Citations

Abstract Growth of unruptured intracranial aneurysms (UIAs) is a strong predictor of rupture. Clinical observations suggest that UIAs might grow faster after endovascular treatment than untreated UIAs. There are no head-to-head comparisons of incidence rates of UIAs so far. In this meta-analysis, we compared the incidence rates of growth of untreated UIAs and endovascularly treated UIAs. Methods: We searched PubMed, Embase and Google Scholar for relevant articles and conference abstracts in English, German or French from the inception of the databases to March 2020. We performed a meta-analysis by pooling the incidence rates for growth of aneurysms from natural history studies and endovascular treatment studies. Generalized linear models were used for multivariable adjustment for the prespecified confounders age, size and location. Results: 25 studies (10 describing growth in natural history and 15 reporting growth after endovascular therapy) with 6325 aneurysms were included in the meta-analysis. Median size of the aneurysm was 3.7 mm in the natural history studies and 6.4 mm in endovascular treatment studies (p = 0.001). The pooled incidence rate (IR) of growth was significantly higher in endovascular treatment studies (IR 52 per 1000 person-years, 95% Confidence Interval (CI) 36–79) compared to natural history studies (IR 28 per 1000 person-years, 95% CI 17–46), also after adjustment. Conclusion: The incidence rate of growth in endovascularly treated aneurysms was higher than in natural history studies. However, these results should be viewed in the light of high risk of bias of the individual studies and risk of ecological bias.

Chimeric antigen receptor T (CAR-T) cell therapy is a transformative approach to cancer eradication. CAR-T is expensive in part due to the restricted use of each CAR construct for a specific set of tumors such as B cell lymphoma targeted with CD19 and multiple myeloma targeted with BCMA. A CAR construct with broad anti-tumor activity can be advantageous due to wide applicability and scalability of production. We show that CD126, the IL-6 receptor alpha, is an antigen that is expressed by many hematologic and solid malignancies including multiple myeloma, non-Hodgkin lymphoma, acute myeloid leukemia, pancreatic and prostate adenocarcinoma, non-small cell lung cancer and malignant melanoma amongst others. High CD126 expression is a negative prognostic marker in many malignancies. The two CD126 targeting CAR-T cell constructs contain the CD28 anchoring domain followed by 4-1BB and CD3 zeta signaling domain. Lentiviral vectors were generated with triple plasmid (CAR, psPAX2 and pMD2.G) transfection of 293T cells and the vector concentrated by ultracentrifugation and used to transduce human T cells. T cells were isolated from leuko-reduction cones using negative selection with magnetic beads. The transduction efficiency was around 60%. The T cells were activated with anti-CD3/CD28 beads and expanded for two weeks before using for downstream experiments. CD126 CAR-T cells are able to kill many tumor cells in an antigen specific manner and with an efficiency that is directly proportional to the cell surface expression of CD126 expression (rho = 0.6, p = 0.0019). The presence of soluble CD126 in the culture media did not interfere with CAR-T cell killing. The CAR-T constructs bind murine CD126. However, injection of CD126 targeting CAR-T cells in NSG mice did not lead to any evidence of hepatotoxicity and weight loss despite possible expression of this antigen on hepatocytes. In vivo studies in NSG mice with multiple myeloma (RPMI-8226) and prostate adenocarcinoma (DU-145) xenograft models (n=10 tumors per group) showed that the intravenously injected CD126 targeted CAR-T cells (107) infiltrated the tumors, expanded, produced human interferon gamma and killed the tumor cells (p<0.001). Bioluminescence imaging showed control of tumor growth in the actively treated tumors compared to the controls (p<0.05). At post mortem, mice injected with CD126 targeted CAR-T cells had smaller residual tumors compared to controls injected with non-engineered human T cells from the same donor. Binding of sIL-6R by CAR-T cells could mitigate cytokine release syndrome. In support of this, murine SAA-3 levels (the equivalent of human CRP) were lower in mice injected with CD126 CAR-T compared to controls (p<0.05), suggesting that binding of sIL-6R by CAR-T cells could mitigate cytokine release syndrome. CD126 provides a novel therapeutic for CAR-T cells in a broad variety of tumors with low risk of toxicity. Disclosures Dingli: Apellis: Consultancy; Millenium: Consultancy; Janssen: Consultancy; Bristol Myers Squibb: Research Funding; Sanofi-Genzyme: Consultancy; Alexion: Consultancy; Rigel: Consultancy; Karyopharm Therapeutics: Research Funding.

