Intratumoral drug-releasing microdevices allow in situ high-throughput pharmaco phenotyping in patients with gliomas.

The lack of reliable predictive biomarkers to guide effective therapy is a major obstacle to the advancement of therapy for high-grade gliomas, particularly glioblastoma (GBM), one of the few cancers whose prognosis has not improved over the past several decades. With this pilot clinical trial (number NCT04135807), we provide first-in-human evidence that drug-releasing intratumoral microdevices (IMDs) can be safely and effectively used to obtain patient-specific, high-throughput molecular and histopathological drug response profiling. These data can complement other strategies to inform the selection of drugs based on their observed antitumor effect in situ. IMDs are integrated into surgical practice during tumor resection and remain in situ only for the duration of the otherwise standard operation (2 to 3 hours). None of the six enrolled patients experienced adverse events related to the IMD, and the exposed tissue was usable for downstream analysis for 11 out of 12 retrieved specimens. Analysis of the specimens provided preliminary evidence of the robustness of the readout, compatibility with a wide array of techniques for molecular tissue interrogation, and promising similarities with the available observed clinical-radiological responses to temozolomide. From an investigational aspect, the amount of information obtained with IMDs allows characterization of tissue effects of any drugs of interest, within the physiological context of the intact tumor, and without affecting the standard surgical workflow.

First-in-Human Intrathoracic Implantation of Multidrug-Eluting Microdevices for In Situ Chemotherapeutic Sensitivity Testing as Proof of Concept in Nonsmall Cell Lung Cancer.

OBJECTIVE: To evaluate the safety and feasibility of implantation and retrieval of a novel implantable microdevice (IMD) in NSCLC patients undergoing operative resection. BACKGROUND: Adjuvant therapy has limited impact on postsurgical outcomes in NSCLC due to the inability to predict optimal treatment regimens. METHODS: An IMD measuring 6.5 mm by 0.7 mm, containing micro-reservoirs allowing for high-throughput localized drug delivery, was developed and loaded with 12 chemotherapeutic agents. Five patients with peripheral lung lesions larger than 1.0 cm were enrolled in this phase 1 clinical study. IMDs were inserted into tumors intraoperatively under direct vision, removed with the resected specimen, and retrieved in pathology. Surrounding tissues were sectioned, stained, and analyzed for tissue drug response to the IMD-delivered microdoses of these agents by a variety of pharmacodynamic markers. RESULTS: A total of 14 IMDs were implanted intraoperatively with 13 (93%) successfully retrieved. After technique refinement, IMDs were reliably inserted and retrieved in open, Video-Assisted Thoracoscopic Surgery, and robotic cases. No severe adverse reactions were observed. The one retained IMD has remained in place without movement or any adverse effects. Analysis of patient blood revealed no detection of chemotherapeutic agents. We observed differential sensitivities of patient tumors to the drugs on the IMD. CONCLUSIONS: A multi-drug IMD can be safely inserted and retrieved into lung tumors during a variety of surgical approaches. Future studies will encompass preoperative placement to better examine specific tumor responsiveness to therapeutic agents, allowing clinicians to tailor treatment regimens to the microenvironment of each patient.

Intratarget Microdosing for Deep Phenotyping of Multiple Drug Effects in the Live Brain.

A main impediment to effective development of new therapeutics for central nervous system disorders, and for the in vivo testing of biological hypotheses in the brain, is the ability to rapidly measure the effect of novel agents and treatment combinations on the pathophysiology of native brain tissue. We have developed a miniaturized implantable microdevice (IMD) platform, optimized for direct stereotactic insertion into the brain, which enables the simultaneous measurement of multiple drug effects on the native brain tissue in situ. The IMD contains individual reservoirs which release microdoses of single agents or combinations into confined regions of the brain, with subsequent spatial analysis of phenotypic, transcriptomic or metabolomic effects. Using murine models of Alzheimer's disease (AD), we demonstrate that microdoses of various approved and investigational CNS drugs released from the IMD within a local brain region exhibit in situ phenotypes indicative of therapeutic responses, such as neuroprotection, reduction of hyperphosphorylation, immune cell modulation, and anti-inflammatory effects. We also show that local treatments with drugs affecting metabolism provide evidence for regulation of metabolite profiles and immune cell function in hMAPT AD mice. The platform should prove useful in facilitating the rapid testing of pharmacological or biological treatment hypotheses directly within native brain tissues (of various animal models and in patients) and help to confirm on-target effects, in situ pharmacodynamics and drug-induced microenvironment remodeling, much more efficiently than currently feasible.

