Neratinib + fulvestrant + trastuzumab for HR-positive, HER2-negative, HER2-mutant metastatic breast cancer: outcomes and biomarker analysis from the SUMMIT trial.

BACKGROUND: HER2 mutations are targetable alterations in patients with hormone receptor-positive (HR+) metastatic breast cancer (MBC). In the SUMMIT basket study, patients with HER2-mutant MBC received neratinib monotherapy, neratinib + fulvestrant, or neratinib + fulvestrant + trastuzumab (N + F + T). We report results from 71 patients with HR+, HER2-mutant MBC, including 21 (seven in each arm) from a randomized substudy of fulvestrant versus fulvestrant + trastuzumab (F + T) versus N + F + T. PATIENTS AND METHODS: Patients with HR+ HER2-negative MBC with activating HER2 mutation(s) and prior cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) therapy received N + F + T (oral neratinib 240 mg/day with loperamide prophylaxis, intramuscular fulvestrant 500 mg on days 1, 15, and 29 of cycle 1 then q4w, intravenous trastuzumab 8 mg/kg then 6 mg/kg q3w) or F + T or fulvestrant alone. Those whose disease progressed on F + T or fulvestrant could cross-over to N + F + T. Efficacy endpoints included investigator-assessed objective response rate (ORR), clinical benefit rate (RECIST v1.1), duration of response, and progression-free survival (PFS). Plasma and/or formalin-fixed paraffin-embedded tissue samples were collected at baseline; plasma was collected during and at end of treatment. Extracted DNA was analyzed by next-generation sequencing. RESULTS: ORR for 57 N + F + T-treated patients was 39% [95% confidence interval (CI) 26% to 52%); median PFS was 8.3 months (95% CI 6.0-15.1 months). No responses occurred in fulvestrant- or F + T-treated patients; responses in patients crossing over to N + F + T supported the requirement for neratinib in the triplet. Responses were observed in patients with ductal and lobular histology, 1 or ≥1 HER2 mutations, and co-occurring HER3 mutations. Longitudinal circulating tumor DNA sequencing revealed acquisition of additional HER2 alterations, and mutations in genes including PIK3CA, enabling further precision targeting and possible re-response. CONCLUSIONS: The benefit of N + F + T for HR+ HER2-mutant MBC after progression on CDK4/6is is clinically meaningful and, based on this study, N + F + T has been included in the National Comprehensive Cancer Network treatment guidelines. SUMMIT has improved our understanding of the translational implications of targeting HER2 mutations with neratinib-based therapy.

Regional and annual patterns in respiratory virus co-infection etiologies and antibiotic prescriptions for pediatric mycoplasma pneumoniae pneumonia.

OBJECTIVE: Mycoplasma pneumoniae (M. pneumoniae) pneumonia is the second-most common cause of community-acquired pneumonia (CAP). This study aimed at investigating into the prevalence of macrolide-resistant M. pneumoniae (MRMP) with respiratory virus co-infection and the antibiotic prescriptions in children with CAP in four provinces in Korea, and to assess the variations in the findings across regions and throughout the year. PATIENTS AND METHODS: This prospective study was conducted in 29 hospitals in Korea between July 2018 and June 2020. Among the enrolled 1,063 children with CAP, all 451 patients with M. pneumoniae underwent PCR assays of M. pneumoniae and respiratory viruses, and the presence of point mutations of residues 2063 and 2064 was evaluated. RESULTS: Gwangju-Honam (88.6%) showed the highest prevalence of MRMP pneumonia, while Daejeon-Chungcheong (71.3%) showed the lowest, although the differences in prevalence were not significant (p=0.074). Co-infection of M. pneumoniae pneumonia and respiratory virus was observed in 206 patients (45.4%), and rhinovirus co-infection (101 children; 22.2%) was the most frequent. The prevalence of MRMP pneumonia with respiratory virus co-infection and the antibiotic prescriptions differed significantly among the four provinces (p < 0.05). The monthly rate of MRMP pneumonia cases among all cases of M. pneumoniae pneumonia and tetracycline or quinolone prescriptions did not differ significantly among the four regions (trend p > 0.05) during the study period. CONCLUSIONS: The prevalence of M. pneumoniae pneumonia with virus co-infection and antibiotic prescriptions could differ according to region, although the MRMP pneumonia rate showed no difference within Korea.

Evaluation of immunologic parameters in canine glioma patients treated with an oncolytic herpes virus.

