Immune checkpoint inhibitors for patients with advanced lung cancer and oncogenic driver alterations: results from the IMMUNOTARGET registry.

BACKGROUND: Anti-PD1/PD-L1 directed immune checkpoint inhibitors (ICI) are widely used to treat patients with advanced non-small-cell lung cancer (NSCLC). The activity of ICI across NSCLC harboring oncogenic alterations is poorly characterized. The aim of our study was to address the efficacy of ICI in the context of oncogenic addiction. PATIENTS AND METHODS: We conducted a retrospective study for patients receiving ICI monotherapy for advanced NSCLC with at least one oncogenic driver alteration. Anonymized data were evaluated for clinicopathologic characteristics and outcomes for ICI therapy: best response (RECIST 1.1), progression-free survival (PFS), and overall survival (OS) from ICI initiation. The primary end point was PFS under ICI. Secondary end points were best response (RECIST 1.1) and OS from ICI initiation. RESULTS: We studied 551 patients treated in 24 centers from 10 countries. The molecular alterations involved KRAS (n = 271), EGFR (n = 125), BRAF (n = 43), MET (n = 36), HER2 (n = 29), ALK (n = 23), RET (n = 16), ROS1 (n = 7), and multiple drivers (n = 1). Median age was 60 years, gender ratio was 1 : 1, never/former/current smokers were 28%/51%/21%, respectively, and the majority of tumors were adenocarcinoma. The objective response rate by driver alteration was: KRAS = 26%, BRAF = 24%, ROS1 = 17%, MET = 16%, EGFR = 12%, HER2 = 7%, RET = 6%, and ALK = 0%. In the entire cohort, median PFS was 2.8 months, OS 13.3 months, and the best response rate 19%. In a subgroup analysis, median PFS (in months) was 2.1 for EGFR, 3.2 for KRAS, 2.5 for ALK, 3.1 for BRAF, 2.5 for HER2, 2.1 for RET, and 3.4 for MET. In certain subgroups, PFS was positively associated with PD-L1 expression (KRAS, EGFR) and with smoking status (BRAF, HER2). CONCLUSIONS: : ICI induced regression in some tumors with actionable driver alterations, but clinical activity was lower compared with the KRAS group and the lack of response in the ALK group was notable. Patients with actionable tumor alterations should receive targeted therapies and chemotherapy before considering immunotherapy as a single agent.

PD-L1 expression, tumor mutational burden, and response to immunotherapy in patients with MET exon 14 altered lung cancers.

Background: MET exon 14 alterations are actionable oncogenic drivers. Durable responses to MET inhibitors are observed in patients with advanced MET exon 14-altered lung cancers in prospective trials. In contrast, the activity of immunotherapy, PD-L1 expression and tumor mutational burden (TMB) of these tumors and are not well characterized. Patients and methods: Patients with MET exon 14-altered lung cancers of any stage treated at two academic institutions were identified. A review of clinicopathologic and molecular features, and an analysis of response to single-agent or combination immune checkpoint inhibition were conducted. PD-L1 immunohistochemistry was carried out and TMB was calculated by estimation from targeted next-generation sequencing panels. Results: We identified 147 patients with MET exon 14-altered lung cancers. PD-L1 expression of 0%, 1%-49%, and ≥50% were 37%, 22%, and 41%, respectively, in 111 evaluable tumor samples. The median TMB of MET exon 14-altered lung cancers was lower than that of unselected non-small-cell lung cancers (NSCLCs) in both independently evaluated cohorts: 3.8 versus 5.7 mutations/megabase (P < 0.001, n = 78 versus 1769, cohort A), and 7.3 versus 11.8 mutations/megabase (P < 0.001, n = 62 versus 1100, cohort B). There was no association between PD-L1 expression and TMB (Spearman's rho=0.18, P = 0.069). In response-evaluable patients (n = 24), the objective response rate was 17% (95% CI 6% to 36%) and the median progression-free survival was 1.9 months (95% CI 1.7-2.7). Responses were not enriched in tumors with PD-L1 expression ≥50% nor high TMB. Conclusion: A substantial proportion of MET exon 14-altered lung cancers express PD-L1, but the median TMB is lower compared with unselected NSCLCs. Occasional responses to PD-1 blockade can be achieved, but overall clinical efficacy is modest.

