Coulter Foundation Research Articles

Impact of the AACC Global Laboratory Quality Initiative in Partnership with Professional Societies and Universities in Latin America and the Caribbean.

The Global Lab Quality Initiative (GLQI), formerly known as the Emerging Countries program, was funded through a generous endowment from the Wallace H. Coulter Foundation. The aims of GLQI are to develop and implement innovative programs to promote education and training in laboratory medicine for low- or lower middle-income countries worldwide. From its inception in 2010, the GLQI was focused solely on the Latin America and Caribbean (LAC) region under the purview of AACC's Latin American Working Group (LAWG), the members of which have strong ties to the region thereby facilitating the partnerships with national societies. The LAWG has provided in-person workshops in the LAC countries, at the AACC Annual Scientific Meeting, and on-demand webinars. The LAWG aims to implement the GLQI aims in the LAC region. In-person workshops are based on best-practice recommendations and sources such as Clinical Laboratory Standard Institute guidelines and supplemented with professional experiences of the LAWG's lecturers and local experts of the countries visited. In 2015, the GLQI expanded to other regions of the world. Here we report the experience of the LAWG workshops, results of participant surveys, in-person visits to laboratories post-workshop, and the lessons learned throughout the years across different geographic areas. We are hopeful this report provides insights into the challenges and successes of the LAWG in LAC to help support the expansion of the GLQI.

An End-to-End Integrated Clinical and CT Based Radiomics Nomogram for Predicting Disease Severity and Need for Ventilator Support in COVID-19 Patients: A Large Multi-Site Retrospective Study

Objective: The disease COVID-19 has caused a widespread global pandemic with ~3.93 million deaths worldwide. In this work, we present three models- Radiomics (MRM), Clinical (MCM), and combined Clinical-Radiomics (MRCM) nomogram to predict COVID-19 positive patients who will end up needing invasive mechanical ventilation from the baseline CT scans. Method: We performed a retrospective multicohort study of individuals with COVID-19 positive findings for a total of 980 patients from 2 different institutions (Renmin hospital of Wuhan University, D1 =787 and University Hospitals, US D2 = 110). The patients from institution-1 were divided into 60% training, D1 T (N=473), and 40% test set D1 V (N=314). The patients from institution-2 were used for an independent validation test set D2 V(N=110). A U-Net-based neural network (CNN) was trained to automatically segment out the COVID consolidation regions on the CT scans. The segmented regions from the CT scans were used for extracting first-order and higher-order Radiomic textural features. The top Radiomic and clinical features were selected using the Least Absolute Shrinkage and Selection Operator (LASSO) with an optimal binomial regression model within D1 T. Results: The 3 out of the top 5 features identified using D1 T were higher-order textural features (GLCM, GLRLM, GLSZM), whereas the last two features included the total infection size on the CT scan and the total intensity of the COVID consolidations. The Radiomics Model (MRM ) was constructed using the Radiomic Score built using the coefficients obtained from the LASSO logistic model used within the linear regression (LR) classifier. The MRM yielded an area under the receiver operating characteristic curve (AUC) of 0.754 [0.709-0.799] on D1 T, 0.836 on D1 V, and 0.748 D2 V. The top prognostic clinical factors identified in the analysis were dehydrogenase (LDH), age, and albumin (ALB). The clinical model had an AUC of 0.784 [0.743-0.825] on D1 T, 0.813 on D1 V, and 0.723 on D2 V. Finally, the combined model, MRCM integrating Radiomic Score, age, LDH and ALB, yielded an AUC of 0.814 [0.774-0.853] on D1 T, 0.847 on D1 V, and 0.772 on D2 V. The MRCM had an overall improvement in the performance of ~3.77% (D1 T: p = 0.0003; D1 V p= 0.0165; D2 V : p = 0.024) over MCM Conclusion: The novel integrated imaging and clinical model (MRCM) outperformed both models (MRM) and (MCM). Our results across multiple sites suggest that the integrated nomogram could help identify COVID-19 patients with more severe disease phenotype and potentially requiring mechanical ventilation. Funding: National Cancer Institute of the US National Institutes of Health, National Center for Research Resources, US Department of Veterans Affairs Biomedical Laboratory Research and Development Service, Department of Defense, National Institute of Diabetes and Digestive and Kidney Diseases, Wallace H Coulter Foundation, Case Western Reserve University, and Dana Foundation. Declaration of Interest: AM reports grants from National Cancer Institute of the National Institutes of Health, grants from National Center for Research Resources, grants from VA Merit Review Award, grants from DOD Cancer Investigator-Initiated Translational Research Award, during the conduct of the study; grants from DOD Prostate Cancer Idea Development Award, grants from DOD Peer Reviewed Cancer Research Program, grants from National Institute of Diabetes and Digestive and Kidney Diseases , grants from the Ohio Third Frontier Technology Validation Fund, grants from the Wallace H. Coulter Foundation Program in the Department of Biomedical Engineering and the Clinical and Translational Science Award Program (CTSA) at Case Western Reserve University, grants from Department of Defense Peer Reviewed Cancer Research Program (PRCRP) Career Development Award, grants from Dana Foundation David Mahoney Neuroimaging Program. Ethical Approval: The study conformed to HIPAA guidelines was approved by University Hospitals, Cleveland (STUDY20200463), and the Ethics committee of the Renmin Hospital of Wuhan University (ethics number: V1.0).

A prognostic and predictive computational pathology image signature for added benefit of adjuvant chemotherapy in early stage non-small-cell lung cancer.

We developed and validated a prognostic and predictive computational pathology risk score (CoRiS) using H&E stained tissue images from patients with early-stage non-small cell lung cancer (ES-NSCLC). 1330 patients with ES-NSCLC were acquired from 3 independent sources and divided into four cohorts D1-4. D1 comprised 100 surgery treated patients and was used to identify prognostic features via an elastic-net Cox model to predict overall and disease-free survival. CoRiS was constructed using the Cox model coefficients for the top features. The prognostic performance of CoRiS was evaluated on D2 (N=331), D3 (N=657) and D4 (N=242). Patients from D2 and D3 which comprised surgery+chemotherapy were used to validate CoRiS as predictive of added benefit to adjuvant chemotherapy (ACT) by comparing survival between different CoRiS defined risk groups. CoRiS was found to be prognostic on univariable analysis, D2 (hazard ratio (HR)=1.41, adjusted (adj.) P=.01) and D3 (HR=1.35, adj. P < .001). Multivariable analysis showed CoRiS was independently prognostic, D2 (HR=1.41, adj. P < .001) and D3 (HR=1.35, adj. P < .001), after adjusting for clinico-pathologic factors. CoRiS was also able to identify high-risk patients who derived survival benefit from ACT D2 (HR=0.42, adj. P=.006) and D3 (HR=0.46, adj. P=.08). CoRiS is a tissue non-destructive, quantitative and low-cost tool that could potentially help guide management of ES-NSCLC patients. Data collection, anlaysis, and computation resources of the research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under award numbers: 1U24CA199374-01, R01CA202752-01A1, R01CA208236-01A1, R01 CA216579-01A1, R01 CA220581-01A1, 1U01 CA239055-01. National Center for Research Resources under award number 1 C06 RR12463-01. VA Merit Review Award IBX004121A from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service, the DOD Prostate Cancer Idea Development Award (W81XWH-15-1-0558), the DOD Lung Cancer Investigator-Initiated Translational Research Award (W81XWH-18-1-0440), the DOD Peer Reviewed Cancer Research Program (W81XWH-16-1-0329), the Ohio Third Frontier Technology Validation Fund, the Wallace H. Coulter Foundation Program in the Department of Biomedical Engineering and the Clinical and Translational Science Award Program (CTSA) at Case Western Reserve University.

