Inferior Treatment Response Research Articles

Prognostic impact of body composition in hepatocellular carcinoma patients with immunotherapy

Objective This study aims to examine the possible relationship between body composition parameters, sarcopenia, and clinical outcomes in hepatocellular carcinoma (HCC) patients who received immune checkpoint inhibitor (ICI) treatment. Methods Three online databases, including Embase, PubMed, and the Cochrane Library, were thoroughly searched for literature describing the relationship between body composition parameters, sarcopenia, and outcomes of ICI-treated HCC patients from the start of each database to 21 January 2024. The Newcastle-Ottawa Scale was used to rate the quality of the studies. The assessed outcomes included hazard ratio (HR) for OS and PFS, as well as odds ratio (OR) for ORR and DCR. Results This analysis included a total of 15 articles with a combined patient cohort of 1543 individuals. The results demonstrated that HCC patients with low skeletal muscle index (SMI) had significantly inferior OS (HR: 1.68, p < 0.001), PFS (HR: 1.45, p < 0.001), ORR (OR: 0.64, p = 0.044), and DCR (OR: 0.58, p = 0.009) compared to those with high SMI. The presence of sarcopenia in HCC patients was significantly related to poorer OS (HR: 1.63, p < 0.001) and PFS (HR: 1.48, p < 0.001), as well as a lower ORR (OR: 0.64, p = 0.020) and DCR (OR: 0.58, p = 0.007) in comparison to those without sarcopenia. Subgroup analysis demonstrated that these findings were consistent with the multivariate analysis. Moreover, high subcutaneous adipose index (SAI) levels were associated with better OS (HR: 0.46, p = 0.001) and PFS (HR: 0.68, p = 0.021) than those with low SAI levels. Conclusion The presence of sarcopenia and low SMI in HCC patients undergoing treatment with ICIs was found to be related to inferior treatment response and reduced long-term effectiveness.

Real-World Data on Tezepelumab in Patients With Severe Asthma in Germany

Tezepelumab is a novel biologic blocking thymic stromal lymphopoetin, approved for severe asthma irrespective of biomarker levels or phenotype. To characterize a real-world tezepelumab patient cohort and the efficacy among various asthma phenotypes. We performed a retrospective, multicenter study on patients with severe asthma initiating tezepelumab. Clinical response was evaluated at 3 and 6 months. We included 129 patients with an average age of 52.5 ± 13.1 years, 59.7% were female. The majority (86.0%) had increased type 2 (T2) biomarkers, 68.2% an allergic and 31.8% an eosinophilic phenotype. 23.3% of patients were biologic-naive. 22 (18.2%) patients discontinued tezepelumab therapy owing to suspected side effects or insufficient efficacy. At 6 months' follow-up, median reduction in annualized exacerbation rate was-1 [25th percentile; 75% percentile {-2.9; 0.0}], the reduction of oral corticosteroid dose among patients with long-term oral corticosteroid therapy was -5 mg [-10; 0] and the Asthma Control Test (ACT) improved by 2 [0; 5] points. A treatment response according to Biologic Asthma Response Score of 80.8% was demonstrated. There were no significant differences in treatment response between T2-high versus T2-low, early- versus adult-onset and eosinophilic versus non-eosinophilic asthma. Prior treatment with other biologics was associated with inferior treatment response. In this real-life cohort, including a large proportion of patients with history of previous biologic use and encompassing various subgroups, the majority responded to tezepelumab. Our data further suggest a steroid-sparing effect of tezepelumab.

Outcomes of intensive and nonintensive blast-reduction strategies in accelerated and blast-phase MPN

AbstractTransformation of BCR::ABL1-negative myeloproliferative neoplasms (MPN) to an accelerated or blast phase is associated with poor outcomes. The efficacy of acute myeloid leukemia (AML)–type intensive and nonintensive hypomethylating agent–based regimens is not well studied. We therefore performed a retrospective analysis of patients with MPN-AP/BP (N = 138) treated with intensive (N = 81) and nonintensive (N = 57) blast-reduction strategies. We used clinically relatable response criteria developed at the Princess Margaret Cancer Centre. The overall best response, comprising complete remission (CR), complete remission with incomplete hematologic recovery (CRi), and reversion to chronic phase MPN (cMPN), in the intensive and nonintensive groups was 77% (62 of 81) and 39% (21 of 54), respectively. Similar overall best response rates were observed in patients receiving induction with daunorubicin combined with cytarabine arabinoside (daunorubicin + ara-C) (74% [23 of 31]) or FLAG-IDA/NOVE-HiDAC (78% [39 of 50], P = .78). However, patients receiving daunorubicin + ara-C more often required second inductions (29% [9 of 31] vs 4% [2 of 50], P = .002). Most responses in the entire cohort were reversions to cMPN (55 of 83 [66%]). CR and CRi comprised 30% (25 of 83) and 4% (3 of 83) of responses, respectively. Mutations in TP53 (overall response [OR] 8.2 [95% confidence interval [CI] 2.01, 37.1], P = .004) and RAS pathway (OR 5.1 [95%CI 1.2, 23.7], P = .03) were associated with inferior treatment response for intensively treated patients, and poorer performance status (Eastern Cooperative Oncology Group) was associated with inferior treatment response in both intensively (OR 10.4 [95% CI 2.0, 78.5], P = .009) and nonintensively treated groups (OR 12 [95% CI 2.04, 230.3], P = .02). In patients with paired samples before and after therapy (N = 26), there was a significant residual mutation burden remaining irrespective of response to blast-reduction therapy.

