Search

Supplementary Table 2. Baseline characteristics of the multicenter EV cohort.

Purpose:The antibody–drug conjugate enfortumab vedotin (EV) releases a cytotoxic agent into tumor cells via binding to the membrane receptor NECTIN-4. EV was recently approved for patients with metastatic urothelial carcinoma (mUC) without prior assessment of the tumor receptor status as ubiquitous NECTIN-4 expression is assumed. Our objective was to determine the prevalence of membranous NECTIN-4 protein expression in primary tumors (PRIM) and patient-matched distant metastases (MET).Experimental Design:Membranous NECTIN-4 protein expression was measured (H-score) by IHC in PRIM and corresponding MET (N = 137) and in a multicenter EV-treated cohort (N = 47). Progression-free survival (PFS) after initiation of EV treatment was assessed for the NECTIN-4–negative/weak (H-score 0–99) versus moderate/strong (H-score 100–300) subgroup. The specificity of the NECTIN-4 IHC staining protocol was validated by establishing CRISPR-Cas9–induced polyclonal NECTIN-4 knockouts.Results:In our cohort, membranous NECTIN-4 expression significantly decreased during metastatic spread (Wilcoxon matched pairs P < 0.001; median H-score = 40; interquartile range, 0–140), with 39.4% of MET lacking membranous NECTIN-4 expression. In our multicenter EV cohort, absence or weak membranous NECTIN-4 expression (34.0% of the cohort) was associated with a significantly shortened PFS on EV (log-rank P < 0.001).Conclusions:Membranous NECTIN-4 expression is frequently decreased or absent in mUC tissue. Of note, the clinical benefit of EV strongly depends on membranous NECTIN-4 expression. Thus, our results are of highest clinical relevance and argue for a critical reconsideration of the current practice and suggest that the NECTIN-4 receptor status should be determined (ideally in a metastatic/progressive lesion) before initiation of EV.See related commentary by Aggen et al., p. 1377

Statistics over-represented peptides HLA class I

Statistics over-represented peptides HLA class II

Supplementary Tables 1-5, 7, 9-12 containing: Suppl. Table 1: Sample characteristics; Suppl. Table 2: Patient characteristics; Suppl. Table 3: Control peptides Suppl. Table 4: Peptide-specific properties Suppl. Table 5: Over-represented Peptides HLA class I; Suppl. Table 7: Over-represented Peptides HLA class II; Suppl. Table 9: STRING results Suppl. Table 9: Protein-protein interactions (STRING) Suppl. Table 10: Over-represented pathways (STRING) Suppl. Table 11: Vaccine peptide selection Suppl. Table 12: Candidate vaccine peptides

Immune cell infiltrates have proven highly relevant for colorectal carcinoma prognosis, making colorectal cancer a promising candidate for immunotherapy. Because tumors interact with the immune system via HLA-presented peptide ligands, exact knowledge of the peptidome constitution is fundamental for understanding this relationship. Here, we comprehensively describe the naturally presented HLA ligandome of colorectal carcinoma and corresponding nonmalignant colon (NMC) tissue. Mass spectrometry identified 35,367 and 28,132 HLA class I ligands on colorectal carcinoma and NMC, attributable to 7,684 and 6,312 distinct source proteins, respectively. Cancer-exclusive peptides were assessed on source protein level using the Kyoto Encyclopedia of Genes and Genomes (KEGG) and protein analysis through evolutionary relationships (PANTHER), revealing pathognomonic colorectal carcinoma–associated pathways, including Wnt, TGFβ, PI3K, p53, and RTK-RAS. Relative quantitation of peptide presentation on paired colorectal carcinoma and NMC tissue further identified source proteins from cancer- and infection-associated pathways to be overrepresented merely within the colorectal carcinoma ligandome. From the pool of tumor-exclusive peptides, a selected HLA-ligand subset was assessed for immunogenicity, with the majority exhibiting an existing T-cell repertoire. Overall, these data show that the HLA ligandome reflects cancer-associated pathways implicated in colorectal carcinoma oncogenesis, suggesting that alterations in tumor cell metabolism could result in cancer-specific, albeit not mutation-derived, tumor antigens. Hence, a defined pool of unique tumor peptides, attributable to complex cellular alterations that are exclusive to malignant cells, might comprise promising candidates for immunotherapeutic applications.Significance: Cancer-associated pathways are reflected in the antigenic landscape of colorectal cancer, suggesting that tumor-specific antigens do not necessarily have to be mutation-derived but may also originate from other alterations in cancer cells. Cancer Res; 78(16); 4627–41. ©2018 AACR.

