Abstract 942: Real-world demographics, baseline characteristics, healthcare resource utilization and costs amongst non-small cell lung cancer (NSCLC) patients tested with a Host Immune Classifier (HIC)

Background: The Host Immune Classifier is a proteomic test that identifies a chronic inflammatory disease state for patients diagnosed with NSCLC. The test stratifies patients into two groups, HIC-H and HIC-C and helps evaluate patient prognosis and response to treatment. While much work has been done to evaluate the clinical validity of the HIC test, to date, no recent real-world studies have described healthcare resource utilization (HCRU) and costs amongst patients utilizing the test. This subset analysis of HIC claims examined demographic and baseline clinical characteristics among patients with lung cancer using the HIC proteomic test as well as HCRU and costs prior to test use.

Methods: This retrospective claims analysis utilized MarketScan® Commercial and Medicare Supplemental Databases using data from January 1, 2016 to June 30, 2021 linked to Biodesix data files of HIC test results. Patients were age 18 or older on index date (date of HIC testing), underwent a HIC proteomic test, were continuously enrolled in the MarketScan database for the 6-months before index (pre-index period), and had at least one non-diagnostic medical claim of lung cancer during the pre-index period. Clinical characteristics and HCRU and costs were measured per patient per month (PPPM) during the pre-index period and compared between HIC-H and HIC-C cohorts.

Results: Of the 328 included patients, 260 patients were HIC-H and 68 were HIC-C. On index, 178 patients had non-metastatic lung cancer and 150 patients had metastatic lung cancer. When assessing lung cancer related comorbid conditions, significantly more HIC-C patients had empyema (3% vs 0%, P<0.05) and pneumonia (34% vs 19%, P<0.05). When examining HCRU in patients prior to the HIC test, significantly more HIC-C patients had an outpatient visit with an oncologist (40% vs 27%, P<0.05) or a primary care physician (71% vs 56%, P<0.05). Total costs and inpatient costs were higher amongst HIC-C patients ($10,299 vs $9,689 and $4,032 vs $3,218, respectively) although not significant. While fewer HIC-C patients underwent lung biopsy (41% vs 53%), HIC-C patients had significantly higher biopsy costs than HIC-H patients ($1,285 vs $400, P<0.05). Although not statistically significant, more HIC-C patients had an inpatient admission (47% vs 38%) and longer average length of stay (5.3 vs 4.2 days).

Conclusion: Patients with NSCLC who are identified as HIC-C have higher HCRU and costs, including lung cancer workup costs, prior to HIC testing. Further analyses are planned to determine long-term clinical outcomes, HCRU, and costs amongst patients post-testing.

Citation Format: Wade Iams, Kimberly Le, Nicole Princic, Isabelle Winer, Taylor Marlin. Real-world demographics, baseline characteristics, healthcare resource utilization and costs amongst non-small cell lung cancer (NSCLC) patients tested with a Host Immune Classifier (HIC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 942.

Associations of influenza vaccination with severity of immune-related adverse events in patients with advanced thoracic cancers on immune checkpoint inhibitors

Background

Whether influenza vaccination (FV) is associated with the severity of immune-related adverse events (IRAEs) in patients with advanced thoracic cancer on immune checkpoint inhibitors (ICIs) is not fully understood.

Methods

Patients enrolled in this retrospective cohort study were identified from the Vanderbilt BioVU database and their medical records were reviewed. Patients with advanced thoracic cancer who received FV within 3 months prior to or during their ICI treatment period were enrolled in the FV-positive cohort and those who did not were enrolled in the FV-negative cohort. The primary objective was to detect whether FV is associated with decreased IRAE severity. The secondary objectives were to evaluate whether FV is associated with a decreased risk for grade 3-5 IRAEs and better survival times. Multivariable ordinal logistic regression was used for the primary analysis.

Results

A total of 142 and 105 patients were enrolled in the FV-positive and FV-negative cohorts, respectively. There was no statistically significant difference in patient demographics or cumulative incidences of IRAEs between the two cohorts. In the primary analysis, FV was inversely associated with the severity of IRAEs (OR 0.63; p=0.046). In the secondary analysis, FV was associated with a decreased risk for grade 3-5 IRAEs (OR 0.42; p=0.005). Multivariable Cox regression showed that FV was not associated with survival times.

