GEP Score Research Articles

Elucidating the genomic and transcriptomic landscape of L858R vs ex19del EGFR-mutated NSCLC.

8530 Background: Epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC) is heterogeneous and L858R derive less benefit from osimertinib than ex19del in both the metastatic and adjuvant setting, which remains poorly understood. We sought to examine the genomic and transcriptomic features of L858R vs ex19del. Methods: Consecutive patients with AJCC7 Stage IA-IIIA EGFR-mutated NSCLC diagnosed 1/1/2010 – 31/12/2019 who underwent surgery at National Cancer Centre Singapore were included. Patients who received neoadjuvant therapy were excluded. Fresh frozen tumour and normal samples were subject to whole exome sequencing (WES) at 400X and 100X coverage respectively, with approximately 50 million paired-end reads for RNA-seq per sample. Wilcoxon and Fisher’s exact test were used for association analysis. Results: A total of 203 patients were included. Median age at diagnosis was 66, 66.0% (134/203) were females and 84.2% (171/203) never-smokers. Stage IA comprised 44.3% (90/203), IB 28.6% (58/203), II 15.8% (32/203) and IIIA 11.3% (23/203). Median tumour mutational burden (TMB) was 1.3 mutations/megabase (range 0.3 – 44.3). Ex19del represented 46.3% (94/203) and L858R 41.9% (85/203). Whole genome doubling (WGD) was found in 70.0% (142/203) and was more common in TP53-mutated compared to TP53-wildtype (81.1% vs. 63.6%, p=0.01). TP53 mutations were more common in stage II/IIIA tumours compared with stage IB and IA (50.9% vs 32.8% vs 30.0%, p=0.035). Comparing ex19del and L858R, there was no difference in stage distribution (p=0.337), proportion of TMB≥10 (1.1% vs 5.9%, p=0.103), number of cancer co-driver mutations (p=0.174), TP53 mutations (39.4% vs 32.9%, p=0.437) and WGD (69.1% vs 76.5%, p=0.316). L858R had a higher incidence of smoking mutational signature (median 0.35 vs 0.28, p=0.018) compared to ex19del despite similar smoking history (15.3% vs 12.8%, p=0.67), whereas APOBEC mutational signature was higher in ex19del (median 0.06 vs 0.04, p=0.015). L858R tumors were associated with a higher incidence of co-mutations in RBM10 (21.2% vs 6.38%, p=0.004), RNF213 (10.6% vs 1.06%, p=0.007) and amplification of NTHL1 (15.3% vs 2.13%, p=0.001) and AXIN1 (17.6% vs 3.19%, p=0.002) compared to ex19del. Transcriptomic subtype differed significantly by EGFR mutation with a higher representation of TRU subtype among L858R than ex19del (51.0% vs 35.3%, p=0.010), while GEP score was similar (median 0.189 vs 0.325, p=0.122). Conclusions: L858R have distinct co-mutations and copy number alterations compared to ex19del, in addition to a higher representation of smoking mutational signature and TRU subtype. TP53 co-mutations are more frequently observed in higher stage tumours and are associated with WGD. Our findings highlight the molecular heterogeneity of resected EGFR-mutated NSCLC, which could contribute to the differential outcomes to adjuvant osimertinib between ex19del and L858R.

Tumor immune microenvironment of different lesions in patients with multiple primary lung cancer.

e20549 Background: More and more multiple primary lung cancers (MPLCs) are found clinically. The driver genes and clinical differences between different lesions in MPLCs are obvious, which may affect the choice of subsequent treatment options. As a new type of therapy, immunotherapy has improved the survival of lung cancer patients to a certain extent. However, the efficacy of immunotherapy on different lesions of the same patient with MPLCs is not yet clear. Our study explored the similarities and differences of the tumor immune microenvironment in MPLCs lesions and provided a theoretical basis for immunotherapy in MPLCs. Methods: We collected 20 surgical tumor lesion samples from 10 patients with MPLCs for 289-gene panel RNA sequencing using NanoString nCounter. All tumor tumor immune microenvironment (TIME) cell infiltration scores were calculated as arithmetic mean of the constituent genes. Immune infiltration and expression of immune-related genes in different groups were assessed. Results: All 10 patients in our study were lung adenocarcinoma. Firstly, we classified them using an unsupervised consensus clustering based on TIME-signature gene expression used nonnegative matrix factorization of R package. The results revealed the cluster number of two was optimal (TIME Cluster1: n = 6 patients / 12 lesions; TIME Cluster2: n = 4 patients / 8 lesions). It is worth noting that the two lesions of the same patient are divided into the same group, indicating that the immune microenvironment status of the two lesions of the same person is basically similar. In addition, the nertrophils, NK CD56dim cells and GEP score of Cluster1 is significantly higher than that of Cluster2. Then we grouped them according to gender, ipsilateral or heteroside primary lesions, left or right lung, and pathological infiltration or non-infiltration, and found there was no significant difference in the immune microenvironment between the all the two groups. Conclusions: Dual primary samples from the same individual have similar immune microenvironments and may respond similarly to immunotherapy. Prospective immune-related clinical trials can be designed for further verification in MPLCs patients.