Day 100 Levels of Blood Immune Cells Are Prognostic Biomarkers for Allogeneic Hematopoietic Stem Cell Transplant Outcomes: Results from BMT CTN 0201

Background: BMT CTN 0201 was a randomized trial of bone marrow (BM) vs. G-CSF mobilized blood (G-PB) grafts in 550 pediatric and adult patients with leukemia or MDS undergoing allogeneic hematopoietic stem cell transplantation from unrelated donors. Overall survival (OS) was equivalent between both arms, with more chronic graft-versus-host disease (GvHD) among recipients of G-PB grafts and more graft failure among recipients of BM grafts (Anasetti NEJM 2012; 367:1487-1496). We have previously reported donor plasmacytoid dendritic cell (pDC) content in BM grafts are linked with improved survival and less death from acute GvHD (Waller JCO 2014 32:2365-2372). Here, we compare the kinetics of immune cell reconstitution between BM and G-PB recipients to test the hypothesis that graft source leads to differences in blood levels of donor-derived immune cells, and that higher levels of dendritic cells are associated with lower GvHD-related death rates.Methods: Demographics among randomized patients were similar with respect to diagnosis, conditioning regimens, GvHD prophylaxis, and CMV serostatus. Flow cytometry measured immune cells in blood samples at 1, 3, 6, 12, and 24 months post-transplant in recipients of BM (N=161) or G-PB (N=147) grafts from unrelated donors. Univariate and multivariable analyses evaluated associations between donor immune cells and outcomes.Results: Reconstitution kinetics of immune cells at day +100 were associated with graft source, a history of GvHD, and subsequent GvHD-related death.G-PB recipients had higher 1 and 3-month levels of blood T cells and B cells than BM recipients, as well as higher numbers of γ/δ, CD4+ T-reg, CD4+ T cells at later time points (Table 1). In contrast, recovery kinetics for pDC, mDC,and immature CD56+CD16- NK cellswere similar between each graft arm (Table 1). B cell reconstitution kinetics were slower in BM recipients, especially in BM recipients who developed acute GvHD prior to day +100 as opposed to those who did not (in Figure 1, p < .001). No significant association existed between aGvHD history and lymphocyte reconstitution in G-PB recipients.Blood levels of immune cells at day +100 were associated both with a history of acute GvHD as well as subsequent 2-year OS, and GvHD-related death. All patients who developed grades 2-4 acute GvHD by day +100 had worse 2-year OS than non-GvHD patients (66% vs. 53%, p=.01). However, patients with a history of GvHD and >median numbers of blood mDC, CD4+, or CD8+ T cells at day +100 had better 2-year OS (95% CI): [mDC, 63 (51-74)% vs. 43 (32-55)% p=.02; CD4+ T cells, 64 (53-75)% vs. 42 (31-53)%, p=0.007; CD8+ T cells, 65 (54-76)% vs. 42 (31-53)%, p= 0.004] than GvHD-patients with <median numbers of these cells. Furthermore, significantly fewer GvHD-related deaths occurred in patients with >median numbers of mDC compared to in those with <median numbers of mDC (23% vs 40%, respectively, p<.05).In contrast, G-PB recipients with >median numbers of blood central memory CD8+ (p=.01), CD8+ (p=.004), and γ/δ T cells (p=.002) by day +100 had significantly higher 2-year OS compared to those with <median numbers of these cells. BM recipients with >median numbers of mDC had higher 2-year OS compared to those with <median numbers (p=.06).The content of blood mDC was prognostic for post-transplant outcomes for the entire cohort of patients and the subset of BM recipients. Significantly improved 2-year OS (95% CI) was observed in patients with >median numbers of mDC by day +100 post-transplant (68 (61-76)%) compared to those with <median numbers of mDC (51 (43-59)%; p=.008; Figure 2). Compared to the latter, the former also had significantly less (p=.04) treatment-related mortality at 2-years post-transplant (12 (8-18)% vs. 23 (17-31)%) and no difference in relapse (30 (23-38)%) vs. 29 (22-37)%).Conclusions: Graft source is associated with differences in reconstitution kinetics of T and B cells. Blood levels of immune cells at day +100 are cellular bio-markers for both GvHD-related death and OS in transplant recipients, and are correlated with a history of acute GvHD. Specific cell subsets prognostic for OS vary by graft source. Higher levels of blood mDC at day +100 in BM recipients are associated with improved OS, while higher numbers of T-cells predict better OS in GPB recipients. Compared to BM recipients, G-PB recipients have faster T and B cell reconstitution as well as greater resiliency of lymphogenesis following acute GvHD. [Display omitted] DisclosuresLee:Mallinckrodt: Honoraria; Amgen: Other: One-time advisory board member; Bristol-Myers-Squibb: Other: One-time advisory board member; Kadmon: Other: One-time advisory board member. Waller:Helocyte: Consultancy; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; Coulter Foundation: Research Funding; Katz Foundation: Research Funding; Chimerix: Equity Ownership; AMGEN: Consultancy; Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Celldex: Consultancy; Cerus: Equity Ownership; National Institutes of Health: Research Funding; PRA: Consultancy.

Graft Versus Host Disease Activity of Donor T Cells Is Regulated By Vasoactive Intestinal Polypeptide Synthesized By Donor Plasmacytoid Dendritic Cells

Introduction: Increased numbers of plasmacytoid dendritic cells (pDC) in the bone marrow graft improve clinical outcomes with decreased graft-versus-host disease (GvHD) and improved survival in previous pre-clinical murine experiments (Lu Y, Blood. 2012;119:1075-1085) and in clinic data from BMT CTN 201 (Waller JCO 2014; 32:2365-72). The mechanism by which donor pDC limit severe GvHD and improve survival after allo-BMT is unknown. We have previously described higher levels of donor T cell activation and expansion (measured as bio-luminescent radiance) among recipients of VIP-KO pDC (Li, J.X Blood 2016 128:2154). We hypothesize that blocking VIP signaling augment the magnitude of T cell activation and expansion, and that modulating the VIP pathway may be a potential therapeutic target for regulating GvHD in allo-HSCT.Methods:We used a MHC mismatched C57BL/6 àB10BR allo-BMT model, transplanting purified populations of FACS sorted Lin-Sca-1+C-kit+ (LSK) stem cells combined with FACS purified BM pDC and MACS purified splenic T cells. Lethally irradiated B10BR recipients received 5,000 HSC, 50,000 pDC from wild type (WT) or VIP-KO donor and 1×106 T cells from WT C57BL6 donor mice. Survival and GvHD were measured based on fur texture, posture, activity, skin integrity and weight body loss. To test VIP production by pDC cells, we purified donor pDC from VIP-GFP C57 BL/6 mice, in which GFP transcription is under the control of the VIP gene promotor, and transplanted them into lethally irradiated MHC mis-matched B10.BR recipients. VIP expression in mice receiving pDC cells from a VIP-GFP transgenic donor was detected by fluorescence confocal microscopy. Immune polarization of donor T cells was accessed by intracellular cytokine staining and flow cytometry. Mice transplanted with VIP-GFP pDC cells were sacrificed on D10 and spleens were collected in OCT.Results: Survival of recipients receiving HSC, T cells and WT pDC was 71% on day100 post-transplant while survival of those receiving VIP-KO pDC was 31% (Fig 1A). Splenocytes were obtained from recipients on day 3 post-transplant. IFN-γexpression was higher and IL-10 epression was significantly lower in donor CD8+ T cells in mice receiving VIP-KO pDC compared with WT pDC (Fig 1B). Confocal microscopy showed VIP expression in donor pDC among recipients of VIP-GFP pDC (Fig 2)Conclusion:These data indicated VIP signaling occurs via interactions between donor T cells and donor pDC. Local production of VIP inhibits activation and Th1 immune polarization of donor T cells. In murine allo-BMT, absence of VIP expression in pDC leads to increased T cell activation, expansion, allo-reactivity and Th1 polarization resulting in worse survival. Thus VIP is a critical pathway in regulating GvHD and GvL action of donor T cells and an attractive pharmacological target for GvHD prevention. [Display omitted] DisclosuresWaller:AMGEN: Consultancy; PRA: Consultancy; Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Celldex: Consultancy; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; Helocyte: Consultancy; Cerus: Equity Ownership; National Institutes of Health: Research Funding; Chimerix: Equity Ownership; Coulter Foundation: Research Funding; Katz Foundation: Research Funding.

