A Pilot Study of Neoadjuvant Nivolumab, Ipilimumab, and Intralesional Oncolytic Virotherapy for HER2-negative Breast Cancer

Purpose

Neoadjuvant combination immune checkpoint blockade and intralesional oncolytic virotherapy have the potential to activate antitumor responses in patients with breast cancer.

Experimental Design

Eligibility for this pilot phase I trial included patients with localized HER2-negative breast cancer who received systemic nivolumab and ipilimumab and intratumor talimogene laherparepvec (T-VEC; NCT04185311). The primary objective was to evaluate the safety and adverse event profile of immunotherapy combined with T-VEC in patients with localized, HER2-negative breast cancer.

Results

Six patients were enrolled, 4 having relapses after prior neoadjuvant chemotherapy and 2 who were previously untreated. Toxicities included 1 patient having grade 3 hypotension and type 1 diabetes mellitus, 3 patients with hypothyroidism, and all patients having constitutional symptoms known to be associated with the administration of T-VEC. One patient had a pathologic complete response, 3 patients had pathologic partial responses, 1 showed no significant response, and 1 had disease progression. Biopsies demonstrated increased immune cell infiltration in samples from patients who responded to therapy.

Conclusions

This triple immunotherapy regimen provided responses in patients with advanced or relapsed HER2-negative breast cancer, at the expense of long-term toxicities.

Significance

Systemic immune checkpoint blockade with a programmed death receptor 1 and a CTL antigen-4 blocking antibody, combined with intralesional oncolytic virotherapy, is a chemotherapy-free combination aimed at inducing an antitumor immune response locally and systemic immunity.

Quantitative Nodal Burden and Mortality Across Solid Cancers

BACKGROUND

Nodal staging systems vary substantially across solid tumors, implying heterogeneity in the behavior of nodal variables in various contexts. We hypothesized, in contradiction to this, that metastatic lymph node (LN) number is a universal and dominant predictor of outcome across solid tumors.

METHODS

We performed a retrospective cohort analysis of 1 304 498 patients in the National Cancer Database undergoing surgery between 2004 and 2015 across 16 solid cancer sites. Multivariable Cox regression analyses were constructed using restricted cubic splines to model the association between nodal number and mortality. Recursive partitioning analysis (RPA) was used to derive nodal classification systems for each solid cancer based on metastatic LN count. The reproducibility of these findings was assessed in 1 969 727 patients from the Surveillance, Epidemiology, and End Results registry. Two-sided tests were used for all statistical analyses.

RESULTS

Consistently across disease sites, mortality risk increased continuously with increasing number of metastatic LNs (P < .001 for all spline segments). Each RPA-derived nodal classification system produced multiple prognostic groups spanning a wide spectrum of mortality risk (P < .001). Multivariable models using these RPA-derived nodal classifications demonstrated improved concordance with mortality compared with models using American Joint Committee on Cancer staging in sites where nodal classification is not based on metastatic LN count. Each RPA-derived nodal classification system was reproducible in a large validation cohort for all-cause and cause-specific mortality (P < .001). High quantitative nodal burden was the single strongest tumor-intrinsic variable associated with mortality in 12 of 16 disease sites.

CONCLUSIONS

Quantitative metastatic LN burden is a fundamental driver of mortality across solid cancers and should serve as a foundation for pathologic nodal staging across solid tumors.

Increasing sample diversity in psychiatric genetics - Introducing a new cohort of patients with schizophrenia and controls from Vietnam - Results from a pilot study

OBJECTIVES

Genome-Wide Association Studies (GWAS) of Schizophrenia (SCZ) have provided new biological insights; however, most cohorts are of European ancestry. As a result, derived polygenic risk scores (PRS) show decreased predictive power when applied to populations of different ancestries. We aimed to assess the feasibility of a large-scale data collection in Hanoi, Vietnam, contribute to international efforts to diversify ancestry in SCZ genetic research and examine the transferability of SCZ-PRS to individuals of Vietnamese Kinh ancestry.

