A new era in the treatment of urothelial carcinoma

The advances in targeted therapies, immunotherapy, and the recent emergence of antibody-drug conjugates (ADCs) herald a potential paradigm shift in treating patients with metastatic urothelial cancer. Yet, there are inherent challenges in utilizing these therapies, including the management of treatment-related toxicities. In this special Urologic Oncology: Seminars and Original Investigations issue, we review the latest developments and discuss insights into future research needs.

Tumor-immune microenvironment revealed by Imaging Mass Cytometry in a metastatic sarcomatoid urothelial carcinoma with a prolonged response to pembrolizumab

Sarcomatoid urothelial carcinoma (SUC) is a rare subtype of urothelial carcinoma (UC) that typically presents at an advanced stage compared to more common variants of UC. Locally advanced and metastatic UC have a poor long-term survival following progression on first-line platinum-based chemotherapy. Antibodies directed against the programmed cell death 1 protein (PD-1) or its ligand (PD-L1) are now approved to be used in these scenarios. The need for reliable biomarkers for treatment stratification is still under research. Here, we present a novel case report of the first Imaging Mass Cytometry (IMC) analysis done in SUC to investigate the immune cell repertoire and PD-L1 expression in a patient who presented with metastatic SUC and experienced a prolonged response to the anti-PD1 immune checkpoint inhibitor pembrolizumab after progression on first-line chemotherapy. This case report provides an important platform for translating these findings to a larger cohort of UC and UC variants.

Validation of a Circulating Tumor DNA-Based Next-Generation Sequencing Assay in a Cohort of Patients with Solid tumors: A Proposed Solution for Decentralized Plasma Testing

BACKGROUND

Characterization of circulating tumor DNA (ctDNA) has been integrated into clinical practice. Although labs have standardized validation procedures to develop single locus tests, the efficacy of on-site plasma-based next-generation sequencing (NGS) assays still needs to be proved.

MATERIALS AND METHODS

In this retrospective study, we profiled DNA from matched tissue and plasma samples from 75 patients with cancer. We applied an NGS test that detects clinically relevant alterations in 33 genes and microsatellite instability (MSI) to analyze plasma cell-free DNA (cfDNA).

RESULTS

The concordance between alterations detected in both tissue and plasma samples was higher in patients with metastatic disease. The NGS test detected 77% of sequence alterations, amplifications, and fusions that were found in metastatic samples compared with 45% of those alterations found in the primary tumor samples (p = .00005). There was 87% agreement on MSI status between the NGS test and tumor tissue results. In three patients, MSI-high ctDNA correlated with response to immunotherapy. In addition, the NGS test revealed an FGFR2 amplification that was not detected in tumor tissue from a patient with metastatic gastric cancer, emphasizing the importance of profiling plasma samples in patients with advanced cancer.

CONCLUSION

Our validation experience of a plasma-based NGS assay advances current knowledge about translating cfDNA testing into clinical practice and supports the application of plasma assays in the management of oncology patients with metastatic disease. With an in-house method that minimizes the need for invasive procedures, on-site cfDNA testing supplements tissue biopsy to guide precision therapy and is entitled to become a routine practice.

IMPLICATIONS FOR PRACTICE

This study proposes a solution for decentralized liquid biopsy testing based on validation of a next-generation sequencing (NGS) test that detects four classes of genomic alterations in blood: sequence mutations (single nucleotide substitutions or insertions and deletions), fusions, amplifications, and microsatellite instability (MSI). Although there are reference labs that perform single-site comprehensive liquid biopsy testing, the targeted assay this study validated can be established locally in any lab with capacity to offer clinical molecular pathology assays. To the authors' knowledge, this is the first report that validates evaluating an on-site plasma-based NGS test that detects the MSI status along with common sequence alterations encountered in solid tumors.

Abstract 859: Deep learning predicts expression-based molecular subtypes and immune status of urothelial cancer using digital pathology slides

RNA-sequencing (RNA-seq) has revealed intrinsic subtypes of urothelial carcinoma (UC). We have recently developed a molecular classifier to separate UC tumors to ‘hot' and ‘cold' based on the expression of immune-related genes. Both molecular subtype and immune-status correlate with response to different treatments, however, RNA-seq data is not readily available for all tumors thus limiting our ability to predict treatment response. We hypothesized that a deep learning approach can predict urothelial cancer molecular subtype and classify immune cell levels from pathology tissue slides. To test this hypothesis, we developed a deep learning model to classify urothelial carcinoma subtypes from hematoxylin and eosin (H&E) stained tissue sections using BASE47 luminal-basal classification and our immune-status classifiers based on RNA-seq data from patients in the TCGA dataset as ground truth. Patches of 2048x2048 pixels were generated from 446 whole slide images (WSIs) resulting in a total of 79,053 images. 70% of the patients were used for training, and 15% are being used as a validation set. The remaining 15% of the data will be a blind test set. We used the Resnet-18 architecture, which performed best based on empirical testing (high accuracy while minimizing overfitting). We performed a color normalization step based on the Vahadane algorithm (IEEE Trans Med Imaging. 2016;35(8):1962 71) to analyze the predictive performance and generalizability of the model compared to non-normalized slides. We also used gradient-weighted class activation mapping to highlight the regions of the tissue that may be important for classification. After 20 epochs of training, we achieved a 74% patch prediction accuracy on the validation set with a ROC-AUC of 0.80 for non-normalized immune cell classification. For normalized images, we achieved a 70% patch prediction accuracy on the validation set with a ROC-AUC of 0.75. For the luminal-basal subtype classification task, we achieved a 68% patch wise accuracy on the validation set with a ROC-AUC of 0.76 for normalized data and 68% patch-wise accuracy with a ROC-AUC of 0.74 for non-normalized data. We are currently testing the model on an internal urothelial cancer cohort at Weill Cornell Medicine. Our data demonstrates the utility of deep learning methods in predicting UC molecular subtype and immune status from digital pathology slides. This data has important implications for predicting prognosis and treatment response in UC patients.

Citation Format: Matthew Bryan Brendel, Pegah Khosravi, Emily Tse, Lilly Gu, Kyrillus Shohdy, Rohan Bareja, Bhavneet Bhinder, Olivier Elemento, Bishoy Faltas, Iman Hajirasouliha. Deep learning predicts expression-based molecular subtypes and immune status of urothelial cancer using digital pathology slides [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 859.