A multigene circulating biomarker to predict the lack of FOLFIRINOX response after a single cycle in patients with pancreatic ductal adenocarcinoma

Introduction5-fluorouracil, folinic acid, irinotecan and oxaliplatin (FOLFIRINOX) is promising in treating patients with pancreatic ductal adenocarcinoma. However, many patients and physicians are reluctant to start FOLFIRINOX due to its high toxicity and limited clinical response rates. In this study, we investigated the effect of a single FOLFIRINOX cycle, in combination with a granulocyte colony-stimulating factor, on the blood immune transcriptome of patients with pancreatic ductal adenocarcinoma. We aimed to identify an early circulating biomarker to predict the lack of FOLFIRINOX response. MethodsBlood samples of 68 patients from all disease stages, who received at least four FOLFIRINOX cycles, were collected at baseline and after the first cycle. The response to treatment was radiologically evaluated following the Response Evaluation Criteria in Solid Tumours criteria 1.1. Targeted immune-gene expression profiling (GEP) was performed using NanoString technologies. To predict the lack of FOLFIRINOX response, we developed a FOLFIRINOX delta GEP (FFX-ΔGEP) score. ResultsA single FOLFIRINOX cycle significantly altered 395 genes, correlating to 30 significant alterations in relative immune cell abundances and pathway activities. The eight-gene (BID, FOXP3, KIR3DL1, MAF, PDGFRB, RRAD, SIGLEC1 and TGFB2) FFX-ΔGEP score predicted the lack of FOLFIRINOX response with a leave-one-out cross-validated area under the curve (95% confidence interval) of 0.87 (0.60–0.98), thereby outperforming the predictiveness of absolute and proportional Δcarbohydrate antigen19-9 values. ConclusionsA single FOLFIRINOX cycle, combined with granulocyte colony-stimulating factor, alters the peripheral immune transcriptome indisputably. Our novel FFX-ΔGEP is, to our knowledge, the first multigene early circulating biomarker that predicts the lack of FOLFIRINOX response after one cycle. Validation in a larger independent patient cohort is crucial before clinical implementation.

The Tumor Immune Microenvironment and Frameshift Neoantigen Load Determine Response to PD-L1 Blockade in Extensive-Stage SCLC

IntroductionDespite a considerable benefit of adding immune checkpoint inhibitors (ICIs) to platinum-based chemotherapy for patients with extensive-stage SCLC (ES-SCLC), a durable response to ICIs occurs in only a small minority of such patients. MethodsA total of 135 patients with ES-SCLC treated with chemotherapy either alone (chemo-cohort, n = 71) or together with an ICI (ICI combo-cohort, n = 64) was included in this retrospective study. Tumors were classified pathologically as inflamed or noninflamed on the basis of programmed death-ligand 1 expression and CD8+ tumor-infiltrating lymphocyte density. Immune-related gene expression profiling was performed, and predicted neoantigen load was determined by whole-exome sequencing. ResultsAmong patients in the ICI combo-cohort, median progression-free survival was 10.8 and 5.1 months for those with inflamed (n = 7) or noninflamed (n = 56) tumors, respectively (log-rank test p = 0.002; hazard ratio of 0.26). Among the 89 patients with immune-related gene expression profiling data available, inflamed tumors had a higher T cell-inflamed GEP score than did noninflamed tumors (−0.18 versus −0.58, p < 0.001). The 12-month progression-free survival rate was 16.1% and 0% for patients in the ICI combo-cohort harboring tumors with a high (n = 26) or low (n = 18) frameshift neoantigen load, respectively. A high-frameshift neoantigen load was associated with up-regulation of gene signatures related to antigen presentation and costimulatory signaling. A durable clinical benefit of ICI therapy was observed only in patients with inflamed tumors and a high-frameshift neoantigen load. ConclusionsExpression of programmed death-ligand 1, CD8+ T cell infiltration, and a high-frameshift neoantigen load are associated with clinical benefit of ICI therapy in ES-SCLC. Clinical trial registrationUMIN000041056

Immune-suppressive microenvironment was revealed from NSCLC patients with hyperprogressive disease (HPD) from immunotherapy.