Aim: To molecularly characterize the tumor microenvironment and evaluate immunologic parameters in canine glioma patients before and after treatment with oncolytic human IL-12-expressing herpes simplex virus (M032) and in treatment naïve canine gliomas. Methods: We assessed pet dogs with sporadically occurring gliomas enrolled in Stage 1 of a veterinary clinical trial that was designed to establish the safety of intratumoral oncoviral therapy with M032, a genetically modified oncolytic herpes simplex virus. Specimens from dogs in the trial and dogs not enrolled in the trial were evaluated with immunohistochemistry, NanoString, Luminex cytokine profiling, and multi-parameter flow cytometry. Results: Treatment-naive canine glioma microenvironment had enrichment of Iba1 positive macrophages and minimal numbers of T and B cells, consistent with previous studies identifying these tumors as immunologically "cold". NanoString mRNA profiling revealed enrichment for tumor intrinsic pathways consistent with suppression of tumor-specific immunity and support of tumor progression. Oncolytic viral treatment induced an intratumoral mRNA transcription signature of tumor-specific immune responses in 83% (5/6) of canine glioma patients. Changes included mRNA signatures corresponding with interferon signaling, lymphoid and myeloid cell activation, recruitment, and T and B cell immunity. Multiplexed protein analysis identified a subset of oligodendroglioma subjects with increased concentrations of IL-2, IL-7, IL-6, IL-10, IL-15, TNFα, GM-CSF between 14 and 28 days after treatment, with evidence of CD4+ T cell activation and modulation of IL-4 and IFNγ production in CD4+ and CD8+ T cells isolated from peripheral blood. Conclusion: These findings indicate that M032 modulates the tumor-immune microenvironment in the canine glioma model.

The BET bromodomain inhibitor JQ1 suppresses growth of pancreatic ductal adenocarcinoma in patient-derived xenograft models.

The primary aim of this study was to evaluate the antitumor efficacy of the bromodomain inhibitor JQ1 in pancreatic ductal adenocarcinoma (PDAC) patient-derived xenograft (tumorgraft) models. A secondary aim of the study was to evaluate whether JQ1 decreases expression of the oncogene c-Myc in PDAC tumors, as has been reported for other tumor types. We used five PDAC tumorgraft models that retain specific characteristics of tumors of origin to evaluate the antitumor efficacy of JQ1. Tumor-bearing mice were treated with JQ1 (50 mg/kg daily for 21 or 28 days). Expression analyses were performed with tumors harvested from host mice after treatment with JQ1 or vehicle control. An nCounter PanCancer Pathways Panel (NanoString Technologies) of 230 cancer-related genes was used to identify gene products affected by JQ1. Quantitative RT-PCR, immunohistochemistry and immunoblots were carried out to confirm that changes in RNA expression reflected changes in protein expression. JQ1 inhibited the growth of all five tumorgraft models (P<0.05), each of which harbors a KRAS mutation; but induced no consistent change in expression of c-Myc protein. Expression profiling identified CDC25B, a regulator of cell cycle progression, as one of the three RNA species (TIMP3, LMO2 and CDC25B) downregulated by JQ1 (P<0.05). Inhibition of tumor progression was more closely related to decreased expression of nuclear CDC25B than to changes in c-Myc expression. JQ1 and other agents that inhibit the function of proteins with bromodomains merit further investigation for treating PDAC tumors. Work is ongoing in our laboratory to identify effective drug combinations that include JQ1.

The expression of hyperpolarization-activated cyclic nucleotide-gated channel 1 (HCN1) and HCN2 in the rat trigeminal ganglion, sensory root, and dental pulp.

Hyperpolarization-activated cyclic nucleotide-gated channel 1 (HCN1) and 2 (HCN2) are abundantly expressed in primary sensory neurons and contribute to neuronal excitability and pathological pain. We studied the expression of HCN1 and HCN2 in the rat trigeminal ganglion (TG) neurons and axons in the dental pulp, and the changes in their expression following inflammation, using light- and electron-microscopic immunocytochemistry and quantitative analysis. HCN1 and HCN2 were expressed predominantly in large-sized, neurofilament 200-immunopositive (+) or parvalbumin+ soma in the TG whereas they were expressed mostly in unmyelinated and small myelinated axons in the sensory root. The expression was particularly strong along the plasma membrane in the soma. In the dental pulp, majority of HCN1+ and HCN2+ axons coexpressed calcitonin gene-related peptide. They were expressed mainly in the peripheral pulp and pulp horn where the axons branch extensively in the dental pulp. The expression of HCN1 and HCN2 in TG neurons increased significantly in rats with experimentally induced inflammation of the dental pulp. Our findings support the notion that HCN1 and HCN2 are expressed mainly by both the soma of mechanosensitive neurons in the TG and peripheral axons of nociceptive neurons in the sensory root, and may play a role in the mechanisms of inflammatory pain from the dental pulp.