Abstract 5941: Integrin signaling modulation demonstrates potential therapeutic strategy in bladder cancer using three-dimensional organoid culture

Introduction: Integrin signaling plays an important role in cellular proliferation and migration via interactions with extracellular matrix proteins. Prior studies indicate that integrin signaling facilitates tumor invasion and metastasis, and there are several ongoing clinical trials using agents that modulate this pathway. We recently identified clonal enrichment in missense mutations in the integrin cell surface interactions pathways in advanced chemotherapy-resistant urothelial carcinoma. An ideal strategy for investigating integrin signaling is via 3D organoid culture, maintaining intercellular interactions that replicate the epithelial microenvironment. We hypothesize that pharmacologic integrin signaling modulation will impair organoid growth in human bladder cancer cells and demonstrate a potential therapeutic utility for this approach.

Methods: RT4 human bladder cancer cell line was used as well as a second cell line established from a patient-derived bladder cancer sample (PM748). Cells were grown in 3D organoid culture as previously described. For in vitro integrin modulation, defactinib (VS-6063), an orally-bioavailable selective inhibitor of focal adhesion kinase (FAK, a convergent and conserved enzyme activated by integrin ligand binding), was used. SDS-PAGE and immunoblotting were performed to show in vitro FAK inhibition. Single-cell suspensions and formed organoids were plated in the presence of various concentrations of defactinib to determine the impact on organoid formation and regression.

Results: Both RT4 and PM748 bladder cancer cell lines demonstrated consistent organoid growth in three-dimensional culturing conditions. Addition of defactinib to cultured cells showed a dose-dependent decrease in autophosphorylation of FAK for both cell lines, demonstrating effective FAK inhibition. 3D culture of single cells in the presence of defactinib produced a dose-dependent decrease in organoid size after 96 hours (mean size for DMSO only, 100nM, 1uM, and 10uM were 128um, 75um, 48um, and 26um, respectively; p<0.0001 versus DMSO for all dilutions). Established bladder cancer organoids showed a dose-dependent regression in size after 72 hours of defactinib exposure (mean size for DMSO, 100nM, 1uM, and 10uM were 225um, 96um, 70um, and 34um, respectively; p<0.0001 versus DMSO). Experiments utilizing Crispr-Cas9-mediated FAK knock-out as well as in vivo studies with FAK inhibitors in mouse xenograft models are currently underway.

Conclusions: Integrin modulation via FAK inhibition with defactinib causes both inhibition of organoid formation as well as regression of formed organoids, and the effects are seen at concentrations well below the cytotoxic range for the drug. This study suggests a utility for these agents in bladder cancer treatment.

Citation Format: LaMont Barlow, Rebecca Meyer, Ethan Shelkey, Bishoy Faltas, Mark Rubin. Integrin signaling modulation demonstrates potential therapeutic strategy in bladder cancer using three-dimensional organoid culture [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 5941. doi:10.1158/1538-7445.AM2017-5941

Next-Generation Rapid Autopsies Enable Tumor Evolution Tracking and Generation of Preclinical Models

PURPOSE

Patients with cancer who graciously consent for autopsy represent an invaluable resource for the study of cancer biology. To advance the study of tumor evolution, metastases, and resistance to treatment, we developed a next-generation rapid autopsy program integrated within a broader precision medicine clinical trial that interrogates pre- and postmortem tissue samples for patients of all ages and cancer types.

MATERIALS AND METHODS

One hundred twenty-three (22%) of 554 patients who consented to the clinical trial also consented for rapid autopsy. This report comprises the first 15 autopsies, including patients with metastatic carcinoma (n = 10), melanoma (n = 1), and glioma (n = 4). Whole-exome sequencing (WES) was performed on frozen autopsy tumor samples from multiple anatomic sites and on non-neoplastic tissue. RNA sequencing (RNA-Seq) was performed on a subset of frozen samples. Tissue was also used for the development of preclinical models, including tumor organoids and patient-derived xenografts.

RESULTS

Three hundred forty-six frozen samples were procured in total. WES was performed on 113 samples and RNA-Seq on 72 samples. Successful cell strain, tumor organoid, and/or patient-derived xenograft development was achieved in four samples, including an inoperable pediatric glioma. WES data were used to assess clonal evolution and molecular heterogeneity of tumors in individual patients. Mutational profiles of primary tumors and metastases yielded candidate mediators of metastatic spread and organotropism including CUL9 and PIGM in metastatic ependymoma and ANKRD52 in metastatic melanoma to the lung. RNA-Seq data identified novel gene fusion candidates.

CONCLUSION

A next-generation sequencing-based autopsy program in conjunction with a pre-mortem precision medicine pipeline for diverse tumors affords a valuable window into clonal evolution, metastasis, and alterations underlying treatment. Moreover, such an autopsy program yields robust preclinical models of disease.

Phase I dose-escalation study of fractionated-dose 177Lu-PSMA-617 for progressive metastatic castration resistant prostate cancer (mCRPC)

TPS5093

Background: PC is a radiosensitive disease. PSMA is selectively overexpressed in advanced PC with upregulation by androgen receptor (AR) pathway dysregulation; limited expression exists in other organs. A series of sequential studies of radiolabeled anti-PSMA antibody J591 revealed 1) targeting and safety [Bander 2003]; 2) safety and prelim efficacy [Milowsky 2004, Bander 2005]; 3) efficacy and initial dose-response [Tagawa 2013]; 4) dose-fractionation allows higher doses, ability to combine with docetaxel, confirmation of dose-response (PSA and overall survival) [ASCO 2010, 2014, 2016]; 5) predictable, reversible myelosuppression is dose-limiting [Tagawa 2013]. Small molecule PSMA inhibitor ligands can be successfully radiolabeled and are widely used for imaging and treatment in Europe. 177Lu-PSMA-617 is the most commonly used, but experience is mostly anecdotal/retrospective and no formal dose-escalation studies have been performed. Methods: Men with progressive mCRPC following at least 1 potent AR-targeted agent (e.g. abi/enza) and docetaxel (or unfit/refuse chemo) without limit of # prior therapies provided adequate organ function will undergo imaging with 68Ga-PSMA-HBED-CC PET/CT followed by escalating fractionated doses of 177Lu-PSMA-617. Cohort 1 = 3.7 GBq x2 two weeks apart up to 11.1 GBq x2 in a 3+3 dose-escalation study. Dose-limiting toxicity (DLT) is defined as attributable grade 4 heme toxicity or grade 3/4 non-heme toxicity. Planned cohort expansion will occur at recommended phase 2 dose (RP2D) in a 2-stage design. The primary endpoint is determination of DLT and RP2D. Secondary endpoints include toxicity, PSA decline rate, RECIST response, PFS, rPFS, OS. Correlatives include baseline/follow up PSMA imaging, whole body distribution of 177Lu-PSMA-617, CTC count (CellSearch) changes, tissue and circulating genomic assessment of DNA repair pathways, patient reported outcomes (FACT-P and BPI-SF). Clinical trial information: NCT03042468.

