Marker For Overall Survival Research Articles

Development of a prognostic model for survival time prediction in castration-resistant prostate cancer patients

BackgroundTo identify predictors of survival in patients treated with docetaxel chemotherapy for castration-resistant prostate cancer (CRPC). MethodsWe retrospectively analyzed clinical data from 186 patients who underwent docetaxel chemotherapy for CRPC from 2005 to 2016 at a single center. Pretreatment baseline variables including demographic and clinicopathological data were reviewed. Disease progression was defined by imaging and/or consecutive prostate-specific antigen (PSA) elevation. The systemic immune-inflammation index (SII), the modified Glasgow Prognostic Score (mGPS), and the neutrophil-lymphocyte ratio (NLR) were calculated. Univariable and multivariable Cox proportional hazards regression analyses reporting hazard ratios assessed the risk for disease progression and overall survival (OS). A survival nomogram was constructed. ResultsMost patients (n = 139, 74.7%) completed at least 6 cycles of docetaxel chemotherapy. 156 patients (82.9%) experienced disease progression during the studied period. Only mGPS was independently associated with disease progression in a multivariable model (P < 0.01). During the studied period, 98 patients (52.1%) died. The built survival nomogram included statistically significant variables for OS in univariable analysis: hemoglobin, PSA, alkaline phosphatase (AP), lactate dehydrogenase, SII, neutrophil-lymphocyte ratio, mGPS, and site of metastases; and had a concordance index of 0.703. At decision curve analysis, the nomogram led to superior outcomes for any decision associated with a threshold probability of above 40%. In multivariable analysis, only AP (P = 0.02), hemoglobin and PSA (P < 0.01, respectively) remained associated with OS. ConclusionsPSA, AP, and hemoglobin are independent prognosticators for OS. Although mGPS is a promising marker for tumor progression and SII is a plausible prognostic marker for OS, valid integration of inflammatory indices into a prognostic model requires validation studies. Predictive and prognostic biomarkers are desperately needed to guide physicians in treatment counseling given the heterogeneous nature of CRPC and the plethora of effective therapies.

Assessment of Progression-Free Survival as a Surrogate End Point of Overall Survival in First-Line Treatment of Ovarian Cancer

The Gynecologic Cancer InterGroup (GCIG) recommended that progression-free survival (PFS) can serve as a primary end point instead of overall survival (OS) in advanced ovarian cancer. Evidence is lacking for the validity of PFS as a surrogate marker of OS in the modern era of different treatment types. To evaluate whether PFS is a surrogate end point for OS in patients with advanced ovarian cancer. In September 2016, a comprehensive search of publications in MEDLINE was conducted for randomized clinical trials of systematic treatment in patients with newly diagnosed ovarian, fallopian tube, or primary peritoneal cancer. The GCIG groups were also queried for potentially completed but unpublished trials. Studies with a minimum sample size of 60 patients published since 2001 with PFS and OS rates available were eligible. Investigational treatments considered included initial, maintenance, and intensification therapy consisting of agents delivered at a higher dose and/or frequency compared with that in the control arm. Using the meta-analytic approach on randomized clinical trials published from January 1, 2001, through September 25, 2016, correlations between PFS and OS at the individual level were estimated using the Kendall τ model; between-treatment effects on PFS and OS at the trial level were estimated using the Plackett copula bivariate (R2) model. Criteria for PFS surrogacy required R2 ≥ 0.80 at the trial level. Analysis was performed from January 7 through March 20, 2019. Overall survival and PFS based on measurement of cancer antigen 125 levels confirmed by radiological examination results or by combined GCIG criteria. In this meta-analysis of 17 unique randomized trials of standard (n = 7), intensification (n = 5), and maintenance (n = 5) chemotherapies or targeted treatments with data from 11 029 unique patients (median age, 58 years [range, 18-88 years]), a high correlation was found between PFS and OS at the individual level (τ = 0.724; 95% CI, 0.717-0.732), but a low correlation was found at the trial level (R2 = 0.24; 95% CI, 0-0.59). Subgroup analyses led to similar results. In the external validation, 14 of the 16 hazard ratios for OS in the published reports fell within the 95% prediction interval from PFS. This large meta-analysis of individual patient data did not establish PFS as a surrogate end point for OS in first-line treatment of advanced ovarian cancer, but the analysis was limited by the narrow range of treatment effects observed or by poststudy treatment. These results suggest that if PFS is chosen as a primary end point, OS must be measured as a secondary end point.

A TP53-associated gene signature for prediction of prognosis and therapeutic responses in lung squamous cell carcinoma

ABSTRACT The tumor-suppressor gene tumor protein p53 (TP53) is one of the most commonly mutated genes in human lung cancer, and TP53 mutations are associated with a worsened prognosis and causes resistance to cancer therapy. RNA sequencing and TP53 mutation data were downloaded to determine specific TP53-associated signature based on differentially expressed genes between patients with lung squamous cell carcinoma (LUSC) with wild type (TP53 WT) and mutated (TP53 MUT) TP53. We investigated the predictive value of this signature on the immune microenvironment, tumor mutational burden (TMB), and likelihood of response to immunotherapy and chemotherapy. In total, 1,556 differentially expressed genes were identified based on TP53 mutation status. Three genes (KLK6, MUC22 and CSN1S1) identified by univariate and multivariate Cox regression analyses, comprised the prognostic signature which was an independent and specific prognostic marker of overall survival in patients with LUSC. A nomogram was also established to validate this signature for clinical use. Moreover, the high-risk group was characterized by increased infiltration of monocytes and macrophages M1, and decreased T cells CD8 and T cells follicular helper. High-risk group exhibited a higher TMB, and was much more sensitive to immunotherapy and chemotherapy. KLK6 and CSN1S1 expression and the prognostic prediction values were further validated in clinical samples. The derived TP53-associated signature is a specific and independent prognostic biomarker for LUSC patients, and could provide potential prognostic biomarker or therapeutic targets for the development of novel immunotherapies and chemotherapies.

