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Objectives Peritoneal metastasis (PM) from appendiceal cancer or colorectal cancer (CRC) has significant morbidity and limited survival. Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) is a minimally invasive approach to treat PM. We aim to conduct a dose-escalation trial of mitomycin C (MMC)-PIPAC combined with systemic chemotherapy (FOLFIRI) in patients with PM from appendiceal cancer or CRC. Methods This is a multicenter Phase I study of MMC-PIPAC (NCT04329494). Inclusion criteria include treatment with at least 4 months of first- or second-line systemic chemotherapy with ineligibility for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Exclusion criteria are: progression on chemotherapy; extraperitoneal metastases; systemic chemotherapy intolerance; bowel obstruction; or poor performance status (ECOG>2). Escalating MMC-PIPAC doses (7–25 mg/m2) will be administered in combination with standard dose systemic FOLFIRI. Safety evaluation will be performed on 15 patients (dose escalation) and six expansion patients: 21 evaluable patients total. Results The primary endpoints are recommended MMC dose and safety of MMC-PIPAC with FOLFIRI. Secondary endpoints are assessment of response (by peritoneal regression grade score; Response Evaluation Criteria in Solid Tumors [RECIST 1.1], and peritoneal carcinomatosis index), progression free survival, overall survival, technical failure rate, surgical complications, conversion to curative-intent CRS-HIPEC, patient-reported outcomes, and functional status. Longitudinal blood and tissue specimens will be collected for translational correlatives including pharmacokinetics, circulating biomarkers, immune profiling, and single-cell transcriptomics. Conclusions This Phase I trial will establish the recommended dose of MMC-PIPAC in combination with FOLFIRI. Additionally, we expect to detect an early efficacy signal for further development of this therapeutic combination.

Patient demographic and tumor pathology

Image cytometry infiltration results by layer

Image cytometry methods overview

Live microscopy analysis of CD8+ T cell distribution in slice cultures

PDA tumor slice culture platform utilized for multimodal analysis before and after ex vivo immune modulation

TCR overlap analysis

Purpose:Pancreatic ductal adenocarcinoma (PDA) is rarely cured, and single-agent immune checkpoint inhibition has not demonstrated clinical benefit despite the presence of large numbers of CD8+ T cells. We hypothesized that tumor-infiltrating CD8+ T cells harbor latent antitumor activity that can be reactivated using combination immunotherapy.Experimental Design:Preserved human PDA specimens were analyzed using multiplex IHC (mIHC) and T-cell receptor (TCR) sequencing. Fresh tumor was treated in organotypic slice culture to test the effects of combination PD-1 and CXCR4 blockade. Slices were analyzed using IHC, flow cytometry, and live fluorescent microscopy to assess tumor kill, in addition to T-cell expansion and mobilization.Results:mIHC demonstrated fewer CD8+ T cells in juxtatumoral stroma containing carcinoma cells than in stroma devoid of them. Using TCR sequencing, we found clonal expansion in each tumor; high-frequency clones had multiple DNA rearrangements coding for the same amino acid binding sequence, which suggests response to common tumor antigens. Treatment of fresh human PDA slices with combination PD-1 and CXCR4 blockade led to increased tumor cell death concomitant with lymphocyte expansion. Live microscopy after combination therapy demonstrated CD8+ T-cell migration into the juxtatumoral compartment and rapid increase in tumor cell apoptosis.Conclusions:Endogenous tumor-reactive T cells are present within the human PDA tumor microenvironment and can be reactivated by combined blockade of PD-1 and CXCR4. This provides a new basis for the rational selection of combination immunotherapy for PDA.See related commentary by Medina and Miller, p. 3747

Combination immunotherapy tumor slice culture experiment replicates

Background Robotic hepatectomy (RH) is increasingly utilized for minor and major liver resections. The IWATE criteria were developed to classify minimally invasive liver resections by difficulty. The objective of this study was to apply the IWATE criteria in RH and to describe perioperative and oncologic outcomes of RH over the last decade at our institution. Methods Perioperative and oncologic outcomes of patients who underwent RH between 2011 and 2019 were retrospectively collected. The difficulty level of each operation was assessed using the IWATE criteria, and outcomes were compared at each level. Univariate linear regression was performed to characterize the relationship between IWATE criteria and perioperative outcomes (OR time, EBL, and LOS), and a multivariable model was also developed to address potential confounding by patient characteristics (age, sex, BMI, prior abdominal surgery, ASA class, and simultaneous non-hepatectomy operation). Results Two hundred and twenty-five RH were performed. Median IWATE criteria for RH were 6 (IQR 5–9), with low, intermediate, advanced, and expert resections accounting for 23% (n = 51), 34% (n = 77), 32% (n = 72), and 11% (n = 25) of resections, respectively. The majority of resections were parenchymal-sparing approaches, including anatomic segmentectomies and non-anatomic partial resections. 30-day complication rate was 14%, conversion to open surgery occurred in 9 patients (4%), and there were no deaths within 30 days postoperatively. In the univariate linear regression analysis, IWATE criteria were positively associated with OR time, EBL, and LOS. In the multivariable model, IWATE criteria were independently associated with greater OR time, EBL, and LOS. Two-year overall survival for hepatocellular carcinoma and intrahepatic cholangiocarcinoma was 94% and 50%, respectively. Conclusion In conclusion, the IWATE criteria are associated with surgical outcomes after RH. This series highlights the utility of RH for difficult hepatic resections, particularly parenchymal-sparing resections in the posterosuperior sector, extending the indication of minimally invasive hepatectomy in experienced hands and potentially offering select patients an alternative to open hepatectomy or other less definitive liver-directed treatment options.