Conclusions

Our study showed that FV does not increase toxicity for patients with advanced thoracic cancer on ICIs and is associated with a decreased risk for grade 3-5 IRAEs. No statistically significant survival differences were found between patients with and without FV.

Small Cell Lung Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Small Cell Lung Cancer (SCLC) provide recommended management for patients with SCLC, including diagnosis, primary treatment, surveillance for relapse, and subsequent treatment. This selection for the journal focuses on metastatic (known as extensive-stage) SCLC, which is more common than limited-stage SCLC. Systemic therapy alone can palliate symptoms and prolong survival in most patients with extensive-stage disease. Smoking cessation counseling and intervention should be strongly promoted in patients with SCLC and other high-grade neuroendocrine carcinomas. The "Summary of the Guidelines Updates" section in the SCLC algorithm outlines the most recent revisions for the 2022 update, which are described in greater detail in this revised Discussion text.

Framework for Implementing and Tracking a Molecular Tumor Board at a National Cancer Institute-Designated Comprehensive Cancer Center

BACKGROUND

Over the past few years, tumor next-generation sequencing (NGS) panels have evolved in complexity and have changed from selected gene panels with a handful of genes to larger panels with hundreds of genes, sometimes in combination with paired germline filtering and/or testing. With this move toward increasingly large NGS panels, we have rapidly outgrown the available literature supporting the utility of treatments targeting many reported gene alterations, making it challenging for oncology providers to interpret NGS results and make a therapy recommendation for their patients.

METHODS

To support the oncologists at Vanderbilt-Ingram Cancer Center (VICC) in interpreting NGS reports for patient care, we initiated two molecular tumor boards (MTBs)-a VICC-specific institutional board for our patients and a global community MTB open to the larger oncology patient population. Core attendees include oncologists, hematologist, molecular pathologists, cancer geneticists, and cancer genetic counselors. Recommendations generated from MTB were documented in a formal report that was uploaded to our electronic health record system.

RESULTS

As of December 2020, we have discussed over 170 patient cases from 77 unique oncology providers from VICC and its affiliate sites, and a total of 58 international patient cases by 25 unique providers from six different countries across the globe. Breast cancer and lung cancer were the most presented diagnoses.

CONCLUSION

In this article, we share our learning from the MTB experience and document best practices at our institution. We aim to lay a framework that allows other institutions to recreate MTBs.

IMPLICATIONS FOR PRACTICE

With the rapid pace of molecularly driven therapies entering the oncology care spectrum, there is a need to create resources that support timely and accurate interpretation of next-generation sequencing reports to guide treatment decision for patients. Molecular tumor boards (MTB) have been created as a response to this knowledge gap. This report shares implementation strategies and best practices from the Vanderbilt experience of creating an institutional MTB and a virtual global MTB for the larger oncology community. This report describe a reproducible framework that can be adopted to initiate MTBs at other institutions.

Circulating Tumor DNA as a Biomarker of Radiographic Tumor Burden in SCLC

Introduction

Blood-based next-generation sequencing assays of circulating tumor DNA (ctDNA) have the ability to detect tumor-associated mutations in patients with SCLC. We sought to characterize the relationship between ctDNA mean variant allele frequency (VAF) and radiographic total-body tumor volume (TV) in patients with SCLC.

Methods

We identified matched blood draws and computed tomography (CT) or positron emission tomography (PET) scans within a prospective SCLC blood banking cohort. We sequenced plasma using our previously developed 14-gene SCLC-specific ctDNA assay. Three-dimensional TV was determined from PET and CT scans using MIM software and reviewed by radiation oncologists. Univariate association and multivariate regression analyses were performed to evaluate the association between mean VAF and total-body TV.