Stage-specific prognostic value of carcinoembryonic antigen and cancer antigen 19-9 serum levels on survival and recurrence in pancreatic adenocarcinoma

Background: Few studies reported on carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) as markers for overall survival (OS) and disease free survival (DFS). This study aimed to determine the stage-specific prognostic value of CEA and CA19-9 serum levels at diagnosis on OS and DFS in patients with pancreatic ductal adenocarcinoma (PDAC), discussed at pancreatic Multidisciplinary Team (MDT) meetings. Material and Methods: All consecutive patients with PDAC, discussed at MDT meetings between from 2013 through 2017 at a single tertiary referral center, were retrospectively reviewed. Advanced stage was defined as either locally advanced PDAC or presence of distant metastases. The Kaplan-Meier method was used to estimate the OS and DFS. Prognostic factors were evaluated in uni- and multivariable Cox proportional hazard models. Approval of the local Medical Research and Ethical Committee was obtained for this study. Results: 375 patients were available for analyses, of which 151 (40.3%) patients underwent resection and 224 (59.7%) patients had advanced stage PDAC. In the total cohort, both elevated CA19-9 (>305 kU/L) and CEA (>7 μg/L) levels were significantly associated with a poor median [95% confidence interval] OS compared to lower serum levels: 8 [5.6-10.4] vs. 12 [7.7-16.3] months (P<0.001) and 5 [3.2-6.8] vs. 13 [10.2-15.8] months (P=0.009), respectively (Figure 1). Multivariable analysis showed that CA19-9 is an independent factor (Hazard Ratio (HR):1.56 [1.18-2.06]; P=0.002) for poor OS, whereas CEA did not yield a significant association anymore (HR: 1.35 [0.96 -1.89]; P=0.083). In patients who underwent resection, CA19-9>305 kU/L was significantly (P=0.012) associated with a shorter median DFS (11 [7.9-14.1] months) compared with lower levels (16 [10.1-21.9] months), which was confirmed by multivariable analysis (HR:1.86 [1.09-3.17]; P=0.023). Conclusions: Increased CA19-9 levels appeared to be an independent prognostic factor for poor survival in the total cohort and early disease recurrence in patients who underwent tumor resection.

Activation of JNK and p38 MAPK Mediated by ZDHHC17 Drives Glioblastoma Multiforme Development and Malignant Progression.

Rationale: Glioblastoma multiforme (GBM) almost invariably gain invasive phenotype with limited therapeutic strategy and ill-defined mechanism. By studying the aberrant expression landscape of gliomas, we find significant up-regulation of p-MAPK level in GBM and a potent independent prognostic marker for overall survival. DHHC family was generally expressed in glioma and closely related to the activation of MAPK signaling pathway, but its role and clinical significance in GBM development and malignant progression are yet to be determined.Method: Bioinformatics analysis, western blotting and immunohistochemistry (IHC) were performed to detect the expression of ZDHHC17 in GBM. The biological function of ZDHHC17 was demonstrated by a series of in vitro and in vivo experiments. Pharmacological treatment, flow cytometry, Transwell migration assay, Co- Immunoprecipitation and GST pulldown were carried out to demonstrate the potential mechanisms of ZDHHC17.Results: ZDHHC17 is up-regulated and coordinated with MAPK activation in GBM. Mechanistically, ZDHHC17 interacts with MAP2K4 and p38/JNK to build a signaling module for MAPK activation and malignant progression. Notably, the ZDHHC17-MAP2K4-JNK/p38 signaling module contributes to GBM development and malignant progression by promoting GBM cell tumorigenicity and glioma stem cell (GSC) self-renewal. Moreover, we identify a small molecule, genistein, as a specific inhibitor to disrupt ZDHHC17-MAP2K4 complex formation for GBM cell proliferation and GSC self-renewal. Moreover, genistein, identified herein as a lead candidate for ZDHHC17-MAP2K4 inhibition, demonstrated potential therapeutic effect in patients with ZDHHC17-expressing GBM.Conclusions: Our study identified disruption of a previously unrecognized signaling module as a target strategy for GBM treatment, and provided direct evidence of the efficacy of its inhibition in glioma using a specific inhibitor.

High serum extracellular vesicle miR-10b expression predicts poor prognosis in patients with acutemyeloid leukemia.

Increasing evidence have demonstrated that serum extracellular vesicle microRNAs (EV-miRNAs) are promising noninvasive biomarkers for various cancer types. In this study, we aimed to investigate and evaluate the potential clinical significance of serum EV-miR-10b for acute myeloid leukemia (AML). Blood samples were collected from a cohort of 95 de novo AML patients and 80 healthy individuals. Of all AML patients, 51 patients were considered as cytogenetic normal AML (CN-AML). Quantitative reverse-transcription polymerase chain reaction (qRT-PCR) was performed to measure the expression levels of serum EV-miR-10b. The extracellular vesicles we extracted from the serum samples were positive for EV/exosome markers including TSG101, CD63, Flotillin-1 and CD9. The expression levels of serum EV-miR-10b were significantly higher in AML/CN-AML patients than healthy controls. In addition, serum EV-miR-10b expression was strongly correlated with aggressive clinical characteristics. Moreover, receiver operating characteristic analysis showed serum EV-miR-10b yielded an area under the curve of 0.875, with 77.89% specificity and 82.50% sensitivity in identifying AML patients from normal controls. Furthermore, AML patients with higher serum EV-miR-10b expression had significantly shorter survival and serum EV-miR-10b was demonstrated to be an independent prognostic marker for overall survival in AML. Taken together, serum EV-miR-10b might serve as a promising biomarker for predicting the prognosis of AML.

Pretransplant serum beta-2 microglobulin level is a potential novel prognostic marker of overall survival after allogeneic hematopoietic cell transplantation - a retrospective observational study.