Clinical Pharmacology of CTL019 in Patients with Relapsed/Refractory (r/r) Diffuse Large B-Cell Lymphoma (DLBCL)

Clinical Pharmacology of CTL019 in Patients with Relapsed/Refractory (r/r) Diffuse Large B-Cell Lymphoma (DLBCL)

Primary Analysis of Juliet: A Global, Pivotal, Phase 2 Trial of CTL019 in Adult Patients with Relapsed or Refractory Diffuse Large B-Cell Lymphoma

Primary Analysis of Juliet: A Global, Pivotal, Phase 2 Trial of CTL019 in Adult Patients with Relapsed or Refractory Diffuse Large B-Cell Lymphoma

Assessing Individual Comorbidities in Elderly Non-Hodgkin Lymphoma Patients Undergoing Autologous Stem Cell Transplant — Obesity Associated with Inferior Outcomes

Assessing Individual Comorbidities in Elderly Non-Hodgkin Lymphoma Patients Undergoing Autologous Stem Cell Transplant — Obesity Associated with Inferior Outcomes

Optimization of Ex Vivo Activation and Expansion of T Cells for Therapy of Lymphoma Via Antagonism of PI3K δ and Vasoactive Intestinal Peptide Signaling

Introduction: Success of T cell therapy is restricted by the variable success of expanding patients9 T cells ex vivo and the limited persistence of cultured T cells in T cell-treated patients. These problems may be particularly relevant to lymphoma patients previously treated with numerous cycles of chemotherapy, and motivate the development of novel strategies to enhance ex vivo T cell expansion and their persistence in vivo . Recently we have shown that antagonism of vasoactive intestinal peptide (VIP) signaling on lymphocytes augments in vivo T cell activation and growth leading to significant and durable T cell-dependent anti-cancer immune response in murine models of lymphoma and leukemia (Li Cancer Research 2016; Petersen Oncoimmunology 2017). We tested the hypothesis that VIP antagonists would synergize with phosphatidyl inositol-3 kinase inhibitors (PI3Ki) to augment T-cells ex vivo expansion of T cells with anti-cancer immune functions. Methods: Peripheral blood mononuclear cells were obtained from consenting DLBCL patients and healthy controls. Frozen PBMC were thawed and rested overnight in RPMI 1640 supplemented with 10% fetal bovine serum, 100 U/mL penicillin, 100 μg/mL streptomycin, and 50 μM 2-mercaptoethanol then cultured in 96 well flat-bottom plates with 30 U/mL IL-2 and anti-CD3/CD28 beads at a 1:1 bead to cell ratio in the presence of idelalisib, duvelisib, a peptide antagonist to VIP (VIPhyb, KPRRPYTDNYRELRKQMAVKKYLNSILN), or mast cell chymase, a VIP-degrading enzyme. Flow cytometric analysis of T cells from patients, healthy volunteers, and mice prior to and following ex vivo cell expansion measured expression of CD3, CD4, CD8, CD27, CD28 and intracellular cytokines (IL2, IFN-gamma). In vivo persistence of cultured human T -cells was monitored in following ex vivo expansion and transfer into RAG mice. Anti-lymphoma activity of cultured murine T cells was assessed by culturing a mixture of wild-type, OT1, and OT2 murine T-cells and transfer into immune-competent mice bearing subcutaneous E.G7 OVA murine B cell lymphoma. Results: T cells from heavily treated DLBCL patients had a senescent phenotype with loss of CD27 and CD28 expression, with a median of 36.8% (range 4.58-77.3) CD27-CD28- T cells compared with median values of 5.8%, range 1.7-12.4% in healthy controls and 3.9%, range 0.5-23.1% in untreated DLBCL patients. FACS-purified senescent CD27- CD28- T cells failed to expand ex vivo and had fratricide-mediated inhibition of non-senescent T cells expansion. Blockade of PI3K δ and antagonism of vasoactive intestinal peptide (VIP) signaling during T-cell culture with low dose IL2 and anti- CD3/CD28 beads partially inhibited terminal differentiation (mean frequency 54.4% CD27+CD28+ T cells vs 27.4% in control cultures, p Discussion: Taken together, these data demonstrate that synergistic blockade of the PI3K and VIP pathways is an attractive strategy to enhance the expansion and functional capacity of T cells during clinical manufacturing, and that optimization of culture expansion conditions can improve the magnitude and durability of anti-lymphoma responses in vivo . Disclosures Waller: Coulter Foundation: Research Funding; PRA: Consultancy; Chimerix: Equity Ownership; Katz Foundation: Research Funding; Celldex: Consultancy; Helocyte: Consultancy; AMGEN: Consultancy; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; Cambium Medical Technologies: Equity Ownership, Membership on an entity9s Board of Directors or advisory committees, Patents & Royalties; Cerus: Equity Ownership; National Institutes of Health: Research Funding. Jagirdar: Kite: Consultancy. Flowers: Research to Practice: Research Funding; Burroughs Welcome Fund: Research Funding; National Institutes Of Health: Research Funding; Educational Concepts: Research Funding; Prime Oncology: Research Funding; Acerta: Research Funding; Pharmacyclics LLC, an AbbVie Company: Research Funding; Spectrum: Consultancy; Seattle Genetics: Consultancy; Millennium/Takeda: Research Funding; Genentech/Roche: Consultancy, Research Funding; Eastern Cooperative Oncology Group: Research Funding; OptumRx: Consultancy; TG Therapeutics: Research Funding; Infinity: Research Funding; Onyx: Research Funding; Clinical Care Options: Research Funding; Janssen Pharmaceutical: Research Funding; National Cancer Institute: Research Funding; Celgene: Consultancy, Research Funding; V Foundation: Research Funding; Gilead: Consultancy; Bayer: Consultancy; Abbvie: Consultancy, Research Funding.