Prior antibiotic administration disrupts anti-PD-1 responses in advanced gastric cancer by altering the gut microbiome and systemic immune response

Evidence on whether prior antibiotic (pATB) administration modulates outcomes of programmed cell death protein-1 (PD-1) inhibitors in advanced gastric cancer (AGC) is scarce. In this study, we find that pATB administration is consistently associated with poor progression-free survival (PFS) and overall survival (OS) in multiple cohorts consisting of patients with AGC treated with PD-1 inhibitors. In contrast, pATB does not affect outcomes among patients treated with irinotecan. Multivariable analysis of the overall patients treated with PD-1 inhibitors confirms that pATB administration independently predicts worse PFS and OS. Administration of pATBs is associated with diminished gut microbiome diversity, reduced abundance of Lactobacillus gasseri, and disproportional enrichment of circulating exhaustive CD8+ Tcells, all of which are associated with worse outcomes. Considering the inferior treatment response and poor survival outcomes by pATB administration followed by PD-1 blockade, ATBs should be prescribed with caution in patients with AGC who are planning to receive PD-1 inhibitors.

Characteristics of rapid cycling in 1261 bipolar disorder patients

BackgroundRapid-cycling (RC; ≥ 4 episodes/year) in bipolar disorder (BD) has been recognized since the 1970s and associated with inferior treatment response. However, associations of single years of RC with overall cycling rate, long-term morbidity, and diagnostic subtypes are not clear.ResultsWe compared descriptive and clinical characteristics in 1261 BD patients with/without RC, based on history and prospective follow-up for several years. RC in any previous year was identified in 9.36% of BD subjects (3.74% in BD1, 15.2% BD2), and somewhat more among women than men. RC-BD subjects had 3.21-fold greater average prospective annual rates of recurrence but not hospitalizations, had less difference in %-time-ill, received more mood-stabilizing treatments, and had greater suicidal risk, lacked familial psychiatric illnesses, had more cyclothymic temperament, were more likely to be married, had more siblings and children, experienced early sexual abuse, but were less likely to abuse drugs (not alcohol) or smoke. In multivariable regression modeling, older age, mood-switching with antidepressants, and BD2 > BD1 diagnosis, as well as more episodes/year were independently associated with RC. Notably, prospective mean recurrence rates were below 4/year in 79.5% of previously RC patients, and below 2/year in 48.1%.ConclusionsLifetime risk of RC in BD was 9.36%, more likely in women, with older age, and in BD2 > BD1. With RC, recurrence rates were much higher, especially for depression with less effect on %-time ill, suggesting shorter episodes. Variable associations with unfavorable outcomes and prospective recurrence rates well below 4/year in most previously RC patients indicate that RC was not a sustained characteristic and probably was associated with use of antidepressants.

Cluster headache polygenetic risk and known functional variants of CYP3A4 are not associated with treatment response.

The response to cluster headache treatments has a high interindividual variation. To date, treatment response has only been assessed by a candidate gene approach and no investigations into metabolic pathways have been performed. Our aim was to investigate the association between the polygenetic risk of cluster headache and treatment response to first-line cluster headache treatments as well as known functional variants of CYP3A4 and the response to verapamil. Further, it was aimed to replicate previous single nucleotide polymorphisms found to be associated with treatment response in cluster headache and/or migraine. In, 508 cluster headache patients diagnosed according to the International Classification of Headache Disorders were genotyped and participated in a semi-structured interview to evaluate treatment response. Polygenetic risk scores were calculated by the effect retrieved from a meta-analysis of the latest two genome-wide association studies on cluster headache. Inferior treatment response to oxygen, triptans and verapamil is associated with chronicity of cluster headache were confirmed but no evidence was found that a response could be predicted by a high genetic risk of cluster headache. Likewise, verapamil response was not associated with functional variants of CYP3A4. No support of the genetic variants previously reported to be associated with treatment response to triptans or verapamil was found. The clinically relevant variation in treatment response for cluster headache was not influenced by genetic factors in the present study.

Clinical characteristics and prognosis of patients with co-existing follicular lymphoma and diffuse large B-cell lymphoma components in rituximab era.

This single-centre study aimed to determine the clinicopathological characteristics and prognosis for patients with co-existing FL and DLBCL components (FL/DLBCL). We retrospectively analysed the clinical characteristics and prognosis of patients diagnosed with FL/DLBCL (n = 56) and with pure FL (n = 260) or de novo DLBCL (n = 812) (controls) between January 2013 and December 2021. The median age of patients with FL/DLBCL was 52years. The amount of the DLBCL component ranged from 5 to 95%. Among the 56 FL/DLBCL cases analysed, 67.9% were of germinal centre B-cell (GCB) origin, 26.8% non-GCB origin, and 5.3% were unclassified. The clinical features of patients with FL/DLBCL were intermediate, falling between those of FL and DLBCL. Propensity-score matching was performed for patients with similar baseline characteristics who were receiving the rituximab plus cyclophosphamide, doxorubicin or epirubicin, vindesine, and prednisone (R-CHOP) regimen. Patients with FL/DLBCL showed inferior outcomes compared to those with FL, with a lower complete remission (CR) rate, progression-free survival (PFS), and overall survival (OS). Bone marrow involvement and B symptoms were identified as independent adverse prognostic factors for PFS among patients with FL/DLBCL. Patients with FL/DLBCL presented a lower CR rate and PFS but similar OS to those with DLBCL when receiving the R-CHOP regimen. Patients with FL/DLBCL showed inferior treatment response and survival than those with pure FL and had a lower CR rate and PFS, but similar OS to those with DLBCL in the rituximab era.