Although elevated serum beta-2 microglobulin (BMG) has been reported as a poor prognostic marker for various hematological malignancies, no study has assessed its prognostic significance in allogenec hematopoietic cell transplantation (allo-HCT). Therefore, we conducted this retrospective observational study in 227 consecutive patients with available pretransplant serum BMG levels between April 2010 and September 2017 at our institute. We also collected and retrospectively analyzed various pretransplant variables likely related to transplant outcomes. Multivariable analysis, including major prognostic variables, such as the disease risk index and the hematopoietic cell transplant-comorbidity index, showed a significant association between higher serum BMG levels and poorer overall survival (OS) in all three adjusted models [hazard ratio (HR) per its standard deviation (SD) (SD=1.094): 1.67 (1.35-2.03; P<0.001), HR per SD: 1.46 (1.14-1.86; P=0.002), HR per SD: 2.03 (1.62-2.55; P<0.001)], respectively, due to the significant association between higher serum BMG levels and relapse/progression [HR 1.52 (1.20-1.94; P<0.001)] instead of nonrelapse mortality [HR 1.06 (0.70-1.60; P=0.780)]. Moreover, DRI and serum BMG had statistically significantly higher c-statistic estimates for OS compared with DRI alone (c-index 0.74 and 0.68, respectively; P<0.001). In conclusion, pretransplant serum BMG level may serve as a useful prognostic marker and help clinical decision in allo-HCT.

Impact of pretherapeutic neutrophil-to-lymphocyte ratio, serum albumin, body-mass index, and advanced lung cancer inflammation index on clinical outcome in sinonasal squamous cell carcinoma

BackgroundSquamous cell carcinoma of the nasal cavity and paranasal sinuses is a rare and aggressive cancer entity with poor survival rates. Data on this group of head and neck tumors are scarce. Inflammation and cachexia-based markers and their impact on clinical outcome have been studied in several cancer groups. The aim of this study was to evaluate their prognostic potential in sinonasal squamous cell carcinoma. Patients and methodsThis retrospective analysis included all patients treated for sinonasal squamous cell carcinoma at a tertiary referral center between 2002 and 2015. Patients were divided into groups with low and high pretherapeutic values based on the values of serum albumin (ALB, median 41.6 g/l), neutrophil-to-lymphocyte ratio (NLR, median 3.5), body-mass index (BMI, median 24.7), or advanced lung cancer inflammation index (ALI, median 29.5). Main outcome measures were overall survival (OS) and disease-free survival (DFS). Statistical analysis included calculation of survival differences using log-rank tests, hazard ratios (HR), and respective 95% confidence intervals (CI). Results41 patients were included. Low ALB values did not influence OS (median OS not reached in both groups; p = 0.59, HR = 0.75, CI = 0.3–2.1) or DFS (median DFS 0.9 years vs 2.2 years; p = 0.6, HR = 0.8, CI = 0.4–1.8). High NLR was significantly associated with worse OS rates (median OS not reached vs 1.7 years, p = 0.02, HR = 3.4, CI = 1.0–108) but with no influence on DFS (median DFS 3.1 years vs 0.8 years; p = 0.15, HR = 1.8, CI = 0.8–4.2). Similar results were observed for patients with low ALI (median OS 1.7 years vs not reached; p = 0.03, HR = 0.3, CI = 0.1–0.9 and median DFS 0.8 years vs 2.2 years; p = 0.58, HR = 0.8, CI = 0.3–1.8). BMI was the strongest prognosticator in our study. Low pretherapeutic BMI was linked to significantly worse OS (median OS 1.4 years vs not reached; p = 0.003, HR = 0.2, CI = 0.0–0.6) and DFS (median DFS 0.8 years vs not reached; p = 0.02, HR = 0.4, CI = 0.2–0.8). In multivariate analysis BMI was revealed as an independent marker for OS (p = 0.015). No marker reached the level of significance in regard to DFS in multivariate analysis. ConclusionPretherapeutic BMI had a superior prognostic value in patients with sinonasal squamous cell carcinoma in comparison with other tested variables. BMI may be a simple tool for estimating clinical outcome in SNSCC. However, larger studies are necessary to validate our results.

Hormone Receptor Expression in Multicentric/Multifocal versus Unifocal Breast Cancer: Especially the VDR Determines the Outcome Related to Focality.

The aim of this study was to evaluate the prognostic impact that hormone receptor (HR) expressions have on the two different breast cancer (BC) entities—multifocal versus unifocal BC. As the prognosis determining aspects, we investigated the overall survival (OS) and disease-free survival (DFS) by univariate and multivariate analysis. To underline the study’s conclusions, we additionally considered the histopathological grading and the tumor node metastasis (TNM) staging. A retrospective analysis was performed on survival-related events in a series of 320 breast cancer patients treated at the Department of Gynecology and Obstetrics at the Ludwig Maximillian University in Munich between 2000 and 2002. All three steroid receptors analyzed by immunohistochemistry, namely, the estrogen receptor (ER), the progesterone receptor (PR), and the vitamin D receptor (VDR), showed a significantly positive influence on the course of the disease, but only for the unifocal breast tumor patients. The prognosis of patients with multifocal breast cancer was either not affected by estrogen and/or progesterone receptor expression or even involved a worse etiopathology for the vitamin D receptor-positive patients. The estrogen receptor in unifocal breast cancer and the vitamin D receptor in multifocal breast cancer were especially identified as an independent prognostic marker for overall survival, when adjusted for age, grading, and staging. Altogether, our results strengthen the need to further investigate the behavior of the hormone receptors in breast cancer and understand why they have different effects on each focality type. Moreover, the studies for an adopted vitamin D supplementation due to breast cancer focality type must be enlarged to fully comprehend the remarkable and interesting role played by the vitamin D receptor.

Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) after CD19-Directed Chimeric Antigen Receptor T-Cell Therapy (CAR-T) for Large B-Cell Lymphoma: Predictive Biomarkers and Clinical Outcomes

