Metastatic gastric cancer target lesion complete response with Claudin18.2-CAR T cells

Treatment of hematologic malignancies with patient-derived anti-CD19 chimeric antigen receptor (CAR) T-cells has demonstrated long-term remissions for patients with otherwise treatment-refractory advanced leukemia and lymphoma. Conversely, CAR T-cell treatment of solid tumors, including advanced gastric cancer (GC), has proven more challenging due to on-target off-tumor toxicities, poor tumor T-cell infiltration, inefficient CAR T-cell expansion, immunosuppressive tumor microenvironments, and demanding preconditioning regimens. We report the exceptional results of autologous Claudin18.2-targeted CAR T cells (CT041) in a patient with metastatic GC, who had progressed on four lines of combined systemic chemotherapy and immunotherapy. After two CT041 infusions, the patient had target lesion complete response and sustained an 8-month overall partial response with only minimal ascites. Moreover, tumor-informed circulating tumor DNA (ctDNA) reductions coincided with rapid CAR T-cell expansion and radiologic response. No severe toxicities occurred, and the patient's quality of life significantly improved. This experience supports targeting Claudin18.2-positive GC with CAR T-cell therapy and helps to validate ctDNA as a biomarker in CAR T-cell therapy. Clinical Insight: Claudin18.2-targeted CAR T cells can safely provide complete objective and ctDNA response in salvage metastatic GC.

Emerging challenges and opportunities in innovating food science technology and engineering education

Progress in science, technology, innovation, and digital capabilities call for reassessing food science, technology, and engineering (FST&E) education and research programs. This survey targeted global professionals and students across food disciplines and nutrition. Its main objectives included assessing the status of FST&E higher education, identifying challenges and opportunities, and furnishing recommendations. Seven topics affecting the future of the FST&E curricula were evaluated by the panel as 'High' to 'Very high', namely: 'Critical thinking', followed by 'Problem-solving projects', 'Teamwork/collaboration', 'Innovation/Open innovation' and 'Multidisciplinary'. The importance of academic partnership/collaboration with the Food Industry and Nutrition Sciences was demonstrated. Significant positive roles of the food industry in collaboration and partnerships were found. Other essential food industry attributes were related to internships, education, strategy, and vision. Collaboration between FST&E and nutrition sciences indicated the high standing of this direction. The need to integrate or converge nutrition sciences and FST&E is emphasized, especially with the growing consumer awareness of health and wellness. The study provides insights into new education and learning opportunities and new topics for future curricula.

Transoral Surgery in HPV-Positive Oropharyngeal Carcinoma: Oncologic Outcomes in the Veterans Affairs System

OBJECTIVES

Most transoral robotic surgery (TORS) literature for HPV-positive oropharyngeal squamous cell carcinoma (HPV-OPC) derives from high-volume tertiary-care centers. This study aims to describe long-term recurrence and survival outcomes among Veterans Health Administration patients.

MATERIALS AND METHODS

Using the US Veterans Affairs database, we identified patients with HPV-OPC treated with TORS between January 2010 and December 2016. Patients were stratified in risk categories: low (0-1 metastatic nodes, negative margins), intermediate (close margins, 2-4 metastatic nodes, lymphovascular or perineural invasion, pT3-pT4 tumor), or high (positive margins, extranodal extension (ENE), and/or ≥5 metastatic nodes). Primary outcomes included overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS).

RESULTS

The cohort included 161 patients of which 29 (18%) were low-risk, 45 (28%) intermediate-risk, and 87 (54%) high-risk. ENE was present in 41% of node-positive cases and 24% had positive margins. Median follow-up was 5.6 years (95% CI, 3.0-9.3). The 5-year DSS for low, intermediate, and high-risk groups were: 100%, 90.0% (95% CI, 75.4-96.1%), and 88.7% (95% CI, 78.3-94.2%). Pathologic features associated with poor DSS on univariable analysis included pT3-T4 tumors (HR 3.81, 95% CI, 1.31-11; p = 0.01), ≥5 metastatic nodes (HR 3.41, 95% CI, 1.20-11; p = 0.02), and ENE (HR 3.53, 95% CI, 1.06-12; p = 0.04). Higher 5-year cumulative incidences of recurrence were observed in more advanced tumors (pT3-T4, 33% [95% CI, 14-54%] versus pT1-T2, 13% [95% CI, 8-19%]; p = 0.01).

CONCLUSIONS

In this nationwide study, patients with HPV-OPC treated with TORS followed by adjuvant therapy at Veterans Affairs Medical Centers demonstrated favorable survival outcomes comparable to those reported in high-volume academic centers and clinical trials.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:207-214, 2024.

The Effect of Leflunomide as Adjunctive Therapy With a TNF Inhibitor in Pediatric Patients With Uveitis

PURPOSE

To describe the effectiveness of leflunomide as adjunctive therapy with anti-tumor necrosis factor (anti-TNF) agents in pediatric patients with uveitis who are not able to tolerate methotrexate.

METHODS

A retrospective case series was performed of pediatric patients who were receiving leflunomide in conjunction with anti-TNF agent therapy after intolerance to a combination of methotrexate with anti-TNF therapy. Dose and duration of methotrexate, leflunomide, and anti-TNF therapy were recorded. Extensive history, demographics, laboratory data, and uveitis flare rate were obtained.

RESULTS

A total of five children were included in the study. Most patients were initially receiving methotrexate and an anti-TNF agent was added subsequently due to inadequate response to monotherapy. After discontinuation of methotrexate, leflunomide was initiated with anti-TNF therapy. The replacement of methotrexate with leflunomide showed decreased side effects and was associated with lower flare rates and steroid-free remission.

CONCLUSIONS

Leflunomide was found to be well tolerated and effective at maintaining uveitis quiescence in conjunction with anti-TNF agents in pediatric patients who do not tolerate methotrexate. [J Pediatr Ophthalmol Strabismus. 2023;60(6):417-420.].

Incidence and Risk Factors for Eosinophilia and Lung Disease in Biologic-Exposed Children With Systemic Juvenile Idiopathic Arthritis

OBJECTIVE

Although interleukin-1 (IL-1)/IL-6 inhibitors are effective therapies for systemic juvenile idiopathic arthritis (JIA), some patients develop eosinophilia and lung disease during treatment. This study was undertaken to retrospectively evaluate incidence and risk factors for eosinophilia and describe lung disease outcomes in IL-1/IL-6 inhibitor-exposed patients with systemic JIA.

METHODS

Among JIA patients at our institution exposed to interleukin-1 (IL-1)/IL-6 inhibitors (1995-2022), we compared incidence rate of eosinophilia in systemic JIA compared to other JIA, stratified by medication class (IL-1/IL-6 inhibitors, other cytokine inhibitors, methotrexate). We used Cox models to identify predictors of eosinophilia during IL-1/IL-6 inhibitor use and summarized treatment changes and outcomes after eosinophilia, including lung disease. HLA typing was performed on a clinical or research basis.

RESULTS

There were 264 new medication exposures in 75 patients with systemic JIA and 41 patients with other JIA. A total of 49% of patients with systemic JIA with HLA typing (n = 45) were positive for HLA-DRB1*15 alleles. Eosinophilia was common during IL-1/IL-6 inhibitor use and did not differ by systemic JIA compared to other JIA (0.08 and 0.07 per person-year, respectively; P = 0.30). Among systemic JIA patients, pretreatment macrophage activation syndrome (MAS) was associated with a higher rate of subsequent eosinophilia on biologic therapy (unadjusted hazard ratio 3.2 [95% confidence interval 1.2-8.3]). A total of 4 of 5 patients who switched therapy within 10 weeks of eosinophilia experienced disease flare compared to none of the patients who continued the original therapy. A total of 8 of 25 patients with pulmonary evaluations had lung disease, and all had severe manifestations of systemic JIA (MAS, intensive care unit stay). One death was attributed to systemic JIA-lung disease.

