Roswell Park Cancer Institute Research Articles

Checkpoint Immunotherapy Is Associated with Preferential Activation of Tumor-Antigen Specific CD4 + T Cells in MDS

Background: Patients with intermediate and higher-risk MDS are generally treated with the DNA hypomethylating agents (HMAs) azacytidine and decitabine. These agents improve survival and cytopenias in ~50% of those treated; but only responders derive clinical benefit, and no pre-treatment response prediction has proven efficacy. There is thus an urgent need to develop new approaches to complement or enhance the response to standard-of-care HMA therapies. Studies suggest that HMAs might act in part via activation of anti-tumor immune mechanisms. Based upon this hypothesis a series of early phase trials combining immune checkpoint inhibitors (ICI: both anti-PD1/PDL1 and CTLA4) with azacitidine in MDS/AML patients were undertaken but clinical and immunological efficacy have proven disappointing. In these studies, the lack of antigen specificity made systematic assessment of the anti-MDS immune response and milieu challenging. Antigen specific assessments are particularly important in MDS patients treated with ICIs because distinct from solid tumors, myeloid stem cell cancers involve the populations of antigen presenting cells that modify the capacity for T-cell response, such as dendritic cells. Our group has shown that MDS/AML patients treated with decitabine show increased expression of NY-ESO-1, a well-characterized tumor antigen whose expression is normally suppressed through dense promoter hypermethylation. In our prior Phase I study, MDS patients received vaccination against NY-ESO-1 in combination with standard decitabine. This combination was not only safe, but it also induced NY-ESO-1 specific CD4 + and CD8 + T cell responses in most patients. We hypothesized that combining anti-NY-ESO-1 vaccination (an antigen specific approach) with decitabine and an ICI would allow us to understand the immune synapse in patients with MDS. Methods: We developed an investigator-initiated Phase 1 trial in transplant-ineligible patients with MDS/low blast count AML adding an anti-PD-1 ICI to our established combination of decitabine + NY-ESO-1 vaccination (#NCT 0335871). This open-label, non-randomized single center Phase 1 study used an HLA unrestricted NY-ESO-1 vaccine (CDX-1401 (1 mg) + poly-ICLC (1.8 mg)) in combination with standard dose decitabine (20mg/m2/d x 5 days) and nivolumab (3 mg/kg every 2 weeks), 4 cycles of combination therapy were planned on study; patients deriving clinical benefit could continue treatment at the discretion of the treating physician. The study was conducted in accordance with the Declaration of Helsinki and approved by the Roswell Park Cancer Institute (RPCI) Internal Review Board. Six patients were enrolled, treated, and completed > 4 cycles of decitabine; serial bone marrow and peripheral blood samples were collected for analysis. The combination was safe. Results: Two patients developed CR and the remainder had stable disease as the best response to therapy (Table 1). The majority of patients mounted NY-ESO-1 specific CD4 + T cell responses associated with up-regulation of anti-PD-1 immunotherapy gene signatures in the CD4 + memory T cell compartment. No responses in CD8 + T cells were seen. In seeking explanation for the disparate findings in CD4 + and CD8 + T-cell compartments, we examined conventional dendritic cell populations associated with activation of CD8 + T cells and identified that our patients had markedly reduced numbers of conventional dendritic cells marked by high expression of CD141 (cDC1). This population is critical for a successful response to immunotherapy. cDC1 from MDS patients also showed reduced expression of genes that are key for optimal T-cell activation and expansion. Conclusions: These results suggest that the use of immunotherapy to induce effective, cytotoxic anti-tumor T cell responses depends upon the myeloid immunologic milieu in MDS patients. The critical importance of cDC1 function has recently been described and appreciated in the context of solid tumor immunotherapy. The observation of both numerical and functional defects of this cell population in patients with myeloid neoplasia provides a possible explanation for the disappointing efficacy of immunotherapies in this disease state. Approaches to augment the number and function of specific cDC1 populations in myeloid disease might overcome this defect and thereby enhance the efficacy of immunotherapy for patients with MDS.

In Memoriam: Soldano Ferrone MD, PhD (1940–2023)

In Memoriam: Soldano Ferrone MD, PhD (1940–2023)

Donald P. Pinkel: In Memoriam (1926–2022)

Donald P. Pinkel: In Memoriam (1926–2022)

DNMT3A and TET2 mutant Clonal Hematopoiesis May Drive a Proinflammatory State and Predict Enhanced Response to Immune Checkpoint Inhibitors

DNMT3A and TET2 mutant Clonal Hematopoiesis May Drive a Proinflammatory State and Predict Enhanced Response to Immune Checkpoint Inhibitors

337 Intratumoral immune therapy for recurrent breast cancer with polyICLC, and tremelimumab combined with systemic durvalumab