Punctuated evolution of copy-number alterations to define two molecular subtypes of muscle-invasive urothelial carcinoma

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Background: Somatic copy-number alterations (SCNAs) are distinct molecular events occurring in muscle-invasive urothelial carcinoma (UC). Defining the biologic role and the timing of SCNAs in UC’s evolution is critical for precision therapy. Methods: To examine whether distinct SCNAs define specific subtypes of UC and characterize the evolutionary dynamics of SCNA acquisition, we conducted whole-exome sequencing (WES) of a discovery cohort of 44 advanced UC tumors and matching germline samples, including 13 pairs of matched primary and metastatic tumors prospectively collected before and after chemotherapy. We queried WES data from 285 UCs from The Cancer Genome Atlas (TCGA) as a validation cohort. We performed a novel in-depth allele-specific copy-number analysis in 2503 cancer genes using the CLONET computational framework, which accounts for tumor ploidy and cellularity to infer the clonal hierarchy of SCNAs. Results: Analysis of SCNAs from tumor pairs within each patient revealed punctuated evolution of SCNAs occurring early in UC’s development followed by minor changes (clonal stasis) throughout the tumor’s lifetime. Two distinct clusters of UCs with strikingly different SCNA profiles in the discovery cohort emerged. Cluster A was defined by diploid copy number background and focal deletions in the 9p21 region (CDKN2A, CDKN2B and MTAP). Cluster B was defined by genome-wide duplications and several enriched amplifications including 1q21.1 (SETDB1 and MLLT11), (P = 0.0002) and 6p22.3 (E2F3), (P = 0.001). TP53 mutations (P = 0.0001) were enriched in the cluster B, consistent with the role of functional p53 as a “guardian of the genome” preventing chromosomal instability. SCNAs clusters A and B were confirmed in the TCGA validation cohort. Cluster A was enriched with tumors belonging to TCGA bladder cancer cluster III (“basal/squamous-like”) (P = 0.02). Conclusions: Using novel allele-specific SCNAs analysis, we define two distinct clusters of UC presenting a framework for understanding this aspect of UC’s biology. In contrast to somatic mutations, SCNAs are clonally static during each tumor’s evolution. This data has important implications for precision medicine for UC.

Therapy for chemopretreated metastatic urothelial cancer (mUC) with the antibody-drug conjugate (ADC) sacituzumab govitecan (IMMU-132)

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Background: Patients (pts) with mUC pre-treated with platinum-containing chemotherapy have limited therapeutic options, with checkpoint-inhibitor immunotherapy (IO) responses in a minority of pts. We present an interim update of the safety and activity of sacituzumab govitecan (IMMU-132), an anti-Trop-2-SN-38 ADC, as therapy for chemotherapy-pretreated mUC pts (ClinicalTrials.gov, NCT01631552). Methods: We enrolled 32 pts with mUC and ECOG PS 0-1 who failed ≥ 1 prior standard therapy (median=3; range, 1-5). IMMU-132 was administered at 8 or 10 mg/kg on days 1 and 8 every 21 days, continued until disease progression (PD) or unacceptable toxicity. Response-evaluable pts received ≥ 2 doses, and had ≥ 1 post-baseline response assessment. Results: Twenty-five pts [median age 68 yrs (range: 50-91), 24 males] are currently assessable for safety and response; 23 had prior platinum-containing therapy; 46% had >2 prior therapies; 4 also had IO agents. Sites of metastases included liver (N=4; 16%), lungs (N=7; 28%), bone (N=4; 16%), and lymph nodes (N=16; 64%). Pts received a median of 7 cycles (range, 2-23) of IMMU-132. ORR was 36% (9/25) [1 complete (CR) and 8 partial responses (PR)]; 44% (11/25) had stable disease (SD). Further, pts with 1 line of prior chemotherapy had an ORR of 53.8% (7/13), and 16.7% for those with 2 to 5 prior therapy lines. Median PFS for all patients is 7.2 mos (95% CI, 4.9-10.7); median survival is not reached yet. Of the 4 pts with progression after prior IO, there were 1 PR and 2 SDs with IMMU-132. Duration of response for CR/PR pts is currently 5.1 mos (95% CI, 4.1-12.9) and 10/11 pts (5 with ≥ 20% tumor reduction) had stable disease > 4 mos. Grade 4 neutropenia (16%) lasted < 7 days, and non-hematological grade 3 AEs included fatigue (12%) and hypophosphatemia (8%). No treatment-related deaths were observed. Analysis of Trop-2 expression revealed 1+ to 3+ positive staining in 95% of 19 archival patient specimens. Conclusions: With an ORR of 36% and a median PFS of 7.2 months in a heavily pretreated population, these interim results suggest that IMMU-132 is a promising agent as 2nd line or later therapy for platinum- or IO- pretreated mUC pts. Clinical trial information: NCT01631552.

Abstract CT064: Treatment for metastatic platinum-resistant urothelial cancer (PRUC) with an anti-Trop-2-SN-38 antibody-drug conjugate (ADC), sacituzumab govitecan (IMMU-132): phase I/II clinical experience

Background. Patients (pts) with PRUC have an aggressive disease with limited therapeutic options. Sacituzumab govitecan (IMMU-132) is an ADC comprised of SN-38, the active metabolite of the topoisomerase inhibitor, irinotecan, conjugated to an anti-Trop-2 humanized mAb. In vitro and in vivo preclinical data show that this is a unique ADC, with a high drug:antibody ratio of 7.6. It is capable of delivering up to 136-fold more SN-38 than its parent drug, irinotecan, in a human cancer xenograft. The ADC and mAb are immunotherapeutic in vitro (ADCC). Expression of Trop-2 is elevated in most epithelial cancers (&gt;80%), including UC. The efficacy and safety of this new ADC is examined in PRUC pts.