Ganglioneuromas are rare, benign, well-differentiated neural crest tumors arising in the paravertebral sympathetic chain, and are classically non-secretory and clinically asymptomatic. As the diagnosis of ganglioneuroma is based on histopathology, the clinical presentation prior to surgical excision often mirrors that of pheochromocytoma or adrenal cortical adenoma. We describe a case of an incidentally found right sided calcified adrenal mass with evidence of marked dopamine excess, suspicious for pheochromocytoma in a 70-year-old female. The patient endorsed a 6-month history of intermittent right flank pain and a 2-year history of weight loss and fatigue. She reported mild symptoms of hypomania but denied other symptoms of dopamine excess including agitation, anxiety, nausea, and vomiting. Exam revealed isolated mild hypertension. The imaging features of this mass were concerning for malignancy including the presence of macrocalcification and irregular borders. After preoperative alpha blockade, the patient underwent open right adrenalectomy and the final pathology was consistent with ganglioneuroma rather than pheochromocytoma. Following resection, the dopamine level normalized, confirming the resected right adrenal ganglioneuroma as the source of dopamine excess. This case represents a rare presentation of dopamine-secreting adrenal ganglioneuroma. This illustrates that although rare, ganglioneuroma should be included on the differential diagnosis for functional adrenal tumors.

Mutations in the epidermal growth factor receptor (EGFR) are common amongst those with non-small cell lung cancer and represent a major factor in treatment decisions, most notably in the advanced stages. Small molecule tyrosine kinase inhibitors (TKIs) that target the EGFR, such as erlotinib, gefitinib, icotinib, afatinib, dacomitinib and osimertinib, have all shown to be effective in this setting. Osimertinib, a third-generation EGFR TKI, is a favorable option, but almost all patients develop resistance at some time point. There are no effective treatment options for patients who progress on osimertinib, but ongoing trials will hopefully address this unmet need. The aim of this review is to provide a comprehensive review of the data with EGFR TKIs, management of the toxicities and the ongoing trials with this class of agents.

Simple Summary Liver surgery can be performed simultaneously with operations to remove other organs in certain circumstances, such as removal of colorectal cancer in the colon or rectum at the same time as metastatic lesions to the liver. These types of operations have been performed as open or laparoscopic procedures; however, more recently, they can be performed with a robotic approach. In this article, we review the literature and describe robotic liver resections performed with robotic resection of other organs, including colon, rectum, and pancreas. These published reports demonstrate that, in select cases and experienced hands, robotic multivisceral resection can be safely performed with good outcomes. Abstract Minimally invasive surgery techniques are expanding in utilization in liver resections and now include robotic approaches. Robotic liver resection has been demonstrated to have several benefits, including surgeon ergonomics, wrist articulation, and 3D visualization. Similarly, for multivisceral liver resections, the use of minimally invasive techniques has evolved and expanded from laparoscopy to robotics. The aim of this article is to review the literature and describe multivisceral resections, including hepatectomy, using a robotic technique. We describe over 50 published cases of simultaneous robotic liver resection with colon or rectal resection. In addition, we describe several pancreatectomies performed with liver resection and one extra-abdominal pulmonary resection with liver resection. In total, these select reported cases at experienced centers demonstrate the safety of robotic multivisceral resection in liver surgery with acceptable morbidity and rare conversion to open surgery. As robotic technology advances and experience with robotic techniques grows, robotic multivisceral resection in liver surgery should continue to be investigated in future studies.

Gallbladder cancer is a lethal disease when diagnosed at later stages, and gallbladder polyps may have malignant potential or harbor cancer, especially as the polyp increases in size. Therefore, cholecystectomy has been recommended by guidelines for gallbladder polyps ≥ 10 mm, or smaller polyps with risk factors. In this article, we review minimally invasive approaches to the management of gallbladder polyps. The predominant method of cholecystectomy has been laparoscopic, which has advantages in faster recovery compared to open cholecystectomy. More recently, many surgeons have converted their minimally invasive techniques to robotic approaches. In addition, combined laparoscopic-endoscopic or purely endoscopic approaches have been reported. The ultimate goal of gallbladder polyp management using minimally invasive approaches is to minimize morbidity, given the low incidence of cancer within polyps, while preventing polyps with malignant potential from converting to cancer, or curing cancerous polyps.

ObjectiveProgrammed cell death protein 1 (PD-1) checkpoint inhibition and adoptive cellular therapy have had limited success in patients with microsatellite stable colorectal cancer liver metastases (CRLM). We sought to evaluate the effect of interleukin 10 (IL-10) blockade on endogenous T cell and chimeric antigen receptor T (CAR-T) cell antitumour function in CRLM slice cultures.DesignWe created organotypic slice cultures from human CRLM (n=38 patients’ tumours) and tested the antitumour effects of a neutralising antibody against IL-10 (αIL-10) both alone as treatment and in combination with exogenously administered carcinoembryonic antigen (CEA)-specific CAR-T cells. We evaluated slice cultures with single and multiplex immunohistochemistry, in situ hybridisation, single-cell RNA sequencing, reverse-phase protein arrays and time-lapse fluorescent microscopy.ResultsαIL-10 generated a 1.8-fold increase in T cell-mediated carcinoma cell death in human CRLM slice cultures. αIL-10 significantly increased proportions of CD8+T cells without exhaustion transcription changes, and increased human leukocyte antigen - DR isotype (HLA-DR) expression of macrophages. The antitumour effects of αIL-10 were reversed by major histocompatibility complex class I or II (MHC-I or MHC-II) blockade, confirming the essential role of antigen presenting cells. Interrupting IL-10 signalling also rescued murine CAR-T cell proliferation and cytotoxicity from myeloid cell-mediated immunosuppression. In human CRLM slices, αIL-10 increased CEA-specific CAR-T cell activation and CAR-T cell-mediated cytotoxicity, with nearly 70% carcinoma cell apoptosis across multiple human tumours. Pretreatment with an IL-10 receptor blocking antibody also potentiated CAR-T function.ConclusionNeutralising the effects of IL-10 in human CRLM has therapeutic potential as a stand-alone treatment and to augment the function of adoptively transferred CAR-T cells.