BackgroundIntratumoral (IT) cancer therapies may enhance T cell activation and tumor infiltration when combined with systemic checkpoint blockade. This approach may improve treatment of advanced breast cancer, which is commonly resistant to immune therapy.MethodsA multicenter basket-style trial (NCT02643303) was performed in patients with advanced solid tumors, who received polyICLC IT 1mg x 6, then intramuscular (IM) x 3, combined with intravenous (IV) durvalumab 1500 mg q4W. Most were assigned to cohorts also receiving tremelimumab: 10 mg IT or 75 mg IV. Goals were to assess tolerability and clinical activity. Treated tumors were evaluated for immune infiltrates on days (d) 0, 15, and 29 by multiparameter immunofluorescence histology. A strong signal for clinical response was in breast cancer patients; thus, an expansion cohort was enrolled. We report analysis of that breast cancer subgroup.ResultsNineteen participants with treatment-refractory recurrent breast cancer with median 4 prior lines of therapy were enrolled and treated with IV durvalumab and IT/IM polyICLC. Seventeen also received tremelimumab (15 IT, 2 IV). Common treatment-related AEs were fatigue, injection site pain, and chills. There was one dose-limiting toxicity in a participant who received tremelimumab IV, and died with severe hyponatremia (DLT) and progressive disease. Objective clinical responses (1 complete; 4 partial (1 unconfirmed)) were observed in 5 (26%), including 2/9 patients with triple-negative breast cancer (TNBC) and 3/10 with non-TNBC. Median OS was longer for those with CR, PR, or SD (not reached) vs. those with PD or not evaluable (5 months): two responders remain alive at 34+ and 40+ months. In injected tumors, there were significant increases from d0 to d29 in numbers/mm2 of CD8+ T cells, CD20+ B cells, mature dendritic cells (DC), macrophages, and CD56+ NK cells, and in CD8+ cells with antigen-experience (CD45RO), cytotoxic function (granzyme B), activation (ICOS1), or proliferation (Ki67). CD8+ cells expressing LAG3 and TIM3 increased, as did PDL1+ tumor cells and stromal cells. There were no differences in cells expressing IDO, ARG1, CD39, or CD73. Among patients with objective response, vs. all others, proportions of intratumoral CD8+ cells expressing Ki67 increased (p < 0.04).ConclusionsIT tremelimumab and polyICLC plus systemic durvalumab is safe and has clinical activity in patients with advanced TNBC and non-TNBC. The therapy enhances intratumoral immune effectors and markers of T cell function in hypothesis-generating data that warrant confirmatory studies. Clinical response was associated with longer survival and increased CD8 T cell proliferation.Trial RegistrationNCT02643303Ethics ApprovalThe study has been performed with approval of the institutional review boards of each participating institution (Roswell Park Cancer Institute: STUDY 00000121/I291016; Mount Sinai School of Medicine: IRB-17-01692; University of Virginia: IRB # 19276; Cleveland Clinic: 18-694; Toledo: 300176; Dartmouth: STUDY00031630; Emory: IRB00099445). All participants give informed consent before enrolling and participating. The study was also performed with approval from the FDA

Polatuzumab Vedotin Alone or in Combination with Obinutuzumab Synergistically Enhances In-Vitro Cytotoxicity and Cytokine Release Against CD20+/ CD79b+ Burkitt Lymphoma (BL) /Primary Mediastinal Large B Cell Lymphoma (PMBL)

Background: Pediatric Burkitt Lymphoma (PBL) represents the most common malignancy in childhood and adolescent non-Hodgkin Lymphoma (NHL) but occurs in less than 5% of adult NHL cases (Hochberg/Cairo et al, BJH 2009; Miles/Cairo, BJH. 2012). Mature B-cell NHL, including Burkitt lymphoma (BL) and primary mediastinal large B cell lymphoma (PMBL) express CD20+/CD79b+ and have an excellent prognosis with rituximab based immunochemotherapy (Cairo et al Blood. 2007,Goldman/Cairo et al. Leukemia, 2013, Gerrard/Cairo et al. Blood. 2013). The prognosis of PBL has significantly improved over the last 40 years through the use of short and intense multi-agent immunochemotherapy, however, a subset of patients with relapsed/refractory disease has immunochemotherapy resistant disease and a dismal prognosis (≤ 20% 5 yr. EFS),(Cairo et al.Blood. 2007; Cairo et al. JCO.2012). It is therefore critical to investigate and to develop targeted translational strategies in BL/PMBL in order to reduce acute morbidities, decrease late effects, and provide new options for those with recurrent disease.The hu-anti-CD79b-vc-MMAE (Polatuzumab Vedotin, PV) an antibody drug conjugate (ADC) has demonstrated significant preclinical activity against indolent CD79b+NHL (Polson et. al.Can. Res.2009). More recently PV has well tolerated in adults with CD79b refractory CLL (Palanca-Wessels et al. Lancet Oncol, 2014). Obinutuzumab, a glycoengineered type II CD20 antibody, has been shown to enhance cell death and antibody dependent cytotoxicity assay (ADCC) vs. rituximab (RTX) (Herter et al, Clinc Can Res, 2013). We previously observed that PV or obinutuzumab alone (Awasthi/Cairo et al., AACR 2017, Awasthi/Cairo et al., BJH 2015) significantly enhanced tumor cell death and increased overall survival against BL and PMBL xenografted mice. However, additive/synergistic effects of PV with obinutuzumab against mature PMBL/BL are unknown.Objective: To determine the efficacy of the PV, obinutuzumab or RTX alone or in combination with PV+ obinutuzumab vs. PV+RTX against PMBL and RTX sensitive/resistant BL tumor cell lines.Methods: Raji/Raji4RH (provided by M. Barth, MD, Roswell Park Cancer Institute) and PMBL: Karpas1106P (ATCC, USA) tumor cells were cultured in RPMI with 10 or 20% FBS.Tumor cells were incubated with PV (generously supplied by Genentech Inc.) with obinutuzumab (generously provided by Roche) or rituximab (100ug/ml) for 4 hrs with NK cells.PBMCs were expanded with lethally irradiated K562-mbIL21-41BBL cells (Lee et al, PLoS One, 2012).CD56+/CD3- isolated and expanded NK cells were used for cytotoxicity assay. Cytotoxicity was determined by DELFIA cytotoxicity assay at 10:1 E: T ratio and cytokine secretion was measured by multiplex ELISA assay kit.Results: Obinutuzumab+NK, RTX+NK (100µg/ml) compared to PV+NK cells (20ug/ml, 10:1E:T ratio) significantly enhanced cell lysis in Raji, 65.9±2.4% vs. 38.9±5.4% vs. 44.24±8.1%, (p=0.001 and p=0.001), Raji4RH, 52.8±9.4% vs. 16.04±7.2% vs.47.0±8.2% (p=0.03 and p=NS), respectively and Karpas1106P, 66.10±5.3% vs.48.2±3.9% vs. 61.6±10.06% (p=0.004 and NS), respectively. PV+ obinutuzumab+NK, further significantly improved in-vitro cytotoxicity compared to PV+ rituximab+NK, Raji, 93.6±6.1% vs 79.9±5.3% (p=0.007, Figure 1A), Raji4RH, 78.07±2.05% vs 63.5±0.16% (p=0.004, Figure1B) and Karpas1106P, 88.3±6.3 %vs.73.03±3.03% (p=0.003, Figure1C), respectively. Furthermore, IFN-g level from supernatant of PV+obinutuzumab+NK was significantly increased compared to obinutuzumab+NK alone, Raji, 22.14±2.1 vs. 9.41±6.5 ug/ml (p=0.01), Raji4RH, 20.30±9.8vs.17.02±2.5 ug/ml (p=0.05) and Karpas1106P, 18.10±1.5vs.9.56±5.5 ug/ml (p=0.03), respectively.Conclusion: Our preliminary data indicates thatPV in combination with obinutuzumab significantly enhances cell death in RTX sensitive/resistant CD79b+/CD20+ BL and PMBL compared to obinutuzumab or PV alone. Furthermore, PV+ obinutuzumab significantly enhanced cytokine secretion in BL (RTX sensitive/resistant) and PMBL compared to obinutuzumab alone. [Display omitted] DisclosuresKlein:Roche: Employment, Equity Ownership, Other: patents. Lee:Miltenyi: Speakers Bureau; Cyto-Sen Therapeutics, Inc: Other: Founder, Vice President, Medical Director; Intellia Therapeutics, Inc: Consultancy; Courier Therapeutics, Inc: Membership on an entity's Board of Directors or advisory committees. Cairo:Jazz Pharmaceuticals: Speakers Bureau.