CONCLUSION

Eosinophilia is common in JIA patients using IL-1/IL-6 inhibitors. Severe disease may be associated with eosinophilia and lung disease in systemic JIA.

Combining transcutaneous interferential-current for nerve inhibition with a robotic assistant device for increasing ankle dorsiflexion in walking

BACKGROUND

A kilohertz-frequency alternating current transcutaneously applied was introduced as a novel neuromodulation technology for nerve inhibition innervating antagonist muscles. Combining this electrical nerve inhibition with a robotic assistance device has been proposed but not investigated.

RESEARCH QUESTION

This study aimed to demonstrate the effect of combining electrical nerve inhibition with a wearable robotic device on increasing ankle dorsiflexion during walking. We hypothesized that the wearable robotic device would elicit a greater ankle dorsiflexion angle with the same force in walking by applying the transcutaneous interferential-current nerve inhibition (TINI) technique to the tibial nerve.

METHODS

Eleven healthy young adults performed three experimental conditions. The ankle assistance (AA) condition was walking while wearing an ankle device with operating dorsiflexion assistance during pre-swing and swing phases. For the ankle assistance with electrical stimulation (AE) condition, TINI on the tibial nerve was additionally applied from the AA condition. In the ankle non-assistance (AN) condition, participants wore the device, but assistance was not provided. The joint angles during walking were measured and digitized through a motion analysis system.

RESULTS

During a gait cycle, immediate changes in ankle joint motions were observed in the sagittal plane. In the pre-swing phase, ankle dorsiflexion angle was significantly greater in AE condition than AA and AN. There was no significant difference in joint angle between AA and AN.

SIGNIFICANCE

This study demonstrates the effectiveness of combining TINI with a wearable robotic ankle device in increasing dorsiflexion angle during the pre-swing phase. This finding provides the feasibility of using TINI as a neuromodulation technique for assisting functional movement in human walking.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

OBJECTIVE

To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.

METHODS

Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.

RESULTS

The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.

CONCLUSION

Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Deeply Virtual Compton Scattering Cross Section at High Bjorken x_{B}

We report high-precision measurements of the deeply virtual Compton scattering (DVCS) cross section at high values of the Bjorken variable x_{B}. DVCS is sensitive to the generalized parton distributions of the nucleon, which provide a three-dimensional description of its internal constituents. Using the exact analytic expression of the DVCS cross section for all possible polarization states of the initial and final electron and nucleon, and final state photon, we present the first experimental extraction of all four helicity-conserving Compton form factors (CFFs) of the nucleon as a function of x_{B}, while systematically including helicity flip amplitudes. In particular, the high accuracy of the present data demonstrates sensitivity to some very poorly known CFFs.

POS1365 THE FMF&AID SURVEY - A PATIENT ORGANIZATION DRIVEN SURVEY FOR AUTOINFLAMMATORY DISEASES

Background

Autoinflammatory diseases (also referred to as hereditary periodic fever syndromes) are caused by defects in the innate immune system. Many autoinflammatory syndromes arise from inherited genetic mutations which begin in childhood and persist throughout adult life. These diseases are often present in several members and generations within a family. Newer research also reflects that, cases can often present at any age through-out childhood, teenage years, and even into older adulthood. These cases appear to be acquired, perhaps due to the interplay of genetic, immune, and environmental factors (somaticism). It is not uncommon that a patient is diagnosed with rheumatoid arthritis, multiple sclerosis or another autoimmune issue, as many physicians are not aware of monogenic inborn errors, nor how to conduct a thorough work up due to a lack of medical knowledge.

Objectives

Unfortunately, the knowledge base that many doctors have with regards to autoinflammatory genetic diseases is minimal to non-existent, when compared to the well-established expertise of autoimmune disease management. Concerns about the increasing patient accounts detailing lack of medical diagnosis, treatment, and pain management, lead to the important decision to collect further data from the autoinflammatory patient community. The aim of the survey responses collected, and post data aggregation will help identity patient trends and use this information to educate and increase awareness amongst the medical community as to the unmet diagnostic and treatment requirements for the autoinflammatory population.

Methods

A questionnaire comprised of thirty questions was developed by members of the patient organization FMF & AID Global Association (Executive Director, Malena Vetterli with Research Director, H. Ellen Cohen) under the guidance of Dr. med. Juergen Rech focused on collecting basic information (e.g. age, country, onset and duration of symptoms, pain and fatigue). The survey was published at the end of 2020 on social media (Facebook) and on the FMF&AID website (www.fmfandaid.org). Participation was voluntary and the patients agreed that the anonymised response information of the survey may be evaluated and published. This international survey was approved by the ETHICS Committee FAU in Erlangen-Nuremberg, Germany.

Results

Worldwide, over a thousand patients or parents/caregivers of patients (younger than 18 years) in fifty-two countries took part in this survey and answered the questionnaire. Eighty percent (80%) of the participants had already been diagnosed with an autoinflammatory disease. However, despite classic periodic symptom presentation, twenty percent (20%) of the participants were still without a concise diagnosis. FMF - forty-three percent (43%) was cited as the most common diagnosis and M. Behçet thirty percent (30%) as the second, with a variety of others (e.g. PFAPA, CAPS, HIDS, TRAPS, DADA, Yao syndrome, and uSAID). The minimum age at diagnosis ranged from 1 to 70+ years old with an average age of 33 years when properly diagnosed. Three-hundred and nine (309) patients reported that their pain had not been taken seriously and adequately treated in the past. Pain and fatigue, as measured by the standard visual analogue scale (VAS 0-10), was high in the past 30 and 7 days, respectively. VAS pain 30 days was 4.8 (SD +/-2.7) or 7 days with 4.2 (SD +/- 3), as well as fatigue VAS 30 days 5.7 (SD +/- 2.8) or fatigue VAS 7 days with 5.5 (SD +/- 3).

Conclusion

One-fifth of patients with classic symptoms of autoinflammatory diseases remain undiagnosed and therefore not specifically treated. Although, the rest of the participants eighty percent (80%) have a diagnosis of an autoinflammatory disease, therapy does not appear to be sufficient to manage their wide-ranging and debilitating symptoms, in particular pain and fatigue. Patients continue to carry the burden of receiving mental diagnosis vs actual medical diagnosis and are still forced to seek additional medical support, often incurring travel or relocation costs to obtain proper care.