Nanoparticle assisted solvent selective transdermal combination therapy of curcumin and 5-flurouracil for efficient cancer treatment.

Skin cancer is one among the many prominent diseases of the modern world and millions of people are suffering due to the lack of proper medication. Even though transdermal drug delivery systems (TDDS) provide an efficient route of drug administration, the advantages of combination chemotherapy have rarely been extended into TDDS. In the present work, a polymer capable of simultaneously encapsulating two anti-cancer drugs: 5-flurouracil (5-FU) and curcumin (CUR), and releasing them with varying kinetics as a function of the leaching solvent was developed. The prepared TDDS had two copolymers: alginate coated aminated nanodextran (ALG@AND) and chitosan coated folate decorated aminated ß-CD nano particles (CS@FA-g-AßCD). After inducing surface charges, both copolymers were coupled together by electrostatic forces. All the synthetic procedures for the preparation of TDDS were monitored using FTIR, DLS, Zeta Potential, SEM and TEM. The final TDDS was then evaluated for its solvent selectivity. Sustained release of 5-FU and CUR was observed with ethanol (EtOH) and 1-butanol (BuOH) respectively. However, these solvents could also release a small amount of the second drug which led to combinatorial therapy. The in vitro solvent selective drug permeation profiles were evaluated using Franz diffusion cell on rat skin. In order to evaluate the economic feasibility of the prepared TDDS, in vivo skin adhesion tests, skin irritation analysis, water vapour permeability and average visible transmittance were performed. Results proved that solvents could not only elute the drugs in a sustained manner, but could also act as penetration enhancers. Biological and histological studies carried out on skin and cancer cell lines suggested the potential usefulness of the prepared material in combinatorial chemotherapy.

Clinical outcomes with pemetrexed-based systemic therapies in RET-rearranged lung cancers.

BACKGROUND: RET rearrangements are targetable, oncogenic lung cancer drivers. While previous series have shown durable clinical benefit with pemetrexed-based therapies in ALK- and ROS1-rearranged lung cancers, the benefits of pemetrexed-based treatments in patients with RET-rearranged lung cancers relative to other genomic subsets have not previously been explored. PATIENTS AND METHODS: A retrospective review of patients with pathologically confirmed stage IIIB/IV lung adenocarcinomas and evidence of a RET, ROS1, or ALK rearrangement, or a KRAS mutation was conducted. Patients were eligible if they received treatment with pemetrexed alone or in combination. The primary outcome of progression-free survival (PFS), and secondary outcomes of overall response rate (ORR, RECIST v1.1), time to progression (TTP), and time to treatment discontinuation were compared between RET-rearranged and groups of ROS1-rearranged, ALK-rearranged, and KRAS-mutant lung cancers. RESULTS: We evaluated 104 patients. Patients with RET-rearranged lung cancers (n = 18) had a median PFS of 19 months [95% confidence interval (CI) 12-not reached (NR)] that was comparable with patients with ROS1- (23 months, 95% CI 14-NR, n = 10) and ALK-rearranged (19 months, 95% CI 15-36, n = 36) lung cancers, and significantly improved compared with patients with KRAS-mutant lung cancers (6 months, 95% CI 5-9, P < 0.001, n = 40). ORR (45%), median TTP (20 months, 95% CI 17-NR), and median time to treatment discontinuation (21 months, 95% CI 6-NR) in patients with RET-rearranged lung cancers were not significantly different compared with patients with ALK- and ROS1-rearranged lung cancers, and improved compared with patients with KRAS-mutant lung cancers. CONCLUSION: Durable benefits with pemetrexed-based therapies in RET-rearranged lung cancers are comparable with ALK- and ROS1-rearranged lung cancers. When selecting therapies for patients with RET-rearranged lung cancers, pemetrexed-containing regimens should be considered.

