Treatment Time Points Research Articles

MO796IMPACT OF ACTIVE VITAMIN D AND CALCIUM PREPARATION ON VASCULAR CALCIFICATION MARKERS IN HEMODIALYSIS PATIENTS WITH HYPOCALCEMIA INDUCED BY CALCIMIMETICS

Abstract Background and Aims Recently, we demonstrated the efficacy of etelcalcetide for control of secondary hyperparathyroidism (SHPT) in the DUET trial; a 12-week multicenter, open-label, randomized (1:1:1), parallel-group study treated with etelcalcetide + active vitamin D (Group E+D), etelcalcetide + oral calcium preparation (Group E+Ca), or control groups (Group C) in 124 subjects undergoing maintenance hemodialysis. Moreover, we also showed that active vitamin D was useful in correcting hypocalcemia induced by calcimimetics, but the oral calcium preparation was superior for suppression of hyperphosphatemia. In this post hoc analysis, we evaluated vascular calcification markers, fibroblast growth factor 23 (FGF23) and calciprotein particles (CPPs), in patients using etelcalcetide (n = 77) extracted from the registrants of the DUET trial. Method Serum levels of FGF23 and CPPs were measured at baseline, 6 weeks and 12 weeks after start of the trial. Skewed data (FGF23 and CPPs) were transformed to natural logarithm to achieve normal distribution prior to statistical analysis. The changes in log CPPs and log FGF23 were estimated in a linear mixed model with each treatment group, time point, and interaction of the treatment group and time point as the fixed effects. We compared these changes between treatment the groups using a linear mixed model and also the Tukey-Kramer method to correct for multiplicity. Additionally, we exploratory examined the correlations among changes of FGF23, CPPs and other biomarkers related to bone mineral metabolisms, iPTH, Ca, P, and calcium-phosphate product, tested by Spearman’s rank correlation coefficient. Results The decreases at the 12-week time point after the trial start in log FGF23 were estimated -1.13 pg/mL in Group E+Ca and -0.10 pg/mL in Group E+D in a linear mixed model, respectively. Similarly, the decreases in CPPs were estimated -1.60 AU in Group E+Ca and -0.82 AU in Group E+D, respectively. Changes of both FGF23 (P = 0.017) and CPPs (P < 0.001) in Group E+Ca significantly decreased compared with those in in Group E+D by Tukey-Kramer multiple-comparison test at 12 weeks after the trial start, while both changes in CPPs and FGF23 could not reach the significant differences between two groups at 6 weeks after the trial start (Figure 1). Reductions in FGF23 positively correlated with reductions in calcium (ρ = 0.42, P < 0.01) and phosphate (ρ = 0.48, P < 0.01) at 6 weeks after the trial start, and in calcium (ρ = 0.30, P < 0.01) and phosphate (ρ =0.70, P < 0.01) at 12 weeks after 6 weeks of the trial start), but there was no correlation with reductions in iPTH at any time point. Reductions in CPPs positively correlated with reductions only in phosphate at 6 weeks after the trial start (ρ = 0.47, P < 0.01) and at 12 weeks after 6 weeks of the trial start (ρ = 0.54, P < 0.01). Conclusion In this analysis, vascular calcification markers were significantly decreased in Group E+Ca compared to those in Group E+D. Further studies should be needed, our study suggests that oral calcium preparation may have an advantage against vascular calcification rather than active vitamin D for the correction of hypocalcemia induced by etelcalcetide in hemodialysis patients with SHPT.

OP31 RESTORE: Interim analysis of a Phase 2 study of QBECO SSI for the induction and maintenance of clinical and endoscopic remission in subjects with Moderate to Severe Crohn’s Disease

Abstract Background Innate immune defects play a role in the pathogenesis of CD. Enhancing innate immune competency and restoring mucosal barrier function provide a novel approach to treat CD. QBECO SSI is a first-in-class immunotherapy designed to correct innate immune dysfunction underlying CD. This analysis is from subjects in the open label portion of a planned controlled trial. Objectives were to assess endoscopic response at Wks 16 and 26, and select the optimal induction timepoint for the RCT. Safety and treatment compliance were also evaluated. Methods 20 pts with moderate-to-severe CD were enrolled and received QBECO SSI by sc injection every other day for up to 52 wks. Minimum eligibility: Simple Endoscopic Score for CD (SES-CD) ≥7 (ileitis ≥4), abdominal pain (AP) score >21 (11-point scale) or liquid/very soft stools (SF) (BFS Type 6 or 7) >10 for 7 consecutive days during screening. Pts were evaluated for clinical symptoms and endoscopy at Wks 16, 26, and 52. After evaluation at the induction period (Wk 26) pts could continue in maintenance up to Wk 52. Endoscopies were evaluated by central blinded read and pts reported daily symptoms. Endoscopic response defined as ≥50% reduction in SES-CD from baseline. Clinical remission defined as AP and SF ≤21. Results Mean age was 43.6 (SD 13.6) yrs; 60% men and 60% previously treated with biologics. Mean yrs since CD diagnosis was 14.4 (10.1), AP score 30.4 (15.8), SF score 36.2 (19.1) and mean SES-CD at baseline was 12.5 (6.7) indicating a more difficult to treat population. Endoscopic response rate by central read during the induction period was 30% (6/20) overall, 38% (3/8) for biologic naïve and 25% (3/12) biologic experienced pts (ITT analysis). Similar number of pts achieved endoscopic response at Wk 16 (4 pts) as 26 (3 pts). Mean SES-CD improved through Wk 26 with a 0.6 point greater reduction at Wk 26 compared to 16. Change in SES-CD from baseline in biologic naïve pts was -2.9 (5.8) at Wk 16 and -4.1 (6.7) at 26. Clinical remission was achieved by 45% (9/20) of pts at Wk 16 and 40% (8/20) at Wk 26; 16 pts continued into the maintenance phase of the study. By central evaluation, 13% (2/16) were in endoscopic response at Wk 52. QBECO SSI was very well tolerated. 8/20 (40%) pts reported AEs related to treatment. Most frequency reported related AE was injection site erythema (2/20, 10% pts). Majority of AEs were mild and no other related AE was reported by more than 1 patient. Conclusion Week 26 was the optimal endoscopic evaluation timepoint for QBECO SSI treatment and will be utilized in the larger RCT. Both biologics naïve and experienced patients showed response to QBECO SSI treatment by Weeks 26 and 52, with higher response rates in biologics naïve patients. QBECO SSI was well tolerated.

