Citations

This economic evaluation estimates the implementation costs and cost per additional patient receiving the vaccine associated with each of the intervention strategies for increasing rates of human papillomavirus (HPV) vaccination in primary care practices.

Abstract Background Glioblastoma IDH-wildtype (GBM) may be diagnosed histologically (hGBM) or based on molecular features when microvascular proliferation and histologic necrosis are absent (mGBM). Clinical and radiographic distinction between hGBM and mGBM remains unclear. Methods 101 hGBM cases were matched to 109 mGBM cases by age, sex, year of diagnosis, and TERT promoter mutation (TERTp) status. Clinical outcome, radiographic, and molecular features were compared across mGBM and hGBM. Results Median time from first MRI to diagnosis was longer for mGBM versus hGBM (34 vs 7 days, p < .001). mGBM more often presented with seizures (51% vs 26%, p < .001), gliomatosis pattern (12% vs 2%, p = .005), basal ganglia involvement (17% vs 0%, p < .001). Contrast enhancement appeared on MRI for 98% (96/98) of hGBM and 50% (54/107) of mGBM (p < .001). mGBM with non-enhancing MRI were rarely multifocal (2% vs 30%, p < .001). mGBM harbored fewer total copy number alterations (median 20 vs 16.5, p = .029), less often had EGFRamp (34% vs 48%, p = .051), isolated chromosome 10 loss (84% vs 96%, p = .013), and CDKN2A/B homozygous deletion (56% vs 77%, p = .005). Median overall survival was longer for mGBM (2.16 vs 1.44 years, p < .001), and for mGBM without MRI contrast enhancement versus hGBM with enhancement (3.11 vs 1.62 years, adjusted p = .003). mGBM without +7/−10 or without CDKN2A/B homozygous deletion had longer survival and time-to-progression versus hGBM with these alterations. Conclusion mGBM with MRI enhancement may represent undersampled or early/evolving hGBM. mGBM that are non-enhancing, present with seizures, prolonged time to diagnosis, absent CDKN2A/B alteration or +7/−10 may represent other IDH-wildtype entities.

ABSTRACT Enzalutamide and abiraterone are hormonal treatments that improve survival in metastatic castration‐resistant prostate cancer. Identifying genetic variants associated with the clearance of these drugs may aid in improved dosing and outcomes. We performed genetic association studies of enzalutamide and abiraterone oral clearance in the Alliance A031201 clinical trial. Genome‐wide genotyping was performed with the primary analysis limited to European‐descent participants. Pharmacogene metabolic phenotypes were estimated using PyPGx and Stargazer. Associations of metabolic activity groups for CYP3A4 , CYP3A5 , CYP2C19 and SLCO1B1 with enzalutamide clearance ( N = 706) and CYP3A4 , SLCO2B1 and UGT1A4 with abiraterone clearance ( N = 323) were tested by linear regression. Targeted SNP associations were assessed for abiraterone clearance at loci proximal to major metabolizing genes. Full genome‐wide association studies were performed for both sets of clearance values. No significant associations were identified between metabolic phenotypes and enzalutamide or abiraterone oral clearance SNPs in the SULT2A1 5′ flanking region were significantly associated with lower abiraterone clearance, (rs296373, minor allele frequency = 0.15, β = −0.457, p = 3.2E‐06). Liver protein and liver and adrenal gland gene expression QTL databases indicated significantly lower SULT2A1 expression patterns for individuals carrying associated alleles, likely explaining the lower abiraterone oral clearance. CYP2C8*3 was associated with higher enzalutamide clearance ( p = 0.012), but this was not significant after correction for multiple testing. This study is the first to identify the genetic association of SULT2A1, known to be involved in the metabolism of steroids in the liver and adrenal glands, with abiraterone clearance. Genetic variation in SULT2A1 may be useful to inform personalized dosing of abiraterone. ClinicalTrials.gov Identifier: NCT01949337

