The ATR inhibitor ceralasertib potentiates cancer checkpoint immunotherapy by regulating the tumor microenvironment

The Ataxia telangiectasia and Rad3-related (ATR) inhibitor ceralasertib in combination with the PD-L1 antibody durvalumab demonstrated encouraging clinical benefit in melanoma and lung cancer patients who progressed on immunotherapy. Here we show that modelling of intermittent ceralasertib treatment in mouse tumor models reveals CD8+ T-cell dependent antitumor activity, which is separate from the effects on tumor cells. Ceralasertib suppresses proliferating CD8+ T-cells on treatment which is rapidly reversed off-treatment. Ceralasertib causes up-regulation of type I interferon (IFNI) pathway in cancer patients and in tumor-bearing mice. IFNI is experimentally found to be a major mediator of antitumor activity of ceralasertib in combination with PD-L1 antibody. Improvement of T-cell function after ceralasertib treatment is linked to changes in myeloid cells in the tumor microenvironment. IFNI also promotes anti-proliferative effects of ceralasertib on tumor cells. Here, we report that broad immunomodulatory changes following intermittent ATR inhibition underpins the clinical therapeutic benefit and indicates its wider impact on antitumor immunity.

Neoadjuvant Durvalumab Alone or Combined with Novel Immuno-Oncology Agents in Resectable Lung Cancer: The Phase II NeoCOAST Platform Trial

Neoadjuvant chemoimmunotherapy improves pathologic complete response rate and event-free survival in patients with resectable non-small cell lung cancer (NSCLC) versus chemotherapy alone. NeoCOAST was the first randomized, multidrug platform trial to examine novel neoadjuvant immuno-oncology combinations for patients with resectable NSCLC, using major pathologic response (MPR) rate as the primary endpoint. Eighty-three patients received a single cycle of treatment: 26 received durvalumab (anti-PD-L1) monotherapy, 21 received durvalumab plus oleclumab (anti-CD73), 20 received durvalumab plus monalizumab (anti-NKG2A), and 16 received durvalumab plus danvatirsen (anti-STAT3 antisense oligonucleotide). MPR rates were higher for patients in the combination arms versus durvalumab alone. Safety profiles for the combinations were similar to those of durvalumab alone. Multiplatform immune profiling suggested that improved MPR rates in the durvalumab plus oleclumab and durvalumab plus monalizumab arms were associated with enhanced effector immune infiltration of tumors, interferon responses and markers of tertiary lymphoid structure formation, and systemic functional immune cell activation.

SIGNIFICANCE

A neoadjuvant platform trial can rapidly generate clinical and translational data using candidate surrogate endpoints like MPR. In NeoCOAST, patients with resectable NSCLC had improved MPR rates after durvalumab plus oleclumab or monalizumab versus durvalumab alone and tumoral transcriptomic signatures indicative of augmented immune cell activation and function. See related commentary by Cooper and Yu, p. 2306. This article is featured in Selected Articles from This Issue, p. 2293.

Abstract 1235: Presence of TLS and combined high densities of PD-L1+ macrophages & CD8+ T cells predict long-term overall survival for patients with advanced NSCLC treated with durvalumab

Introduction: Predictive biomarkers of anti‒PD-(L)1 therapies have largely focused on the tumor - T cell axis where tumor cell PD-L1 expression has demonstrated its clinical utility in predicting overall survival (OS) in patients with advanced non-small cell lung cancer (NSCLC). Although, other immune cell subsets were shown to be associated with clinical efficacy, their relative impact and combined effect in predicting improved long-term survival warrant further investigation. Using computational image analysis of multiplex immunofluorescence (mIF) and immunohistochemistry (IHC) immune marker panels, we sought to identify single and combined biomarkers of the tumor immune contexture in association with long-term OS in advanced NSCLC patients treated with Durvalumab.

Methods: Pre-treatment tumor samples from advanced NSCLC patients (n = 210) enrolled in durvalumab nonrandomized phase 1/2 trial (10 mg/kg Q2W, CP1108/NCT01693562), were stained using IHC and 6-marker mIF panels to detect markers of immune cells, cell functional state and tertiary lymphoid structure (TLS) (PD-L1, CD8, PD-1, Ki67, CD68, CD20, CD1c, NKp46, CD66b, ICOS, FOXP3). Cell marker density (cells/mm2), distribution and proximity were quantified and analyzed in association with overall survival.

Results: Computational image analysis of the tumor immune contexture revealed a greater immune inflamed phenotype, both innate (macrophages, dendritic cells) and adaptive (T and B cells), in NSCLC patients with long OS >2 years compared to those with short OS < 1 year (fold change > 2, p < 0.0001). Patient subgroup with high density of individual immune subsets show a median OS (mOS) of 10-20 months (p < 0.01 high vs. low subgroups) while combined markers of innate and adaptive immune cells show an improved mOS > 2 years (p < 0.001). Specifically, among the key findings, combined biomarkers of CD68+ PD-L1+ macrophages and CD8+ T cells predicts for a significant increase in OS for patients with high vs low marker density (HR = 0.21, 95%CI 0.12 - 0.39, p <10-7; mOS 39.5 months [high], 6.5 months [low]). Whereas, in patients with high density of either single biomarkers CD68+ PD-L1+ macrophage or CD8+ T cells mOS is 20.2 or 18.4 months respectively. Moreover, high density of CD20+ B cells, reflective of presence of TLS, associates with improved OS (mOS NR [high], 11 months [low], p = 0.003). In addition, TLS enriched tumors show an increased level of macrophages expressing PD-L1 in synapsis with CD8+ T cells (activated PD1+ or proliferative Ki67+ T cells).

Conclusion: These findings demonstrate the importance of both tertiary lymphoid structure and high pre-existing innate-adaptive immunity in driving long-term overall survival of durvalumab-treated patients with NSCLC and highlight the need for the development of multiparametric predictive biomarkers beyond tumor-T cell axis.

