The efficacy of immune checkpoint blockade for melanoma in-transit with or without nodal metastases - A multicenter cohort study

PURPOSE

Guidelines addressing melanoma in-transit metastasis (ITM) recommend immune checkpoint inhibitors (ICI) as a first-line treatment option, despite the fact that there are no efficacy data available from prospective trials for exclusively ITM disease. The study aims to analyze the outcome of patients with ITM treated with ICI based on data from a large cohort of patients treated at international referral clinics.

METHODS

A multicenter retrospective cohort study of patients treated between January 2015 and December 2020 from Australia, Europe, and the USA, evaluating treatment with ICI for ITM with or without nodal involvement (AJCC8 N1c, N2c, and N3c) and without distant disease (M0). Treatment was with PD-1 inhibitor (nivolumab or pembrolizumab) and/or CTLA-4 inhibitor (ipilimumab). The response was evaluated according to the RECIST criteria modified for cutaneous lesions.

RESULTS

A total of 287 patients from 21 institutions in eight countries were included. Immunotherapy was first-line treatment in 64 (22%) patients. PD-1 or CTLA-4 inhibitor monotherapy was given in 233 (81%) and 23 (8%) patients, respectively, while 31 (11%) received both in combination. The overall response rate was 56%, complete response (CR) rate was 36%, and progressive disease (PD) rate was 32%. Median PFS was ten months (95% CI 7.4-12.6 months) with a one-, two-, and five-year PFS rate of 48%, 33%, and 18%, respectively. Median MSS was not reached, and the one-, two-, and five-year MSS rates were 95%, 83%, and 71%, respectively.

CONCLUSION

Systemic immunotherapy is an effective treatment for melanoma ITM. Future studies should evaluate the role of systemic immunotherapy in the context of multimodality therapy, including locoregional treatments such as surgery, intralesional therapy, and regional therapies.

Germline ATM variants predispose to melanoma: a joint analysis across the GenoMEL and MelaNostrum consortia

PURPOSE

Ataxia-Telangiectasia Mutated (ATM) has been implicated in the risk of several cancers, but establishing a causal relationship is often challenging. Although ATM single-nucleotide polymorphisms have been linked to melanoma, few functional alleles have been identified. Therefore, ATM impact on melanoma predisposition is unclear.

METHODS

From 22 American, Australian, and European sites, we collected 2,104 familial, multiple primary (MPM), and sporadic melanoma cases who underwent ATM genotyping via panel, exome, or genome sequencing, and compared the allele frequency (AF) of selected ATM variants classified as loss-of-function (LOF) and variants of uncertain significance (VUS) between this cohort and the gnomAD non-Finnish European (NFE) data set.

RESULTS

LOF variants were more represented in our study cohort than in gnomAD NFE, both in all (AF = 0.005 and 0.002, OR = 2.6, 95% CI = 1.56-4.11, p < 0.01), and familial + MPM cases (AF = 0.0054 and 0.002, OR = 2.97, p < 0.01). Similarly, VUS were enriched in all (AF = 0.046 and 0.033, OR = 1.41, 95% CI = 1.6-5.09, p < 0.01) and familial + MPM cases (AF = 0.053 and 0.033, OR = 1.63, p < 0.01). In a case-control comparison of two centers that provided 1,446 controls, LOF and VUS were enriched in familial + MPM cases (p = 0.027, p = 0.018).

CONCLUSION

This study, describing the largest multicenter melanoma cohort investigated for ATM germline variants, supports the role of ATM as a melanoma predisposition gene, with LOF variants suggesting a moderate-risk.

Global Radiotherapy: Current Status and Future Directions-White Paper

Recognizing the increase in cancer incidence globally and the need for effective cancer control interventions, several organizations, professional bodies, and international institutions have proposed strategies to improve treatment options and reduce mortality along with minimizing overall incidence. Despite these efforts, an estimated 9.6 million deaths in 2018 was attributed to this noncommunicable disease, making it the second leading cause of death worldwide. Left unchecked, this will further increase in scale, with an estimated 29.5 million new cases and 16.3 million deaths occurring worldwide in 2040. Although it is known and generally accepted that cancer services must include radiotherapy, such access is still very limited in many parts of the world, especially in low- and middle-income countries. After thorough review of the current status of radiotherapy including programs worldwide, as well as achievements and challenges at the global level, the International Atomic Energy Agency convened an international group of experts representing various radiation oncology societies to take a closer look into the current status of radiotherapy and provide a road map for future directions in this field. It was concluded that the plethora of global and regional initiatives would benefit further from the existence of a central framework, including an easily accessible repository through which better coordination can be done. Supporting this framework, a practical inventory of competencies needs to be made available on a global level emphasizing the knowledge, skills, and behavior required for a safe, sustainable, and professional practice for various settings. This white paper presents the current status of global radiotherapy and future directions for the community. It forms the basis for an action plan to be developed with professional societies worldwide.