Abstract Description Therapeutic in situ chimeric antigen receptor (isCAR) T cells can be generated by targeting activated T cells within a lymph node (LN) with retroviruses encoding CARs. While isCAR T cells are successfully generated by intradermal LN priming using adenovirus encoding allogeneic MHC in all mouse lines tested, differences in emerging therapeutic peripheral isCAR T cells are found in a strain dependent manner. Potentially harmful off target retroviral transduction of B cells with CARs is observed within the targeted LN. Here we report the blockade of B cell transduction using anti-CD20 antibody B cell depletion with the introduction of anti-CD19 chimeric antigen receptors into the activated CD8+ T cells. Lymphocytes were analyzed in blood and LN following isCAR T cell generation. When B cells were depleted by systemic administration of anti-CD20 antibodies during isCAR T cell induction, >97.5% systemic depletion of B cells was achieved. Whereas very small numbers of CAR transduced B cells were found in the blood of mice not treated with anti-CD20, none were observed in animals systemically depleted of B cells. In contrast, CAR B cells persisted in the LN of local anti-CD20 treated animals. However, animals expressing dominant CD8+ isCAR T cell populations eliminated LN B cells expressing CARs by week two. Furthermore, systemic treatment of lymphoma in animals with anti-CD20 antibody complemented anti-CD19 isCAR T therapy while blocking off target B cell transduction. Funding Sources Mayo Clinic Ventures Mayo Clinic Graduate School of Biomedical Sciences Mayo Clinic Topic Categories Tumor Immunology: Checkpoints, Prevention, and Treatment (TIPT)

Abstract Description This study dissects mechanisms of spontaneous tumor rejection leading to better understanding of successful immune responses to cancer. Cancers persist despite expression of tumor-specific neoantigens promoting ongoing anti-tumor immune responses. While some occult tumor cells likely are cleared by effective anti-tumor immune responses, the targeted antigens are not easily identifiable as those cells spontaneously disappear. Congenic mouse breast carcinoma models expressing a defined protein mimicking neoantigens were used to dissect the protective spontaneous immune response. BALB/c (MHC H-2d) mice challenged with BALB/c breast tumors expressing the rat-erbB2 oncoprotein succumb to their tumors despite demonstrated tumor immunogenicity, mimicking known patient responses to cancer. Meanwhile, H-2b positive BALB.B and H-2d/H-2b F1 hybrid mice spontaneously eliminate genetically matched tumors in an MHC-II dependent manner. CD4+ T-cells and B-cells or the rat-erbB2-specific antibodies they produce are crucial mediators of this protective response. Differences in the tumor microenvironments in rat-erbB2+ tumor-bearing BALB.B and BALB/c mice at the time of fate decision in the models reflect the differences between effective and ineffective anti-tumor immunity. Identifying the nature of the optimal MHC-II antigens, how they activate protective CD4+ T-cells, and the interactions that promote protective antibodies will better inform future cancer therapies. Funding Sources Bernie Fineman Research Fund Mayo Clinic Center for Biomedical Discovery Mayo Clinic Department of Immunology Mayo Clinic Graduate School of Biomedical Sciences NIH Traning Grant 5 R25 GM 55252 Topic Categories Tumor Immunology: Cellular Responses and Tumor Microevironment (TIME)