Targeting Mcl-1 By Proteasome Inhibitors Enhances the Anti-Tumor Activity of Venetoclax in Mantle Cell Lymphoma Pre-Clinical Models

Background: Mantle cell lymphoma (MCL) accounts for 6% of all non-Hodgkin lymphomas and is a therapeutic challenge. At the molecular level, MCL is characterized by the deregulation of Bcl-2 family members (Mcl-1, BIM) altering apoptosis, as well as, cell cycle (cyclin D1) partially regulated by the ubiquitin-proteasome system (UPS). Inhibitors of the UPS, also known as proteasome inhibitors (PI), have been tested against MCL. The lethality by PIs has been associated with pronounced up-regulation of the pro-apoptotic protein Noxa, which prevented the upregulation of Mcl-1. Changes in the ratio of Mcl-1 and Bak/Bax result in the release of Bak triggering apoptosis particularly in cells with functional p53. Venetoclax is a highly selective Bcl-2 inhibitor, BH-3 mimetic with potent activity against MCL, follicular lymphoma (FL) and diffuse large B-cell lymphoma (DLBCL) cell lines, as well as in a t(14;18)-carrying xenograft model with an established tolerability and safety in a recent phase I trial. We sought to look at further enhancing the pre-clinical activity of venetoclax using PIs in MCL models. We hypothesized that dual inhibition of anti-apoptotic proteins Bcl-2 and Mcl-1 could result in synergistic activity that could be translated clinically. Materials and Methods: We performed in vitro studies on a panel cytarabine sensitive (Rec-1, Jeko, Granta, HBL-2, Z-138 and Mino) and resistant (araC) cell line clones (Jeko araC, HBL-2 araC, and Mino araC). MCL cell lines were exposed to venetoclax, carfilzomib, ixazomib and bortezomib for 24, 48 and 72 hours. Cell viability was calculated measuring the ATP content. IC50 drug concentrations were calculated for each agent. Subsequently, MCL cell lines were exposed to escalating doses of venetoclax (0.001uM-5uM) and carfilzomib, an irreversible PI (1.5625nM-50nM); or two clinically available PI: bortezomib (3.125nM-100nM) or ixazomib (3.125nM-100nM). Cell viability was determined by Cell Titerglo. Coefficient of synergy were calculated using CalcuSyn. Primary tumor cells isolated from B-cell lymphoma patients (N= 15) including MCL were exposed ex vivo to venetoclax +/- carfilzomib or bortezomib. Results: In vitro exposure of MCL cell lines to either venetoclax, carfilzomib, bortezomib and ixazomib induced cell death in a dose- and time-dependent manner. Anti-tumor activity was observed in cytarabine sensitive or resistant cell lines. Significant synergistic activity was observed by combining both venetoclax with carfilzomib or ixazomib at known sub-therapeutic and therapeutic doses of individual agents. Similar findings were observed in primary tumor cells isolated from B-cell lymphoma patients. Conclusion: Our data suggests that venetoclax exhibits strong synergistic activity with carfilzomib and ixazomib in vitro and ex vivo MCL models. This pharmacological interaction could be related to the effects of proteasome inhibition on Mcl-1 in MCL cells, further enhancing the activity of venetoclax. In vivo experiments will further confirm the synergistic activity observed between BH3 mimetics and PIs. (Supported by a NCI SPORE Lymphoma grant: 5 P50 CA130805-04, an NIH grant R01 CA136907-01A1 and a grant from The Roswell Park Cancer Institute Alliance Foundation) DisclosuresNo relevant conflicts of interest to declare.

Repurposing Itraconazole As an Anti-Cancer Agent Against Diffuse Large B-Cell Lymphoma