Disclosure of Interests

Jürgen Rech Speakers bureau: Abbvie, Biogen, BMS, Chugai, GSK, Lilly, MSD; Novartis, Roche, Sanofi, Sobi, UCB, Consultant of: Biogen, BMS, Chugai, GSK, Lilly, MSD, Novartis, Roche, Sanofi, Sobi, UCB, Grant/research support from: Novartis, Sobi, Koray Tascilar: None declared, Abdurrahman Tufan: None declared, Marco Gattorno: None declared, J. B. Kuemmerle-Deschner: None declared, Seza Ozen: None declared, Tobias Krickau: None declared, Ellen Cohen: None declared, Leonardo Oliveira Mendonca: None declared, Apostolos Kontzias: None declared, Malena Vetterli: None declared

Phase 2 study of the IDO/PD-L1-targeted immune-modulatory vaccine, IO102-IO103, plus pembrolizumab as first-line treatment for metastatic non–small cell lung cancer (NSCLC), squamous cell carcinoma of the head and neck (SCCHN), or urothelial bladder cancer (UBC)

TPS2699

Background: Immunotherapy has transformed the treatment of NSCLC and other solid tumors, such as SCCHN and UBC. However, even with standard-of-care anti-PD-1/PD-L1 therapies, few patients achieve durable benefit even when PD-L1 is overexpressed. IO102-IO103 is a potentially first-in-class, dual-antigen, immune-modulatory therapy that stimulates T cells to target tumoral immune escape via key checkpoint molecules IDO and PD-L1. It is thought that activating IDO/PD-L1-specific T cells in cancer patients through vaccination may support anticancer immunity by restricting immunosuppressive signaling and restoring the tumor immune microenvironment to render the tumor more susceptible to anti-PD-1 blockade. Thus there is a rationale for combining IO102-IO103 with anti-PD-1 therapy in the first-line treatment of metastatic tumors, such as NSCLC, SCCHN, or UBC. Combined IO102-IO103 and anti-PD-1 therapy (nivolumab) has already shown a robust signal of clinical activity (overall response rate [ORR], 80%; complete response rate [CRR], 43%; median progression-free survival [PFS], 26 months) and was well tolerated with minimal added toxicity to nivolumab in a Phase 1/2 study of anti-PD1-naïve patients with metastatic melanoma (Kjeldsen, et al. Nat Med 2021). Methods: This is a Phase 2, international, multicenter (US and Europe), non-comparative, open-label, multi-arm (basket) trial (EudraCT No. 2021-003026-69; ClinicalTrials.gov No. NCT05077709). Patients with recurrent, unresectable or metastatic solid tumors in 3 indications and no prior treatments for metastatic disease are being enrolled: NSCLC with a PD-L1 Tumor Proportion Score (TPS) ≥50% (Arm A); SCCHN with PD-L1 Combined Positive Scores (CPS) ≥20 (Arm B); or UBC with PD-L1 CPS ≥10 and not eligible for platinum-containing chemotherapy (Arm C). All patients, ̃30 in each arm, will receive 3-week cycles of IO102-IO103 (85-85 µg on Day [D] 1 and 8 of Cycle 1 and 2, and D1 thereafter) subcutaneously plus pembrolizumab (200 mg on D1) intravenously, for up to 2 years. Primary endpoints are ORR by RECIST v1.1 or 6-month PFS rate by investigator assessment (to be analyzed either 6 months after last patient started treatment or after target ORR is achieved, whichever is earliest). Secondary endpoints include PFS, duration of response, complete response rate, disease control rate, time to response, overall survival, and safety. Exploratory endpoints include biomarker and immune marker correlative studies, and PFS by iRECIST. The trial will assess the opportunity for a positive risk–benefit based on 2 efficacy boundaries for the ORR and 6-month PFS rate in each arm, with cohort expansion permitted if a clinically relevant efficacy signal is observed. Clinical trial information: EudraCT No. 2021-003026-69; ClinicalTrials.gov No. NCT05077709.

Form Factors and Two-Photon Exchange in High-Energy Elastic Electron-Proton Scattering

We present new precision measurements of the elastic electron-proton scattering cross section for momentum transfer (Q^{2}) up to 15.75  (GeV/c)^{2}. Combined with existing data, these provide an improved extraction of the proton magnetic form factor at high Q^{2} and double the range over which a longitudinal or transverse separation of the cross section can be performed. The difference between our results and polarization data agrees with that observed at lower Q^{2} and attributed to hard two-photon exchange (TPE) effects, extending to 8  (GeV/c)^{2} the range of Q^{2} for which a discrepancy is established at >95% confidence. We use the discrepancy to quantify the size of TPE contributions needed to explain the cross section at high Q^{2}.

Covid-19 vaccination and possible link to Herpes zoster

PURPOSE

To report 3 otherwise healthy patients with Herpes zoster reactivation shortly after administration of a mRNA vaccine against the novel COVID-19 virus.

OBSERVATIONS

Patient 1 is a 54 year old who presented with Herpes zoster meningitis complicated by enhancing nodular leptomeningeal lesions of the spinal cord. The subsequent two patients had Herpes zoster ophthalmicus of the cornea (Case 2) and eyelid (Case 3). All three presented within 2 weeks of receiving the Pfizer/BioNTech COVID-19 vaccine.

CONCLUSIONS

Herpes zoster may be a side effect of m RNA vaccination against the Sars-CoV2 vaccine and requires further investigation.

Complex chronic conditions among children born to women with schizophrenia

PURPOSE

Maternal schizophrenia is linked to complications in offspring near the time of birth. Whether there is also a higher future risk of the child having a complex chronic condition (CCC) - a pediatric condition affecting any bodily system expected to last at least 12 months that is severe enough to require specialty care and/or a period of hospitalization - is not known.

METHODS

In this population-based health administrative data cohort study (Ontario, Canada, 1995-2018), the risk for CCC was compared in 5066 children of women with schizophrenia (the exposed) vs. 2,939,320 unexposed children. Adjusted hazard ratios (aHR) were generated for occurrence of any CCC, by CCC category, and stratified by child sex, and child prematurity.

RESULTS

CCC was more frequent in the exposed (7.7 per 1000 person-years [268 children]) than unexposed (4.2 per 100 person-years [124,452 children]) - an aHR of 1.25 (95% CI 1.10-1.41). aHRs were notably higher in 5 of 9 CCC categories: neuromuscular (1.73, 1.28-2.33), cardiovascular (1.94, 1.64-2.29), respiratory (1.83, 1.32-2.54), hematology/immunodeficiency (2.24, 1.24-4.05) and other congenital or genetic defect (1.59, 1.16-2.17). The aHR for CCC was more pronounced among boys (1.32, 1.13-1.55) than girls (1.16, 0.96-1.40), and of similar magnitude in term (1.22, 1.05-1.42) and preterm infants (1.18, 0.95-1.46).

CONCLUSIONS

The risk for a CCC appears to be higher in children born to women with schizophrenia. This finding introduces opportunities for targeted preconception counselling, optimization of maternal risk factors, and intervention to support a vulnerable parent population who will experience unique challenges caring for a child with CCCs.

Correction of carotid artery stenosis by stent placement ameliorated paroxysmal hypertension after radiation treatment of hypopharyngeal carcinoma: a case report

Background

Paroxysmal hypertension can be associated with failure of the carotid artery baroreceptors due to past exposure to radiation treatment. This report describes a patient whose repeated paroxysmal hypertensive episodes were ameliorated following placement of a carotid artery stent for the treatment of carotid artery stenosis.

Case report

A 79-year-old caucasian male was diagnosed with hypopharyngeal squamous cell carcinoma (T1, L0, M0) in 2006, and received 70 Gy intensity-modulated radiotherapy in 2006 and underwent a total laryngectomy in 2008. He experienced paroxysmal hypertensive episodes since 2010 that exacerbated in frequency in 2019. Eighty percent left internal carotid artery stenosis was demonstrated by ultrasound and arteriography. Angioplasty and stenting of the left carotid artery was performed. A Doppler ultrasound study performed 5 months after the stent placement did not reveal any hemodynamic stenosis in the left carotid artery. The patient experienced postprandial hypotension and had experienced only three episodes of paroxysmal hypertension in the following 24 months. He was able to abort paroxysmal hypertensive episodes by eating warm food.

