Serial Monitoring of Circulating Tumor DNA by Next-Generation Gene Sequencing as a Biomarker of Response and Survival in Patients With Advanced NSCLC Receiving Pembrolizumab-Based Therapy

Although the majority of patients with metastatic non-small-cell lung cancer (mNSCLC) lacking a detectable targetable mutation will receive pembrolizumab-based therapy in the frontline setting, predicting which patients will experience a durable clinical benefit (DCB) remains challenging.

MATERIALS AND METHODS

Patients with mNSCLC receiving pembrolizumab monotherapy or in combination with chemotherapy underwent a 74-gene next-generation sequencing panel on blood samples obtained at baseline and at 9 weeks. The change in circulating tumor DNA levels on-therapy (molecular response) was quantified using a ratio calculation with response defined by a > 50% decrease in mean variant allele fraction. Patient response was assessed using RECIST 1.1; DCB was defined as complete or partial response or stable disease that lasted > 6 months. Progression-free survival and overall survival were recorded.

RESULTS

Among 67 patients, 51 (76.1%) had > 1 variant detected at a variant allele fraction > 0.3% and thus were eligible for calculation of molecular response from paired baseline and 9-week samples. Molecular response values were significantly lower in patients with an objective radiologic response (log mean 1.25% v 27.7%, P < .001). Patients achieving a DCB had significantly lower molecular response values compared to patients with no durable benefit (log mean 3.5% v 49.4%, P < .001). Molecular responders had significantly longer progression-free survival (hazard ratio, 0.25; 95% CI, 0.13 to 0.50) and overall survival (hazard ratio, 0.27; 95% CI, 0.12 to 0.64) compared with molecular nonresponders.

CONCLUSION

Molecular response assessment using circulating tumor DNA may serve as a noninvasive, on-therapy predictor of response to pembrolizumab-based therapy in addition to standard of care imaging in mNSCLC. This strategy requires validation in independent prospective studies.

[Argentinean consensus guidelines on the identification and clinical care of secondary progressive multiple sclerosis]

INTRODUCTION

The identification, diagnosis, follow-up, and treatment of patients with secondary progressive multiple sclerosis (SPMS) show significant differences between health care professionals in Argentina.

AIM

To provide consensus recommendations on the management of patients with SPMS in Argentina to optimize patient care.

DEVELOPMENT

A panel of expert neurologists from Argentina dedicated to the diagnosis and care of multiple sclerosis patients gathered during 2019 and 2020 to carry out a consensus recommendation on the diagnosis and treatment of SPMS patients in Argentina. To achieve consensus, the methodology of 'formal consensus-RAND/UCLA method' was used. Recommendations were established based on published evidence and the expert opinion. Recommendations focused on how to define SPMS and how to follow SPMS patients.

CONCLUSION

The recommendations of this consensus guidelines attempt to optimize the care of SPMS patients in Argentina.

Baseline Plasma Tumor Mutation Burden Predicts Response to Pembrolizumab-based Therapy in Patients with Metastatic Non-Small Cell Lung Cancer

PURPOSE

The role of plasma-based tumor mutation burden (pTMB) in predicting response to pembrolizumab-based first-line standard-of-care therapy for metastatic non-small cell lung cancer (mNSCLC) has not been explored.

EXPERIMENTAL DESIGN

A 500-gene next-generation sequencing panel was used to assess pTMB. Sixty-six patients with newly diagnosed mNSCLC starting first-line pembrolizumab-based therapy, either alone or in combination with chemotherapy, were enrolled (Clinicaltrial.gov identifier: NCT03047616). Response was assessed using RECIST 1.1. Associations were made for patient characteristics, 6-month durable clinical benefit (DCB), progression-free survival (PFS), and overall survival (OS).