Methods. A Phase I/II clinical trial (ClinicalTrials.gov, NCT01631552) is enrolling PRUC pts. IMMU-132 is administered on days 1 and 8 of 21-day treatment cycles. Treatment is continued based on tolerance or until progression, with safety and response assessments (RECIST 1.1) made every week and every 8 weeks, respectively.

Results. Fifteen PRUC pts were enrolled by 11/10/15 and 14 are evaluable [median age 68 yrs, 93% M, 71% with ECOG 1, 71% with visceral metastases], with a median of 2 (range, 1-5) prior chemotherapies. IMMU-132 doses given were 8 mg/kg (N = 3), 10 mg/kg (N = 10), or 12 mg/kg (N = 1).

Six patients have confirmed partial response, providing an objective tumor response rate of 46% in 13 patients assessable by RECIST 1.1. The clinical benefit ratio (PR+SD &gt; 4 months) is 57%. The current median progression-free survival (PFS) is 8.1 months with 50% maturity (# events divided by # patients), and median overall survival (OS) is 10.8 months, with 79% patients still alive.

Among collected adverse events so far among 15 UC pts enrolled before 8/31/15, grade 3+ drug-related toxicities above 5% incidence (single events) are neutropenia (9%), diarrhea (9%) and staphylococcal bacteremia (9%). No patient developed antibodies (by ELISA) to the antibody or drug.

Conclusion. Compared to historical response rates of &lt; 20% in this clinical setting, PFS of 2-4 mos, and OS of 4-9 mos for pts with PRUC, the early efficacy seen in this study to date combined with the toxicity profile encourage further study of IMMU-132 at the 10 mg/kg dosing level.

Citation Format: Scott T. Tagawa, Bishoy Faltas, Elaine Lam, Wells A. Messersmith, Philip Saylor, Aditya Bardia, Julio J. Hajdenberg, Alicia K. Morgans, Jordan D. Berlin, Emerson Lim, Kevin Kalinsky, Pius Maliakal, Robert M. Sharkey, Francois Wilhelm, David M. Goldenberg, Allyson J. Ocean. Treatment for metastatic platinum-resistant urothelial cancer (PRUC) with an anti-Trop-2-SN-38 antibody-drug conjugate (ADC), sacituzumab govitecan (IMMU-132): phase I/II clinical experience. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT064.

Whole-Exome Sequencing of Metastatic Cancer and Biomarkers of Treatment Response

IMPORTANCE

Understanding molecular mechanisms of response and resistance to anticancer therapies requires prospective patient follow-up and clinical and functional validation of both common and low-frequency mutations. We describe a whole-exome sequencing (WES) precision medicine trial focused on patients with advanced cancer.

OBJECTIVE

To understand how WES data affect therapeutic decision making in patients with advanced cancer and to identify novel biomarkers of response.

DESIGN, SETTING, AND PATIENTS

Patients with metastatic and treatment-resistant cancer were prospectively enrolled at a single academic center for paired metastatic tumor and normal tissue WES during a 19-month period (February 2013 through September 2014). A comprehensive computational pipeline was used to detect point mutations, indels, and copy number alterations. Mutations were categorized as category 1, 2, or 3 on the basis of actionability; clinical reports were generated and discussed in precision tumor board. Patients were observed for 7 to 25 months for correlation of molecular information with clinical response.

MAIN OUTCOMES AND MEASURES

Feasibility, use of WES for decision making, and identification of novel biomarkers.

RESULTS

A total of 154 tumor-normal pairs from 97 patients with a range of metastatic cancers were sequenced, with a mean coverage of 95X and 16 somatic alterations detected per patient. In total, 16 mutations were category 1 (targeted therapy available), 98 were category 2 (biologically relevant), and 1474 were category 3 (unknown significance). Overall, WES provided informative results in 91 cases (94%), including alterations for which there is an approved drug, there are therapies in clinical or preclinical development, or they are considered drivers and potentially actionable (category 1-2); however, treatment was guided in only 5 patients (5%) on the basis of these recommendations because of access to clinical trials and/or off-label use of drugs. Among unexpected findings, a patient with prostate cancer with exceptional response to treatment was identified who harbored a somatic hemizygous deletion of the DNA repair gene FANCA and putative partial loss of function of the second allele through germline missense variant. Follow-up experiments established that loss of FANCA function was associated with platinum hypersensitivity both in vitro and in patient-derived xenografts, thus providing biologic rationale and functional evidence for his extreme clinical response.

CONCLUSIONS AND RELEVANCE

The majority of advanced, treatment-resistant tumors across tumor types harbor biologically informative alterations. The establishment of a clinical trial for WES of metastatic tumors with prospective follow-up of patients can help identify candidate predictive biomarkers of response.

Integrated whole exome and RNA sequencing to reveal distinct genomic and transcriptomic landscape of upper tract urothelial carcinoma

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Background: Upper tract urothelial carcinoma (UTUC) represents up to 10% of all urothelial carcinoma (UC). UTUC is a lethal malignancy, with nearly one half the patients dying within 5 years. Our objective was to understand the biological differences between UTUC and bladder UC.Methods: Fresh frozen chemotherapy-naïve primary tumors from nephroureterectomy cases and corresponding germline samples underwent whole exome sequencing (WES) and RNA sequencing (RNAseq). The Cancer Genome Atlas (TCGA) WES and RNAseq raw data was reanalyzed through our in-house bioinformatic pipeline to compare the mutational and transcriptomic landscape of UTUC to bladder UC. We evaluated the expression values for a set of 40 housekeeping genes between the two different datasets to exclude batch effects. We used gene set Enrichment Analysis (GSEA) to identify differentially enriched pathways in UTUC.Results: 17 tumors underwent WES, 20 RNAseq, with 11 analyzed for both WES and RNAseq. UTUC samples harbored several recurrent mutations including PIK3CA (4/17), FGFR3 (2/17), MLL2 (4/17), MLL3 (2/17), ATM 2/17). Three KRAS mutations were discovered in two patients (G12D, G12V and Q61H), which were confirmed by targeted sequencing. Frequent copy number alterations included CDKN2A/B deletions (3/17), BG4ALT3, SEMG1 and USP6 amplifications (2/17 each). GSEA analysis revealed significant enrichment of the KRAS signaling in UTUC whereas bladder UC showed an enrichment of genes involved in mTOR and E2F signaling. There were significant differences in the expression of several key DNA damage repair (DDR) pathway genes between the two entities including TP53, RAD51 and ERCC4 despite infrequent or absent mutations in these genes (q value 0.03 for DDR gene set). MSH5, a gene associated with cisplatin-resistance was the most highly ranked DDR overexpressed gene in UTUC compared to bladder UC (enrichment score = 0.8).Conclusions: This study generates a detailed genomic and transcriptomic profile of UTUC. RNAseq demonstrated a distinct pattern of DDR pathway expression in UTUC independent of genomic alterations; these findings may have important implications for platinum-based chemotherapy.