Introduction : With increased use of CAR-T for relapsed/refractory (R/R) large B-cell lymphoma (LBCL), CAR-T related complications including cytokine release syndrome (CRS) and ICANS pose a significant clinical challenge. While CAR-T mediated inflammation leading to endothelial activation and blood-brain barrier disruption may play a key role in ICANS, the exact mechanism remains unclear. Prognostic or predictive biomarkers for ICANS are not well established. Recent reports (Karschnia et al, Blood 2019) suggested an association between ICANS and inferior overall survival (OS). To better understand ICANS, we herein report a single-center analysis of LBCL patients treated with CD19-directed CAR-T, exploring the associated clinical features, predictive biomarkers, and its prognostic significance. Methods: Patients (pts) with R/R LBCL treated with axicabtagene ciloleucel (Axi-cel) between 4/2018-5/2019 were identified. Data regarding patient and disease characteristics, treatment course, and clinical outcomes was collected (Table 1). Laboratory variables were collected at time of mononuclear cell harvest, day of initiation of lymphodepletive therapy, and day of CAR-T infusion (D0). CRS and ICANS were graded per the Lee and CTCAE v4.03 criteria, respectively. Time to progression (TTP) and OS were estimated by the Kaplan-Meier method and groups compared with the logrank test. Cox Proportional Hazard Model was applied for prognostic modeling. Binary logistic regression was used for multivariable analysis of patient characteristics at D0 associated with ICANS. Results: Forty-five pts with R/R LBCL (35 DLBCL, 7 TFL, 3 PMBCL) treated with Axi-cel were identified (Table 1). Twenty-five pts developed ICANS: n=7 with Grade (Gr) I-II, n=18 with Gr III-IV. Most common initial ICANS symptoms were dysgraphia, confusion, and somnolence; median time to ICANS was 5 days (range 3-11 days). Acute abnormalities were seen on brain MRI in 7 (28%) ICANS pts; EEG done in 10 ICANS pts showed diffuse slowing in all pts and focal slowing in 3 pts. All ICANS pts had preceding CRS, treated with tocilizumab (n=25, median 2.5 doses) and siltuximab (n=2). Twenty-three (92%) pts with ICANS required steroid therapy, with a median total dose equivalent to 221 mg of dexamethasone for a median duration of 12.5 days. Two pts exhibited protracted neurotoxicity manifested by short-term memory loss and profound weakness with immobility. Twenty-two (49%, 95% CI 34-64%) pts achieved CR, 16 PR, and 5 PD. At time of analysis, n=18 had disease relapse/progression and n=35 were alive. Censoring pts that progressed, the median observation time for TTP was 9.3 months. Censoring pts who died, the median observation time for OS was 7.9 months. At 9 months OS (±1 SE) was 76.1%±7.4%, and 56.0%±8.0% were progression-free. Logistic regression showed increasing fibrinogen level at D0 was associated with increasing risk of ICANS (p=0.003) and specifically, Gr III-IV ICANS [p&lt;0.001, OR 3.02 for a case with a D0 fibrinogen of 533.5 mg/dL (3rd quartile of population distribution) vs. 382 mg/dL (1st quartile)]. Germinal center B-cell (GCB) subtype was also associated with risk of Gr III-IV ICANS (p=0.022, OR=11.9). Patient age, sex, race, disease stage at diagnosis, and D0 platelet count, WBC, LDH, CRP, and ferritin were not predictive of ICANS. ICANS was not associated with TTP (p=0.66, HR=1.24, 95% CI 0.48-3.2) nor with OS (p=0.47, HR=1.67, 95% CI 0.42-6.7). Elevated baseline fibrinogen was associated with inferior TTP (p=0.04, HR=1.89, 95% CI 1.03-3.5) and shorter OS (p=0.07, HR=2.12, 95% CI 0.94-4.8); Neither duration nor total dose of steroid treatment significantly affected TTP or OS. Conclusion: ICANS after Axi-cel for R/R LBCL was seen in approximately 50% of patients, 72% of which was severe (Gr III-IV). Contrary to prior reports, no association was seen between development of ICANS and TTP or OS. Elevated D0 fibrinogen and GCB subtype identified pts at higher risk for ICANS. D0 fibrinogen was also a prognostic marker for inferior TTP and OS. The novel finding of baseline fibrinogen as a marker both predictive of ICANS and prognostic for treatment outcomes after CAR-T may be attributed to its role in inflammation and vascular injury, which warrants further investigation. Disclosures Hutnick: Kite/Gilead: Other: Yescarta Speakers Bureau, Speakers Bureau. Badros:Celgene Corporation: Consultancy; Amgen: Consultancy.

Estimated Glomerular Filtration Rate Is an Independent Predictor of Outcome in High-Risk Myelodysplastic Syndrome (MDS) and Low Blast Count Acute Myeloid Leukaemia (AML) Patients Treated with Azacytidine (AZA). a Retrospective Study from the MDS Registry of the Hellenic MDS Study Group

Introduction. Myelodysplastic Syndrome (MDS) is a disease of the elderly. Apart from IPSS, IPSS-R and WPSS, several indexes incorporating patient comorbidities (such as the MDS CI index- Della Porta et al Haematologica 2011, the HCT-CI index - Sorror et al Blood 2005) and performance status (the GFM index- Itzykson et al Blood 2011) have been used to predict outcome in MDS patients treated with azacytidine (AZA). We sought to investigate the effect of comorbidities on the outcome after AZA in a large group of patients from the MDS registry of the Hellenic MDS Study Group. Methods. The present study has been conducted as a retrospective observational cohort one. It included high-risk MDS and low blast count AML patients treated with AZA from 26 centers in Greece from 2007 to 2018. T-test and ANOVA were used to compare scale variables between two or more groups respectively. Univariate analysis of nominal and scale survival data was performed using Kaplan-Meier survival curves and Cox regression respectively. All variables achieving p&lt;0.05 at univariate analysis were considered eligible for multivariate analysis; the latter was based on Cox regression method. Results. We analyzed 536 consecutive patients. Patient characteristics are depicted in Table 1. The median follow-up period was 27.5±4.8 months. 371 patients received at least four cycles of AZA and 165 patients received less than 4 cycles of AZA. Patients who received ≥4 cycles of AZA did not differ from those who received &lt;4 cycles regarding gender, age, estimated Glomerular Filtration Rate (eGFR), cardiovascular, renal, and tumor comorbidities. Significantly higher IPSS-R and GFM scores at baseline were found in the group of patients receiving &lt; 4 cycles of AZA compared to patients who received ≥ 4 cycles of AZA (p=0.042 and 0.05 respectively), while transfusion dependence at baseline occurred more often in patients who received ≥ 4 cycles of AZA (p=0.039). To assess the prognostic significance of risk factors on leukemia free survival (LFS) and overall survival (OS), univariate and multivariate analysis for the whole population was performed, as well as a landmark analysis for patients who were treated with at least 4 cycles of AZA. ECOG performance status and the presence of peripheral blasts were independent prognostic factors for LFS and OS for the whole cohort analysis while response to AZA and the presence of peripheral blasts were independent prognosticators for LFS and OS in the landmark analysis. In addition, prior low dose cytarabine was an independent adverse prognostic factor for LFS in the landmark analysis. As regards comorbidities, neither of MDS-CI, HCT-CI and GFM systems independently predicted LFS or OS in either analysis, but eGFR with a cut-off of 45 ml/min was a strong and independent prognosticator for LFS and OS in both the standard and the landmark analysis. Kaplan-Meier survival curves regarding LFS and OS at AZA initiation and landmark analysis after 4th cycle of AZA in relation with eGFR are shown in Figure 1. Conclusion. This is the first study to demonstrate the importance of eGFR at baseline as a prognostic marker for LFS and OS in high-risk MDS and low-blast AML patients treated with AZA. The role of comorbidities and PS needs to be further evaluated in this patient group. Disclosures Symeonidis: Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; MSD: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding; Tekeda: Membership on an entity's Board of Directors or advisory committees, Research Funding. Vassilakopoulos:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; WinMedica: Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene / GenesisPharma: Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Panayiotidis:Bayer: Other: Support of clinical trial. Pappa:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Research Funding; Gilead: Honoraria, Research Funding; Novartis: Honoraria, Research Funding, Speakers Bureau; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene / GenesisPharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Research Funding; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Kotsianidis:Celgene: Research Funding.