Intra-articular injection of compound betamethasone and hyaluronic acid for the treatment of moderate-severe knee osteoarthritis:a randomized controlled trial

To compare clinical effects of compound betamethasone and compound betamethasone with hyaluronic acid in treating moderate-severe knee osteoarthritis (KOA). A prospective randomized controlled study was conducted in 116 patients with unilateral moderate-severe KOA patients from February 2017 to November 2017 and divided into observation group and control group, 58 patients in each group. In observation group, there were 15 males and 43 females aged from 45 to 80 years old with an average of (66.45±6.31) years old;according to Kellgren-Lawrence(K-L) classification, 42 patients were type Ⅲ and 16 patients were type Ⅳ;the courses of disease ranged from 4 to 8 years with an average of (5.25±2.21) years;the patients were treated by injecting 1 ml compound betamethasone into knee joint. In control group, there were 13 males and 45 females aged from 45 to 80 years old with an average of (64.89±6.41) years old;according to K-L classification, 43 patients were type Ⅲ and 15 patients were type Ⅳ;the courses of disease ranged from 4 to 10 years with an average of (5.41±2.35) years;the patients were treated by knee joint injection of 4 ml hyaluronic acid and 1 ml compound betamethasone. Visual analog scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) were used to evaluate clinical effects before treatment and 1 week, 1, month, 3 and 6 months after treatment. Totally 55 patients in observation group were followed up for 6 months, and 3 patients were quit at 3 months after treatment for poor efficacy. Totally 56 patients in control group were followed up for 6 months, and 2 patients were withdrew from the follow-up on the first and third month respectively for poor efficacy. There were no statistical difference in VAS and WOMAC between two groups before treatment and different time points after treatment (P>0.05), and no significant difference in VAS and WOMAC before treatment and 6 months after treatment between two groups(P>0.05). For patients with moderate-severe KOA, there is no significant difference in therapeutic effect between compound betamethasone injection and compound betamethasone combined with hyaluronic acid injection, and long-term effect of two methods is not good.

Impact of pre-treatment derived neutrophil-lymphocyte-ratio on outcomes in patients with triple-negative breast cancer.

e12556 Background: There is an ambiguity of data regarding the predictive and prognostic significance of pre-treatment-derived neutrophil-lymphocyte-ratio (DNLR) to attain pathologic complete response (pCR) after neo-adjuvant chemotherapy (NACT) and survival in patients with triple-negative breast cancer (TNBC). Methods: In this ambispective study, conducted at Dr. B.R.A., I.R.C.H., AIIMS, New Delhi, 328 patients of TNBC registered from a period of May 2013 to June 2020, who received treatment with curative intent were included. Patients with oligometastatic TNBC who received NACT with curative intent were also included in the analysis. Survival analysis to evaluate the correlation of pre-treatment DNLR with relapse-free survival (RFS) and overall survival (OS) was done. Logistic regression analysis was done to evaluate the association of DNLR with pCR among the subset of the sample who completed NACT and underwent surgery. Results: The median age of our cohort was 45 (18-74) years. Study cohort comprised of 165 (50.3%) pre-menopausal, 150 (45.7%) post-menopausal and 12 (3.7%) peri-menopausal patients respectively. Stage distribution as per AJCC 7th edition was stage-I 8 (2.4%), stage-II 127 (38.7%), stage-III 171(52.1%), and stage-IV 22 (6.7%) patients respectively. The median duration of symptoms was 3 (0.25-36) months. One seventy-three (52.7%) patients received NACT and underwent surgery, out of which 52 (30.1%) patients achieved pCR. Median DNLR in the overall population was 1.7 (0.4-10.1) and the median derived lymphocyte count of 2290 (370-11700) with < 5%(n = 14) having baseline lymphopenia( < 1000). Based on the maximum sensitivity and specificity, a DNLR cut-off point of 1.77 in the overall population and 1.88 among those patients who underwent surgery following NACT were used to categorize low and high DNLR. Median RFS was 73.5 months in our sample, whereas median OS was not reached. The 3-year RFS and OS rates were 65.8% (59.0-71.8) and 85.1% (79.5-89.2%) respectively. High DNLR( > 1.77) was not associated with RFS [HR (95%CI): 1.36 (0.90-2.06)] and OS [HR (95% CI): 0.97 (0.52-1.81)]. In a subset analysis of patients (173) undergoing surgery following NACT, high DNLR ( > 1.88) was not found to be associated with pCR [OR (95% CI): 0.81 (0.42-1.57)]. Conclusions: Pre-treatment DNLR is an easily available inflammatory marker. Indian patients of TNBC usually have raised baseline lymphocyte count, hence, pre-treatment DNLR may not be a reliable predictor of pCR and survival outcomes in these patients. Association of DNLR at various treatment and post-treatment time points with survival outcomes needs further exploration.