A rare missense mutation in CHRNA4 associates with smoking behavior and its consequences

Using Icelandic whole-genome sequence data and an imputation approach we searched for rare sequence variants in CHRNA4 and tested them for association with nicotine dependence. We show that carriers of a rare missense variant (allele frequency=0.24%) within CHRNA4, encoding an R336C substitution, have greater risk of nicotine addiction than non-carriers as assessed by the Fagerstrom Test for Nicotine Dependence (P=1.2 × 10(-4)). The variant also confers risk of several serious smoking-related diseases previously shown to be associated with the D398N substitution in CHRNA5. We observed odds ratios (ORs) of 1.7-2.3 for lung cancer (LC; P=4.0 × 10(-4)), chronic obstructive pulmonary disease (COPD; P=9.3 × 10(-4)), peripheral artery disease (PAD; P=0.090) and abdominal aortic aneurysms (AAAs; P=0.12), and the variant associates strongly with the early-onset forms of LC (OR=4.49, P=2.2 × 10(-4)), COPD (OR=3.22, P=2.9 × 10(-4)), PAD (OR=3.47, P=9.2 × 10(-3)) and AAA (OR=6.44, P=6.3 × 10(-3)). Joint analysis of the four smoking-related diseases reveals significant association (P=6.8 × 10(-5)), particularly for early-onset cases (P=2.1 × 10(-7)). Our results are in agreement with functional studies showing that the human α4β2 isoform of the channel containing R336C has less sensitivity for its agonists than the wild-type form following nicotine incubation.

Abstract PD09-10: DNA Damage and Repair in Mammary Gland Development

Numerous factors are linked to breast cancer risk including reproductive history, early exposure to radiation, age and genetic background. Events that occur during specific stages of mammary development are believed to alter the lifetime risk of breast cancer. Epidemiological studies over the past 3 decades have suggested an association between parity and decreased lifetime breast cancer risk. Studies have also shown that breast cancer risk is significantly higher in women who received radiotherapy to the chest as adolescents compared to those who received chest radiation as adults. These associations implicate development specific changes in mammary epithelium that affect the molecular mechanisms whereby cells respond to DNA damage and, importantly, are at subsequent cancer risk.

Because many of the genes linked to hereditary breast cancer are associated with DNA double-strand break (DSB) repair, we hypothesize that there are differences in overall DSB repair, homologous recombination (HR), and cell fate following damage in mammary epithelium at different stages of mammary gland development—puberty, pregnancy, lactation and post-involution. To assess these differences we are using mice containing the DR-GFP reporter targeted to chromosome 17 to study HR at chromosome breaks induced by the transient expression of I-SceI in mammary epithelial cells. DR-GFP is a widely used repair reporter in which direct repeats of two defective GFP genes are induced to recombine by I-SceI endonuclease cleavage of one of the repeats. We have observed that the efficiency of HR in primary mammary epithelial cells derived from 8-week old virgin mice is similar to that observed in other primary cells of somatic origin (approximately 0.65% of cells heterozygous for the DR-GFP reporter). Interestingly, the amount of HR is increased in mammary epithelium derived from pregnant mice compared to age-matched virgin controls (0.98 versus 0.65%). This 1.5 fold increase in HR suggests that in pregnancy, mammary epithelium is more proficient in the accurate repair of DNA DSBs. We are also assessing DNA damage signaling in different periods of mammary gland development. Preliminary analysis of histone H2AX phosphorylation following whole-body irradiation suggests more rapid kinetics of DNA damage signaling response in mammary tissue derived from pregnant as compared to age-matched virgin mice.

We have recently generated DR-GFP containing mice that express I-SceI from a randomly integrated I-SceI transgene under the control of a tetracycline-inducible promoter. We are currently using these mice to assess HR in an entirely in vivo system and are in the process of breeding this reporter line with mice carrying mutations in Brca1 or Brca2. This mouse model will be used to assess HR in vivo in the mammary tissue of these mice during different stages of mammary gland development.

This project will provide valuable insight into how developmental changes unique to mammary gland epithelium affect cellular responses to DNA damage. We hope to consider therapeutic manipulation of identified stage-specific differences to decrease breast cancer susceptibility.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD09-10.

