Fungal Depletion Bolsters Anti-Tumor Immune Response Elicited by Anti-PD1 Alone and in Combination with Radiation Therapy

PURPOSE/OBJECTIVE(S)

Pembrolizumab in combination with chemotherapy has become the standard of care treatment for both metastatic and early-stage triple negative breast cancer (TNBC). Clinical trials are currently underway investigating the use of pembrolizumab with radiation in the neoadjuvant setting in early TNBC. Several groups have described a link between the microbiome and the efficacy of chemotherapy and anti-PD1 immune checkpoint inhibitors (ICIs) in preclinical models. Recent work from our lab has shown that targeting commensal fungi in the microbiome enhances the radiation induced antitumor immune response. Therefore, we hypothesized that fungal depletion might positively impact anti-PD1 therapy and combination treatment with anti-PD1 and radiation therapy (RT).

MATERIALS/METHODS

This study utilized an orthotopic syngeneic breast tumor model in which the syngeneic cell line E0771 was injected into the mammary fat pad of female C57BL/6 mice. Tumor-bearing mice were then treated with and without the antifungal fluconazole, anti-PD1, and radiation (16 Gy single fraction) using the X-RAD SmART platform with CT guidance. Tumor volumes were compared using 2-way ANOVA and survival curves analyzed using log rank. In a separate set of experiments, tumor-infiltrating immune cells were isolated and analyzed by high-dimensional multiplex flow cytometry.

RESULTS

We found that fungal depletion with fluconazole prior to treatment with anti-PD1 reduced the tumor volume and significantly improved survival in comparison to those treated with anti-PD1 alone (P = 0.0016). To identify what changes in the tumor immune microenvironment is driving this increased anti-tumor response, we performed flow cytometry on immune cells isolated from the tumors. We found that the use of fluconazole prior to anti-PD1 treatment reduced the proportion of CD11b+F4/80+ tumor-associated macrophages (TAMs) (P = 0.01) and increased tumor infiltrating cytotoxic T cell population (P = 0.04) when compared with the use of anti-PD1 alone. We also evaluated the effect of fungal depletion on combination therapy with RT and anti-PD1. Strikingly, we found that mice depleted of fungi with fluconazole prior to radiation and anti-PD1 therapy, have decreased tumor burden and significantly increased survival when compared to their fungally-intact counterparts (P = 0.043).

CONCLUSION

Our data indicates that the depletion of the gut fungal populations induces an increased antitumor response following anti-PD1 alone and in combination with radiation. This increased antitumor immune response is associated with an increase in the cytotoxic CD8+ T cell compartment with concomitant decrease in immunosuppressive tumor associated macrophages.

Reshaping Macrophage Polarization Potential Enhances Antitumor Immune Response to Radiation Therapy

PURPOSE/OBJECTIVE(S)

Although radiation therapy (RT) remains a cornerstone in the treatment of breast cancer, many trials combining RT with immune checkpoint blockade (ICB) have failed to demonstrate benefit in solid tumors including breast cancer. Maximal efficacy of RT relies on the generation of antitumor immunity following treatment which largely consists of cytotoxic T cells and macrophages. Broad depletion of macrophages modestly enhances tumor responses to RT suggesting that they can shape RT-induced antitumor immunity. Although IL4 signaling through GATA-3 is known to polarize T cells into the protumor Th2 phenotype, such central drivers of macrophage polarization are not well established. Given that macrophages abundantly express IL4 receptor, we hypothesized that GATA-3 may direct the transition of macrophages to M2/alternative phase and that genetic ablation of GATA-3 in macrophages can enhance antitumor immunity by arresting macrophage transition to an M2-like pro-tumor state.

MATERIALS/METHODS

We generated a macrophage specific GATA-3 KO mouse model (mG3KO) driven by the LysM-Cre promoter. Using a syngeneic orthotopic murine model of breast cancer (EO771), we evaluated the differential effect of RT (16Gy x 1) in WT and mG3KO mice. Multiparametric flow cytometry was performed to investigate the immune changes within the tumor microenvironment on day 3, day 5 and day 10 after RT. T cell depletion was performed using antibodies to CD4 and CD8 by intraperitoneal injections to understand the role of adaptive immunity in the response to RT in WT and mG3KO mice.