Amp 1q21 is more predictable with dismal survival than gain 1q21 of newly diagnosed multiple myeloma in real-world analysis.

IntroductionThe gain/amplification (amp) of 1q21 is one of the most common high‐risk chromosome abnormality (HRCA) in multiple myeloma (MM). The prognostic value of 1q21+ remains to be controversial on the status of gain or amp and the combination of other HRCAs.MethodsIn this retrospective study, we included 318 newly diagnosed MM (NDMM) patients who had fluorescence in situ hybridization (FISH) data and treated with novel agents in our department.ResultsOur study noted MM patients with amp 1q21 were more likely accompanied with t(4;14), t(14;16), and t(14;20). Patients with amp 1q21 presented with elder age, advanced Revised International Staging System (R‐ISS) stages, anemia, and more plasma cells in bone marrow compared to patients with gain 1q21 alone and no 1q21+. Moreover, amp 1q21 alone correlated with shorter progression‐free survival (PFS) (22.8m vs. 40.5m vs. 39.6m) and overall survival (OS) (45.2m vs. NA vs. 83.5m) compared with gain 1q21 alone and no FISH abnormalities. Although the high ratio of proteasome inhibitor and immunomodulatory drugs used in patients with amp 1q21, the overall response (ORR) was the lowest compared with no 1q21+ and gain 1q21. Multivariate analysis defined amp 1q21 as an independent prognostic marker for NDMM patients, rather than gain 1q21.ConclusionThe amp 1q21 predict inferior treatment response and survival, especially coexisted with high‐risk IgH translocation.

Breast MRI during Neoadjuvant Chemotherapy: Lack of Background Parenchymal Enhancement Suppression and Inferior Treatment Response.

Background Suppression of background parenchymal enhancement (BPE) is commonly observed after neoadjuvant chemotherapy (NAC) at contrast-enhanced breast MRI. It was hypothesized that nonsuppressed BPE may be associated with inferior response to NAC. Purpose To investigate the relationship between lack of BPE suppression and pathologic response. Materials and Methods A retrospective review was performed for women with menopausal status data who were treated for breast cancer by one of 10 drug arms (standard NAC with or without experimental agents) between May 2010 and November 2016 in the Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging and Molecular Analysis 2, or I-SPY 2 TRIAL (NCT01042379). Patients underwent MRI at four points: before treatment (T0), early treatment (T1), interregimen (T2), and before surgery (T3). BPE was quantitatively measured by using automated fibroglandular tissue segmentation. To test the hypothesis effectively, a subset of examinations with BPE with high-quality segmentation was selected. BPE change from T0 was defined as suppressed or nonsuppressed for each point. The Fisher exact test and the Z tests of proportions with Yates continuity correction were used to examine the relationship between BPE suppression and pathologic complete response (pCR) in hormone receptor (HR)-positive and HR-negative cohorts. Results A total of 3528 MRI scans from 882 patients (mean age, 48 years ± 10 [standard deviation]) were reviewed and the subset of patients with high-quality BPE segmentation was determined (T1, 433 patients; T2, 396 patients; T3, 380 patients). In the HR-positive cohort, an association between lack of BPE suppression and lower pCR rate was detected at T2 (nonsuppressed vs suppressed, 11.8% [six of 51] vs 28.9% [50 of 173]; difference, 17.1% [95% CI: 4.7, 29.5]; P = .02) and T3 (nonsuppressed vs suppressed, 5.3% [two of 38] vs 27.4% [48 of 175]; difference, 22.2% [95% CI: 10.9, 33.5]; P = .003). In the HR-negative cohort, patients with nonsuppressed BPE had lower estimated pCR rate at all points, but the P values for the association were all greater than .05. Conclusions In hormone receptor-positive breast cancer, lack of background parenchymal enhancement suppression may indicate inferior treatment response. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Philpotts in this issue.

Obesity Is Not Associated With an Increased Risk of Serious Infections in Biologic-Treated Patients With Inflammatory Bowel Diseases.

INTRODUCTION:Obesity has been associated with adverse disease-related outcomes and inferior treatment response to biologic agents in patients with inflammatory bowel diseases (IBDs), but its impact on the risk of treatment-related complications is unknown. We performed a cohort study examining the association between obesity and risk of serious infections in biologic-treated patients with IBD.METHODS:Using an administrative claims database, in a cohort of biologic-treated patients with IBD between 2014 and 2018 with follow-up 1 year before and after treatment initiation, we compared the risk of serious infections (infections requiring hospitalization) between obese vs nonobese patients (based on validated administrative claims) using Cox proportional hazard analysis.RESULTS:We included 5,987 biologic-treated patients with IBD (4,881 on tumor necrosis factor-α antagonists and 1,106 on vedolizumab), of whom 524 (8.8%) were classified as obese. Of the 7,115 person-year follow-up, 520 patients developed serious infection. Risk of serious infection was comparable in obese vs nonobese patients (8.8% vs 8.5%; unadjusted hazard ratio, 1.15; 95% confidence interval, 0.86–1.54). After adjusting for age, comorbidities, disease characteristics, health care utilization, use of corticosteroids, immunomodulators, and opiates, obesity was not associated with an increased risk of serious infection (adjusted hazard ratio, 0.74 [95% confidence interval, 0.55–1.01]). Similar results were seen on stratified analysis by disease phenotype (Crohn's disease and ulcerative colitis) and index biologic therapy (tumor necrosis factor-α antagonists and vedolizumab).DISCUSSION:After adjusting for comorbid conditions and disease characteristics, obesity is not independently associated with an increased risk of serious infections in biologic-treated patients with IBD.