Complete supplementary figures containing: Suppl. Fig. 1: HLA-coverage (Caucasian); Suppl. Fig. 2: Maximum attainable quantities of source proteins; Suppl. Fig. 3: Comparsion with complete benign dataset; Suppl. Fig. 4: Legend PANTHER analysis; Suppl. Fig. 5: Legend KEGG analysis; Suppl. Fig. 6: Representation analysis HLA class II

Purpose: The antibody–drug conjugate enfortumab vedotin (EV) releases a cytotoxic agent into tumor cells via binding to the membrane receptor NECTIN-4. EV was recently approved for patients with metastatic urothelial carcinoma (mUC) without prior assessment of the tumor receptor status as ubiquitous NECTIN-4 expression is assumed. Our objective was to determine the prevalence of membranous NECTIN-4 protein expression in primary tumors (PRIM) and patient-matched distant metastases (MET). Experimental Design: Membranous NECTIN-4 protein expression was measured (H-score) by IHC in PRIM and corresponding MET (N = 137) and in a multicenter EV-treated cohort (N = 47). Progression-free survival (PFS) after initiation of EV treatment was assessed for the NECTIN-4–negative/weak (H-score 0–99) versus moderate/strong (H-score 100–300) subgroup. The specificity of the NECTIN-4 IHC staining protocol was validated by establishing CRISPR-Cas9–induced polyclonal NECTIN-4 knockouts. Results: In our cohort, membranous NECTIN-4 expression significantly decreased during metastatic spread (Wilcoxon matched pairs P < 0.001; median H-score = 40; interquartile range, 0–140), with 39.4% of MET lacking membranous NECTIN-4 expression. In our multicenter EV cohort, absence or weak membranous NECTIN-4 expression (34.0% of the cohort) was associated with a significantly shortened PFS on EV (log-rank P < 0.001). Conclusions: Membranous NECTIN-4 expression is frequently decreased or absent in mUC tissue. Of note, the clinical benefit of EV strongly depends on membranous NECTIN-4 expression. Thus, our results are of highest clinical relevance and argue for a critical reconsideration of the current practice and suggest that the NECTIN-4 receptor status should be determined (ideally in a metastatic/progressive lesion) before initiation of EV. See related commentary by Aggen et al., p. 1377

Smart City is an emerging concept in global urban development. A Smart City applies ICT technologies to provide greater efficiencies for its urban areas and civilian population. One of the key requ...

Immune cell infiltrates have proven highly relevant for colorectal carcinoma prognosis, making colorectal cancer a promising candidate for immunotherapy. Because tumors interact with the immune system via HLA-presented peptide ligands, exact knowledge of the peptidome constitution is fundamental for understanding this relationship. Here, we comprehensively describe the naturally presented HLA ligandome of colorectal carcinoma and corresponding nonmalignant colon (NMC) tissue. Mass spectrometry identified 35,367 and 28,132 HLA class I ligands on colorectal carcinoma and NMC, attributable to 7,684 and 6,312 distinct source proteins, respectively. Cancer-exclusive peptides were assessed on source protein level using the Kyoto Encyclopedia of Genes and Genomes (KEGG) and protein analysis through evolutionary relationships (PANTHER), revealing pathognomonic colorectal carcinoma–associated pathways, including Wnt, TGFβ, PI3K, p53, and RTK-RAS. Relative quantitation of peptide presentation on paired colorectal carcinoma and NMC tissue further identified source proteins from cancer- and infection-associated pathways to be overrepresented merely within the colorectal carcinoma ligandome. From the pool of tumor-exclusive peptides, a selected HLA-ligand subset was assessed for immunogenicity, with the majority exhibiting an existing T-cell repertoire. Overall, these data show that the HLA ligandome reflects cancer-associated pathways implicated in colorectal carcinoma oncogenesis, suggesting that alterations in tumor cell metabolism could result in cancer-specific, albeit not mutation-derived, tumor antigens. Hence, a defined pool of unique tumor peptides, attributable to complex cellular alterations that are exclusive to malignant cells, might comprise promising candidates for immunotherapeutic applications. Significance: Cancer-associated pathways are reflected in the antigenic landscape of colorectal cancer, suggesting that tumor-specific antigens do not necessarily have to be mutation-derived but may also originate from other alterations in cancer cells. Cancer Res; 78(16); 4627–41. ©2018 AACR.