RESULTS

We found that mG3KO mice bearing advanced EO771 tumors demonstrated significantly improved tumor regression compared to WT mice (p<0.001), which translated to increased overall survival. In vitro characterization of bone-marrow derived macrophages from mG3KO and WT mice suggest that macrophages with ablated GATA-3 expressed increased levels of iNOS and decreased levels of Arginase (Arg-1), consistent with an M1-like phenotype. Immune profiling of the tumors also revealed that mGATA-3 KO animals have significant enrichment of CD8+ T cells in the tumor milieu post RT and these CD8+ T cells express higher amounts of interferon gamma (p<0.001) and Granzyme B (p<0.0015) than their WT counterparts. Using neutralizing antibodies to deplete CD8+ T cells, we show that anti-tumor effects in the mG3KO mice were abolished, suggesting that mG3KO macrophages impact survival, at least, in part by enhancing cytotoxic CD8+T cells. Studies are currently ongoing to reveal the detailed mechanism of GATA-3 ablation in improving the efficacy of RT.

CONCLUSION

Our data indicates that GATA-3 is a central regulator of macrophage polarization in response to RT. Further, directed ablation of GATA-3 appears to drive macrophages towards an M1-like phenotype, which enhances T cell recruitment to irradiated tumors. These data suggest that the antitumor efficacy of RT can be prolonged by targeting GATA-3-dependent signaling within myeloid cells.

Healthy minds from 0-100 years: Optimising the use of European brain imaging cohorts ("Lifebrain")

The main objective of "Lifebrain" is to identify the determinants of brain, cognitive and mental (BCM) health at different stages of life. By integrating, harmonising and enriching major European neuroimaging studies across the life span, we will merge fine-grained BCM health measures of more than 5,000 individuals. Longitudinal brain imaging, genetic and health data are available for a major part, as well as cognitive and mental health measures for the broader cohorts, exceeding 27,000 examinations in total. By linking these data to other databases and biobanks, including birth registries, national and regional archives, and by enriching them with a new online data collection and novel measures, we will address the risk factors and protective factors of BCM health. We will identify pathways through which risk and protective factors work and their moderators. Exploiting existing European infrastructures and initiatives, we hope to make major conceptual, methodological and analytical contributions towards large integrative cohorts and their efficient exploitation. We will thus provide novel information on BCM health maintenance, as well as the onset and course of BCM disorders. This will lay a foundation for earlier diagnosis of brain disorders, aberrant development and decline of BCM health, and translate into future preventive and therapeutic strategies. Aiming to improve clinical practice and public health we will work with stakeholders and health authorities, and thus provide the evidence base for prevention and intervention.

Variants in several genomic regions associated with asperger disorder

Asperger disorder (ASP) is one of the autism spectrum disorders (ASD) and is differentiated from autism largely on the absence of clinically significant cognitive and language delays. Analysis of a homogenous subset of families with ASP may help to address the corresponding effect of genetic heterogeneity on identifying ASD genetic risk factors. To examine the hypothesis that common variation is important in ASD, we performed a genome-wide association study (GWAS) in 124 ASP families in a discovery data set and 110 ASP families in a validation data set. We prioritized the top 100 association results from both cohorts by employing a ranking strategy. Novel regions on 5q21.1 (P = 9.7 × 10(-7) ) and 15q22.1-q22.2 (P = 7.3 × 10(-6) ) were our most significant findings in the combined data set. Three chromosomal regions showing association, 3p14.2 (P = 3.6 × 10(-6) ), 3q25-26 (P = 6.0 × 10(-5) ) and 3p23 (P = 3.3 × 10(-4) ) overlapped linkage regions reported in Finnish ASP families, and eight association regions overlapped ASD linkage areas. Our findings suggest that ASP shares both ASD-related genetic risk factors, as well as has genetic risk factors unique to the ASP phenotype.