Pancreatic ductal adenocarcinoma (PDA) is a lethal disease with limited response to cytotoxic chemoradiotherapy, as well as newer immunotherapies. The PDA tumor microenvironment contains infiltrating immune cells including cytotoxic T cells; however, there is an overall immunosuppressive milieu. Hypoxia is a known element of the solid tumor microenvironment and may promote tumor survival. Through various mechanisms including, but not limited to, those mediated by HIF-1α, hypoxia also leads to increased tumor proliferation and metabolic changes. Furthermore, epithelial to mesenchymal transition is promoted through several pathways, including NOTCH and c-MET, regulated by hypoxia. Hypoxia-promoted changes also contribute to the immunosuppressive phenotype seen in many different cell types within the microenvironment and thereby may inhibit an effective immune system response to PDA. Pancreatic stellate cells (PSCs) and myofibroblasts appear to contribute to the recruitment of myeloid derived suppressor cells (MDSCs) and B cells in PDA via cytokines increased due to hypoxia. PSCs also increase collagen secretion in response to HIF-1α, which promotes a fibrotic stroma that alters T cell homing and migration. In hypoxic environments, B cells contribute to cytotoxic T cell exhaustion and produce chemokines to attract more immunosuppressive regulatory T cells. MDSCs inhibit T cell metabolism by hoarding key amino acids, modulate T cell homing by cleaving L-selectin, and prevent T cell activation by increasing PD-L1 expression. Immunosuppressive M2 phenotype macrophages promote T cell anergy via increased nitric oxide (NO) and decreased arginine in hypoxia. Increased numbers of regulatory T cells are seen in hypoxia which prevent effector T cell activation through cytokine production and increased CTLA-4. Effective immunotherapy for pancreatic adenocarcinoma and other solid tumors will need to help counteract the immunosuppressive nature of hypoxia-induced changes in the tumor microenvironment. Promising studies will look at combination therapies involving checkpoint inhibitors, chemokine inhibitors, and possible targeting of hypoxia. While no model is perfect, assuring that models incorporate the effects of hypoxia on cancer cells, stromal cells, and effector immune cells will be crucial in developing successful therapies.

Fibrolamellar carcinoma is a rare liver cancer, which primarily afflicts adolescents and young adults worldwide and is frequently lethal. Given the rarity of this disease, patient recruitment for clinical trials remains a challenge. In November 2017, the Second Fibrolamellar Cancer Foundation Scientific Summit (Stamford, CT, USA) provided an opportunity for investigators to discuss recent advances in the characterization of the disease and its surrounding liver and immune context. The Fibrolamellar Cancer Foundation has thus set out a road map to identify and test therapeutic targets in the most efficient possible manner.

Background: It is established that a family history of coronary heart disease (FHCHD) is associated with coronary atherosclerosis in healthy first-degree relatives, but the extent to which FHCHD is associated with silent cerebrovascular disease (cSVD) is unknown. We hypothesized a higher prevalence of cSVD in healthy persons with FHCHD, independent of traditional risk factors, compared to those without FHCHD. Methods: ARIC is a community-based cohort study with self-reported family history data and brain magnetic resonance imaging (visit 5; 2011-13). The association between binary markers of cSVD (lacunar infarcts and/or cerebral microbleeds), or log-transformed white matter hyperintensity volume (WMH), and FHCHD (parent and/or sibling), or number of relatives was examined using separate adjusted multivariable logistic or linear regression models respectively. Sensitivity analysis (N=183) excluded prevalent CHD. Race interaction terms were included. Results: Of 1828 participants (76±5yo, 60% female, 28% black), 787 had FHCHD (699 parental, 209 sibling FHCHD). There were increased adjusted odds of lacunar infarct among those with parental FHCHD (Table). An increased odds of cerebral microbleeds were seen among those with sibling history but not parental. Effect estimates were similar when excluding those with prevalent CHD (Table). Greater number of siblings affected was associated with higher odds of lacunar infarct (OR 1.35, CI 1.04-1.74), lobar (OR 1.53, CI 1.12-2.09) and subcortical microbleeds (OR 1.30, CI 1.01-1.66). Odds of a lacunar infarct being present were higher among blacks (p-interaction 0.04) with paternal FHCHD (OR 2.20, CI 1.35-3.58) compared to whites (OR 1.17, CI 0.87-1.56). Neither FHCHD nor number of affected relatives was associated with WMH. Conclusions: Our results suggest that some cSVD manifestations are associated with FHCHD, potentially representing shared mechanisms in different vascular beds, and perhaps a genetic propensity for vascular disease.

Glypican-3 (GPC3) is a tumor associated antigen expressed by hepatocellular carcinoma (HCC) cells. This preclinical study evaluated the efficacy of a theranostic platform using a GPC3-targeting antibody αGPC3 conjugated to zirconium-89 (89Zr) and yttrium-90 (90Y) to identify, treat, and assess treatment response in a murine model of HCC. A murine orthotopic xenograft model of HCC was generated. Animals were injected with 89Zr-labeled αGPC3 and imaged with a small-animal positron emission/computerized tomography (PET/CT) imaging system (immuno-PET) before and 30 days after radioimmunotherapy (RIT) with 90Y-labeled αGPC3. Serum alpha fetoprotein (AFP), a marker of tumor burden, was measured. Gross tumor volume (GTV) and SUVmax by immuno-PET was measured using fixed intensity threshold and manual segmentation methods. Immuno-PET GTV measurements reliably quantified tumor burden prior to RIT, strongly correlating with serum AFP (R2 = 0.90). Serum AFP was significantly lower 30 days after RIT in 90Y-αGPC3 treated animals compared to those untreated (p = 0.01) or treated with non-radiolabeled αGPC3 (p = 0.02). Immuno-PET GTV measurements strongly correlated with tumor burden after RIT (R2 = 0.87), and GTV of animals treated with 90Y-αGPC3 was lower than in animals who did not receive treatment or were treated with non-radiolabeled αGPC3, although this only trended toward statistical significance. A theranostic platform utilizing GPC3 targeted 89Zr and 90Y effectively imaged, treated, and assessed response after radioimmunotherapy in a GPC3-expressing HCC xenograft model.

