Intratumoral T-cell receptor repertoire composition predicts overall survival in patients with pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy that is refractory to immune checkpoint inhibitor therapy. However, intratumoral T-cell infiltration correlates with improved overall survival (OS). Herein, we characterized the diversity and antigen specificity of the PDAC T-cell receptor (TCR) repertoire to identify novel immune-relevant biomarkers. Demographic, clinical, and TCR-beta sequencing data were collated from 353 patients across three cohorts that underwent surgical resection for PDAC. TCR diversity was calculated using Shannon Wiener index, Inverse Simpson index, and "True entropy." Patients were clustered by shared repertoire specificity. TCRs predictive of OS were identified and their associated transcriptional states were characterized by single-cell RNAseq. In multivariate Cox regression models controlling for relevant covariates, high intratumoral TCR diversity predicted OS across multiple cohorts. Conversely, in peripheral blood, high abundance of T-cells, but not high diversity, predicted OS. Clustering patients based on TCR specificity revealed a subset of TCRs that predicts OS. Interestingly, these TCR sequences were more likely to encode CD8+ effector memory and CD4+ T-regulatory (Tregs) T-cells, all with the capacity to recognize beta islet-derived autoantigens. As opposed to T-cell abundance, intratumoral TCR diversity was predictive of OS in multiple PDAC cohorts, and a subset of TCRs enriched in high-diversity patients independently correlated with OS. These findings emphasize the importance of evaluating peripheral and intratumoral TCR repertoires as distinct and relevant biomarkers in PDAC.

A graph theoretic approach to neurodegeneration: five data-driven neuropsychological subtypes in mild cognitive impairment

Mild cognitive Impairment (MCI) is notoriously heterogenous in terms of clinical presentation, neuroimaging correlates, and subsequent progression. Predicting who will progress to dementia, which type of dementia, and over what timeframe is challenging. Previous work has attempted to identify MCI subtypes using neuropsychological measures in an effort to address this challenge; however, there is no consensus on approach, which may account for some of the variability. Using a hierarchical community detection approach, we examined cognitive subtypes within an MCI sample (from the Alzheimer's Disease Neuroimaging Initiative [ADNI] study). We then examined whether these subtypes were related to biomarkers (e.g., cortical volumes, fluorodeoxyglucose (FDG)-positron emission tomography (PET) hypometabolism) or clinical progression. We identified five communities (i.e., cognitive subtypes) within the MCI sample: 1) predominantly memory impairment, 2) predominantly language impairment, 3) cognitively normal, 4) multidomain, with notable executive dysfunction, 5) multidomain, with notable processing speed impairment. Community membership was significantly associated with 1) cortical volume in the hippocampus, entorhinal cortex, and fusiform cortex; 2) FDG PET hypometabolism in the posterior cingulate, angular gyrus, and inferior/middle temporal gyrus; and 3) conversion to dementia at follow up. Overall, community detection as an approach appears a viable method for identifying unique cognitive subtypes in a neurodegenerative sample that were linked to several meaningful biomarkers and modestly with progression at one year follow up.

Memory-like Differentiation Enhances NK Cell Responses to Melanoma

PURPOSE

Treatment of advanced melanoma is a clinical challenge. Natural killer (NK) cells are a promising cellular therapy for T cell-refractory cancers, but are frequently deficient or dysfunctional in patients with melanoma. Thus, new strategies are needed to enhance NK-cell antitumor responses. Cytokine-induced memory-like (ML) differentiation overcomes many barriers in the NK-cell therapeutics field, resulting in potent cytotoxicity and enhanced cytokine production against blood cancer targets. However, the preclinical activity of ML NK against solid tumors remains largely undefined.

EXPERIMENTAL DESIGN

Phenotypic and functional alterations of blood and advanced melanoma infiltrating NK cells were evaluated using mass cytometry. ML NK cells from healthy donors (HD) and patients with advanced melanoma were evaluated for their ability to produce IFNγ and kill melanoma targets in vitro and in vivo using a xenograft model.