Introduction: Results from the Retrospective Non-Hodgkin Lymphoma Research (SCHOLAR-1) study demonstrated that relapsed/refractory Diffuse Large B cell Lymphoma (r/r DLBCL) have a low response rate to third-line therapy (20-30%) and an overall survival of 6 months. It stresses the need to develop novel therapeutic strategies for patients with r/r lymphoma. Itraconazole (ITZ) is a common widely clinical used orally bioavailable azole antifungal drug, with a more than thirty years well-documented safety record. Recently, scientific evidence has highlighted ITZ anti-tumor effects at clinically achievable doses in patients with variety of solid tumor malignancies. However, little is known about ITZ activity in B-cell lymphoma, especially in chemotherapy resistant lymphoma. Here we are the first group to report that potent anti-tumor activity of ITZ as a single agent or combined with other chemotherapeutic drugs in both sensitive and resistant lymphoma pre-clinical models. We also further explored the mechanism of action of ITZ to overcome drug resistance.Methods: A panel of rituximab-chemotherapeutic therapy-sensitive (TSCL), -resistant (TRCL) cell lines, developed in our laboratory, and primary tumor cells isolated from B-cell lymphoma patients were exposed to escalating doses of ITZ (0-20uM). IC50 values were calculated using the GraphPad Prism6 software. Changes in cell viability, cell number and cellular ATP levels were evaluated using the Presto Blue, Trypan Blue and Titer Glo assay, respectively. Mitochondrial respiration rate indicated as oxygen consumption rate (OCR) were measured by an XFe96 flux analyzer. Mitochondrial membrane potential (MMP) were quantified by DiOC6 staining and flow cytometry. Subsequently, TSCL and TRCL cells were exposed to ITZ alone or in combination with various chemotherapy agents or small inhibitors and differences in cell viability was determined. Coefficient of synergy was calculated using the CalcuSyn software. HKII-VDAC complex disruption by ITZ was identified by co-immunoprecipitation and western blot. HKII knockdown was generated by using ON-TARGET plus SMART pool siRNA containing a mixture of 4 siRNAs designed to specifically target HKII. Standard 51Cr release assays were conducted to study the effects of ITZ on the anti-tumor activity of monoclonal antiCD20 antibodies against TSCL and TRCL cell lines. For in vivo studies, severe combined immunodeficiency (SCID) mice were inoculated via tail vein injection (iv) with Raji cells (day 0) and assigned to observation, rituximab (at 10mg/kg/dose), obinotuzumab (at 10mg/kg/dose) with or without ITZ. Anti-tumor activity was evaluated by functional imaging and length of survival.Results: We found that ITZ induced a dose-dependent cell death in TSCL, TRCL and primary patient lymphoma cells. Single agent of ITZ decreased cell growth, reduced ATP production, lower the mitochondrial respiration rate and MMP in both TSCL and TRCL. ITZ exhibited additive/synergistic effects when combined with chemotherapeutic drugs (dexamethasone and cisplatin), proteasome inhibitors (bortezomib, carfilzomib, or ixazomib), targeted inhibitors (ABT199 and A-1210477 [an MCL-1 inhibitor]). At the molecular level, we found that, ITZ disrupted HKII/VDAC complex formation. Silencing HKII in TRCL attenuated the killing effect of ITZ. More importantly, ITZ in combination with rituximab or obinutuzumab led to reduced tumor intensity by functional imaging than rituximab or obinotuzumab single agent in vivo.Conclusion: Our findings support the potential benefits for using ITZ as an anti-cancer drug are: 1) reduce costs, 2) clear defined toxicity profile, 3) availability, and 4) pre-clinical activity in rituximab-chemotherapy resistant lymphomas. ITZ can be an inexpensive and effective agent to enhance standard chemotherapy in B-cell lymphoma. Repurposing of ITZ can result in novel therapeutic options for lymphoma patients. (Research supported by Roswell Park Cancer Institute Alliance Grant, National Natural Science Foundation of China (NSFC) 81573063) DisclosuresNo relevant conflicts of interest to declare.

Protein Kinase C Delta in Diffuse Large B-Cell Lymphoma Post-Rituximab Era: Potential Prognostic Marker in Germinal Center B-Cell Lymphoma

Background: Diffuse Large B-cell lymphoma (DLBCL) is the most common subtype of lymphoma. Acquirement of resistance in DLBCL is a major clinical problem. The identification of biomarkers of clinical behavior may aid in the implementation of novel therapeutic strategies. Protein Kinase C (PKC) delta is a class serine/threonine kinase among the PKC family and contributes to cell proliferation, survival and apoptosis. The role of PKC delta in apoptosis is still controversial. Previously studies reported that overexpressed PKC delta promoted apoptosis. However, recently data showed inhibition of PKC delta blocked proliferation and survival of cancer stem cells in vitro and in vivo . The value of PKC delta expression in lymphoma patients remains unclear. We conducted a retrospective study to investigate the impact of PKC delta expression in DLBCL patients. Methods: Histologically confirmed DLBCL patients (N=98) treated at Fudan University Shanghai Cancer Center with available diagnostic biopsy material were identified. Forty-three patients were treated with CHOP and fifty-nine patients with R+CHOP. PKC delta expression was determined and quantified by immunohistochemistry (IHC) with staining intensity or percentage of positive cells. Tumors were considered positive when at least IRS>9 of tumor cells expressed PKC delta. Kaplan-Meier method was used to calculate progression free survival (PFS) and overall survival (OS) and curves were compared with the long-rank test in both groups. Correlation between the PKC delta expression and clinical variables were tested by Pearson Chi Square test and a two-sided P value of <0.05 was considered to be statistically significant. Additionally, PKC delta was inhibited using a PKC delta inhibitor (Rotterin) in DBCL cell lines. Changes in cell viability following in vitro exposure to rotterin were determined by Presto Blue Assay. Result: In CHOP treatment DLBCL, PKC delta expression was detected in 10/41 (24.4%) DLBCL patients. PKC delta expression was associated with a worse progression free survival (PFS) compared to PKC delta negative patients (50% vs 77%, p=0.036) treated with CHOP. The overall survival (OS) of PKC delta positive patients was also worse compared to the negative group (50% vs. 80%, p=0.023). In rituximab-CHOP (R-CHOP) treated patients, PKC delta was present in 17/57 (29.8%) patients. Surprisingly, no differences between the PKC delta positive group and negative R-CHOP treated groups were observed in terms of PFS or OS. Of interest, a subset analysis of R-CHOP treated DLBCL patients base on the cell of origin (COO) demonstrated that PKC delta expression in germinal center B-cell lymphoma (GCB) DLBCL was associated with an inferior OS outcome. The OS was 67% for GCB-DLBCL expressing PKC delta vs 83% for GCB-DLBCL patients without PKC delta expression (p=0.01). To identify the contribution of PKC delta to the survival of B-cell lymphoma, we performed the in vitro viability assay in different subtype of lymphoma cell lines using Rotterin, a PKC delta inhibitor. We found that in vitro exposure of cell lines to rotterin resulted in cell death in vitro suggesting that PKC delta can serve as a targetable biomarker in DLBCL. Additional pre-clinical studies are underway. Conclusion: This is the first report demonstrating that, PKC delta expression is a negative predictor of clinical outcome. PKC delta is a potential novel target to treat lymphoma and further investigation of PKC delta need to be done in the near future. (Research supported by Shanghai Municipal Commission of Health and Family Planning Project (no.20134030), National Natural Science Foundation of China (no.81670177, no.81001048), Roswell Park Cancer Institute Alliance Grant) [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Global Disparities in the Preparedness for Radiation Emergencies