Late immune-related adverse events with immune checkpoint inhibitors.

2635 Background: Immune Checkpoint Inhibitors (ICIs) are associated with unique immune-related adverse events (irAEs). IrAEs can occur at any timepoint of ICI treatment. Late irAEs are not well reported in the literature. Herein, we attempt to characterize irAEs that occur 6-month, one year and two years after ICI treatment initiation. Methods: We identified patients treated with ICIs (anti-CTLA-4, anti-PD(L)-1 either alone or in combination or with chemotherapy) across Hackensack Meridian Health hospital and MedStar Georgetown University Health systems from 12011 to 4/2018. Patients' baseline demographics, treatment history, and irAEs were collected from EHR. CTCAE V4.03 was used to grade irAEs. Results: We identified 1332 patients treated with 1443 unique ICIs. The ICI therapies were nivolumab 38% (543), pembrolizumab 23% (332), ipilimumab plus nivolumab 12% (180), ipilimumab 11% (161), Atezolizumab 3% (47) and others 13% (180). Tumor types were lung cancer 34% (496), melanoma 27% (389), GI cancers 6% (92), kidney cancer 6% (87), and other cancers 26% (379). The median age was 66 (21-87), age >75 37% (541), Caucasian 67% (970). We identified a total of 911 any grade irAEs among 37% (552) therapies. Among, 911 irAEs, grade 1-2, grade ≥3 and unknown grade irAEs were 39% (572), 12% (182) and 11% (157), respectively. The most common any grade irAEs were skin rash 22% (202), colitis 13% (120), and hepatitis 12% (108). 84% of all irAEs and 85% of ≥ Grade 3 irAEs occurred within 6 months of treatment initiation. Of the 350, patients on active treatment at six months, 37 % (132) and 7% (26) developed any grade and grade ≥3 irAEs, respectively. irAEs that had > 10% of their occurrences after six months were skin rash and colitis 14% each. Other common irAEs were hypothyroidism, hepatitis, joint pain, pruritis and pneumonitis at 7% each. Among 170 patients on active treatment at one year, 37% (62) and 7% (12) developed any grade and grade ≥3 irAEs respectively. irAEs with >10% incidence after one year of treatment were rash 19% and hepatitis 13%. Conclusions: Our RWE findings suggest although 85% irAEs occurs within the first six months of treatment, late irAEs can occur with ICI treatment. The incidence and pattern of late irAEs appears similar to early irAEs, (e.g., skin rash, colitis, hypothyroidism and hepatitis) with pneumonitis being a notable exception. It is uncertain if these results will be influenced by changing patterns of ICI use (e.g. different diseases and/or regimens) over time.[Table: see text]

Weight changes according to treatment in a diverse cohort of breast cancer patients.

e12513 Background: Weight changes are common among breast cancer patients. The majority of studies to date have focused on weight gain after a breast cancer diagnosis and its implications on health in survivors. Fewer studies have examined weight loss and its related characteristics. Weight changes have been reported to be influenced by several factors such as age, treatment, stage and pre-diagnostic weight. We evaluated weight changes during key treatment time points in early stage breast cancer patients. Methods: We characterized 389 female patients diagnosed in Hawaii with early stage breast cancer from 2003-2017 in the Multiethnic Cohort (MEC) linked with Kaiser Permanente Hawaii electronic medical record data. We evaluated weight changes from surgery to 4 years post-diagnosis with six time points along a patient’s treatment trajectory (chemotherapy, radiation, endocrine, or surgery alone) and annually thereafter, adjusting for age, race/ethnicity and initial body mass index (BMI). Results: We found key time points of significant weight change for breast cancer patients according to their adjuvant treatment. In patients who had surgery alone (S), surgery-radiation (SR), or surgery-endocrine therapy (SE), the percentage of patients with stable weight, while generally comprising the majority, consistently decreased over time. However, the percentages of patients with weight loss and weight gain during this time steadily increased up to 4 years after initial surgery. Weight loss was more common than weight gain by about 2 fold in these treatment groups (weight loss 33.2%-42% vs weight gain 11.6%-21.4%). For patients with surgery-chemotherapy (SC), there was significant increase in patients with weight loss seen within the first 3 months after surgery (16.2% to 43.7%), during the time when patients receive chemotherapy. And this weight loss trend persisted until year 4. Weight gain was less commonly seen in this treatment group. Conclusions: We identified key time points during breast cancer treatment that may provide a therapeutic window to positively influence outcomes. Tailored weight management interventions should be utilized to promote overall health and long term survivorship.

Effect of fire needling on mild to moderate knee osteoarthritis and related serum inflammatory cytokines