RESULTS

Of 66 patients, 52 (78.8%) were pTMB-evaluable. Median pTMB was 16.8 mutations per megabase (mut/Mb; range, 1.9-52.5) and was significantly higher for patients achieving DCB compared with no durable benefit (21.3 mut/Mb vs. 12.4 mut/Mb, P = 0.003). For patients with pTMB ≥ 16 mut/Mb, median PFS was 14.1 versus 4.7 months for patients with pTMB < 16 mut/Mb [HR, 0.30 (0.16-0.60); P < 0.001]. Median OS for patients with pTMB ≥ 16 was not reached versus 8.8 months for patients with pTMB < 16 mut/Mb [HR, 0.48 (0.22-1.03); P = 0.061]. Mutations in ERBB2 exon 20, STK11, KEAP1, or PTEN were more common in patients with no DCB. A combination of pTMB ≥ 16 and absence of negative predictor mutations was associated with PFS [HR, 0.24 (0.11-0.49); P < 0.001] and OS [HR, 0.31 (0.13-0.74); P = 0.009].

CONCLUSIONS

pTMB ≥ 16 mut/Mb is associated with improved PFS after first-line standard-of-care pembrolizumab-based therapy in mNSCLC. STK11/KEAP1/PTEN and ERBB2 mutations may help identify pTMB-high patients unlikely to respond. These results should be validated in larger prospective studies.

P1839Platelet aggregability evaluation in patients with acute coronary syndromes scheduled for coronary artery bypass graft. The PLAT-CABG study

Background

Dual antiplatelet therapy is recommended for patients (pts) with acute coronary syndromes (ACS). However, 10–15% of pts have indication of coronary artery bypass graft (CABG) for the index event and current guidelines recommend stopping clopidogrel at least 5 days prior to CABG. This waiting time could increase hospital length of stay, thus having negative impacts on costs and clinical complications.

Purpose

To evaluate if release to CABG based on platelet aggregability by Multiplate AnalyzerTM would be non-inferior in comparison with common practice (5 days) in terms of 24-hours post-CABG bleeding.

Methods

The PLAT-CABG (NCT 02516267) is a randomized, open label, non-inferiority trial (boundary 25%) testing a strategy of platelet aggregability-guided release to CABG versus standard-of-care on the primary endpoint of chest tube drainage in the first 24 hours post CABG. A total of 190 pts admitted with ACS, treated with aspirin + clopidogrel and with indication for CABG, were assigned to clopidogrel discontinued 5 days prior to CABG (control group) vs. daily measurements of platelet aggregability to ADP using Multiplate AnalyzerTM (intervention group) with CABG occurring after recovering from platelet inhibition (pre-defined as a threshold of 46 AU).

Results

The main results are depicted in the table

Main results of PLAT-CABG study Variables Control Group (n=95) Intervention Group (n=95) P-value for superiority P-value for non-inferiority Chest tube drainage (mL), Median (25th–75th) 350 (250–500) 350 (250–500) 0.680 0.001 Time symptom to CABG (hours), Median (25th–75th) 191 (150–281) 166 (119–225) <0.001 NA Time surgery indication to CABG (hours), Median (25th–75th) 136 (112–161) 112 (66–142) <0.001 NA CABG = coronary artery bypass graft.

Conclusion

Platelet-aggregability guided release to CABG is non-inferior to standard of care in ACS patients awaiting CABG in terms of peri-operative bleeding and significantly shortens the time to CABG.

Acknowledgement/Funding

Roche Diagnostica Brazil

Matrix isolation sublimation: An apparatus for producing cryogenic beams of atoms and molecules

We describe the apparatus to generate cryogenic beams of atoms and molecules based on matrix isolation sublimation. Isolation matrices of Ne and H2 are hosts for atomic and molecular species which are sublimated into vacuum at cryogenic temperatures. The resulting cryogenic beams are used for high-resolution laser spectroscopy. The technique also aims at loading atomic and molecular traps.

Oral manifestations leading to the diagnosis of acute lymphoblastic leukemia in a young girl

BACKGROUND

oral complications may be leukemia's first presentation.

AIM

to present a case of a young girl with a swelling on the face that led to the diagnosis of acute lymphoblastic leukemia is reported.

RESULTS

a 10-year old anemic girl was referred for evaluation and treatment of a swelling at the left-nasolabial region. Symptoms reported (tiredness, poor appetite, fever, lethargy, and musculoskeletal pain) and clinical findings (enlargement at the presternal region and brownish stain in the lumbar region) led to the suspicion of a hematopoietic malignancy. The diagnosis of lymphoblastic leukemia was attained after specific examination conducted by the pediatric oncologist and hematologist.

