Chemotherapy decreases the risk of relapse and mortality in early-stage breast cancer (BC), but it comes with the risk of toxicity. Chemotherapy efficacy depends on relative dose intensity (RDI), and ...an RDI < 85% is associated with worse overall survival. The pro-inflammatory (interleukin (IL)-6, C-reactive protein (CRP)) and coagulation factors (D-dimer) serve as biomarkers of aging. The purpose of this study is to determine if these biomarkers are associated with reduced RDI in women with stage I-III BC.
This study enrolled women with stage I-III BC. Prior to adjuvant or neoadjuvant chemotherapy, peripheral blood was collected for biomarker measurement. Dose reductions and delays were captured and utilized to calculate the RDI delivered. Univariate and multivariate analyses were performed to describe the association between pre-chemotherapy IL-6, CRP, and D-dimer levels and an RDI < 85%, controlling for relevant tumor and patient factors (age, stage, receptor status, chemotherapy regimen, and pre-chemotherapy physical function and comorbidity).
A total of 159 patients (mean age 58 years, range 30-81, SD 11.3) with stage I-III BC were enrolled. An RDI < 85% occurred in 22.6% (N = 36) of patients and was associated with higher pre-chemotherapy IL-6 (OR 1.14, 95% CI 1.04-1.25; p = 0.006) and D-dimer (OR 2.32, 95% CI 1.27-4.24; p = 0.006) levels, increased age (p = 0.001), increased number of comorbidities (p = 0.01), and decreased physical function by the Medical Outcomes Survey Activities of Daily Living (ADL) Scale (p = 0.009) in univariate analysis. A multivariate model, including two biomarkers (IL-6 and D-dimer), age, ADL, BC stage, and chemotherapy regimen, demonstrated a significant association between the increased biomarkers and reduced RDI < 85% (OR 2.54; p = 0.04).
Increased pre-chemotherapy biomarkers of aging (IL-6 and D-dimer) are associated with reduced RDI (<85%). Future studies are underway to validate these findings.
ClinicalTrials.gov, NCT01030250 . Registered on 3 November 2016.
Wide-spread application of chimeric antigen receptor (CAR) T cell therapy for cancer is limited by the current use of autologous CAR T cells necessitating the manufacture of individualized ...therapeutic products for each patient. To address this challenge, we have generated an off-the-shelf, allogeneic CAR T cell product for the treatment of glioblastoma (GBM), and present here the feasibility, safety, and therapeutic potential of this approach.
We generated for clinical use a healthy-donor derived IL13Rα2-targeted CAR+ (IL13-zetakine+) cytolytic T-lymphocyte (CTL) product genetically engineered using zinc finger nucleases (ZFNs) to permanently disrupt the glucocorticoid receptor (GR) (GRm13Z40-2) and endow resistance to glucocorticoid treatment. In a phase I safety and feasibility trial we evaluated these allogeneic GRm13Z40-2 T cells in combination with intracranial administration of recombinant human IL-2 (rhIL-2; aldesleukin) in six patients with unresectable recurrent GBM that were maintained on systemic dexamethasone (4-12 mg/day).
The GRm13Z40-2 product displayed dexamethasone-resistant effector activity without evidence for in vitro alloreactivity. Intracranial administration of GRm13Z40-2 in four doses of 108 cells over a two-week period with aldesleukin (9 infusions ranging from 2500-5000 IU) was well tolerated, with indications of transient tumor reduction and/or tumor necrosis at the site of T cell infusion in four of the six treated research subjects. Antibody reactivity against GRm13Z40-2 cells was detected in the serum of only one of the four tested subjects.
This first-in-human experience establishes a foundation for future adoptive therapy studies using off-the-shelf, zinc-finger modified, and/or glucocorticoid resistant CAR T cells.
Neural stem cells (NSCs) are tumor tropic and can be genetically modified to produce anti-cancer therapies locally in the brain. In a prior first-in-human study we demonstrated that a single dose of ...intracerebrally administered allogeneic NSCs, which were retrovirally transduced to express cytosine deaminase (CD), tracked to glioma sites and converted oral 5-fluorocytosine (5-FC) to 5-fluorouracil (5-FU). The next step in the clinical development of this NSC-based anti-cancer strategy was to assess the feasibility of administering multiple intracerebral doses of CD-expressing NSCs (CD-NSCs) in patients with recurrent high-grade gliomas. CD-NSCs were given every 2 weeks using an indwelling brain catheter, followed each time by a 7-d course of oral 5-FC (and leucovorin in the final patient cohort). Fifteen evaluable patients received a median of 4 (range 2-10) intracerebral CD-NSC doses; doses were escalated from 50 × 10
to 150 × 10
CD-NSCs. Neuropharmacokinetic data confirmed that CD-NSCs continuously produced 5-FU in the brain during the course of 5-FC. There were no clinical signs of immunogenicity, and only three patients developed anti-NSC antibodies. Our results suggest intracerebral administration of serial doses of CD-NSCs is safe and feasible and identified a recommended dose for phase II testing of 150 × 10
CD-NSCs.