METHODS

In a pilot study, 368 individuals (including 190 SCZ cases) were recruited at the Hanoi Medical University's associated psychiatric hospitals and outpatient facilities. Data collection included sociodemographic data, baseline clinical data, clinical interviews assessing symptom severity and genome-wide SNP genotyping. SCZ-PRS were generated using different training data sets: (i) European, (ii) East-Asian and (iii) trans-ancestry GWAS summary statistics from the latest SCZ GWAS meta-analysis.

RESULTS

SCZ-PRS significantly predicted case status in Vietnamese individuals using mixed-ancestry (R² liability = 4.9%, p = 6.83 × 10^-8), East-Asian (R² liability = 4.5%, p = 2.73 × 10^-7) and European (R² liability = 3.8%, p = 1.79 × 10^-6) discovery samples.

DISCUSSION

Our results corroborate previous findings of reduced PRS predictive power across populations, highlighting the importance of ancestral diversity in GWA studies.

Development and Validation of a Modified Pathologic Nodal Classification System for Cutaneous Melanoma

Importance

Given the evolving patterns of lymph node evaluation for cutaneous melanoma, it is unclear whether the current nodal classification system will continue to accurately reflect prognosis in the modern era. Existing nodal staging for cutaneous melanoma was developed primarily for patients undergoing completion lymph node dissection (CLND) for node-positive disease and does not produce groups with continuously increasing mortality.

Objective

To develop and validate a modified nodal classification system for cutaneous melanoma.

Design, Setting, and Participants

This retrospective cohort analysis included 105 785 patients with cutaneous melanoma undergoing surgery and nodal evaluation from January 1, 2004, to December 31, 2015, in the National Cancer Database. Extent of lymph node dissection was available for patients diagnosed in 2012 and onward. Multivariable models were generated with number of positive lymph nodes modeled using restricted cubic splines. A modified nodal classification system was derived using recursive partitioning analysis (RPA). The proposed lymph node classification system was validated in 85 499 patients from the Surveillance, Epidemiology, and End Results (SEER-18) database. Data were analyzed from April 9, 2020, to May 28, 2021.

Main Outcomes and Measures

Overall survival.

Results

Among the 105 785 patients included in the analysis (62 496 men [59.1%]; mean [SD] age, 59.9 [15.5] years), number of positive lymph nodes (hazard ratio [HR] per lymph node for 0 to 2 positive lymph nodes, 2.48 [95% CI, 2.37-2-61; P < .001]; HR per lymph node for ≥3 positive lymph nodes, 1.10 [95% CI 1.07-1.13; P < .001]), clinically detected metastases (HR, 1.35; 95% CI, 1.27-1.42; P < .001), and in-transit metastases (HR, 1.48; 95% CI, 1.34-1.65; P < .001) were independently associated with mortality. An RPA-derived system using these variables demonstrated continuously increasing mortality for each proposed lymph node classification group, with HRs of 1.83 (95% CI, 1.76-1.91) for N1a, 2.72 (95% CI, 2.58-2.86) for N1b, 3.79 (95% CI, 3.51-4.08) for N2a, 4.56 (95% CI, 4.22-4.92) for N2b, 6.15 (95% CI, 5.59-6.76) for N3a, and 8.25 (95% CI, 7.64-8.91) for N3b in the proposed system (P < .001). By contrast, the current American Joint Committee on Cancer (AJCC) nodal classification system produced a more haphazard mortality profile, with HRs of 1.83 (95% CI, 1.76-1.91) for N1a, 3.81 (95% CI, 3.53-4.12) for N1b, 2.59 (95% CI, 2.30-2.93) for N1c, 2.71 (95% CI, 2.56-2.87) for N2a, 4.51 (95% CI, 4.17-4.87) for N2b, 3.44 (95% CI, 2.60-4.55) for N2c, 6.06 (95% CI, 5.51-6.67) for N3a, 8.15 (95% CI, 7.54-8.81) for N3b, and 6.90 (95% CI, 5.60-8.49) for N3c. As a sensitivity analysis, the proposed system continued to accurately stratify patients when excluding those undergoing CLND for microscopic lymph node metastases. This system was validated for overall survival and cause-specific mortality in SEER-18. Last, a new overall staging system for node-positive patients was developed by RPA and demonstrated improved concordance vs the AJCC, 8th edition system (C statistic, 0.690 [95% CI, 0.689-0.691] vs 0.666 [95% CI, 0.666-0.668]).