To compare the clinical effect of fire needling and filiform needling for mild to moderate knee osteoarthritis (KOA) and observe the influence on related serum inflammatory sytokines. A total of 60 patients with mild to moderate KOA were randomly divided into an observation group (30 cases, 4 cases dropped off) and a control group (30 cases, 4 cases dropped off). Both groups were given basic health management, and the acupoints of the two groups were Liangqiu (ST 34), Xuehai (SP 10), Neixiyan (EX-LE 4), Dubi (ST 35), Yanglingquan (GB 34) and ashi point. The observation group was treated with fire needling, while the control group was treated with filiform needling. Both groups were treated once every other day, 3 times a week for 2 weeks. The Western Ontario and McMaster University osteoarthritis index (WOAMC) scores of the two groups were compared before treatment, in 1, 2 weeks of treatment and 2, 6 weeks of follow-up. ELISA method was used to detect the levels of serum interleukin 1α (IL-1α), tumor necrosis factor α (TNF-α) and matrix metalloproteinase 3 (MMP-3) before treatment and in 2 weeks of treatment. The clinical effect of the two groups was evaluated in 1, 2 weeks of treatment and 2, 6 weeks of follow-up. At each time point of treatment and follow-up, the pain, stiffness, difficulty of daily activities scores and WOMAC total scores of the two groups were lower than those before treatment (P<0.05); the stiffness score of the observation group was lower than that of the control group in 1 week of treatment (P<0.05); the various scores and total scores of the WOMAC scale of the observation group were lower than those of the control group in 1, 2 weeks of treatment and 2, 6 weeks of follow-up (P<0.05). In 2 weeks of treatment, the levels of serum MMP-3 and IL-1α in the observation group and IL-1α in the control group were higher than those before treatment (P<0.05). In 1 week of treatment and 2, 6 weeks of follow-up, the total effective rates of the observation group were higher than those in the control group (P<0.05). Fire needling can improve the pain, stiffness and joint dysfunction of patients with mild to moderate KOA, and increase serum MMP-3 and IL-1α levels. Its short and long term clinical effects are better than filiform needling.

Early Assessment Window for Predicting Breast Cancer Neoadjuvant Therapy using Biomarkers, Ultrasound, and Diffuse Optical Tomography.

The purpose of the study was to assess the utility of tumor biomarkers, ultrasound (US) and US-guided diffuse optical tomography (DOT) in early prediction of breast cancer responseto neoadjuvant therapy (NAT). This prospective HIPAA compliant study was approved by the institutional review board. Forty one patients were imaged with US and US-guided DOT prior to NAT, at completion of the first three treatment cycles, and prior to definitive surgery from February 2017 to January 2020. Miller-Payne grading was used to assess pathologic response. Receiver operating characteristic curves (ROCs) were derived from logistic regression using independent variables, including: tumor biomarkers, US maximum diameter, percentage reduction of the diameter (%US), pretreatment maximum total hemoglobin concentration (HbT) and percentage reduction in HbT (%HbT) at different treatment time points. Resulting ROCs were compared using area under the curve (AUC). Statistical significance was tested using two-sided two-sample student t-test with P < 0.05 considered statistically significant. Logistic regression was used for ROC analysis. Thirty-eight patients (mean age = 47, range 24-71years) successfully completed the study, including 15 HER2 + of which 11 were ER + ; 12 ER + or PR + /HER2-, and 11 triple negative. The combination of HER2 and ER biomarkers, %HbT at the end of cycle 1 (EOC1) and %US (EOC1) provided the best early prediction, AUC = 0.941 (95% CI 0.869-1.0). Similarly an AUC of 0.910 (95% CI 0.810-1.0) with %US (EOC1) and %HbT (EOC1) can be achieved independent of HER2 and ER status. The most accurate prediction, AUC = 0.974 (95% CI 0.933-1.0), was achieved with %US at EOC1 and %HbT (EOC3) independent of biomarker status. The combined use of tumor HER2 and ER status, US, and US-guided DOT may provide accurate prediction of NAT response as early as the completion of the first treatment cycle. NCT02891681. https://clinicaltrials.gov/ct2/show/NCT02891681 , Registration time: September 7, 2016.

Lipid-Polymer Hybrid Nanoparticles Enhance the Potency of Ampicillin against Enterococcus faecalis in a Protozoa Infection Model.

Enterococcus faecalis (E. faecalis) biofilms are implicated in endocarditis, urinary tract infections, and biliary tract infections. Coupled with E. faecalis internalization into host cells, this opportunistic pathogen poses great challenges to conventional antibiotic therapy. The inability of ampicillin (Amp) to eradicate bacteria hidden in biofilms and intracellular niches greatly reduces its efficacy against complicated E. faecalis infections. To enhance the potency of Amp against different forms of E. faecalis infections, Amp was loaded into Lipid-Polymer hybrid Nanoparticles (LPNs), a highly efficient nano delivery platform consisting of a unique combination of DOTAP lipid shell and PLGA polymeric core. The antibacterial activity of these nanoparticles (Amp-LPNs) was investigated in a protozoa infection model, achieving a much higher multiplicity of infection (MOI) compared with studies using animal phagocytes. A significant reduction of total E. faecalis was observed in all groups receiving 250 μg/mL Amp-LPNs compared with groups receiving the same concentration of free Amp during three different interventions, simulating acute and chronic infections and prophylaxis. In early intervention, no viable E. faecalis was observed after 3 h LPNs treatment whereas free Amp did not clear E. faecalis after 24 h treatment. Amp-LPNs also greatly enhanced the antibacterial activity of Amp at late intervention and boosted the survival rate of protozoa approaching 400%, where no viable protozoa were identified in the free Amp groups at the 40 h postinfection treatment time point. Prophylactic effectiveness with Amp-LPNs at a concentration of 250 μg/mL was exhibited in both bacteria elimination and protozoa survival toward subsequent infections. Using protozoa as a surrogate model for animal phagocytes to study high MOI infections, this study suggests that LPN-formulated antibiotics hold the potential to significantly improve the therapeutic outcome in highly complicated bacterial infections.

Nicotinamide suppresses bevacizumab-induced epithelial-mesenchymal transition of ARPE-19 cells by attenuating oxidative stress.