Citation Format: Lina Meinecke, Jorge Blando, Thomas Herz, Michael Surace, Thomas Padel, Monica Azqueta Gavaldon, Harald Hessel, Farzad Sekhavati, Megha Saraiya, Anmarie Boutrin, Karma Da Costa, Jaime Rodriguez Canales, Ashok Gupta, Carl Barrett, Zachary Aaron Cooper, Ikbel Achour. Presence of TLS and combined high densities of PD-L1+ macrophages & CD8+ T cells predict long-term overall survival for patients with advanced NSCLC treated with durvalumab [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1235.

Abstract 1711: A multi-modal analysis approach leveraging multiplexed spatial phenotyping and multi-omics analysis to better understand the prognostic value of tertiary lymphoid structures in non-small cell lung cancer

Introduction: Tertiary Lymphoid Structures (TLS) are highly organized ectopic lymphoid structures found in inflamed or tumor tissues, acting as sites of lymphoid recruitment and immune activation. A high TLS density within the tumor is commonly associated with an increased prognostic effect of TILs and with an improved disease free survival and overall survival for patients. However, the existence of conflicting studies suggest that multiple TLS features should be taken into account when assessing their prognostic value, such as their location, cellular composition, maturation stage and spatial organisation, as those may affect their functionalities.

Methods: With the aim of gaining insights into TLS biology and evaluating the prognostic role of TLS in Non-Small Cell Lung Carcinoma (NSCLC) according to their multiple features, we developed a TLS multiplex immunofluorescent (mIF) panel that includes T cell (CD3, CD8), B cell (CD20), Follicular Dendritic cell (CD21, CD23) and mature dendritic cell (DC-LAMP) markers. We deployed this panel across a cohort of primary tumors from NSCLC patients (n=408) and established a mIF image analysis workstream to assess the status and spatial location of each cell within the tissue. A H&E staining of the same tissue section was performed to evaluate mIF spatial data in relation to the tumor context. Additional multi-omics assessments were conducted across the same cohort including; whole exome sequencing, NanoString transcriptomics, and immunohistochemistry (e.g. PD-L1, FOXP3). We have leveraged clinical metadata, including demographics (e.g. age, sex, smoking status) and clinical risk factors (e.g. stage, grade, Standard of Care treatment) with clinical follow up (e.g. OS, PFS) for prevalence analysis, novel biomarker identification, and survival association.

Results: Assessment of the prevalence of each cell phenotype within the tumor tissue and TLS (tumor centre vs invasive margin; tumor epithelium vs stroma), the distance between each cell type, and the distance of non-TLS immune cells to the closest TLS will be described, demonstrating the different types of lymphoid aggregates and TLS and their functional status. An integrative analysis combining these spatial biology data with multi-omics and clinical data will be presented evaluating the prognostic value of TLS composition, maturation status and spatial organization, in correlation with additional biomarkers and clinical characteristics.

Conclusion: This exploratory study using cutting-edge technologies enables us to better understand how TLS orchestrate an organised anti-tumour response, defining TLS spatial biomarker signatures, TLS gene signatures, and TLS features associated with NSCLC patient outcomes to evaluate in the clinic.

Citation Format: Julie Berthe, Felix Segerer, Emily C. Jennings, Alma Andoni, Marco Testori, Megha Saraiya, Miljenka Vuko, Harald Hessel, Andreas Spitzmüller, Mari Heininen-Brown, Jorge Blando, Felicia Ng, Emma Jones, Sophie Willis, Michael Surace, Rieneke van de Ven, Tanja De Gruijl, Helen Angell. A multi-modal analysis approach leveraging multiplexed spatial phenotyping and multi-omics analysis to better understand the prognostic value of tertiary lymphoid structures in non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1711.

39 A multi-modal analysis approach leveraging multiplexed spatial phenotyping and multi-omics analysis to better understand the prognostic value of tertiary lymphoid structures in NSCLC

Background

Tertiary Lymphoid Structures (TLS) are highly organized ectopic lymphoid structures found in inflamed or tumor tissues, acting as sites of lymphoid recruitment and immune activation. A high TLS density within the tumor is commonly associated with an increased prognostic effect of TILs and with an improved disease free survival and overall survival for patients.1 However, the existence of conflicting studies suggest that multiple TLS features should be taken into account when assessing their prognostic value, such as their location, cellular composition, maturation stage and spatial organisation, as those may affect their functionalities.2

Methods

With the aim of gaining insights into TLS biology and evaluating the prognostic role of TLS in Non-Small Cell Lung Carcinoma according to their multiple features, we developed a TLS multiplex immunofluorescent (mIF) panel that includes T cells (CD3, CD8), B cells (CD20), Follicular Dendritic cells (CD21, CD23) and mature dendritic cells (DC-LAMP) markers. We deployed this panel across a cohort of primary tumors from NSCLC patients (n=408) and established a mIF image analysis workstream to assess the status and spatial location of each cell within the tissue. A H&E staining of the same tissue section was performed to evaluate mIF spatial data in relation to the tumor context. Additional multi-omics assessments were conducted across the same cohort including; whole exome sequencing, NanoString transcriptomics, and immunohistochemistry (e.g. PD-L1, FOXP3, NKp46, LKB1, CTLA4). We have leveraged clinical metadata, including demographics (e.g. age, sex, smoking status) and clinical risk factors (e.g. stage, grade, Standard of Care treatment) with clinical follow up (e.g. OS, PFS) for prevalence analysis, novel biomarker identification, and survival association.

Results

Assessment of the prevalence of each cell phenotype within the tumor tissue and TLS, the cell-cell interactions, the distance between each cell type, and the distance of non-TLS immune cells to the closest TLS will be described, demonstrating the different types of lymphoid aggregates and TLS and their functional status. An integrative analysis combining spatial biology data with multi-omics and clinical data will be presented evaluating the prognostic value of TLS composition, maturation status and spatial organization, in correlation with additional biomarkers and clinical characteristics.