Discussion

This is the first report of a patient whose paroxysmal hypertensive episodes that occurred following radiation of the neck subsided after placement of a stent in a stenotic carotid artery. The exact mechanism leading to this phenomena is unknown but may be due to several factors. The reversal of the carotid artery stent and improvement in blood flow to the carotid artery baroceptors may play a role in this phenomenon.

Conclusion

The ability to ameliorate paroxysmal hypertensive episodes in a patient with carotid artery stenosis by stent placement may be a promising therapeutic intervention for paroxysmal hypertension.

Analysis of CDK12 alterations in a pan-cancer database

BACKGROUND

CDK12 inactivation leading to increased neoantigen burden has been hypothesized to sensitize tumors to immune checkpoint inhibition. Pan-cancer data regarding the frequency of CDK12 alterations are limited. We aimed to characterize CDK12 alterations across all cancer types through real-world clinical-grade sequencing.

METHODS

This was a single-center retrospective analysis of 4994 cancer patients who underwent tissue or blood genomic profiling, including CDK12 assessment, conducted as part of routine care from December 2012 to January 2020. Prevalence, clinical characteristics, and treatment outcomes of patients with tumors with pathogenic CDK12 alterations were described.

RESULTS

In all, 39 (0.78%, n = 39/4994) patients had pathogenic CDK12 alterations. Among CDK12-altered tumors, the most common organ site was prostate (n = 9, 23.1%) followed by colorectal (n = 5, 12.8%). Adenocarcinoma was the most common histology (n = 26, 66.7%). Median follow-up from time of diagnosis was 4.02 years. Median overall survival from time of metastasis was 4.43 years (95% CI: 3.11-5.74). Ten patients with CDK12-altered tumors received at least one immune checkpoint inhibitor-containing regimen. The majority of patients (n = 6/10, 60%) experienced an objective response. Progression-free survival for patients who had metastatic disease and received a checkpoint inhibitor-containing regimen was 1.16 years (95% CI: 0.32-2.00).

CONCLUSION

CDK12 alterations are rare events across hematologic and solid tumor malignancies. They represent a clinically distinct molecular cancer subtype which may have increased responsiveness to checkpoint inhibition. Prospective studies are warranted to investigate checkpoint inhibition in CDK12-altered tumors.

439 A phase 2 study of evorpacept (ALX148) in combination with pembrolizumab in patients with advanced head and neck squamous cell carcinoma (HNSCC); ASPEN-03

Background

Both innate and adaptive immune responses are important components of anticancer immunity. CD47 is a marker of self that interacts with SIRPα on myeloid immune cells, inhibiting their function. CD47 is upregulated by tumors to evade immune responses and its expression is associated with poor prognosis. Evorpacept is a high affinity CD47-blocking fusion protein with an inactive Fc region designed to be safely combined with and to enhance the efficacy of standard anticancer therapeutics. Evorpacept used in combination with pembrolizumab has the potential to augment both innate and adaptive anti-tumor immune responses. As an antibody inhibiting PD-1/PD-L1 signaling in the T cell immune checkpoint, pembrolizumab has demonstrated anti-tumor efficacy through activation of tumor-infiltrating lymphocytes. Pembrolizumab as a single agent is a standard treatment option for patients with previously untreated recurrent or metastatic (R/M) HNSCC with PD-L1-positive (combined positive score [CPS] ≥1) tumors. The combination of evorpacept + pembrolizumab has shown preliminary efficacy and acceptable tolerability in initial results available from the cohort of patients with ≥2nd line advanced HNSCC in the ongoing Phase 1 ASPEN-01 study.1 PD-L1-unselected patients who had not received prior checkpoint inhibitor treatment were treated with evorpacept + pembrolizumab and experienced a 40% ORR and 4.6 months median PFS, comparing favorably with historical controls. Based on these encouraging results, the ASPEN-03 study will assess the efficacy and safety of evorpacept in combination with pembrolizumab in previously untreated patients with metastatic or unresectable recurrent PD-L1 positive HNSCC.

Methods

ASPEN-03 (figure 1) is an ongoing non-comparative, open-label, randomized Phase 2 global study of evorpacept + pembrolizumab or pembrolizumab alone in patients with metastatic or unresectable recurrent, PD-L1-positive (CPS ≥1) HNSCC who have not yet been treated for their advanced disease. After an initial safety lead-in cohort, ~105 patients will be randomized 2:1 to receive evorpacept + pembrolizumab or pembrolizumab alone. Minimization factors used to randomize patients include geography, CPS, and HPV (p16) status. Patients in the evorpacept + pembrolizumab treatment arm will receive evorpacept 45 mg/kg IV Q3W. All patients will receive pembrolizumab 200 mg IV Q3W (maximum of 35 cycles). The primary endpoint in this Simon two-stage trial design is objective response rate using RECIST v1.1. Key secondary endpoints include duration of response, progression-free survival, overall survival, and safety. Exploratory endpoints will characterize pharmacodynamic properties.

Abstract 439 Figure 1

ASPEN-03 study schema

Acknowledgements

We would like to thank all the participating patients, their families, and site research teams.

Trial Registration

ClinicalTrials.

gov identifier, NCT04675294

References

Keun-Wook Lee, Hyun Cheol Chung, Won Seog Kim, et al. ALX148, a CD47 blocker, in combination with standard chemotherapy and antibody regimens in patients with gastric/gastroesophageal junction (GC) cancer and head and neck squamous cell carcinoma (HNSCC); ASPEN-01. Poster presented at: Society for Immunotherapy of Cancer Annual Meeting; November 2020.

Ethics Approval

The study was approved by all participating institutions’ Ethics and/or Review Boards.

601 Sequencing immunotherapy before lymphatic ablation unleashes cDC1-dependent antitumor immunity in HNSCC

Background

Despite the proven efficacy of immune checkpoint inhibitor (ICI) therapy in the recurrent/metastatic setting for head and neck squamous cell carcinoma (HNSCC), clinical trials of ICI combined with curative-intent therapies have yielded equivocal results [1–4]. Collectively, this highlights gaps in our understanding of rational immune oncology (IO) treatment sequencing and suggests that the efficacy ICI may be disrupted by standard therapies, which necessarily compromise regional lymphatics.

Methods

We employ a preclinical model of tobacco-signature HNSCC to identify sequences of therapy that maximize durable response. By mapping the cervical lymphatic basins in the mouse, we define patterns of active antitumor immunosurveillance. Additionally, we establish tumors with distinct patterns of regional lymphatic drainage and develop a murine neck dissection (ND) model.

Results

We find that cervical lymphatic ablation, with ND or stereotactic body radiation therapy, in tumor bearing animals abolishes the response to ICI therapy, significantly impacting overall survival. Examination of the tumor immune microenvironment following ND reveals dramatic changes with a ten-fold increase in CD45 cells and exclusion of cytotoxic and antigen-specific lymphocytes. By examining the lymphatics removed at the time of ND, we find that conventional type I dendritic cells (cDC1s) and type I interferon (IFN-I) signaling are significantly increased, suggesting that these effectors are lost after curative-intent therapy. Depleting IFN-I or cDC1s blocks the response to ICI similar to lymphatic ablation. We find that successful primary response to ICI leads to durable immunity, conferred by systemically distributed memory T cells, not impaired by delayed ND. Lastly, we discover a rational IO treatment sequence by delivering neoadjuvant ICI followed by ND. Neoadjuvant ICI leads to complete tumor response, accumulation of nodal cDC1, and durable immunity. Surprisingly, the incidence of nodal metastasis at early timepoints reveals a similar burden of nodal disease between control and ICI-treated animals that decreases at late timepoints only with ICI treatment (44% vs 15%, n=25, p=0.033). This suggests that ICI also drives active immunosurveillance in regional, tumor-draining lymphatics, challenging the landmark findings from the definitive clinical trial demonstrating the benefit of elective versus therapeutic neck dissection for oral SCC patients with clinically negative necks.