Altered activity of the serratus anterior during unilateral arm elevation in patients with cervical disorders

Altered activity in the axioscapular muscles is considered to be an important feature in patients with neck pain. The activity of the serratus anterior (SA) and trapezius muscles during arm elevation has not been investigated in these patients. The objectives of this study was to investigate whether there is a pattern of altered activity in the SA and trapezius in patients with insidious onset neck pain (IONP) (n=22) and whiplash associated disorders (WAD) (n=27). An asymptomatic group was selected for baseline measurements (n=23). Surface electromyography was used to measure the onset of muscle activation and duration of muscle activity of the SA as well as the upper, middle, and lower trapezius during unilateral arm elevation in the three subject groups. Both arms were tested. With no interaction, the main effect for the onset of muscle activation and duration of muscle activity for serratus anterior was statistically significant among the groups. Post hoc comparison revealed a significantly delayed onset of muscle activation and less duration of muscle activity in the IONP group, and in the WAD group compared to the asymptomatic group. There were no group main effects or interaction effects for upper, middle and lower trapezius. This finding may have implications for scapular stability in these patients because the altered activity in the SA may reflect inconsistent or poorly coordinated muscle activation that may reduce the quality of neuromuscular performance and induce an increased load on the cervical and the thoracic spine.

Lentivirus gene transfer in murine hematopoietic progenitor cells is compromised by a delay in proviral integration and results in transduction mosaicism and heterogeneous gene expression in progeny cells

Human immunodeficiency virus type 1-based lentivirus vectors containing the green fluorescent protein (GFP) gene were used to transduce murine Lin(-) c-kit(+) Sca1(+) primitive hematopoietic progenitor cells. Following transduction, the cells were plated into hematopoietic progenitor cell assays in methylcellulose and the colonies were scored for GFP positivity. After incubation for 20 h, lentivirus vectors transduced 27.3% +/- 6.7% of the colonies derived from unstimulated target cells, but transduction was more efficient when the cells were supported with stem cell factor (SCF) alone (42. 0% +/- 5.5%) or SCF, interleukin-3 (IL-3), and IL-6 (53.3 +/- 1.8%) during transduction. The, vesicular stomatitis virus glycoprotein-pseudotyped MGIN oncoretrovirus control vector required IL-3, IL-6, and SCF for significant transduction (39.3 +/- 9.4%). Interestingly, only a portion of the progeny cells within the lentivirus-transduced methylcellulose colonies expressed GFP, in contrast to the homogeneous expression in oncoretrovirus-transduced colonies. Secondary plating of the primary GFP(+) lentivirus vector-transduced colonies revealed vector PCR(+) GFP(+) (42%), vector PCR(-) GFP(-) (46%), and vector PCR(+) GFP(-) (13%) secondary colonies, indicating true genetic mosaicism with respect to the viral genome in the progeny cells. The degree of vector mosaicism in individual colonies could be reduced by extending the culture time after transduction and before plating into the clonal progenitor cell assay, indicating a delay in the lentiviral integration process. Furthermore, supplementation with exogenous deoxynucleoside triphosphates during transduction decreased mosaicism within the colonies. Although cytokine stimulation during transduction correlates with higher transduction efficiency, rapid cell division after transduction may result in loss of the viral genome in the progeny cells. Therefore, optimal transduction may require activation without promoting intense cell proliferation prior to vector integration.

[Views of Icelandic physicians and nurses towards limitation of treatment at the end of life.]

With increasingly advanced life-prolonging technology, the issue of when and how treatment should be limited becomes ever more important. To shed a light on the views of Icelandic physicians and registered nurses a survey was conducted at the Reykjavik Hospital and the National University Hospital. A questionnaire was sent to 184 doctors and 239 nurses. They were asked to respond to several ethical dilemmas regarding limitation of treatment at the end of life. Special emphasis was placed on respect for the patient's autonomy and communication. There were 234 (55%) answers retrieved. The general view was that one should respect patient's autonomy and honor the wish to deny life-prolonging measures. Cost could be an issue in such decisions according to 35% of physicians and 15% of nurses. Under certain conditions, euthanasia could be justified according to five (5%) physicians and 11 (9%) nurses, although only four (2%) could consider themselves as participating in such an act. The majority, 201/230 (87%), supported using written guidelines within hospitals regarding decision-making process in limiting treatment at the end of life. In a case of a dispute between patients or families and health care professionals, 49% of physicians and 84% of nurses were willing to take it to a multidisciplinary ethical committee at the hospital. In a case of a dispute between health care professionals 62% of physicians and 50% of nurses were willing to take it to the Director General of Health.