The intersection between DNA damage response and cell death pathways.

Apoptosis is a finely regulated process that serves to determine the fate of cells in response to various stresses. One such stress is DNA damage, which not only can signal repair processes but is also intimately involved in regulating cell fate. In this review we examine the relationship between the DNA damage/repair response in cell survival and apoptosis following insults to the DNA. Elucidating these pathways and the crosstalk between them is of great importance, as they eventually contribute to the etiology of human disease such as cancer and may play key roles in determining therapeutic response. This article is part of a Special Issue entitled "Apoptosis: Four Decades Later".

Biomarkers to assess the targeting of DNA repair pathways to augment tumor response to therapy.

Hyper-activation of DNA repair pathways can enable tumor cells to survive DNA damage. Therefore, targeting specific DNA repair pathways might prove efficacious for cancer therapy. The advent of personalized therapy necessitates novel biomarkers to assess tumor response to therapy. Biological indicators are vital in the field of cancer research and treatment. The focus of this review is on the DNA repair machinery as an emerging target for enhancement of therapy. Additionally, DNA damage and repair biomarkers for prognosis in different types of cancer will be discussed. The application of biomarkers to assess tumor response to therapy based on targeting DNA repair pathways can potentially improve patient quality of life and aid in treatment design.

Body site colonization in patients with community-associated methicillin-resistant Staphylococcus aureus and other types of S. aureus skin infections.

Efforts to control spread of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) are often based on eradication of colonization. However, the role of nasal and non-nasal colonization in the pathogenesis of these infections remains poorly understood. Patients with acute S. aureus skin and soft tissue infection (SSTI) were prospectively enrolled. Each subject's nasal, axillary, inguinal and rectal areas were swabbed for S. aureus and epidemiological risk factors were surveyed. Among the 117 patients enrolled, there were 99 patients who had an SSTI and for whom data could be analysed. Sixty-five patients had a CA-MRSA SSTI. Among these patients, MRSA colonization in the nares, axilla, inguinal area and rectum was 25, 6, 11 and 13%, respectively, and 37% overall were MRSA colonized. Most (96%) MRSA colonization was detected using nose and inguinal screening alone. Non-nasal colonization was 25% among CA-MRSA patients, but only 6% among patients with CA-methicillin-susceptible S. aureus (MSSA) or healthcare-associated MRSA or MSSA. These findings suggest that colonization patterns in CA-MRSA infection are distinct from those in non-CA-MRSA S. aureus infections. The relatively high prevalence of non-nasal colonization may play a key role in CA-MRSA transmission and acquisition of infection.

In vivo tumor detection on rabbit with biopsy needle as MRE driver.

Magnetic Resonance Elastography (MRE) is a phase contrast imaging technique to quantitatively measure the elasticity of tissues. Typically, the oscillating driver is placed on the surface of objects to generate shear waves. When it is applied to detect tumors in deep location, the depth penetration of the wave is limited by attenuation and the biopsy procedure has to be performed separately. In this study, we describe a method using biopsy needle as the MRE driver to produce shear waves in tissues. We made comparison between the MRE acquisitions obtained with biopsy needle and surface drivers. Because the well-defined propagation wave pattern reduces the error in wavelength calculation, the acquisitions of biopsy needle driver shows better homogeneity in stiffness map. We also performed the experiment with the biopsy needle for in vivo tumor detection in rabbits. This study demonstrates that the biopsy needle driver is more effective than the surface driver for accurately measuring the stiffness and location of the tumor.

A study of femoral artery by twin drivers in magnetic resonance interference elastography.

Magnetic Resonance Elastography (MRE) is a phase-contrast technique using conventional Magnetic Resonance Imaging system to visualize propagating shear waves and study the stiffness of tissues. Usually, shear vibrations are applied to the surface of tissues by means of mechanical driver at one point. But in femoral artery study, the shear wave generated by the single driver on the surface of thigh cannot reach the femoral artery behind vein because of the blockage from the vein. In this study, the twin drivers set developed in our laboratory is used to overcome the problem. By using twin drivers driven simultaneously, interference shear wave pattern is generated. MR Interference Elastography is using interference shear wave image to study the stiffness of tissues. And, a finite element modeling was used to simulate single and twin driver datasets. The method was applied to in vivo human's femoral artery. And the result demonstrates the feasibility of this method. Further study will be conducted with the twin drivers in more in-vivo studies.