Conclusions

This work demonstrates the necessity of preserving tumor-draining lymphatics during the tumor response to ICI therapy in HNSCC. Overall, we define rational IO treatment sequences to achieve optimal primary tumor response, durable antitumor immunity and immunosurveillance of regional metastatic disease. These findings can inform future clinical trials investigating combination IO therapy and treatment sequencing.

References

Harrington, K. J. et al. Nivolumab versus standard, single-agent therapy of investigator’s choice in recurrent or metastatic squamous cell carcinoma of the head and neck (CheckMate 141): health-related quality-of-life results from a randomised, phase 3 trial. Lancet Oncology 18, 1104–1115 (2017).

Burtness, B. et al. Pembrolizumab alone or with chemotherapy versus cetuximab with chemotherapy for recurrent or metastatic squamous cell carcinoma of the head and neck (KEYNOTE-048): a randomised, open-label, phase 3 study. Lancet (London, England) 394, 1915–1928 (2019).

Lee, N. Y. et al. Avelumab plus standard-of-care chemoradiotherapy versus chemoradiotherapy alone in patients with locally advanced squamous cell carcinoma of the head and neck: a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial. Lancet Oncol 22, 450–462 (2021).

D’Cruz, A. K. et al. Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer. New England Journal of Medicine 373, 521–529 (2015).

433 A phase 2 study of evorpacept (ALX148) in combination with pembrolizumab and chemotherapy in patients with advanced head and neck squamous cell carcinoma (HNSCC); ASPEN-04

Background

Anticancer immunity relies on the release of tumor antigens and subsequent activation of the innate and adaptive immune systems. After cytotoxic chemotherapy induces neoantigen release, myeloid checkpoint inhibitors can help potentiate innate immune cell activity including antigen presentation. CD47 is a marker of self that interacts with SIRPα on myeloid immune cells and is upregulated by tumors to evade immune responses. Evorpacept is a high affinity CD47-blocking fusion protein with an inactive Fc region designed to safely enhance standard anticancer therapeutics. Pembrolizumab, a T cell checkpoint inhibitor that activates cytotoxic lymphocytes, is a standard option for patients with previously untreated recurrent/metastatic (R/M) HNSCC, both as a monotherapy and in combination with 5FU + platinum. Through increased activation of the immune system, a combination of evorpacept + pembrolizumab + 5FU/platinum might have more anti-tumor activity in R/M HNSCC than current standard therapeutic approaches. This combination approach could be particularly beneficial to R/M HNSCC patients with low PD-L1 expression, where anti-PD-(L)1 therapy historically has diminished efficacy. The combination of evorpacept + pembrolizumab + 5FU/platinum has undergone preliminary testing in the ongoing Phase 1 ASPEN-01 study,1 demonstrating initial clinical response and tolerability. In previously untreated, PD-L1-unselected R/M HNSCC patients treated with evorpacept + pembrolizumab + 5FU/platinum, patients experienced objective responses, including complete response. The ASPEN-04 study will assess the efficacy and safety of evorpacept in combination with pembrolizumab and chemotherapy in previously untreated patients with PD-L1-unselected R/M HNSCC.

Methods

ASPEN-04 (figure 1) is an ongoing non-comparative, open-label, randomized Phase 2 global study of evorpacept + pembrolizumab + chemotherapy (5FU + either carboplatin or cisplatin) or pembrolizumab + chemotherapy in patients with PD-L1-unselected metastatic or unresectable recurrent HNSCC who have not yet been treated for their advanced disease. After an initial safety lead-in cohort, ~106 patients will be randomized to receive evorpacept + pembrolizumab + chemotherapy or pembrolizumab + chemotherapy. Minimization factors used to randomize patients include geography, PD-L1 combined positive score, and HPV (p16) status. Patients in the evorpacept treatment arm will receive evorpacept 45 mg/kg IV Q3W. All patients will receive pembrolizumab 200 mg IV Q3W (maximum of 35 cycles) and standard administration of 5FU and platinum agents. The primary endpoint in this Simon two-stage trial design is objective response rate using RECIST v1.1. Key secondary endpoints include duration of response, progression-free survival, overall survival, and safety. Exploratory endpoints will characterize pharmacodynamic properties.

Abstract 433 Figure 1

ASPEN-04 Study Schema

Acknowledgements

We would like to thank all the participating patients, their families, and site research teams.

Trial Registration

ClinicalTrials.

gov identifier, NCT04675333

References

Keun-Wook Lee, Hyun Cheol Chung, Won Seog Kim, et al. ALX148, a CD47 blocker, in combination with standard chemotherapy and antibody regimens in patients with gastric/gastroesophageal junction (GC) cancer and head and neck squamous cell carcinoma (HNSCC); ASPEN-01. Poster presented at: Society for Immunotherapy of Cancer Annual Meeting; November 2020.

Ethics Approval

The study was approved by all participating institutions’ Ethics and/or Review Boards.

523 Preliminary clinical experience with XmAb20717, a PD-1 x CTLA-4 bispecific antibody, in patients with advanced solid tumors

Background

XmAb20717 is a humanized bispecific monoclonal antibody that simultaneously targets PD-1 and CTLA-4. We report updated data on patients treated at the recommended expansion dose from an ongoing, multicenter, Phase 1, dose-escalation and -expansion study of intravenous XmAb20717 in patients with selected advanced solid tumors that progressed after treatment with all standard therapies or with no standard therapeutic options.

Methods

A maximum tolerated dose was not reached in dose escalation. XmAb20717 10 mg/kg every 2 weeks (Q2W) was selected as the expansion dose, based on consistent T-cell proliferation in peripheral blood indicative of dual PD-1/CTLA-4 checkpoint blockade, and response to treatment (RECIST[1.1]).1 Parallel expansion cohorts included ~20 patients each with melanoma, renal cell carcinoma (RCC), non-small cell lung cancer (NSCLC), castration-resistant prostate cancer (CRPC), and a basket of tumor types without an FDA-approved checkpoint inhibitor (CI). Patients treated with 10 mg/kg in dose escalation were pooled with expansion cohorts for analysis of clinical activity and safety.

Results

As of 9 June 2021, 110 patients, ranging in age from 39 to 89 years and 66.4% male, were treated, and 5 were continuing treatment. Patients had received a median of 4 prior systemic treatment regimens, including CI therapy for 64.5%. The objective response rate was 13.0% (10/77 patients evaluable for efficacy), including 1 complete response (melanoma [confirmed]) and 9 partial responses (confirmed: 1 melanoma, 2 RCC, 2 CRPC, 1 ovarian cancer; unconfirmed: 1 melanoma, 2 NSCLC). The CRPC responders (2/7 with RECIST-measurable disease) had confirmed PSA decreases ≥ 50% from baseline (to 0.02 and 0.3 ng/mL); neither had progression on bone scans. All responders had prior CI exposure, except those with CRPC. Robust CD4 and CD8 T-cell activation was seen. Low baseline tumoral expression of myeloid recruitment genes, including IL-8, was associated with clinical benefit. Grade ≥ 3 immunotherapy-related adverse events in ≥ 3 patients included rash (16.4%), transaminase elevations (9.1%), hyperglycemia (4.5%), acute kidney injury (3.6%), amylase and lipase increased (2.7%), and lipase increased (2.7%).