Background: Radiation emergencies are rare but can have minor confined effects to catastrophic consequences across the large geographical territories. Geographical disparities in the preparedness for radiation emergencies can negatively impact public-safety and delay protective actions. We examined such disparities using the global and regional radiation preparedness data from the revised annual International Health Regulations (IHR) datasets. Methods: We used IHR State Party Annual Reporting (SPAR) tool and its associated health indicators developed to mitigate public health-risk from radiation emergencies. Using the most recent (2019) SPAR database developed for radiation emergencies, along with 12 other cross-sector indicators, we examined the disparities among World Health Organization (WHO) state and region-wide capacity scores for operational preparedness. Findings: Based on the analysis of the 2019 annual reporting datasets from 171 countries, radiation emergency was one of the top 3 global challenges with an average global preparedness capacity of 55%. Radiation emergency preparedness capacity scores showed highest dispersion score amongst all 13 capacities suggesting higher disparities for preparedness across the globe. Only 38% of the countries had advanced functional capacity with ≥80% operational readiness, with 28% countries having low to very-low operational readiness. No geographical regions had ≥80% operational readiness for radiation emergencies, with 4/6 geographical regions showing limited capacity or effectiveness. Interpretation: We found major global disparities for the operational preparedness against radiation emergencies. Collaborative approaches involving the public health officials and policymakers at the regional and state levels are needed to develop additional guidance to adapt emergency preparedness plans for radiation incidents. Funding Information: This research was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR001412 to the University at Buffalo and Roswell Park Comprehensive Cancer Center, and by Roswell Park and National Cancer Institute under award number P30CA016056. UCS is supported by KO8HL131987 and RO1HL152090 Award from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI). SP received support from NIH/NHLBI (Award Numbers R21HL154028 and RO1HL150266). Declaration of Interests: None.

The goal of geroscience is life extension.

Although numerous drugs seemingly extend healthspan in mice, only a few extend lifespan in mice and only one does it consistently. Some of them, alone or in combination, can be used in humans, without further clinical trials.

Statin Type and Cancer Outcomes in Patients with Diabetes Type 2 and Solid Tumors.

Objective:Type 2 diabetes mellitus (T2DM) affects 10% of Americans and is associated with an increased incidence of cancer. Statins are first-line cholesterol-lowering medications in the treatment of hyperlipidemia. Several studies have demonstrated a relationship between statin use and reduced cancer incidence. We examined the cancer benefits of statin subtypes, with specific attention to disease-free survival (DFS) and overall survival (OS).Methods:This retrospective review included adults with T2DM diagnosed with solid tumors at Roswell Park Cancer Institute in Buffalo, NY, USA (2003–2010). Individuals with gestational diabetes, incomplete records, or diagnosed with rare solid tumors were excluded. Follow-up began at the date of diagnosis and ended with the first confirmed recurrence, death, or loss of contact. Demographics were assessed by Chi-square, Kaplan–Meier survival analyses, and Cox proportional hazards regression.Findings:Overall, 1102 patients met inclusion criteria, 52.1% of the study participants were female, and 578 participants (52.5%) died during the follow-up period which ranged from 0 to 156 months. Hydrophilic statin use was associated with improved DFS at 5-year follow-up (41.0% vs. 36.9%, P = 0.0077) compared to lipophilic statin use. Multivariate regression revealed that hydrophilic statins were associated with improved DFS (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.526–0.947) and OS (HR: 0.685, 95% CI: 0.503–0.934). Pravastatin was associated with improved OS (HR: 0.674, 95% CI: 0.471–0.964).Conclusion:In patients with T2DM and cancer, hydrophilic statins, and pravastatin in particular, are associated with improved DFS as well as OS. Further research examining the cancer-specific effects of hydrophilic and lipophilic statins is needed to better understand their beneficial effects.

Clonal Hematopoiesis in Patients with Neuroendocrine Tumors Receiving Peptide Receptor Radionuclide Therapy (PRRT)

Background. Clonal hematopoiesis (CH) prevalence increases with age. Elderly (&amp;gt;70 years) healthy individuals have a 10% incidence of CH. Cancer cohorts are at increased risk of harboring CH mutations (~25%). Specific tumor types such as thyroid, ovarian, and bladder, have previously been shown to be at the highest risk of CH due to increased exposure to radionuclide and chemo-radiotherapies. Radionuclide therapies in particular are associated with a high incidence of subsequent myeloid disorders. Exposure to peptide receptor radionuclide therapy (PRRT, Lu 177 dotatate) leads to an increased risk (~2-5%) of therapy related myeloid neoplasms (MNs). It is not known if baseline CH architecture of neuroendocrine tumors (NETs) contributes to the increased risk or the protracted course of NETs or exposure to leukemogenic therapies. With a broader view to understand emergence of therapy induced myeloid neoplasms in various malignancies, we aimed to characterize baseline rates of CH in patients (pts) with NETs and assess clonal evolution in serial blood samples procured prior to and after exposure to PRRT. Methods. The NET Biobank housed at Roswell Park Comprehensive Cancer Center contains banked serial samples for pts receiving PRRT since its FDA approval in 2018. In this retrospective analysis, we identified pre-PRRT blood samples from 13 pts with NET treated at our institute from 2018-19. Serial samples (post PRRT exposure) were available for 6 of 13 pts. Genomic DNA collected from pts before and after PRRT treatment initiation was analyzed for CH mutations using a custom panel targeting 93 genes. A VAF cut off of 1% was used to define putative CH mutations. Relationships among clinical, laboratory and mutational variables were examined using chi-square test, at a significance level of 0.05. Results. Pt characteristics (n=13) are shown in Table 1. Median age was 58 years. 70% were men. Only 1/13 pt had prior chemotherapy exposure, and 3/13 had prior RT exposure. The primary location of NETs was small bowel (46%) followed by pancreas (23%) and others (cecal, rectal or unknown - 31%). All pts had stage IV disease. Over half (54%) harbored CH mutations, despite their relatively young age. This prevalence is much higher than previously reported CH prevalence of 25.1% in pts with other solid tumors.1TET2 (25%) was the most commonly mutated gene, followed by ASXL1 (12.5%), CHEK (12.5%), PPM1D (12.5%) and TP53 (12.5%) which together accounted for 50% of all mutations. Other mutations (DNMT3A, JAK2, DDX41, SRCAP) were less common (Figure 1). DNMT3A mutations (usually most prevalent mutation in cancer cohorts) were uncommon in this cohort and did not occur in the R882 AML/MDS hotspot, previously described in CH. Frameshift mutations and truncations comprised 53.3% of all mutations, and these mutations had higher mean VAFs (6.14%) than single nucleotide variants (1.93%; p = 0.001). This may suggest that frameshift mutations and truncations provide survival advantage to the affected clone. Mutations were more common in smokers than in non-smokers (100% vs 40%, p = 0.067). As expected, mutations were more common in individuals age 61 and above (75% harbored 1 or more mutation) vs only 20% mutation occurrence was noted in age 60 or below (p=0.05). Conclusion. CH with a distinct mutation profile occurs in NET patients, and in higher prevalence (54%) than observed in other solid tumors (25%). High baseline prevalence of putative CH mutations in NET patients may be an important contributor to heightened risk of MN development after PRRT exposure. Ongoing serial sample evaluation will provide further insights into clonal evolution of the above detected CH mutations after exposure to PRRT. The results regarding clonal evolution may have implications in predicting risk of MN associated with PRRT therapy and influence treatment selection in pts planned for PRRT. References Coombs CC, Zehir A, Devlin SM, et al. Therapy-Related Clonal Hematopoiesis in Patients with Non-hematologic Cancers Is Common and Associated with Adverse Clinical Outcomes. Cell Stem Cell. 2017;21(3):374-382.e374. Acknowledgement: Data and samples for this study were provided by the Data Bank and BioRepository (DBBR), which is funded by the National Cancer Institute (P30 CA016056) and is a Roswell Park Cancer Institute Cancer Center Support Grant shared resource. Disclosures Iyer: Advanced Accelerator Applications: Consultancy. Guzman:SeqRx: Honoraria; Cellectis: Research Funding. Wang:Abbvie: Consultancy; Jazz Pharmaceuticals: Consultancy; Genentech: Consultancy; Stemline: Speakers Bureau; PTC Therapeutics: Consultancy; Astellas: Consultancy; Macrogenics: Consultancy; Pfizer: Speakers Bureau; Bristol Meyers Squibb (Celgene): Consultancy.