Results

We analyzed 75 matched blood draws and CT or PET scans from 25 unique patients with SCLC. Univariate analysis revealed a positive association between mean VAF and total-body TV (Spearman’s ρ = 0.292, p < 0.01), and when considering only treatment-naive and pretreatment patients (n = 11), there was an increase in the magnitude of association (ρ = 0.618, p = 0.048). The relationship remained significant when adjusting for treatment status and bone metastases (p = 0.046). In the subgroup of patients with TP53 variants, univariate analysis revealed a significant association (ρ = 0.762, p = 0.037) only when considering treatment-naive and pretreatment patients (n = 8).

Conclusions

We observed a positive association between mean VAF and total-body TV in patients with SCLC, suggesting mean VAF may represent a dynamic biomarker of tumor burden that could be followed to monitor disease status.

Beyond Programmed Death-Ligand 1: B7-H6 Emerges as a Potential Immunotherapy Target in SCLC

INTRODUCTION

The programmed death-ligand 1 (PD-L1) immune checkpoint inhibitors, atezolizumab and durvalumab, have received regulatory approval for the first-line treatment of patients with extensive-stage SCLC. Nevertheless, when used in combination with platinum-based chemotherapy, these PD-L1 inhibitors only improve overall survival by 2 to 3 months. This may be due to the observation that less than 20% of SCLC tumors express PD-L1 at greater than 1%. Evaluating the composition and abundance of checkpoint molecules in SCLC may identify molecules beyond PD-L1 that are amenable to therapeutic targeting.

METHODS

We analyzed RNA-sequencing data from SCLC cell lines (n = 108) and primary tumor specimens (n = 81) for expression of 39 functionally validated inhibitory checkpoint ligands. Furthermore, we generated tissue microarrays containing SCLC cell lines and patient with SCLC specimens to confirm expression of these molecules by immunohistochemistry. We annotated patient outcomes data, including treatment response and overall survival.

RESULTS

The checkpoint protein B7-H6 (NCR3LG1) exhibited increased protein expression relative to PD-L1 in cell lines and tumors (p < 0.05). Higher B7-H6 protein expression correlated with longer progression-free survival (p = 0.0368) and increased total immune infiltrates (CD45+) in patients. Furthermore, increased B7-H6 gene expression in SCLC tumors correlated with a decreased activated natural killer cell gene signature, suggesting a complex interplay between B7-H6 expression and immune signature in SCLC.

CONCLUSIONS

We investigated 39 inhibitory checkpoint molecules in SCLC and found that B7-H6 is highly expressed and associated with progression-free survival. In addition, 26 of 39 immune checkpoint proteins in SCLC tumors were more abundantly expressed than PD-L1, indicating an urgent need to investigate additional checkpoint targets for therapy in addition to PD-L1.

Abstract 715: Circulating tumor DNA as a potential biomarker of radiographic tumor burden in small cell lung cancer

Introduction

Blood-based next generation sequencing assays of circulating tumor DNA (ctDNA) have the ability to detect canonical SCLC tumor-associated mutations1,2. In non-small cell lung cancer, mean variant allele frequency (VAF) of clonal mutations in ctDNA is associated with radiographic tumor volume (TV)3. We sought to characterize the relationship between ctDNA mean VAF and total-body tumor burden in patients with SCLC.

Methods

Patients with both limited- and extensive-stage SCLC were identified prospectively and underwent serial blood draws as part of an IRB-approved protocol (IRB #030763). Using our previously developed ctDNA assay, mean VAF was calculated from patient plasma by sequencing 14 genes (all coding exons of TP53, RB1, BRAF, KIT, NOTCH1-4, PIK3CA, PTEN, and copy number variations in FGFR1, MYC, MYCL1, and MYCN)1,4. Three-dimensional total-body tumor burden was determined from positron emission tomography and computed tomography scans obtained during routine care using a radiation oncology treatment-planning software (MIM), and tumor segmentations were verified by radiation oncologists. Univariate association and multivariable mixed effects regression analyses (including presence of bone metastases and treatment status) were performed to evaluate the association between mean VAF and overall TV. We performed separate analyses for mean VAF of all variants identified and of TP53 variants only.