Epigenetic regulation of microRNA-370 by interleukin-6 in malignant human cholangiocytes

Interleukin-6 (IL-6) is overexpressed and contributes to tumor cell growth in cholangiocarcinoma. Enforced IL-6 production can alter the expression of specific microRNAs (miRNAs) involved in tumor growth, and moreover can modulate expression of methylation-dependent genes. Thus, we assessed the methylation-dependent regulation of miRNA expression in human malignant cholangiocytes stably transfected to overexpress IL-6. The expression of the methyltransferases DNA methyltransferase enzyme-1 and HASJ4442 was increased by IL-6 overexpression, but was decreased by the methylation inhibitor 5-aza-2'-deoxycytidine (5-aza-CdR). Expression profiling identified seven miRNAs that were significantly downregulated by IL-6 overexpression (<0.4-fold) and upregulated (>2-fold) by 5-aza-CdR. One of these, miR-370, is embedded in a CpG island. Although 5-aza-CdR increased miR-370 expression by 2.1-fold in malignant cells, the expression in nonmalignant cells was unchanged. The oncogene mitogen-activated protein kinase kinase kinase 8 (MAP3K8) was identified as a target of miR-370, and its expression was decreased by 5-aza-CdR in cholangiocarcinoma cells. Overexpression of IL-6 reduced miR-370 expression and reinstated MAP3K8 expression in vitro as well as in tumor cell xenografts in vivo. Thus, IL-6 may contribute to tumor growth by modulation of expression of selected miRNAs, such as miR-370. These studies define a mechanism by which inflammation-associated cytokines can epigenetically modulate gene expression and directly contribute to tumor biology.

Hemodynamic correlates of EEG: A heuristic

In this note we describe a heuristic, starting with a dimensional analysis, which relates hemodynamic changes to the spectral profile of ongoing EEG activity. In brief, this analysis suggests that 'activation', as indexed by increases in hemodynamic signals, should be associated with a loss of power in lower EEG frequencies, relative to higher frequencies. The fact that activation is expressed in terms of frequency (i.e., per second) is consistent with a dimensional analysis in the sense that activations reflect the rate of energy dissipation (per second). In this heuristic, activation causes an acceleration of temporal dynamics leading to (i) increased energy dissipation; (ii) decreased effective membrane time constants; (iii) increased effective coupling among neuronal ensembles; and (iv) a shift in the EEG spectral profile to higher frequencies. These predictions are consistent with empirical observations of how changes in the EEG spectrum are expressed hemodynamically. Furthermore, the heuristic provides a simple measure of neuronal activation based on spectral analyses of EEG.

Mass screening in low-income populations: the challenges of securing diagnostic and treatment services in a national cancer screening program

Funding for many mass screening programs for low-income and uninsured populations provides resources for screening tests, yet only rarely does it provide coverage for necessary follow-up diagnostic and treatment services. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a federally funded initiative that provides cancer screening to low-income uninsured and underinsured women, covers some diagnostic follow-up tests and no treatment services. We conducted in-depth case studies of seven state programs participating in the NBCCEDP to investigate the strategies and approaches being used to secure diagnostic and treatment services. The results suggest that the program relies on a patchwork of resources--at state and local levels--to provide diagnostic and treatment services. This includes a number of components of local safety nets, all of which are unstable and have uncertain futures. Public health disease-screening initiatives need to reconsider the feasibility of continued reliance on case-by-case appeals to the local safety net for diagnostic follow-up and treatment services.

Implementing recommendations for the early detection of breast and cervical cancer among low-income women

SCOPE OF THE PROBLEM

Among U.S. women, breast cancer is the most commonly diagnosed cancer and remains second only to lung cancer as a cause of cancer-related mortality. The American Cancer Society (ACS) estimates that 182,800 new cases of female breast cancer and 41,200 deaths from breast cancer will occur in 2000. Since the 1950s, the incidence of invasive cervical cancer and mortality from this disease have decreased substantially; much of the decline is attributed to widespread use of the Papanicolaou (Pap) test. ACS estimates that 12,800 new cases of invasive cervical cancer will be diagnosed, and 4,600 deaths from this disease will occur in the United States in 2000.