Conservative and nonconservative mutations of the transmembrane CPC motif in ZntA: effect on metal selectivity and activity.

ZntA from Escherichia coli belongs to the P1B-ATPase transporter family and mediates resistance to toxic levels of selected divalent metal ions. P1B-type ATPases can be divided into subgroups based on substrate cation selectivity. ZntA has the highest selectivity for Pb2+, followed by Zn2+ and Cd2+; it also shows low levels of activity with Cu2+, Ni2+, and Co2+. It has two high-affinity metal-binding sites, one each in the N-terminus and the transmembrane domains. Ligands to the transmembrane metal site in ZntA include the cysteine residues of the conserved 392CPC394 motif in the sixth transmembrane helix. Pro393 is invariant in all P-type ATPases. For ZntA homologues with different metal ion selectivity, the cysteines are replaced by serine, histidine, and threonine. To test the effect on activity and metal ion selectivity, single alanine, histidine, and serine substitutions at Cys392 or Cys394 in ZntA were characterized, as well as double substitutions of both cysteines by histidine or serine. P393A was also characterized. C392A, C394A, and P393A lost the ability to bind a metal ion with high affinity in the transmembrane domain. Histidine and serine substitutions at Cys392 and Cys394 resulted in loss of binding of Pb2+ at the transmembrane site, indicating that both cysteines of the CPC motif are required for binding Pb2+ with high affinity in ZntA homologues. However, C392H, C392S, C394H, C394S, C392S/C394S, and C392H/C394H could bind other divalent metal ions at the transmembrane site and retained low but measurable activity. Interestingly, these mutants lost the predominant selectivity for Zn2+ and Cd2+ shown by wtZntA. Therefore, conserved residues contribute to metal selectivity by supplying ligands that bind metal ions not only with high affinity, as for Pb2+, but also with the most favorable binding geometry that results in efficient catalysis.

Conserved aspartic acid 714 in transmembrane segment 8 of the ZntA subgroup of P1B-type ATPases is a metal-binding residue.

ZntA from Escherichia coli is a member of the P1B-type ATPase family that confers resistance specifically to Pb2+, Zn2+, and Cd2 salts by active efflux across the cytoplasmic membrane. P1B-type ATPases are important for homeostasis of metal ions such as Cu+, Ag+, Pb2+, Zn2+, Cd2+ Cu2+, and Co2+, with different subgroups showing specificity for different metal ions. Sequence alignments of P1B-type ATPases show that ZntA and close homologues have a strictly conserved Asp714 in the eighth transmembrane domain that is not conserved in other subgroups of P1B-type ATPases. However, in the sarcoplasmic reticulum Ca2+-ATPase, a structurally characterized P-type ATPase, the residue corresponding to Asp714 is a metal-binding residue. Four site-specific mutants at Asp714, D714E, D714H, D714A, and D714P, were characterized. A comparison of their metal-binding affinity with that of wtZntA revealed that Asp714 is a ligand for the metal ion in the transmembrane site. Thus, Asp714 is one of the residues that determine metal ion specificity in ZntA homologues. All four substitutions at Asp714 in ZntA resulted in complete loss of in vivo resistance activity and complete or large reductions in ATPase activity, though D714E and D714H retained the ability to bind metal ions with high affinity at the transmembrane site. Thus, the ability to bind metal ions with high affinity did not correlate with high activity. The metal-binding affinity of the N-terminal site remained unchanged in all four mutants. The affinities of the two metal-binding sites in wtZntA determined in this study are similar to values reported previously for the individual sites in isolated ZntA fragments.

Metal-binding affinity of the transmembrane site in ZntA: implications for metal selectivity.