Results

We analyzed 75 concordant scans and blood draws from 25 patients with SCLC. The median interval between imaging and blood collection was 1 day (mean 3.5, range 0-16).

Univariate analysis showed a positive association between mean VAF of all variants and overall TV (Spearman's ρ=0.292, p&lt;0.01). When considering only treatment-naïve and pre-treatment samples (n=11), the magnitude of association increased and remained significant (ρ=0.618, p=0.048). The relationship between mean VAF of all variants and overall TV remained significant when adjusting for treatment status and bone metastases (p=0.046). When considering only TP53 variants, an overall univariate correlation analysis did not show a significant association between mean VAF and overall TV (ρ=0.184, p=0.175). However, among treatment-naïve and pre-treatment samples (n=8) with TP53 variants, the association was significant (ρ=0.762, p=0.037). This association remained significant (p=0.021) after adjusting for treatment status and presence of bone metastasis, with VAF increasing 3.7% for each fold increase in TV (95% CI: 0.7-6.7%).

Conclusion

In our study mean VAF (both overall and TP53 variants only) was positively correlated with three-dimensional total-body tumor burden in patients with SCLC. These results suggest that mean VAF may provide a useful snapshot of overall tumor burden and represent a dynamic biomarker that could be followed to monitor for disease progression in patients with SCLC.

References 1. Almodovar K, et al. Longitudinal Cell-Free DNA Analysis in Patients with Small Cell Lung Cancer... J Thorac Oncol 2018;13:112-23. 2. Nong J, et al. ctDNA analysis depicts subclonal architecture...of small cell lung cancer. Nat Commun 2018;9:3114. 3. Abbosh C, et al. Phylogenetic ctDNA analysis depicts early-stage lung cancer evolution. Nature 2017;545:446-51. 4. George J, et al. Comprehensive genomic profiles of small cell lung cancer. Nature 2015;524:47.

Citation Format: Jarrod T. Smith, Aneri Balar, Dhairya A. Lakhani, Christien Kluwe, Zhiguo Zhao, Prasad Kopparapu, Karinna Almodovar, Anel Muterspaugh, Yingjun Yan, Sally York, Leora Horn, Sanja Antic, Caterina Bertucci, Tristan Shaffer, Lauren Hodsdon, Kavita Garg, Seyed Ali Hosseini, Lee Lim, Evan Osmundson, Pierre Massion, Christine Lovly, Wade Iams. Circulating tumor DNA as a potential biomarker of radiographic tumor burden in small cell lung cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 715.

Abstract B20: Prolonged time to clearance of circulating-tumor DNA from patients with limited-stage small-cell lung cancer is associated with inferior progression-free and overall survival

Introduction: Despite recent incremental advances, patients with small-cell lung cancer (SCLC) continue to have a poor prognosis, with a median overall survival (OS) of 12-20 months in limited-stage disease (LS-SCLC) and approximately 12 months in extensive-stage disease (ES-SCLC). In an attempt to improve the detection and monitoring of SCLC, assays of circulating tumor DNA (ctDNA) via blood-based next-generation sequencing (NGS) have been validated. In this study, we used a blood-based 14 gene SCLC ctDNA NGS panel to evaluate the prognostic significance of the diagnostic maximum ctDNA variant allele frequency (VAF), diagnostic mean ctDNA VAF, and time to ctDNA clearance while on first-line therapy.

Design: In our previous work, we developed a ctDNA assay to sequence 14 genes (TP53, RB1, BRAF, KIT, NOTCH1-4, PIK3CA, PTEN, FGFR1, MYC, MYCL1, and MYCN) that are commonly mutated in SCLC. A total of 104 plasma samples were analyzed from a cohort of 14 patients with LS-SCLC who completed definitive chemoradiation (n=13) or surgical resection (n=1) and had an end-of-treatment blood collection within nine weeks (mean 10.5 days, range 0-63 days) of completion of definitive initial therapy. We used a Cox Proportional Hazards model to estimate the hazard ratio (HR) for progression-free survival (PFS) or death based on the diagnostic maximum ctDNA VAF, diagnostic mean ctDNA VAF, and time to ctDNA clearance on first-line therapy.