The aim of our study was to evaluate the immunohistochemical expression of SOX11, PAX5, TTF-1 and ISL-1 in medulloblastoma (MB) to investigate their diagnostic usefulness.Immunohistochemical expression of PAX5 (two antibodies: Dako, DAK-Pax5; and BD, clone 24), TTF-1 (Dako, 8G7G3/1), SOX11 (CL0142; Abcam) and ISL-1 (1 H9, Abcam) was analyzed using the h-score and Remmele score in 25 cases of MB.There were 18 MBs of classic and 7 of desmoplastic type. SOX11 was strongly expressed in all tumors. The expression of PAX5 was higher and more frequent in a case of DAK-Pax5 clone (25/25) than clone 24 (6/25). ISL-1 was positive in 11 (44%) and TTF-1 in 3 (12%) cases. ISL-1 expression correlated positively (p0.001), while TTF-1 correlated negatively with the age of patients (p=0.039). PAX5 expression correlated with ISL-1 (p=0.039) and showed a trend toward higher expression in the desmoplastic subtype (p=0.069).SOX11 is strongly and robustly expressed in MBs. PAX5 expression pattern differs substantially among two antibody clones. TTF-1 and ISL-1 is associated with the age of patients.

Red‐naped sapsuckers (Sphyrapicus nuchalis) are functionally important because they create sapwells and cavities that other species use for food and nesting. Red‐naped sapsucker ecology within aspen (Populus tremuloides) has been well studied, but relatively little is known about red‐naped sapsuckers in conifer forests. We used light detection and ranging (LiDAR) data to examine occupancy patterns of red‐naped sapsuckers in a conifer‐dominated system. We surveyed for sapsuckers at 162 sites in northern Idaho, USA, during 2009 and 2010. We used occupancy models and an information‐theoretic approach to model sapsucker occupancy as a function of four LiDAR‐based metrics that characterized vegetation structure and tree harvest, and one non‐LiDAR metric that characterized distance to major roads. We evaluated model support across a range of territory sizes using Akaike's information criterion. Top model support was highest at the 4‐ha extent, which suggested that 4 ha was the most relevant scale describing sapsucker occupancy. Sapsuckers were positively associated with variation of canopy height and harvested area, and negatively associated with shrub and large tree density. These results suggest that harvest regimes and structural diversity of vegetation at moderate extents (e.g., 4 ha) largely influence occurrence of red‐naped sapsuckers in conifer forests. Given the current and projected declines of aspen populations, it will be increasingly important to assess habitat relationships, as well as demographic characteristics, of aspen‐associated species such as red‐naped sapsuckers within conifer‐dominated systems to meet future management and conservation goals.

Primary lymphoma of the lung is a rare entity. Clinical features, optimal treatment, role of surgery and outcomes are not well defined, and the follow-up is variable in published data. Clinical data of 205 patients who were confirmed to have bronchus mucosa-associated lymphoid tissue lymphoma from December 1986 to December 2011 in 17 different centres worldwide were evaluated. Fifty-five per cent of the patients were female. The median age at diagnosis was 62 (range 28-88) years. Only 9% had a history of exposure to toxic substances, while about 45% of the patients had a history of smoking. Ten per cent of the patients had autoimmune disease at presentation, and 19% patients had a reported preexisting lung disease. Treatment modalities included surgery alone in 63 patients (30%), radiotherapy in 3 (2%), antibiotics in 1 (1%) and systemic treatment in 128 (62%). Patients receiving a local approach, mainly surgical resection, experienced significantly improved progression-free survival (p = 0.003) versus those receiving a systemic treatment. There were no other significant differences among treatment modalities. The survival data confirm the indolent nature of the disease. Local therapy (surgery or radiotherapy) results in long-term disease-free survival for patients with localized disease. Systemic treatment, including alkylating-containing regimens, can be reserved to patients in relapse after incomplete surgical excision or for patients with advanced disease. Copyright © 2015 John Wiley & Sons, Ltd.