Background Metastasectomy is standard of care for pediatric patients with metastatic sarcoma with limited disease. For patients with unresectable disease, stereotactic body radiotherapy (SBRT) may serve as an alternative. Herein, the authors report the results of a prospective, multi‐institutional phase 2 trial of SBRT in children and young adults with metastatic sarcoma. Methods Patients aged >3 years and ≤40 years with unresected, osseous metastatic nonrhabdomyosarcoma sarcomas of soft tissue and bone were eligible. Patients received SBRT to a dose of 40 Gray (Gy) in 5 fractions. Local control (LC), progression‐free survival (PFS), and overall survival (OS) were calculated using the Kaplan‐Meier method. Results Fourteen patients with a median age of 17 years (range, 4‐25 years) were treated to 37 distinct metastatic lesions. With a median follow‐up of 6.8 months (30.5 months in surviving patients), the Kaplan‐Meier patient‐specific and lesion‐specific LC rates at 6 months were 89% and 95%, respectively. The median PFS was 6 months and the median OS was 24 months. In a post hoc analysis, PFS (median, 9.3 months vs 3.7 months; log‐rank P = .03) and OS (median not reached vs 12.7 months; log‐rank P = .02) were improved when all known sites of metastatic disease were consolidated with SBRT compared with partial consolidation. SBRT was well tolerated, with 2 patients experiencing grade 3 toxicities. Conclusions SBRT achieved high rates of LC in pediatric patients with inoperable metastatic nonrhabdomyosarcoma sarcomas of soft tissue and bone. These results suggest that the ability to achieve total consolidation of metastatic disease with SBRT is associated with improved PFS and OS.