Results: In our 14-patient cohort, we did not observe any association between progression or death and maximum diagnostic ctDNA VAF (PFS HR: 1.01, CI 0.97-1.05; OS HR: 1, CI 0.95-1.04) or mean diagnostic ctDNA VAF (PFS HR: 1.01, CI 0.94-1.08; OS HR: 0.99, CI 0.91-1.07). Of the specific mutations representing the maximum diagnostic ctDNA VAF, TP53 represented 14.2% (n=2), while the remaining included RB1 associated mutations (n=5), PIK3CA (n=1), MYCL1 amplification (n=1), or no ctDNA at diagnosis (n=5). Among patients with clearance of ctDNA during first-line therapy (n=9), delayed time to ctDNA clearance was associated with inferior PFS (HR 1.1, CI 1.01-1.19) and OS (HR 1.07, CI 1.01-1.15), with median time to clearance of 63 days (range 29-92 days). Notably, 3 patients cleared ctDNA on their first on-treatment draw at approximately 30 days (29, days, 29 days, and 32 days). These patients have had no evidence of relapse and all remain alive since the start of first-line treatment (1467, 965, and 383 days of follow-up). Of the patients who had disease recurrence, the median time to clearance on first-line therapy was 65 days and median time to progression was 249 days, with all but 1 patient succumbing to their disease (median OS 437 days).

Conclusion: In patients with LS-SCLC, prolonged time to ctDNA clearance during first-line therapy is associated with inferior PFS and OS. Larger patient cohorts are needed to validate this finding.

Citation Format: Christopher Cann, Prasad Kopparapu, Yingjun Yan, Anel Muterspaugh, Heidi Chen, Zhiguo Zhao, Sally York, Leora Horn, Kristen Ancell, Kenneth Wyman, Caterina Bertucci, Tristan Shaffer, Lauren Hodson, Kavita Garg, Seyed Ali Hosseini, Lee Lim, Christine M. Lovly, Wade Iams. Prolonged time to clearance of circulating-tumor DNA from patients with limited-stage small-cell lung cancer is associated with inferior progression-free and overall survival [abstract]. In: Proceedings of the AACR Special Conference on Advances in Liquid Biopsies; Jan 13-16, 2020; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(11_Suppl):Abstract nr B20.

Evaluation of immune checkpoints in small cell lung cancer: implications for immunotherapy

Introduction

The FDA recently approved Atezolizumab, a programmed death-ligand 1 (PD-L1) inhibitor, for first-line combinatory treatment in patients with extensive-stage small cell lung cancer. Across several cancer types, immunotherapy has been shown to provide durable benefit in patients with metastatic disease. However, Atezolizumab only improves overall survival by 2 months. This could be due to the fact that &lt;20% of patients express &gt;1% tumor PD-L1 positivity. We assert that a better understanding of this immune contexture – defined as abundance and type of checkpoint molecules in SCLC – may provide important criteria for patient stratification.

Objectives

In these studies, we will test the hypothesis that immune checkpoints in addition to the PD-1/PD-L1 axis play a role in immune evasion in SCLC.

Methods

To evaluate expression of immune checkpoint molecules, we acquired bulk RNA-Seq data of SCLC cell lines and primary tumor specimens. Further, we generated tissue-microarrays containing &gt;20 unique cell lines and &gt;200 unique patient specimens with fully annotated clinical data to confirm expression of these molecules by immunohistochemistry.

Results

Preliminary RNA-Seq analyses show low PD-L1 expression in SCLC cell lines and primary tumors. Further, ubiquitously high expression of certain checkpoint molecules (B7-H3) is seen. Future analysis will confirm abundance and type of checkpoint molecules as well as capture interpatient heterogeneity.

Conclusions

Understanding the checkpoint molecules present in SCLC could further understanding of SCLC immune suppression, ultimately leading to optimal single-agent immunotherapy deployment and rational, effective combination therapy for patients with SCLC.