e21109 Background: Immune checkpoint inhibitors (ICIs) demonstrated clear survival benefit in advanced non-small cell lung cancer (NSCLC) and was considered as a standard treatment. However, 10%-20% of ICI treated patients presented hyper-progressive disease (HPD) and shortened OS (&lt; 5 months). In this study, we analyzed the tumor immune microenvironment (TME) of HPD and non-HPD NSCLC patients, aiming to reveal their discrepancies. Methods: Advanced NSCLC patients treated with ICIs in West China Hospital from March 2015 to January 2020 were retrospectively analyzed. HPD was defined as: 1) RECIST progression at first response evaluation, or time-to-treatment failure (TTF) &lt; 2 months; 2) increase in tumor volume &gt; 50%; 3) tumor growth rate (TGR) &gt; 2-fold. Total cellular RNA was extracted from FFPE samples and subjected to gene expression evaluation using NanoString nCounter. A customized code set consisting of a 289-gene panel related to the tumor, immune regulation, and tumor microenvironment was used. Results: A total of 296 patients were screened, including 26 (8.8%) HPD and 272 (91.2%) non-HPD patients. A total of 52 specimens were subjected to TME analysis. At last, data from 27 (8 HPD and 19 non-HPD) samples were suitable for final analysis. We revealed 22 differential expressed genes (DEGs) (fold change &gt; = 2, FDR &lt; 0.05) in the HPD group using DESeq2, including 14 up-regulated genes and 8 down-regulated genes. Gene ontology (GO) enrichment analysis revealed that the DEGs were significantly enriched in leukocyte migration, leukocyte chemotaxis, and neutrophil migration. The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis results revealed that the DEGs were significantly enriched in IL-17 signaling pathway. Levels and proportions of 16 immune cell types, tumor-infiltrating lymphocytes (TILs) score, cytolytic activity (CYT) score, cytotoxic T lymphocytes (CTL) level, IFN-γ signature, T cell markers, teff score and 18-gene T cell-inflamed GEP score were estimated using characteristic gene expression signatures. We found that immune cells had a lower tendency in the HPD group, and B-cells, CD45, cytotoxic cells, T-cells, and Th1-cells reached significantly lower levels. Further analysis revealed that the HPD group had significantly lower total TILs score, Teff score, and T cell-inflamed GEP score. Conclusions: HPD patients in NSCLC had immune-suppressive TME which were significantly different from non-HPD patients. Patients with low TILs score, Teff score, and T cell-inflamed GEP score may develop HPD and have a poor prognosis after receiving ICIs therapy. The TME signatures in the tissues before ICIs treatment might become a predictive biomarker of HPD risk.

YAP1 transcription factor expression to define subsets of cancers with T-cell inflamed phenotype in a pan-tumor analysis across 33 tumor types.

2610 Background: Immune checkpoint blockade (ICB) has become an established treatment option for the majority of solid tumors. PD-L1 expression, tumor mutation burden (TMB) and mismatch repair (MMR) deficiency are established but suboptimal predictive markers to select patients for ICB therapy. The identification of better predictive biomarkers to complement existing biomarkers is an area of need. We previously identified Yes Associated Protein 1 (YAP1) gene expression as a marker of inflamed tumor phenotype in small cell lung cancer. We sought to elucidate the role of YAP1 as a tumor agnostic biomarker of inflamed tumor phenotype. Methods: We obtained the publicly available TCGA normalized RSEM expression data (version dated September 29, 2019) from the GDC legacy archive (https://portal.gdc.cancer.gov/legacy-archive) for this analysis. We used the shinySISPA method ( https://bbisr.shinyapps.winship.emory.edu/shinySISPA/ ) to classify the primary tumor samples into YAP1 high or low on the basis of the normalized expression profile for YAP1 gene. The T-cell–inflamed gene expression profile score for each sample was calculated as weighted sum of the normalized expression values of the 18 genes ( PSMB10, HLA-DQA1, HLA-DRB1, CMKLR1, HLA-E, NKG7, CD8A, CCL5, CXCL9, CD27, CXCR6, IDO1, STAT1, TIGIT, LAG3, CD274, PDCD1LG2, CD276) as originally published in the Patent filed under “WO201609437” and validated as a predictor of clinical efficacy in patients treated with anti PD1 immunotherapy drug, pembrolizumab. Results: A total of 11283 samples from 33 different histologic tumor types contained in the TCGA database were included in this analysis. A small but meaningful subset of cases 271 (2%) were classified as YAP1 high with a wide range in proportion of YAP1 high tumors of 0.67% to 12.09% across the 33 histologic tumor types. Adrenocortical, cholangiocarcinoma, chromophobe RCC, DLBCL, and mesothelioma had a high rate of YAP1 high tumors (&gt; 10% of cases). Overall trend showed a higher median interferon gamma GEP score in YAP1 high versus YAP1 low tumors with a GEP score of 11.2 vs. 10.7 respectively. A minority of histologic tumor subtypes (HNSCC, clear cell RCC, sarcoma, uterine carcinosarcoma, testicular GCT, melanoma, mesothelioma and ovarian cancer) showed a reverse trend of lower GEP score in association with YAP1 high status. Ongoing validation of these findings in an independent cohort of clinical samples and correlation of YAP1 status with other predictive biomarkers (TMB, PD-L1 and MSS status) will be presented at the meeting. Conclusions: YAP1 is highly expressed in a small but meaningful subsets of cancers and is associated with the inflamed phenotype in the majority of cancers. YAP1 expression is most common in rarer tumor types and in histologic types where currently available biomarkers have not been shown to predict the benefit of ICB.

Putative biomarkers of response to anti-PD-1 therapy in metastatic castration-resistant prostate cancer (mCRPC).