CONCLUSION

dentists must be able to clearly recognize oral physiological characteristics, and, when identifying changes of normalcy, to fully investigate it requesting additional tests or referring the patient to specialized professionals.

Leishmanolysin (gp63 metallopeptidase)-like activity extracellularly released byHerpetomonas samuelpessoai

In previous studies, we showed thatHerpetomonas samuelpessoaiproduced a large amount of a surface-located metallopeptidase that presented similar biochemical properties to that of gp63 fromLeishmaniaspp., which is a well-known virulence factor expressed by these digenetic parasites. The present study aims to identify the proteolytic activity released by livingH. samuelpessoaicells. In this context, the parasites were incubated in phosphate buffer up to 4 h, and the supernatants were obtained by centrifugation and filtration steps and were then applied on SDS–PAGE to determine the secretory protein profile and on gelatin-SDS–PAGE to identify the proteolytic activity. The results demonstrated thatH. samuelpessoaisecreted at least 12 polypeptides and an extracellular peptidase of 66 kDa. This enzyme had its activity diminished by 1,10-phenanthroline, EDTA and EGTA. This metallopeptidase was active in a broad spectrum of pH, showing maximum activity at pH 6·0 at 37 °C. Casein was also cleaved by this secretory proteolytic enzyme, while bovine serum albumin and haemoglobin were not degraded under these conditions. Fluorescence microscopy and flow cytometry using anti-gp63 antibody against leishmanolysin ofL. amazonensisdemonstrated the presence of similar molecules on the cell-surface ofH. samuelpessoai. Moreover, immunoblot analysis showed the presence of a reactive polypeptide in the cellular extract and in the supernatant fluid ofH. samuelpessoai, which suggests immunological similarities between these two distinct trypanosomatids. The zinc-metallopeptidase inhibitor 1,10-phenanthroline was able to inhibit the secretion of the 66 kDa metallopeptidase in a dose-dependent manner, while the phospholipase C inhibitor (p-CMPS) did not alter the secretion pattern. Additionally, anti-cross-reacting determinant (CRD) antibody failed to recognize any secreted polypeptide fromH. samuelpessoai. Collectively, these results suggest that the gp63-like molecule was released from theH. samuelpessoaisurface by proteolysis instead of phospholipolysis, in a similar mechanism to that observed inLeishmania.

Negative inotropic and chronotropic effects on the guinea pig atrium of extracts obtained from Averrhoa carambola L. leaves

It has been reported that star fruit can lead to a fatal outcome in uremic patients. The intoxication syndrome consists of hiccups, mental confusion, dizziness, and vomiting. On the other hand, folk medicine uses teas and infusions of carambola leaves to treat headache, vomiting, cough, insomnia, and diabetes. This motivated us to determine if Averrhoa carambola can act on the contractility and automaticity of the guinea pig heart. We measured the atrial isometric force in stimulated left atria and determined the chronotropic changes in spontaneously beating right atria. The carambola leaf extracts (1.5 mg/ml) abolished the contractile force in a concentration-dependent manner. Among the crude, methanolic, ethanolic, aqueous, and acetic extracts, the aqueous one was the most potent (EC50 = 520 +/- 94 microg/ml; flavonoids and tannins are the main constituents; Na+ and K+ contents in 1.0 mg/ml of aqueous extract were 0.12 +/- 0.016 and 1.19 +/- 0.15 mM, respectively). The aqueous extract abolished the positive Bowditch staircase phenomenon and reduced the inotropic response to CaCl2 (0.17-8.22 mM), events that are dependent on the cellular Ca2+ inward current. The adrenergic, muscarinic or opioid membrane receptors do not seem to participate in the mechanism of action of the cardioactive substance(s). In spontaneously beating atria, the aqueous extract promoted a negative chronotropic effect that was antagonized by 0.1 microM isoproterenol bitartrate. With this agonist, the EC50 of the aqueous extract increased from 133 +/- 58 to 650 +/- 100 microg/ml. These data regarding the effect of A. carambola on guinea pig atrial contractility and automaticity indicate an L-type Ca2+ channel blockade.