Introduction: With a median overall survival (OS) measured in months, successful treatment of Richter's transformation (RT) of chronic lymphocytic leukemia (CLL) to diffuse large B-cell lymphoma (DLBCL) remains a major unmet medical need. While targeted agents, such as Bruton tyrosine kinase inhibitor (BTKi) monotherapy, have greatly improved outcomes for patients (pts) with CLL and some B-cell lymphomas, available BTKi therapies have been ineffective for RT, as well as for large cell transformation of indolent B-cell lymphomas and relapsed/refractory (r/r) DLBCL, which rapidly develop mechanisms of resistance by activation of downstream targets of BTKi or upregulation of alternative/parallel pathways. Focusing on a synthetic lethality approach via in vitro and in vivo studies, we discovered that concurrent inhibition of BTK & mTOR targets plus an IMiD synergistically kill malignant B-cells. DTRM-555 is an optimized oral triple combination of a novel irreversible BTKi DTRMWXHS-12 (DTRM-12), everolimus (EV) and pomalidomide (POM). This once daily therapy was tested in a stepwise, phase I, multicenter study in pts with the greatest unmet medical needs. Here we present results for this novel combination therapy in pts with RT, and r/r DLBCL. Methods: We conducted a phase I (3+3 design), first in human trial exploring DTRM-555 in adult pts with B-cell lymphomas with no available standard therapies (NCT02900716) at 6 US cancer centers. Our goal was to determine the optimal dose for DTRM-555. In phase Ia, an MTD was not reached for DTRM-12 monotherapy; In phase Ib and expansion cohorts, we evaluated double (DTRM-12/EV at 200mg/5mg or 300mg/5mg) and triple combinations (DTRM-12/EV/POM at 200mg/5mg/2mg or 300mg/5mg/2mg) administered once daily for 21 days of a 28-day cycle, until disease progression or unacceptable toxicity. The primary endpoint was safety and the dose limiting toxicity (DLT) period was cycle 1 (28 days). Secondary endpoints included overall response rate (ORR; Cheson 2014), duration of response (DOR), and DTRM-12 pharmacokinetics. The trial began on 9/27/2016 and completed enrollment with evaluable follow-up data cut-off date on 08/06/2020. Results: 39 pts were enrolled and treated, including 24 with RT (n=12) or r/r DLBCL (n=12). The safety analyses included all 39 pts treated with combination therapies while efficacy analyses were focused on RT and r/r DLBCL. Baseline characteristics (n=39): 66% male, median age 71 years (range 43-94) and 94% white. For the entire study cohort, median number of prior therapies was 3 (range 1-10), 49% had been treated with prior BTKi monotherapy,13% prior CAR-T or stem cell transplant (SCT) and 59% ≥1 prior small molecule targeted agent. For pts with RT and r/r DLBCL (n=24), median prior therapies were 5 (range 1-10) and 2 (range 10), respectively. Table 1 summarizes prior therapies for the 24 RT and r/r DLBCL pts. Table 2 describes Grade 3 and 4 related AEs for 39 pts treated with the combination therapies. AEs were manageable and similar to known AEs for BTKi, EV or POM, with a total of 4 DLTs observed with combination therapies. The most common AEs were hematological events; specifically, thrombocytopenia, neutropenia, and anemia. The MTD of DTRM-555 was determined to be DTRM-12 200mg, EV 5mg, & POM 2mg. For 11 evaluable RT pts, ORR was 45% (1 CR, 4 PR); 1 RT pt has not undergone first response assessment. For 10 evaluable DLBCL pts, ORR was 60% (2 CR, 4 PR). Responders with RT or r/r DLBCL have durable responses (Figure 1). Kaplan Meier estimated median duration of response for RT and DLBCL pts was 15 months as of the cut-off. Dose dependent DTRM-12 drug plasma levels were observed in all arms with minimal inter-pt variability. Conclusions: This clinical trial met its primary endpoint. The once-daily oral triple combination therapy DTRM-555 has an acceptable safety profile. Encouraging clinical activity was observed in several high-risk, multi-refractory pts with RT (median 5 prior therapies, ORR 45%) or r/r DLBCL (median 2 prior therapies, ORR 60%), including pts previously treated with targeted therapies, cellular therapies, checkpoint inhibitors and other experimental agents. A phase II US expansion study is underway targeting pts with RT, r/r DLBCL, r/r transformed follicular lymphoma and BTKi/BCL2 inhibitor exposed r/r CLL pts. Disclosures Mato: Adaptive: Consultancy, Research Funding; TG Therapeutics: Consultancy, Other: DSMB, Research Funding; AbbVie: Consultancy, Research Funding; AstraZeneca: Consultancy, Research Funding; BeiGene: Consultancy; LOXO: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Pharmacyclics LLC, an AbbVie Company: Consultancy, Research Funding. Schuster:AlloGene, AstraZeneca, BeiGene, Genentech, Inc./ F. Hoffmann-La Roche, Juno/Celgene, Loxo Oncology, Nordic Nanovector, Novartis, Tessa Therapeutics: Consultancy, Honoraria; Novartis, Genentech, Inc./ F. Hoffmann-La Roche: Research Funding. Ding:DTRM: Research Funding; Astra Zeneca: Research Funding; Abbvie: Research Funding; Octapharma: Membership on an entity's Board of Directors or advisory committees; MEI Pharma: Membership on an entity's Board of Directors or advisory committees; alexion: Membership on an entity's Board of Directors or advisory committees; Beigene: Membership on an entity's Board of Directors or advisory committees; Merck: Membership on an entity's Board of Directors or advisory committees, Research Funding. Brander:Tolero: Research Funding; NCCN: Other; Teva: Consultancy, Honoraria; Novartis: Consultancy, Other; NCCN: Other; Verastem: Consultancy, Honoraria, Other, Research Funding; TG Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other, Research Funding; Pfizer: Consultancy, Other; Pharmacyclics LLC, an AbbVie Company: Consultancy, Honoraria, Other, Research Funding; MEI Pharma: Other, Research Funding; Juno/Celgene/BMS: Other, Research Funding; Genentech: Consultancy, Honoraria, Other, Research Funding; DTRM: Other, Research Funding; AstraZeneca: Consultancy, Honoraria, Other, Research Funding; BeiGene: Other, Research Funding; Ascentage: Other, Research Funding; ArQule: Consultancy, Other, Research Funding; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other, Research Funding; Tolero: Research Funding; Teva: Consultancy, Honoraria; Novartis: Consultancy, Other. Tun:Bristol-Myers Squibb: Research Funding; Celgene: Research Funding; Mundipharma: Research Funding; Curis: Research Funding; TG Therapeutics: Research Funding; Acrotech: Research Funding; DTRM Biopharma: Research Funding. He:DTRM Biopharma LLC: Current Employment. Kearney:DTRM Biopharma LLC: Current Employment. Gui:DTRM Biopharma LLC: Current Employment. McKinlay:DTRM Biopharma LLC: Current Employment. Roeker:American Society of Hematology: Research Funding; AbbVie: Other: spouse with minority ownership interest ; Abbott Laboratories: Other: spouse with minority ownership interest . Huntington:Pharmacyclics: Honoraria; Novartis: Consultancy; Genentech: Consultancy; DTRM: Research Funding; AbbVie: Consultancy; Astrazeneca: Honoraria; Bayer: Consultancy, Honoraria; Celgene: Consultancy, Research Funding; TG Therapeutics: Research Funding.