Reduced GvHD in Recipients of BM Derived Versus G-CSF Mobilized Plasmacytoid Dendritic Cells: Role of Inducible IL-12

Introduction: BMT CTN 0201, a randomized clinical trial, demonstrated that overall survival is equivalent between recipients of allogeneic bone marrow (BM) vs. granulocyte-colony stimulating factor (G-CSF) mobilized peripheral blood grafts. Increased graft failure was observed in recipients of BM grafts, while recipients of G-CSF mobilized peripheral blood (G-PB) grafts had more chronic graft-versus-host disease (GvHD) (Anasetti NEJM 2012). Donor plasmacytoid dendritic cell (pDC) content is associated with increased overall survival and decreased acute GvHD related mortality among recipients of BM grafts from unrelated donors, but not G-PB grafts (Waller JCO 2014). We have previously shown that in murine bone marrow transplant (BMT), donor pDC from the bone marrow reduce GvHD and improve survival while maintaining graft-versus-leukemia effect when added to grafts containing purified hematopoietic stem cells (HSC) and T cells (Lu BLOOD 2012). We hypothesized that the difference in chronic GvHD observed in BMT CTN 0201 is due to donor pDC content and function that vary according to graft source differences: BM vs. G-PB.Methods and Results: To assess the effects of pDC source on overall survival and GvHD, we used an established MHC mismatched model of murine BMT (C57BL/6 to B10.BR). To test whether the graft source of donor pDC was relevant to GvHD, we used flow cytometry to sort populations of HSC and T cells from untreated donor mice and pDC from either untreated BM or G-CSF mobilized splenocytes. We performed a BMT with 5,000 HSC, 1 million T cells, and either 50,000 BM or G-PB pDC from C57BL/6 mice into B10.BR recipients. Overall survival was significantly reduced among recipients of G-PB donor pDC compared with recipients of BM pDC, while late stage GvHD was higher in recipients of G-PB pDC (Fig. 1).To determine possible differences in function of pDC from each graft source: BM vs. G-PB, we assessed cytokine and enzymatic profiles by flow cytometry. Intracellular levels of IL-12 was significantly higher in CpG stimulate purified BM pDC compared to G-PB pDC co-cultured with purified T cells stimulated by anti-CD3/CD28 beads (Fig. 2). Additionally, Th1 polarization was higher in T cells sitmulated with anti-CD3/CD38 and cocultured with BM pDC, resulting in higher TNFa and IFNy production from these T cells. Levels of intracellular cytokines IFNa and IL-10 and levels of IDO showed no significant differences between pDC from Bm vs. G-PB.The transplant detailed above was repeated with BM pDC from wild-type (WT) mice or IL-12 KO mice. Overall survival of recipients of IL-12 KO BM pDC was significantly reduced when compared with recipients of WT BM pDC (Fig. 3).Conclusion: These data confirm that donor BM pDC are protective against lethal GvHD and indicate a loss of GvHD protection in donor pDC from G-PB grafts due to decreased inducible IL-12 synthesis. Because both graft sources are widely used clinically, mechanisms to recapitulate the immune-modulating properties of BM pDC in pDC of G-PB grafts are of great interest to the BMT field. [Display omitted] DisclosuresWaller:National Institutes of Health: Research Funding; Celldex: Consultancy; Cerus: Equity Ownership; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; Katz Foundation: Research Funding; AMGEN: Consultancy; Chimerix: Equity Ownership; Helocyte: Consultancy; Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; PRA: Consultancy; Coulter Foundation: Research Funding.

Efficacy of Early Post-Transplant Vaccination Using a Prime and Boost Strategy Is Independent of a Prior History of GvHD: Results from BMT CTN 0201

Introduction: BMT CTN 0201 was a randomized trial of bone marrow (BM) vs G-CSF mobilized peripheral blood (G-PB) grafts in 550 patients with leukemia or MDS undergoing allogeneic hematopoietic stem cell transplantation from unrelated donors. Responses to the 23-valent-pneumococcal vaccine are poor in elderly and immune-compromised patients, including allo-transplant recipients. A secondary objective of BMT CTN 0201 compared responses to post-transplant vaccination using protein-based diphtheria-tetanus (dT) vaccine followed by two doses of a diphtheria-pneumococcal polysaccharide conjugate (PCV7) and the 23-valent pneumococcal polysaccharide vaccine (PPV23).Methods: Vaccination started at 6 months post-transplant with dT followed by PCV7 at 7 and 9 months and PPV23 at 11 months post-transplant. Hepatitis B vaccination occurred at 6, 7 and 11 months. Serological responses in BMT CTN 0201 patients surviving to one year post-transplant were compared among those vaccinated per protocol (N=71), those that received partial vaccination (N=58) or no vaccines (N=39). Primary end-points were the fractions of vaccinated individuals with protective antibody titers to the 14 common pneumococcal bacterial serotypes, Hepatitis B, diphtheria and tetanus. Clinical history of acute or chronic GVHD, blood B-cells and T-cells, and serum immunoglobulin levels were studied as covariates of protective immunological responses.Results: Overall survival at 3 years across the cohorts that received full, partial, or no vaccination was similar (81%, 87%, 84%). Lack of compliance with protocol vaccination did not vary according to whether subjects had a history of acute or chronic GVHD. The frequency of patients with prior history of grade 2-4 acute GVHD or chronic GVHD were similar across the three cohorts (82%, 90%, 82%), with comparable rates of severe grades 3-4 acute (10%, 12%, 13%) and extensive chronic GVHD (63%, 67%, 64%, respectively). Serological responses to vaccines did not differ between recipients of BM vs G-PB grafts, or whether patients had a history of grade 2-4 acute GVHD or chronic GVHD. Serological responses were highly associated with protocol-specified vaccination, with median (range) of titers (ug/mL) for fully vaccinated versus non-vaccinated individuals for HepB: 10.81 (0.05-110) versus 0.49 (0.05-63) p=0.01; tetanus, 2.80 (0.16-20) versus 0.40 (0.05-20) p<0.001; diphtheria: 1.62 (0.05-20) versus 0.08 (0.05-1.2) p<0.001; as well as protective antibody titers to each of the component pneumococcal epitopes shared between PCV7 and PPV23 (Table 1, N=71 fully vaccinated and N=48 with no pneumococcal vaccines). Among the fully-vaccinated cohort, a greater proportion had protective antibodies to individual pneumococcal serotypes present in the PCV7 “prime” vaccine (median 66%) versus those restricted to the PPV23 “boost” vaccine (median 41%). Serum levels of IgA, IgM, and IgG at 12 months post-transplant were correlated with the kinetics of B-cell recovery in the blood at 3, 6, and 12 months. Antibody titers to tetanus, diphtheria and 8/14 of the tested pneumococcal serotypes were correlated with total serum IgG levels at 12 months post-transplant. Titers to diphtheria, a T-cell dependent antigen, were correlated with day +100 blood levels of T-cells, myeloid dendritic cells and B-cells (p<0.05), while antibody levels to serotypes in PCV7 were correlated with day +100 levels of B-cells in the blood.Conclusion: The efficacy of vaccination to specific pneumococcal serotypes among recipients of allogeneic transplants is enhanced by priming with dT and PCV7 prior to vaccination with the PPV23 vaccine. Vaccination is effective in patients with a history of acute or chronic GVHD. Strategies that enhance B-cell recovery post-transplant may improve responses to vaccines, especially those that are T-cell independent. [Display omitted] DisclosuresWaller:National Institutes of Health: Research Funding; Helocyte: Consultancy; Chimerix: Equity Ownership; Cerus: Equity Ownership; Coulter Foundation: Research Funding; PRA: Consultancy; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Katz Foundation: Research Funding; AMGEN: Consultancy; Celldex: Consultancy.