Conclusions

This exploratory study using cutting-edge technologies enables us to better understand how TLS orchestrate an organised anti-tumour response, defining TLS spatial biomarker signatures, TLS gene signatures, and TLS features associated with patient outcomes to evaluate in the clinic.

References

Marie-Caroline Dieu-Nosjean, Jérémy Goc, Nicolas A Giraldo, Catherine Sautès-Fridman, Wolf Herman Fridman. Tertiary lymphoid structures in cancer and beyond. Trends Immunol 2014;35(11):571–580.

Catherine Sautès-Fridman, Florent Petitprez, Julien Calderaro, Wolf Herman Fridman. Tertiary lymphoid structures in the era of cancer immunotherapy. Nat Rev Cancer 2019;19(6):307–325.

Ethics Approval

The study was approved by AstraZeneca.

822 GraphITE: unsupervised graph embeddings approach to multiplex immunofluorescence image exploration reveals new insights into NSCLC and HNSCC tumor microenvironment

Background

Predictive biomarkers for response to IO therapies remain insufficient. Although multiplex immunofluorescence has the potential to provide superior biomarkers, the information garnered from these studies is frequently underleveraged. Due to the large number of markers that must be analyzed (6 - 40 +), and the complexity of the spatial information, the number of hypotheses is large and must be tested systematically and automatically. GraphITE (Graphs-based Investigation of Tissues with Embeddings) is a novel method of converting multiplex IF image analysis results into embeddings, numerical vectors which represent the phenotype of each cell as well as the immediate neighborhood. This allows for the clustering of embeddings based on similarity as well as the discovery of novel predictive biomarkers based on both the spatial and multimarker data in multiplex IF images. Here we demonstrate initial observations from deployment of GraphITE on 564 commercially-sourced NSCLC and HNSCC resections stained with a multiplex IF panel containing CD8, PDL1, PD1, CD68, Ki67, and CK.

Methods

4 μm FFPE tumor sections were stained with CD8, PDL1, PD1, CD68, Ki67, and CK at Akoya Biosciences using OPAL TSA-linked fluorophores and imaged on a Vectra Polaris. Images were analyzed by Computational Biology (AstraZeneca). Graphs were built by mapping each cell in the mIF image as a node, using the X, Y coordinates and connecting nodes with edges according to distance. 64-dimensional embeddings were generated using Deep Graph InfoMax (DGI).1 Embeddings are downprojected to 2 dimensions using UMAP.2. Details are available in the preprint of the GraphITE methods manuscript.3

Results

A single downprojection was developed using embeddings from 158 HNSCC and 406 NSCLC cases. 60–80 distinct clusters were observed, some of which contained embeddings from both indications and others which were exclusive to one indication. Exclusive clusters describe tissue neighborhoods observed only in one indication. Drivers of cluster exclusivity included increased cell density in HNSCC as compared to NSCLC both in PD-L1- tumor centers with few infiltrating lymphocytes as well as in PD-L1- macrophagedominated neighborhoods. HNSCC and NSCLC embeddings were more colocalized in PD-L1+ tumor centers and in tumor stroma with high CD8+ or CD68+ immune cell content and high PD-L1+ expression.

Conclusions

This study demonstrates the utility and potential of the GraphITE platform to discriminate between and describe both unique and common neighborhood-level features of the tumor microenvironment. Deploying GraphITE across multiple indications effectively leverages spatial heterogeneity and multimarker information from multiplex IF panels.

References

1. Veličković P, Fedus W, Hamilton WL, Liò P, Bengio Y, DevonHjelm R. Deep Graph Infomax. 2018. arxiv:1809.10341 [stat.ML].

2. McInnes L, Healy J, Melville J. UMAP: Uniform manifold approximationand projection for dimension reduction. 2020; arxiv:1802.03426 [stat.ML].

3. Innocenti C, Zhang Z, Selvaraj B, Gaffney I, Frangos M, Cohen-Setton J, Dillon LAL, Surace MJ, Pedrinaci C, Hipp J, Baykaner K. An unsupervised graph embeddings approach to multiplex immunofluorescence image explorationbioRxiv 2021.06.09.447654; doi: https://doi.org/10.1101/2021.06.09.447654

Ethics Approval

The study was approved by AstraZeneca.

Abstract PR-05: Leveraging graphs to do novel hypothesis and data-driven research using multiplex immunofluorescence images

Characterization of the location and phenotype of cells in the tumor microenvironment (TME) is important to inform the development and monitoring of anti-cancer therapeutic interventions, especially immunotherapies designed to stimulate the immune system to have an anti-cancer effect. Multiplex immunofluorescence (mIF) imaging is being increasingly employed to simultaneously label multiple cell types and subtypes in the tumor microenvironment, but interpretation of these images to gain a robust understanding of tumor and immune cell interactions remains a complicated and challenging process. The rich phenotypic information contained in mIF images has to be taken into account with the spatial topology of the cells in order to be able to distil potential predictive indicators of patient response to therapies as well as prognostic indicators of outcome. While contemporary computational methods allow pathologists to view aggregated phenotypical information and cell interactions on a limited, generally one-to-one basis, these methods have been largely descriptive and geared toward addressing hypotheses as opposed to holistically leveraging the spatial and phenotypic data into a single predictive model. Additional methods are needed to provide a fuller picture of the spatial structure of the TME as captured in mIF images. In this work, we propose a novel pipeline that uses graphs generated from image analysis results and user-defined distance criteria to represent the tumor cellular microstructure. This graph-based approach complements existing mIF analysis techniques by providing information on the spatial, phenotypic, and morphological features of cells in the context of their neighborhood. These graphs subsequently enable characterization of protein expression in detail, description of interactions between individual cells or cell types and their neighbors, interactive tissue querying, and exploration of the cell-level biodiversity. The graph approach not only allows pathologists to efficiently interrogate data contained in mIF images in a hypothesis-driven manner, but importantly also supports more holistic data-driven approaches which, by leveraging state of the art graph convolutional neural networks to obtain numerical embeddings representing each graph and its nodes, enable additional downstream activities such as cell similarity search, and the development of predictive models for patient outcomes and response to therapies.

