Anti-PD-1: When to Stop Treatment.

PURPOSE OF REVIEW: Emerging data indicate that immune checkpoint blockade (ICB) in patients with metastatic melanoma can be stopped electively or at the time of toxicity with an acceptable risk for progression. However, the optimal treatment duration remains to be defined. We review published data on treatment duration, outcome after treatment discontinuation, and treatment re-introduction in patients with metastatic melanoma. RECENT FINDINGS: Published studies indicate that disease control can be maintained after discontinuation of ICB therapy. Discontinuation of therapy in responders decreases the risk for treatment-related adverse events and lowers the financial burden of ICB. With the limitation of the limited and heterogenous available published data, elective treatment discontinuation after 1 year of treatment appears safe with an acceptable risk of disease progression. The depth of response is currently the best predictor of prolonged response. The metabolic response on 18F-FDG-PET/CT is expected to gain importance, especially for partial responders.

Discontinuation of anti-PD-1 antibody therapy in the absence of disease progression or treatment limiting toxicity: clinical outcomes in advanced melanoma.

BACKGROUND: Programmed cell death protein 1 (PD-1) blocking monoclonal antibodies improve the overall survival of patients with advanced melanoma but the optimal duration of treatment has not been established. PATIENTS AND METHODS: This academic real-world cohort study investigated the outcome of 185 advanced melanoma patients who electively discontinued anti-PD-1 therapy with pembrolizumab (N = 167) or nivolumab (N = 18) in the absence of disease progression (PD) or treatment limiting toxicity (TLT) at 14 medical centres across Europe and Australia. RESULTS: Median time on treatment was 12 months (range 0.7-43). The best objective tumour response at the time of treatment discontinuation was complete response (CR) in 117 (63%) patients, partial response (PR) in 44 (24%) patients and stable disease (SD) in 16 (9%) patients; 8 (4%) patients had no evaluable disease (NE). After a median follow-up of 18 months (range 0.7-48) after treatment discontinuation, 78% of patients remained free of progression. Median time to progression was 12 months (range 2-23). PD was less frequent in patients with CR (14%) compared with patients with PR (32%) and SD (50%). Six out of 19 (32%) patients who were retreated with an anti-PD-1 at the time of PD obtained a new antitumour response. CONCLUSIONS: In this real-world cohort of advanced melanoma patients discontinuing anti-PD-1 therapy in the absence of TLT or PD, the duration of anti-PD-1 therapy was shorter when compared with clinical trials. In patients obtaining a CR, and being treated for >6 months, the risk of relapse after treatment discontinuation was low. Patients achieving a PR or SD as best tumour response were at higher risk for progression after discontinuing therapy, and defining optimal treatment duration in such patients deserves further study. Retreatment with an anti-PD-1 at the time of progression may lead to renewed antitumour activity in some patients. CLINICAL TRIAL REGISTRATION: NCT02673970 (https://clinicaltrials.gov/ct2/show/NCT02673970?cond=melanoma&cntry=BE&city=Jette&rank=3).

Differentiation between normal and metastatic lymph nodes in patients with skin melanoma: Preliminary findings using a DIXON-based whole-body MRI approach.

Purpose: Metastatic melanoma lymph nodes (MMLns) might be challenging to detect on MR-WBI, as both MMLns and normal lymph nodes (NLns) can show restricted water diffusion. Our purpose is to assess the potential contribution of the DIXON sequence in differentiating MMLns from NLns. Material and methods: We followed a cohort of 107 patients with stage IIIb/c and IV skin melanoma for 32 months using MR-WBI with DIXON, STIR, and DWI/ADC sequences. We compared signal intensity (SI) values of MMLns and NLns in the four series of the DIXON sequence (in/out-of-phase, fat_only, and water_only series). The fat fraction (SIfat_only/SIin) and the long:short axis ratio of MMLns were calculated. The fat fraction was also calculated in the fatty hila of NLns. Results: All MMLns (8 from 7 patients) showed SIout>SIin with a mean fat fraction of 10%. In 40 normal fatty hila (25 patients), the proportion of SIout>SIin was 100% and mean fat fraction was 89% (p<0.001 for fat fraction, Mann-Whitney U-test). In the cortex of NLns, a SIout>SIin pattern was identified in 41/113 cases from 19/40 patients. The median long:short axis ratio in MMLns was 1.13 (range 1.03-1.25). Conclusion: The combination of three features of MMLns (SIout>SIin, low-fat fraction and rounded shape) might hold promise in differentiating NLns from MMLns in patients with skin melanoma. Further research is warranted due to the small number of MMLns in our cohort.

Receptor autoradiographic mapping of the mesial motor and premotor cortex of the macaque monkey.