Absence of Vasoactive Intestinal Peptide Synthesis in Recipients in Allogeneic Bone Marrow Transplant Increases Graft Versus Host Diseases

Introduction: Vasoactive intestinal polypeptide (VIP) is an immunosuppressive neuropeptide. Activation of donor T cells leading to graft-versus-host disease (GvHD) in allogeneic bone marrow transplant (allo-BMT) occurs via early post transplant interactions between donor T cells and host antigen presenting cells and leads to upregulation of immune co-inhibitory pathways, including expression of VIP in T cells and dendritic cells. We have previously shown VIP signaling favorably regulates the activation status and enhances the graft-versus-leukemia (GvL) activities of donor T cells (Li et al., Cancer Research 2016). The role of the VIP produced by host antigen presenting cells in regulating GvHD in allo-BMT is unknown. We tested the hypothesis that absence of VIP expression by host cells would augment donor T cell activation and increase GvHD.Methods and Results: We used the B10BR->B6 MHC fully mismatched murine model of allogeneic BMT. Recipient wildtype (WT) and VIP knockout B6 (VIP-KO) mice were lethally irradiated with 11Gy and injected i.v. with 5×106 T cell depleted (TCD) bone marrow cells (BM) plus 0, 1 or 3 ×106 splenocytes from WT B10BR donors. Fifteen mice (males and females) were assigned to each splenocytes dosage group. The survival of recipients after BMT was recorded daily and the average clinical GvHD scores were obtained by combining weight-loss, activity, posture, fur texture and skin integrity data following standard published procedures. All three groups of WT recipients had better survival than VIP-KO recipients. VIP-KO mice transplanted with TCD BM alone had only 33.3% survival at day 75 compared with 73.3% survival among the WT recipients. Chimerism studies on day 10 post-BMT showed equivalent level of donor chimerism: 80% donor in WT recipients vs 72% donor in VIP-KO recipients, indicating increased mortality in the VIP-KO recipients was not due to early graft rejection. The addition of donor splenocytes to the graft resulted in significantly more GvHD-related mortality in VIP-KO recipients compared with WT recipients (Figure 1), with 80% vs 100% day 75 survival among recipients of 1x106 splenocytes (p=NS) and 0% vs 40% survival (p<0.01) among recipients of 3x106 donor splenocytes, respectively.To determine how the absence of VIP production in KO recipients modulates immune effector mechanisms that contributes to the differential survival rate post allo-BMT, we analyzed the recipients' splenocytes on day 30 post transplant with flow cytometry and staining with CD3, CD4, CD8, CD62L, CD44 and PD1 antibodies. VIP-KO recipients transplanted with 5M TCD BM plus 1M splenocytes had more CD4+ central memory and effector T cells, and CD8+ central memory and effector T cells. VIP-KO recipients transplanted with 5×106 TCD BM alone in addition had significantly more CD4 and CD8 effector T cells (p<0.01). VIP-KO recipients transplanted with 5×106 TCD BM plus 1x106 splenocytes had more PD1 expression on donor CD4+ central memory and effector T cells, and CD8+ central memory effector T cells, consistent with enhanced antigen-mediated activation.To visualize VIP produced by the host cells, we transplanted C57/BL6 recipients expressing a GFP transgene under the control of the VIP promoter (n=10) with 5×106 TCD BM plus 3 ×106 splenocytes from WT B10BR donors, and visualized VIP gene promoter activity as GFP expression in recipient lymphoid tissues and GvHD target organs. Only small number of CD45+ VIP-GFP+ cells were detected from in host liver, spleen and lymph nodes on day 10 post transplant (Figure 2), suggesting residual host leukocytes, particularly dendritic cells, expressed VIP.Conclusion: VIP production by recipient antigen presenting cells is a key pathway in limiting the activation of donor T cells. Physiological expression of VIP by host leukocytes regulate the GvHD activity of donor T cells. Novel methods to enhance VIP production in transplant recipients or the parenteral administration of VIP receptor agonists may limit GvHD, and may be particularly important in allo-BMT where GvL is not necessarily critical for success, such as transplants for hemoglobinopathy. [Display omitted] DisclosuresWaller:Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; PRA: Consultancy; AMGEN: Consultancy; National Institutes of Health: Research Funding; Coulter Foundation: Research Funding; Helocyte: Consultancy; Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Katz Foundation: Research Funding; Chimerix: Equity Ownership; Cerus: Equity Ownership; Celldex: Consultancy.

Ibrutinib Inhibits cGVHD Pathogenic Pre-Germinal Center B-Cells and Follicular Helper Cells While Preserving Immune Memory and Th1 T-Cells