155 Background: Metastatic castration resistant prostate cancer (mCRPC) is a heterogeneous disease in which molecular stratification is needed to improve clinical outcomes. Targeting programmed cell death protein 1 (PD-1) elicits durable antitumor responses in multiple cancer types. Putative biomarkers predictive of response to anti-PD-1 therapies include programmed death-ligand-1 (PD-L1), tumour mutational burden (TMB), T cell-inflamed 18-gene expression profile (GEP), and DNA repair defects. Objective: To study potential biomarkers of response in mCRPC to anti-PD-1 therapy (PD-L1, GEP, mismatch repair (MMR) protein), other biomarkers of interest including BRCA2, PALB2, CDK12, PTEN, TP53, SOX2, and to determine association with clinical outcomes. Methods: The study population included 100 men with mCRPC treated at the Royal Marsden Hospital with available fresh mCRPC biopsy tissue. All men had received at least one line of therapy with a next generation hormonal agent and one line of taxane-based chemotherapy. Clinical characteristics and outcomes were extracted from medical records. mCRPC biopsies were assayed by whole exome sequencing (WES), targeted next generation sequencing (NGS), RNA sequencing (RNAseq), GEP score (Nanostring), PD-L1 immunohistochemistry (IHC; DAKO 22C3 assay), SOX2 IHC, ATM IHC. Correlations among these biomarkers and clinical outcomes were assessed. Results: The median age of patients was 68.0 years; 46/84 (54.8%) had de novo metastatic disease at diagnosis and 24/100 (24.0%) patients had visceral disease. Median follow-up from mCRPC biopsy was 56.2 months. The prevalence of loss of protein expression by IHC and/or pathogenic mutation by NGS of MMR was 7/100 (7%). Loss of PTEN and ATM by IHC was 29/100 (29%) and 13/100 (13%) respectively. SOX2 expression (defined as expression in &gt;5% of cells) was 27/100 (27%). The prevalence of TP53 mutation was 25/100 (25%); deleterious alterations of BRCA2 was 9/100 (9%), CDK12 3/100 (3%) and PALB2 1/100 (1%). PDL1 and GEP results were available for 70 and 93 samples respectively. PD-L1 was expressed (combined positive score ≥1) in 24 (33%) mCRPC biopsies; 23 (26%) had high GEP scores (&gt; -0.318). PD-L1 and GEP expression were positively correlated (Phi 0.63). No other biomarkers showed strong correlations. Of 5 samples with MMR loss for which PD-L1 was available, 1 (20%) had PD-L1 ≥1; one of the CDK12 samples had PD-L1 ≥1 (33%). 0/6 BRCA2 mutated biopsies expressed PD-L1 (0%). Based on univariate analysis, PD-L1 expression [HR: 1.75 (1.00;3.06), p=0.045], high GEP score [HR: 2.00 (1.18;3.39), p=0.0083] and SOX2 expression [HR: 1.81 (1.12;2.94), p=0.015] were associated with worse overall survival (OS). No other biomarkers associated with OS. Conclusions: PD-L1 IHC expression was detected in 33% of mCRPC patients and associated with high GEP score. Higher PD-L1, GEP, and SOX2 expression were associated with poor prognosis.

Impact of cytomegalovirus infection on gene expression profile in heart transplant recipients

Cytomegalovirus (CMV) infection has been implicated in the pathogenesis of allograft rejection in heart transplant (HT) recipients. The effect of a CMV infection on the gene expression profiling (GEP, AlloMap) scores in the absence of acute rejection is not known. Data from 14,985 samples collected from 2,288 adult HT recipients enrolled in Outcomes AlloMap Registry were analyzed. Patients with known CMV serology at the time of HT who had at least 1 AlloMap score reported during follow-up were included. AlloMap scores for those patients with CMV (but no ongoing rejection) were compared with those who were never infected. An exploratory analysis on the impact of CMV on available donor-derived cell-free DNA (AlloSure) was also performed. A total of 218 patients (10%) were reported to have CMV infection after transplantation. AlloMap score in those samples with CMV infection (n = 311) had a GEP score (34; range: 29-36) significantly higher than the GEP score from samples (n = 14,674) obtained in the absence of CMV infection (30; range: 26-34; p < 0.0001). Both asymptomatic viremia and CMV disease demonstrated significantly higher AlloMap scores than no CMV infection samples (median scores: 33, 35, and 30, respectively; p < 0.0001). AlloSure levels, available for 776 samples, were not significantly different (median: 0.23% in 18 samples with CMV infection vs 0.15% in 776 samples without CMV infection; p = 0.66). CMV infection in HT recipients is associated with an increase in AlloMap score, whereas AlloSure results do not appear to be impacted. This information should be considered when clinically interpreting abnormal/high AlloMap scores in HT recipients.

The Effect of Pre-Transplant Mechanical Circulatory Support Devices on the Post-Transplant dd-cfDNA and GEP in Heart Transplantation

Evidence around sensitization and increased risk of rejection from use of pre-transplant mechanical circulatory support (MCS) devices remains conflicting. Some evidence suggests devices cause inflammation and association with increased antibody production, which has been shown to be associated with AMR, CMR, and early onset of microvasculopathy at one year post-heart transplant. However other evidence suggests no difference or increased risk of adverse outcome using pre-transplant MCS devices. dd-cfDNA (AlloSure) has been shown to rise in advance to the new formation of de-novo anti-HLA antibodies, with changes in AlloMap also seen in patients who become newly sensitized. The aim of this study was to review MCS patients post-transplant with AlloSure and AlloMap to assess if they had different patterns from those who had no MCS, to support suggestion of early post-transplant complications. Patients who were enrolled in Outcomes AlloMap® Registry (OAR) and the dd-cfDNA extension (D-OAR) were included in this analysis if pre-transplant MCS history was recorded and signs or symptoms of rejection during a visit with an accompanying blood draw were absent (i.e. no biopsy accompanied the visit or if a biopsy occurred it yielded Grade 0R). A total of 282 patients met these criteria, 130 had pre-transplant MCS and 152 did not. A total of 652 samples were collected where both AlloSure and AlloMap scores were obtained. The cumulative distribution of AlloSure and AlloMap scores were assessed via a two-sample Kolmogorov-Smirnov test to determine if differences were observed that may be attributed to mechanical assist support prior to transplant. No difference in the distribution of AlloMap scores from patients that received pre-transplant mechanical support versus those that did not was observed, similarly for AlloSure measurements, there was no statistically significant difference in the distribution of AlloSure scores between those that receive pre-transplant mechanical assist support versus those that do not receive support. Pre-transplant MCS does not correlate with increased dd-cfDNA or GEP score, suggesting the adverse outcomes seen early post-transplant are unlikely to be due to MCS devices.