RESULTS

NK cells in advanced melanoma exhibited a decreased cytotoxic potential compared with blood NK cells. ML NK cells differentiated from HD and patients with advanced melanoma displayed enhanced IFNγ production and cytotoxicity against melanoma targets. This included ML differentiation enhancing melanoma patients' NK-cell responses against autologous targets. The ML NK-cell response against melanoma was partially dependent on the NKG2D- and NKp46-activating receptors. Furthermore, in xenograft NSG mouse models, human ML NK cells demonstrated superior control of melanoma, compared with conventional NK cells.

CONCLUSIONS

Blood NK cells from allogeneic HD or patients with advanced melanoma can be differentiated into ML NK cells for use as a novel immunotherapeutic treatment for advanced melanoma, which warrants testing in early-phase clinical trials.

Abstract OT1-01-05: Endocrine treatment alone as primary treatment for elderly patients with estrogen receptor positive good prognosis operable breast cancer: A single arm phase II, single institution study

Background: It is estimated that approximately 46,000 women age >75 are diagnosed annually with breast cancer. Due to competing co-morbidities, there is wide variation in treatment recommendations which can lead to over- or under-treatment. Though surgery for breast cancer is considered low-morbidity, many elderly women given a choice, choose not to have surgery. Previous randomized trials comparing surgery with tamoxifen versus endocrine therapy alone in women age >70 unselected for ER status demonstrated similar overall survival with poorer local control in the latter group. A new standard of care needs to be defined for elderly women with good prognosis ER+ tumors, since these women may benefit from endocrine therapy alone to treat their cancer without compromising local and distant control.

Hypothesis: We hypothesize that endocrine therapy alone provides adequate local and systemic control of breast cancer in a subpopulation of women age 70 or older with ER+ breast cancer and good prognostic characteristics.

Primary Objective

To correlate response to neoadjuvant endocrine treatment at 6 months with Oncotype DX Recurrence Score (RS) in women with early-stage ER+ breast cancer who are age >70.

Secondary Objective

1. To determine the breast cancer-specific survival of women with early-stage ER+ breast cancer, age >70, treated with endocrine therapy alone.

2. To determine the rate of overall survival of women with early-stage ER+ breast cancer, age >70 treated with endocrine therapy alone.

Study Design: This is a prospective single arm phase II study. Patients with clinical stage I/II ER+ breast cancer, grade 1-2, Ki67<30 or RS <18 (performed on the diagnostic core biopsy) continue to be enrolled and followed for time to progression. A Kaplan-Meier model will be used to estimate the 5-year local progression rate. If the true 5-year progression rate is 10%, then 50 patients will provide power = .90 at a one-sided .05 significance level to demonstrate that the rate is less than 25.5%. Exploratory objectives include: evaluation of the molecular characteristics of breast cancers of responders versus non-responders, determine compliance with medications, evaluate cost-effectiveness, and quality of life.

Results: Between February 2017 and April 2018, 11 patients were enrolled into the study. Two patients could not tolerate endocrine therapy and received standard of care treatment. For the 9 patients on study, average tumor size was 1.7cm, average Ki67 was 15%, average RS was 14. All of the patients received an aromatase inhibitor. At 6 months, 71% of the patients had a partial response, 28% had stable disease. None of the patients developed progressive disease.

Conclusion: A new standard of care needs to be defined for women age >70 with good prognosis ER+ tumors, since these women may benefit from endocrine therapy alone to treat their cancer without compromising local and distant control. We continue to enroll patients to determine the optimal tumor markers for identifying women who can be treated with PET only to control their cancer.

Citation Format: Aft R, Cherian M, Frith A, Suresh R, Glover-Collins K, Naughton M, Moon C, Conant L, Ma C. Endocrine treatment alone as primary treatment for elderly patients with estrogen receptor positive good prognosis operable breast cancer: A single arm phase II, single institution study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-01-05.

A Rapid and Cost-Effective Device for Testing Minimal Erythema Dose

INTRODUCTION

We describe a novel device for rapid and economical minimal erythema dose testing in patients undergoing ultraviolet (UV) light phototherapy for treatment of skin diseases.