Evaluation of Genetic Variants in Signaling Pathway Genes as Prognostic Biomarkers for Nasopharyngeal Carcinoma

We hypothesized that genetic variants in signaling pathways identified by next generation sequencing (NGS) are novel prognostic biomarkers for nasopharyngeal carcinoma. The purpose of this study was to evaluate gene variants in Adherens junction, PI3K-Akt, AMPK, Wnt and mTOR signaling pathway genes in patients with nasopharyngeal carcinoma (NPC) to predict treatment response and survival. A total of 32 NPC patients were enrolled from February 2018 to November 2018. Eligible patients were aged 33-66 years with histologically proven WHO Ⅱ-Ⅲ, stage Ⅱ-ⅣB (AJCC 7th) NPC. All patients received induction chemotherapy followed by concurrent chemoradiotherapy. Paraffin-embedded endoscopically NPC samples by endoscopic biopsy were available for all patients. The custom next generation sequencing assay was used to detect exons of 288 genes, introns, promoters or fusion in the dot region of 38 genes and partial exons of 728 genes related to NPC. Alterations of genes encoding the components of Adherens junction, PI3K-Akt, AMPK, Wnt and mTOR signaling pathway were detected. The association between genetic variants in these signaling pathway genes and treatment response and survival of NPC patients were analyzed. Patients with genetic variants in PI3K-Akt (HR = 0.32, P = 0.023), AMPK (HR = 0.26, P = 0.033), and mTOR (HR = 0.21, P = 0.016) signaling pathway genes had significantly inferior complete response rates as compared to patients without such genetic variants. Presence of gene variants in PI3K-Akt (P = 0.045), AMPK (P = 0.005) and mTOR signaling pathway (P = 0.001) were associated with significantly inferior 1-year regional failure-free survival (RFFS) and disease-free survival (DFS). No significant differences were observed in local failure-free survival (LFFS), distant metastasis-free survival (DMFS), and overall survival (OS) in patients with or without genetic variants in all of these signaling pathways. Gene variants in PI3K-Akt, AMPK and mTOR signaling pathway were associated with significantly inferior treatment response and disease-free survival in NPC patients. Gene variants in these signaling pathways identified by NGS profiling are potential novel prognostic markers for NPC.

Abstract PD9-05: Lack of background parenchymal enhancement suppression in breast MRI during neoadjuvant chemotherapy may be associated with inferior treatment response in hormone receptor positive breast cancer