Background: Chronic graft-versus-host disease (cGVHD) is a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (allo-HCT). Treatment relies upon corticosteroids and immunosuppressive agents with limited efficacy and considerable side-effects. Evolving research points to the complex involvement of immune T, B, and myeloid cells in the pathogenesis of cGVHD. Ibrutinib is an irreversible inhibitor of Bruton's tyrosine kinase (BTK) and interleukin-2-inducible T-cell kinase (ITK) which inhibits the activation of B-cells, specific T-cell subsets, and certain myeloid cells that are implicated in cGVHD. Substantial clinical benefit was demonstrated in an open-label phase 1b/2 study of ibrutinib in patients with cGVHD that had failed frontline therapy (Miklos et al ASH 2016). Based upon this data, ibrutinib is indicated by the US FDA for the treatment of adult patients with cGVHD after failure of one or more lines of systemic therapy.Methods: Blood samples were collected before and multiple timepoints after starting ibrutinib 420mg daily therapy from 42 subjects with cGVHD that had failed frontline therapy (Miklos et al ASH 2016). Correlative analyses included Nanostring gene expression profiling, Luminex and ELISA based plasma testing, CyTOF phospho-immunophenotyping, and ex-vivo T-cell stimulation assays.Results: Initial data from 8 patients using targeted, Nanostring gene expression analysis showed ibrutinib reduced inflammatory genes including NFkB-1 and chemokines CXCL10, CCL7 and CCL3 (2.6, 2.3, 25, and 1.8-fold decrease over first 3 months, respectively). Luminex plasma quantification supported gene expression profiling results, and unveiled several additional chemotactic, inflammatory, and fibrotic factors which were down modulated by ibrutinib therapy including CCL22, CXCL9, CXCL10, IL-8, sCD25, CCL4, and ST2 (69-80% of patients showed decreasing trend). 42-parameter CyTOF single cell analysis revealed a 10-fold reduction in absolute numbers of cGVHD implicated pre-germinal center B-cells (CD19+, CD27+, CD38+, IgD+), and notably diminished Tfh, Th17, and total B cells (2.6, 1.5, and 1.4-fold decrease over first 90 days, respectively) following ibrutinib therapy. Relative numbers of CD4 and CD8 T-cells, class-switched B-cells, and CD14+ monocytes remained unchanged, and iNKT, Th1, and Treg cells increased incrementally (1.8, 1.2, and 1.1-fold at day 90, respectively). IgG plasma levels persisted while IgM significantly decreased corroborating an ibrutinib germinal center effect that did not deplete long-lived plasma cells. Furthermore, T cell reactivity against influenza increased, and antibodies against EBV and tetanus remained unchanged. Strikingly, single cell phosphorylation analysis showed BTK and ITK signaling was attenuated following ibrutinib treatment in defined B and T cell subsets (Figure 1). Specifically, PLCγ1/2 activation was simultaneously diminished in the pre-germinal center and plasmablast B-cell subsets.Conclusions: Our examination of the biologic and cellular mechanisms which support the clinical results of ibrutinib in the setting of cGVHD demonstrate that ibrutinib selectively inhibits cGVHD pathogenic pre-germinal center B-cells and Tfh cells, while preserving immune memory and Th1 T-cells. These data are especially salient given the clinical efficacy of ibrutinib in cGVHD, and the meticulous nature of the correlative studies designed to elucidate the multifactorial mechanism of action in this life-threatening disease. [Display omitted] DisclosuresSahaf:Pharmacyclics: Research Funding; Stanford: Patents & Royalties. Tebaykin:Stanford University: Patents & Royalties. Hopper:Pharmacyclics: Employment. Cheung:Pharmacyclics: Employment; AbbVie: Equity Ownership. Bittencourt:Pharmacyclics: Employment, Research Funding; AbbVie: Equity Ownership, Research Funding. Cutler:Astellas: Consultancy; Incyte: Consultancy; Bristol-Myers Squibb: Consultancy; Kite: Consultancy; Pharmacyclics: Consultancy; Pfizer: Consultancy. Arora:Takeda Oncology: Consultancy. Waller:Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Cerus: Equity Ownership; Helocyte: Consultancy; National Institutes of Health: Research Funding; Katz Foundation: Research Funding; AMGEN: Consultancy; PRA: Consultancy; Coulter Foundation: Research Funding; Celldex: Consultancy; Chimerix: Equity Ownership; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding. Jagasia:Janssen: Consultancy, Research Funding; Mallinckrodt: Consultancy; Therakos: Consultancy, Research Funding. Flowers:Pharmacyclics: Consultancy. Logan:Novartis: Consultancy, Research Funding; Incyte: Consultancy; Kite: Research Funding; Astellas: Research Funding; Jazz: Consultancy; Amgen: Consultancy; Pharmacyclics: Research Funding; Shire: Consultancy. Jaglowski:Pharmacyclics: Consultancy, Research Funding. Lih:AbbVie: Equity Ownership; Pharmacyclics: Employment. Solman:Pharmacyclics LLC, an AbbVie Company: Employment, Other: Travel, Accommodations, Expenses; AbbVie: Equity Ownership. Lal:Gilead Sciences: Employment; AbbVie: Equity Ownership; The Permanente Medical Group (TPMG): Employment; Pharmacyclics LLC, an AbbVie Company: Employment. Styles:Pharmacyclics LLC, an AbbVie Company: Employment; AbbVie: Equity Ownership. Hill:Amgen: Employment, Equity Ownership, Patents & Royalties; Pharmacyclics: Employment; AbbVie: Equity Ownership; Miravant Medical: Patents & Royalties. James:AbbVie: Equity Ownership; Pharmacyclics LLC, an AbbVie Company: Employment. Bendall:Fluidigm Sciences: Consultancy, Other: Travel, Accomodations, Expenses; Bluebird Bio: Other: Travel, Accomodations, Expenses, Research Funding; Ionpath, Inc.: Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Boehringer-ingelheim: Consultancy, Other: Travel, Accomodations, Expenses; Pharmacyclics: Research Funding. Dubovsky:Pharmacyclics LLC, an AbbVie Company: Employment; AbbVie: Equity Ownership.

Hierarchical Differences in Defensin Gene Expression in Plasmacytoid Dendritic Cells and Progenitor Cells from Five Different Hematopoietic Stem Cell Transplant Graft Types

Introduction: We have previously reported that the source of the graft for allogeneic hematopoietic stem cell transplantation (bone marrow (BM) vs. G-CSF mobilized peripheral blood (G-PB)), and the content of plasmacytoid dendritic cells (pDCs) in the graft are factors associated with improved long-term clinical outcomes. We have also shown differences in homing receptor expression on donor pDCs from BM vs. G-PB grafts that suggest important functional differences related to GvHD and rejection outcomes. Here, we have extended our analysis to study differences in gene expression in pDC and CD34+ hematopoietic progenitor cells from graft types including BM, G-PB, umbilical cord blood (CB), plerixafor-mobilized PB (PLX-PB) and FLT3L-mobilized PB (FLT3L-PB). We hypothesized that comparisons of expression array data from the various graft types would reveal additional differentially-expressed genes and pathways that may have importance in allo-HSCT outcomes, and suggest strategies for improving allo-HSCT procedures through graft selection or screening.Methods: Aliquots of donor hematopoietic stem cell transplant (HSCT) grafts were obtained under IRB-approved clinical research protocols. These graft types included BM (N=4), CB (N=4), G-PB (N=4), PLX-PB (N=3), and FLT3L-PB (N=5). CD45+CD34+ hematopoietic progenitor cells and CD45+BDCA4+ pDCs were sorted into separate tubes using a FACS Aria cell sorter. The purified cell populations were pelleted and processed for RNA extraction. cDNA was amplified and labeled using a NuGen Ovation Pico system, and gene expression data was generated using the Illumina Human HT-12_V4 array at the Emory Integrated Genomics Core. Raw microarray data were preprocessed, quantile normalized, background-corrected and log 2 transformed prior to differential gene expression analyses using the Limma package to make comparisons between groups, using volcano plots and heatmaps to visualize the data. Pathway analyses were then performed on the differentially expressed genes.Results: Selecting for pathways that showed differential expression in multiple comparisons, we identified the defensins and alpha-defensins pathways as representing a gene family of interest that varies significantly for both pDCs and CD34+ cells from different graft sources. Defensins had significantly higher expression (p < 0.05) in pDCs from BM, G-PB and CB compared to PLX-PB, and in BM and G-PB compared to FLT3L-PB. The average fold-differences in defensin family gene expression levels were calculated, with pDCs derived from PLX-mobilized grafts having the lowest expression. Defensin gene expression in PLX-PB pDCs was arbitrarily set to 1 as a reference value, and the fold-increase was calculated for pDCs from FLT3L-PB (2.5), CB (33), BM (52) and G-PB (104) grafts. Similar results were found for hierarchical expression of defensin genes in sorted CD34+ cells from the 5 graft types.Conclusions: Different mobilization strategies result in altered levels of defensin family gene expression in purified pDC and CD34+ hematopoietic progenitor cells. Enhanced levels of defensin expression in mature pDC and myeloid progeny of CD34+ progenitor cells are predicted to improve resistance to opportunistic infections. Classification of defensin levels in these graft sources may be prognostic in identifying transplant patients with an increased risk of infection. DisclosuresWaller:Coulter Foundation: Research Funding; PRA: Consultancy; AMGEN: Consultancy; Chimerix: Equity Ownership; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding; Celldex: Consultancy; Helocyte: Consultancy; Katz Foundation: Research Funding; Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Cerus: Equity Ownership; National Institutes of Health: Research Funding.