Adenocarcinoma with mixed subtypes is a rare but aggressive histologic subtype in colorectal cancer

BackgroundAlthough numerous studies have investigated the clinicopathologic and prognostic relevance of mucinous adenocarcinoma (MAC) and signet-ring cell carcinoma (SRCC) compared with classic adenocarcinoma (CA), little is known about the prognosis of adenocarcinoma with mixed subtypes (AM) and the differences among these four subtypes.MethodsThe statistics of colorectal cancer registered in the Surveillance, Epidemiology and End Results (SEER) database were retrieved and analyzed. We also compared the clinicopathologic and prognostic relevance between CA, SRCC, MAC, and AM.ResultsThe frequencies of these four subtypes were 69.9% (CA, n = 15,812), 25.1% (MAC, n = 5689), 3.6% (SRCC, n = 814) and 1.4% (AM, n = 321), respectively. All of MAC, SRCC, and AM were significantly related with aggressive features. Only SRCC and AM were identified as independent poor prognostic markers for overall survival by multivariate analysis. The aggressiveness of AM was between MAC and SRCC according to the clinicopathologic associations. The prognosis of AM was significantly worse than MAC but comparable with SRCC.ConclusionsWe confirmed the clinicopathologic relevance with aggressive features of MAC and SRCC, as well as poor prognostic relevance of SRCC by analyzing a large study population data set. Furthermore, we identified AM as a rare but aggressive histologic subtype in colorectal cancer, to which particular attention should be given in clinical practice.

High expression of ALDH1A3 might independently influence poor progression-free and overall survival in patients with glioma via maintaining glucose uptake and lactate production.

Recent studies have found that the acetaldehyde dehydrogenase 1A3 (ALDH1A3) gene is a marker of glioma stem cells. A total of 115 brain glioma specimens were collected and classified into grade I-IV, while non-tumor brain tissue specimens, taken from 12 patients of vascular malformation surgery, were used as control. ALDH1A3 gene promoter methylation in glioma tissues was detected by pyrosequencing, while immunohistochemistry and western blot were used to detect ALDH1A3 protein expressions in different grades of glioma tissues and normal brain tissues. The expression of ALDH1A3 in the glioma cell line U87 was detected by quantitative real-time polymerase chain reaction and RNA-Seq technology was applied to investigate differentially expressed genes before and after silencing the ALDH1A3 gene. Among the 115 glioma tissue specimens, 50 (43.48%) showed low and 65 (56.52%) high expression of ALDH1A3, but no expression was detected in the control. Univariate and multivariate COX regression analyses showed that the patient's tumor pathological grade, the methylation status of ALDH1A3 promoter, and the expression of ALDH1A3 protein were risk factors for progression-free survival (PFS) and overall survival (OS) (all P < 0.05) and the OS of mice with silenced ALDH1A3 in a glioma nude mouse model was prolonged. U87 experiments revealed that ALDH1A3 expression had significant effects on apoptosis, proliferation, cell cycle, mitochondrial membrane potential, glucose consumption, lactate production, invasion ability, and expression of the pyruvate kinase M2 (PKM2) and hexokinase 2 (HK2) in glioma cells. ALDH1A3 protein expression is a marker for poor PFS and OS in glioma patients.

Disease-free survival as a surrogate for overall survival in neoadjuvant trials of gastroesophageal adenocarcinoma: Pooled analysis of individual patient data from randomised controlled trials

IntroductionDisease-free survival (DFS) is increasingly being used as surrogate end-point for overall survival (OS) in cancer trials. So far, there has been no validation of the surrogacy of DFS for OS for neoadjuvant treatment of gastroesophageal adenocarcinoma. MethodsThe study uses individual patient data (IPD) from eight randomised controlled trials (RCTs) (n = 1126 patients) comparing neoadjuvant therapy followed by surgery with surgery alone for gastroesophageal adenocarcinoma. Correlation between OS time and DFS time was calculated to evaluate individual-level surrogacy. For each trial, survival curves using the Kaplan-Meier method were plotted and hazard ratios (HRs) on the treatment effects were calculated for OS and DFS separately. Those HRs were pooled in a random-effects meta-analysis. Observed HRs were compared with predicted HRs for OS using results from an error-in-variables linear regression model accounting for the uncertainty about the estimated effect. The strength of the association was quantified by the coefficient of determination to assess trial-level surrogacy. The surrogate threshold effect was calculated to determine the minimum treatment effect on DFS necessary to predict a non-zero treatment effect on OS. ResultsA strong correlation between OS time and DFS time was observed, indicating a high individual-level surrogacy. For all RCTs, estimated HRs for OS and DFS were highly similar. In the meta-analysis, the overall HR for OS was virtually identical to that for DFS. The estimated coefficient of determination r2 for the association between HRs for OS and DFS was 0.912 (95% confidence interval: 0.75–1.0), indicating a very good fit of the regression model and thus a strong trial-level surrogacy between OS and DFS. The surrogate threshold effect based on the regression analysis was 0.79. DiscussionBased on strong correlations between DFS and OS, as well as a strong correlation of the treatment effects of the two end-points in the error-in-variable regression, DFS seems an appropriate surrogate marker for OS in randomised trials of neoadjuvant chemotherapy or chemoradiotherapy for gastroesophageal adenocarcinoma.