Generating a neoantigen map of advanced urothelial carcinoma by whole exome sequencing

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Background: immune-checkpoint blockade is a promising treatment of advanced urothelial carcinoma (UC) that unleashes pre-existing immune responses against recognized tumor antigens. Somatic mutations lead to the formation of neoantigens, which are highly antigenic mutant proteins. Methods: Our objective was to generate a neoantigen map through analysis of whole exome sequencing data of our cohort of patients (pts) with platinum-resistant UC. Whole exome sequencing (WES) data from 73 prospectively collected UC samples from 34 patients were analyzed using our neoantigen prediction pipeline. We defined neoantigens as mutant nonamers with high affinity binding to predicted class I MHC molecules for each patient. HLA haplotypes were inferred from WES of matched germline DNA. Results: A significant correlation between global somatic mutation rates, and neo-epitope burden was observed (R2 = 0.93), a similar correlation was observed between single nucleotide variants (SNV) and neo-epitope burdens (R2 = 0.94). We identified a strong positive correlation between the numbers of pack-years of smoking and neoepitope burden in patients with advanced UC (p = 0.0004). No correlation between global somatic mutational and predicted neoepitope burdens with overall survival was identified. Metastatic samples had a trend of harboring more SNVs (median 49 vs. 22, P = 0.13), and neoepitopes (median 17 vs 12, P = 0.22) compared to primary samples. Interestingly, only 32% of total SNVs and 8 % of neoepitopes (with binding affinities of ≤ 50nM) that were initially identified, reappeared in metastatic samples from the same patients obtained at a later time point. A significant selection against strong binding neo-epitopes was observed in subsequent samples from metastatic tumors (p-value < 0.005). Conclusions: A strong correlation between mutational burden and predicted neoantigenic load was observed in UC. Neoantigenic signatures were shaped by environmental exposures such as smoking. The significant heterogeneity in primary and metastatic neoantigens was possibly due to immunoediting as the tumor evolved. These findings may have important implications for selecting patients for immunotherapeutic approaches.

Sacituzumab Govitecan, a Novel Antibody--Drug Conjugate, in Patients With Metastatic Platinum-Resistant Urothelial Carcinoma

Patients with metastatic, platinum-resistant urothelial carcinoma (PRUC) have no Food and Drug Administration-approved therapies. The response rates to second-line chemotherapy have generally been < 20%, with a median overall survival of < 1 year. We report our experience with 6 heavily pretreated patients with advanced PRUC (ClinicalTrials.gov identifier NCT01631552) with the novel antibody-drug conjugate, sacituzumab govitecan (IMMU-132). This antibody-drug conjugate comprises the active metabolite of irinotecan, SN-38, conjugated to an anti-Trop-2 antibody. Trop-2 is widely expressed in ≤ 83% of urothelial carcinomas. Of the 6 patients, 3 had a clinically significant response (progression-free survival, 6.7 to 8.2 months; overall survival, 7.5+ to 11.4+ months). Sacituzumab govitecan was well tolerated. Because of these results, a phase II trial has been initiated. The present report highlights the promise of antibody-drug conjugates, such as sacituzumab govitecan, as a novel therapeutic strategy for the treatment of PRUC.

Abstract 4745: Precision cancer medicine program for whole-exome sequencing of metastatic tumors reveals biomarkers of response

Background: Understanding molecular mechanisms of response and resistance to anticancer therapies requires prospective patient follow-up and clinical and functional validation of both common and low frequency mutations. We describe an evidence-based precision medicine program designed to bring whole exome sequencing into clinical practice and illustrate how this can be utilized to identify novel predictive biomarkers associated with exceptional systemic response.

Methods: Metastatic and treatment-resistant cancer patients are prospectively enrolled under an IRB approved protocol for paired metastatic tumor and normal WES through our Precision Medicine Clinic. Using a comprehensive computational pipeline, point mutations, indels and copy number alterations are detected. Mutations are categorized as Category I-III based on actionability and a report is generated and discussed in tumor board. Patients are followed prospectively for correlation of molecular information with clinical response and patient outcomes. A rapid response functional team follows on key findings to expand actionability based on the WES results.

Results: In the first year, 154 tumor-normal pairs from 97 patients were sequenced, with an average coverage of 95X of over 21,000 genes and 16 somatic alterations detected on average per patient. In total, 16 mutations were Category I, 98 were Category II, and 1474 were Category III. Tumor purity ranged from 14 to near 100%. Among unexpected findings, a prostate cancer exceptional responder was identified that harbored a somatic hemizygous deletion of the DNA repair gene FANCA and likely loss of function of the second allele through germline missense variant. Follow-up experiments established that loss of FANCA function was associated with platinum hypersensitivity both in vitro and in patient-derived xenografts, thus providing biologic rationale and functional evidence for his extreme clinical response.

Conclusions: The establishment of a clinical program for whole exome sequencing of metastatic tumors with prospective follow-up of patients can help identify candidate predictive biomarkers of response.