Biopsy needle as MRE driver for tumor detection.

Magnetic Resonance Elastography (MRE) is a phase contrast imaging technique to quantitatively measure the elasticity of tissues. Typically, an oscillating driver is placed on the surface to generate the shear waves. The depth penetration of the wave is limited by attenuation and the biopsy procedure has to be done separately. In this study, we use a biopsy needle as the driver to detect the 15% porcine gel inclusion in a 10% porcine gel phantom which simulates a tumor in tissues. We also perform the experiment with the biopsy needle for in-vivo tumor detection in rabbits. It is shown that the biopsy needle driver can accurately measure the stiffness and location of the tumor.

Magnetic resonance elastography with twin pneumatic drivers for wave compensation.

MR Elastography is a new technique using conventional MRI system to assess the elastic properties of tissues. When using pneumatic driver, usually one driver was put at one place of tissue. But the shear wave generated by one pneumatic driver cannot illuminate the large area due to the attenuation. So we use two pneumatic drivers driven synchronously to generate interference shear wave in our experiments. The results from the phantom study show the interference wave pattern generated by the twin pneumatic drivers can compensate the attenuation of the shear wave when propagating in phantom. Also, a finite element modeling was used to simulate twin pneumatic driver datasets. It is hoped that by twin pneumatic drivers, we can illuminate the whole brain; the liver and large areas in-vivo. Further study will be conducted with the twin pneumatic drivers in ex-vivo and in-vivo studies.

Antioxidant enzyme inhibitors enhance nitric oxide-induced cell death in U937 cells.

Nitric oxide (NO), a radical species produced by many types of cells, is known to play a critical role in many regulatory processes, yet it may also participate in collateral reactions at higher concentrations, leading to cellular oxidative damage. The protective role of antioxidant enzymes against NO-induced oxidative damage in U937 cells was investigated in control and cells pre-treated with diethyldithiocarbamic acid, aminotriazole, and oxlalomalate, specific inhibitors of superoxide dismutase, catalase, and NADP(+)-dependent isocitrate dehydrogenase, respectively. Upon exposure to 1 mM S-nitroso-N-acetylpenicillamine (SNAP), the nitric oxide donor, to U937 cells, the viability was lower and the protein oxidation, lipid peroxidation and oxidative DNA damage reflected by an increase in 8-hydroxy-2'-deoxyguanosine, were higher in inhibitor-treated cells as compared to control cells. We also observed the significant increase in the endogenous production of reactive oxygen species, as measured by the oxidation of 2'7'-dichlorodihydrofluorescin as well as the significant decrease in the intracellular GSH level in inhibitor-treated U937 cells upon exposure to NO. Upon exposure to 0.2 mM SNAP, which induced apoptotic cell death, a clear inverse relationship was observed between the control and inhibitor-treated U937 cells in their susceptibility to apoptosis. These results suggest that antioxidant enzymes play an important role in cellular defense against NO-induced cell death including necrosis and apoptosis.

Needle shear wave driver for magnetic resonance elastography.

Magnetic resonance elastography (MRE) is capable of quantitatively depicting the mechanical properties of tissues in vivo. In contrast to mechanical excitation at the surface of the tissue, the method proposed in this study describes shear waves produced by an inserted needle. The results demonstrate that MRE performed with the needle driver provides shear stiffness estimates that correlate well with those obtained using mechanical testing. Comparisons between MRE acquisitions obtained with surface and needle drivers yielded similar results in general. However, the well-defined wave propagation pattern provided by the needle driver in a target region can reduce section orientation-related error in wavelength estimation that occurs with surface drivers in 2D MRE acquisitions. Preliminary testing of the device was performed on animals. This study demonstrates that the needle driver is an effective option that offers advantages over surface drivers for obtaining accurate stiffness estimates in targeted regions that are accessible by the needle.

Magnetic resonance elastography with twin drivers for high homogeneity and sensitivity.

Magnetic Resonance Elastography (MRE) is a phase-contrast technique using conventional Magnetic Resonance Imaging system to visualize propagating shear waves and study the stiffness of tissues. Usually, shear vibrations are applied to the surface of tissues by means of mechanical driver at one point. But it is hard for the single driver to detect very small tumors. Multiple drivers are expected to provide better elastogram and to be more sensitive to the small stiff inclusions. In this study, a pair of drivers was used and compared with the single driver. The result shows that using the twin drivers is more sensitive to small hard inclusions than using single driver. It is expected that the twin drivers can detect small tumors in tissues which can hardly be detected by a single driver. Further study will be conducted with the twin drivers in ex-vivo and in-vivo studies.