Abstract Purpose In breast MRI, contrast enhancement of normal fibroglandular tissue is referred to as background parenchymal enhancement (BPE). Hormonal status significantly affects the degree of BPE, potentially due to the association with mammary vascularity and activity1-5. Studies have shown that BPE may be associated with breast cancer survival6, treatment response to neoadjuvant chemotherapy (NAC)7,8 and future breast cancer risk9. In most patients undergoing NAC, BPE is suppressed by the nonspecific anti-proliferative effects of chemotherapy on normal breast and/or ovary5,10. However, some patients exhibit equivalent or even stronger BPE post-NAC compared to pre-NAC. We hypothesized that non-suppressed BPE in post-NAC MRI may be associated with inferior treatment response. This study aimed to investigate the association between BPE suppression and treatment response as defined by pathologic complete response (pCR). Methods This study included patients with stage II/III breast cancer enrolled in the I-SPY 2 TRIAL being treated with standard NAC with or without investigational agents. The whole cohort was split into two subgroups based on hormone receptor status (HR+, n= 536; HR-, n=452). Patients underwent dynamic contrast enhanced MRIs at four time points during NAC: baseline (T0), after 3 weeks of the first regimen (T1), inter-regimen (T2), and pre-surgery (T3). Using in-house software, the contralateral breast parenchyma was automatically segmented for the entire breast volume. Quantitative BPE (qBPE) was calculated as the mean early (~150s post-contrast injection) percent enhancement of the central 50% of the axial slices. A breast radiologist reviewed all exams and excluded those where automated segmentation failed to accurately define tissue. For T1, T2 and T3, BPE was categorized based on the change from T0 as suppressed (qBPE &amp;lt; qBPE[T0]) or non-suppressed (qBPE ≥ qBPE[T0]). Chi-squared test was used to examine the association between BPE suppression and pCR, with p&amp;lt;0.05 considered statistically significant. Results HR+ cohort: pCR rates were lower for patients with non-suppressed BPE than those with suppressed BPE at every visit (T1-T3) (Table 1). The difference was statistically significant at T2 (p=0.04) and T3 (p=0.01). Table 1: HR+ cohortpCR rate (%)No. of pCR patientsNo. of non-pCR patientsTotal number of patientsP valueOverall22.8122414536BPE at T1suppressed23.6822663480.45non-suppressed20.532124156BPE at T2suppressed25.7972803770.04*non-suppressed16.01789106BPE at T3suppressed25.7982833810.01*non-suppressed12.5128496 HR- cohort: pCR rates were slightly lower for the non-suppressed BPE group, but no statistically significant association was found (Table 2). Table 2: HR- cohortpCR rate (%)No. of pCR patientsNo. of non-pCR patientsTotal number of patientsP valueOverall44.7202250452BPE at T1suppressed46.81411603010.66non-suppressed44.45265117BPE at T2suppressed48.81441512950.79non-suppressed47.3434891BPE at T3suppressed49.31461502960.94non-suppressed48.9434588 Conclusion In HR+ breast cancer, lack of BPE suppression may indicate inferior treatment response. The contrasting results in HR+ and HR- cohorts are noteworthy in terms of the possible relationship between suppression of normal mammary and ovarian activity and treatment response in HR+ cancer. Reference Radiographics 2014; 34: 234-47. Radiology 1997; 203: 137-44. Radiology 1997; 203: 145-9. Breast J 2005; 11: 236-41. AJR Am J Roentgenol 2015; 204: 669-73. Eur Radiol 2018; 28: 4705-16. Eur Radiol 2016; 26: 1590-6. Transl Oncol 2015; 8: 204-9. J Clin Oncol 2019; : JCO1800378. Radiology 2015; 277: 687-96. Citation Format: Natsuko Onishi, Wen Li, David C. Newitt, Roy Harnish, Jessica Gibbs, Ella F. Jones, Alex Nguyen, Lisa Wilmes, Bonnie N. Joe, Michael J. Campbell, Amrita Basu, Laura J. van’t Veer, Angela DiMichele, Douglas Yee, Donald A. Berry, Kathy S. Albain, Judy C. Boughey, A. Jo Chien, Amy S. Clark, Kirsten K. Edmiston, Anthony D. Elias, Erin D. Ellis, David M. Euhus, Heather S. Han, Claudine Isaacs, Qamar J. Khan, Julie E. Lang, Janice Lu, Jane L. Meisel, Zaha Mitri, Rita Nanda, Donald W. Northfelt, Tara Sanft, Erica Stringer-Reasor, Rebecca K. Viscusi, Anne M. Wallace, Rachel Yung, Michelle E. Melisko, Jane Perlmutter, Hope S. Rugo, Richard Schwab, W. Fraser Symmans, Smita M. Asare, Julie E. Yau, Christina Yau, Laura J. Esserman, Nola M. Hylton. Lack of background parenchymal enhancement suppression in breast MRI during neoadjuvant chemotherapy may be associated with inferior treatment response in hormone receptor positive breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD9-05.

Direct-acting antivirals response in hepatocellular carcinoma: Does the presence of hepatocellular carcinoma matter?

During the clinical trial development of directly acting antivirals (DAAs), evidence regarding the treatment efficacy in chronic hepatitis C patients with hepatocellular carcinoma (HCC) was scarce because these patients have always been excluded. Apart from the clinical trials, more HCC patients are currently being treated in daily practice, given that these treatments are highly effective and involve well-tolerated regimens. Large scale, real-world studies have demonstrated potentially suboptimal antiviral treatment efficacy in HCC patients who received DAAs. It is postulated that the impairment of the bioavailability of DAAs may account for the inferior treatment response. However, the results could not be generalized across all studies. The differing results were attributed to diverse patient characteristics, suboptimal regimens or imprecise definitions of active cancer statuses at the time of treatment initiation. Additional large-scale studies that utilize the treatment of choice in clearly defined HCC patients with different disease severities are warranted to clarify the issue.

Abstract LB-222: Long-term subclonal evolution of CLL from immune selective pressure after allogeneic stem cell transplant and donor lymphocyte infusion