Citation Format: Jason Hipp, Christopher Innocenti, Zhenning Zhang, Jake Cohen-Setton, Balaji Selvaraj, Michalis Frangos, Carlos Pedrinaci, Michael Surace, Laura Dillon, Khan Baykaner. Leveraging graphs to do novel hypothesis and data-driven research using multiplex immunofluorescence images [abstract]. In: Proceedings of the AACR Virtual Special Conference on Artificial Intelligence, Diagnosis, and Imaging; 2021 Jan 13-14. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(5_Suppl):Abstract nr PR-05.

Characterization of the immune microenvironment of NSCLC by multispectral analysis of multiplex immunofluorescence images

Multiplex immunofluorescence (MIF) staining of tumor sections combined with computational pathology quantifies phenotypic variants of tumor and immune cells and assesses their spatial relationships. Here, we discuss a MIF panel composed of cytokeratin, PD-L1, PD1, CD8, CD68, and Ki67 applied to non-small cell lung cancer (NSCLC) to demonstrate key components of the immune response to this cancer. We also describe a method of whole-slide multiplex imaging and digital multispectral image analysis. Key aspects of marker labeling and digital tissue and cellular classification are highlighted. We then illustrate how digital analysis can measure the spatial relationships among important cell types. This approach is presented in the context of a multidisciplinary team of scientists who together can optimize the combined methods to increase the impact of the study findings. Recommendations are provided to assist others to apply similar methods to further understand the immune response to NSCLC.

Abstract 491: Tumor heterogeneity and its impact on immunoprofiling data: Whole tumor vs regions of interest (ROI) analysis of multiplex immunofluorescence in four carcinoma types

Background: Multiplex immunofluorescence (mIF) is a key tool for cancer immunoprofiling in tissue samples. These techniques typically require an investigator to select regions of interest (ROI) within the tumor for digital image analysis. However, tumor heterogeneity and sampling bias may result in data that may not be representative of the whole tumor. Our goal was to compare immunoprofiling data from ROI analysis versus whole tumor in lung, colorectal, and bladder carcinomas using mIF and multispectral image analysis.

Methods: 9 lung adenocarcinomas, 11 lung squamous cell carcinomas, 10 colorectal adenocarcinomas (CRC), and 10 bladder urothelial carcinomas (BC) were stained with a 6-marker mIF panel (PDL1, CD8, Ki67, CD68, AE1/AE3, PD1) using the Opal technique, and imaged using a Polaris multispectral scanner. Two pathologists independently selected 5 ROI (0.64 mm2) within the tumor for each case. To address the possibility of human sampling bias, 2 additional sets of 5 ROI were randomly generated in the tumor by a computer. HALO software was used to analyze the ROIs and the whole tumor area. The data was compared using Spearman’s ranked correlation coefficients.

Results: 6 cell populations were assessed in the tumor epithelium and stroma: cytotoxic T-lymphocytes (CTL, CD8+), antigen-experienced CTL (CD8+/PD1+), proliferating CTL (CD8+/Ki67+), macrophages (CD68+), PDL1+ tumor cells (AE1AE3+/PDL1+), and proliferating tumor cells (AE1AE3+/Ki67+). These immunophenotypes were assessed in each set of 5 ROI and compared with data from the whole tumor. Spearman’s correlation coefficients (r) ranged from -0.25 to 1.00 depending on markers and tumor type. The best correlations across all tumor types were percentage of PDL1+ tumor cells (r=0.82 to 0.89), while cell densities of CTL and PD1+CTL showed the lowest correlations (r=0.35). Among tumor types, lung tumors and BC showed overall good correlation (r=0.82 to 0.83), depending on the marker. CRC showed the highest variability (average r=0.68), with correlation coefficients as low as 0.35 (PD1+CTL) and 0.46 (PDL1+macrophages). Computer selected ROI were not significantly more or less concordant with whole tumor analysis as compared to ROI selected by pathologists.

Conclusion: Our results suggest that for immunoprofiling data, particularly proportion-based endpoints such as percent of PDL1+ tumor cells in lung and BC, ROI analysis has acceptable correlation with data from the whole tumor. However, CRC showed high variability, particularly in PD1+CTL, Ki67+CTL, and PDL1+macrophages, suggesting that CRC has higher tumor immunological heterogeneity compared with lung cancer and BC. These results suggest that investigators should analyze the whole tumor areas, otherwise, special attention should be paid to the image analysis strategy and its validation.

Citation Format: Jaime Rodriguez-Canales, Michael Surace, Jennifer Cann. Tumor heterogeneity and its impact on immunoprofiling data: Whole tumor vs regions of interest (ROI) analysis of multiplex immunofluorescence in four carcinoma types [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 491.

Automated Multiplex Immunofluorescence Panel for Immuno-oncology Studies on Formalin-fixed Carcinoma Tissue Specimens

Continued developments in immuno-oncology require an increased understanding of the mechanisms of cancer immunology. The immunoprofiling analysis of tissue samples from formalin-fixed, paraffin-embedded (FFPE) biopsies has become a key tool for understanding the complexity of tumor immunology and discovering novel predictive biomarkers for cancer immunotherapy. Immunoprofiling analysis of tissues requires the evaluation of combined markers, including inflammatory cell subpopulations and immune checkpoints, in the tumor microenvironment. The advent of novel multiplex immunohistochemical methods allows for a more efficient multiparametric analysis of single tissue sections than does standard monoplex immunohistochemistry (IHC). One commercially available multiplex immunofluorescence (IF) method is based on tyramide-signal amplification and, combined with multispectral microscopic analysis, allows for a better signal separation of diverse markers in tissue. This methodology is compatible with the use of unconjugated primary antibodies that have been optimized for standard IHC on FFPE tissue samples. Herein we describe in detail an automated protocol that allows multiplex IF labeling of carcinoma tissue samples with a six-marker multiplex antibody panel comprising PD-L1, PD-1, CD68, CD8, Ki-67, and AE1/AE3 cytokeratins with 4',6-diamidino-2-phenylindole as a nuclear cell counterstain. The multiplex panel protocol is optimized in an automated IHC stainer for a staining time that is shorter than that of the manual protocol and can be directly applied and adapted by any laboratory investigator for immuno-oncology studies on human FFPE tissue samples. Also described are several controls and tools, including a drop-control method for fine quality control of a new multiplex IF panel, that are useful for the optimization and validation of the technique.