Introduction: The infiltration or density of immunosuppressive or M2-macrophages has been correlated with worse prognosis in gastric cancer (GC). We hypothesized that a highly polarized transcriptional phenotype of M2 macrophages would be prognostic if detected in primary and peritoneal fluid samples of GC. Methods: We derived a novel transcriptomic gene signature (MRC1, MS4A4A, CD36, CCL13, CCL18, CCL23, SLC38A6, FGL2, FN1, MAF) from published highly differentially expressed M2 genes that were identified from peripheral blood. We also evaluated a M1 signature (CCR7, IL2RA, CXCL11, CCL19, CXCL10, PLA1A, PTX3) and T cell cytolytic signature (GZMA, GZMB, GZMH, GZMM, PRF1). In primary GC, we used the UCSC Xena tool to analyze the TCGA Stomach Cancer cohort and compared transcriptional signature expression to histologic subtype and pathologic stage. We used log-rank test to compare Kaplan-Meier curves of overall survival (OS) and disease-free interval (DFI) for high versus low signature expression. In our institutional cohort consisting of GC patients with a range of T and N stages as well as with and without metastatic disease (n=28), we evaluated peritoneal fluid samples using single cell RNA sequencing for high and low signature expression in CD68+CD163+ monocytes and used log-rank test to compare OS. Results: A total of 341 TCGA entries of primary GC were included. High expression of the M2 signature in GC was associated with diffuse- and mucinous-type adenocarcinoma, compared to tubular- and papillary-type adenocarcinoma (p Conclusions: Our study validates a unique M2-associated transcriptomic gene signature as a biomarker of poor outcomes in both primary gastric tumors and peritoneal fluid of GC patients. Because both endoscopic biopsy and laparoscopy with peritoneal fluid collection are part of the standard workup for locoregional GC, an ubiquitous immune signature detected in primary tumor and peritoneal fluid of patients across TNM stages may serve as a clinically valuable indicator of an immunosuppressive patient state associated with poor survival. Citation Format: Kevin M. Sullivan, Haiqing Li, Kelly Mahuron, Yate-Ching Yuan, Joseph Chao, Benjamin Paz, Haiyong Han, Yuman Fong, Yanghee Woo. Novel M2 macrophage gene signature as a biomarker of poor outcomes independent of TNM stage in peritoneal liquid biopsy of gastric cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6144.

BACKGROUND: Opioid use after bariatric surgery is not clearly understood. Few guidelines exist to inform opioid prescribing practices after bariatric surgery. OBJECTIVE: To understand opioid use following bariatric surgery. SETTING: University Hospital. METHODS: Bariatric surgery patients at a single center were prospectively surveyed at the time of their post-operative visit (January-May 2018). Patients were asked about their opioid use following surgery, whether they received education about opioid use, and what they did with leftover medications. Demographic and operative details were obtained from the medical record. RESULTS: Among 33 patients, the majority (n=29, 88%) were female with a median age of 40 (20–68) and body mass index of 44.8 (33–78.5). Most patients had leftover narcotics (n=25, 73%). The median number of pills used was 15 (0–48). Only 12 patients (36%) thought that they had been prescribed “too much” pain medication. Most patients reported receiving education about expectations for post-operative pain (n=22, 69%); few recalled education about reducing or stopping opioids (n=13, 40%). More than half of patients (n=17, 53%) kept their leftover opioids rather than disposing of them or bringing them to an approved turn in location. CONCLUSIONS: Despite most patients having leftover opioids following surgery, few patients recognized possible over prescription. Education regarding opioid use following surgery is inconsistent, potentially contributing to the amount of retained opioids currently available. Future guidelines should focus on determining the appropriate amount of opioids to be prescribed following surgery and standardizing and improving education given to patients.

Summary Metastatic colorectal cancer (CRC) is a major cause of cancer-related death, and incidence is rising in younger populations (younger than 50 years). Current chemotherapies can achieve response rates above 50%, but immunotherapies have limited value for patients with microsatellite-stable (MSS) cancers. The present study investigates the impact of chemotherapy on the tumor immune microenvironment. We treat human liver metastases slices with 5-fluorouracil (5-FU) plus either irinotecan or oxaliplatin, then perform single-cell transcriptome analyses. Results from eight cases reveal two cellular subtypes with divergent responses to chemotherapy. Susceptible tumors are characterized by a stemness signature, an activated interferon pathway, and suppression of PD-1 ligands in response to 5-FU+irinotecan. Conversely, immune checkpoint TIM-3 ligands are maintained or upregulated by chemotherapy in CRC with an enterocyte-like signature, and combining chemotherapy with TIM-3 blockade leads to synergistic tumor killing. Our analyses highlight chemomodulation of the immune microenvironment and provide a framework for combined chemo-immunotherapies., Graphical Abstract, Highlights CRLM slice culture can assess immune response to chemotherapy Single-cell analysis identifies cancer subtypes with differing response to chemotherapy 5-FU+irinotecan modulates interferon and PD-L1 pathways in stem-like CRLM Combining chemotherapy with TIM-3 blockade is synergistic in enterocyte-like CRLM, The response of colorectal liver metastases (CRLM) to chemotherapy is analyzed in 3D organotypic tumor slices by single-cell RNA-seq. Jabbari et al. find two subtypes (stem-like and enterocyte-like) of CRLM that express different immune checkpoint ligands and respond differently to chemotherapy. The study highlights the chemomodulation of the tumor immune microenvironment that can be targeted therapeutically.