Conclusions and Relevance

The findings of this cohort study suggest that a modified nodal classification system can accurately stratify mortality risk in cutaneous melanoma in an era of increasing use of sentinel lymph node biopsy without CLND and should be considered for future staging systems.

Abstract OT-13-01: A phase I study of preoperative ipilimumab, nivolumab, and talimogene laherparepvec for localized breast cancer

Background: Immunotherapy has emerged as a novel therapeutic strategy in many solid malignancies. In breast cancer, treatment with checkpoint inhibitors alone showed minimal response rates, likely because breast cancers are not sufficiently immunogenic to induce adequate baseline T cell activation. Talimogene laherparepvec (T-VEC) is an attenuated herpes simplex virus 1 (HSV-1) engineered to introduce the GM-CSF gene selectively into tumor cells to thereby enhance the immunogenicity of transduced tumor cells. T-VEC has been approved in the treatment of patients with advanced melanoma and injectable tumors. In a phase 1b clinical trial, T-VEC was well tolerated in combination with immunotherapy in patients with advanced melanoma. We evaluated the safety and tolerability of T-VEC, nivolumab, and ipilimumab in the preoperative treatment of early stage localized triple-negative breast cancer (TNBC) and hormone receptor (HR)-positive breast cancer.

Trial design and eligibility criteria: This is a single site open-label phase 1b window of opportunity trial of neoadjuvant T-VEC in combination with nivolumab and ipilimumab in patients with localized breast cancer. Twenty patients with localized TNBC or HR-positive breast cancer with palpable tumors will be included. T-VEC is administered intratumorally in week 1 (106 plaque-forming units/mL [pfu/ml]) and then every 3 weeks (108 plaque-forming units/mL [pfu/ml]) for a total of 3 injections. Nivolumab (240 mg) is administered intravenously in week 1 and every 2 weeks for a total of 4 infusions. Ipilimumab (1 mg/kg) is administered intravenously in week 1 and week 6 for a total of 2 infusions. Breast cancer surgery will be carried out after completion of study treatment. Neoadjuvant chemotherapy could be administered before or after study treatment.

Study objectives: The primary objective is to evaluate the safety and tolerability of T-VEC in combination with nivolumab and ipilimumab in this population. The secondary objectives are 1) to assess tumor response to T-VEC, nivolumab, and ipilimumab and 2) to descriptively analyze surgical specimens for evidence of tumor necrosis and inflammatory infiltration on histopathological examination.

Present accrual: To date, 5 patients have been enrolled. As described above, the projected sample size is 20 patients.

Clinical trials identification: NCT04185311

Citation Format: Vina P. Nguyen, Helena R. Chang, Maggie L. DiNome, Denise K. Oseguera, Deborah J. Wong, Anthony T. Nguyen, Stephen L. Shiao, John A. Glaspy. A phase I study of preoperative ipilimumab, nivolumab, and talimogene laherparepvec for localized breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-13-01.

Abstract C004: End-of-life care in patients with advanced cancer in an urban safety net hospital

Abstract End-of-life care (EoL) in patients with advanced cancer is uniquely challenging in an urban safety net hospital. Low socioeconomic status, poor health literacy and non-congruent language barriers are only a few of the possible challenges that patients can encounter. The purpose of this study was to understand patterns of EoL care for patients with advanced cancer treated at a racially diverse, urban academic safety net hospital. Experimental Procedures We performed a retrospective analysis of 308 adult patients with advanced cancer who died between 2012 and 2015. A standardized chart abstraction tool included sociodemographic, clincopathologic and health services variables. We defined under-utilization of EoL care as no enrollment in hospice or enrollment for three days or less. Aggressive EoL care was defined as 1) receipt of chemotherapy in the last 14 days of life, 2) admission to the intensive care unit in the last 30 days of life, 3) more than one admission (to the hospital or emergency department) in the last 30 days of life, or 4) dying in an acute care setting. Summary of Data Among 308 abstracted records, 54% were racial minorities, 63% were not born in the United States, 72% had public health insurance. In all, 48% of cases demonstrated under-utilization of EoL care, and 45% demonstrated aggressive EoL care. A multivariate analysis demonstrated that, after adjusting for other factors, every month of increased survival was associated with a 3% decreased risk of aggressive EoL care and of under-utilization of hospice. We also demonstrate that having a documented healthcare proxy and older age was also associated with utilization of EoL care. Conclusions In conclusion, appropriate EoL care is critical for all advanced cancer patients and can be improved for patients seeking care at safety net hospitals. Our study demonstrates that advanced age, having a healthcare proxy, and longer survival from a cancer diagnosis was associated with improved EoL care. These findings can help to inform targeted interventions to improve EoL care for diverse populations.