Abstract 5547: Durable remission with nivolumab, anti-PD-1 monoclonal antibody, in a patient with advanced thymic carcinoma

Thymic carcinoma is a rare neoplasm with poor prognosis that forms on the outside surface of the thymus. Due to the rarity of the disease, there are no randomized clinical trials that guide therapy. Currently, there are clinical trials under way to assess the efficacy of anti-programmed death 1 (PD-1) monoclonal antibodies for the treatment of advanced thymic carcinomas. However, the role of PD-1 inhibitors in treating thymic carcinoma remains mostly unknown. Here we present a case of a patient with thymic carcinoma who showed durable remission when treated with nivolumab. 61-year-old male was diagnosed with thymic carcinoma during an episode of COPD exacerbation in April 2015. The patient was treated with neoadjuvant chemotherapy regimen consisting of four cycles of carboplatin and paclitaxel every three weeks from June to September 2015. The mass was resected in October 2015. Margins were found to be grossly positive. The patient was deemed a poor candidate for adjuvant chemotherapy, and in February 2016 the decision was made to begin 3 mg/kg nivolumab therapy considering the poor prognosis of disease and high risk of recurrence. Close to two years after initiating therapy, he currently has no measurable disease and tolerates the medication without side effects. This is the first report demonstrating durable remission of thymic carcinoma with nivolumab treatment. Our case suggests that prospective trials evaluating the use of nivolumab in patients with thymic carcinoma are warranted.

Citation Format: Young Kwang Chae, Anderson Cho, Kyunghoon Rhee, Andrew Davis, Wade Iams, Manali Bhave, Marcelo Cruz, Lee Chun Park. Durable remission with nivolumab, anti-PD-1 monoclonal antibody, in a patient with advanced thymic carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5547.

Current landscape and future of dual anti-CTLA4 and PD-1/PD-L1 blockade immunotherapy in cancer; lessons learned from clinical trials with melanoma and non-small cell lung cancer (NSCLC)

Immunotherapy is among the most rapidly evolving treatment strategies in oncology. The therapeutic potential of immune-checkpoint inhibitors is exemplified by the recent hail of Food and Drug Administration (FDA) approvals for their use in various malignancies. Continued efforts to enhance outcomes with immunotherapy agents have led to the formulation of advanced treatment strategies. Recent evidence from pre-clinical studies evaluating immune-checkpoint inhibitors in various cancer cell-lines has suggested that combinatorial approaches may have superior survival outcomes compared to single-agent immunotherapy regimens. Preliminary trials assessing combination therapy with anti-PD-1/PD-L1 plus anti-CTLA-4 immune-checkpoint inhibitors have documented considerable advantages in survival indices over single-agent immunotherapy. The therapeutic potential of combinatorial approaches is highlighted by the recent FDA approval of nivolumab plus ipilimumab for patients with advanced melanoma. Presently, dual-immune checkpoint inhibition with anti-programmed death receptor-1/programmed cell death receptor- ligand-1 (anti-PD-1/PD-L1) plus anti-cytotoxic T lymphocyte associated antigen-4 (anti-CTLA-4) monoclonal antibodies (MoAbs) is being evaluated for a wide range of tumor histologies. Furthermore, several ongoing clinical trials are investigating combination checkpoint inhibition in association with traditional treatment modalities such as chemotherapy, surgery, and radiation. In this review, we summarize the current landscape of combination therapy with anti-PD-1/PD-L1 plus anti-CTLA-4 MoAbs for patients with melanoma and non-small cell lung cancer (NSCLC). We present a synopsis of the prospects for expanding the indications of dual immune-checkpoint inhibition therapy to a more diverse set of tumor histologies.