ZntA, a P1B-type ATPase, confers resistance specifically to Pb2+, Zn2+, and Cd2 in Escherichia coli. Inductively coupled plasma mass spectrometry measurements show that ZntA binds two metal ions with high affinity, one in the N-terminal domain and another in the transmembrane domain. Both sites can bind monovalent and divalent metal ions. Two proteins, deltaN-ZntA, in which the N-terminal domain is deleted, and C59A/C62A-ZntA, in which the N-terminal metal-binding site is disabled by site-specific mutagenesis, can only bind one metal ion. Because C59A/C62A-ZntA can bind a metal ion at the transmembrane site, the N-terminal domain does not block direct access of metal ions to it from the cytosol. A third mutant protein, C392A/C394A-ZntA, in which cysteines from the conserved CPC motif in transmembrane helix 6 are altered, binds metal ions only at the N-terminal site, indicating that both these cysteines form part of the transmembrane site. The metal affinity of the transmembrane site was determined in deltaN-ZntA and C59A/C62A-ZntA by competition titration using a metal ion indicator and by tryptophan fluorescence quenching. The binding affinity for the physiological substrates, Zn2+, Pb2+, and Cd2+, as well as for the extremely poor substrates, Cu2+, Ni2+, and Co2+, range from 10(6)-10(10) M(-1), and does not correlate with the metal selectivity shown by ZntA. Selectivity in ZntA possibly results from differences in metal-binding geometry that produce different structural responses. The affinity of the transmembrane site for metal ions is of similar magnitude to that of the N-terminal site [Liu J. et al. (2005) Biochemistry 44, 5159-5167]; thus, metal transfer between them would be facile.

Kinetic analysis of metal binding to the amino-terminal domain of ZntA by monitoring metal-thiolate charge-transfer complexes.

ZntA, a P(1B)-ATPase transporter from Escherichia coli, mediates resistance specifically to Pb(2+), Zn(2+), and Cd(2+) by active efflux. ZntA has a hydrophilic N-terminal domain that binds one metal ion. This domain, approximately 120 residues long, contains the GXXCXXC motif that has been shown to be the binding site for metal ions such as Cu(+) and Zn(2+) in P(1B)-type ATPases, and an additional cysteine-rich motif, CCCDGAC. We report here that binding of Pb(2+) and Cd(2+) to this domain produces changes in the absorbance spectrum in the 250-400 nm range indicative of metal-thiolate charge-transfer complexes. The spectral changes indicate that only two cysteines are ligands to Cd(2+), but three or more cysteines are involved in binding Pb(2+); this confirms earlier results that the GXXCXXC sequence is not sufficient to bind Pb(2+), which likely involves residues from the CCCDGAC motif. The absorbance changes were used to measure metal binding kinetics of the N-terminal domain using stopped-flow techniques. Binding was described by simple second-order kinetics with a rate constant, k(on), of approximately 10(6)-10(7) M(-)(1) s(-)(1), at 4 degrees C. The activation energy of binding is similar for both Pb(2+) and Cd(2+); however, the entropy change is greater for Pb(2+). The surprisingly large rate constant for metal binding to the N-terminal domain of ZntA, compared to its low turnover rate, indicates that this step is not rate limiting in the overall transport mechanism. These results, in conjunction with earlier studies, suggest that metal binding to the transmembrane site in ZntA or metal release from the transporter is the slow step in the reaction cycle.

Constraint-induced motor relearning after stroke: a naturalistic case report.

Constraint-induced movement therapy (CIMT) is a promising approach to promoting recovery of functional arm movement after stroke. However, controlled studies have been limited to persons who sustained strokes at least 1 year before beginning the treatment protocol. This case study documents the neurologic history and motor recovery of a woman whose natural circumstances lend support to the principles of CIMT. The patient sustained a right midpontine vascular infarct and fell simultaneously, fracturing her right humerus. Orthopedic intervention for the fracture mirrored the protocol suggested by proponents of CIMT by immobilizing her right arm. Her significant recovery of left arm use over a 1-year period was more extensive than what would be typically expected after the type of cerebral infarct she incurred. Her case provides the first evidence in the literature that supports the principles of CIMT when it is applied immediately poststroke.

Reflections upon rehabilitation by members of a community based stroke club.