Atypical microglial response to biodiesel exhaust in healthy and hypertensive rats

Accumulating evidence suggests a deleterious role for urban air pollution in central nervous system (CNS) diseases and neurodevelopmental disorders. Microglia, the resident innate immune cells and sentinels in the brain, are a common source of neuroinflammation and are implicated in air pollution-induced CNS effects. While renewable energy, such as soy-based biofuel, is of increasing public interest, there is little information on how soy biofuel may affect the brain, especially in people with preexisting disease conditions. To address this, male spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto (WKY) rats were exposed to 100% Soy-based Biodiesel Exhaust (100SBDE; 0, 50, 150 and 500μg/m³) by inhalation, 4h/day for 4 weeks (5 days/week). Ionized calcium-binding adapter molecule-1 (IBA-1) staining of microglia in the substantia nigra revealed significant changes in morphology with 100SBDE exposure in rats from both genotypes, where SHR were less sensitive. Aconitase activity was inhibited in the frontal cortex and cerebellum of WKY rats exposed to 100SBDE. No consistent changes occurred in pro-inflammatory cytokine expression, nitrated protein, or arginase1 expression in brain regions from either rat strain exposed to 100SBDE. However, while IBA-1 mRNA expression was not modified, CX3CR1 mRNA expression was lower in the striatum of 100SBDE exposed rats regardless of genotype, suggesting a downregulation of the fractalkine receptor on microglia in this brain region. Together, these data indicate that while microglia are detecting and responding to 100SBDE exposure with changes in morphology, there is reduced expression of CX3CR1 regardless of genetic background and the activation response is atypical without traditional inflammatory markers of M1 or M2 activation in the brain.

Antiviral treatment for hepatitis C virus infection: effectiveness at general population level in a highly endemic area

BACKGROUND

Peginterferon plus ribavirin treatment induced a sustained virological response in >50% of HCV-RNA-positive individuals enrolled in published clinical trials.

AIM

To determine anti-HCV treatment effectiveness at a general population level.

PATIENTS AND METHODS

In 2002, a 1:5 random sample of >11 years old inhabitants of a small Italian town (Cittanova) was invited for HCV screening. HCV-RNA-positive individuals were evaluated for antiviral treatment.

RESULTS

1645 of 1924 invited individuals (85.5%) participated in the screening. 84 HCV-RNA-positive individuals were detected: median age was 65 years (range: 32-87); 67% was infected with genotype 1 or 4. Antiviral treatment was judged unnecessary for 43 (51.2%), due to persistently normal alanine aminotransferases, mild disease at liver biopsy or age >70 years without cirrhosis. Twenty-eight of the remaining 41 patients (68.3%) were ineligible for treatment, because of medical/psychiatric contraindications (42.9%), alcohol/drug abuse (17.9%), decompensated cirrhosis/hepatocellular carcinoma (17.9%), not attending official appointments (10.7%), previous intolerance/non-response to interferon plus ribavirin (10.7%). 5 of 13 eligible patients (38.5%) did not receive treatment (4 refused and 1 accidental death). 3 of 8 treated patients (37.5%) reached a sustained virological response.

CONCLUSIONS

Although efficacy of anti-HCV therapy improved in recent years, we found that low eligibility to treatment still limited its effectiveness at general population level in a highly endemic town.

Selected food intake and risk of endometriosis

BACKGROUND

To offer data on the relationship between diet and risk of pelvic endometriosis, we analysed data collected in the framework of two case-control studies.

METHODS

Data from two case-control studies conducted in Northern Italy between 1984 and 1999 were combined. Cases were 504 women aged < 65 years (median age 33 years, range 20-65) with a laparoscopically confirmed diagnosis of endometriosis, admitted to a network of obstetrics and gynaecology departments in Milan, Brescia and Pavia. Controls were 504 women (median age 34 years, range 20-61) admitted for acute non-gynaecological, non-hormonal, non-neoplastic conditions.

RESULTS

Compared to women in the lowest tertile of intake, a significant reduction in risk emerged for higher intake of green vegetables [odds ratio (OR) = 0.3 for the highest tertile of intake] and fresh fruit (OR = 0.6), whereas an increase in risk was associated with high intake of beef and other red meat (OR = 2.0) and ham (OR = 1.8). Consumption of milk, liver, carrots, cheese, fish and whole-grain foods, as well as coffee and alcohol consumption, were not significantly related to endometriosis.

CONCLUSIONS

This study suggests a link between diet and risk of endometriosis.

Risk factors for different histological types of ovarian cancer

Various histological types of ovarian cancer may develop from different etiological aspects. Data separated by histological subtypes collected in the framework of a large case-control study on ovarian cancer conducted in Italy were analyzed. The cases were women below the age of 75 years, admitted to a network of hospitals in Milan. Cases were grouped into four categories by histological type: mucinous tumor (n = 52), serous tumor (n = 680), endometrioid tumor (n = 41), and other histologies including clear-cell and undifferentiated epithelial tumors (n = 50). Controls were 2758 patients admitted to the same network of hospitals for a wide spectrum of acute, nongynecological, non-hormone-related, non-neoplastic conditions. In comparison with nulliparae, the risk of serous, endometrioid, and other histologies of ovarian cancer tended to be lower in parous women, but the odds ratios (OR) were above unity for mucinous ovarian cancer. Oral contraceptive use was associated with OR lower than unity for serous (OR = 0.7) and endometrioid (OR = 0.8) ovarian cancers but not for mucinous (OR = 1.4) and other histologies (OR = 1.6). Finally, our results on dietary fat intake did not show substantial differences in all histological types of ovarian cancer.