Abstract
BACKGROUND
Human NSCs are tumor tropic, making them attractive vehicles for delivery of therapeutics. An immortalized, clonal NSC line was retrovirally transduced to express CD, which ...converts 5-FC to 5-fluorouracil (5-FU). The primary objectives of this study were to assess the feasibility of serially administering CD-NSCs intracranially via a Rickham catheter and determine the recommended doses for phase II testing (RP2D).
METHODS
Adult patients with recurrent high grade gliomas underwent tumor resection or biopsy and placement of a Rickham. CD-NSCs were injected during surgery and thereafter infused through the Rickham every 2 weeks. Three days after each dose of CD-NSCs, patients took 5-FC (and leucovorin—dose level 3 patients only) orally every 6 hours for 7 days. The dose of CD-NSCs was escalated from 50 x 106 to 150 x 106 using a standard 3 + 3 design. 5-FC and leucovorin doses were 37.5 mg/kg and 25 mg, respectively. A treatment cycle was 28 days, with CD-NSCs administered on days 1 and 15, followed by 5-FC (and leucovorin) on days 4–10 and 18–24. Blood samples were drawn to assess for possible anti-NSC antibody and T cell responses.
RESULTS
Fifteen evaluable patients received a median of 2 (range 1–5) cycles of study treatment. One dose-limiting toxicity occurred: grade 3 wound infection. Three patients developed anti-NSC antibodies after receiving 3 doses of NSCs. There was no correlation between these results and use of dexamethasone or number of cycles. Analyses of PK and possible anti-NSC T cell responses are ongoing. Three patients had stable disease for 5 months.
CONCLUSIONS
Use of a Rickham to serially administer CD-NSCs intracranially is safe and feasible. Study treatment was well tolerated. There were no clinical signs of immunogenicity to these allogeneic CD-NSCs. The RP2D is 150 million CD-NSCs, 37.5 mg/kg of 5-FC, and 25 mg of leucovorin per dose.
Little is known about the penetration and bioactivity of systemically administered programmed cell death 1 (PD-1) antibodies in the central nervous system. Such information is critical for advancing ...checkpoint antibody therapies for treatment of brain tumors.
To evaluate pembrolizumab concentrations and PD-1 blockade on T cells in the cerebrospinal fluid (CSF) after intravenous administration.
Cerebrospinal fluid and blood samples were collected from 10 adult patients with high-grade gliomas who were participating in clinical trials of intracranially administered chimeric antigen receptor (CAR) T cells and intravenous pembrolizumab at City of Hope in Duarte, California, from 2017 through 2019. Neuropharmacokinetic and immunologic correlative studies were performed on CSF and serum samples.
Pembrolizumab, 200 mg, was given intravenously every 3 weeks with a median of 2 cycles (range, 1-8). CAR T cells were administered intracranially every 1 to 4 weeks. Cerebrospinal fluid and blood samples were collected on the day of CAR T-cell administration and then 24 hours later for a total of 100 paired samples.
Pembrolizumab concentrations were measured by enzyme-linked immunosorbent assay, PD-1 blocking on T cells by flow cytometry, and results of PD-1 blockade on CAR T-cell function by in vitro tumor rechallenge assays.
Of the 10 patients included in this study, the mean (SD) age was 45.7 (11.0) years, and 6 (60%) were women. Steady-state pembrolizumab concentrations in the CSF were achieved by 24 hours after initial intravenous administration, with a mean CSF:serum ratio of 0.009 (95% CI, 0.004-0.014). The CSF concentrations of pembrolizumab effectively blocked PD-1 on both endogenous T cells and intracranially administered CAR T cells in the CSF, with flow cytometric detection of surface PD-1 on the T cells decreasing from a mean (SD) of 39.3% (20.2%) before pembrolizumab to a mean (SD) of 3.8% (5.8%) 24 hours after pembrolizumab infusion. Steady-state concentrations in the CSF were maintained throughout the 21-day cycle of pembrolizumab, as was the PD-1 blocking effect, evidenced by no increase in detectable surface PD-1 on T cells in the CSF during that time period. Incubation of PD-1-expressing T cells with CSF samples from patients treated with pembrolizumab also resulted in PD-1 blockade.
Results of this study demonstrate steady-state concentrations of pembrolizumab in CSF after intravenous administration as well as CSF concentrations that are sufficient for blocking PD-1 on endogenous and adoptively transferred T cells. This provides mechanistic insight regarding the ability of systemically administered PD-1 blocking antibodies to modulate T-cell activity in the brain.