METHODS

A minimal erythema testing device was designed and created using transparent plastic sheeting and printed patterns with increasing ink density, allowing for graded UV transmission of 100%, 80%, 60%, 40%, 20%, and 10% energy through six 10-mm square apertures. The plastic sheet was placed in a UV-impenetrable and Velcro-fitted adjustable sleeve, designed to fit easily onto a patient's arm. A pilot validation study was performed, comparing this device with a commercially available windowed device in which the dose is controlled by varying the UV exposure time through sequential opening of each window. The pilot was conducted on healthy skin of two human subjects with different Fitzpatrick skin types.

RESULTS

In our subjects, tested with one device on each forearm, the minimal erythema dose (MED), judged visually, was identical. However, the test device allowed MED testing in 3 min compared with 15 min for the traditional device. The test device is equally effective for use with ultraviolet-A (UVA), narrowband ultraviolet-B (NB-UVB) and broadband ultraviolet-B (BB-UVB) wavelengths. The test device is economical, with manufacturing cost of less than US $2.

CONCLUSION

We designed an MED testing device that is quick, accurate, cost-effective, and easy to use in the setting of a busy phototherapy practice. This device therefore has many advantages over existing MED testing approaches.

Nipple-sparing mastectomies: Clinical outcomes from a single academic institution

Nipple-sparing mastectomies (NSMs) are increasingly used in the surgical treatment of patients with breast cancer and for prevention of breast cancer. The present study was performed to review the outcomes of patients undergoing NSMs at a single large university setting. A retrospective chart review was performed on all patients undergoing NSMs from 2008-2014. Charts were reviewed for demographic data and patient characteristics. Tumor and breast size, cancer recurrence and complications were also evaluated. Descriptive statistics were utilized to summarize the findings. From 2008-2014, 110 patients underwent 197 NSMs. The mean patient age was 44.4 years (range, 20-77). The average body mass index was 24 (range, 18-47). Breast weight was available for 106 specimens, with a mean weight of 475.5 g (range, 124.1-1,625.0 g). Seventy-three NSMs were performed for cancer and 124 were performed prophylactically. The mean tumor width was 1.38 cm (range, 0-6.0 cm), with an average nipple to tumor distance of 5.87 cm (range, 2.93-10.0 cm). Three (4%) patients required removal of the nipple areolar complex (NAC) due to pathological extension of the tumor. A total of 34 (17.2%) complications occurred, including infections, hematomas and nipple necrosis, with 9 requiring removal of the NAC and 13 requiring removal of the tissue expander or implant. Smokers had a 36.0% (9/25) complication rate, compared with 14.5% (25/172) of nonsmokers (P<0.05). During follow-up, one recurrence was noted, located on the chest wall. There were no recurrences in the NAC group. Therefore, NSMs may safely be performed without compromising oncologic outcomes or increasing complication rates in properly selected patients.

Predictive factors and patterns of recurrence in patients with triple negative breast cancer

BACKGROUND

We investigated the outcomes of patients with triple negative breast cancer ([TNBC] = estrogen receptor negative, progesterone receptor negative, and HER2 nonamplified).

METHODS

We identified 414 patients with stage I-III TNBC treated between 1999 and 2008. Data included patient/tumor characteristics, surgical, systemic, and radiation treatment received, and breast cancer-specific survival. Data were compared using Chi square, Fisher exact test, and logistic regression. A p value <.05 was considered significant.

RESULTS

The cohort included 414 patients (mean age 53.8 ± 12.5 years) with a mean follow-up of 68.2 ± 36.4 months. Of 414 patients, 304 (73.4 %) had no evidence of recurrence, while 110 (26.6 %) had recurrent disease, including 19 (17.3 %) with isolated locoregional recurrence, 70 (63.6 %) with isolated distant recurrence, and 21 (19.1 %) with both. Of 91 patients with distant recurrences, lung was most common (n = 38), followed by brain (n = 32), bone (n = 31), and liver (n = 29). Factors significantly associated with recurrence included increasing tumor size, positive nodal status, increasing stage, and type of chemotherapy (adjuvant vs neoadjuvant). After controlling for all potential confounders in multivariate stepwise regression, these same factors were also found to be independent predictors of recurrence. In the survival analysis, these same factors, in addition to receipt of radiation were found to be predictive of survival.