Basal-cell carcinomas may show irregular, asymmetric subclinical growth. This study analyzed the efficacy of ‘breadloaf’ microscopy (serial sectioning) and three-dimensional (3D) microscopy in detecting positive tumor margins. Two hundred eighty-three (283) tumors (51.2%) were put into the breadloaf microscopy group; 270 tumors (48.8%) into the 3D microscopy group. The position of any detected tumor outgrowths was identified in clock face fashion. The time required for cutting and embedding the specimens and the examination of the microscopic slides was measured. Patient/tumor characteristics and surgical margins did not differ significantly. Tumor outgrowths at the excision margin were found in 62 of 283 cases (21.9%) in the breadloaf microscopy group and in 115 of 270 cases (42.6%) in the 3D microscopy group, constituting a highly significant difference (p

Background: Toll-like receptor (TLR) expression in patients with inflammatory bowel disease is increased when compared with healthy controls. However, the impact of TLR signaling during inflammatory bowel disease is not fully understood. Methods: In this study, we used a murine model of acute phase inflammation in bone marrow chimeric mice to investigate in which cell type TLR2/4 signal induction is important in preventing intestinal inflammation and how intestinal dendritic cells are influenced. Mice were either fed with wild-type bacteria, able to initiate the TLR2/4 signaling cascade, or with mutant strains with impaired signal induction capacity. Results: The induction of the TLR2/4 signal cascade in epithelial cells resulted in inflammation in bone marrow chimeric mice, whereas induction in hematopoietic cells had an opposed function. Furthermore, feeding of wild-type bacteria prevented disease; however, differing signal induction of bacteria had no effect on lamina propria dendritic cell activation. In contrast, functional TLR2/4 signals resulted in increased frequencies of CD103-expressing lamina propria and mesenteric lymph node dendritic cells, which were able to ameliorate disease. Conclusions: The TLR-mediated amelioration of disease, the increase in CD103-expressing cells, and the beneficial function of TLR signal induction in hematopoietic cells indicate that the increased expression of TLRs in patients with inflammatory bowel disease might result in counterregulation of the host and serve in preventing disease.

ZusammenfassungHintergrund Die luckenlose Aufarbeitung der Rander eines Tumors mittels dreidimensionaler (3D) Histologie erscheint oft kompliziert und auf eine Personalunion von Operateur und Histopathologe reduziert. Wir stellen klare Regeln vor, die eine Kommunikation zwischen allen Beteiligten erlaubt und uberprufen deren Anwendung in der taglichen Routine. Methodik Die Gewebeeinbettung, Befundinterpretation sowie Kommunikation zwischen Operateur und Histopathologe basiert auf einem festgelegten Algorithmus unter Zuhilfenahme von Uhrzeiten und Einbettkassetten, welche eine exakte topographische Orientierung erlauben. Die Anwendung dieses Verfahrens in der taglichen Routine wurde an 947 operierten Basalzellkarzinomen hinsichtlich der Entwicklung von Rezidivtumoren evaluiert. Ergebnisse Bei einer medianen Nachbeobachtungszeit von 47 Monaten entwickelten sich bei 10 von 947 operierten Basalzellkarzinomen (1,1 %) Rezidivtumoren. Basalzellkarzinome vom fibrosierenden Typ sowie Basalzellkarzinome, welche im Rahmen der Erstoperation nicht R0 reseziert werden konnten, zeigten ein signifikant haufigeres Auftreten von Rezidiven (p < 0,05 bzw. p < 0,001). Schlussfolgerungen Standardisierte Regeln fur den Umgang mit exzidiertem Gewebe erlauben eine effektive Anwendung der 3D-Histologie im taglichen klinischen Alltag. 3D-Histologie fuhrt zu einer niedrigen Rezidivquote. Primar nicht R0 resezierte Basalzellkarzinome vom fibrosierenden Typ wurden als Risikogruppe fur Rezidive identifiziert.