To investigate the effects of nicotinamide (NAM) on bevacizumab (BEV)-induced epithelial-mesenchymal transition (EMT) of human retinal pigment epithelial cells (ARPE-19) and the underling mechanisms. ARPE-19 cells were treated with BEV for 24, 48, and 72h, and the variation degrees of EMT-related markers (fibronectin, α-SMA, vimentin, and ZO-1) were assessed by Western blotting to select the optimal treatment time point which exhibited the most obvious changes of EMT-related markers for the subsequent experiments. Furthermore, NAM was added to the medium, the mRNA and protein levels of the EMT-related markers were then measured. The accumulation of reactive oxygen species (ROS) and H2O2 and the total antioxidant capacity (TAC) of the cells were also measured to evaluate the level of oxidative stress. After being treated with BEV for 72h, the protein expression levels of EMT-related markers in ARPE-19 cells showed significant changes. Meanwhile the levels of ROS and H2O2 were obviously increased, and the TAC of ARPE-19 cells was decreased. Totally 72h was chosen to be the optimal treatment time point in subsequent experiments. Furthermore, NAM inhibited BEV-induced EMT by downregulating fibronectin, α-SMA, and vimentin and upregulating ZO-1, decreased the accumulation of ROS and H2O2, and enhanced TAC in BEV-treated ARPE-19 cells. This study demonstrates that NAM suppressed BEV-induced EMT in ARPE-19 cells by attenuating oxidative stress. Hence, NAM may be a potential therapeutic agent for alleviating neovascular fibrosis of the ocular fundus after anti-vascular endothelial growth factor therapy.

IDO1-Targeted Therapy Does Not Control Disease Development in the Eµ-TCL1 Mouse Model of Chronic Lymphocytic Leukemia.

Simple SummaryThe tryptophan-catabolizing enzyme IDO1 and its metabolite kynurenine were shown to be enhanced in patients with chronic lymphocytic leukemia (CLL), and their involvement in T cell suppression and immune escape was suggested. As we have observed increased IDO1 expression and kynurenine serum levels in the Eµ-TCL1 mouse model of CLL, we evaluated the therapeutic potential of targeting IDO1 in preclinical treatment studies with two IDO1 inhibitors in mice developing CLL. As both studies revealed only minor effects of IDO1 inhibition on leukemia development and the immune compartment at early time points of treatment which disappeared over time, our data suggest that even though IDO1 might be involved in immunosuppressive mechanisms in CLL, its targeting is not sufficient for preventing immune escape. Thus, compensatory mechanisms beyond IDO1 seem to be of relevance to prevent clinically relevant benefits with IDO1-targeting drugs.Indoleamine-2,3-dioxygenase 1 (IDO1), a tryptophan (Trp)-catabolizing enzyme producing metabolites such as kynurenine (Kyn), is expressed by myeloid-derived suppressor cells (MDSCs) and associated with cancer immune escape. IDO1-expressing monocytic MDSCs were shown to accumulate in patients with chronic lymphocytic leukemia (CLL) and to suppress T cell activity and induce suppressive regulatory T cells (Tregs) in vitro. In the Eµ-TCL1 mouse model of CLL, we observed a strong upregulation of IDO1 in monocytic and granulocytic MDSCs, and a significantly increased Kyn to Trp serum ratio. To explore the potential of IDO1 as a therapeutic target for CLL, we treated mice after adoptive transfer of Eµ-TCL1 leukemia cells with the IDO1 modulator 1-methyl-D-tryptophan (1-MT) which resulted in a minor reduction in leukemia development which disappeared over time. 1-MT treatment further led to a partial rescue of the immune cell changes that are induced with CLL development. Similarly, treatment of leukemic mice with the clinically investigated IDO1 inhibitor epacadostat reduced the frequency of Tregs and initially delayed CLL development slightly, an effect that was, however, lost at later time points. In sum, despite the observed upregulation of IDO1 in CLL, its inhibition is not sufficient to control leukemia development in the Eµ-TCL1 adoptive transfer model.

Abstract PO-048: VISTA immune-checkpoint blunts radiotherapy induced anti-tumor immune response

Abstract Radiotherapy (RT) is the primary treatment of many solid neoplasms including head and neck cancer (HNC). Itis well accepted that the tumoricidal effects of RT can be significantly influenced by the immune system. Induction of cell death by radiation can elicit an anti-tumor immune response; however, it could also promote pathways of immunosuppression, which in turn can stimulate local tumor recurrence and/or distant metastases. A mechanism by which RT or chemoradiation (CRT) contributes to immunosuppression is by expansion of myeloid derived suppressive cells (MDSCs). MDSCs are a heterogeneous population of immature myeloid cells, which undergo significant expansion during cancer development and progression. Although MDSCs have been linked to inferior prognosis and treatment failure, the mechanisms by which they contribute to treatment RT failure are not well understood. Through this study we investigated the role of VISTA (V-domain Ig Suppressor of T cell Activation) immune-checkpoint on MDSCs in regulating RT response in vivo. Using syngeneic mouse models of HNC (MOC2 [HPV-] &amp; MEERL [HPV+]), we show that both single fraction/fractionated irradiation regimens significantly increase polymorphonuclear (PMN)-MDSCs in both the tumor and the blood post-RT. We see a similar increase in PMN-MDSCs in HNC patient blood samples (12/16) at mid treatment time point (3-4 weeks after starting RT). Further analyses of immune cells reveal a significant induction of the inhibitory immune-checkpoint VISTA on PMN-MDSCs post-RT. VISTA is a multifaceted negative checkpoint protein that is expressed on most hematopoietic cells, especially on myeloid lineage. VISTA is known to contribute to the overall T cell-suppressive function. We find that irradiation of bone marrow derived-MDSCs or patient PBMC derived PMN-MDSCs leads to upregulation of VISTA surface expression as early as 24 hours after RT. Additionally, the VISTAhi MDSCs have significantly elevated levels of the immunosuppressive cytokine IL-10. We then seek to study the impact of inhibiting VISTA on RT induced immune response and tumor control in a HNC model. The combination of anti-VISTA antibody and fractionated RT (3Gy X 5) leads to a significant decrease in tumor volume compared to either RT alone or anti-VISTA antibody alone. Therapeutic blocking of VISTA checkpoint along with radiation also lead to a reduction in metastatic seeding in the lung in these mice compared to RT alone group. These findings are associated with a decrease of PMN-MDSCs in both tumor and the lungs and an increase in CD4+ T cells and dendritic cells in the tumor of the anti-VISTA antibody + RT group compared to RT alone group. These results underline the role of VISTA in compromising the anti-tumor effects of RT and suggest that targeting VISTA may enhance RT efficacy in HNC patients. Citation Format: Dhanya K. Nambiar, Nishant Mehta, Sainiteesh Maddineni, Hongbin Cao, Vignesh Viswanathan, Tia Cheunkarndee, Jennifer R. Cochran, Quynh Thu Le. VISTA immune-checkpoint blunts radiotherapy induced anti-tumor immune response [abstract]. In: Proceedings of the AACR Virtual Special Conference on Radiation Science and Medicine; 2021 Mar 2-3. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(8_Suppl):Abstract nr PO-048.