Citation Format: Vina P Nguyen, Kate Festa, Minda Gowarty, Shabatun Islam, Gregory J Patts, Naomi Y Ko. End-of-life care in patients with advanced cancer in an urban safety net hospital [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C004.

Outcomes of patients with AL amyloidosis and low serum free light chain levels at diagnosis

Serum free light chains (sFLC) are independent prognostic markers of disease in light chain (AL) amyloidosis, and are used in the haematologic response criteria for treatment. However, up to 20% of patients have low sFLCs at diagnosis, with a difference between involved and uninvolved free light chains (dFLC) of less than 50 mg/L, making responses to treatment difficult to evaluate. In order to characterize this distinct subgroup of patients, we retrospectively analyzed 123 AL amyloidosis patients with dFLC <50 mg/L who were diagnosed between 2002 and 2013. The majority (n = 117) were treated for their AL amyloidosis, with over half (n = 68) receiving high-dose melphalan and autologous stem cell transplantation as first-line therapy. Overall they had a prolonged median survival of 9.2 years with less cardiac involvement (30%) and more renal involvement (76%). We also evaluated the newly proposed low dFLC partial response (PR) criteria, defined as a dFLC <10 mg/L if the initial dFLC 20-50 mg/L. The 14 patients with low dFLC PR had improved survival and organ responses compared with patients with no haematologic response. However, one-third of patients (n = 41) had an initial dFLC <20 mg/L so could not be evaluated. More sensitive methods of monitoring response to treatment for this subgroup population are still needed.

A quantitative dietary study of the ?Critically Endangered? Gilbert?s potoroo Potorous gilbertii

Faecal analysis from the only known population of Gilbert?s potoroo (Potorous gilbertii) near Albany, Western Australia revealed that it, like other rat-kangaroo species is primarily mycophagous. Diet was determined by faecal collections from live-captured animals within Two Peoples Bay Nature Reserve. Microscopic examination of samples collected from June - September 2000 and additional samples from storage, found fungi to comprise over 90% of faecal matter. A total of 44 fungal spore types were identified with many believed to be of hypogeous origin. Fungal spores belonging to the genera Mesophellia, Elaphomyces, Hysterangium and an unknown spore type (Unknown 1) were frequently recorded in samples. Non-fungal material including plants (stems, roots and seeds) and invertebrates represented the remainder. This investigation found that P. gilbertii fed almost exclusively on fungi and could be considered a specialised mycophagist.

Results of up to 9 years of high-temperature-fixed valvular bioprostheses in a young population

BACKGROUND

Bioprosthetic valve replacement in young patients remains a controversial issue due to a high rate of early calcification. Previous studies in our laboratory have shown that high-temperature fixation of glutaraldehyde preserved bioprosthesis (HTF) mitigates calcification. The first clinical application of this technique was started in 1991.

METHODS

From January 1991 to September 1998, 50 patients in whom anticoagulants were contraindicated underwent single aortic valve replacement (n = 33) or mitral valve replacement (n = 17) using HTF bioprostheses. The age of the patients ranged from 7 months to 35 years (mean 22.7+/-6.8 years). The mean New York Heart Association status was 2.4. Mean follow-up 4 years +/- 1.8 for a total follow-up of 196 patient-years.