Abstract
BACKGROUND
Checkpoint inhibitors have shown efficacy in other solid tumors and are being studied in glioblastoma. For patients treated with anti-PD-1 monoclonal antibodies, such as ...pembrolizumab, CSF concentrations and blockade of PD-1 on T cells present in the CSF have not been reported. Such information would provide valuable context for applying checkpoint inhibitors for the treatment of CNS malignancies.
METHODS
CSF and blood samples were obtained from 6 glioblastoma CAR T cell study patients who received intraventricularly administered CAR T cells. These patients were also treated with pembrolizumab 200 mg intravenously every 3 weeks. Pembrolizumab levels in CSF and blood were measured using an ELISA assay. FACS analysis for PD-1 blockade was performed on endogenous and CAR T cells detected in CSF samples, and the results were compared to cells in CSF without pembrolizumab treatment.
RESULTS
Data analyzed from 3 patients samples so far show that average pembrolizumab levels in the CSF and serum were 330 ± 114 ng/mL and 64 ± 8 µg/mL, respectively. The average CSF/serum ratio was 0.5 ± 0.1%. In 1 patient from whom multiple CSF/blood samples were obtained over 3 months, steady-state CSF levels ranged from 155–394 ng/mL throughout each 21 day cycle of pembrolizumab. PD-1 was completely blocked on both endogenous T cells as well as CAR T cells that were delivered directly into the CSF.
CONCLUSIONS
To our knowledge, this is the first report of pembrolizumab concentrations in the CSF after intravenous administration. CSF levels were 0.5% of serum concentrations and remained stable throughout a 21 day cycle of pembrolizumab. PD-1 was found to be blocked on endogenous T cells in the CSF. Furthermore, even though they were relatively low, pembrolizumab levels in the CSF were sufficient to block PD-1 on intraventricularly administered CAR T cells.
Sponges are the richest source of bioactive organic small molecules, referred to as natural products, in the marine environment. It is well established that laboratory culturing-resistant symbiotic ...bacteria residing within the eukaryotic sponge host matrix often synthesize the natural products that are detected in the sponge tissue extracts. However, the contributions of the culturing-amenable commensal bacteria that are also associated with the sponge host to the overall metabolome of the sponge holobiont are not well defined. In this study, we cultured a large library of bacteria from three marine sponges commonly found in the Florida Keys. Metabolomes of isolated bacterial strains and that of the sponge holobiont were compared using mass spectrometry to reveal minimal metabolomic overlap between commensal bacteria and the sponge hosts. We also find that the phylogenetic overlap between cultured commensal bacteria and that of the sponge microbiome is minimal. Despite these observations, the commensal bacteria were found to be a rich resource for novel natural product discovery. Mass spectrometry-based metabolomics provided structural insights into these cryptic natural products. Pedagogic innovation in the form of laboratory curricula development is described which provided undergraduate students with hands-on instruction in microbiology and natural product discovery using metabolomic data mining strategies.
Background
Pro‐inflammatory and coagulation factors serve as biomarkers of aging and functional reserve. The purpose of this study was to determine if pro‐inflammatory (interleukin‐6 IL‐6, C‐reactive ...protein CRP), and coagulation (D‐dimer) factors were associated with pre‐chemotherapy functional status in women with stage I–III breast cancer.
Patients and Methods
Prior to chemotherapy initiation in patients with stage I–III breast cancer, the following was captured: IL‐6, CRP, D‐dimer blood levels, and physical function measures including activities of daily living (ADL, subscale of Medical Outcomes Study Physical Health); instrumental activities of daily living (IADL, subscale of the Older Americans Resources and Services Program); Timed Up and Go (TUG); physician‐rated Karnofsky Performance Status (KPS); and self‐rated KPS. The association of these biomarkers with physical function measures was evaluated.
Results
One hundred sixty patients (mean age 58.3 years, range 30–81 years) with stage I–III breast cancer (stages I n = 34; 21.5%, II n = 88; 55.7%, III n = 36; 22.8%) were enrolled. The group with poorest physical function (defined by ADL <70, IADL <14, and TUG ≥10 seconds) had higher levels of IL‐6 (p = .05), D‐dimer (p = .0004), and CRP (p = .05). There was no significant association between these biomarkers and KPS. Patients with at least two biomarkers in the highest quartile were more likely to have poorer physical function (odds ration OR 18.75, p < .001). In multivariate analysis adjusting for age, stage, number of comorbidities, and body mass index, the association remained (OR 14.6, p = .002).