CONCLUSIONS

Approximately 25 % of patients with TNBC experienced a locoregional and/or distant recurrence, resulting in greater than 75 % breast cancer-specific mortality for those who experienced a distant recurrence. The lack of targeted therapy for this aggressive breast cancer subtype likely contributed to this finding.

A council of elders: creating a multi-voiced dialogue in a community of care

In an era of 'medical care delivery systems', there is an increasing need for the patient's voice to be heard, for it to be invited, listened to, and taken seriously. This challenge is particularly evident in geriatrics education, a domain of clinical training in which educators and clinicians alike must struggle to overcome adverse attitudes towards the elderly ('ageism'). In this paper we introduce a 'Council of Elders' as an educational innovation in which we invited community elders to function as our 'Senior Faculty', to whom medical residents present their challenging and heartfelt dilemmas in caring for elder patients. In the conversations that ensue, the elders come to function not simply as teachers, but collaborators in a process in which doctors, researchers, and elders together create a community of resources, capable of identifying novel ways to overcome health-related difficulties which might not have been apparent to either group separately. Using the first meeting of the Council as an exemplar, we describe and discuss the special nature of such meetings and also the special preparations required to build a dialogic relationship between participants from very different worlds--different generations, different cultures (including the professional culture and the world of lived experience). Meetings with the council have become a required part of the primary care residency program--a very different kind of 'challenging case conference' in which moral dilemmas can be presented, discussed and reflected upon. It is not so much that elders give good advice in their responses--although they often do--as that they provide life world and value orientation as young residents gain a better sense of the elder's experience and what matters most to them. This project has been particularly worthwhile in addressing the problem of ageism--a way to render visible stereotypes and adverse physician values, with implications for decision-making with the patient, not for the patient.

The role of hospice philosophy of care in nonhospice settings

Many advances in public health and medical technology have contributed to the improved wellbeing and overall longevity of Americans. Such benefits, however, have been offset by a change in the nature and prolongation of the dying process. Daniel Callahan offers a challenge to caregivers in his observation of violent death by technological attenuation, and he sets an agenda to identify a more appropriate approach to the needs of the dying.

Over the past quarter century, hospice has increasingly been used as a resource for care at the end of life. However, according to 1995 estimates by the National Hospice Organization (NHO), hospice care presently accounts for only about 15 percent of the care of terminally ill patients in the United States. We will review issues of access and use of hospice services and examine the various institutional, professional, societal, and cultural barriers to hospice principles of care, and consider various options to promote optimal care at the end of life.

Using proxies to evaluate quality of life. Can they provide valid information about patients' health status and satisfaction with medical care?

Instruments using interview data to measure health status have been increasingly used to measure patient outcomes. To assess the potential utility of proxy responses about health status when subjects are unable to respond, the authors compared the responses of 60 subject and proxy pairs on instruments measuring overall current health, functional status, social activity, emotional health, and satisfaction with medical care. Proxies were asked to respond as they thought the subject would. Subject and proxy responses were strongly correlated with each other for overall health, functional status, social activity, and emotional health (P less than .001), and moderately correlated for satisfaction (P less than .005). Proxies reported lower emotional health and satisfaction than did subjects (P less than .005). Proxy and subject mean responses were generally similar for overall health, functional status, and social activity. However, those proxies who spent more time per week helping the subject rated the subject's functional status and social activity as more impaired than did the subject (P less than .05). Subjects who had poorer overall health tended to rate their health relatively lower than did the proxies (P less than .05). These results suggest that use of proxies intermingled with subjects to measure health status through interview may lead to biased results.

Indicators of recovery from fractures of the hip

Patients with similar injuries who were at a similar level of function before the injury differ in the extent of recovery. In an attempt to identify important factors that affect recovery, we collected extensive physical, psychological and sociological data on a group of 108 elderly people with fractures of the hip in order to study the influence of the many variables on their recovery. We found that of all the items studied, those that best indicated the degree of recovery were: (1) the physical therapist's rating of functional ability; (2) how often the patient got outside the home prior to injury; (3) the patient's mental clarity.