Summary Background The continuous evaluation of the edges of a tumor by means of three-dimensional (3D) histology often appears complicated and require the surgeon and dermatopathologist to work together closely. We present clear rules that allow communication between all parties involved and then verify their application in daily routine. Methods Tissue processing, interpretation of results, as well as communication between the surgeon and the dermatopathologist are based on an algorithm with the aid of exact times and embedding cassettes, which allow precise topographic orientation. We evaluated the use of this method in daily clinic practice, taking into account 947 operated basal cell carcinomas in regard to the development of recurrent tumors. Results At a median follow-up of 47 months, 10 of the 947 operated basal cell carcinomas (1.1 %) recurred. Sclerodermiform basal cell carcinomas and basal cell carcinomas which could not be curatively resected (R0 resection) during the initial surgery showed a significantly higher recurrence rate (p < 0.05 and p < 0.001). Conclusions Standardized rules for dealing with excised tissue allow an effective application of 3D histology in daily clinical practice. 3D histology results in low recurrence rates. Sclerodermiform basal cell carcinomas which could not be curatively resected (R0 resection) were identified as a risk group for the development of recurrent tumors.

Long-term space missions require minimized boil-off from liquid hydrogen and oxygen tanks to increase the payload mass fraction at launch. Vapor-cooled shielding technologies can use liquid hydrogen boil-off vapors to refrigerate and potentially eliminate boil-off from liquid oxygen tanks. Statistical thermodynamic calculations estimate that the amount of refrigeration provided by hydrogen for a liquid oxygen tank can be increased up to 50% through catalysis of parahydrogen–orthohydrogen conversion. Based on this prediction, a cryocatalysis hydrogen experiment facility was developed as a proof of concept. Hydrogen is liquefied in a noncatalytic condenser and vapor venting controlled via a proportional-integral-derivative controller. The effective heat capacity of the effluent is measured directly through a change in temperature of the known mass flow and applied heater power. The change in parahydrogen–orthohydrogen composition is validated independently with a thermal conductivity probe calibrated in sit...

ABSTRACT: Since the discovery of ALK-positive anaplastic large-cell lymphoma in 1994 many other types of tumors showing ALK expression were disclosed. They form a heterogeneous group, including lung, renal and soft tissue tumors. The biological function of ALK, its role in carcinogenesis and impact exerted on the clinical outcome have been studied by many research groups. New drugs specifically dedicated for ALK inhibition, for example, crizotinib, have been synthesized and have become a viable treatment option for ALK-positive lung adenocarcinoma, and potentially for other ALK-positive cancers. This review summarizes the current state of knowledge concerning ALK-positive neoplasms, focusing on the clinical aspects of the subject.

Bei einer 55-jahrigen Patientin mit peritoneal metastasiertem Rektumkarzinom wurden in einem in der Bildgebung auffalligen epiphrenischen Lymphknoten neben einer Metastase des Karzinoms papillare und solide epitheloide Proliferate gefunden, die auch in angrenzenden Gefasstrukturen nachweisbar waren. In der immunhistochemischen Analyse zeigte sich eine Koexpression von Pankeratin, Calretinin und WT1, sodass Absiedlungen eines Mesothelioms erwogen wurden. Bei fehlendem diesbezuglichem Nachweis in der Bildgebung wurde eine weitere Immuntypisierung durchgefuhrt. Hier zeigten sich eine Positivitat fur Desmin, eine Negativitat fur EMA, GLUT1, p53, und ein Ki67-Index von 2–3 %. Somit konnten die Proliferate abschliesend als in das Lymphgefassystem und den nachgeschalteten Lymphknoten versprengte gutartige Mesothelien eingeordnet werden.