Conclusions

Preliminary data indicate 10 mg/kg XmAb20717 Q2W was associated with complete and partial responses in multiple tumor types and was generally well-tolerated in these heavily pretreated patients with advanced cancer. Changes in T-cell populations in the periphery and tumor are consistent with robust dual checkpoint blockade. These findings support further development of XmAb20717 in advanced solid tumors, including metastatic prostate cancer.

Trial Registration

NCT03517488

References

Shum E, Daud A, Reilley M, et al. Preliminary safety, pharmacokinetics/pharmacodynamics, and antitumor activity of XmAb20717, a PD-1 x CTLA-4 bispecific antibody, in patients with advanced solid tumors. JITC 2020;8(3):A247-8.

Ethics Approval

The study was approved by each institution’s IRB.

Multisystem Inflammatory Syndrome in an Adult With COVID-19-A Trial of Anakinra: A Case Report

COVID-19 disease has been a pandemic caused by a β-coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A life-threatening multisystem inflammatory syndrome (MIS), secondary to SARS-CoV-2 virus infection, sharing common features with Kawasaki disease shock syndrome, staphylococcal/streptococcal shock syndrome, and macrophage activation syndrome in pediatric patients has been described. A total of 27 cases in adults (MIS-A) with a similar presentation have been reported so far. Here we describe the case of a 21-year-old man admitted with abdominal pain, diarrhea, tachycardia, and low blood pressure. He had elevated troponin, ferritin, and interleukin-2 receptor levels and had evidence of myocarditis. He tested positive for SARS-CoV-2 IgG antibody, and a diagnosis of MIS-A was made. Our case adds to the scant literature on this topic, and to our knowledge, it is the first case where anakinra was administered. He recovered well. MIS-A should be considered when young adults present with multiorgan dysfunction.

Deep Exclusive Electroproduction of π^{0} at High Q^{2} in the Quark Valence Regime

We report measurements of the exclusive neutral pion electroproduction cross section off protons at large values of x_{B} (0.36, 0.48, and 0.60) and Q^{2} (3.1 to 8.4  GeV^{2}) obtained from Jefferson Lab Hall A experiment E12-06-014. The corresponding structure functions dσ_{T}/dt+εdσ_{L}/dt, dσ_{TT}/dt, dσ_{LT}/dt, and dσ_{LT^{'}}/dt are extracted as a function of the proton momentum transfer t-t_{min}. The results suggest the amplitude for transversely polarized virtual photons continues to dominate the cross section throughout this kinematic range. The data are well described by calculations based on transversity generalized parton distributions coupled to a helicity flip distribution amplitude of the pion, thus providing a unique way to probe the structure of the nucleon.

The Cancer Epitope Database and Analysis Resource: A Blueprint for the Establishment of a New Bioinformatics Resource for Use by the Cancer Immunology Community

Recent years have witnessed a dramatic rise in interest towards cancer epitopes in general and particularly neoepitopes, antigens that are encoded by somatic mutations that arise as a consequence of tumorigenesis. There is also an interest in the specific T cell and B cell receptors recognizing these epitopes, as they have therapeutic applications. They can also aid in basic studies to infer the specificity of T cells or B cells characterized in bulk and single-cell sequencing data. The resurgence of interest in T cell and B cell epitopes emphasizes the need to catalog all cancer epitope-related data linked to the biological, immunological, and clinical contexts, and most importantly, making this information freely available to the scientific community in a user-friendly format. In parallel, there is also a need to develop resources for epitope prediction and analysis tools that provide researchers access to predictive strategies and provide objective evaluations of their performance. For example, such tools should enable researchers to identify epitopes that can be effectively used for immunotherapy or in defining biomarkers to predict the outcome of checkpoint blockade therapies. We present here a detailed vision, blueprint, and work plan for the development of a new resource, the Cancer Epitope Database and Analysis Resource (CEDAR). CEDAR will provide a freely accessible, comprehensive collection of cancer epitope and receptor data curated from the literature and provide easily accessible epitope and T cell/B cell target prediction and analysis tools. The curated cancer epitope data will provide a transparent benchmark dataset that can be used to assess how well prediction tools perform and to develop new prediction tools relevant to the cancer research community.

Abstract CT134: A phase I study of avelumab, palbociclib, and cetuximab (APC) in recurrent or metastatic head and neck squamous cell carcinoma (RM HNSCC)

Background: Checkpoint inhibitors have activity in RM HNSCC, but response rates to single agent therapy are low. Combination therapy may improve outcomes. We aimed to study a novel combination of palbociclib (P) and cetuximab (C) with the PD-L1 inhibitor avelumab (A) in RM HNSCC. Methods: Eligible patients (pts) with RM HNSCC received P in combination with A 10 mg/kg IV every 2 wks and C 400 mg/m2 IV x 1, then 250 mg/m2 weekly. The starting dose of P was 75 mg PO daily on days 1 to 21 of a 28 day cycle. The 3+3 dose escalation design included planned doses of P 100 mg and P 125 mg, with no intra-patient escalation. The primary objective was to identify the recommended phase II dose (RP2D); secondary objectives included response rate and progression free survival (PFS). Results: As of 10/15/20, 12 pts have been treated in 3 cohorts: P 75 mg PO daily (3 pts), 100 mg PO daily (3 pts), and 125 mg PO daily (6 pts). Median age was 56 yo, 92% were male, with 58% p16+, 25% p16-, 17% p16 unknown. One DLT was observed in cohort 3: a grade 3 infusion reaction related to C. The RP2D was P 125 mg, with A and C at standard doses. Other grade 3 AEs were leukopenia (4 pts), neutropenia (4 pts), acneiform rash (2 pts), cellulitis (1pt), increased WBC (1pt). One pt had grade 4 leukopenia. There were no grade 5 AEs. Tx related AEs occurring in > 30% of pts were: acneiform rash (11pts), fatigue (10pts), mucositis (7pts), dry skin (6 pts), decreased WBCs (5 pts), paronychia (5 pts), nausea (5pts), hypomagnesemia (4pts). Response rate by RECIST 1.1 was 42% (3 CRs, 2PRs); median duration of response has not been reached. Median PFS was 6.5 m. Reasons for discontinuation were disease progression (8 pts), pt choice (1 pt). 3 patients remain on therapy (after 20, 15, and 9 months). Conclusions: The combination of APC was well tolerated in patients with RM HNSCC; no unexpected toxicities were seen. The RP2D is A 10 mg/kg every 2 wks, C 400 mg/m2 x 1 then 250 mg/m2 wkly, and P 125 mg daily, 3 wks on, one wk off. Promising response rates were seen, and several pts have had durable responses. These data support further development of this combination. Biomarker analyses on tissue and blood are ongoing. NCT03498378.

Citation Format: Kathryn A. Gold, Assuntina Sacco, Julie Bykowski, Gregory Daniels, Emily Pittman, Karen Messer, Ruifeng Chen, Ezra Cohen. A phase I study of avelumab, palbociclib, and cetuximab (APC) in recurrent or metastatic head and neck squamous cell carcinoma (RM HNSCC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT134.

