do not have widespread negative effects on health and well-being.

Prasugrel compared to clopidogrel in patients with acute coronary syndrome undergoing percutenaous coronary intervention: a Spanish model-based cost effectiveness analysis

OBJECTIVE

To assess the long-term cost-effectiveness of 12 months treatment of prasugrel compared to clopidogrel in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) in the Spanish health care system.

METHODS

A Markov state transition model was developed to estimate health outcomes, quality adjusted life years (QALYs), life years (LY), and costs over patients' lifetimes. Clinical inputs were based on an analysis of the TRITON-TIMI 38 clinical trial. Hospital readmissions captured during the trial in a sub-study of patients from eight countries (and subsequent re-hospitalisations modelled to accrue beyond the time horizon of the trial), were assigned to Spanish diagnosis-related group payment schedules to estimate hospitalisation costs.

RESULTS

Mean total treatment costs were ?11,427 and ?10,910 for prasugrel and clopidogrel respectively. The mean cost of the study drug was ?538 higher for prasugrel vs. clopidogrel, but rehospitalisation costs at 12 months were ?79 lower for prasugrel due to reduced rates of revascularisation. Hospitalisation costs beyond 12 months were higher with prasugrel by ?55, due to longer life expectancy (+0.071 LY and +0.054 QALYs) associated with the decreased nonfatal myocardial infarction rate in the prasugrel group. The incremental cost per life year and QALY gained with prasugrel was ?7,198, and ?9,489, respectively.

CONCLUSION

Considering a willingness-to-pay threshold of ?30,000/QALY gained in the Spanish setting, prasugrel represents a cost-effective option in comparison with clopidogrel among patients with ACS undergoing PCI.

Bulky mediastinal Hodgkin's disease management and prognosis

Of a total of 235 Stage I and II Hodgkin's disease patients treated between 1970 and 1979, 103 (43.8 per cent) had mediastinal involvement in 45 of whom the disease was bulky and in 58 non-bulky. This report concentrates on bulky disease patients of whom 45 per cent did not relapse after therapy and 71 per cent are alive. Patients with mediastinal disease were treated with radiotherapy (63), sequential chemo-radiotherapy (37) or chemotherapy alone (3). In the radiotherapy group the relapse rate for bulky disease was significantly higher (65 per cent) than for non-bulky disease (44 per cent) (P less than 0.05) although there was no significant difference in survival. Neither relapse rate nor survival differed significantly in bulky disease patients treated with radiotherapy compared with combined chemo-radiotherapy although there was a 20 per cent difference in relapse-free survival rate in favour of the combined treatment group at five years. Treatments were not allocated randomly and the chemo-radiotherapy group contained a disproportionate number of patients with adverse features (greater than 3 node areas involved, limited lung extension) compared with the irradiated group; 11/25 and 2/17 respectively. The number of lymph node areas involved appeared to influence the relapse rate in the radiotherapy group. There was no correlation between mediastinal mass size and number of node areas involved suggesting that these two features may be independent prognostic factors.