Impact of Post-Transplant Lymphoproliferative Disorder Subtype on Survival

IntroductionPost-transplant lymphoproliferative disease (PTLD) arises in the setting of immunosuppression following solid organ transplantation (SOT) or hematopoietic stem cell transplantation. PTLD incidence ranges from 1 to 20% in SOT; mortality estimates of >30% make this entity a significant life-threatening complication of transplantation. PTLD is broadly categorized into four groups: early; polymorphic; monomorphic, including T/natural killer cell neoplasms and most B cell neoplasms; and classical Hodgkin lymphoma. The heterogeneity of PTLD histology, compounded by relative disease rarity and absence of a standard treatment approach, has made evaluating clinical outcomes in specific patient populations difficult. We analyzed data from a systematic review of the literature to investigate the impact of PTLD histologic subtype on survival in a large dataset.MethodsCase series were identified on PubMed using the search terms “post-transplant lymphoproliferative disorder/disease,” “PTLD”, and “solid organ transplantation,” with additional publications identified through reference lists of these papers. Inclusion criteria were: 1) articles published in English between January 1, 1974 and July 1, 2016 with pathology diagnosis and survival details; 2) adult cases following SOT. Patient characteristics, immunosuppressive regimen, treatment, survival, and follow-up time of 306 cases were extracted from 94 articles and combined with 11 cases from our institution.Patients with recorded subtype information were included in survival analysis. Kaplan-Meier analysis compared overall survival (OS) for four major subtypes (polymorphic, monomorphic B cell, monomorphic T cell, and Hodgkin-type neoplasms), and for four subgroups of B cell neoplasms. Univariate and multivariable Cox proportional hazard regression analyses were performed to identify predictors of OS for each subtype and B cell subgroup.ResultsOf 234 cases with available subtype information, 52.1% were monomorphic B cell neoplasms, of which DLBCL was the most frequent subtype (n=59, 48.3% of B neoplasms); 28.6% were monomorphic T cell neoplasms, 10.6% were Hodgkin-type, and 4.3% were polymorphic. OS was significantly different between monomorphic T cell neoplasms (median 9 months) and polymorphic, monomorphic B cell, and Hodgkin-type neoplasms, for which median OS was not reached (p = 0.0001, Figure 1a). Significant differences in OS among B-subgroups were not detected, but there was a trend towards decreased survival in Burkitt-type PTLD (Figure 1b). Kidney transplant and treatment with reduction of immunosuppression were associated with increased OS in multivariable analysis in B cell neoplasms. Immunosuppression with azathioprine was associated with decreased OS in T cell neoplasms, while treatment with radiotherapy was associated with improved OS in that subtype.ConclusionsHistologic subtype represents an important factor in PTLD prognosis, with T cell monomorphic subtype exhibiting a particularly poor OS. The possibility of lower survival in certain subsets of B cell PTLD should be explored in future studies and suggests the need for subtype-specific treatment strategies to improve outcomes. [Display omitted] DisclosuresFlowers:Onyx: Research Funding; TG Therapeutics: Research Funding; Research to Practice: Research Funding; Genentech/Roche: Consultancy, Research Funding; Prime Oncology: Research Funding; Burroughs Welcome Fund: Research Funding; OptumRx: Consultancy; Seattle Genetics: Consultancy; Bayer: Consultancy; Eastern Cooperative Oncology Group: Research Funding; Janssen Pharmaceutical: Research Funding; Pharmacyclics LLC, an AbbVie Company: Research Funding; Celgene: Consultancy, Research Funding; Millennium/Takeda: Research Funding; National Institutes Of Health: Research Funding; National Cancer Institute: Research Funding; Acerta: Research Funding; Clinical Care Options: Research Funding; Infinity: Research Funding; Spectrum: Consultancy; V Foundation: Research Funding; Abbvie: Consultancy, Research Funding; Educational Concepts: Research Funding; Gilead: Consultancy. Waller:PRA: Consultancy; National Institutes of Health: Research Funding; AMGEN: Consultancy; Cambium Medical Technologies: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties; Katz Foundation: Research Funding; Chimerix: Equity Ownership; Celldex: Consultancy; Coulter Foundation: Research Funding; Helocyte: Consultancy; Cerus: Equity Ownership; Novartis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding.

CT derived radiomic score for predicting the added benefit of adjuvant chemotherapy following surgery in stage I, II resectable non-small cell lung cancer: a retrospective multicohort study for outcome prediction

Use of adjuvant chemotherapy in patients with early-stage lung cancer is controversial because no definite biomarker exists to identify patients who would receive added benefit from it. We aimed to develop and validate a quantitative radiomic risk score (QuRiS) and associated nomogram (QuRNom) for early-stage non-small cell lung cancer (NSCLC) that is prognostic of disease-free survival and predictive of the added benefit of adjuvant chemotherapy following surgery. We did a retrospective multicohort study of individuals with early-stage NSCLC (stage I and II) who either received surgery alone or surgery plus adjuvant chemotherapy. We selected patients for whom we had available pre-treatment diagnostic CT scans and corresponding survival information. We used radiomic texture features derived from within and outside the primary lung nodule on chest CT scans of patients from the Cleveland Clinic Foundation (Cleveland, OH, USA; cohort D1) to develop QuRiS. A least absolute shrinkage and selection operator-Cox regularisation model was used for data dimension reduction, feature selection, and QuRiS construction. QuRiS was independently validated on a cohort of patients from the University of Pennsylvania (Philadephia, PA, USA; cohort D2) and a cohort of patients whose CT scans were derived from The Cancer Imaging Archive (cohort D3). QuRNom was constructed by integrating QuRiS with tumour and node descriptors (according to the tumour, node, metastasis staging system) and lymphovascular invasion. The primary endpoint of the study was the assessment of the performance of QuRiS and QuRNom in predicting disease-free survival. The added benefit of adjuvant chemotherapy estimated using QuRiS and QuRNom was validated by comparing patients who received adjuvant chemotherapy versus patients who underwent surgery alone in cohorts D1-D3. We included: 329 patients in cohort D1 (73 [22%] had surgery plus adjuvant chemotherapy and 256 (78%) had surgery alone); 114 patients in cohort D2 (33 [29%] had surgery plus adjuvant chemotherapy and 81 (71%) had surgery alone); and 82 patients in cohort D3 (24 [29%] had surgery plus adjuvant chemotherapy and 58 (71%) had surgery alone). QuRiS comprised three intratumoral and 10 peritumoral CT-radiomic features and was found to be significantly associated with disease-free survival (ie, prognostic validation of QuRiS; hazard ratio for predicted high-risk vs predicted low-risk groups 1·56, 95% CI 1·08-2·23, p=0·016 for cohort D1; 2·66, 1·24-5·68, p=0·011 for cohort D2; and 2·67, 1·39-5·11, p=0·0029 for cohort D3). To validate the predictive performance of QuRiS, patients were partitioned into three risk groups (high, intermediate, and low risk) on the basis of their corresponding QuRiS. Patients in the high-risk group were observed to have significantly longer survival with adjuvant chemotherapy than patients who underwent surgery alone (0·27, 0·08-0·95, p=0·042, for cohort D1; 0·08, 0·01-0·42, p=0·0029, for cohorts D2 and D3 combined). As concerns QuRNom, the nomogram-estimated survival benefit was predictive of the actual efficacy of adjuvant chemotherapy (0·25, 0·12-0·55, p<0·0001, for cohort D1; 0·13, <0·01-0·99, p=0·0019 for cohort D3). QuRiS and QuRNom were validated as being prognostic of disease-free survival and predictive of the added benefit of adjuvant chemotherapy, especially in clinically defined low-risk groups. Since QuRiS is based on routine chest CT imaging, with additional multisite independent validation it could potentially be employed for decision management in non-invasive treatment of resectable lung cancer. National Cancer Institute of the US National Institutes of Health, National Center for Research Resources, US Department of Veterans Affairs Biomedical Laboratory Research and Development Service, Department of Defence, National Institute of Diabetes and Digestive and Kidney Diseases, Wallace H Coulter Foundation, Case Western Reserve University, and Dana Foundation.