The bodymind model of Art Therapy in coping with problem substance use

ABSTRACT Background The bodymind model of Art Therapy delineates the mechanisms through which artmaking, in a therapeutic setting, with the support of an art therapist, may have salutary effects. The model is designed to serve as a guide to design empirical studies of the mechanisms of art therapy. Context In this paper, we describe how the bodymind model can be implemented to observe clinical work done in art therapy with individuals in problem substance use (PSU) treatment. Approach Using one case example we describe the bodymind model’s mechanisms and how they may manifest in PSU treatment. Outcomes We observed ways in which artmaking may serve multiple purposes at different time points in treatment, such as, getting in touch with bodily pain that was rooted in difficult childhood experiences, thus, paving the way for the transformation of implicit somatic information to explicit emotional content. Later in treatment, artmaking was observed to possibly assist our client to engage in reflective practices, perspective taking and cognitive decision making. Conclusions There are multiple potential mechanisms through which art therapy may have a salutary role. Implications for research This case example can help researchers and clinicians engage with the bodymind model in ways that will deepen their clinical understanding and design future studies that will expand the body of research of art therapy practices. Plain-language summary Art Therapy is a health profession that uses artmaking in the framework of a supportive relationship with a qualified art therapist to help individuals and groups improve their well-being and mental health. There is research that demonstrates the benefit of participating in art therapy to improve wellbeing, however, how this occurs continues to be unclear. The bodymind model of Art therapy was created to describe some of the ways through which art therapy may benefit participants. The model is designed to help art therapists design studies that will examine which parts of art therapy benefit participants. In this paper, through one case example we describe the different mechanisms of the bodymind model as seen in problem substance use treatment. We describe how artmaking possibly served multiple purposes at different times in treatment. Artmaking possibly enabled the client to get in touch with bodily pain that was rooted in difficult and painful emotional childhood experiences, thus, possibly paving the way for emotions that were stored in the body to be transferred to the art and then to words. The experience of touching and moving the art materials possibly helped change these bodily experiences into emotional and cognitive ones. Later in treatment, artmaking potentially helped the client reflect on her past and examine it from a distance and engage in decision making. The sense of accomplishment that accompanied artmaking possibly enabled this client to feel a sense hope in their ability to become and remain sober. We hope that providing this case example will help researchers and clinicians engage with the bodymind model in ways that will promote their clinical work and expand the body of research of art therapy practices.

Thymoquinone chemosensitizes human colorectal cancer cells to imatinib via uptake/efflux genes modulation.

Imatinib (IM) is a pharmaceutical drug that inhibits tyrosine kinase enzymes that are responsible for the activation of many proteins by signal transduction cascades as c-Abl, c-Kit and the platelet-derived growth factor (PDGF) receptor. Thymoquinone (TQ) is an active constituent of Nigella sativa seeds. Thymoquinone benefits are attributed to its medicinal uses as antioxidant, anticancer and antimicrobial agent. This study aimed to investigate the impact of using TQ with IM in the HCT116 human colorectal cancer cell line model. The HCT116 cells were treated with IM or/and TQ in non-constant ratios, in which the fixed concentrations of TQ (5, 10 or 20µmol/L) were co-treated with various concentrations of IM (7.5-120µmol/L) for 24, 48 and 72hours. Imatinib-TQ interaction was analysed using CompuSyn software. The IC50 values for IM were 105, 72μmol/L after 48 and 72hours, respectively, and were significantly reduced to 7.3, 7 and 5.5μmol/L after combination with TQ (10μmol/L) and to 5.8, 5.6 and 4.6μmol/L after combination with TQ (20μmol/L) to 24, 48 and 72hours, respectively. The combination index (CI) and dose reduction index (DRI) values indicate a significant synergism in HCT-116 cells at different treatment time points. Thymoquinone significantly enhances the cellular uptake of IM in HCT116 cells in a time and concentration-dependent manner. A significant downregulation in ATP-binding cassette (ABC) subfamily B member 1 (ABCB1), ABC subfamily G member 2 (ABCG2) and human organic cation transporter 1 (hOCT1) genes was observed in the cells exposed to IM+TQ combination as compared to IM alone, which resulted in a substantial elevation in uptake/efflux ratio in combination group. In conclusion, TQ potentiates IM efficacy on HCT116 cells via uptake/efflux genes modulation.