Moderate alcohol drinking and risk of preterm birth

OBJECTIVE

We have analysed the association between alcohol drinking before and during the three trimesters of pregnancy and risk of preterm birth of babies with normal weight for gestational age or with low weight for gestational age (SGA).

DESIGN

Case-control study.

SETTING

General and university hospitals in Italy.

SUBJECTS

Cases were 502 women who delivered preterm births <37 weeks gestation. The controls included 1966 women who gave birth at term (>/=37 weeks of gestation) to healthy infants of normal weight (ie between 10th and 90th centile according to the Italian standard) on randomly selected days at the hospitals where cases had been identified.

INTERVENTIONS

Interview.

RESULTS

No increased risk of preterm birth was observed in women drinking one or two drinks/die in pregnancy, but three or more drinks/die increased the risk (multivariate odds ratios (OR) 2.0 for >/=3 drinks during the first trimester, 1.8 during the second and 1.9 during the third). When the analysis was conducted separately for preterm births with normal weight or SGA, the increased risk was observed in preterm SGA only (multivariate OR for >/=3 drinks/die during the first trimester=3.6, 95% confidence interval (CI) 1.3-11.1); the estimated multivariate OR for >/=3 drinks/die during the first trimester of preterm babies with normal weight for gestational age was only slightly above unity and not statistically significant (multivariate OR 1.4, 95% CI 0.5-3.7).

CONCLUSIONS

The study shows an increased risk in mothers who drink >/=3 die units alcohol in pregnancy of preterm births.

Risk factors for endometrial hyperplasia: results from a case-control study

We analyzed epidemiologic characteristics of women at risk for endometrial hyperplasia (EH), using data from a case-control study. One hundred twenty nine women aged 35-73 (median 51 years) with histologically confirmed complex endometrial hyperplasia without atypies identified at the University of Milan during the period 1990-99 were examined. Controls were 258 non hysterectomized women aged 36-74 (median 52 years), admitted to a network of hospitals covering the same area where cases had been identified for conditions other than gynecological, malignant, or hormone-related. Cases with EH were more educated than controls (OR > 12 years of education vs. < 7: 2.8, 95% CI 1.7-4.8), more frequently obese (OR 2.7, 95% CI 1.5-5.0) and diabetic (OR 2.4, 95% CI 0.8-6.9). Parous women (OR 1.8) and women reporting induced abortions (OR 1.6) showed an increased risk of EH, but the associations were not statistically significant. Compared to premenopausal women, the OR of EH was 0.2 (95% 0.1-0.5) for postmenopausal ones. Compared to women reporting menopause at age 50 or less, the OR of endometrial hyperplasia was 1.5 (95% CI 0.6-3.5) and 2.2 (95%CI 0.7-6.7), respectively, in women with menopause at age 50-52 and > or = 53. Considering postmenopausal women only the OR was 3.1 (95% CI 1.1-9.3) for use of hormonal replacement therapy (HRT). We conclude that this study indicates that high education, obesity, diabetes, and HRT use increase the risk of endometrial hyperplasia.

Risk factors for endometrial hyperplasia: Results from a case-control study

Abstract.

Ricci E, Moroni S, Parazzini F, Surace M, Benzi G, Salerio B, Polverino G, La Vecchia C. Risk factors for endometrial hyperplasia: Results from a case-control study.

We analyzed epidemiologic characteristics of women at risk for endometrial hyperplasia (EH), using data from a case-control study. One hundred twenty nine women aged 35–73 (median 51 years) with histologically confirmed complex endometrial hyperplasia without atypies identified at the University of Milan during the period 1990–99 were examined. Controls were 258 non hysterectomized women aged 36–74 (median 52 years), admitted to a network of hospitals covering the same area where cases had been identified for conditions other than gynecological, malignant, or hormone-related. Cases with EH were more educated than controls (OR > 12 years of education vs. < 7: 2.8, 95% CI 1.7–4.8), more frequently obese (OR 2.7, 95% CI 1.5–5.0) and diabetic (OR 2.4, 95% CI 0.8–6.9). Parous women (OR 1.8) and women reporting induced abortions (OR 1.6) showed an increased risk of EH, but the associations were not statistically significant. Compared to premenopausal women, the OR of EH was 0.2 (95% 0.1–0.5) for postmenopausal ones. Compared to women reporting menopause at age 50 or less, the OR of endometrial hyperplasia was 1.5 (95% CI 0.6–3.5) and 2.2 (95%CI 0.7–6.7), respectively, in women with menopause at age 50–52 and ≥ 53. Considering postmenopausal women only the OR was 3.1 (95% CI 1.1–9.3) for use of hormonal replacement therapy (HRT). We conclude that this study indicates that high education, obesity, diabetes, and HRT use increase the risk of endometrial hyperplasia.

Dietary factors and risk of spontaneous abortion

OBJECTIVE

This study examines the association between dietary habits and risk of spontaneous abortion.

DESIGN

Hospital-based case-control study.

SETTING

Obstetric hospitals in Milan, Italy.

SUBJECTS

Cases were: 912 women admitted for spontaneous abortion (within the 12th week of gestation). Controls were: women who gave birth at term to healthy infants on randomly selected days at the same hospitals where cases had been identified.

RESULTS

The risk of spontaneous abortion was inversely and significantly related to green vegetables, fruit, milk, cheese, eggs and fish consumption. The multivariate odds ratios (OR), for highest versus lowest levels of intake, were 0.3 for fruit, 0.5 for cheese, 0.6 for green vegetables and milk and 0.7 for fish and eggs. The major type of seasoning fats have showed a direct association with risk of miscarriage. Comparing the highest with the lowest intake, the ORs were 2.0 (95% confidence interval, CI 1.1-3.6) and 1.6 (95% CI 1.1-2.3) for butter and oil, respectively. No consistent association emerged between meat, liver, ham and carrots intake and the risk of spontaneous abortion.