Clonal Hematopoiesis in Patients Receiving Immune Checkpoint Inhibitor Therapy

Background. Clonal hematopoiesis (CH) is an aging associated phenomenon with potential to transform to overt myeloid disease at a rate of 1% per year. CH is hypothesized to represent a precursor state for leukemogenesis. CH is detected in 10% of healthy, elderly (&amp;gt;70 years) individuals at variant allele frequencies (VAFs) above 2%, but prevalence is higher in patients (pts) with malignancies (~25%). We recently demonstrated in a large population database study that recent changes in therapy for melanoma and non-small lung cancer (NSCLC) are associated with a decreased incidence of therapy-related myeloid neoplasms (tMNs).1 This trend may reflect declining utilization of chemo-radiotherapies or even regression of CH clones in the context of immune checkpoint inhibitor therapy (ICI). To improve our understanding of the evolving clonal architecture in patients with CH receiving ICI we analyzed blood samples from pts with melanoma and NSCLC at baseline and after exposure to ICIs. We aimed to characterize (i) baseline prevalence of CH in pts with melanoma and NSCLC (ii) alterations in clonal architecture associated with ICI treatment in serial blood samples from these pts. Methods. In this retrospective analysis, stored blood samples from pts with melanoma (N=32) and NSCLC (N= 109) treated with ICIs were analyzed. To detect CH, genomic DNA collected before treatment initiation and serially on ICI were analyzed using a custom panel targeting 93 genes. A 1% VAF cutoff was used to define CH. Relationships among clinical, laboratory and mutational variables were examined using chi-square test, at a significance level of 0.05. Results. We present preliminary results on 25 pts with melanoma (Table 1). Median age was 61 years. 52% (13/25) were men. One/25 pts had previously received chemotherapy and 4/25 had prior radiation therapy exposure. 64% (16/25) had stage IV disease and 36% (9/25) had stage III disease. 20% (5/25) had a history of autoimmune disease. CH was present in 32% of cohort, consistent with prior reports in solid tumor pts. Mutations in DNMT3A (36%) were most common, followed by TET2 (18%). Mutations in PPM1D, ARID1A, SF3B1, LPA and TGFBR2 accounted for 46% of the mutations (Figure 1). The mutational pattern was similar to prior reports in other cancer cohorts. DNMT3A mutations were most common in this cohort, with only one patient harboring a mutation in the R882 AML/MDS hotspot, previously described in CH. Most common mutation type was single nucleotide variants (55%), followed by frameshift (27%), and splice site mutations and truncations. The mean VAF for somatic mutations was 9%, much higher than the usual VAF cutoff for CH. Mutations were more common in smokers (40% vs 26.7%), and in individuals older than 60 years (37.5% vs 22%). Pts with autoimmune disease did not demonstrate CH mutations (0/5), whereas 40% (8/20) of pts without autoimmune diseases harbored mutations, (p=0.08). Conclusions. Our findings demonstrate a high baseline prevalence of putative CH mutations and high mean VAFs in a cohort of melanoma patients, even in the setting of minimal prior chemotherapy and radiation exposure. Despite this high CH prevalence, risk of tMN development after melanoma is declining with the use of newer therapies, suggesting a possible immune clearance or halt in progression of clonal hematopoiesis with newer therapies (ICI). Lack of CH mutations in individuals with autoimmune disease is an interesting finding and warrants further investigation. Ongoing serial sample analysis of the melanoma cohort after exposure to ICI will provide insight into the impact of ICI on the underlying clonal architecture. These findings are also being tested in the NSCLC validation cohort. References Singh A, Mrad C, Faber MG, et al. Evolving risk of therapy-related myelodysplastic syndromes and acute myeloid leukemia (tMDS/AML) following modern cancer therapies. Journal of Clinical Oncology. 2020;38(15_suppl):7516-7516. Acknowledgement: Data and samples for this study were provided by the Data Bank and BioRepository (DBBR), which is funded by the National Cancer Institute (P30 CA016056) and is a Roswell Park Cancer Institute Cancer Center Support Grant shared resource. Disclosures Griffiths: Persimmune: Research Funding; Boston Biomedical: Honoraria; Genentech Inc: Research Funding; Astex Pharmceuticals: Research Funding; Alexion Pharmaceuticals: Honoraria, Research Funding; Celgene/BMS: Honoraria, Research Funding; AbbVie Inc: Honoraria; Novartis: Honoraria, Research Funding. Guzman:Cellectis: Research Funding; SeqRx: Honoraria. Wang:Stemline: Speakers Bureau; PTC Therapeutics: Consultancy; Macrogenics: Consultancy; Astellas: Consultancy; Pfizer: Speakers Bureau; Abbvie: Consultancy; Jazz Pharmaceuticals: Consultancy; Bristol Meyers Squibb (Celgene): Consultancy; Genentech: Consultancy.