Abstract Next-generation sequencing (NGS) has revealed that the malignant subclones comprising a patient's cancer can possess tremendous genetic heterogeneity at different sites of disease and over time. In leukemia, chemotherapy can hasten subclonal evolution allowing for rare leukemic subclones with aggressive driver mutations to gain a competitive advantage and to predominate at relapse, often portending an inferior treatment response. The impact of immunotherapy on subclonal evolution is less well studied. To determine the effects of allogeneic stem cell transplant (alloSCT) and donor lymphocyte infusion (DLI) on subclonal evolution, we performed whole exome sequencing (WES) on longitudinal peripheral blood and bone marrow from 4 patients with CLL. Specifically, timepoints analyzed included pre-transplant, post-transplant relapse, and post-DLI relapse over a period of up to 8.5 years. B-CLL cells (CD19+CD5+) and normal T cells (CD3+) were sort-purified by fluorescence-activated cell sorting prior to genomic DNA extraction. Libraries for WES were constructed and sequenced to an average depth of 300x on an Illumina HiSeq 2000 using 76 bp paired-end reads. Somatic single nucleotide variants (sSNVs) and indels were called using MuTect and Pindel, respectively, and copy number changes were assessed using an in-house algorithm. In general, these patients had more nonsynonymous mutations per pre-alloSCT sample than reported in other CLL NGS studies (average 30.3; range 8-45), likely related to the significant amount of pre-transplant therapies. Heterogeneous patterns of linear and branched subclonal evolution were seen after alloSCT and DLI in both responders and non-responders. Mutations in several candidate CLL driver genes were seen in this cohort, including SF3B1, SAMHD1, BCOR, EGR2, TP53, and DDX3X. Interestingly, sSNVs in multiple recurrently mutated CLL or cancer census genes (e.g. MAP2K1) rose to levels of detection only after alloSCT or DLI, suggesting they may play a role in immune evasion. In addition, several subclonal genetic variants, including missense mutations in FAM126B and LTBP3, were no longer detected after alloSCT or DLI and may thus represent potential neoantigens. In one treatment-refractory patient, a somatic nonsynonymous clonal CHEK2 mutation was found in 8 longitudinal samples and may represent a novel unique driver mutation. Finally, in one patient who experienced a durable complete remission after DLI, concurrent CLL WES and T-cell receptor beta chain CDR3 NGS was performed, which demonstrated a rapidly evolving T-cell repertoire at the time of complete remission after DLI. For CLL, alloSCT and DLI offer a potentially curative treatment strategy and a better understanding of the genes that confer susceptibility or resistance to these immunotherapies may help unlock the mechanisms that underlie these durable responses. Citation Format: Haven R. Garber, Hannah Beird, Yu Cao, Jianhua Zhang, Rachel Sargent, Pei Lin, Sahil Seth, Xingzhi Song, Huandong Sun, Xizeng Mao, Lisa St John, Karen Clise-Dwyer, Gheath Alatrash, P. Andrew Futreal, Jeffrey J. Molldrem. Long-term subclonal evolution of CLL from immune selective pressure after allogeneic stem cell transplant and donor lymphocyte infusion. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr LB-222. doi:10.1158/1538-7445.AM2015-LB-222

Genotype-Associated Differential NKG2D Expression on CD56+CD3+ Lymphocytes Predicts Response to Pegylated-Interferon/Ribavirin Therapy in Chronic Hepatitis C.

Hepatitis C virus (HCV) genotype 1 infections are significantly more difficult to eradicate with PEG-IFN/ribavirin therapy, compared to HCV genotype 2. The aim of this work is to investigate the difference of immunological impairments underlying this phenomenon. Pre-treatment NKG2D expression on peripheral CD56+CD3+ lymphocytes and CD56+CD3− NK cells from cases of chronic hepatitis C were analyzed and assessed by treatment effect. Two strains of HCV were used to co-incubate with immune cells in vitro. NKG2D expression on peripheral CD56+CD3+ lymphocytes, but not NK cells, was significantly impaired in genotype 1 infection, compared to genotype 2. When peripheral blood mononuclear cells from healthy donors were co-incubated with TNS2J1, a genotype 1b/2a chimera strain, or with JFH1, a genotype 2a strain, genotype-specific decrease of NKG2D on CD56+CD3+ lymphocytes, but not NK cells, was observed. Pre-treatment NKG2D expression on peripheral CD56+CD3+ lymphocytes significantly correlated with reduction in serum HCV RNA levels from week 0 to week 4, and predicted treatment response. Ex vivo stimulation of peripheral CD56+CD3+ lymphocytes showed NKG2D expression-correlated IFN-γ production. In conclusion, Decreased NKG2D expression on CD56+CD3+ lymphocytes in chronic HCV genotype 1 infection predicts inferior treatment response to PEG-IFN/ribavirin therapy compared to genotype 2.

Bringing an Old Drug to a New Treatment Strategy in Treating FLT-ITD AML - Combination of Homoharringtonine and Sorafenib