Avelumab plus standard-of-care chemoradiotherapy versus chemoradiotherapy alone in patients with locally advanced squamous cell carcinoma of the head and neck: a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial

BACKGROUND

Chemoradiotherapy is the standard of care for unresected locally advanced squamous cell carcinoma of the head and neck. We aimed to assess if addition of avelumab (anti-PD-L1) to chemoradiotherapy could improve treatment outcomes for this patient population.

METHODS

In this randomised, double-blind, placebo-controlled, phase 3 study, patients were recruited from 196 hospitals and cancer treatment centres in 22 countries. Patients aged 18 years or older, with histologically confirmed, previously untreated, locally advanced squamous cell carcinoma of the oropharynx, hypopharynx, larynx, or oral cavity (unselected for PD-L1 status), an Eastern Cooperative Oncology Group performance status score of 0 or 1, and who could receive chemoradiotherapy were eligible. Patients were randomly assigned (1:1) centrally by means of stratified block randomisation with block size four (stratified by human papillomavirus status, tumour stage, and nodal stage, and done by an interactive response technology system) to receive 10 mg/kg avelumab intravenously every 2 weeks plus chemoradiotherapy (100 mg/m2 cisplatin every 3 weeks plus intensity-modulated radiotherapy with standard fractionation of 70 Gy [35 fractions during 7 weeks]; avelumab group) or placebo plus chemoradiotherapy (placebo group). This was preceded by a single 10 mg/kg avelumab or placebo lead-in dose given 7 days previously and followed by 10 mg/kg avelumab or placebo every 2 weeks maintenance therapy for up to 12 months. The primary endpoint was progression-free survival by investigator assessment per modified Response Evaluation Criteria in Solid Tumors, version 1.1, in all randomly assigned patients. Adverse events were assessed in patients who received at least one dose of avelumab or placebo. This trial is registered with ClinicalTrials.gov, NCT02952586. Enrolment is no longer ongoing, and the trial has been discontinued.

FINDINGS

Between Dec 12, 2016, and Jan 29, 2019, from 907 patients screened, 697 patients were randomly assigned to the avelumab group (n=350) or the placebo group (n=347). Median follow-up for progression-free survival was 14·6 months (IQR 8·5-19·6) in the avelumab group and 14·8 months (11·6-18·8) in the placebo group. Median progression-free survival was not reached (95% CI 16·9 months-not estimable) in the avelumab group and not reached (23·0 months-not estimable) in the placebo group (stratified hazard ratio 1·21 [95% CI 0·93-1·57] favouring the placebo group; one-sided p=0·92). The most common grade 3 or worse treatment-related adverse events were neutropenia (57 [16%] of 348 patients in the avelumab group vs 52 [15%] of 344 patients in the placebo group), mucosal inflammation (50 [14%] vs 45 [13%]), dysphagia (49 [14%] vs 47 [14%]), and anaemia (41 [12%] vs 44 [13%]). Serious treatment-related adverse events occurred in 124 (36%) patients in the avelumab group and in 109 (32%) patients in the placebo group. Treatment-related deaths occurred in two (1%) patients in the avelumab group (due to general disorders and site conditions, and vascular rupture) and one (<1%) in the placebo group (due to acute respiratory failure).

INTERPRETATION

The primary objective of prolonging progression-free survival with avelumab plus chemoradiotherapy followed by avelumab maintenance in patients with locally advanced squamous cell carcinoma of the head and neck was not met. These findings may help inform the design of future trials investigating the combination of immune checkpoint inhibitors plus CRT.

FUNDING

Pfizer and Merck KGaA, Darmstadt, Germany.

Doctors of chiropractic working with or within integrated healthcare delivery systems: a scoping review protocol

INTRODUCTION

Back and neck pain are the leading causes of disability worldwide. Doctors of chiropractic (DCs) are trained to manage these common conditions and can provide non-pharmacological treatment aligned with international clinical practice guidelines. Although DCs practice in over 90 countries, chiropractic care is rarely available within integrated healthcare delivery systems. A lack of DCs in private practice, particularly in low-income communities, may also limit access to chiropractic care. Improving collaboration between medical providers and community-based DCs, or embedding DCs in medical settings such as hospitals or community health centres, will improve access to evidence-based care for musculoskeletal conditions.

METHODS AND ANALYSES

This scoping review will map studies of DCs working with or within integrated healthcare delivery systems. We will use the recommended six-step approach for scoping reviews. We will search three electronic data bases including Medline, Embase and Web of Science. Two investigators will independently review all titles and abstracts to identify relevant records, screen the full-text articles of potentially admissible records, and systematically extract data from selected articles. We will include studies published in English from 1998 to 2020 describing medical settings that have established formal relationships with community-based DCs (eg, shared medical record) or where DCs practice in medical settings. Data extraction and reporting will be guided by the Proctor Conceptual Model for Implementation Research, which has three domains: clinical intervention, implementation strategies and outcome measurement. Stakeholders from diverse clinical fields will offer feedback on the implications of our findings via a web-based survey.

ETHICS AND DISSEMINATION

Ethics approval will not be obtained for this review of published and publicly accessible data, but will be obtained for the web-based survey. Our results will be disseminated through conference presentations and a peer-reviewed publication. Our findings will inform implementation strategies that support the adoption of chiropractic care within integrated healthcare delivery systems.

Distinct clinical and immunological features of SARS-CoV-2-induced multisystem inflammatory syndrome in children

BACKGROUNDPediatric SARS-CoV-2 infection can be complicated by a dangerous hyperinflammatory condition termed multisystem inflammatory syndrome in children (MIS-C). The clinical and immunologic spectrum of MIS-C and its relationship to other inflammatory conditions of childhood have not been studied in detail.METHODSWe retrospectively studied confirmed cases of MIS-C at our institution from March to June 2020. The clinical characteristics, laboratory studies, and treatment response were collected. Data were compared with historic cohorts of Kawasaki disease (KD) and macrophage activation syndrome (MAS).RESULTSTwenty-eight patients fulfilled the case definition of MIS-C. Median age at presentation was 9 years (range: 1 month to 17 years); 50% of patients had preexisting conditions. All patients had laboratory confirmation of SARS-CoV-2 infection. Seventeen patients (61%) required intensive care, including 7 patients (25%) who required inotrope support. Seven patients (25%) met criteria for complete or incomplete KD, and coronary abnormalities were found in 6 cases. Lymphopenia, thrombocytopenia, and elevation in inflammatory markers, D-dimer, B-type natriuretic peptide, IL-6, and IL-10 levels were common but not ubiquitous. Cytopenias distinguished MIS-C from KD and the degree of hyperferritinemia and pattern of cytokine production differed between MIS-C and MAS. Immunomodulatory therapy given to patients with MIS-C included intravenous immune globulin (IVIG) (71%), corticosteroids (61%), and anakinra (18%). Clinical and laboratory improvement were observed in all cases, including 6 cases that did not require immunomodulatory therapy. No mortality was recorded in this cohort.CONCLUSIONMIS-C encompasses a broad phenotypic spectrum with clinical and laboratory features distinct from KD and MAS.FUNDINGThis work was supported by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases; the National Institute of Allergy and Infectious Diseases; Rheumatology Research Foundation Investigator Awards and Medical Education Award; Boston Children's Hospital Faculty Career Development Awards; the McCance Family Foundation; and the Samara Jan Turkel Center.

407 Preliminary safety, pharmacokinetics/pharmacodynamics, and antitumor activity of XmAb20717, a PD-1 x CTLA-4 bispecific antibody, in patients with advanced solid tumors

Background

XmAb20717 is a humanized bispecific monoclonal antibody that simultaneously targets PD-1 and CTLA-4. We report preliminary data from an ongoing, multicenter, Phase 1 study investigating the safety/tolerability, pharmacokinetics/pharmacodynamics, and clinical activity (RECIST 1.1) of XmAb20717 in patients with selected advanced solid tumors.