Transcriptomic landscape of tumour cells undergoing T-cell attack

Abstract Background The study of crosstalks between cancer cells and T cells in the tumour microenvironment (TME) can inform on tumour immune escape and help in predicting responses to immunotherapy. By reproducing in vitro how tumour infiltrating lymphocytes (TILs) interact with cancer cells, novel methodologies may allow a thorough characterization of the transcriptomic changes induced in tumours undergoing a T cell attack (TuTACK). Methods Thirteen pairs of highly tumour-reactive TILs and autologous cancer cell lines, covering four distinct tumour types, were selected and co-cultured to induce a cytostatic effect in tumour cultures. The global TuTACK transcriptome was characterized, and a TuTACK gene signature was extracted to be tested for prediction of response to anti-PD-1/anti-PD-L1. Results We showed that an autologous T cell attack induced large transcriptomic changes in tumours, that were independent of IFN-g signaling. Transcriptomic changes were tumour-type independent and allowed the identification of a gene-set (TuTACK gene-set) containing 256 genes covering 55 defined biological processes, that included several potential actionable adaptive immune resistance pathways. We extracted a 14-gene signature (TuTACK signature) that allowed a novel scoring of the TME. The TuTACK score correlated well to the estimated immunological activity in the TME (measured by the T cell-inflamed gene expression profile or GEP), and was predictive of response to anti-PD-1/PD-L1 therapy across 26 tumour types (Spearman R = 0.54, Pearson R = 0.57) outperforming the T cell-inflamed GEP score (Spearman R = 0.25, Pearson R = 0.34) and with a comparable predictive power to the tumour mutational burden (TMB; Spearman R = 0.65, Pearson R = 0.56). The TuTACK score was only moderately correlated to the TMB (Spearman R = 0.36; Pearson R = 0.53), indicating that these biomarkers may be independent. Conclusion TuTACK measured the effects of an immune response rather than its activity and it represents an innovative method to identify immunologically hot tumours. Our findings suggested that TuTACK may allow better patient selection in immunotherapy clinical trials and provide hints to improve the treatment of “hot” tumours resistant to current immunotherapies. Legal entity responsible for the study The authors. Funding The Danish Cancer Society (grant number R148-A9862); The Lundbeck Foundation (grant number R233-2016-3728); The Capital Region of Denmark Research Foundation (grant number R146-A5693); The National Research, Development and Innovation Fund of Hungary (FIEK_16-1-2016-0005). Disclosure All authors have declared no conflicts of interest.

Psychiatric Home Hospitalisation Unit of the Hospital del Mar. A crisis resolution and home treatment team in Barcelona

IntroductionAlthough home hospitalisation has begun to develop widely in recent years there is a notable lack of studies. The following study includes data from the Psychiatric Home Hospitalisation Unit of the Hospital del Mar (HADMar). This programme has been running for 2 years and takes place in a socio-demographically depressed area in Barcelona. It receives patients from community and hospital services. Monitoring is limited in time and at discharge patient are referred to the ambulatory unit. Material and methodsAll patients visited from 2015 to the present time were selected. A total of 135 patients were included in the sample. A qualitative descriptive study was carried out in order to define the socio-demographic characteristics. The severity of symptoms, suicidal risk and changes in the functionality were considered as clinical outcomes. ResultsThe mean age of patients was 44.6 years and there were no gender differences. A total of 26 patients had a history of suicidal attempts and 11.1% lived alone; 51.1% were diagnosed with a psychotic disorder. The mean GEP score for the severity of the psychiatric symptoms was 2.39 and the mean risk of suicide was 0.49. There is an increase in the EEAG score from admission to discharge, which means an improvement in the functionality of patients. ConclusionsThe results obtained in our study are consistent with previous results. Home crisis intervention teams have proved to be an alternative to traditional hospitalisation. However, more studies are needed to support these results.

Distinct Patterns of Gene Expression Identified Longitudinally and within AlloMap Score Ranges are Associated with Clinical Outcomes