Citation Format: Himisha Beltran, Kenneth Eng, Juan Miguel Mosquera, Alexandros Sigaras, Alessandro Romanel, Hanna Rennart, Myriam Kossai, Chantal Pauli, Bishoy Faltas, Jacqueline Fontugne, Brian Robinson, David M. Nanus, Scott T. Tagawa, Jenny Z. Xiang, Francesca Demichelis, David Rickman, Andrea Sboner, Olivier Elemento, Mark A. Rubin. Precision cancer medicine program for whole-exome sequencing of metastatic tumors reveals biomarkers of response. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4745. doi:10.1158/1538-7445.AM2015-4745

Precision medicine program for whole-exome sequencing (WES) provides new insight on platinum sensitivity in advanced prostate cancer (PCa)

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Background: WES has provided insight into the genomic landscape of PCa. The next step for precision medicine requires prospective patient (pt) follow-up and clinical and functional validation of both common and low frequency mutations. We describe a precision medicine WES program and illustrate how this can be used to identify novel biomarkers associated with response. Methods: Metastatic PCa pts were prospectively enrolled. WES of metastatic biopsies or rapid autopsies and normal DNA were sequenced by Illumina HiSeq 2500. Results: Tumor-normal pairs from 71 pts with metastatic PCa (11 hormone naïve, 38 CRPC, 23 NEPC) were sequenced including 3 rapid autopsies, with a biopsy success rate of >95%, avg tumor purity 10-95%, avg coverage 85X. The spectrum of mutations across metastatic PCa and how serial biopsies and rapid autopsies were used to assess heterogeneity and clonal evolution will be presented. WES from a metastatic PCa pt (PM12) with exceptional response to platinum with complete remission of liver and lung metastases at 2 years follow-up, demonstrated a hypermutated genotype and hemizygous deletion of the DNA repair gene FANCA in both his primary and metastatic PCa. A loss of function germline variant was detected within the second allele, and only the mutated allele was expressed in his tumor. Genome editing of FANCA using CRISPR in PCa cell lines resulted in cisplatin hypersensitivity and a significant decrease in FANC complex formation. In patient derived xenograft (PDX) models, PM12’s PDX was significantly more sensitive to cisplatin compared to a control Pca PDX of similar morphology but lacking FANCA deletion. By screening larger cohorts, FANCA loss was detected by FISH in 16% of localized PCa (n= 69), 14% metastatic Pca (n= 29), and not detected in any benign prostate (n=69). Conclusions: Our study provides a proof of principle for developing a precision medicine approach to cancer care with the capability to identify potential biomarkers of response. Our findings suggest that a subset of PCa with FANCA loss may be particularly vulnerable to cytotoxic therapy and provides biologic rationale to help explain the exceptional response of pt PM12 to platinum chemotherapy.

Outcomes of preoperative chemotherapy in bladder cancer patients including node-positive disease

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Background: Neoadjuvant chemotherapy is associated with improved overall survival benefit and the concept of systemic therapy followed by local consolidation may also lead to favorable long-term outcomes for those with lymph node (LN) metastases at presentation. Our goal was to examine the outcome of preoperative chemotherapy in patients (pts) with and without clinical evidence of LN metastases. Methods: After informed consent, patients were enrolled in a prospective database prior to radical cystectomy with lymph node dissection for bladder cancer between December 2001 to February 2014. Data were analyzed using descriptive statistics. Results: Our cohort included 63 patients receiving pre-operative chemotherapy with a median age 68 (range 38-91), 46 (72%) were male, and 17 (27%) had gross metastatic disease to lymph nodes (LNs). 13 pts received MVAC (20%), 44 gemcitabine and cisplatin (GC) (69%), 1 gemcitabine and carboplatin, 1 received ifosfamide, paclitaxel, and cisplatin and 4 pts had unknown neoadjuvant chemo outside of the institution. Most patients with LN positive (71%) disease received GC preoperative regimens. The median and the modal number of cycles were 4 (range 1-6). 44 patients underwent robotic-assisted radical cystectomy (RARC) (69%), 19 underwent open radical cystectomy (30%), and another pt. had RARC converted to an open procedure. Overall, 20 (31%) patients achieved pathologic complete response (pCR). Four pts (24%) with initial metastatic disease achieved pCR after preoperative chemotherapy. Overall pCR rates were similar between MVAC (38%) and GC (33%). All LN positive patients who achieved pCR had received gemcitabine-cisplatin preoperatively and underwent RARC. Recurrence-free and overall-survival data will be presented at the meeting. Conclusions: Preoperative chemotherapy was associated with a significant pCR rate in all bladder cancer patients including LN positive patients.

Clonal heterogeneity in platinum-resistant metastatic urothelial cancer

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Background: Beyond platinum-based chemotherapy, there are currently no approved therapies for advanced PRUC. Our objective was to generate the first detailed genomic profile of metastatic PRUC to identify molecular changes critical to platinum-resistance and metastasis development. Methods: Following informed consent, we collected 50 urothelial cancer (UC) tissue samples, from 23 patients. Metastatic tumor samples were obtained from biopsies or metastatectomy. Germline samples were prospectively collected and matched archival formalin-fixed paraffin-embedded primary tumors from the same patients were retrieved. Our cohort comprises 23 metastatic samples, 37 PRUC samples and 18 trios of matched primary, metastatic and germline samples including 2 rapid autopsies yielding tumor samples from multiple sites. We performed whole exome sequencing of all tumor and germline samples followed by integrated analysis of somatic single nucleotide variants and copy-number alterations and to analyze clonality. We utilized DAVID bioinformatic tool for pathway analysis. Results: Advanced PRUC samples were enriched for several molecular alterations, we identified 414 recurrently mutated genes including common genes such as TP53 (45%) as well as actionable alterations in PIK3CA (11%) and TSC1 (19%). We also identified frequent alterations in novel genes such as DPCR1 (38%) and NIN (28%). Frequent copy number alterations included CDKN2A deletion (33%), E2F3 amplification (10%) and ERBB2 amplification (7%). Pathway analysis showed enrichment of mutations in the apoptosis (p=1.0E-7) and cell cycle regulation (p=1.6E-2) pathways compared to TCGA primary UC dataset. We reconstructed phylogenetic trees from matched primary, metastatic and germline trios. Variant allele frequencies of certain shared mutations increased from primary tumors to lymph node and visceral metastases revealing clonal selection of mutations present in primary tumors. Conclusions: This study generates a detailed profile of the genomic landscape of advanced PRUC revealing extensive heterogeneity and clonal selection underlying platinum-resistance and metastatic spread.