ETIOLOGIC FACTORS

The risk for breast cancer increases with advancing age; other risk factors include personal or family history of breast cancer, certain benign breast diseases, early age at menarche, late age at menopause, white race, nulliparity, and igher socioeconomic status. Risk factors for cervical cancer include certain human papilloma virus infections, early age at first intercourse, multiple male sex partners, a history of sexually transmitted diseases, and low socioeconomic status. Black, Hispanic, or American Indian racial/ethnic background is considered a risk factor because cervical cancer detection and death rates are higher among these women.

RECOMMENDATIONS FOR PREVENTION

Because studies of the etiology of breast cancer have failed to identify feasible primary prevention strategies suitable for use in the general population, reducing mortality from breast cancer through early detection has become a high priority. The potential for reducing death rates from breast cancer is contingent on increasing mammography screening rates and subsequently detecting the disease at an early stage--when more treatment options are available and survival rates are higher. Effective control of cervical cancer depends primarily on early detection of precancerous lesions through use of the Papanicolaou test, followed by timely evaluation and treatment. Thus, the intended outcome of cervical cancer screening differs from that of breast cancer screening. In 1991, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was implemented to increase breast and cervical cancer screening among uninsured, low-income women.

RESEARCH AGENDA

To support recommended priority activities for NBCCEDP, CDC has developed a research agenda comprising six priorities. These six priorities are a) determining effective strategies to communicate changes in NBCCEDP policy to cancer screening providers and women enrolled in the program; b) identifying effective strategies to increase the proportion of enrolled women who complete routine breast and cervical cancer rescreening according to NBCCEDP policy; c) identifying effective strategies to increase NBCCEDP enrollment among eligible women who have never received breast or cervical cancerscreening; d) evaluating variations in clinical practice patterns among providers of NBCCEDP screening services; e) determining optimal models for providing case-management services to women in NBCCEDP who have an abnormal screening result, precancerous breast or cervical lesion, or a diagnosis of cancer; and f) conducting economic analyses to determine costs of providing screening services in NBCCEDP.

CONCLUSION

The NBCCEDP, through federal, state, territorial, and tribal governments, in collaboration with national and community-based organizations, has increased access to breast and cervical cancer screening among low-income and uninsured women. This initiative enabled the United States to make substantial progress toward achieving the Healthy People 2000 objectives for breast and cervical cancer control among racial/ethnic minorities and persons who are medically underserved. A continuing challenge for the future is to increase national commitment to providing screening services for all eligible uninsured women to ultimately reduce morbidity and mortality from breast and cervical cancer.

Neuroimaging evidence for dissociable forms of repetition priming

Repetition priming has been characterized neurophysiologically as a decreased response following stimulus repetition. The present study used event-related functional magnetic resonance imaging to investigate whether this repetition-related response is sensitive to stimulus familiarity. A right fusiform region exhibited an attenuated response to the repetition of familiar stimuli, both faces and symbols, but exhibited an enhanced response to the repetition of unfamiliar stimuli. Moreover, both repetition effects were modulated by lag between successive presentations. Further experiments replicated the interactions between repetition, familiarity, and lag and demonstrated the persistence of these effects over multiple repetitions. Priming-related responses are therefore not unitary but depend on the presence or absence of preexisting stimulus representations.

Injury control strategies: extending the quality and quantity of data relating to road traffic accidents in children

This review describes how an extended database of information can provide the opportunity to go beyond the traditionally distinct health, engineering, and education initiatives in order to identify the effectiveness of more overarching policies for injury control. Such information can be used to raise awareness and to encourage community participation in designing a road traffic accident prevention strategy.

Cervical cancer screening among low-income women: results of a national screening program, 1991-1995

OBJECTIVE

To evaluate the results of cervical cytology screening in the National Breast and Cervical Cancer Early Detection Program and to compare the findings with results from other screening programs.

METHODS

We analyzed data on 312,858 women aged 18 years and older who received one or more Papanicolaou smears, and follow-up if indicated, from October 1991 through June 1995 at screening sites across the United States providing comprehensive National Breast and Cervical Cancer Early Detection Program services.