Acute myeloid leukemia (AML) is a heterogeneous group of diseases characterized by an abnormal increase of myeloblasts in bone marrow (BM) and peripheral blood (PB). Conventional approach of treatment with standard induction chemotherapy and allogeneic hematopoietic stem cell transplantation (HSCT) has reached an impasse with a cure rate of only 30%. A gain-of-function internal tandem duplication (ITD) of fms-like tyrosine kinase 3 (FLT3) was found in 30% of AML and was associated with an inferior treatment response and clinical prognosis. Despite much interests in FLT3 inhibitors in clinical trials, the response was at best transient, limiting their clinical application. Homoharringtonine (HHT) is a natural alkaloid widely used in Mainland China for the treatment of AML. It is a protein translation inhibitor and affects primarily proteins with short half-lives, including many of the downstream effectors of FLT3 signaling. In this study, we evaluated if HHT can be used in combination with sorafenib in the treatment of FLT3-ITD+ AML and examined the mechanistic basis of their synergism.The anti-leukemia effects of drugs on AML cell lines with or without FLT3-ITD mutation were evaluated by a high throughput PrestoBlue® fluorometric assay (a measure of viable cell number) after 3-day culture. Synergism between drugs in combination treatment was evaluated based on Excess Over Bliss Additivism (EOBA). The drug effects on leukemia initiating cells (LIC) activity were examined by xenotransplantation using NOD/SCID/IL2Rg-/- NSG mice and engraftment was enumerated by the presence of human CD45+/mouse CD45.1- cells 6 weeks after transplantation. The effects of HHT and FLT3 inhibitors on FLT3 signaling were examined by Western Blot and Phospho-flow analysis by flow cytometry.HHT exhibited more potent growth inhibitory effect on FLT3-ITD+ AML cell lines, MV4-11 and MOLM-13 (IC50: 3.65 and 3.67 nM) than other AML cell lines (IC50: 7.7 - 32.3 nM). Combination of HHT and sorafenib (H+S) showed pronounced synergism in growth inhibition based on EOBA (29.7% ± 5%) at 3.65 nM (HHT) and 3.85 nM (S). H+S also induced significant increase in apoptosis in MV4-11 based on Annexin V+ population (H+S: 21.3% ± 2.3%; HHT: 11.7% ± 1.9%; S: 8.4% ± 1.0%). Synergism with HHT could also be demonstrated with other FLT3 inhibitors, quizartinib (EOBA: 16% ± 8%) and ponatinib (EOBA: 24% ± 6%) on MV4-11 cell lines. There was no synergism between sorafenib and conventional chemotherapy as exemplified by cytarabine. H+S in vitro significantly reduced engraftment of MV4-11 cells (Vehicle: 65.0% ± 9.7%; H+S: 21.8% ± 8.7%, p<0.01, n=6). HHT alone also inhibited leukemia growth of primary AML samples (IC50: 38.4 ± 7.2 nM, n=88), that was below the peak plasma concentration of HHT (66 nM) in patients receiving treatment. Synergism between H+S was also seen in primary AML samples. Mechanistically, HHT treatment for 6 hours reduced total FLT3 and p-FLT3 protein levels in MV4-11 and MOLM-13. Protein levels of downstream effectors of FLT3 pathway including total Stat5, pStat5, pStat3, pErk were also reduced.A phase II clinical trial of sorafenib (200-400 mg twice daily continuous) and HHT (1.5 mg/m2 for 7 days every 28 days for the first cycle and for 4 days in subsequent cycles, until leukemia progression) combination treatment in patients with chemo-refractory FLT3-ITD+ AML has begun in Hong Kong since January 2014. Bone marrow was performed before and on day 21 after treatment and repeated every two cycles thereafter. Five patients have been treated, including two patients who were primarily refractory to sorafenib monotherapy. Complete remission (CR) was achieved in 1 patient and CR with incomplete hematological recovery (CRi) in four others after 1 cycle. The FLT3-ITD allelic burdens before treatment and at CR/CRi were 77.7 ± 9.6% and 20.0 ± 9.6% (p=0.007). As of 5th August 2014, the two primary sorafenib refractory patients had leukemia progression at 65 and 95 days after treatment. The other three patients remained in remission at 113, 134 and 150 days after treatment.In conclusion, HHT and sorafenib demonstrated significant synergistic effect in suppressing the growth of FLT3-ITD+ AML cells both in vitro and in vivo. It provides a promising strategy in improving treatment outcome of FLT3-ITD+ AML patients. DisclosuresNo relevant conflicts of interest to declare.

Abstract 2490: Integrative systems analysis of HPV+ and HPV- oropharyngeal carcinomas

Abstract BACKGROUND: Over half of oropharyngeal carcinomas (OPCs) are linked to high-risk human papillomavirus (HPV) infection. As compared to their HPV-positive (HPV+) counterparts, HPV-negative (HPV-) OPCs are associated with significantly worse survival, inferior treatment response and a distinct molecular expression profile. There are currently considerable efforts underway to personalize treatment based on HPV status; however, this remains challenging as the current understanding of the different biological mechanisms in HPV+ vs. HPV- OPCs is limited. Hence, a comprehensive proteomic analysis was performed, utilizing archival OPC tissues, in order to acquire greater insights into the distinct biological pathways. METHODS: Global protein expression profiling was conducted on 26 HPV- and 27 HPV+ pre-treatment formalin-fixed paraffin-embedded (FFPE) OPCs using an automated 5-step Multidimensional Protein Identification Technology (MudPIT) procedure on a LTQ-Orbitrap XL. Protein quantification was achieved by adjusted spectral counting. Differentially expressed proteins (p&amp;lt;0.05) were classified into functionally enriched categories and interaction networks using GeneMania. Finally, differential expression of 4 proteins was evaluated by immunohistochemistry (IHC) on an independent cohort of 17 HPV- and 12 HPV+ pre-treatment FFPE OPC biopsies. RESULTS: Among the 2633 high confidence protein groups identified, 174 were significantly differentially expressed in HPV+ vs. HPV- OPCs. Functional enrichment analysis of these proteins demonstrated enrichment of cell cycle, DNA repair, cytokine signaling, apoptosis, DNA packaging, and metabolism proteins. These results were in concordance with a previous publication of pooled OPCs (Slebos et al, 2012). In addition, utilizing The Cancer Genome Atlas (TCGA) data, we determined that the relative expression levels of many of these proteins could be attributed to changes in copy number, methylation, mRNA, or mutation profiles. Next, the top 4 proteins were selected for verification based on concordance with these datasets and reported biological relevance. Selected proteins are involved in actin assembly, purine metabolism, differentiation, and cell migration and invasion. As a result, the differential expression of 2 proteins was successfully validated by IHC, while 2 additional proteins exhibited the same trend as in the discovery cohort. CONCLUSION: This study provides the most in-depth and integrated protein-centric view of HPV+ and HPV- OPC. As a key finding, we highlight the identification of an actin assembly oncoprotein reported to be involved in a targetable radioresistance pathway. We hypothesize that this pathway is preferentially activated in HPV- OPCs. Hence, future experiments will focus on validating the in vivo observed expression pattern of this protein in vitro, and manipulating its expression to overcome radioresistance in OPC models. Citation Format: Lusia Sepiashvili, Angela Hui, Wei Shi, Wei Xu, Daryl Waggot, Paul Boutros, Alex Ignatchenko, Vladimir Ignatchenko, Shao Hui (Sophie) Huang, John Waldron, Brian O'Sullivan, Jonathan C. Irish, Fei-Fei Liu, Thomas Kislinger. Integrative systems analysis of HPV+ and HPV- oropharyngeal carcinomas. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2490. doi:10.1158/1538-7445.AM2014-2490