Abstract CT310: Molecular correlates of activity and survival in a phase I/II trial of sorafenib plus gemcitabine and capecitabine for advanced renal cell carcinoma

Background: Renal cell carcinoma (RCC) is the most common malignancy of the kidneys. We conducted an NCI-sponsored New York Cancer Consortium phase I/II trial with the combination of sorafenib (SOR) plus the cytotoxic agents gemcitabine (GEM) and capecitabine (CAP).Thymidylate Synthase (TS) is the key enzyme in the catalysis of the methylation from dUMP to dTMP in the DNA synthetic process and high levels may denote poor prognosis, but higher sensitivity to 5-FU in primary cultured RCC cells. In proliferating cells, ribonucleotide reductase (RR) is a key enzyme of de novo nucleotide synthesis pathway; RRM1 expression predicts response to gemcitabine and prognosis in several solid tumors.

Methods: 26 patients (pts) with advanced RCC (65% clear cell, 31% papillary; 23% sarcomatoid differentiation) and 0-2 lines of prior therapy were enrolled in the clinical trial (NCI 6981): 15 in the phase I dose-escalation portion which defined toxicity and recommended phase II dose (RP2D): SOR 200 mg BID D1-21,GEM 750 mg/m2 D1 & D8, and CAP 415 mg/m2 BID D1-D14 in 21-day cycles and 11 pts in the phase II portion. Immunohistochemical staining of archival tissue was performed in 13 patients to determine TS and RRM1 status. Response rate (RR) was assessed by RECIST, association between response and marker expression by Fisher's exact test, and overall survival (OS) was calculated by Kaplan-Meier methodology with comparisons using log-rank.

Results: Overall, in the phase I/II study (all doses), RR is 16%, progression free survival (PFS) 6.1 mo, OS 18.3 mo [95% CI 10.3, 26.4]. For pts treated at the RP2D, RR is 12.5%, PFS 5.0 mo, OS 18.3. Pts positive for TS (61.5%) or RRM1 (53.8%) expression tended to have higher likelihood of stable disease or better by RECIST (though statistical significance was not reached, likely because of small numbers with progressive disease). Interestingly, the OS analysis demonstrated that pts with TS tumor expression lived longer (57.5 vs 18.1 mo, p=0.002) as did those with TS expression in vasculature (72.5 vs 21.7 mo, p=0.003). RRM1 positive pts also tended to live longer (57.5 vs 18.1 mo, p=0.13).

Conclusions: The combination of SOR, GEM, and CAP was tolerated at attenuated doses, but does not appear to have significantly better activity than historical controls. However, TS expression may predict response to capecitabine containing therapy in advanced RCC, which consistent with in-vitro data demonstrating higher sensitivity of cultured RCC cells that express higher TS levels to fluoropyrimidine therapy. These findings are hypothesis-generating and prospective validation is needed.

Citation Format: Bishoy Faltas, Gurveen Kaur, Naveed Akhtar, Paul Christos, Brian Robinson, Beerinder Singh, Himisha Beltran, David Nanus, Scott T. Tagawa. Molecular correlates of activity and survival in a phase I/II trial of sorafenib plus gemcitabine and capecitabine for advanced renal cell carcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr CT310. doi:10.1158/1538-7445.AM2014-CT310

Immunologics and chemotherapeutics for renal cell carcinoma

Treatment of metastatic renal cell carcinoma remains a challenge for clinicians. Traditional chemotherapy is ineffective and immunotherapy with interleukin-2 is only occasionally beneficial. The development of numerous agents targeting vascular endothelial growth factor and mammalian target of rapamycin signaling pathways that have been studied in phase III trials have resulted in significant improvement in survival for patients with clear cell renal cell carcinoma. Currently available U.S. Food and Drug Administration-approved first line targeted agents include sunitinib, pazopanib, temsirolimus, and bevacizumab (with interferon), while axitinib, everolimus, and sorafenib are most extensively used following progression as second- or third line therapy. Attempts to augment the activity of these agents by combining them together or with chemotherapy or immunotherapy have not yet proven to improve outcomes. As a result, the sequential use of single agents remains the current standard of care.

Myelodysplastic syndromes: toward a risk-adapted treatment approach

Several classification and scoring systems have been developed in myelodysplastic syndromes (MDS to predict the risk of progression to acute myeloid leukemia and survival. These prognostication models have been also used to inform therapeutic decision-making in a risk-adapted fashion. Patient-related factors such as age, comorbidities, and functional status have to be considered as well. Here we review a risk-guided therapeutic approach for the management of MDS patients. It is anticipated that the improved understanding of the complex pathogenesis of MDS and the recent discovery of important molecular lesions will be translated into novel therapeutic approaches. Additionally, some prognostic aberrations are expected to be incorporated into the prognostic tools with the goal of improving their prognostic precision and therefore allow for a more informed therapeutic decision-making based on the individual's risk profile.

Myelodysplastic syndromes: what do hospitalists need to know?

Myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal hematopoietic stem cell disorders characterized by dysplasia, ineffective hematopoiesis leading to peripheral blood cytopenias, and a variable risk of leukemic progression. MDS primarily affects the elderly, and although its prevalence is increasing, MDS is frequently overlooked and underdiagnosed. MDS should be suspected in any patient with unexplained cytopenias, and a bone marrow evaluation is ultimately needed to make the diagnosis and exclude other causes of bone marrow failure. The last 15 years have witnessed significant advances in our understanding of the complex pathogenesis, classification and prognostication, and therapeutic approaches to MDS. Several prognostic models facilitate outcome prediction and risk-adapted therapy. The addition of azacitidine, decitabine, and lenalidomide to erythropoiesis-stimulating agents in our armamentarium offered new effective therapeutic options for many patients who are not candidates for intensive interventions. Improved understanding of the genetic, epigenetic, and immunologic mechanisms that operate in MDS will help develop better prognostication tools and rationally design more effective therapies. Hospitalists are likely to encounter both patients with MDS and patients in whom MDS should be suspected. In this review of MDS, we focus on the epidemiology, diagnosis, pathogenesis, classification and prognostic tools, and treatment options.