PolyQ ATXN3 is a pharmacodynamic marker for SCA3, and a SNP associated with the expanded allele may serve to specifically target mutant ATXN3 .

Objective: To explore, in a large, nationally representative U.S. sample of children, potential independent associations between social and community factors and breastfeeding outcomes, using the Social Ecological Model as a theoretical framework. Materials and Methods: A secondary data analysis of the 2011–2012 National Survey of Children's Health was conducted ( N = 29,829). Multivariate logistic regression was performed to estimate associations between predictor variables (parental emotional support, neighborhood social support, neighborhood safety, neighborhood amenities, and medical home) and breastfeeding outcomes (breastfeeding initiation [BFI] and exclusive breastfeeding for 6 months [EBF6m]). For predictor variables reaching statistical significance in the adjusted models, we performed subgroup analyses by race-ethnicity. Results: After adjusting for individual- and family-level sociodemographic and maternal-child health factors, living in a neighborhood with 4 amenities was associated with 1.54 (95% confidence interval [CI] 1.06–2.23) times the odds of BFI, compared to children living in neighborhoods with no amenities. There was a negative association (adjusted odds ratio [aOR] 0.83; 95% CI 0.70–0.99) between neighborhood social support and BFI, although living in a supportive neighborhood was associated with 1.37 (95% CI 1.11–1.69) times the odds of EBF6m. There was a negative association (aOR 0.71; 95% CI 0.54–0.93) between perceived neighborhood safety and EBF6m. The observed associations differed by race-ethnicity. Conclusion: Community-level structural and social support factors influence breastfeeding outcomes, independent of previously described individual level sociodemographic factors, and the observed associations differ by race-ethnicity. These findings have implications for the development of “breastfeeding-friendly” communities and public policies.

AbstractThe WHO Classification of Tumours provides the international standards for the classification and diagnosis of tumours. It enables direct comparisons to be made between different countries. In the new fifth edition, the series has gone digital with the launch of a website as well as a series of books, known widely as the WHO Blue Books. The first volume to be produced is on the classification of Digestive System tumours, replacing the successful 2010 version. It has been rewritten and updated accordingly. This article summarises the major diagnostic innovations that have occurred over the last decade and that have now been incorporated in the classification. As an example, it incorporates the recently proposed classification of neuroendocrine tumours, based on the recognition that neuroendocrine tumours and carcinomas differ substantially in the genetic abnormalities that drive their growth, findings relevant to treatment selection and outcome prediction. Several themes have emerged during the production process. One is the importance of the progression from hyperplasia to dysplasia to carcinoma in the evolution of the malignant process. Advances in imaging techniques and endoscopy have resulted in enhanced access to precancerous lesions in the gastrointestinal and biliary tract, necessitating both changes in classification schema and clinical practice. Diagnosis of tumours is no longer the sole purview of pathologists, and some patients now receive treatment before tissue is obtained, based on clinical, radiological and liquid biopsy results. This makes the classification relevant to many disciplines involved in the care of patients with tumours of the digestive system.

Objectives Women with Turner syndrome (TS) are frequently counselled against pregnancy due to lack of data and unclear aortic dissection risk. However, with advances in fertility therapy, more women with TS are contemplating pregnancy. This study compared rates of adverse cardiovascular (CV) outcomes among: (1) pregnant and non-pregnant women with TS and (2) pregnant women with TS with/without structural heart disease. Methods Retrospective analysis of pregnant and age-matched non-pregnant controls with TS (2005–2017) across 10 CV centres was done. Data were collected at initial evaluation in pregnancy and outcomes were assessed to 6 months postpartum. Adverse CV events were defined as CV death, aortic dissection/rupture and/or aortic intervention. Non-pregnant age-matched controls were followed over the same time period. Results Sixty-eight pregnancies were included (60 women, mean age 33 years, 48% primigravid, 49% fertility therapy, 80% structurally normal heart, 25% XO karyotype). Based on American Society of Reproductive Medicine criteria, 10 pregnancies occurred in women stratified to high-risk category. There were no CV events in the pregnant women or in the non-pregnant women with TS. Obstetric events complicated 12 (18%) pregnancies with 9 (13%) attributed to hypertensive disorder of pregnancy. Fetal events included small for gestational age neonates (18%), preterm delivery (15%) and fetal death (3%). Conclusions This study helps to refine the approach to pregnancy in women with TS. Among women with TS without structural heart disease, pregnancy does not impose an increased risk of CV outcomes. Among women with TS with structural heart disease, the risk of pregnancy is not as prohibitive as previously described but does require ongoing evaluation.