RESULTS

There were no operative deaths and but there were two late deaths, one valve related. Structural failure occured in 4 patients (2%/patient-year) requiring a reoperation in 3 patients (1.5%/patient-year). No endocarditis or thromboembolic episodes were observed. At late examination (June 2000), 46 patients (92%) were in New York Heart Association class I or II, with a well functioning valve.

CONCLUSIONS

Replacement with HTF bioprostheses in young patients has demonstrated encouraging midterm results with a low incidence of structural failure

Coronavirus envelope glycoprotein assembly complexes

Protein:protein interactions, and their subcellular localization, play important roles in coronavirus assembly. In this study, we have identified similar envelope glycoprotein complexes that are present in mouse hepatitis coronavirus A59 (MHV-A59) and bovine coronavirus (BCV) infected cells. Complexes consisting of the spike (S) and membrane (M) proteins were identified in cells infected with MHV-A59 or BCV. Kinetic analyses demonstrated that S and M quickly associated after translation, and suggested that both initially interacted in a pre-Golgi site. In addition, the hemagglutinin esterase (HE) was identified as part of a complex with M and S in BCV infected cells. Taken together, our data indicate that similar glycoprotein complexes are present in cells infected with two different coronaviruses, and thus likely represent important prerequisite complexes involved in virus assembly.

Variation in the immune status of two Australian pig breeds

OBJECTIVE

To investigate the variation in immune competence of two Australian pig breeds.

DESIGN

A panel of immune tests were used to assess breed and sire differences in weaner piglets of Large White and Duroc breeds.

PROCEDURE

All piglets were immunised against porcine leptospirosis. Blood samples were taken for studies on lymphocyte phenotypes, mitogenic responses of blood cells and serological analysis.

RESULTS

Significantly larger blood leucocyte numbers were found in Large White piglets compared with Duroc piglets after vaccinations. No significant difference in concanavalin A induced blood cell proliferation was found between these two breeds before or after vaccinations. Some significant breed variation in blood lymphocyte phenotypes was found. While the age-related changes of lymphocyte phenotypes were similar for the two breeds, the Large White breed had significantly larger numbers of CD2+ and CD4+ cells than the Duroc breed after the two vaccinations. There were also significant sire effects on CD8+ cells within the Large White breed after the first vaccination. No significant breed difference was detectable in serum IgG concentrations but sire differences within each breed before the primary vaccination were found. The serum antibody response to vaccination against leptospirosis was generally small, and showed no variations due to either breed or sire. No gender effects were found during the entire study.

CONCLUSION

The study demonstrated significant differences in some important immune components of the pig breeds studied. This may in turn indicate the variation in their immune competence or disease resistance. However, further investigation into the heritability and correlation with specific immune responses is required.

Protein interactions during coronavirus assembly

Coronaviruses assemble and obtain their envelope at membranes of the intermediate compartment between the endoplasmic reticulum and Golgi complex. Like other enveloped viruses, coronavirus assembly is presumably dependent on protein localization and protein-protein as well as protein-RNA interactions. We have used the bovine coronavirus (BCV) as a model to study interactions between the viral proteins in virus-infected cells that are important for coronavirus assembly. BCV is a prototype for the coronaviruses that express an additional major structural protein, the hemagglutinin esterase (HE), in addition to the spike (S) glycoprotein, membrane (M) glycoprotein, and nucleocapsid (N) protein. Complexes consisting of the M, S, and HE proteins were detected in virus-infected cells by coimmunoprecipitations. Kinetic analyses demonstrated that S protein and HE each quickly formed a complex with M protein after synthesis, whereas heterocomplexes consisting of all three proteins formed more slowly. The kinetics of HE biosynthesis revealed that the half-life of oligomerization was approximately 30 min, which correlated with the appearance of complexes consisting of M, HE, and S proteins, suggesting that oligomerization and/or conformational changes may be important for the S-M-HE protein complexes to form. Only HE dimers were found associated with the heterocomplexes consisting of all three proteins. S-M-HE protein complexes were detected prior to processing of the oligosaccharide chains on HE, indicating that these protein complexes formed in a premedial Golgi compartment before trimming of sugar chains. Transient coexpressions and double-labeling immunofluorescence demonstrated that HE and S proteins colocalized with M protein. This was further supported by coimmunoprecipitation of specific HE-M and S-M protein complexes from transfected cells, indicating that these proteins can form complexes in the absence of other viral proteins.