Myocardial Fiber Length Mapping with MR Diffusion Tensor Imaging.

Diffusion tensor MRI is emerging as a rapid, nondestructive method to map myocardial fiber organization. A precise biological description of myocardial fiber performance requires knowledge of four variables: length, force, velocity and time. However, study of quantification of myocardial fiber length is lacking. The current study aims to show myocardial fiber length maps of formalin-fixed heats. Diffusion tensor MRI with medium diffusion resolution (15 directions) was performed in one isolated pig heart. Fiber length maps were investigated in multiple short-axis slices. The results provide supplementary information of myocardial fiber organization. To our knowledge, the present study is the first report of the myocardial fiber length mapping.

Shear waves induced by moving needle in MR elastography.

Magnetic resonance elastography (MRE) is a phase contrast-based method for observing shear wave propagation in a material to determine its stiffness. The objective of this study was to determine whether shear waves suitable for MRE could be induced using a moving acupuncture needle. Tissue-simulating bovine gel phantom and a 0.4 mm diameter acupuncture needle were used in the experiment. The results showed that observable shear waves could be induced in the gel phantom by cyclic needle motion. The observed wavelength varied with excitation frequency, as expected. Generating shear waves using moving needles may be a useful tool to study the basic mechanism of acupuncture with MRE. Further study will be conducted to observe the wave motion in inhomogeneous media and acupuncture-induced effects in in-vivo studies.

Protective role of superoxide dismutases against ionizing radiation in yeast.

The protective role of superoxide dismutases (SODs) against ionizing radiation, which generates reactive oxygen species (ROS) harmful to cellular function, was investigated in the wild-type and in mutant yeast strains lacking cytosolic CuZnSOD (sod1Delta), mitochondrial MnSOD (sod2Delta), or both SODs (sod1Deltasod2Delta). Upon exposure to ionizing radiation, there was a distinct difference between these strains in regard to viability and the level of protein carbonyl content, which is the indicative marker of oxidative damage to protein, intracellular H2O2 level, as well as lipid peroxidation. When the oxidation of 2',7'-dichlorofluorescin was used to examine the hydroperoxide production in yeast cells, the SOD mutants showed a higher degree of increase in fluorescence upon exposure to ionizing radiation as compared to wild-type cells. These results indicated that mutants deleted for SOD genes were more sensitive to ionizing radiation than isogenic wild-type cells. Induction and inactivation of other antioxidant enzymes, such as catalase, glucose 6-phosphate dehydrogenase, and glutathione reductase, were observed after their exposure to ionizing radiation both in wild-type and in mutant cells. However, wild-type cells maintained significantly higher activities of antioxidant enzymes than did mutant cells. These results suggest that both CuZnSOD and MnSOD may play a central role in protecting cells against ionizing radiation through the removal of ROS, as well as in the protection of antioxidant enzymes.

Tight binding of pyridoxal 5'-phosphate to recombinant Escherichia coli pyridoxine 5'-phosphate oxidase.

Escherichia coli pyridoxine (pyridoxamine) 5'-phosphate oxidase (PNPOx) catalyzes the oxidation of pyridoxine 5'-phosphate and pyridoxamine 5'-phosphate to pyridoxal 5'-phosphate (PLP) using flavin mononucleotide (FMN) as the immediate electron acceptor and oxygen as the ultimate electron acceptor. This reaction serves as the terminal step in the de novo biosynthesis of PLP in E. coli. Removal of FMN from the holoenzyme results in a catalytically inactive apoenzyme. PLP molecules bind tightly to both apo- and holoPNPOx with a stoichiometry of one PLP per monomer. The unique spectral property of apoPNPOx-bound PLP suggests a non-Schiff base linkage. HoloPNPOx with tightly bound PLP shows normal catalytic activity, suggesting that the tightly bound PLP is at a noncatalytic site. The tightly bound PLP is readily transferred to aposerine hydroxymethyltransferase in dilute phosphate buffer. However, when the PNPOx. PLP complex was added to aposerine hydroxymethyltransferase suspended in an E. coli extract the rate of reactivation of the apoenzyme was several-fold faster than when free PLP was added. This suggests that PNPOx somehow targets PLP to aposerine hydroxymethyltransferase in vivo.