Background The tumor microenvironment (TME) is critical to every aspect of cancer biology. Organotypic tumor slice cultures (TSCs) preserve the original TME and have demonstrated utility in predicting drug sensitivity, but the association between clinicopathologic parameters and in vitro TSC behavior has not been well-defined. Methods One hundred and eight fresh tumor specimens from liver resections at a tertiary academic center were procured and precisely cut with a Vibratome to create 250 μm × 6 mm slices. These fixed-dimension TSCs were grown on polytetrafluoroethylene inserts, and their metabolic activities were determined by a colorimetric assay. Correlation between baseline activities and clinicopathologic parameters was assessed. Tissue CEA mRNA expression was determined by RNAseq. Results By standardizing the dimensions of a slice, we found that adjacent tumor slices have equivalent metabolic activities, while those derived from different tumors exhibit >30-fold range in baseline MTS absorbances, which correlated significantly with the percentage of tumor necrosis based on histologic assessment. Extending this to individual cancers, we were able to detect intra-tumoral heterogeneity over a span of a few millimeters, which reflects differences in tumor cell density and Ki-67 positivity. For colorectal cancers, tissue CEA expression based on RNAseq of tumor slices was found to correlate with clinical response to chemotherapies. Conclusions We report a standardized method to assess and compare human cancer growth ex vivo across a wide spectrum of tumor samples. TSC reflects the state of tumor behavior and heterogeneity, thus providing a simple approach to study of human cancers with an intact TME.

The era of immunotherapy has changed the face of how we approach treatment for many oncologic and hematologic malignancies. Lung cancer has been in the forefront of checkpoint inhibition for the past 2 years and has paved the path for other subspecialties. While PD-1 inhibitors nivolumab and pembrolizumab have been approved for non-small cell lung cancer (NSCLC), this review focuses on atezolizumab, its landmark studies, and ongoing trials. Atezolizumab is the first programmed death ligand 1 (PD-L1) inhibitor to receive US Food and Drug Administration (FDA) approval for metastatic NSCLC patients who have progressed on frontline chemotherapy. This approval was based on two open-label Phase II multicenter trials, POPLAR (NCT01903993) and BIRCH (NCT02031458). Both studies revealed a benefit in overall survival (OS), progression-free survival, and response rate in the atezolizumab arm when compared to single-agent docetaxol. There were also fewest Grade 3–5 treatment-related adverse events (TRAEs) in the atezolizumab cohort. The open-label randomized Phase III OAK trial (NCT02008227) further established the role of atezolizumab in previously treated NSCLC. This study compared atezolizumab with docetaxel in patients with advanced NSCLC (squamous or nonsquamous histologies) who had progressed on one to two prior chemotherapy regimens. OS in the PD-L1-enriched population was superior in the atezolizumab arm (n=241) at 15.7 months compared with docetaxel (n=222) at 10.3 months (hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.58–0.93; p=0.0102). Patients lacking PD-L1 also had survival benefit with atezolizumab with a median OS (mOS) of 12.6 months versus 8.9 months with chemotherapy (HR 0.75, 95% CI 0.59–0.96). Benefit was noted in both squamous and nonsquamous NSCLC subsets and regardless of PD-L1 expressivity. As seen in the POPLAR and BIRCH studies, the toxicity profile was significantly better with immunotherapy. The future is unfolding rapidly as new checkpoint inhibitors are gaining FDA approval. It is still not known if these agents will be used in combination with chemotherapy, with other immune-modulating agents, radiation therapy, or all of the above. The results of these studies investigating their use in combination with chemotherapy agents, with other immunotherapy agents such as CTLA-4 inhibitors, and with radiation therapy, are eagerly awaited.

Fibrolamellar carcinoma (FLC) is a rare liver cancer. FLCs uniquely produce DNAJ-PKAc, a chimeric enzyme consisting of a chaperonin-binding domain fused to the Cα subunit of protein kinase A. Biochemical analyses of clinical samples reveal that a unique property of this fusion enzyme is the ability to recruit heat shock protein 70 (Hsp70). This cellular chaperonin is frequently up-regulated in cancers. Gene-editing of mouse hepatocytes generated disease-relevant AML12DNAJ-PKAc cell lines. Further analyses indicate that the proto-oncogene A-kinase anchoring protein-Lbc is up-regulated in FLC and functions to cluster DNAJ-PKAc/Hsp70 sub-complexes with a RAF-MEK-ERK kinase module. Drug screening reveals Hsp70 and MEK inhibitor combinations that selectively block proliferation of AML12DNAJ-PKAc cells. Phosphoproteomic profiling demonstrates that DNAJ-PKAc biases the signaling landscape toward ERK activation and engages downstream kinase cascades. Thus, the oncogenic action of DNAJ-PKAc involves an acquired scaffolding function that permits recruitment of Hsp70 and mobilization of local ERK signaling., eLife digest Fibrolamellar carcinoma (or FLC for short) is a rare type of liver cancer that affects teenagers and young adults. FLC tumors are often resistant to standard radiotherapy or chemotherapy treatments. The only way to treat FLC is to remove tumors by surgery. However, often the tumors come back after initial treatment and spread to other locations. Therefore, there is a genuine need to improve the treatment options available to FLC patients. The tumor cells of FLC patients contain a genetic defect that fuses together two genes, which produce proteins called DNAJ and PKAc. Normally, DNAJ helps other proteins in the cell to fold into their correct shapes, while PKAc is an enzyme that can control how cells communicate. However, it is not clear what the abnormal DNAJ-PKAc fusion protein does, or how it causes FLC. Turnham, Smith et al. have now used gene editing to make mouse liver cells that mimic the human FLC mutation. Biochemical experiments on these cells showed that the DNAJ-PKAc protein brings together unique combinations of enzymes that drive uncontrolled cell growth. Analyzing cells taken from tumors in FLC patients confirmed that these enzymes are also activated in the human disease. Turnham, Smith et al. also found that combinations of drugs that simultaneously target the DNAJ-PKAc protein and the recruited enzymes slowed down the growth of FLC cells. More experiments are now needed to test these drug combinations on human FLC cells or in mice.