CONCLUSIONS

This result suggests that a diet poor in several aspects, including vegetables and fruit, milk and dairy products, but rich in fats, may be a determinant or a correlate of increased risk of spontaneous abortion.

Selected food intake and risk of multiple pregnancies

In order to explore the association between multiple birth risk and diet, data were analysed from a case-control study on risk factors for multiple births conducted in Italy between 1988 and 1998. A total of 185 cases (median age 30 years) were interviewed: 36 women delivered monozygotic and 149 delivered spontaneous dizygotic multiple births. The control group comprised 498 women who gave birth at term (>37 weeks gestation) to healthy infants on randomly selected days at the same clinic. Women were specifically excluded if they reported a history of multiple pregnancy or they had received treatment for infertility for the index pregnancy. No marked differences emerged in daily intake between cases and controls and a total of 35 foods items, including the major sources of beta-carotene, retinol, ascorbic acid, vitamin D, E, methionine folate and calcium in the Italian diet. Likewise intake of selected micronutrients was largely similar in dizygotic cases, monozygotic cases and controls, with the only exception of a slightly lower intake of folates in dizygotic pregnancies in comparison with controls: this difference was statistically significant (P < 0.05), but limited in quantitative terms (mean daily intake of folate 192.4, 183.2 and 191.4 microg respectively in monozygotic, dizygotic cases and controls). In conclusion, the results of this study do not support the role of diet in the development of multiple births.

Influence of menstrual and reproductive factors on ovarian cancer risk in women with and without family history of breast or ovarian cancer

BACKGROUND

As women with a family history of ovarian and/or breast cancer possibly inherit genetic changes that alter their risk of ovarian cancer, other established risk factors for ovarian cancer may influence the risk differently in women with and without a family history of the disease.

METHODS

Case-control study conducted between 1983 and 1991 in Northern Italy. Cases were 971 women, under 75 years, with incident, histologically confirmed epithelial ovarian cancer, and controls were 2758 women, under 75 years, admitted to hospitals for non-malignant, non-hormone-related conditions, who had not undergone bilateral oophorectomy. Of these, 93 cases and 139 controls had a family history of ovarian and/or breast cancer.

RESULTS

The risk of ovarian cancer increased with irregular menstrual cycles, late age at menopause, natural menopause, nulliparity, never use of oral contraceptives and use of hormone replacement therapy. We computed an 'adult life risk score' (ALRS) considering the combined effect of these factors. Compared to women without a family history and a low ALRS, the OR was 1.7 for women without family history and high ALRS, 1.4 for women with a family history and low ALRS, and 3.5 for women with a family history and high ALRS.

CONCLUSIONS

Intervention on selected hormonal risk factors for ovarian cancer might be important for women with a family history of the disease.

Risk factors for urinary incontinence in women

OBJECTIVES

To review the epidemiological evidence on risk factors for urinary incontinence (UI) in women.

METHODS

Using Medline and a manual search we identified the main papers published in English up to 1998.

RESULTS

There is consistent evidence that the frequency of UI increases with age, but there is little information on the frequency of different types of UI in different age groups. With regard to other risk factors, there is a clinical consensus that vaginal delivery and, more in general, obstetric traumas are associated with UI, although epidemiological studies are not always consistent. Less defined is the role of race, menopausal status, history of gynecological surgery, body mass index, smoking, and coffee and alcohol consumption on the risk of UI.

CONCLUSION

In the coming years, epidemiological research should focus particularly on the potential differences in the epidemiological characteristics of different types of UI in order to gain insight into the pathogenic mechanisms.

Population attributable risk for ovarian cancer

Parity, oral contraceptive (OC) use, age at menopause, a family history of the disease and selected aspects of diet have been related to the risk of ovarian cancer. The quantification of their impact on a population level may help focus and rank the importance of potential prevention strategies. Using data from a case-control study conducted in Italy between 1983 and 1991 on 971 ovarian cancer cases and 2758 control women we computed the multivariate relative risk estimates, and population attributable risks (PARs), i.e. the proportion of ovarian cancers that would have been avoided if a given exposure had not been present in the population. Overall, the PARs were 5% for nulliparity, 12% for never OC use and 4% for a family history of breast or ovarian cancer in first-degree relatives. Among women aged >/=50 years, later age at menopause accounted for 16% of all ovarian cancer cases. Low intake of green vegetables accounted for 24% of cases and a high fat score for 7%. All these factors together explained 51% of cases. In conclusion, even if the PAR estimates were based on several arbitrary assumptions, available knowledge could, in principle, explain over 50% of all ovarian cancer cases in this Italian population, thus indicating and quantifying the theoretical scope for prevention.

Use of oral contraceptives and uterine fibroids: results from a case-control study

OBJECTIVE

To analyse the association between oral contraceptive use and the risk of uterine fibroids.

DESIGN

We considered data collected in a case-control study on risk factors for uterine fibroids.

PARTICIPANTS

We studied 843 women with uterine fibroids, whose clinical diagnosis dated back no more than two years. Controls were 1557 non-hysterectomised patients younger than 55 years admitted for acute, non-gynecological, non-hormonal, non-neoplastic conditions.

RESULTS

A total of 254 cases (30.1%) and 360 controls (23.1%) reported ever using oral contraceptives: the odds ratio (OR) for ever vs never users was 1.1 (95% CI 0.8-1.3). The risk in current users was below unity when compared with never users (OR 0.3, 95% CI 0.2-0.6), while ex-users had a risk of fibroids comparable with never users (OR 1.1, 95% CI 0.9-1.4). The risk of uterine fibroids decreased with duration of oral contraceptive use: compared with never users, the estimated OR was 0.8 (95% CI 0.5-1.2) in ever users for four to six years and 0.5 (95% CI 0.3-0.9) for seven years or more (chi2 trend = 4.6, P = 0.03).

CONCLUSIONS

Although the role of selection bias should be carefully evaluated, the present data suggest that uterine fibroids should not be considered a contra-indication for oral contraceptive use.