Immune checkpoint pathways in non-small cell lung cancer

Immunotherapy has evolved at a phenomenal pace in cancer therapeutics. This has primarily been fueled by the much perceived necessity to procure an alternative to current standard of care chemotherapy agents, owing to several concerns such as treatment-related toxicity and poor long-term survival associated with the same. The knowledge of various mechanisms involved in regulation of immune response to cancer cells has served a fundamental role in identifying key molecules through which immune cell activity may be modulated. This in-turn led to the development of immune-checkpoint inhibitors. Presently, lung cancer is among the most enthusiastically investigated targets for treatment with immune-checkpoint inhibitors. Encouraging results with initial trials have now translated to attempts directed at further enhancement of outcomes through various strategies. Herein, we shall present a critical assessment of data from pivotal trials that led to the Food and Drug Administration (FDA) approval of various immune-checkpoint inhibitors and also discuss novel strategies that may potentially yield outcomes superior to standard of care chemotherapy in patients diagnosed with advanced non-small cell lung cancer (NSCLC).

Epithelial-mesenchymal transition (EMT) signature is inversely associated with T-cell infiltration in non-small cell lung cancer (NSCLC)

Epithelial-mesenchymal transition (EMT) is able to drive metastasis during progression of multiple cancer types, including non-small cell lung cancer (NSCLC). As resistance to immunotherapy has been associated with EMT and immune exclusion in melanoma, it is important to understand alterations to T-cell infiltration and the tumor microenvironment during EMT in lung adenocarcinoma and squamous cell carcinoma. We conducted an integrated analysis of the immune landscape in NSCLCs through EMT scores derived from a previously established 16 gene signature of canonical EMT markers. EMT was associated with exclusion of immune cells critical in the immune response to cancer, with significantly lower infiltration of CD4 T-cells in lung adenocarcinoma and CD4/CD8 T-cells in squamous cell carcinoma. EMT was also associated with increased expression of multiple immunosuppressive cytokines, including IL-10 and TGF-β. Furthermore, overexpression of targetable immune checkpoints, such as CTLA-4 and TIM-3 were associated with EMT in both NSCLCs. An association may exist between immune exclusion and EMT in NSCLC. Further investigation is merited as its mechanism is not completely understood and a better understanding of this association could lead to the development of biomarkers that could accurately predict response to immunotherapy.

A Multidisciplinary Housestaff-Led Initiative to Safely Reduce Daily Laboratory Testing

PURPOSE

Provision of high-value care is a milestone in physician training. The authors evaluated the effect of a housestaff-led initiative on laboratory testing rates.

METHOD

Vanderbilt University Medical Center's Choosing Wisely steering committee, led by housestaff with faculty advisors, sought to reduce unnecessary daily basic metabolic panel (BMP) and complete blood count (CBC) testing on inpatient general medicine and surgical services. Intervention services received a didactic session followed by regular data feedback with goal rates and peer comparison. Testing rates during January 1, 2013-February 9, 2015, were compared on intervention services and control services using a difference-in-differences analysis and an interrupted time-series analysis with segmented linear regression.

RESULTS

Compared with concurrent controls, the mean number of BMP tests per patient day decreased by an additional 0.23 (95% CI 0.17-0.29) on medical housestaff and 0.15 (95% CI 0.09-0.21) on hospitalist intervention services. Daily CBC tests decreased by an additional 0.28 (95% CI 0.23-0.33) on medical housestaff, 0.08 (95% CI 0.03-0.13) on hospitalist, and 0.12 (95% CI 0.05-0.20) on surgical housestaff intervention services. Patients with lab-free days (0 labs ordered in 24 hours) increased by an additional 4.1 percentage points (95% CI 2.1-6.1) on medical housestaff and 9.7 percentage points (95% CI 6.6-12.8) on hospitalist intervention services. There were no adverse changes in length of stay or intensive care unit transfer, in-hospital mortality, or 30-day readmission rates.

CONCLUSIONS

A housestaff-led intervention utilizing education and data feedback with goal setting and peer comparison resulted in safe, significant reductions in daily laboratory testing rates.

Who is going to make the wise choice?

Inspired by the American Board of Internal Medicine's Choosing Wisely® campaign, a group of housestaff at Vanderbilt University Medical Center created the Vanderbilt Choosing Wisely Steering Committee (VCWSC) to explore ways to apply the campaign's principles of high value care to daily practice. In this article, we propose that housestaff leadership is key in the implementation of high value care initiatives at academic health centers (AHCs). We then describe the formation and activities of the VCWSC in the hope that our success will inspire residents at other AHCs to create similar initiatives.