Conclusion
Pre‐chemotherapy biomarkers of aging are associated with poorer physical function among patients with breast cancer across the aging spectrum. The Oncologist 2017;22:1189–1196
Implications for Practice
Commonly used physical function assessment tools may not reflect the diverse nature of physical function and risk for chemotherapy toxicity, particularly in older adults. No laboratory test reflects functional reserve. Pro‐inflammatory and coagulation factors, such as IL‐6, CRP, and D‐dimer, can serve as biomarkers of aging and physical function; however, few studies have evaluated their utility in patients with cancer. This study was designed to understand the association between pre‐chemotherapy biomarkers and physical function in women with early stage breast cancer undergoing adjuvant chemotherapy. Results indicate that elevated pre‐chemotherapy levels in two of the three peripheral biomarkers are associated with the poorest physical function among patients with breast cancer across the aging spectrum.
Breast cancer is a disease associated with aging. Before initiation of chemotherapy, an assessment of functional reserve is needed; however, simple performance assessment scores may not reflect the diverse nature of physical function and risk of toxicity among older adults. The focus of this article is on understanding the association between pre‐chemotherapy biomarkers (IL‐6, CRP, and D‐dimer) and measures of physical function.
Abstract
Background: Pro-inflammatory and coagulation factors such as IL-6, CRP and D-dimer serve as biomarkers for aging. The utility of these markers as biologic correlates of physical function in ...patients with BC is not known. This study was performed to determine if baseline serum markers of inflammation (IL-6, CRP) and coagulation (D-dimer) correlate with baseline functional status in women with stage I-III BC requiring chemotherapy (chemo). Methods: This is a prospective longitudinal study that enrolled 153 women across all age groups with BC who had pre-chemotherapy peripheral blood captured for IL-6, CRP, and D-dimer and a baseline assessment of the following functional status measures: activities of daily living (Medical Outcomes Study MOS Physical Health); instrumental activities of daily living (IADL); self-rated Karnofsky performance status (KPS); physician-rated KPS; number of falls in last 6 months; and Timed Up and Go (TUG). Peripheral blood samples were collected for measurement of IL-6, CRP and D-dimer. Quantitative IL-6 and CRP levels were obtained using NOVEX® immunoassay (Invitrogen) and D-dimer levels were measured with Nanopia®D-dimer(Sekisui). Univariate analyses were performed to describe correlations of these three biomarkers and 6 measures of physical function. Results: 153 patients (mean age of 57.5 y, range 30-81 y) with stage I- III BC (Stages I n=35; 23%, II n=82; 54%, III n=36; 24%) were enrolled. Chemo regimens include: doxorubicin+cyclophosphamide/ paclitaxel(AC-T: 44%), docetaxel/cyclophosphamide (TC: 35%), docetaxel/carboplatin/trastuzumab (TCH: 7%) and other regimen(14%). Scores for the physical function measures are as follow: MOS (median 89, range 0-100); IADL (median 14, range 4-14); self-rated KPS (median 90, range 60-100); physician-rated KPS (median 100, range 80-100); TUG (median 9 seconds, range 5-18). Serum biomarkers measurements and distributions are listed in table 1. There were associations between decreased physical function by IADL and increased IL-6 (p<0.01); decreased MOS and increased D-dimer (p<0.01); increased number of falls and increased CRP (p=0.02) and D-dimer (p=0.04); increased TUG and increased IL-6 (p<0.01), CRP (p<0.01) and D-dimer (p=0.06) (Table 2). Physician and patient-rated KPS did not correlate with IL-6, CRP and D-dimer level. Conclusions: Baseline measures of inflammation and coagulation correlate with physical function measures among patients with breast cancer. Future analyses evaluating the association between aging biomarkers and measures of physical function with subsequent risk of chemotherapy toxicity is underway.
Table 1. Serum biomarkers measurement at baseline prior to initiation of chemotherapyBiomarkerMeanStandard DeviationMedianRangeIL-6 (pg/ml)4.35.13.00-48.0CRP(µg/ml)5.77.92.80.1-48.4D-dimer(µg/ml)0.70.60.60.1-3.3
Table 2. Univariate analysis of measures of physical functions versus biomarkersVariablesSpearman Coefficientp valueMOS vs D-dimer-0.21<0.01IADL vs IL-6-0.27<0.01No. of falls vs D-dimer0.160.04No. of falls vs CRP0.190.02TUG vs D-dimer0.150.06TUG vs IL-60.26<0.01TUG vs CRP0.23<0.01
Citation Format: Yuan Yuan, Nilesh Vora, Tao Feng, Joanne Mortimer, Thehang Luu, George Somlo, Joseph Chao, Vivi Tran, Shu Mi, Tim Synold, James Waisman, Laura Zavala, Vani Katheria, Arti Hurria. Association of baseline pro-inflammatory (IL-6, CRP) and coagulation (D-dimer) markers with baseline functional status in women with breast cancer (BC) undergoing chemotherapy abstract. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-01-07.
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