EBV-miR-BHRF1-1 Targets p53 Gene: Potential Role in Epstein-Barr Virus Associated Chronic Lymphocytic Leukemia.

PurposeThe purpose of this study was to investigate the prognostic impact of Epstein-Barr virus (EBV)–microRNA (miRNA, miR)-BHRF1-1 with chronic lymphocytic leukemia (CLL) as well as role of EBV-miR-BHRF1-1 in p53 gene.Materials and MethodsQuantitative reverse transcription–polymerase chain reaction and western blotting were used to quantify EBV-miR-BHRF1-1 and p53 expression in cultured CLL.Resultsp53 aberration was associated with the higher expression level of EBV-miR-BHRF1-1 (p < 0.001) which was also an independent prognostic marker for overall survival (p=0.028; hazard ratio, 5.335; 95% confidence interval, 1.193 to 23.846) in 97 newly-diagnosed CLL patients after adjusted with International Prognostic Index for patients with CLL. We identified EBV-miR-BHRF1-1 as a viral miRNA regulator of p53. EBV-miR-BHRF1-1 repressed luciferase reporter activity by specific interaction with the seed region within the p53 3′-untranslated region. Discordance of p53 messenger RNA and protein expression was associated with high EBV-miR-BHRF1-1 levels in CLL patients and cell lines. EBV-miR-BHRF1-1 inhibition upregulated p53 protein expression, induced cell cycle arrest and apoptosis and decreased cell proliferation in cell lines. EBV-miR-BHRF1-1 mimics downregulated p53 protein expression, decreased cell cycle arrest and apoptosis, and induced cell proliferation in cell lines.ConclusionThis study supported the role of EBV-miR-BHRF1-1 in p53 regulation in vitro. Our results support the potential of EBV-miR-BHRF1-1 as a therapeutic target in EBV-associated CLL with p53 gene aberration.

Prognostic significance of 8-hydroxy-2\u2032-deoxyguanosine in solid tumors: a meta-analysis

BackgroundHigh level of reactive oxygen species (ROS) has been detected in almost all cancers, which make it become one of the best-characterized phenotypes in cancers. Though ROS plays an important role in tumors, the degree of oxidative stress can be better evaluated by assessing stable metabolites of oxidative reactions because of its high instability. 8-hydroxy-2′-deoxyguanosine (8-OHdG), a product of oxidative damage to 2′-deoxyguanosine, is known as a useful marker for assessing oxidative DNA damage and has been a feature of carcinogenesis in several researches. But the exact prognostic value of 8-OHdG expression in patients with cancer is still unclear.MethodsA comprehensive search was performed in PubMed, Web of Science, EMBASE. Eligible studies were included based on defined exclusion and inclusion criteria to perform a meta-analysis. STATA 14.0 was used to estimate pooled hazard ratios (HRs) with 95% confidence interval (95% CI), the heterogeneity among studies and publication bias to judge the prognostic value.ResultsA total of 2121 patients from 21 eligible studies were included in the meta-analysis. A significant association was found between elevated 8-OHdG expression and poor OS (overall survival) in cancer patients (pooled HR 1.921, 95% CI: 1.437–2.570); In the subgroup analysis, race of sample, cancer types, detection method of 8-OHdG, sample classification, detection location of 8-OHdG and paper quality (score more or less than 7) did not alter the association between 8-OHdG expression and cancer prognosis. Furthermore, 8-OHdG expression was an independent prognostic marker for overall survival in patients with cancer (pooled HR 2.110, 95% CI: 1.482–3.005) using Cox multivariate analyses.ConclusionsThis meta-analysis found that highly expressed 8-OHdG in tumor tissues may be a predictor of prognosis in most solid tumors. However, especially in breast cancer, low 8-OHdG expression is associated with poor prognosis, which is partly because of the increased antioxidant mechanisms in breast cancer tissues. This study demonstrates for the first time that 8-OHdG expression is associated with the prognosis of cancer patients. In the future, whether the expression level of 8-OHdG can be used as a biomarker for the prognosis of all human cancers requires more research.

1313PD - 3-year relapse-free survival (RFS), overall survival (OS) and long-term toxicity of (neo)adjuvant ipilimumab (IPI) + nivolumab (NIVO) in macroscopic stage III melanoma (OpACIN trial)