This study analyzes regional and laminar distribution patterns of neurotransmitter binding sites in the motor areas of the macaque mesial frontal cortex. Differences in distribution patterns are compared with the cytoarchitectonic parcellation. Binding sites were analyzed with quantitative in vitro receptor autoradiography in unfixed brains of five macaque monkeys. Alpha-amino-3-hydroxy-5-methyl-4-isoxalone propionic acid (AMPA), kainate, and N-methyl-D-aspartate (NMDA) binding sites were labeled with [3H]AMPA, [3H]kainate, and [3H]MK-801, respectively, muscarinic binding sites with [3H]pirenzepine or [3H]oxotremorine-M, noradrenergic binding sites with [3H]prazosin or [3H]UK-14304, gamma-aminobutyric acid (GABA)A binding sites with [3H]muscimol, and serotoninergic binding sites with [3H]ketanserine. Adjacent sections were stained with a modified Nissl method for cytoarchitectonic analysis. In the motor areas F1, F3, and F6, [3H]AMPA, [3H]pirenzepine, and [3H]oxotremorine-M binding was maximal in layers II, III, and V, and [3H]kainate binding was maximal in layers V and VI. Clear-cut changes in laminar distribution patterns of [3H]AMPA, [3H]kainate, and [3H]oxotremorine-M binding sites very closely matched corresponding cytoarchitectonic borders. Mean areal binding densities of all ligands to F1, F3, and F6 were plotted as polar plots for each area. A polygon was obtained for each area ("neurochemical fingerprint") when all the density values belonging to one area were connected with each other. The "neurochemical fingerprints" of F1, F3, and F6 were virtually identical in shape but increased in size from F1 to F6. This result reflects the functional similarity of these motor-related areas and possibly correlates with their differential involvement in motor control. Areas F1, F3, and F6 can thus be grouped into one "neurochemical family" of areas.

[The quality of ambulance transportation between regional hospitals and a central hospital]. / De kwaliteit van het ambulancevervoer tussen streekziekenhuizen en een centrumziekenhuis.

We studied the quality of ambulance transport of critically ill and wounded patients between rural hospitals and a referral centre (so-called secondary transport). The study group comprised all patients transported in the course of one year from a rural hospital in the southwestern part of the Netherlands to a centre hospital in Rotterdam (n = 59). Their records were reviewed retrospectively. A distinction was made between patients whose vital functions were acutely threatened before transport and patients in whom this was not the case. Results show that 24% of all patients were transferred inadequately. The inadequately transferred patients all belonged to the group in whom vital functions were acutely threatened. Frequently occurring shortcomings concerned oxygenation and intravenous lines. It is concluded that medical assistance by a specialist is indicated with all secondary transports, because it is difficult to predict if vital functions will be threatened during transport. Further research may be directed at the question which mode of transportation (ambulance or helicopter) is suited for long-distance interhospital transport.

Yersinia ruckeri, an unusual microorganism isolated from a human wound infection.

We report the first documented case of Yersinia ruckeri isolated from a wound infection, in a 16-year-old male after hitting a stone while paddling in a river.

T cell receptor and peptide-contacting residues in the HLA-DR17(3) beta 1 chain.

Previously, we have proposed that the beta 1 residues 9-13, 26, 28 and 86 in HLA-DR17, the most common subtype of DR3, might be critical for the binding of an immunodominant, mycobacterial epitope (peptide 3-13 of the 65-kDa heat shock protein). In order to examine directly (i) which DR17 residues are involved in peptide binding, (ii) whether the same or other DR17 residues are involved in the binding of different peptides, and (iii) whether subtle differences in the mode of peptide binding can influence T cell stimulation, we have now systematically mutated 15 highly polymorphic DR17 beta 1 residues, located in the proposed peptide binding groove of DR17, and examined the effect thereof on binding and presentation of two peptides, hsp65 p3-13 and p56-65 of the 30/31-kDa secreted mycobacterial protein. Mutations in residues 28 (D-->H) and 86 (V-->G) completely eliminated binding of p3-13 and significantly reduced binding of p56-65. A mutation in residue 26 (Y-->F) decreased binding of p3-13 but did not affect binding of p56-65. Substitutions of amino acid residues 28, 67, 71 and 86 in the DR17 beta 1 chain abrogated peptide-specific stimulation of both the p3-13- and the p56-65-specific T cell clones, while specific stimulation by only one peptide was eliminated by substitution at positions 26 and 74 (p3-13) and by substitution of residues 11 and 37 (p56-65). The observation that substitution of several other peptide-contacting DR17 beta 1 chain residues does not significantly affect peptide binding but does affect T cell stimulation, suggests that these substitutions alter the conformation of the bound peptide.