Abstract Description Antigen receptor (CAR) T cells can be generated in vivo within the natural lymph node (LN) environment as the immune response to a virus infection unfolds. This in situ approach entails priming LNs with intradermal inoculations of replication defective adenoviruses encoding MHC class I and class II allo/xeno-antigens. Universal transplant antigens were devised for LN priming by introducing tryptophan into amino acid position 162 of the MHC HLA-A2:01 class I heavy chain and by using the mouse MHC class II beta chain to form chimeric class II antigens with endogenous class II alleles. The virus encoded mismatched MHC antigen presenting molecules are expressed functionally in the LN following intradermal inoculation provoking polyclonal T cells responses. Three days later CAR T cells are generated by directly injecting retroviruses encoding CARs of interest into the responding LN. Mouse CD19-specifc CAR T cells created in this manner in B6-DQ8 and DQ8/A2 mice effectively target endogenous B cells and are therapeutic in male and female Emu-myc lymphomas demonstrating the potential for the generating functional CAR T cells directly in vivo. While in situ CAR T cells are readily produced in B6, B6-IA0/DQ8, B6-IA0/DQ8/A2, and B6-IA0/DQ6 LNs, functional differences among the strains emerged in the periphery suggesting that properties of the autoimmune-associated HLA DQ8 class II allele is particularly reactive during the production of CAR T cells in vivo. Funding Sources MustangBio, Inc Mayo Clinic Center of Biomedical Research Mayo Clinic Department of Immunology Mayo Clinic Graduate School of Biomedical Science Fraternal Order of Eagles Mayo Clinic Ventures NIH R21 AI 097337 NIH R01 CA 178804 NIH T32 AI 07425 Topic Categories Tumor Immunology: Checkpoints, Prevention, and Treatment (TIPT)

Abstract Introduction Penile augmentation or penis enlargement surgery refers to any technique aimed at enhancing penile length or girth. These male enhancement surgical techniques can increase total penile length, either flaccid or erect, while others add to the penile shaft’s girth and/or glans size. Proposed strategies include physical methods such as various penile exercises, mechanical traction devices, and medical therapy, while surgical interventions include cosmetic and phallic reconstructive techniques and use of fillers, sleeves, grafts, and flaps to augment penile size. Objectives The International Consultation on Sexual Medicine (ICSM) consensus statements provide evidence-based recommendations and aim to guide a clinical framework in penile aesthetic and augmentation. Methods A comprehensive literature search was conducted to identify published literature relevant to penile augmentation or enhancement. Preliminary consensus was presented to the delegates attending the 5th ICSM meeting, and feedback was incorporated into the final document. Results Twenty new recommendations are provided with corresponding levels of evidence and grades of recommendation. Conclusions Due to the controversies and lack of longer-term data regarding penile augmentation and cosmetic procedures, comprehensive assessments and careful patient counseling weighing the pros and cons, as well as potential complications, are mandatory before embarking on any treatment. Surgeons should be experienced in anatomy and various surgical techniques, and it is important to individualize surgical options based on patient condition(s) and needs, surgeon expertise, and local resources.

Abstract Introduction There is no ideal treatment for Peyronie’s Disease (PD) since every patient has different needs with varying perceived risks versus benefits of individual treatment options, coupled with the degree of impact relating to PD on sexual function and beyond. Objectives The 5th International Consultation on Sexual Medicine (ICSM) guideline on PD provides an update to the previous ICSM with an aim to provide a clinical framework and best-evidenced consensus recommendations to assist clinicians in managing PD. Methodology Available literature was reviewed, and a modified Delphi consensus was undertaken by leading sexual medicine experts to achieve a set of Quality of Evidence and strength of recommendations. This guideline was developed as an authoritative best-evidenced consensus incorporating state-of-the-art knowledge and contemporary literature. Results A total of thirty-one recommendations were made on PD guidelines. New updates to the 4th ICSM on PD have been made in definition, pathophysiology, and treatment strategies. The presence of penile pain with erection could occur in the chronic phase due to torque or stretch on the penile scar and surrounding tissue. Oral therapy works best during the acute phase and should be provided concurrently with other treatment modalities. Penile traction therapy can reduce penile deformity as monotherapy or may be offered as part of a multimodal therapy approach. There is no convincing evidence supporting cellular-based therapy. The type of plication procedure used depends on the surgeon and patient preference, although excision of the tunica followed by plication may have a higher complication rate. There is currently no ideal graft, and graft contracture can occur postoperatively. Adjunctive procedures such as penile modeling, tunical plication, plaque incision/excision and grafting can be performed when penile deformity and/or penile curvature persist following penile prosthesis implantation. Conclusions The management of PD should be individualized based on the patient’s needs and preferences while balancing the benefits and risks of each treatment option.