BackgroundOutcome of high-risk stage III melanoma patients (pts) was poor with a 5-year OS rate of<50%. Adjuvant (adj) IPI improved 5-year RFS and OS and adjuvant anti-PD-1 improved RFS further. Preclinical data suggested that neoadjuvant (neoadj) treatment might be more favorable due to broader immune activation. The investigator-initiated OpACIN trial compared neoadj with adj IPI + NIVO. Neoadj IPI + NIVO induced a pathologic (path) response in a high percentage of pts (7/9 evaluable pts, 78%). None of the reponders relapsed during the first 2 years, but long-term outcome is pending. Here we present the 3-year landmark safety and survival data. MethodsBetween Augustus 2015 and October 2016, 20 stage IIIB/IIIC melanoma pts with palpable nodal disease were included in the phase Ib feasibility OpACIN trial. Pts were randomized to receive IPI 3mg/kg + NIVO 1mg/kg, either adj 4 courses or split 2 courses neoadj and 2 adj. Path response, as reviewed by a blinded pathologist, was defined as<50% viable tumor cells. Landmark 3-year RFS and OS were estimated using Kaplan Meier method. All efficacy endpoints are descriptive since the study was not powered to compare both arms. ResultsAfter a median FU of 36.7 months (minimum 28.3 months FU of pts alive) none of the 7 pts with a path response in the neoadj arm have relapsed. Both non-responding pts in the neoadj have relapsed versus 4 pts in the adj arm. One pt has died in the neoadj arm and 3 in the adj arm. The estimated 3-year RFS rate was 80% for the neoadj arm and 60% for the adj arm. The 3-year OS rates were 90% and 67%, respectively. Of the 18 (90%) pts that had developed 1 or more grade 3-4 adverse events all have recovered to ≤ grade 1, except for grade 2 endocrine toxicities needing hormonal supplementation therapy that are ongoing in 8 (50%) of 16 pts alive. ConclusionsOpACIN was the first trial investigating neoadj IPI + NIVO in pts with macroscopic stage III melanoma, thus having the longest FU. At 3 years FU, no new safety events occurred and none of the pts with a path response have relapsed, suggesting that path response could be considered as surrogate marker for RFS and OS in neoadjuvant checkpoint inhibitor trials. Clinical trial identificationNCT02437279. Legal entity responsible for the studyNetherlands Cancer Institute. FundingBMS. DisclosureC.U. Blank: Advisory / Consultancy: MSD; Advisory / Consultancy, Research grant / Funding (institution): BMS; Advisory / Consultancy: Roche; Advisory / Consultancy: GSK; Advisory / Consultancy, Research grant / Funding (institution): Novartis; Advisory / Consultancy: Pfizer; Advisory / Consultancy: GenMab; Advisory / Consultancy: Lilly; Research grant / Funding (institution): NanoString; Advisory / Consultancy: Pierre Fabre. J.V. van Thienen: Advisory / Consultancy: Pfizer; Advisory / Consultancy: Novartis. J.B.A.G. Haanen: Advisory / Consultancy, Research grant / Funding (institution): BMS; Advisory / Consultancy, Research grant / Funding (institution): MSD; Advisory / Consultancy: Pfizer; Advisory / Consultancy: AZ/MedImmune; Advisory / Consultancy: Roche/Genentech; Advisory / Consultancy: Ipsen; Advisory / Consultancy: Bayer; Advisory / Consultancy: Immunocore; Advisory / Consultancy, Research grant / Funding (institution): Novartis; Advisory / Consultancy: Seattle Genetics; Advisory / Consultancy, Research grant / Funding (institution): Neon Therapeutics; Advisory / Consultancy: Celsius Therapautics; Advisory / Consultancy: Gadet; Advisory / Consultancy: GSK. A.C.J. van Akkooi: Advisory / Consultancy, Research grant / Funding (institution): Amgen; Advisory / Consultancy, Research grant / Funding (institution): BMS; Advisory / Consultancy, Research grant / Funding (institution): Novartis; Advisory / Consultancy: MSD Merck; Advisory / Consultancy: Merck-Pfizer; Advisory / Consultancy: 4SC. T.N. Schumacher: Advisory / Consultancy: Adaptive Biotechnologies; Advisory / Consultancy, Shareholder / Stockholder / Stock options: AIMM Therapeutics; Advisory / Consultancy, Shareholder / Stockholder / Stock options: Allogene Therapeutics; Advisory / Consultancy: Amgen; Advisory / Consultancy, Shareholder / Stockholder / Stock options: Merus; Advisory / Consultancy, Shareholder / Stockholder / Stock options: Neon Therapeutics; Advisory / Consultancy: Scenic Biotech; Research grant / Funding (institution): MSD; Research grant / Funding (institution): BMS; Research grant / Funding (institution): Merck KGaA; Shareholder / Stockholder / Stock options: Neogene Therapeutics; Shareholder / Stockholder / Stock options, Venture partner: Third Rock Venture. E.A. Rozeman: Travel / Accommodation / Expenses: MSD; Travel / Accommodation / Expenses: NanoString. All other authors have declared no conflicts of interest.

1444P - Pulmonary tumour-draining vein exosomal lincRNA-p21 levels impacts non-small cell lung cancer prognosis

BackgroundIn resected non-small cell lung cancer (NSCLC) considerable recurrence rates has been reported (30%). Tumor secretes small extracellular vesicles known as exosomes, which plays a role in the metastasis process. Pulmonary tumor-draining vein blood has proved to be better source than peripheral vein to analyze the prognosis impact of exosomes (Navarro A, et al. Cancers 2019). LincRNA-p21 is a long non-coding RNA which upregulation in tumor tissue induced by hypoxia was related to poor prognosis in NSCLC (Castellano JJ. et al. JTO 2016). We aimed to evaluate the presence of lincRNA-p21 in exosomes and its potential as prognosis biomarker in resected NSCLC patients. MethodsH23 and H1299 NSCLC cell lines were cultured in exosome-free medium 48h under normoxic/hypoxic conditions. LincRNA-p21 was inhibited using a siRNA and quantified using a TaqMan assay. Exosomes were purified by ultracentrifugation and characterized by electron microscopy, western blot and Nanosight. LincRNA-p21 was analyzed in exosomes from pulmonary tumor-draining vein, obtained during surgery, from 54 NSCLC patients. ResultsLincRNA-p21 was present in exosomes showing 18 times more representation than in their origin cells. Under hypoxic conditions exosomal lincRNA-p21 was upregulated in both cell lines (p<0.05). Cellular lincRNA-p21 silencing resulted in a reduction in exosomal lincRNA-p21 (p=0.04) indicating a relation between cellular and exosomal levels. The analysis in patient samples showed that lincRNA-p21 was present in patient exosomes obtained from tumor-draining vein. The survival analysis showed that high exosomal lincRNA-p21 levels were associated with shorter time to relapse (TTR) (37 vs 56 months; p=0.03) and shorter overall survival (OS) (46 vs 66 months; p=0.04). In the multivariate analysis exosomal lincRNA-p21 emerged as an independent prognostic marker for TTR (HR: 3.1; 95%CI: 1.02-9.4; p=0.04) and OS (HR: 5.3; 95%CI: 1.6-17.2; p=0.006) together with disease stage. ConclusionsTumor exosomes carry LincRNA-p21, which increases under hypoxia, and its analysis in tumor-draining vein arises as a promising prognosis marker. Legal entity responsible for the studyThe authors. FundingSAF2017-88606-P (AEI/FEDER, UE). DisclosureAll authors have declared no conflicts of interest.

Skeletal Muscle Mass Reduction Velocity as a Simple Prognostic Indicator for Patients with Metastatic Urothelial Carcinoma Receiving Second-Line Chemotherapy.