RESULTS

Of the women screened, more than half were 40 years or older; slightly less than half (44%) were of racial and ethnic minorities. During the first screening cycle, 3.8% of Papanicolaou tests were reported as abnormal (squamous intraepithelial lesion [SIL] or squamous cell cancer); proportions of abnormals decreased with increasing age. The age-adjusted rate of biopsy-confirmed cervical intraepithelial neoplasia (CIN) II or worse among women screened was 7.4 per 1000 Papanicolaou tests; rates of CIN were highest among young women, but cancer rates peaked among women in their 50s and 60s. The percentages of first screening cycle-Papanicolaou tests interpreted as high-grade SIL and squamous cell carcinoma associated with biopsy-confirmed CIN II or worse (the positive predictive value) were 56.0% for CIN II/III and 3.7% for invasive cancer. Of the 150 invasive cancers diagnosed, 54.0% were classified as local disease.

CONCLUSION

Observed results emphasize the duality of cervical neoplasia-CIN in younger women and invasive cancer in older women. This finding points to the importance of reaching both younger and older women for cervical cancer screening.

Working memory in chess

Three experiments investigated the role of working memory in various aspects of thinking in chess. Experiment 1 examined the immediate memory for briefly presented chess positions from master games in players from a wide range of abilities, following the imposition of various secondary tasks designed to block separate components of working memory. Suppression of the articulatory loop (by preventing subvocal rehearsal) had no effect on measures of recall, whereas blocking the visuospatial sketchpad (by manipulation of a keypad) and blocking the central executive (by random letter generation) had equivalent disruptive effects, in comparison with a control condition. Experiment 2 investigated the effects of similar secondary tasks on the solution (i.e., move selection) of tactical chess positions, and a similar pattern was found, except that blocking the central executive was much more disruptive than in Experiment 1. Experiment 3 compared performance on two types of primary task, one concerned with solving chess positions as in Experiment 2, and the other a sentence-rearrangement task. The secondary tasks in each case were both designed to block the central executive, but one was verbal (vocal generation of random numbers), while the other was spatial in nature (random generation of keypresses). Performance of the spatial secondary task was affected to a greater extent by the chess primary task than by the verbal primary task, whereas there were no differential effects on these secondary tasks by the verbal primary task. In none of the three experiments were there any differential effects between weak and strong players. These results are interpreted in the context of the working-memory model and previous theories of the nature of cognition in chess.

An analysis of job morale factors of community health nurses who report a low turnover rate. The research

Nurse executives are continually faced with issues related to nursing turnover and staff morale. This sample included 217 registered nurses working in a state health department where the turnover rate was 8%. In this study, the authors found that nurses with advanced educational preparation, higher-level positions, or both, demonstrated increased levels of morale. Conversely, nurses with increased years of service and nursing experience had lower morale levels. These findings could be useful in delineating situations to improve morale and lower turnover rates.

Compliance with anticonvulsant therapy by epileptic youth. Relationships to psychosocial aspects of adolescent development

Independence in daily life, family harmony as perceived by youths and their parents, and self-esteem were investigated in relation to anticonvulsant medication compliance in 25 epileptics aged 9-17 years. Medication compliance was assessed by monthly home saliva sampling for phenobarbital concentrations. Psychosocial issues were assessed by standardized instruments. Each psychosocial issue was highly correlated with compliance. Partial correlation analysis reveals that these findings are not explained by the subject's demographic or clinical characteristics. Medication noncompliance appears to be associated with a restriction of independence in daily life, lack of harmony in family relations, and low self-esteem in teenage epileptics. Clinicians should observe for these conditions and initiate patient and family counseling in order to maximize medication compliance and seizure control.

Pharmacokinetics of intravenous and oral tolmesoxide

A high pressure liquid chromatographic assay was developed for simultaneous measurement of the plasma levels of tolmesoxide and its principal metabolite, RX71112. The assay was used to study the disposition of intravenous and oral tolmesoxide in ten normotensive subjects. Two exponential terms were required to describe the disposition of the drug following intravenous administration, whilst a single exponential term sufficed to account for the decay in the plasma concentration after oral administration. The bioavailability of oral tolmesoxide from capsules averaged 84.5% and was independent of dose. The mean half-life after i.v. dosing was 2.6 h (+/- 0.3 SEM) compared to values of 1.9 h (+/- 0.1 SEM) and 2.7 h (+/- 0.5 SEM) following 200 and 400 mg oral doses respectively. In all subjects RX71112 appeared in plasma shortly after tolmesoxide following both routes of administration. The terminal half-life of the metabolite was significantly longer than tolmesoxide with a mean value of 4.9 h (+/- 0.9 SEM) following the 200 mg oral dose of tolmesoxide. The binding of tolmesoxide and RX71112 at therapeutic plasma concentration was 36.8% (+/- 0.5 SEM) and 58.5% (+/- 0.3 SEM) and this remained unchanged at higher concentrations.