Adult primary pulmonary primitive neuroectodermal tumor: molecular features and translational opportunities

Primitive neuroectodermal tumors (PNET) arising directly from the lung are very rare but particularly aggressive neoplasms. We report a case of a 31-y-old man with primary pulmonary neuroectodermal tumor. We review the clinical as well as pathological features. As typical for these tumors, the diagnosis was initially delayed in our patient and prognosis was poor despite aggressive surgical resection, postoperative chemotherapy and local irradiation. Recent biological insights have revealed unique chromosomal translocations crucial to the pathogenesis of these tumors, most notably the EWS-FLI-1 translocation. We provide an overview of the molecular features of the Ewing Sarcoma Family of Tumors (ESFT) including PNET and their potential implications for therapeutic targeting.

Cornering metastases: therapeutic targeting of circulating tumor cells and stem cells

The last decade has witnessed an evolution of our understanding of the biology of the metastatic cascade. Recent insights into the metastatic process show that it is complex, dynamic, and multi-directional. This process starts at a very early stage in the natural history of solid tumor growth leading to early development of metastases that grow in parallel with the primary tumor. The role of stem cells in perpetuating cancer metastases is increasingly becoming more evident. At the same time, there is a growing recognition of the crucial role circulating tumor cells (CTCs) play in the development of metastases. These insights have laid the biological foundations for therapeutic targeting of CTCs, a promising area of research that aims to reduce cancer morbidity and mortality by preventing the development of metastases at a very early stage. The hematogenous transport phase of the metastatic cascade provides critical access to CTCs for therapeutic targeting aiming to interrupt the metastatic process. Recent advances in the fields of nanotechnology and microfluidics have led to the development of several devices for in vivo targeting of CTC during transit in the circulation. Selectin-coated tubes that target cell adhesion molecules, immuno-magnetic separators, and in vivo photo-acoustic flow cytometers are currently being developed for this purpose. On the pharmacological front, several pharmacological and immunological agents targeting cancer stem cells are currently being developed. Such agents may ultimately prove to be effective against circulating tumor stem cells (CTSCs). Although still in its infancy, therapeutic targeting of CTCs and CTSCs offers an unprecedented opportunity to prevent the development of metastasis and potentially alter the natural history of cancer. By rendering cancer a "local" disease, these approaches could lead to major reductions in metastasis-related morbidity and mortality.

Dabigatran etexilate: what do hospitalists need to know?

Dabigatran etexilate (dabigatran) is a novel, oral, reversible, direct thrombin inhibitor that exhibits several advantages over warfarin for therapeutic anticoagulation. The predictable pharmacokinetic profile and minimal food and drug interactions of dabigatran allow for a fixed-dosing regimen and obviate the need for routine laboratory monitoring. Dabigatran has been approved in the United States for prevention of stroke in patients with nonvalvular atrial fibrillation and in the European Union and other countries for primary prevention of thromboembolic events after total knee or hip replacement. More indications for the use of dabigatran are under review by regulatory authorities and are undergoing active clinical investigation. Due to its rapid onset of action, dabigatran may omit the need for a parenteral anticoagulant for acute treatment of thromboembolic conditions. Because wide-scale use of dabigatran is expected in the near future, hospitalists need to familiarize themselves with this agent. The lack of a standardized reliable laboratory method to monitor the anticoagulant effects of dabigatran complicates verifying compliance, measuring the effects of drug interactions, evaluating cases of dabigatran toxicity, and conducting preoperative evaluations. The lack of an antidote to dabigatran complicates the management of toxicity and makes it largely supportive. The elimination of dabigatran is dependent on renal function, with the potential for drug accumulation and toxicity with renal impairment. The noninferiority design of the clinical trials that evaluated dabigatran and the absence of long-term safety and efficacy data and issues related to the cost effectiveness of dabigatran should all be considered when prescribing this agent.

Prolonged and increased postoperative risk of venous thromboembolism: rationale for even more 'extended' prophylaxis?

It is well known that the risk of venous thromboembolism is increased after surgery; however, specific data on how long this risk lasts or how the risk varies by type of surgery is limited. The Million Women Study is a population-based prospective study that recruited 1.3 million women through the National Health Service breast screening program. This study used data from the Million Women Study to examine the magnitude and the duration of the risk of venous thromboembolism after different types of surgery with a mean follow-up duration of 6.2 years. The risk was found to be higher and longer lasting than previously thought, with considerable variation among different types of surgery; therefore, raising important questions regarding the optimal duration of prophylaxis.

A new anticoagulant for a new era: review of recent data on dabigatran etexilate

Dabigatran etexilate is an oral direct thrombin inhibitor that could be administered in fixed doses and does not require laboratory monitoring. It is currently being evaluated through the RE-VOLUTION clinical trials program, which will involve more than 38,000 patients by the time it is completed. These clinical trials will evaluate the efficacy and safety of dabigatran etexilate for several indications. This article will review the clinical development of dabigatran, the published trial data, and the potential indications for this promising oral anticoagulant.

Update on perioperative bridging in patients on chronic oral anticoagulation

Oral anticoagulation (OAC) with vitamin K antagonists is commonly used for long-term prevention or treatment of arterial or venous thromboembolism. In the USA alone, approximately 250,000 patients will require temporary interruption of OAC annually. Managing anticoagulation in those patients on chronic OAC who require invasive procedures continues to be a major clinical dilemma. This article summarizes the existing evidence in light of the recommendations of the American College of Chest Physicians. Management of anticoagulation in the perioperative period will continue to be an important clinical challenge and an evolving area of research. If new oral anticoagulants are successful in replacing warfarin, the entire perioperative anticoagulation scene will change.

A case of primary meningococcal pericarditis caused by Neisseria meningitidis serotype Y with rapid evolution into cardiac tamponade

Primary meningococcal pericarditis (PMP) is a rare form of acute purulent pericarditis that often evolves into cardiac tamponade and usually requires pericardial drainage. PMP is a rare, difficult to diagnose, rapidly progressive form of meningococcal infections. PMP is typically caused by Neisseria meningitidis of serotype C, or, less commonly, B or W135. We report the second case of PMP caused by Neisseria meningitidis of serotype Y. Our patient was not critically ill at presentation, and her presentation could have been consistent with viral uncomplicated pericarditis with the exception of the mild leukocytosis with a left shift in the differential. Clinicians should be aware that early in the course of PMP, the illness may not be severe. Mild leukocytosis with a left shift or bandemia in the setting of what otherwise seems to be a case of uncomplicated viral pericarditis should prompt suspicion for PMP and further evaluation and/or monitoring.