A Retrospective Cohort Study of Sublingual Immunotherapy with Standardized Dermatophagoides farinae Drops for Allergic Rhinitis.

To evaluate the efficacy and safety of sublingual immunotherapy (SLIT) with standardized Dermatophagoides farinae (Df) drops in monosensitized and polysensitized patients with allergic rhinitis (AR) and to analyze the adverse events (AEs). A retrospective analysis was performed using data for 68 patients with AR who received SLIT. The patients were divided into a monosensitized group (36 cases) and a polysensitized group (32 cases) based on serum-specific IgE test results. In the two groups of patients, total nasal symptoms score (TNSS), total medication score (TMS), visual analog scale (VAS) score, and AEs before treatment and at 1, 3, 6, and 12months of treatment were evaluated. Compared with that before treatment, the TNSS, TMS, and VAS score in the monosensitized and polysensitized groups all decreased significantly at 3, 6, and 12months of SLIT (all P < 0.05). There were no significant differences in treatment efficacy indicators between the two groups at all treatment time points (all P > 0.05). In terms of safety, compared with 1month after initiating SLIT, the incidence of AEs in the monosensitized and polysensitized groups at 6 and 12months of treatment significantly decreased (all P < 0.05). There was a statistically significant decrease in the incidence of AEs in both groups at 6months compared with 3months of treatment (χ2 = 1.92 and 5.85, respectively, all P < 0.05). The difference in incidence of AEs between the monosensitized and polysensitized groups was not statistically significant at any treatment time point (all P > 0.05). AEs in all patients were local mild reactions; no serious AEs were found. SLIT with standardized Df drops has similar efficacy and safety for monosensitized and polysensitized patients with AR. AEs mostly occurred during the first 3months of SLIT in both the monosensitized and polysensitized groups, and the incidence of AEs gradually decreased as the course of treatment extended.

Joint profiling of DNA and proteins in single cells to dissect genotype-phenotype associations in leukemia

Studies of acute myeloid leukemia rely on DNA sequencing and immunophenotyping by flow cytometry as primary tools for disease characterization. However, leukemia tumor heterogeneity complicates integration of DNA variants and immunophenotypes from separate measurements. Here we introduce DAb-seq, a technology for simultaneous capture of DNA genotype and cell surface phenotype from single cells at high throughput, enabling direct profiling of proteogenomic states in tens of thousands of cells. To demonstrate the approach, we analyze the disease of three patients with leukemia over multiple treatment timepoints and disease recurrences. We observe complex genotype-phenotype dynamics that illustrate the subtlety of the disease process and the degree of incongruity between blast cell genotype and phenotype in different clinical scenarios. Our results highlight the importance of combined single-cell DNA and protein measurements to fully characterize the heterogeneity of leukemia.

Repeated courses of escalating doses of Nivolumab in refractory Hodgkin lymphoma with recurrent relapses post allografting: A safe and effective treatment approach.

For patients with Hodgkin Lymphoma (HL) who experience relapse post allogeneic stem cell transplantation, limited treatment options exist, and the ultimate outcome is poor. Recently, the programmed cell death protein-1 (PD-1) inhibitors have shown remarkable efficacy in patients with refractory/relapsed HL, also demonstrating an acceptable safety profile. However, due to effects on T-cell activity, the use of PD-1 inhibitors post allografting may potentially increase the risk of treatment-emergent graft versus host disease. We herein report the clinical course of a patient who experienced multiple relapses of HL post allogeneic stem cell transplantation. He failed several treatment modalities but he responded to escalating doses of the PD-1 inhibitor nivolumab, given at two different treatment time points, also demonstrating minimal and easily manageable toxicity.

Influence of Pelvic Intensity-Modulated Radiation Therapy With Concurrent Cisplatin-Based Chemotherapy of Cervical Cancer on the Vaginal Microbiome.

Pelvic intensity-modulated radiation therapy (IMRT) combined with concurrent chemotherapy is an effective treatment for cervical cancer; however, radiation resistance impairs its clinical benefit. The vaginal microbiome plays an important but poorly understood role in cancer radiochemotherapy. In this study, we investigated the effects of treatment on the overall composition and alteration of the vaginal microbiome in patients receiving pelvic IMRT with concurrent cisplatin-based chemotherapy. We collected samples from twenty patients with cervical cancer and six healthy controls and performed 16S rRNA sequencing. Vaginal microbial composition analysis revealed significant differences between the two groups, but no significant differences between radiation treatment time points. However, the relative abundances of Gammaproteobacteria, Gemmatimonadetes, Gemmatimonadales, Pseudomonadales, Gemmatimonadaceae, Rikenellaceae, Acinetobacter, Desulfovibrio, Prevotella 9, Rikenellaceae RC9 gut group, Turicibacter, and the metagenome increased with time. The results encourage further study into the effects of the vaginal microbiome on cervical cancer treatment strategies, especially radiochemotherapy. Better understanding of these effects could inform new therapeutic approaches to enhance the efficacy of radiochemotherapy.