PURPOSE: To collect qualitative information about personal experiences with stroke rehabilitation from members of a community based stroke club. METHOD: In this focused ethnographic study, four data collectors observed and videotaped two sessions of a community based stroke club. The videotape and written notes were reviewed and analysed according to standard qualitative research procedures. RESULTS: Two themes emerged from analysis of the qualitative data: concerns that individualized needs were not addressed during the rehabilitation process and that services were insufficient to ease the transition to community living. CONCLUSIONS: Rehabilitation professionals can benefit from soliciting reflections and suggestions from individuals who have returned to community living after completing post-stroke rehabilitation programmes. Specific recommendations are provided for tailoring interventions to meet individual goals, for enhancing follow up services provided after inpatient rehabilitation, and for providing early access to available resources in stroke survivors' communities.

Goniometric assessment of shoulder range of motion: comparison of testing in supine and sitting positions.

OBJECTIVE: To examine intrarater reliability in measurements of active range of motion and passive range of motion of shoulder flexion and abduction when motions are assessed in sitting, as compared with supine. DESIGN: Thirty adult subjects were measured eight times, in random order, for each of the two shoulder motions: two passive and two active measurements while sitting, and two passive and two active measurements while supine. Data were analyzed to determine intraclass correlation coefficients (ICCs) and paired t values between trials 1 and 2 for measurements in the same position, and between sitting and supine trials for each type of measurement. SETTINGS: Rehabilitation facility and university. STUDY POPULATION: Volunteer sample: 11 rehabilitation inpatients; 19 university students. RESULTS: ICCs between trials 1 and 2 on comparable measurements in the same position indicated high intrarater reliability for active and passive measurements, regardless of testing position. ICCs between comparable measurements in the two testing positions indicated only a moderate level of agreement. Paired t tests between comparable readings taken in sitting versus supine revealed no significant differences for flexion, but significantly higher measurements of abduction when testing in the supine position. CONCLUSIONS: Measurements in sitting or supine yield similarly high intrarater reliability. Lowered reliability between measurements taken in different positions indicates that test position should be routinely recorded, and repeated clinical measures of individual subjects should be administered in a consistent position.

A competency-based training program in early intervention.

This paper describes a federally funded training program developed to prepare entry-level occupational therapists to deliver early intervention services. The program had two phases. Phase I was designed to provide occupational therapy supervisors with advanced skills for supervising and teaching the students about the provision of early intervention services. These skills were specific supervisory strategies and learning techniques designed to facilitate optimal communication between the student, the supervisor, and the academic faculty members, as well as to facilitate consistency of information between workshops and practices in the clinic. Phase II involved a 12-week clinical fieldwork experience for the students in an early intervention program combined with didactic programs at the university. Both supervisors and students provided feed-back on the program. Supervisors reported that the training strengthened their supervisory skills and techniques. Students reported that the training helped them to clarify the role of occupational therapy in early intervention and that they had developed skills critical to providing family-centered early intervention. These skills included both providing direct treatment to children and working in partnership with families and caregivers.

Motor learning concepts applied to activity-based intervention with adults with hemiplegia.

This paper presents a framework for the integration of motor learning research findings with a neurodevelopmental treatment perspective. The importance of activity-based intervention is emphasized, and a strategy for activity synthesis is presented. Clinical problems seen in persons with hemiplegia are used to clarify concepts and illustrate therapeutic interventions.

Professional socialization: implications for occupational therapy education.

This article examines the implications that adult socialization theory can have on occupational therapy education. Sociological literature about professional socialization is reviewed and related to the preparation of occupational therapists. The discussion includes a description of the goals, processes, and participants in professional socialization. Consistency of socializing influences is presented as a critical factor in the formation of strong professional role identities. Finally, the article considers which values and attitudes may be transmitted during the socialization process for occupational therapists and other health professionals.

The roles and functions of occupational therapy services for the severely disabled.

Occupational therapy is an essential service for providing and maintaining the highest possible quality of life for severely disabled individuals. The occupational therapist intervenes to enable severely disabled clients to function at their maximum potential.