Purpose: Pancreatic ductal adenocarcinoma (PDA) is rarely cured, and single-agent immune checkpoint inhibition has not demonstrated clinical benefit despite the presence of large numbers of CD8+ T cells. We hypothesized that tumor-infiltrating CD8+ T cells harbor latent antitumor activity that can be reactivated using combination immunotherapy. Experimental Design: Preserved human PDA specimens were analyzed using multiplex IHC (mIHC) and T-cell receptor (TCR) sequencing. Fresh tumor was treated in organotypic slice culture to test the effects of combination PD-1 and CXCR4 blockade. Slices were analyzed using IHC, flow cytometry, and live fluorescent microscopy to assess tumor kill, in addition to T-cell expansion and mobilization. Results: mIHC demonstrated fewer CD8+ T cells in juxtatumoral stroma containing carcinoma cells than in stroma devoid of them. Using TCR sequencing, we found clonal expansion in each tumor; high-frequency clones had multiple DNA rearrangements coding for the same amino acid binding sequence, which suggests response to common tumor antigens. Treatment of fresh human PDA slices with combination PD-1 and CXCR4 blockade led to increased tumor cell death concomitant with lymphocyte expansion. Live microscopy after combination therapy demonstrated CD8+ T-cell migration into the juxtatumoral compartment and rapid increase in tumor cell apoptosis. Conclusions: Endogenous tumor-reactive T cells are present within the human PDA tumor microenvironment and can be reactivated by combined blockade of PD-1 and CXCR4. This provides a new basis for the rational selection of combination immunotherapy for PDA. See related commentary by Medina and Miller, p. 3747

Churches and faith institutions can frequently influence health behaviors among older African Americans. The church is a centerpiece of spiritual and social life among African American congregants. We explored its influence on influenza immunization coverage during the 2012-2013 influenza season.A cross-sectional study was conducted among congregation members ages 50-89 years from six churches in the Atlanta region in 2013-2014. We computed descriptive statistics, bivariate associations, and multivariable models to examine factors associated with immunization uptake among this population.Of 208 study participants, 95 (45.7%) reported receiving the influenza vaccine. Logistic regression showed that increased trust in their healthcare providers' vaccine recommendations was a positive predictor of vaccination among participants who had not experienced discrimination in a faith-based setting (OR: 14.8 [3.7, 59.8]), but was not associated with vaccination for participants who had experienced such discrimination (OR: 1.5 [0.2, 7.0]). Belief in vaccine-induced influenza illness (OR: 0.1 [0.05, 0.23]) was a negative predictor of influenza vaccination.Members of this older cohort of African Americans who expressed trust in their healthcare providers' vaccine recommendations and disbelief in vaccine-induced influenza were more likely to obtain seasonal influenza immunization. They were also more likely to act on their trust of healthcare provider's vaccine recommendations if they did not encounter negative influenza immunization attitudes within the church. Having healthcare providers address negative influenza immunization attitudes and disseminate vaccine information in a culturally appropriate manner within the church has the potential to enhance future uptake of influenza vaccination.

Two national surveys were conducted in Jordan in 2002 and 2010 to investigate the micronutrient status in women and children. To determine the prevalence of anemia, iron and folate deficiency among women and children in 2010 and compare with the prevalence of anemia and iron deficiency in 2002. A nationally representative survey was conducted in 2002 (1023 women, 15–49 years of age; 1059 children, 12–59 months of age) and a second survey in 2010 (2035 women; 940 children). Venous blood samples were used to measure hemoglobin, ferritin and red blood cell folate (the latter on a subsample of 393 women). Among women in 2010, the prevalence of folate deficiency and insufficiency was 13.6% and 82.9%, respectively. Geometric mean serum ferritin was higher in 2010 compared with 2002 (21.3 ng/ml vs 18.3, P=0.01); there was no significant change in the prevalence of iron deficiency (35.1% vs 38.7%, P=0.17), iron deficiency anemia (19.1% vs 20.0%, P=0.61) or anemia (29.2% vs 29.3%, P=0.96). Among children, a significantly lower prevalence was observed in 2010 compared with 2002 for iron deficiency (13.7% vs 26.2% P

ObjectiveTo examine the association between overweight and obesity and serum ferritin among women of reproductive age (15–49 years) in Nicaragua, considering the effect of α1-acid glycoprotein (AGP), a marker of inflammation.DesignWe analysed data from the 2004–05 Nicaraguan Integrated Surveillance System for Nutrition Interventions. Three logistic regression models were analysed with low serum ferritin (SettingNicaragua.SubjectsIncluded in this analysis were 832 non-pregnant mother/caregivers (15–49 years) surveyed in 2004–2005.ResultsIn the sample, prevalence of overweight and obesity was 31·8 % and 19·2 %, respectively, and 27·6 % had low serum ferritin. In model 1, the adjusted OR of low serum ferritin was 0·74 (95 % CI 0·52, 1·05) for overweight women and 0·42 (95 % CI 0·26, 0·65) for obese women. In model 2, AGP was significantly independently associated with low serum ferritin (adjusted OR=0·56, 95 % CI 0·34, 0·92) while the adjusted OR for overweight and obesity were largely unchanged. Excluding women with elevated AGP did not appreciably affect the relationship between overweight or obesity and low serum ferritin (model 3).ConclusionsOverall, in this population of reproductive-age women, obese women were less likely to have low serum ferritin levels, and this was independent of inflammation as measured by AGP.