Background:Patients with metastatic urothelial carcinoma (mUC) have an uncertain prognosis. The aim of the current study was to evaluate the prognostic potential of a skeletal muscle mass reduction index measured by computed tomography (CT) for mUC patients undergoing second-line gemcitabine and docetaxel (GD) chemotherapy. Methods:We retrospectively reviewed 44 patients with mUC who received second-line GD chemotherapy between 2006 and 2015 in our hospital. Skeletal muscle area (SMA) at the third lumbar vertebra was measured using CT images obtained from medical records, and a skeletal muscle index (SMI) was calculated for each patient as: SMI = SMA / height2. Changes in SMI across timepoints (SMI inclination) were calculated as: SMI inclination = [( SMI/SMI)/duration of the interval between imaging visits]. Patients were then divided into two groups: a “steep” group (SMI inclination < -0.01) and a “gentle” group (SMI inclination ≥ -0.01). Kaplan-Meier curves and multivariate Cox proportional hazards regression models were used to evaluate the relationship between SMI inclination and overall survival (OS). Results:There were no differences in patient characteristics between the two groups with respect to median age, gender, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), disease control rate or first-line treatment regimen. OS from the start of second-line GD therapy group was significantly shorter in the “steep” group relative to the “gentle” group. The multivariate analysis revealed that “steep” SMI inclination and presence of anemia were strong predictors of poor prognosis. Conclusion:Higher values of SMI inclination, indicating a faster rate of skeletal muscle mass reduction, may serve as a useful predictive marker for OS in mUC patients undergoing second-line GD chemotherapy.

131P - Integrative combination of high-plex digital profiling techniques and cluster analysis to reveal complex immune biology in the tumour microenvironment of mesothelioma

BackgroundMalignant mesothelioma is an aggressive cancer with poor prognosis and few effective therapies. Due to its derivation from the mesothelium of the lung, immune cells in the tumor microenvironment (TME) may behave differently than in other solid tumors. We describe the combination of two techniques to spatially characterize the tumor-immune profile in mesothelioma. Methods47 FFPE mesothelioma tumors were characterized by Definiens’ Immune-Oncology Panel (IOP) and NanoString’s GeoMx™ Digital Spatial Profiling (DSP). Three alternating sequential sections were stained with IOP (CD8/PD-1/FOXP3, CD68/PD-L1/CD3, Granzyme B (GRZMB)). DSP was performed on 12 IOP-derived regions-of-interest (ROIs) on the interleaving slide by a combination of a fluorescent antibodies stain (pan-CK, CD3, CD68) and a panel of 38 UV-photocleavable DNA barcoded antibodies quantified on the nCounter® platform. Gene expression was assessed using NanoString’s PanCancer IO 360™ (IO360) assay. ResultsCluster analysis based on the IOP revealed 6 distinct immune groups. Two of these had high IOP CD68 density, distinguished by an inhibitory phenotype (PD-L1+) and activated macrophage profile. Subsequent DSP analysis showed that e.g. VISTA, B7-H4 amongst others were higher in the active vs. inhibitory macrophage group. Overall survival (OS) was not associated with density of T cell marker expression measured by IOP/DSP. The IO360 analysis confirmed that and showed tumor-related gene signatures (e.g. proliferation, hypoxia), but not lymphoid-related ones were upregulated in patients with <12 months OS. DSP analysis of VISTA, B2M[BM1] , β-catenin and GRZMB were significantly associated with >12 months OS. ConclusionsBased on a novel combination of two high-plex spatial analysis techniques, we propose mesothelioma subtypes where macrophages act as immune inhibitory or activated with the latter displaying a possible T-cell excluded phenotype. We also show that deep-profiling of biology within the TME identifies prognostic markers of OS. Thus, we hypothesize that this approach may guide a better understanding and help to develop effective immunotherapies. Legal entity responsible for the studyBernard A. Fox. FundingNanostring and Definiens. DisclosureT. Herz: Full / Part-time employment: Definiens. S.E. Church: Shareholder / Stockholder / Stock options, Full / Part-time employment: Nanostring. M. Widmaier: Full / Part-time employment: Definiens. A. Budco: Full / Part-time employment: Definiens. D. Medrikova: Full / Part-time employment: Definiens. I. Kanchev: Full / Part-time employment: Definiens. A. Spitzmueller: Full / Part-time employment: Definiens. A. Shaepe: Full / Part-time employment: Definiens. A. White: Shareholder / Stockholder / Stock options, Full / Part-time employment: Nanostring. J. Reeves: Shareholder / Stockholder / Stock options, Full / Part-time employment: Nanostring. A.H. Sullivan: Shareholder / Stockholder / Stock options, Full / Part-time employment: Nanostring. M. Bailey: Shareholder / Stockholder / Stock options, Full / Part-time employment: Nanostring. R. Sanborn: Advisory / Consultancy: CellDex. C. Bifulco: Advisory / Consultancy: Ventana/Roche; Advisory / Consultancy: BMS; Advisory / Consultancy: HalioDx; Advisory / Consultancy, Shareholder / Stockholder / Stock options: PrimeVax. S. Warren: Shareholder / Stockholder / Stock options, Full / Part-time employment: Nanostring. J.M. Beechem: Shareholder / Stockholder / Stock options, Full / Part-time employment: Nanostring. B. Fox: Advisory / Consultancy: Argos; Advisory / Consultancy: AstraZeneca/MedImmune; Advisory / Consultancy, Research support: Bristol-Myers Squibb; Advisory / Consultancy: Bayer; Advisory / Consultancy: CellDex; Advisory / Consultancy: Clearlight; Advisory / Consultancy, Research support: Definiens; Advisory / Consultancy, Research support: Janssen; Advisory / Consultancy, Research support: Macrogenics; Advisory / Consultancy, Research support: Nanostring; Advisory / Consultancy, Research support: OncoSec; Advisory / Consultancy, Research support: PerkinElmer/Akoya; Advisory / Consultancy, Shareholder / Stockholder / Stock options: PrimeVax; Advisory / Consultancy, Research support: Quanterix; Advisory / Consultancy, Research support: Shimadzu; Advisory / Consultancy: Ultivue; Advisory / Consultancy, Research support: Ventana/Roche; Advisory / Consultancy, Research support: Viralytics/Merck; Leadership role, Shareholder / Stockholder / Stock options: UbiVac. All other authors have declared no conflicts of interest.