The duration of undiagnosed bipolar disorder: Effect on outcomes and treatment response

IntroductionThere are commonly long delays between the onset of bipolar disorder (BP), seeking of treatment and acquiring a bipolar disorder diagnosis. Whether a longer duration of undiagnosed bipolar disorder (DUBP) leads to an inferior treatment response is unclear in the literature. MethodWe conducted two studies with independent samples of BP patients who had received a first-time diagnosis of BP – first investigating whether DUBP was related to clinical and social outcomes at the time of assessment (n=173) and, second, whether response to mood stabiliser medication was affected by DUBP when assessed three months following assessment and intervention (n=64). ResultsParticipants׳ mean DUBP was 18–20 years (from the onset of mood episodes). After controlling for age, a longer DUBP was associated with employment difficulties, whereas a shorter DUBP was associated with a history of engaging in self-harm behaviours, as well as a reduced likelihood of experiencing social costs as consequence of the mood disorder. The majority of study variables were statistically unrelated to DUBP. In a multivariate analysis, age was the only predictor variable to make a significant contribution to the DUBP (33%). Across the 3-month intervention period, participants improved significantly on all but one outcome measure. The participants׳ likelihood to improve, become worse or experience minimal/no change over the study period was not significantly related to the DUBP. LimitationsSelf-reporting poses a risk to measurement precision. Being a naturalistic observation, no specific dose of medication was prescribed. The small sample of BP I patients provided insufficient statistical power to undertake meaningful separate analyses of the BP I and BP II participants. ConclusionEarly detection and intervention remains important for helping to reduce morbidity and risks associated with untreated BP. However, the variation in DUBP was mostly a function of age and did not substantially affect clinical status at assessment, or lead to an inferior response to mood stabilising medication.

Course sequences in bipolar disorder: Depressions preceding or following manias or hypomanias

BackgroundInferior response to lithium treatment has been reported in bipolar disorder (BD) patients with mania or hypomania following episodes of major depression (DMI) versus preceding depression (MDI), with intervening euthymic periods. However, additional characteristics of BD course-patterns require further assessment. MethodsWe reviewed computerized clinical records and life-charts of 855 DSM-IV-TR BD-I or -II patients assessed and followed at mood-disorder centers in Cagliari or Rome to characterize their predominant course-sequences. ResultsMorbidity over an average of 9.5 cycles in 18 years was characterized for sequencing of illness-episodes and euthymic intervals. Prevalent sequences included: major depression–hypomania (15.0%), mania–major depression (14.6%), major depression–mania (11.6%), and rapid-cycling (9.6%). Among subjects grouped by course-sequences (based on mania, mixed-states, or hypomania and major or minor depression), depression-before-[hypo]mania (DMI) cases were more likely to be women, diagnosed BD-II, have first-episodes of depressive or anxiety disorder, spend more time ill in depression, and benefit less with long-term mood-stabilizing treatments than with the opposite pattern (MDI). MDI patients were more likely to have substance-abuse and receive long-term mood-stabilizer treatments. Meta-analysis of 5 previous reports plus present findings found inferior treatment-response in DMI vs. MDI cases at a pooled risk-difference of 29% [CI: 18–40%] (p<0.0001). LimitationsSome data were retrospective and subject to recall bias, and treatment was clinical (non-randomized). ConclusionsThe DMI course was strongly associated with first-episode depression or anxiety, excess depressive morbidity, and inferior treatment response, especially for depression.

The moderating role of child callous-unemotional traits in an Internet-based parent-management training program.

Although parent management training (PMT) is generally considered the treatment of choice for children with conduct problems, some specific adaptations might be essential for various subgroups of parents or children to benefit well from PMT. The aim of this study was to examine the influence of child callous-unemotional (CU) traits on the outcome of an Internet-based PMT program for parents of children with conduct problems (n = 57; mean age 6.65). Within a randomized controlled trial of PMT, children assigned to the intervention group were categorized and compared as either "high-CU" (n = 8) or "low-CU" (n = 49) based on a cut-off score on the CU subscale of the Antisocial Process Screening Device (APSD; Frick & Hare, 2001). CU traits in children were associated with more severe conduct problems at baseline, as well as more hyperactivity and peer-related problems. Treatment outcome, in terms of conduct-problem reduction, was poor in the high-CU group compared with the low-CU group, despite the fact that parents in both groups improved equally in parenting skills. The same pattern of results emerged after controlling for initial difficulties of conduct problems and other pretreatment differences between the groups. Elevated levels of CU traits in children seem to contribute to an inferior treatment response in PMT. These findings call for more attention on empathy and emotional patterns in the assessment of children with conduct problems.