OBJECTIVE Nonalcoholic fatty liver (NAFL) is thought to contribute to insulin resistance and its metabolic complications. However, some individuals with NAFL remain insulin sensitive. Mechanisms involved in the susceptibility to develop insulin resistance in humans with NAFL are largely unknown. We investigated circulating markers and mechanisms of a metabolically benign and malignant NAFL by applying a metabolomic approach. RESEARCH DESIGN AND METHODS A total of 265 metabolites were analyzed before and after a 9-month lifestyle intervention in plasma from 20 insulin-sensitive and 20 insulin-resistant subjects with NAFL. The relevant plasma metabolites were then tested for relationships with insulin sensitivity in 17 subjects without NAFL and in plasma from 29 subjects with liver tissue samples. RESULTS The best separation of the insulin-sensitive from the insulin-resistant NAFL group was achieved by a metabolite pattern including the branched-chain amino acids leucine and isoleucine, ornithine, the acylcarnitines C3:0-, C16:0-, and C18:0-carnitine, and lysophosphatidylcholine (lyso-PC) C16:0 (area under the ROC curve, 0.77 [P = 0.00023] at baseline and 0.80 [P = 0.000019] at follow-up). Among the individual metabolites, predominantly higher levels of lyso-PC C16:0, both at baseline (P = 0.0039) and at follow-up (P = 0.001), were found in the insulin-sensitive compared with the insulin-resistant subjects. In the non-NAFL groups, no differences in lyso-PC C16:0 levels were found between the insulin-sensitive and insulin-resistant subjects, and these relationships were replicated in plasma from subjects with liver tissue samples. CONCLUSIONS From a plasma metabolomic pattern, particularly lyso-PCs are able to separate metabolically benign from malignant NAFL in humans and may highlight important pathways in the pathogenesis of fatty liver–induced insulin resistance.

The increasing use of immunohistochemical and molecular investigations of lymphatic tissues results in more frequent detection of early lymphoid proliferations. These show some but not all features of malignant lymphomas without fulfilling the diagnostic criteria for the diagnosis of lymphoid malignancy. In addition to well-known premalignant B-cell proliferations, such as monoclonal gammopathy of unknown significance (MGUS) and monoclonal B-cell lymphocytosis (MBL), so-called in situ lymphomas have recently been described with minimal infiltrates of clonal B-cells in morphologically reactive lymphoid tissues which show the phenotypic and genetic features of specific B-cell lymphoma subtypes and often show a characteristic topographical distribution. This article addresses a group of clonal lymphoproliferations with usually localized disease and excellent clinical prognosis, such as pediatric follicular lymphoma and nodal marginal zone lymphoma. Another group of early lesions not addressed in this review are virally induced lymphoproliferations which represent a grey zone between purely reactive lesions and malignant lymphomas and may pose significant diagnostic as well as clinical problems. In this review diagnostic criteria for early or in situ lesions and their distinction from partial infiltration by malignant lymphoma are described.

Background Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals. Methods Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model. Results Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths. Conclusions Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1269-9) contains supplementary material, which is available to authorized users.

Background: The use of antimalarial drugs and the prevention of man and vector contact remain the major control and prevention strategy of malaria until the availability of effective and safe vaccine. In Africa, one of the major strategies to malaria control and prevention is the home based malaria strategy through which trained community drug distributors identify and provide antimalarial drugs to children under five years with fever. This research aims at exploring the capacity, performance, and motivation of CBAs in Tamale Metropolis, Northern region, Ghana Methodology: A Survey, in-depth interviews and short ethnographic techniques were conducted among 104 CBAs who were trained and given logistical support to assess and treat children less than five years with malaria presumptively at home. Participants were selected randomly and represented urban, peri-urban and rural settings. Results: 96.2% of respondents identified malaria by presence of fever while 92.3% used fever as a cardinal sign. More than 82% of participants provided early treatment in all the three location. 64.4% of participants administered the correct number of days while 32.7% administered daily doses correctly, only 24% of CBAs knew that the Antimalarial medications they use have some side effects. 77.9% knew when to repeat drug dose when child vomit or when parent forget to give the dose. Most of the participant had registers and were reporting monthly, however, only 26.2% are somewhat motivated by some of the existing of the motivational packages. Conclusion: The overall performance and skills demonstrated by the CBAs are encouraging in all the three settings but documentation and reporting remains a challenge. Community based initiatives should be strengthened and promoted to provide homemade solutions in saving lives especially in resources limited settings. If community interventions such as community drug distribution of antimalarial drugs are needed to improving access to malaria prevention, much attention to what motivates individuals to strengthen their spirit of volunteerism is required.