Summary of Objectives Gene expression profiling (GEP, AlloMap) has become the standard of care in heart transplant patient management with over 120,000 performed. The large size of the dataset enables identification of distinct patterns of longitudinal and component gene expression. OAR is a prospective observational heart transplant registry with integrated GEP testing to elucidate factors that contribute to long term outcomes. Samples with GEP scores and individual gene data but not included in OAR have been examined by unsupervised methods to identify patterns of gene expression. These patterns can then be correlated with outcomes collected in OAR to identify specific signals that are indicative of different outcomes. Methods Latent class mixed models were used to estimate profiles of GEP score over time with 62,833 samples from 8,066 patients with at least two GEP score measures. Distinct patterns were identified in a 3-class model; with 69% of the 8,066 patients in a class with a gradual increase in GEP score over time; 23% with a stable GEP score, and 8% with a rapid increase in GEP score. The full dataset of 19,761 patients and 104,827 samples was used to identify patterns of gene expression among the 7 gene terms and the principle components contributing to the GEP Scores. PDCD1, ITGA4, RHOU, and SEMA7A were correlated more closely than the remaining terms. Additionally, the 7 terms were used in an archetypal analysis that identified eight unique archetype patterns of gene expression. For example, two archetypes, #4 and #8 have median GEP scores of 29.4 and 29.9, but different gene patterns. Archetype #4 has high RHOU and PF4/G6B1, but low SEMA7A. Archetype #8 has high IL1R2/FLT3/ITGAM and low PF4/G6B1. Endpoints The principal components analysis identified correlations that match the known and hypothesized biological mechanisms of the genes; the highest correlation was among four genes known or hypothesized to be indicators of T cell activation. The identified archetypal patterns will be assigned to patients in the OAR registry to identify clinical correlates with each archetype group. Among the clinical factors that will be investigated are malignancies, infections, cellular rejection, and cardiac allograft vasculopathy.

Differential Gene Expression by Race and Impact on Risk after Heart Transplantation

Purpose African Americans (AA) have worse survival compared to Caucasians post heart transplantation (HTx). The aim of this analysis was to evaluate racial differences in gene expression and the impact on survival and a composite outcome of death, re-Tx, hemodynamic rejection and graft dysfunction in the Outcomes AlloMap Registry (OAR). Methods AA and Caucasians who had a baseline (BL) and at least 1 follow-up (FU) test within the first year of HTx were included. The KM method with delayed entry was used to describe difference in outcomes. Multivariable cox hazard regression was used to evaluate the associations of GEP score, MARCH8, FLT3 and tacrolimus levels with each outcome, and stratified cox models were developed to quantify the race-specific associations. Results Among 992 eligible recipients, 777 (78%) were Caucasian and 215 (22%) AA. Compared to Caucasians, AA were significantly younger (55 vs 59 yrs), with higher rates of DCMP (68% vs 49%), multiorgan Tx (7% vs 1%), sensitization (>10% PRA 17% vs 10%) and HLA mismatches (6 vs. 7, p=0.02). AA had increased adjusted mortality risk HR 1.16, p Conclusion AA have a significantly higher mortality risk after HTx than Caucasians, even in the low risk OAR population. AA and Caucasians had differential gene expression of MARCH8 and FLT3 genes and differential risk associated with the expression of these genes.

Use of dd-cfDNA in Real World Practice: Single Center Experience

Purpose Gene expression profiling testing (GEP; AlloMap) and donor-derived cell free DNA (dd-cfDNA; AlloSure) each provide non-invasive means to detect possible heart allograft rejection, including acute cellular rejection (ACR). This report describes the largest single center use of dd-cfDNA to date. Methods Post heart transplant (HT) management is standardized at our center such that endomyocardial biopsy is used for rejection surveillance in the early period with crossover to GEP testing at day 56. Elevated GEP (≥34) prompts biopsy. dd-cfDNA was utilized in conjunction with biopsy or in lieu of biopsy (barrier to biopsy). A cohort of 26 HT patients underwent dd-cfDNA testing, including 3 multiorgan (same donor) and 5 retransplant patients. The dd-cfDNA (%, AlloSure) and GEP (AlloMap, score 0-40) results were correlated patient survival. Results Among 26 HT patients there was a total 70 dd-cfDNA tests (mean 2.7 per pt). dd-cfDNA usage was due to inability to biopsy (33%), anticoagulation (22%), elevated GEP (26%), with graft dysfunction, prior rejection, biopsy refusal, tricuspid regurgitation and critically ill status comprising 4% each. Mean day post HT for first dd-cfDNA test was 201 (IQR 90-517), with earliest at day 7 post HT. Mean dd-cfDNA was 0.3 ± 0.5%. Mean GEP score was 32.8 ± 5.3. There were no deaths in this cohort. One patient had confirmed AMR2 (dd-cfDNA 0.25%). Mean LVEF 54% ± 5. Conclusion In surveillance of heart allograft recipients for rejection, consideration of dd-cfDNA levels may improve patient management decisions particularly when endomyocardial biopsy may not be feasible.