Improved Digital Therapy for Developmental Pediatrics Using Domain-Specific Artificial Intelligence

Automated emotion classification could aid those who struggle to recognize emotion, including children with developmental behavioral conditions such as autism. However, most computer vision emotion recognition models are trained on adult affect and therefore underperform when used on child faces. In this study, we designed a strategy to gamify the collection and the labeling of child affect data in an effort to boost the performance of automatic child emotion detection to a level closer to what will be needed for digital healthcare approaches. We leveraged our prototype therapeutic smartphone game, GuessWhat, which was designed in large part for children with developmental and behavioral conditions, to gamify the secure collection of video data of children expressing a variety of emotions prompted by the game. Independently, we created a secure web interface to gamify the human labeling effort HollywoodSquares, tailored for use by any qualified labeler. We gathered and labeled 2,155 videos, 39,968 emotion frames, and 106,001 labels on all images. With this drastically expanded pediatric emotion centric database (>30x larger than existing public pediatric affect datasets), we trained a pediatric emotion classification convolutional neural network (CNN) classifier of happy, sad, surprised, fearful, angry, disgust, and neutral expressions in children. The classifier achieved 66.9% balanced accuracy and 67.4% F1-score on the entirety of CAFE as well as 79.1% balanced accuracy and 78.0% F1-score on CAFE Subset A, a subset containing at least 60% human agreement on emotions labels. This performance is at least 10% higher than all previously published classifiers, the best of which reached 56.0% balanced accuracy even when combining “anger” and “disgust” into a single class. This work validates that mobile games designed for pediatric therapies can generate high volumes of domain-relevant datasets to train state of the art classifiers to perform tasks highly relevant to precision health efforts. Funding Statement: This work was supported in part by funds to DPW from the National Institutes of Health (1R01EB025025-01, 1R21HD091500- 01, 1R01LM013083), the National Science Foundation (Award 2014232), The Hartwell Foundation, Bill and Melinda Gates Foundation, Coulter Foundation, Lucile Packard Foundation, the Weston Havens Foundation, and program grants from Stanford’s Human Centered Artificial Intelligence Program, Stanford’s Precision Health and Integrated Diagnostics Center (PHIND), Stanford’s Beckman Center, Stanford’s Bio-X Center, Predictives and Diagnostics Accelerator (SPADA) Spectrum, Stanford’s Spark Program in Translational Research, and from Stanford’s Wu Tsai Neurosciences Institute’s Neuroscience: Translate Program. We also acknowledge generous support from David Orr, Imma Calvo, Bobby Dekesyer and Peter Sullivan. P.W. would like to acknowledge support from Mr. Schroeder and the Stanford Interdisciplinary Graduate Fellowship (SIGF) as the Schroeder Family Goldman Sachs Graduate Fellow. Declaration of Interests: D.P.W. is the founder of Cognoa.com. This company is developing digital health solutions for pediatric care. A.K. works as part-time consultant to Cognoa.com. All other authors declare no conflict of interests. Ethics Approval Statement: All recruitment and study procedures were approved by the Stanford University Institutional Review Board.

78-OR: Automated Glycemic Control with a Bionic Pancreas Configured for Use in the Critical Care Setting

Tight glycemic control of hospitalized patients is difficult and labor intensive to achieve. We evaluated the feasibility of fully automated glycemic control with a version of the bionic pancreas (BP) designed for use in the critical-care setting. The fully automated BP controlled the intravenous delivery of insulin and 20% dextrose based on glucose values from the Abbott FreeStyle Navigator CGM. The same algorithm, initialized only with body mass, was used in all subjects. Adult subjects with type 1 (n=6) or type 2 (n=6) diabetes with a total daily dose (TDD) of insulin under usual care of 0.5-2.9 u/kg/day were under automated glucose control for an 8-hour period. Subjects started the study period fasted, later consumed an unrestricted meal of their choice, and still later took liquid nutrition nearly continuously for 2 hours before abruptly stopping, in order to simulate continuous enteral feeding and its interruption. Food intake was not announced to the BP. The primary outcome, mean plasma glucose (measured every 15 minutes), was 116±20 mg/dL. The % time within 70-180 mg/dL was 95±8% and the median (IQR) % of time &amp;lt;70 mg/dL was 0 (0, 2.3) and &amp;lt;54 mg/dl was 0 (0, 0). We concluded that the BP can achieve excellent glycemic control in volunteers with a wide range of insulin needs and in the face of realistic glycemic challenges. These results support feasibility testing of the critical care BP in the critical-care setting. Disclosure J. Sherwood: None. M.A. Hillard: None. K.B. Grennan: None. F. El-Khatib: Employee; Self; Beta Bionics. Stock/Shareholder; Self; Beta Bionics. E. Damiano: Advisory Panel; Self; Novo Nordisk A/S. Board Member; Self; Beta Bionics. Employee; Self; Beta Bionics. Stock/Shareholder; Self; Beta Bionics. Stock/Shareholder; Spouse/Partner; Beta Bionics. Other Relationship; Self; Ascensia Diabetes Care, Senseonics. S.J. Russell: Advisory Panel; Self; Companion Medical, Unomedical a/s. Consultant; Self; Flexion Therapeutics. Research Support; Self; Beta Bionics, MITRE Corporation, Novo Nordisk A/S, Zealand Pharma A/S. Other Relationship; Self; ADOCIA, Ascensia Diabetes Care, Ascensia Diabetes Care, Lilly Diabetes, Roche Diabetes Care, Senseonics. Funding Wallace H. Coulter Foundation

267-OR: Cardiomyocyte Insulin Resistance Manifests on High-Glucose Fibroblast-Derived Extracellular Matrix

The primary cause of death in diabetes is heart failure. Growing evidence suggests that remodeling of the physical microenvironment of the heart drives cardiomyocyte pathology, independent of hypertension and coronary artery disease. Several studies have thus far provided evidence that the extracellular matrix (ECM) changes with diabetic peripheral complications by vascular obstruction and fibrotic hypertension. Rather than a secondary phenomenon, our in vitro data implicates fibroblast derived ECM as a direct regulator of cardiomyocyte insulin sensitivity. Using published methods, we observe that ECM derived from plated primary neonatal cardiac fibroblasts is structurally altered when produced in low- (5mM) versus high-glucose (25mM), with respect to density indicative of collagen crosslinking (Aniline blue staining) and increased stiffening (Atomic Force Microscopy). Most importantly, plating primary cardiomyocytes on high-glucose (vs. low-glucose) fibroblast derived matrix reduces insulin sensitivity (Akt/PKB phosphorylation). We also observe reduced Focal Adhesion Kinase (FAK) activation and c-Jun N-terminal kinase (JNK) inactivation within this in vitro platform; pathways which have been shown to regulate insulin sensitivity via integrin binding to ECM proteins. The cardiac fibroblast derived matrix model serves as a high throughput in vitro platform, which we have thus far used to establish the direct relationship between ECM deposition and insulin sensitivity. Future work will use the platform to dig into the underlying mechanisms implicating ECM remodeling and sensing in the pathogenesis of diabetic cardiomyopathy and heart failure. Disclosure S. Nieuwoudt: None. X. Wang: None. S. Senapati: None. P. Park: None. S. Senyo: None. Funding Case Western Reserve University (RES221997); Wallace H. Coulter Foundation; National Heart, Lung, and Blood Institute (T32HL134622-02)

Smart Glasses May Help Children With Autism Recognize Emotions

Smart Glasses May Help Children With Autism Recognize Emotions