E-Cigarettes: A Scientometric Assessment of Global Publications Output during 2001-18

: The paper makes assessment of global e-cigarette publications (3885 publications) trends over the past 18 years (2001-8) via a bibliometric analysis, using Scopus database. The paper further provides an insight into qualitative performance of e-cigarettes research in terms of qualitative indicators, such as relative citation index, citations per paper, highly cited papers, top 15 global organizations and authors in the field, most favored subjects in the field. E-cigarettes annual and nine-year cumulative global publication output registered 113.60% and 7570.0% growth during the last 18 years and its citation impact averaged to 18.71 citations per paper. 89.63% share of the global research output and more than 100% share of global citation output in the field emanates from top 10 (among 37 participating countries) during 2001-18. Seven (out of top 10) countries registered relative citation index above their global average of 1.29: Canada and Italy (2.32 each), Greece (1.75), Australia (1.54), U.K. and Switzerland (1.42 each) and France (1.30) during 2001-18. Medicine is the most preferred subject on e-cigarettes research with 81.75% global publications share, followed distantly by pharmacology, toxicology and pharmaceutics (13.15%), social sciences (9.146%), environment science (7.26%), etc. during this period. Among 525 organizations and 729 authors participating in e-cigarettes research, the top 15 organizations and the authors collectively contributed 26.64% and 13.64% global publication share and 47.78% and 33.25% global citation share, respectively during 2001-18. USA and U.K. were the leading global organizations with global publications share of 52.15% and 12.54%. University of California, San Francisco, USA and University of North Carolina at Chapel Hills, USA were the leading organizations with 135 and 87 papers. Roswell Park Cancer Institute, USA (53.79 and 2.88) and Food and Drug Administration, MD, USA (42.33 and 2.26) were the two leading organizations in terms of citation impact per paper and relative citation index. R. Polosa (61 papers) and K.E. Farsalinos (45 papers) were the two most productive authors on the subject. M.L. Goniewicz (77.02 and 4.12) and S.A. Glantz (69.50 and 3.71) were the two leading authors in terms of citation impact per paper and relative citation index. Nicotine and Tobacco Research (184 papers) and Tobacco Control (168 papers) were the leading journals (among 305 participating journals) publishing on this theme. 141 papers (among 3885 total papers) registered 100 to 2902 citations per paper, cumulating to a total 31459 citations, averaging to 223.11 citations per paper.Key words: E-Cigarettes, Global publications, Scientometrics, Bibliometrics.

88: Assessing the risk of concurrent endometrial cancer among women with endometrial hyperplasia

To identify the independent risk factors of concurrent endometrial cancer among women with endometrial hyperplasia and build the clinical prediction model incorporating the clinical and pathological markers. This cross-sectional retrospective observational study included data from 379 women who had a hysterectomy at the two institutes, Sisters of Charity Hospital and Roswell Park Cancer Institute, of Buffalo, New York from January 2005 to December 2016 following a diagnosis of endometrial hyperplasia with or without atypia. All women with a diagnosis of endometrial hyperplasia who subsequently received hysterectomy with or without staging operation were included in the study and analyzed. Women with a preoperative diagnosis of endometrial cancer prior to hysterectomy were excluded from the study. The variables chosen for the multivariable logistic regression analysis were ‘endometrial hyperplasia (with atypia vs. without atypia), age (≤ 53 vs. > 53), BMI (≤ 35 vs. > 35), the length of endometrial cavity (< 7cm vs. ≥ 7cm), the progestin treatment before hysterectomy (yes vs. no), smoking, diabetes, hypertension, and hyperlipidemia. Then, a stepwise backward regression model to determine the predictors of endometrial cancer was performed. The performance of predictive models was assessed with receiver operating characteristic (ROC) curve and Hosmer-Lemeshow test. Fifty-five (14.51%) of a total of 379 women with endometrial hyperplasia was diagnosed with endometrial cancer after hysterectomy. In bivariate regression analysis, the risk factors significantly associated with concurrent endometrial cancer were atypical endometrial hyperplasia, age ≥ 50, postmenopausal bleeding, the use of progestin, diabetes mellitus, hypertension, and hyperlipidemia. In adjusted multivariate logistic regression analysis, the presence of atypical endometrial hyperplasia was associated with a significant increase in the risk of being diagnosed with concurrent endometrial cancer in the final pathology of hysterectomy specimen (OR, 56.708, 95% CI 7.601-423.056). Using a stepwise backward multivariate regression (alpha set at 0.1) analysis, the model with atypical endometrial hyperplasia, hypertension, smoking, and postmenopausal bleeding was constructed. This model predicted the risk of being diagnosed as endometrial cancer better, in comparison to the model with atypical endometrial hyperplasia alone or the model controlling simultaneously for the variables selected in the bivariate analyses indicated above (stepwise backward regression model, AUC=0.8749; the model with atypical endometrial hyperplasia, AUC=0.7983; multivariate regression model, AUC=0.8696, p-value = 0.0001). The addition of postmenopausal bleeding, hypertension, and smoking to atypical endometrial hyperplasia in the risk prediction model improves the risk assessment of concurrent endometrial cancer.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Utility of Bone Marrow Biopsy in the Staging of T-Cell Lymphoma in the PET-CT Era