Background: Colorectal cancer (CRC) is the 4th most common cancer in the US, and the liver is the most common site of metastatic disease. Immune checkpoint inhibitor therapy has not been successful in achieving a clinical response in most patients with CRC liver metastases (CRCLM). The liver is known to induce tolerance to foreign antigens as a result of immunosuppressive cytokines including IL-10. We hypothesized that blockade of IL-10 signaling in CRCLM would potentiate tumor infiltrating lymphocyte (TIL)-mediated tumor cell death. Methods: We performed single-cell RNA sequencing (scRNAseq) of CRCLM using the 10x platform to evaluate for expression of IL-10 or IL-10 receptor (IL-10R) RNA within the tumor (n=8). To confirm if the IL-10R protein was present within the tumor microenvironment (TME), we also performed immunohistochemistry (IHC) (n=3). In order to study the functional effects of IL-10 blockade, we utilized a tumor slice culture (TSC) model, which allows for the study of cancers with their intact TME including immune cells. For TSCs, cores (6 mm diameter) were taken from freshly resected sterile human CRCLM and cut to 250 µm thick slices using a vibratome (n=3). Duplicate slices were treated with either IgG control or anti-IL-10 monoclonal antibodies and cultured for up to 6 days. To evaluate for histological evidence of necrosis and cell apoptosis within the tumor slice, we stained slides with either hematoxylin and eosin (H&E) or cleaved-Caspase-3 (CC3). To gain insight into the activation state of TIL after treatment, we measured levels of cytokines within the culture supernatants. Results: We found by scRNAseq that that IL-10 was expressed by a subset of tumor-associated macrophages, and IL-10R was expressed by both CD4+ and CD8+ T cells as well as macrophages. We confirmed that IL-10R protein was present within the CRCLM TME by IHC, and IL-10R expression was distributed throughout the stroma in non-tumor cells. In TSC treated with anti-IL-10 antibody, CC3+ cells were found to be 82.8% of total cells, compared to 36.1% of control (p = 1 x 10-6) at day 6. These findings were consistent across all human tumor samples treated with IL-10 blockade versus control at all time points examined. Furthermore, IL-10 blockade led to histologic evidence of generalized necrosis compared to an intact TME seen in the control group. Analysis of cytokines released into the media confirmed that IL-10 was present in controls, but absent in slices blocked with anti-IL-10 antibody. We also found increased levels of granzyme B, IL-2, GM-CSF, and IL-18, as well as a reduction in the immune checkpoint receptor TIM3, after one day of IL-10 blockade in culture. Conclusion: Treatment of human CRCLM TSCs with anti-IL-10 antibody leads to a marked increase in immune-mediated cell death within the tumor. Our data suggest that IL-10 serves as a critical regulator of anti-tumor immunity in the CRCLM TME and may serve as an important immunotherapeutic target. Citation Format: Kevin M. Sullivan, Xiuyun Jiang, Yongwoo David Seo, Heidi L. Kenerson, Xiaowei Yan, Chris Lausted, Changting Meng, Neda Jabbari, Kevin P. Labadie, Sara K. Daniel, Qiang Tian, Teresa S. Kim, Raymond S. Yeung, Venu G. Pillarisetty. IL-10 blockade reactivates antitumor immunity in human colorectal cancer liver metastases [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4489.

Although pregnant women and some groups of reproductive-age women in the US may be at risk of iodine deficiency, data also suggest that iodine intake among many U.S. children may be above requirements. Our objective was to describe the association of iodine sources with iodine status among children. We analyzed 2007-2010 NHANES data of urine iodine concentration (UIC) spot tests for children aged 6-12 y (n = 1553) and used WHO criteria for iodine status (median UIC: 100-199 μg/L = adequate; 200-299 μg/L = above requirements; ≥300 μg/L = excess). The overall median UIC was above requirements for children aged 6-12 y [211 μg/L (95% CI: 194, 228 μg/L)]. Median UIC increased by quartile of previous day dairy intake, ranging from adequate in the lowest quartile [157 μg/L (95% CI: 141, 170 μg/L)] to above requirements in the highest quartile [278 μg/L (95% CI: 252, 336 μg/L)]. Median UIC was 303 μg/L (95% CI: 238, 345 μg/L) among the 17% of children who had taken a dietary supplement containing iodine the previous day, compared with 198 μg/L (95% CI: 182, 214 μg/L) among those who had not. In adjusted regression analyses, recent dairy intake and recent supplement use were significantly positively associated with UIC levels, whereas recent grain intake was negatively associated. Adding salt to food at the table was not associated with UIC. Iodine-containing supplements are likely not needed by most schoolchildren in the US because dietary iodine intake is adequate in this age group.

Although anemia in preschool children is most often attributed to iron deficiency, other nutritional, infectious, and genetic contributors are rarely concurrently measured. In a population-based, cross-sectional survey of 858 children 6-35 months of age in western Kenya, we measured hemoglobin, malaria, inflammation, sickle cell, α-thalassemia, iron deficiency, vitamin A deficiency, anthropometry, and socio-demographic characteristics. Anemia (Hb < 11 g/dL) and severe anemia (Hb < 7 g/dL) prevalence ratios (PRs) for each exposure were determined using multivariable modeling. Anemia (71.8%) and severe anemia (8.4%) were common. Characteristics most strongly associated with anemia were malaria (PR: 1.7; 95% confidence interval [CI] = 1.5-1.9), iron deficiency (1.3; 1.2-1.4), and homozygous α-thalassemia (1.3; 1.1-1.4). Characteristics associated with severe anemia were malaria (10.2; 3.5-29.3), inflammation (6.7; 2.3-19.4), and stunting (1.6; 1.0-2.4). Overall 16.8% of anemia cases were associated with malaria, 8.3% with iron deficiency, and 6.1% with inflammation. Interventions should address malaria, iron deficiency, and non-malarial infections to decrease the burden of anemia in this population.

Inhibitory ligands on tumor cells and their corresponding receptors on T cells are collectively called immune checkpoint molecules and have emerged as druggable targets that harness endogenous immunity to fight cancer. Immune checkpoint inhibitors targeting CTLA-4, PD-1 and PD-L1 have been developed for the treatment of patients with non-small-cell lung cancer and other malignancies, with impressive clinical activity, durable responses and a favorable toxicity profile. This article reviews the development, current status and future directions for some of these agents. The efficacy and safety data for drugs such as ipilimumab, nivolumab, pembrolizumab, atezolizumab and durvalumab are reviewed, along with combination strategies and response evaluation criteria. The toxicity profiles and predictive biomarkers of response are also discussed.