Inotropic effect of Citrus sinensis (L.) Osbeck leaf extracts on the guinea pig atrium

The objective of the present investigation was to determine the contractile effect of crude and acetone leaf extracts of Citrus sinensis (L.) Osb. on mammalian myocardium. Crude leaf extracts have been used in folk medicine to treat neurological disorders. Some flavonoids isolated from this plant presented a positive inotropic effect on myocardium. This motivated us to test the extracts on the atria of guinea pigs of both sexes (300-500 g) and surprisingly we observed inotropic depression instead of an increase in force. The maximum effect of the crude extract was 79.4 +/- 8.1% of the control force amplitude (N = 5 hearts, 10 trials, 27 +/- 0.1 degrees C, stimulus: 2 Hz, 400 V, 0.5 ms). The EC50 for crude, ethanol, acetic, aqueous, and acetone extracts was 300, 300, 600, 1000, and 140 microg/ml, respectively, with a Hill constant of 1.8, 2.0, 2.5, 2.0, and 1.4, respectively. Blockade of cholinergic, beta-adrenergic, or opioid membrane receptors with 1.5 microM atropine sulfate, 1 microM propranolol, and 10 microM naloxone, respectively, did not change the effect of the crude extract. The acetone extract abolished the Bowditch positive staircase phenomenon (N = 5 hearts, 10 trials, 27 +/- 0.1 degrees C), suggesting a possible reduction of the calcium inward current, and also promoted the so-called Woodworth phenomenon. The effect was concentration-dependent and indicated the existence of another inhibitory contractile mechanism such as the simultaneous activation of some of the membrane potassium channels reducing the myocardial action potential duration and further decreasing the cellular calcium entry.

Central antinociceptive effect of a hydroalcoholic extract of Dioclea grandiflora seeds in rodents

The acute treatment of rats and mice with a hydroalcoholic extract from the seeds of Dioclea grandiflora (EHDg) at doses of 250 and 500 mg/kg, by intraperitoneal or oral administration, produced a significant antinociceptive effect in the tail flick and hot plate tests, an effect which was inhibited by naloxone. EHDg given to mice daily for 30 days at a dose of 500 mg/kg, did not cause any observable toxic effect nor any alteration in the pattern of antinociceptive response by the tail immersion test during the course of this treatment. These results suggest that EHDg has a central antinociceptive action devoid of tolerance effect typical of opioid drugs.

Intracellular calcium mobilization as a target for the spasmolytic action of scopoletin

The coumarin scopoletin was isolated in a pure form from the roots of Brunfelsia hopeana Benth. (Solanaceae). In isolated rat aortic rings, scopoletin (26-520 microM) inhibited to approximately the same extent the contractions induced by a variety of substances, including phenylephrine, potassium chloride, serotonin and PGF(2) (alpha). The effect of the coumarin on phenylephrine-induced contractions was not affected by endothelium removal or NO-synthase blockade by L-NAME (100 microM). Scopoletin (78 - 590 microM) antagonized in a concentration-dependent manner (IC(50) = 300 +/- 20 microM, n = 5), transient contractions in Ca(2+)-free media induced by noradrenaline, but not those induced by caffeine. Also, scopoletin did not interfere with the refilling of noradrenaline-sensitive intracellular calcium stores. It is suggested that the non-specific spasmolytic action of scopoletin can be attributed, at least in part, to its ability to inhibit the intracellular calcium mobilization from the noradrenaline-sensitive stores.

[Intensive phototherapy treatment for severe haemolytic disease of the newborn]

OBJECTIVE: To discuss the use of alternative treatment methods in hemolytic disease of newborn to replace common early exchange transfusion. METHODS: Case report of newborn with intensive Rh incompatibility treated with intensive phototherapy, plus phenobarbital instead of traditional early exchange transfusion.RESULTS: The neonatés cord blood showed 9.2 mg/dL of total bilirubin and 39% hematocrit. He was medicated with phenobarbital and intensive phototherapy at once. There was a rapid growing hyperbilirubinemia followed by stabilization for almost 60 hours with little changes, but without levels that justified an exchange transfusion. He became progressively anemic and needed a concentrate transfusion. When he was five days old, he was discharged and returned to follow-up at the 7th week of life when his bone marrow was beginning to recover from anemia.CONCLUSIONS: This case demonstrates that pharmacologic agents and intensive phototherapy can be as useful as advantageous in severe hemolytic disease of newborn. We should always try to use them before adopting more aggressive therapies.