Introduction: T-cell lymphomas (TCL) are a heterogenous group of lymphoid malignancies that account for 10-15% of all lymphoproliferative disorders. Histological bone marrow involvement (BMI) ranges between 20-40% of all TCLs at time of diagnosis with bone marrow aspirate and biopsy (BMAB) considered the gold standard test to detect BMI. 18-Fluoro-deoxyglucose positron emission tomography combined with computed tomography (PET-CT) is a standard pretreatment imaging in the staging of TCL. In other lymphomas like DLBCL, PET-CT may obviate the need for BMAB as a component for staging, but this has not been studied in TCL. The aim of this retrospective study is to determine the accuracy of PET-CT in detecting BMI in newly diagnosed TCL. Methods: This is a single institution retrospective medical chart review study. All TCL patients(pts) diagnosed at Roswell Park Cancer Institute between January 2003 to December 2017 and underwent pre-treatment PET-CT and BMAB were included. PET-CT images were visually assessed for BMI. We excluded cases in which BMAB specimens were qualitatively and/or quantitatively insufficient to determine the presence or absence of BMI. Ann Arbor staging was determined using PET-CT and BMAB and the proportion of patients upstaged to Stage IV due to BMI detected by either modality was calculated. The BMAB and PET-CT results were summarized using a 2x2 contingency table. The performance of the PET-CT was evaluated using the sensitivity, specificity, positive predictive value, and negative predictive value. Confidence intervals for these measures were obtained using Jeffrey's prior method. Results: In total 89 pts were included in the analysis. Median age at time of diagnosis was 60 (range 20-92), 52 were male (58%), 20 had elevated LDH (22%), 7 had ECOG greater or equal to 2 (8%), 66 had an IPI score 0-2 (74%) and 23 had an IPI score 3-4 (26%), 7 had &gt;2 extra-nodal sites of involvement (8%). In total, 38 pts (42.6%) had BMI at time of diagnosis, established by either BMAB (n= 25; 28%), PET-CT (n=13; 15%) or by both modalities (n=10 pts; 11%). There were 15 pts (17%) that were negative for BMI on PET-CT but had positive involvement of TCL on BMAB. The sensitivity and specificity of PET-CT to detect BMI by TCL was 40% (95% CI 22.7, 59.4) and 95.3% (95% CI 88.0, 98.7), respectively. Seventy-one pts (79.7%) had concordant results between lymphomatous BMAB and PET-CT (10 pts were positive for both, 61 pts were negative for both) and 18 pts (20.2%) had discordant interpretation (15 pts were negative by PET-CT and positive by BMAB and 3 pts were negative by BMAB and positive on PET-CT). BMAB upstaged 4 out of the 32 (12.5%) stage I-II pts to stage IV; out of these only 1 patient had positive BMI detected by PET-CT. The positive predictive value of PET-CT for detecting BMI was found to be 76.9 % (50.3, 93.0) with a negative predictive value of 80.3 % (70.3, 88.0) (Figure 1). Conclusion:In our cohort of TCL pts, staging PET-CT does not identify all cases with BMI. BMAB upstaged more pts with Stage I/II to Stage IV than PET-CT. Although PET-CT has high negative predictive value for ruling out marrow involvement by TCL, BMAB remains a necessary component in the evaluation of pts with newly diagnosed TCL because of its ability to detect lymphomatous involvement of bone marrow missed by PET-CT which has implications in staging and treatment of TCL. Disclosures No relevant conflicts of interest to declare.

Atypical Ductal Hyperplasia and Those Bordering on Ductal Carcinoma In Situ Should Be Included in the Active Surveillance Clinical Trials.

Women with atypical ductal hyperplasia (ADH), unlike those with ductal carcinoma in situ (DCIS), are denied eligibility for active surveillance clinical trials. We applied the inclusion criteria of the Comparison of Operative to Monitoring and Endocrine Therapy (COMET) trial to the cases of women (n = 165) at the Roswell Park Cancer Institute who had a diagnosis of ADH, ADH bordering on DCIS, or low- to intermediate-grade DCIS on core biopsy taken during screening mammography. Upgrade of lesions to high risk was based on invasive carcinoma, high-grade DCIS, or DCIS with comedo necrosis. In total, nine (5.5%) lesions were upgraded: two (1.7%) reported ADH, one (5.9%) reported ADH bordering on DCIS, and six (19.4%) reported DCIS (P = .002); and two (1.6%) reclassified ADH vs seven (17.1%) reclassified DCIS (P < .001). In multivariate analysis, only increased number of foci had the potential to predict high risk (odds ratio: 1.39; P = .06). We conclude that ADH and ADH bordering on DCIS have lower upgrade rates than DCIS. We recommend opening an active surveillance clinical trial for women with these diagnoses.

Photodynamic Therapy: A Brief History.

Photodynamic therapy (PDT) involves the selective sensitization of tissues to light. A major advance in the field occurred when Thomas Dougherty at the Roswell Park Cancer Institute initiated a series of clinical studies that eventually led to FDA approval of the procedure. This report contains a summary of Dougherty’s contributions and an assessment of where this has led, along with a summary of implications for future drug development.

Carl and Gerty Cori: A collaboration that changed the face of biochemistry.

Carl Cori and Gerty Cori elucidated basic biochemical mechanisms involved in the utilization of energy by muscle and liver, first at Roswell Park Cancer Institute and then at Washington University. In 1929, they formulated the Cori cycle, the process by which glycogen is converted to glucose in liver and is then reconverted to glycogen in muscle. They later found that glycogen breakdown yielded glucose-1-phosphate (Cori ester) and lactate, key intermediates in the cycle; they also established that lactic acid provided the energy employed in muscle contraction. They later discovered phosphorylase, the enzyme that catalyzed glycogen breakdown. After purifiying and crystallizing muscle phosphorylase, they identified two forms of the enzyme and defined their respective roles in metabolic regulation. These studies emboldened other scientists to advance our knowledge of fundamental regulatory processes such as the adenylate cyclase-cyclic AMP system and enzyme phosphorylation. The Coris also built a world-renowned Department of Biochemistry at Washington University, which included seven future Nobelists. In 1947, the Coris were awarded the Nobel Prize, with Gerty Cori being the first American woman to win this prestigious honor.