Waldenström's macroglobulinemia and autoimmune disease in a family

We diagnosed Waldenström's macroglobulinemia in a father and three offspring. Clinical and subclinical autoimmune disorders occurred excessively in the family. The HLA haplotype A2, B8, DRw3 was detected in all patients with Waldenström's macroglobulinemia and all but one family member with autoimmune manifestations. A lod score [log odds] of 4.86 favors linkage to the HLA complex of a gene predisposing to lymphoproliferative and autoimmune disorders. Associated with this HLA haplotype were the B-cell alloantigens Ia-172 and 350, previously reported in patients with the lymphoma-prone sicca syndrome.

Plasma concentration and disposition of buprenorphine after intravenous and intramuscular doses to baboons

Buprenorphine is a newly-developed strong analgesic. A selected ion monitoring method has been developed to measure its plasma levels over the concentration range 20-3000ng ml-1. Six baboons each received intravenous and intramuscular doses of buprenorphine hydrochloride at a level of 5mg/kg in a cross-over study. The mean peak plasma concentrations (+/-standard deviation) were 2290 +/- 357ng ml-1 and 805 +/- 416ng ml-1 respectively and the corresponding times to the peak levels were 4.0 +/- 1.5 minutes and 30.3 +/- 24.6 minutes suggesting the rapid release of the drug from intramuscular sites. Comparison of areas under the plasma concentration versus time curves to 24 hours after dosing showed the mean bioavailability of buprenorphine from the intramuscular doses was 70% of that from the reference intravenous doses.

Pharmacokinetics of fenclofenac following single and multiple doses

The plasma concentration of the anti-inflammatory drug fenclofenac was investigated in volunteers following single oral doses of 200, 500 and 600 mg, as well as multiple doses of 600mg b.i.d. over five days, using gas chromatography with electron capture detection. The pharmacokinetic parameters derived were independent of dose, and the terminal half-life, t1/2, varied independently of dose between 20 and 38 hours (27.23 +/- 1.8 at 600mg). The apparent volume of distribution (Vd area) had similar values at doses of 200, 500 and 600mg of 15.2 +/- 2.6, 18.2 +/- 1.5 and 14.7 +/- 1.7 litres respectively. These small volumes of distribution indicate that fenclofenac distributes mainly into extracellular space. A mean peak plasma concentration of 63.5 +/- 4.6microgram/ml developed after 3 to4 hours following a single 600mg dose whilst a mean steady state plasma concentration (600mg b.i.d.) of 86.9 +/- 5.7 microgram/ml was achieved within four days, and this decayed with a mean terminal half-life of 25.9 +/- 4.2 hours.

Properties of cupric ions in benzylamine oxidase from pig plasma as studied by magnetic-resonance and kinetic methods

Benzylamine oxidase from pig plasma has been studied by a variety of chemical and physical techniques. 1. Analytical ultracentrifugation, gel electrophoresis and isoelectric-focusing studies suggest that the enzyme is composed of two subunits with closely similar primary structures. 2. E.s.r. and n.m.r. measurements show that the enzyme contains two well-separated (greater than 0.6 nm) Cu2+ ions at chemically distinct sites. Each Cu2+ ion is coordinated by two water molecules, one 'axial' and the other 'equatorial'. Both water molecules undergo fast exchange (10(5)--10(8) s-1) with solvent and are deprotonated in the pH range 8--9, but only the equatorial water molecule is displaced by the inhibitors N3- and CN-. 3. Kinetic and e.s.r. measurements show that azide and cyanide compete against O2 binding and also make the two Cu2+ sites identical. It is concluded that Cu2+ must participate in the re-oxidation of reduced enzyme by molecular O2.