Diabetes and endometrial cancer: an Italian case-control study

We considered the association between diabetes and risk of endometrial cancer using data from a large case-control study conducted in Italy. Cases were 752 women with incident, histologically confirmed endometrial cancer < 75 years of age (median age 60 years, range 28-74) admitted to a network of hospitals in Milan. Controls were 2,606 patients (median age 54 years, range 25-74) aged < 75 years, admitted for acute non-neoplastic, non-gynecological, non-hormone-related conditions to the same network of hospitals where cases had been identified. A total of 132 (17.6%) cases and 116 controls (4.5%) reported a history of diabetes. The corresponding multivariate odds ratio (OR) was 2.9 [95% confidence interval (CI) 2.2-3.9]. No association emerged with diabetes diagnosed under age 40 (likely to be insulin-dependent diabetes), whereas the OR of endometrial cancer was 3.1 (95% CI 2.3-4.2) for diabetes diagnosed at age > or = 40 years. The OR of endometrial cancer in women with history of diabetes was 3.0 for women with a body mass index (BMI) (QI) kg/m2 < 25, 3.6 for those with a BMI of 25-29, and 3.3 for those with a BMI > or = 30. No consistent interaction or modifying effect was observed for any other covariate. Our results confirm that non-insulin-dependent diabetes is associated with the risk of endometrial cancer. The association may be mediated through elevated oestrogen levels in diabetic women, hyperinsulinemia or insulin-like growth factor-I (IGF-I).

Reproductive factors, family history, occupation and risk of urogenital prolapse

OBJECTIVE

We conducted a case-control study to analyze risk factors for urogenital prolapse requiring surgery.

METHODS

Cases were 108 women with a diagnosis of II or III degree uterovaginal prolapse and/or third degree cystocele. Controls were 100 women admitted to the same hospitals as the cases, for acute, non-gynecological, non-neoplastic conditions.

RESULTS

Occupation showed an association with urogenital prolapse: in comparison with professional/managerial women, housewives had an odds ratios (OR) of urogenital prolapse of 3.1 (95% confidence interval (CI), 1.6-8.8). Compared with nulliparae, parous women tended to have a higher risk of genital prolapse (OR 2.6, 95% CI 0.9-7.8). In comparison with women reporting no vaginal delivery, the ORs were 3.0 for women reporting one vaginal delivery (95% CI 1.0-9.5), and 4.5 (95% CI 1.6-13.1) for women with two or more vaginal deliveries. Forceps delivery and birthweight were not associated with risk of prolapse after taking into account the effect of number of vaginal deliveries. The risk of urogenital prolapse was higher in women with mother or sisters reporting the condition: the ORs were, respectively, 3.2 (95% CI 1.1-7.6) and 2.4 (95% CI 1.0-5.6) in comparison with women whose mother or sisters reported no prolapse.

CONCLUSIONS

Our data support the clinical suggestion that parous women are at a higher risk of prolapse and the risk increases with number of vaginal deliveries. First-degree family history of prolapse seems to increase the risk of prolapse.

Placental ratio in pregnancies at different risk for intrauterine growth

OBJECTIVE

We have analyzed the placental/birthweight ratio in women at increased risk of intrauterine growth retardation and pregnancy-induced hypertension and in women with pregnancy 'complicated' by these conditions.

STUDY DESIGN

A total of 89 women with small gestational age (SGA) infants, 355 with appropriate gestational age infants (200 in the uncomplicated pregnancy group) and 28 with large for gestational age (LGA) infants were considered.

RESULTS AND CONCLUSION

The mean placental weight showed a significant increase from the SGA to the LGA in the two groups. The placental ratio tended to increase from the LGA group to the SGA one both in infants of women with uncomplicated pregnancy and with pregnancy complicated by intrauterine growth retardation or pregnancy-induced hypertension; these findings were statistically significant.

Coffee consumption and risk of hospitalized miscarriage before 12 weeks of gestation

In order to analyse the association between drinking coffee in pregnancy and risk of spontaneous abortion, a case-controlled study was conducted in Milan, Northern Italy. Cases were 782 women with spontaneous abortion within the 12th week of gestation. The control group was recruited from women who gave birth at term (> 37 weeks gestation) to healthy infants on randomly selected days at the same hospitals where cases had been identified: 1543 controls were interviewed. A total of 561 (72%) cases of spontaneous abortion and 877 (57%) controls reported coffee drinking during the first trimester of the index pregnancy. The corresponding multivariate odds ratios of spontaneous abortion, in comparison with non-drinkers, were 1.2, 1.8 and 4.0, respectively, for drinkers of 1, 2 or 3, and 4 or more cups of coffee per day. No relationship emerged between maternal decaffeinated coffee, tea and cola drinking in pregnancy, as well as paternal coffee consumption, and risk of spontaneous abortion. With regard to duration in years of coffee drinking, the estimated multivariate odds ratios of spontaneous abortion were, in comparison with non-coffee drinkers, 1.1 (95% confidence interval (CI) 0.9-1.4) and 1.9 (95% CI 1.5-2.6) for women reporting a duration of coffee consumption < or = 10 or > 10 years. In conclusion, coffee drinking early in pregnancy was associated with an increased risk of abortion. This has biological implications, but epidemiological inference on the causality is difficult and still open to debate.

Treatment for fertility and risk of ovarian tumors of borderline malignancy

The relationship between fertility drug use and risk of borderline ovarian cancer has been analyzed using data from a case-control study. Cases were 93 women aged 23 to 64 years with histologically confirmed diagnosis of borderline ovarian tumor (according to the World Health Organization criteria) who were admitted to the Obstetrics and Gynecology Clinics of the University of Milan. Control subjects were 273 women (ages 24-64 years) admitted for acute nongynecological, nonhormonal, and nonneoplastic conditions. Four cases (4.3%) and no control reported fertility drugs use: this difference was statistically significant (Fisher's exact test P = 0.004).