Abstract PD6-05: Subtype-specific MRI models to guide selection of candidates for de-escalation of neoadjuvant therapy

Abstract Background: MRI measured functional tumor volume (FTV) can predict pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) as early as 3 weeks after treatment initiation (1), indicating the potential of using MRI to guide treatment de-escalation. We developed MRI based, subtype-specific models for predicting pCR, to be used as part of a de-escalation strategy combining MRI and inter-regimen core biopsy pathology in I-SPY 2. Methods: I-SPY 2 patients underwent MRI exams at pre-treatment, early treatment (3 wks), inter-regimen (12 wks), and pre-surgery. pCR was assessed at surgery. FTV was calculated semi-automatically for every MRI (2). Subtype-specific FTV-based MRI prediction models were trained using FTV measurements at baseline, early treatment and inter-regimen timepoints for patients enrolled in I-SPY 2 between May 2010 and November 2016. Breast cancer subtype was defined by hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status. The MRI prediction model was then used to predict probability of achieving pCR for each patient at inter-regimen, based on their subtype. The therapy de-escalation strategy focuses on achieving high positive predictive value (PPV, correct identification of patients with pCR) while maximizing sensitivity (proportion of patients with pCR identified by the test). Predicted probability above a specified threshold was considered a positive test for pCR. This study investigated the tradeoff between PPV and sensitivity within subtype groups defined by HR and HER2, and held to constraints set by probability thresholds at the 1st, 2nd (median) and 3rd quartile. Results: A total of 814 patients were included in the analysis. Median age was 49 (range: 24 - 77) years. The pCR rate was 36% (289/814). Table 1 shows patient number and pCR rate by HR/HER2 subtype. The subtype-specific MRI models consist of the predictors: change of FTV (dFTV) at inter-regimen for HR+/HER2- and HR-/HER2+; dFTV at early treatment for HR+/HER2+; pre-treatment FTV and dFTV at inter-regimen for triple negatives. The highest probability varied by subtype: 0.24 for HR+/HER2-, 0.61 for HR+/HER2+, 0.73 for HR-/HER2+, 0.68 for triple negatives. The maximum PPV was 67% for HR+/HER2- and 100% for all other subtypes. Table 1 shows the tradeoff between PPV and sensitivity by subtype using the 1st, median, and 3rd quartile thresholds. Conclusions: Our data demonstrate that PPV and sensitivity vary by breast cancer subtype when the probability threshold generated by MRI model increases from low to high quartile. Results from this study suggest that the probability threshold for recommending treatment de-escalation should be selected carefully based on breast cancer subtype. Imaging results will be combined with core biopsy information obtained at the 12-week timepoint to further improve overall accuracy. Table 1 Tradeoff between positive predictive value (PPV) and sensitivity at different levels of PPVCohortNpCR rateProbability thresholdPPV (%)Sensitivity (%)HR+/HER2-32820% (64/328)1st quartile0.1824912nd quartile0.2128773rd quartile0.233552HR+/HER2+13239% (51/132)1st quartile0.2744862nd quartile0.4053693rd quartile0.515837HR-/HER2+7166% (47/71)1st quartile0.6775852nd quartile0.7181623rd quartile0.728934Triple negative(HR-/HER2-)28345% (127/283)1st quartile0.3454912nd quartile0.5262703rd quartile0.607341 Citation Format: Wen Li, David C Newitt, Jessica Gibbs, Lisa J Wilmes, Ella F Jones, Natsuko Onishi, Bonnie N Joe, Elissa Price, John Kornak, Christina Yau, Denise M Wolf, Barbara LeStage, Susan Samson, the I-SPY 2 Imaging Working Group, the I-SPY 2 Consortium, Laura J Esserman, Nola M Hylton. Subtype-specific MRI models to guide selection of candidates for de-escalation of neoadjuvant therapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD6-05.

Accounting for prompt gamma emission and detection for range verification in proton therapy treatment planning

Prompt gamma (PG) imaging is widely investigated as one of the most promising methods for proton range verification in proton therapy. The performance of this technique is affected by several factors like tissue heterogeneity, number of protons in the considered pencil beam and the detection device. Our previous work proposed a new treatment planning concept which boosts the number of protons of a few PG monitoring-friendly pencil beams (PBs), selected on the basis of two proposed indicators quantifying the conformity between the dose and PG at the emission level, above the desired detectability threshold. To further explore this method at the detection level, in this work we investigated the response of a knife-edge slit PG camera which was deployed in the first clinical application of PG to proton therapy monitoring. The REGistration Graphical User Interface (REGGUI) is employed to simulate the PG emission, PG detection as well as the corresponding dose distribution. As the PG signal detected by this kind of PG camera is sensitive to the relative position of the camera and PG signal falloff, we optimized our PB selection method for this camera by introducing a new camera position indicator identifying whether the expected falloff of the PG signal is centered in the field of view of the camera or not. Our camera-adapted PB selection method is investigated using computed tomography (CT) scans at two different treatment time points of a head and neck, and a prostate cancer patient under scenarios considering different statistics level. The results show that a precision of 0.8 mm for PG falloff identification can be achieved when a PB has more than 2 × 108 primary protons. Except for one case due to unpredictable and comparably large anatomical changes, the PG signals of most of the PBs recommended by all our indicators are observed to be reliable for proton range verification with deviations between the inter-fractional shift of proton range (as deduced from the PB dose distribution) and the detected PG signal within 2.0 mm. In contrast, a shift difference up to 9.6 mm has been observed for the rejected PBs. The magnitude of the proton range shift due to the inter-fractional anatomical changes is observed to be up to 23 mm. The proposed indicators are shown to be valuable for identifying and recommending reliable PBs to create new PG monitoring-friendly TPs. Comparison between our PB boosting method and the alternative PB aggregation, which combines the signal of nearby PBs to reach the desired counting statistics, is also discussed.