Case-control study of laparoscopic versus abdominal myomectomy

PURPOSE

To compare laparoscopic with abdominal approaches to myomectomy.

PATIENTS AND METHOD

Frequency matching was used to ensure similar fibroid weights among the laparoscopic and abdominal groups in this case-control study. The study group consisted of prospectively recruited patients undergoing laparoscopic (N = 5) or laparoscopically assisted (N = 20) myomectomy (lap). The control group represented both prospectively (N = 14) and retrospectively (N = 37) identified abdominal myomectomy patients (abd). Analysis of the variables was performed using a t-test, Wilcoxon rank-sum test, chi-square test, or analysis of covariance at the 0.01 significance level.

RESULTS

All results are reported after matching for fibroid weight, with the median (quartiles) aggregate weight measuring 151 g (31.0, 262.0) and 170.0 g (81.0, 285.0) for the lap and abd patients, respectively (P = 0.15). Median (quartiles) length of hospital stay (30.5 hours [25.0, 52.5] v 65.0 hours [45.0, 76.0]; P < 0.001) and duration of postoperative intravenous narcotic use (14.8 hours [3.0, 18.5] v 24.0 hours [18.0, 40.0]; P = 0.001) were significantly shorter for the lap patients. The laparoscopic cases required a longer median operative time (222.5 minutes [192.5, 270.0]) than the abdominal cases (180.0 minutes [160.0, 220.0]; P = 0.001). No difference was detected in estimated blood loss from surgery (P = 0.57).

CONCLUSIONS

A laparoscopic approach to myomectomy may be safely chosen for patients with fibroids and offers the benefits of less postoperative intravenous narcotic use, a shorter hospital stay, and no greater intraoperative blood loss than abdominal myomectomy.

Desensitization to ANG II in guinea pig ileum depends on membrane repolarization: role of maxi-K(+) channel

Desensitization of ANG II tonic contractile response of the guinea pig ileum is related to membrane repolarization determined by Ca(2+)-activated K(+) (maxi-K(+)) channel opening. ANG II-stimulated depolarized myocytes presented sustained activation of maxi-K(+) channels, characterized by reduction from 415 to 12 ms of the closed time constant. ANG II desensitization was prevented by 100 nM iberiotoxin, being reversible within 30 min. Depolarization by KCl, higher than 4 mM, impaired desensitization, suggesting that the membrane potential must attain a threshold to counteract the repolarization induced by maxi-K(+) channel opening. Once this value is attained, there is no time dependency because the desensitization process was shut off by addition of KCl along the time course of the tonic response. In contrast, the sustained ACh tonic component was not altered by these maneuvers. We conclude that desensitization of the ANG II tonic component is foremost due to the opening of maxi-K(+) channels, leading to membrane repolarization, thus closing the voltage-dependent Ca(2+) channels responsible for the Ca(2+) influx that sustains the tonic component in this muscle.

Activation of Ca(2+)-activated K+ (maxi-K+) channel by angiotensin II in myocytes of the guinea pig ileum

We investigated the regulation of the Ca(2+)-activated K+ (maxi-K+) channel by angiotensin II (ANG II) and its synthetic analog, [Lys2]ANG II, in freshly dispersed intestinal myocytes. We identified a maxi-K+ channel population in the inside-out patch configuration on the basis of its conductance (257 +/- 4 pS in symmetrical 150 mM KCl solution), voltage and Ca2+ dependence of channel opening, low Na(+)-to-K+ and Cl(-)-to-K+ permeability ratios, and blockade by external Cs+ and tetraethylammonium chloride. ANG II and [Lys2]ANG II caused an indirect, reversible, Ca(2+)- and dose-dependent activation of maxi-K+ channels in cell-attached experiments when cells were bathed in high-K+ solution. This effect was reversibly blocked by DUP-753, being that it is mediated by the AT1 receptor. Evidences that activation of the maxi-K+ channel by ANG II requires a rise in intracellular Ca2+ concentration ([Ca2+]i) as an intermediate step were the shift of the open probability of the channel-membrane potential relationship to less positive membrane potentials and the sustained increase in [Ca2+]i in fura 2-loaded myocytes. The preservation of the pharmacomechanical coupling of ANG II in these cells provides a good model for the study of transmembrane signaling responses to ANG II and analogs in this tissue.