Use of dd-cfDNA in Multiorgan Transplantation

Purpose Gene expression profiling testing (GEP; AlloMap) and donor-derived cell free DNA (dd-cfDNA; AlloSure) each provide non-invasive means to detect possible heart allograft rejection, including acute cellular rejection (ACR). Use of dd-cfDNA in multiorgan transplantation has not previously been reported. This report describes the largest single center use of dd-cfDNA to date in this population. Methods Post heart transplant (HT) management is standardized at our center such that endomyocardial biopsy is used for rejection surveillance in the early period with crossover to GEP testing at day 56. Elevated GEP (≥34) prompts biopsy. dd-cfDNA was utilized in conjunction with biopsy or in lieu of biopsy (barrier to biopsy). A cohort of 26 HT patients underwent dd-cfDNA testing, including 3 multiorgan (same donor) and 5 retransplant patients. The dd-cfDNA (%, AlloSure) and GEP (AlloMap, score 0-40) results were correlated patient survival. Results Among 26 HT patients, there were 3 multiorgan transplant recipients (2 heart-kidney & 1 heart-lung). Mean dd-cfDNA was 0.9 ± 0.5%. Mean GEP score was 32.8 ± 4.0. dd-cfDNA usage was due to inability to biopsy (33.3%), anticoagulation (33.3%) & elevated Allomap (33.3%). Mean LVEF was 55 ± 1%. Mean day post transplant for first dd-cfDNA was 153 (IQR 119-347). There were no deaths. Of the heart-kidney recipients, mean ACR & AMR biopsy grade was 0.67 & 0, respectively. The heart-lung recipient underwent 2 lung biopsies with mean grade of 0. Conclusion In surveillance of heart allograft recipients for rejection, consideration of dd-cfDNA levels may improve patient management decisions particularly when endomyocardial biopsy may not be feasible. This is the first report of use of dd-cfDNA in multiorgan transplantation. Baseline levels of dd-cfDNA appear to be higher than that of heart-only recipients. Further study is warranted to assess the utilization of dd-cfDNA in multiorgan transplantation.

Patterns of Gene Expression in High GEP Score Samples Correlated with Clinical Factors in the Outcomes AlloMap Registry

Gene expression profiling (GEP, AlloMap) has become the standard of care in heart transplant patient management with over 100,000 performed. OAR is a prospective observational heart transplant registry study with integrated GEP testing to elucidate factors that contribute to favorable long term outcomes. Gene subsets were examined for correlation with clinical factors with the goal of identifying those associated with expression patterns that shed light on the underlying mechanisms of acute cellular rejection.

How do women trade-off benefits and risks in chemotherapy treatment decisions based on gene expression profiling for early-stage breast cancer? A discrete choice experiment

ObjectivesGene expression profiling (GEP) of tumours informs baseline risk prediction, potentially affecting adjuvant chemotherapy decisions for women with early-stage breast cancer. Since only 15% will experience a recurrence, concerns have...

(148) - Implications of Amiodarone Use Before Heart Transplantation

s S63 Results: Positive CMV serology at the time of HT was noted in all 30 (100%) patients (D+/R+: n= 12; D+/R-: n= 15; D-R+: n= 3). The mean time to CMV infection from HT was 298 days. Mean GEP score at the time of diagnosis of CMV infection was significantly higher when compared to GEP score obtained at other visits (33.1 vs. 28.2, p < 0.001). In 39 visits which occurred during a CMV infection compared to 24 visits occurring after resolution of viremia, mean GEP score changed from 33.1 to 30.6, p= 0.08. There were 2 ACR (≥ 2R) with GEP scores 35 and 37, respectively at the time of CMV infection visits. Conclusion: These data further confirm that CMV infections in HT recipients are associated with an increase in GEP score that is independent of ACR, with a trend towards decrease in the score once viremia is resolved. The likely mechanism is immune activation/modulation of one or more of the 11 genes in the GEP signature. CMV status should be considered when clinically interpreting high GEP scores in HT patients.

Re-Mineralization of Large Pelvic Lytic Lesions By CT Imaging in Patients with Multiple Myeloma: The Arkansas Experience