Methods

A 3+3 dose-escalation design was used to establish a maximum tolerated (MTD)/recommended dose for evaluation in parallel expansion cohorts, including melanoma, renal cell carcinoma, non-small cell lung cancer (NSCLC), prostate cancer, and a basket of tumor types without an FDA-approved checkpoint inhibitor (CI; n≤20 each). XmAb20717 was administered as an infusion on Days 1 and 15 of each 28-day cycle.

Results

As of 08Jul2020, 109 patients had been treated (table 1), and 30 were continuing treatment. In escalation, 6 dose levels (0.15–10.0 mg/kg) were evaluated (n=34); an MTD was not established. Expansion cohorts were initiated at 10 mg/kg (n=72), and a 15 mg/kg escalation cohort was added (n=3). T-cell proliferation was noted in peripheral blood at doses as low as 3 mg/kg and was highest at 10 mg/kg. At this dose, consistent proliferation of CD8+ and CD4+ T cells was observed, indicative of dual PD-1 and CTLA-4 checkpoint blockade (figure 1). Paired pre- and post-dosing biopsies showed increased intratumoral T-cell infiltration and IFN-response signatures following treatment. Grade 3/4 treatment-related adverse events (TRAEs) reported for ≥3 patients included rash (13%), transaminase elevations (7%), lipase increased (4% [2% with amylase increased]), and acute kidney injury (3%), all considered immune-related. There were 2 Grade 5 TRAEs: immune-mediated pancreatitis (in the presence of pancreatic metastases) and immune-mediated myocarditis (Grade 4) that contributed to respiratory failure. A complete response was reported as the best overall response for 1 patient (melanoma); partial responses were reported for 5 patients (2 melanoma, 2 NSCLC, 1 ovarian). The objective response rate was 13% overall and 21% at 10 mg/kg (6/46 and 6/29 evaluable patients, respectively). All responders had prior CI exposure. Responses were observed only at 10 mg/kg and, within the 10 mg/kg group, appeared to correlate with higher peak serum concentration and area under the curve.

Abstract 407 Table 1

Demographics and baseline characteristics

Abstract 407 Figure 1

Mean change from baseline in percentage of Ki67+ T–cell expression in peripheral blood during first two cycles of XmAb20717

Conclusions

XmAb20717 induced T-cell proliferation in peripheral blood consistent with dual-checkpoint blockade. Preliminary data indicate XmAb20717 was generally well-tolerated and associated with evidence of antitumor activity in CI-pretreated patients with various types of advanced solid tumors.

Trial Registration

NCT03517488

Ethics Approval

The study was approved by each institution’s IRB.

Increased maternal new-onset psychiatric disorders after delivering a child with a major anomaly: a cohort study

BACKGROUND

The birth of a child with a major congenital anomaly may create chronic caregiving stress for mothers, yet little is known about their psychiatric outcomes.

AIMS

To evaluate the association of the birth of a child with a major congenital anomaly with subsequent maternal psychiatric risk.

METHODS

This Danish nationwide cohort study included mothers who gave birth to an infant with a major congenital anomaly (n = 19 220) between 1997 and 2015. Comparators were randomly selected mothers, matched on maternal age, year of delivery and parity (n = 195 399). The primary outcome was any new-onset psychiatric diagnosis. Secondary outcomes included specific psychiatric diagnoses, psychiatric in-patient admissions and redeemed psychoactive medicines. Cox models were used to estimate hazard ratios (HRs), adjusted for socioeconomic and medical variables.

RESULTS

Mothers of affected infants had an elevated risk for a new-onset psychiatric disorder vs. the comparison group (adjusted HR, 1.16, 95% CI 1.11-1.22). The adjusted HR was particularly elevated during the first postpartum year (1.65, 95% CI 1.42-1.90), but remained high for years, especially among mothers of children with multiorgan anomalies (1.37, 95% CI 1.18-1.57). The risk was also elevated for most specific psychiatric diagnoses, admissions and medicines.

CONCLUSIONS

Mothers who give birth to a child with a major congenital anomaly are at increased risk of new-onset psychiatric disorders, especially shortly after birth and for mothers of children with more severe anomalies. Our study highlights the need to screen for mental illness in this high-risk population, as well as to integrate adult mental health services and paediatric care.

Abstract IA16: Augmenting anti-PD1 activity via an HLA-agnostic, mutation-burden independent, personalized neoantigen vaccine strategy

Neoantigens (neoAg) offer a unique opportunity for directing a patient’s adaptive immune system against tumors while avoiding damage to normal tissues. Current methods for their accurate identification and therapeutic targeting suffer from three main drawbacks: 1) they predict rather than confirm neoAg, 2) their “hit rate” is often too low to be useful in tumors of low to moderate mutational burden such as HNSCC, and, 3) they fail to inform on whether a given mutation is a natural target that can be recognized by CD8+ T cells on tumor cells or by CD4+ T cells on local antigen-presenting cells (APC). This last aspect is perhaps most critical, as a T cell that recognizes a peptide but not a target cell is of little therapeutic value to a cancer patient. We have developed a new unbiased functional approach to neoAg identification that combines bioinformatic analysis of genomic sequence data with functional T-cell assays from a patient’s own PBMC and tumor-infiltrating lymphocytes (TIL). It is based on the concept that, although in silico algorithms may seek to model one or another features of a given mutation’s predicted immunogenicity, the intact immune system can provide proof as to which mutations have been targeted by T cells, and does so according to defined rules of antigen processing and presentation that operate in both cross-presenting antigen-presenting cells (APC) that prime the response and in the tumor cells that express the source antigen. Our approach does not rely on in silico prediction of MHC binding nor any other speculative aspect of peptide immunogenicity and has minimal tissue and peripheral blood requirements. Our preliminary data show it can identify neoAg at a 10x higher rate than current methods and reveals both CD4+ and CD8+ responses. We have performed this analysis for the 4 neoAg identified for the syngeneic murine SCC VII model, and find that the prime/boost vaccination protocol results in significant but incomplete protection from challenge with live SCC VII tumor cells, thus demonstrating that, as a pool, these peptides induce T cells capable of tumor recognition. Furthermore, we have performed preliminary experiments demonstrating that, although SCC VII tumor responds to both PD-1 and CTLA4 blockade immunotherapy, the growing tumors are eradicated much faster in mice that had a pre-existing neoAg-specific T cell response induced in them prior to challenge and treatment. Mice that were vaccinated twice with neoAg peptides + polyI:C but did not receive immune checkpoint blockade showed some initial tumor control that was subsequently lost, leading to progressive growth. A phase 1b clinical trial is now enrolling subjects with advanced cancer that will produce a personalized vaccine for each patient based on our neoantigen identification methodology. The trial combines the vaccine with the anti-PD1 antibody, pembrolizumab, and enrolls patients into 2 consecutive cohorts to elucidate the effects on neoepitope specific T-cell responses of the vaccine versus anti-PD1 targeting. This presentation will summarize our efforts to identify neoantigens, efficacy of a neoantigen-specific vaccine in the murine model, and the current phase 1b study rationale and design.

Citation Format: Ezra Cohen. Augmenting anti-PD1 activity via an HLA-agnostic, mutation-burden independent, personalized neoantigen vaccine strategy [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr IA16.