The Office of Dietary Supplements (ODS) at the NIH sponsored a workshop on May 12‐13, 2011, to bring together representatives from various NIH institutes and centers as a first step in developing an NIH iodine research initiative. The workshop also provided an opportunity to identify research needs that would inform the dietary reference intakes for iodine, which were last revised in 2001. Iodine is required throughout the life cycle, but pregnant women and infants are the populations most at risk of deficiency, because iodine is required for normal brain development and growth. The CDC monitors iodine status of the population on a regular basis, but the status of the most vulnerable populations remains uncertain. The NIH funds very little investigator-initiated research relevant to iodine and human nutrition, but the ODS has worked for several years with a number of other U.S. government agencies to develop many of the resources needed to conduct iodine research of high quality (e.g., validated analytical methods and reference materials for multiple types of samples). Iodine experts, scientists from several U.S. government agencies, and NIH representatives met for 2 d to identify iodine research needs appropriate to the NIH mission. J. Nutr. 142: 1175S‐1185S, 2012.

Background Anemia status is frequently assessed in cross-sectional surveys. Recently, the assessment of acute phase proteins (APPs) has become more common, primarily for iron and vitamin A biomarkers. Although the so-called “anemia of infection” has been known for years, the relationship between APPs and anemia has been infrequently presented. Objective To assess the relationship between elevated α1-acid glycoprotein (AGP) and the prevalence of anemia among preschool children. Methods A nationally representative household-based cross-sectional survey was conducted in 2003–05 in Nicaragua. Blood samples were collected from preschool children 6 to 59.9 months of age and tested for hemo- globin and AGP. Data were also obtained on sex, weight, height, use of iron supplements, maternal education, and urban or rural status. Results Among the 1,420 children assessed, the overall prevalence of anemia was 20.2% and the prevalence of elevated AGP was 24.0%. Children with elevated AGP had an anemia prevalence of 27.9%, compared with 17.8% among those with a normal AGP, for a crude prev- alence odds ratio (POR) of 1.8 ( p = .010). Accounting for age, maternal educational level, and year of survey using logistic regression, the adjusted POR for the association between elevated AGP and anemia was 1.5 ( p = .053). Conclusions Children in this survey with an elevated AGP had a higher prevalence of anemia, although after controlling for covariates the p-value did not indicate a statistically significant difference ( p = .053). It may be helpful to account for APPs, when this information is available, for purposes of comparing anemia prevalence across populations or within a population over time.

ObjectiveTo assess the association of the acute-phase protein biomarkers, C-reactive protein (CRP) and α1-acid glycoprotein (AGP), with anaemia in children aged 6–59·9 months in Papua New Guinea.DesignA nationally representative household-based cross-sectional survey of children aged 6–59·9 months was used to assess the relationships between various combinations of elevated CRP (>5 mg/l) and AGP (>1·2 g/l) with anaemia. Logistic regression was used to determine if other factors, such as age, sex, measures of anthropometry, region, urban/rural residence and household size, modified or confounded the acute-phase protein–anaemia association.SettingPapua New Guinea.SubjectsA total of 870 children aged 6–59·9 months from the 2005 Papua New Guinea National Micronutrient Survey were assessed.ResultsThe following prevalence estimates were found: anaemia 48 %; elevated CRP 32 %; and elevated AGP 33 %. Children with elevated CRP had a prevalence of anaemia of 66 % compared with children with normal CRP who had a prevalence of 40 %. Corresponding estimates for AGP were 61 % and 42 %, respectively. Similar results were found with combinations of elevated CRP and AGP. The higher prevalence of anaemia in children with elevated CRP and/or AGP was still present after controlling for confounders.ConclusionsElevated levels of CRP and AGP were significantly associated with a higher prevalence of anaemia in the children surveyed. There are no expert group recommendations on whether to or how to account for markers of inflammation in presenting results on anaemia prevalence. Additional research would be helpful to clarify this issue.

BACKGROUND/OBJECTIVES: Vitamin D deficiency, a risk factor for osteomalacia and osteoporosis, is a re-emerging health problem globally. While sunlight is an important vitamin D source, previous investigations among women whose culture encourages skin covering have been small, not nationally representative, or both. We investigated serum 25–hydroxyvitamin D (25(OH)D(3)) status and factors associated with deficiency in a nationally representative survey of 2013 Jordanian women of reproductive age in Spring 2010. SUBJECTS/METHODS: We measured 25(OH)D(3) concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with skin covering and other factors. RESULTS: Results showed 60.3% (95% CI: 57.1–63.4%) deficiency (

Consuming an adequate amount of iodine during pregnancy is critical for fetal neurologic development. Even a mild deficiency can impair cognitive ability. Important sources of iodine in the United States include dairy products and iodized salt. Although the U.S. population has traditionally been considered iodine sufficient, median urinary iodine concentrations (UIC) have decreased 50% since the 1970s. We analyzed 2001-2006 NHANES data from urine iodine spot tests for pregnant (n = 326), lactating (n = 53), and nonpregnant, nonlactating (n = 1437) women of reproductive age (15-44 y). We used WHO criteria to define iodine sufficiency (median UIC: 150-249 microg/L among pregnant women; >or=100 microg/L among lactating women; and 100-199 microg/L among nonpregnant, nonlactating women). The iodine status of pregnant women was borderline sufficient (median UIC = 153 microg/L; 95% CI = 105-196), while lactating (115 microg/L; 95% CI = 62-162) and nonpregnant, nonlactating (130 microg/L; 95% CI = 117-140) women were iodine sufficient. Dairy product consumption was an important contributor to iodine status among both pregnant and nonpregnant, nonlactating women, and those who do not consume dairy products may be at risk for iodine deficiency. Although larger samples are needed to confirm these findings, these results raise concerns about the iodine status of pregnant women and women of reproductive age who are not consuming dairy products. Iodine levels among U.S. women should be monitored, particularly among subgroups at risk for iodine deficiency.