Abstract INTRODUCTION Profound osteolytic lesions are a hallmark of multiple myeloma (MM) bone disease. Bone destruction is associated with severely unbalanced bone remodeling, secondary to the secretion of osteoclast activating factors and significant osteoblast suppression. Lytic lesions of the pelvis are relatively common in MM patients and contribute to increase morbidity due to the high risk of fracture that frequently demands surgical intervention. Since we observed significant improvements in the pelvic CT of patients following total therapy 4 (TT4) we retrospectively analyzed the appearance on pelvic osteolytic lesions by CT during TT4 treatment for myeloma. METHODS The UAMS Myeloma data base was interrogated to identify patients enrolled on the TT4 trial. TT4 is a protocol designed for low risk MM patients as defined by a baseline plasma cell GEP score &lt; than 0.66. The treatment protocol includes two induction chemotherapy cycles followed by tandem autologous bone marrow transplantation, two consolidation cycles and 3 years of maintenance. During treatment, patients were exposed to alkylating agents, IMIDS and proteasome inhibitor agents as well as bisphosphonates. Baseline pelvic osteolytic lesions with &gt; 1 cm in minimal diameter identified by PET/CT or CT of the pelvis were compared to the most recent radiological study available for the same subject. All identified cases were reviewed by radiology faculty to confirm the baseline and follow-up reported findings. Radiological findings were correlated with disease status, molecular subgroup, PET scanning and MRI. RESULTS Sixty-three (63) patients, with a median age of 62 years, were identified for this analysis. Baseline patient characteristics are shown in Table 1. With a median follow up of 41 months, CT studies indicate that 44% (28/63) of patients with large baseline pelvic lytic lesions achieved re-accumulation of radio-dense mineralized tissue at the lytic site. Sixty-eight percent of such patients reached at least VGPR. The average size of the lytic lesions that re-mineralized was 4.0 cm (minimum 1.3 cm - maximum 10 cm). Baseline GEP-defined molecular subgroups and cytogenetic distribution was not different from the entire patient population of TT4. CONCLUSION This study clearly shows that mineral redeposition in large pelvic lytic lesions of MM patients on TT4 is achievable in a significant proportion of individuals. We observed that the amount of re-mineralization was prominent in pelvic lytic lesions with cortical bone destruction. Since flat bones, such as the pelvis, are formed via intramembranous ossification further investigation of the mechanism responsible for this effect is warranted at skeletal sites with different regenerative capacity. These data also suggest that, contrary to much dogma, MM bone lesions can regain matrix mineralization capacity. Table 1. Baseline Patient Characteristics n/N (%) Male 43/63 (69%) IgA Isotype 11/63 (17.5%) IgD Isotype 1/63 (1.6%) IgG Isotype 36/63 (57.1%) Nonsecretory 1/63 (1.6%) Light Chain Isotype 14/63 (22.2%) LDH &gt; = 190 U/L 8/63 (12.7%) Abnormal Cytogenetics 44/63 (69.8%) GEP CD-1 subgroup 4/64 (6.3%) GEP CD-2 subgroup 17/64 (26.6%) GEP HY subgroup 24/64 (37.5%) GEP LB subgroup 8/64 (12.5%) GEP MF subgroup 1/64 (1.6%) GEP MS subgroup 2/64 (3.1%) GEP PR subgroup 5/64 (7.8%) Disclosures Mohan: University of Arkansas for Medical Sciences: Employment. Samant:University of Arkansas for Medical Sciences: Employment. Suva:University of Arkansas for Medical Sciences: Employment. Montgomery:University of Arkansas for Medical Sciences: Employment. Alapat:University of Arkansas for Medical Sciences: Employment. Morello:University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Waheed:University of Arkansas for Medical Sciences: Employment. Thanendrarajan:University of Arkansas for Medical Sciences: Employment. Schinke:University of Arkansas for Medical Sciences: Employment. Heuck:Millenium: Other: Advisory Board; Celgene: Consultancy; Foundation Medicine: Honoraria; Janssen: Other: Advisory Board; University of Arkansas for Medical Sciences: Employment. Jethava:University of Arkansas for Medical Sciences: Employment. Johann:University of Arkansas for Medical Sciences: Employment. Barlogie:University of Arkansas for Medical Sciences: Employment. Davies:University of Arkansas for Medical Sciences: Employment; Celgene: Consultancy; Janssen: Consultancy; Millenium: Consultancy; Onyx: Consultancy. Morgan:CancerNet: Honoraria; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; University of Arkansas for Medical Sciences: Employment; MMRF: Honoraria; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Weismann Institute: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees. Zangari:Novartis: Research Funding; Millennium: Research Funding; Onyx: Research Funding; University of Arkansas for Medical Sciences: Employment.

P.1.k.009 Epidemiology of involuntary hospitalization of schizophrenic patients attended at home

Introduction: The involuntary placement and involuntary treatment of mentally ill patients are central issues in mental health care. Their massive impact upon the liberty and freedom of the persons concerned have made them a topic of controversial legal and ethical debates for more than 100 years. Coercive treatment in psychiatry, including the admission to a psychiatric hospital, remains an understudied issue [1]. The only replicated finding in this highly sensitive area is the significant cross-national variation concerning aspects such as provisions in mental health legislations and rates of involuntary admissions to psychiatric hospitals [2]. Objectives: The purpose of this study is to examine the impact of clinical and contextual characteristics on the decision to perform compulsory admission in psychiatric units in patients with diagnostic of schizophrenia who were attended and treated by a mobile home-care unit in the area of Barcelona (Multidisciplinary Team Support Specialist, EMSE in its Spanish acronym). Methods: We performed a cross-sectional retrospective study of the medical records of 362 patients with diagnosis of schizophrenia according to DSM-IV criteria who were attended at home by a mobile home-care unit in Barcelona. We collected the following data; age, number of visits done by EMSE at home, presence of violent behavior (evaluated with AVAT scale), awareness of disease (evaluated with SUMD scale), functionality of the patient (evaluated with WHO scale), global severity of disease (evaluated with GEP scale), clinical impression (evaluated with CGI scale), score in GAF scale, score in Positive PANSS scale, score in Negative PANSS scale and score in General PANSS scale. The sample was divided in two groups according to if patients were compulsory hospitalized or not. Results: We found more aggressiveness in the group of patients in which we decide to do compulsory hospitalization (mean AVAT score 4.87 Vs 2.99, p = 0.033). We also observed in patients compulsorily admitted to hospital worse awareness of disease (mean SUMD score 12.9 Vs 10.6, p = 0.008), major global severity of disease (mean GEP score 16.55 Vs 12.51, p = 0.047), worse clinical impression (mean CGI score 5.34 Vs 4.41, p< 0.001) and lower score in GAF scale (30.63 Vs 43.36, p< 0.001). Regarding to psychopathology we found higher score in positive PANSS scale in patients compulsorily admitted (29.44 Vs 22.54, p = 0.002), but we haven’t found statistically significant differences in negative PANSS score nor general PANSS score. Conclusions: As previously seen in the literature [3], in our study we observed that the decision to perform an involuntary admission is related with a worse awareness of disease, lower score at GAF scale and more aggressiveness in schizophrenic patients. In our sample we also observed that the decision to perform an involuntary admission is related with major severity of disease, a worse clinical impression and with higher positive psychotic symptoms.