Fertility and family planning in Vietnam: evidence from the 1994 Inter-censal Demographic Survey

Results from the 1994 Vietnam Inter-censal Demographic Survey reveal substantial change over recent years in reproductive behavior and attitudes. Fertility has continued to decline to a level not far above a total fertility rate of three children per woman. Compared with the late 1980s, contraceptive knowledge has broadened and contraceptive prevalence has increased, reaching a level of 65 percent of currently married women of reproductive age. The dominance of the IUD among modern methods has been reduced somewhat. Stated family-size preferences have shifted noticeably downward. Recently married women indicate that they want only 2.3 children, on average, suggesting that fertility will continue to fall in coming years. These findings suggest that Vietnam is in the midst of a transition that will lead to low levels of fertility in the near future.

Repression of glucocorticoid receptor-mediated transcriptional activation by unliganded thyroid hormone receptor (TR) is TR isoform-specific

Two genes, c-ErbA alpha and c-ErbA beta, generate at least three functional T3 receptor (TR) isoforms in the rat: TR alpha-1, TR beta-1, and TR beta-2. The latter is an N-terminal splice variant of TR beta-1 whose expression is high in the pituitary gland, whereas the other isoforms are more widely expressed. It is believed that TR beta-2 might play an important role in the pituitary, but no specific biological activities have been defined. Using in vitro translated receptors, we were unable to detect striking isoform-specific differences in T3 binding, DNA binding, homodimerization and heterodimerization activities with retinoid X receptor in the electrophoretic mobility assay, or T3-dependent repression and activation of basal transcription in transfection assays. The N-terminus of TR beta is completely dispensible for these activities. However, we found that unliganded TR alpha-1 and TR beta-1, but not TR beta-2, can repress glucocorticoid receptor-mediated transcriptional activation if the reporter gene promoter contains binding sites for both receptor species. TR beta-2 also synergizes most efficiently with the glucocorticoid receptor in the presence for the of T3. The TR beta-2-specific N-terminus is required for these effects. This result indicates that the relative abundance of specific TR isoforms may determine the with the glucocorticoid receptor in the presence of T3. The TR beta-2 specific N-terminus is required for these effects. This result indicates that the relative abundance of specific TR isoforms may determine the quantitative response of a gene that is regulated by T3 and glucocorticoids. In particular, pituitary TR beta-2 may be an important mediator of GH gene expression, which is regulated by both of these hormones.

Rat Rev-erbA alpha, an orphan receptor related to thyroid hormone receptor, binds to specific thyroid hormone response elements

Rat Rev-erbA alpha (rRev), which is related to thyroid hormone receptor (TR), is a conserved member of the nuclear hormone receptor superfamily whose physiological roles are unknown ("orphan" receptor). We studied DNA binding of rRev in vitro by electrophoretic mobility shift assay. A fusion protein was constructed, called NGR.Rev, containing part of the N terminus of the glucocorticoid receptor fused to nearly full-length rRev. Inasmuch as rRev and TR share homology in their DNA-binding domains, we tested binding to three different thyroid hormone response elements (TREs) in which the half-sites are arranged in different orientations. NGR.Rev bound direct repeats (DR4), but not palindromic (TREpal) or inverted palindromic (F2H) repeats. Also, transfection of CV1 cells with a reporter gene containing the luciferase gene under control of the inducible thymidine kinase promoter resulted in an increase in luciferase activity when NGR.Rev was cotransfected and when the thymidine kinase promoter contained DR4. In addition, a series of deletions in the ligand-binding domain of NGR.Rev revealed regions that can modulate DNA binding. Finally, we studied DNA binding of bacterially produced fusion proteins that contain the DNA-binding domains of rRev or rTR alpha fused to glutathione S-transferase, to a panel of natural TREs. Our results indicate that Rev binds DNA with a different specificity than TR alpha-1 and might be involved in the regulation of a subset of thyroid hormone-regulated genes.