Consolidative autologous hematopoietic stem-cell transplantation in first remission for non-Hodgkin lymphoma: current indications and future perspective

The non-Hodgkin lymphomas (NHLs) are a heterogeneous group of diseases with variable clinical outcomes. Autologous hematopoietic stem-cell transplantation (ASCT) as frontline, consolidative therapy has been evaluated based upon histological subtype of NHL. In this review, we summarize the major clinical trials guiding the use of frontline ASCT in NHL. With the constantly changing landscape of upfront therapy and multiple promising novel agents, the ability to conduct randomized trials to evaluate the benefit of consolidative ASCT is not only challenging but may be considered by some an inept utilization of resources. Our recommendation for consolidative ASCT is based on analyzing the current available data.

Full-thickness skin graft overlying a separately harvested auricular cartilage graft for nasal alar reconstruction

OBJECTIVE

To evaluate the aesthetic and functional outcomes of a full-thickness skin graft and a separately harvested auricular cartilage graft for nasal alar defects created by Mohs micrographic surgery.

DESIGN

Twenty patients with deep Mohs micrographic surgery defects of the nasal ala who underwent reconstruction with a full-thickness skin graft and an auricular cartilage graft were prospectively studied at a single tertiary care institution between 2010 and 2011 in a nonrandomized, nonblinded study. An ordinal 5-point Likert scale evaluation of overall outcomes was performed by 4 independent surgeon raters.

RESULTS

The mean outcome for use of the full-thickness skin and auricular cartilage graft construct was a score of 2.3 on a scale of 1 through 5, with 1 being excellent and 5 being poor. The mean duration of follow-up was 6 months, with a range of 5 weeks to 23 months. There were no clinically meaningful losses of constructs in the patients studied.

CONCLUSION

A full-thickness skin graft and a separately harvested auricular cartilage graft are valuable and reliable tools for reconstructing deep nasal alar defects that require support to prevent alar retraction or collapse, particularly when a single-stage procedure is preferred or necessary because of medical comorbidities.

Thrombotic microangiopathy during docetaxel, trastuzumab, and carboplatin chemotherapy for early-stage HER2+ breast cancer: a case report

Chemotherapy-induced thrombotic microangiopathy is a severe illness that has occurred in a small number of patients treated with carboplatin and combination of docetaxel and trastuzumab chemotherapy. We describe herein the case of a patient with stage IIB breast cancer who developed thrombotic microangiopathy after five cycles of carboplatin, docetaxel, and trastuzumab.

Peroxisome proliferator-activated receptor delta agonists inhibit T helper type 1 (Th1) and Th17 responses in experimental allergic encephalomyelitis

Multiple sclerosis (MS) is a neurological disorder that affects more than a million people world-wide. The aetiology of MS is not known and there is no medical treatment available that can cure MS. Experimental autoimmune encephalomyelitis (EAE) is a T-cell-mediated autoimmune disease model of MS. The pathogenesis of EAE/MS is a complex process involving activation of immune cells, secretion of inflammatory cytokines and destruction of myelin sheath in the central nervous system (CNS). Peroxisome proliferator-activated receptors (PPARs) are nuclear hormone receptor transcription factors that regulate cell growth, differentiation and homeostasis. PPAR agonists have been used in the treatment of obesity, diabetes, cancer and inflammation. We and others have shown that PPARgamma, alpha and delta agonists inhibit CNS inflammation and demyelination in the EAE model of MS. In this study we show that the PPARdelta agonists GW501516 and L165041 ameliorate MOGp35-55-induced EAE in C57BL/6 mice by blocking interferon (IFN)-gamma and interleukin (IL)-17 production by T helper type 1 (Th1) and Th17 cells. The inhibition of EAE by PPARdelta agonists was also associated with a decrease in IL-12 and IL-23 and an increase in IL-4 and IL-10 expression in the CNS and lymphoid organs. These findings indicate that PPARdelta agonists modulate Th1 and Th17 responses in EAE and suggest their use in the treatment of MS and other autoimmune diseases.