Afferent connections of the subthalamic nucleus: a combined retrograde and anterograde horseradish peroxidase study in the rat

A comprehensive characterization of the afferent connections of the subthalamic nucleus of Luys (STN) is a necessary step in the unraveling of extrapyramidal mechanisms. In the present study, the STN afferents in the rat were systematically investigated with the aid of retrograde and anterograde horseradish peroxidase tracer techniques. The results indicate that, besides a massive input from the dorsal pallidum, the STN receives substantial projections from several districts of the cerebral cortex (the medial division of the prefrontal cortex, the first motor and primary somatosensory areas, and the granular insular territory), the ventral pallidum, the parafascicular nucleus of the thalamus and the pedunculopontine tegmental nucleus, as well as a modest innervation from the dorsal raphe nucleus. In spite of the fact that many additional structures were found to contain retrogradely labeled neurons after tracer injections in the STN, no other projection to the latter nucleus could be effectively established in our anterograde experimental series.

Somatosensory inputs to the subthalamic nucleus: a combined retrograde and anterograde horseradish peroxidase study in the rat

Previous physiological studies have shown that neurons in the subthalamic nucleus (STN) respond to peripheral somatosensory stimulation. In an attempt to identify anatomical pathways that could mediate such responses, the possible existence of direct projections from somatosensory central territories to the STN was investigated in the rat with the aid of retrograde and anterograde horseradish peroxidase tracer techniques. Our main findings indicate the existence of a hitherto undescribed and relatively substantial direct projection from the primary somatosensory cortex to the ipsilateral STN. The projection appears to originate chiefly from neurons in layer Vb of the rostral half of this cortical area and to terminate basically in the dorsolateral district of the STN. Moreover, our data are compatible with the existence of very sparse direct projections from the spinal trigeminal and dorsal column nuclei to the contralateral STN, but the evidence on this point is hardly conclusive.

Afferent connections of the nuclei reticularis pontis oralis and caudalis: a horseradish peroxidase study in the rat

The afferent connections of the nuclei reticularis pontis oralis and caudalis were studied experimentally in the rat by the aid of either free horseradish peroxidase or horseradish peroxidase conjugated with wheat germ agglutinin used as retrograde tracers. The results suggest that the nucleus reticularis pontis oralis receives its main input from the zona incerta and field H1 of Forel, the superior colliculus, the central gray substance, and the mesencephalic and magnocellular pontomedullary districts of the reticular formation. Many other structures seem to represent modest additional sources of projections to the nucleus reticularis pontis oralis; these structures include numerous cortical territories, the nucleus basalis, the central amygdaloid nucleus, hypothalamic districts, the anterior pretectal nucleus, the substantia nigra, the cuneiform, the accessory oculomotor and the deep cerebellar nuclei, trigeminal, parabrachial and vestibular sensory cell groups, the nuclei raphe dorsalis and magnus, the locus coeruleus, the dorsolateral tegmental nucleus, and the spinal cord. While the afferentation of the rostral portion of the nucleus reticularis pontis caudalis appears to conform to the general pattern outlined above, some deviations from that pattern emerge when the innervation of the caudal district of the nucleus reticularis pontis caudalis is considered; the most striking of these differences is the fact that both spinal and cerebellar inputs seem to distribute much more heavily to the referred caudal district than to the remaining magnocellular pontine reticular formation. The present results may contribute to the elucidation of the anatomical substrate of the functionally demonstrated involvement of the nuclei reticularis pontis oralis and caudalis in several domains that include the regulation of the sleep-waking cycle and cortical arousal, somatic motor mechanisms and nociceptive behavior.