Abstract Glioblastoma, IDH-wildtype (GBM), and primary central nervous system lymphoma (PCNSL) are two aggressive brain tumors with distinct treatment strategies but overlapping imaging features on MRI. Accurate preoperative differentiation remains a clinical challenge, due to their overlapping imaging features, even when advanced MRI techniques are employed. This study explored deep learning approaches leveraging multi-sequence MRI to distinguish GBM from PCNSL. Models were developed utilizing 146 PCNSL cases, which were matched to146 GBM by age, sex and year of diagnosis. A 3D-DenseNet121 convolutional neural network was trained using two analytical strategies: (i) loss-based model selection and (ii) ensemble prediction using five-fold cross-validation. Model performance was evaluated on an independent validation set of 256 GBM and 37 PCNSL from the same institution as well as 36 PCNSL cases from an external institution. All MRIs were preprocessed using the FeTS pipeline. Using the independent validation cohort, area under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CI) were computed overall and stratified by demographic characteristics. Using both T1 post-contrast (T1Gd) and T2-weighted images, the loss-based model achieved AUC=0.83 (95% CI: 0.77-0.88) and the ensemble model yielded an AUC=0.82 (95% CI: 0.76-0.89). Model performance was similar across males and females; however, model performance was better for subjects older than 50 years of age versus younger than 50. When using only T1Gd images, the loss-based model dropped to AUC=0.55 (95% CI: 0.48-0.63), whereas the ensemble model had AUC=0.79 (95% CI: 0.72-0.85). Models trained with only T2 images achieved AUCs of 0.67 (95% CI: 0.60-0.73) (loss-based) and 0.75 (95% CI: 0.69-0.82) (ensemble). These results highlight the added value of the multi-sequence input. Our results confirm the feasibility of using automated deep learning models to differentiate GBM from PCNSL. Notably, the model generalized well to external MRI data, emphasizing its potential utility as a diagnostic aid in real-world clinical workflows.

Abstract Glioblastoma (GBM) diagnosis integrates morphology and tumor molecular alterations. Patients with classic morphology are designated as histologic GBM (hGBM). Patients without classic morphology harboring TERT promoter mutation (TERTp), or epidermal growth factor receptor amplification (EGFRamp), or combined gain of chromosome 7 and loss of 10 (+7/-10) designate molecular GBM (mGBM). We compared radiographic features, genomic alterations, and clinical outcome between hGBM and mGBM. 109 mGBM Mayo Clinic cases diagnosed between 1993-2021 were matched to 101 cGBM by age, sex, year of diagnosis, and TERT promoter (TERTp) status. Clinical and radiographic data abstraction was blinded. Progression-free and overall survival were compared across groups in the subset of patients who received standard of care. Contrast enhancement was present on index MRI (MRI at diagnosis) for 98% (96/98) hGBM and 50% (54/107) mGBM (p<0.0001) patients. mGBM tumors harbored fewer total copy number alterations (median of 16.5 vs 20, p=0.029) and were less likely to have CDKN2A/B homozygous deletion (56% vs 77%, p=0.005). Among the 87 mGBM and 82 hGBM receiving standard of care, median overall survival was longer for mGBM versus hGBM (2.24 vs 1.62 years, p=0.016). mGBM patients with +7/-10 (HR=2.60, p=0.035) or CDKN2A/B (HR=3.61, p=0.002) had poorer overall survival compared to mGBM patients without the corresponding alteration. On index MRI mGBM patients without contrast enhancement had better overall survival compared to hGBM (HR=0.50; p=0.003) whereas there was no survival difference between mGBM with enhancement and hGBM. mGBM with enhancement on index MRI likely represent undersampled, or early / evolving hGBM. mGBM patients with non-enhancing MRI, younger than 60, with long symptom profile including seizures, and some combination of non-anaplastic morphology, TERTp only, no homozygous deletion of CDKN2A/B, and low copy number complexity may represent other IDHwt glioma entities. Caution is advised in counseling, management, discussing prognosis, and inclusion in clinical trials.