The Translational and Regulatory Development of an Implantable Microdevice for Multiple Drug Sensitivity Measurements in Cancer Patients.

OBJECTIVE: The purpose of this article is to report the translational process of an implantable microdevice platform with an emphasis on the technical and engineering adaptations for patient use, regulatory advances, and successful integration into clinical workflow. METHODS: We developed design adaptations for implantation and retrieval, established ongoing monitoring and testing, and facilitated regulatory advances that enabled the administration and examination of a large set of cancer therapies simultaneously in individual patients. RESULTS: Six applications for oncology studies have successfully proceeded to patient trials, with future applications in progress. CONCLUSION: First-in-human translation required engineering design changes to enable implantation and retrieval that fit with existing clinical workflows, a regulatory strategy that enabled both delivery and response measurement of up to 20 agents in a single patient, and establishment of novel testing and quality control processes for a drug/device combination product without clear precedents. SIGNIFICANCE: This manuscript provides a real-world account and roadmap on how to advance from animal proof-of-concept into the clinic, confronting the question of how to use research to benefit patients.

High-throughput in situ perturbation of metabolite levels in the tumor micro-environment reveals favorable metabolic condition for increased fitness of infiltrated T-cells.

Tumor-infiltrating immune cells experience significant metabolic reprogramming in the tumor microenvironment (TME), and they share similar metabolic pathways and nutrient needs with malignant cells. This positions these cell types in direct nutrient competition in the TME. We currently lack a complete understanding of the similarities, differences, and functional consequences of the metabolic pathways utilized by activated immune cells from different lineages versus neoplastic cells. This study applies a novel in situ approach using implantable microdevices to expose the tumor to 27 controlled and localized metabolic perturbations in order to perform a systematic investigation into the metabolic regulation of the cellular fitness and persistence between immune and tumor cells directly within the native TME. Our findings identify the most potent metabolites, notably glutamine and arginine, that induce a favorable metabolic immune response in a mammary carcinoma model, and reveal novel insights on less characterized pathways, such as cysteine and glutathione. We then examine clinical samples from cancer patients to confirm the elevation of these pathways in tumor regions that are enriched in activated T cells. Overall, this work provides the first instance of a highly multiplexed in situ competition assay between malignant and immune cells within tumors using a range of localized microdose metabolic perturbations. The approach and findings may be used to potentiate the effects of T cell stimulating immunotherapies on a tumor-specific or personalized basis through targeted enrichment or depletion of specific metabolites.

A Two-Photon Microimaging-Microdevice System for Four-Dimensional Imaging of Local Drug Delivery in Tissues.

Advances in the intratumor measurement of drug responses have included a pioneering biomedical microdevice for high throughput drug screening in vivo, which was further advanced by integrating a graded-index lens based two-dimensional fluorescence micro-endoscope to monitor tissue responses in situ across time. While the previous system provided a bulk measurement of both drug delivery and tissue response from a given region of the tumor, it was incapable of visualizing drug distribution and tissue responses in a three-dimensional (3D) way, thus missing the critical relationship between drug concentration and effect. Here we demonstrate a next-generation system that couples multiplexed intratumor drug release with continuous 3D spatial imaging of the tumor microenvironment via the integration of a miniaturized two-photon micro-endoscope. This enables optical sectioning within the live tissue microenvironment to effectively profile the entire tumor region adjacent to the microdevice across time. Using this novel microimaging-microdevice (MI-MD) system, we successfully demonstrated the four-dimensional imaging (3 spatial dimensions plus time) of local drug delivery in tissue phantom and tumors. Future studies include the use of the MI-MD system for monitoring of localized intra-tissue drug release and concurrent measurement of tissue responses in live organisms, with applications to study drug resistance due to nonuniform drug distribution in tumors, or immune cell responses to anti-cancer agents.

Preparation and sterilization of an implantable drug-delivery microdevice for clinical use.

Implantable drug-delivery microdevices are a key diagnostic and therapeutic tool in medicine with increasing applications. Preparation of such combination drug-delivery devices for human studies requires the development of methods to ensure sterility, safety and integrity on both the device and drug side. Despite growing applications for these technologies, there has been a lack of clear methodology regarding sterilization and preparation to meet strict guidelines set forth by the Food and Drug Administration (FDA). Our laboratory developed a set of widely applicable and straightforward procedures to prepare drug-device combination products for clinical use that consistently achieve the high-quality standards provided by the FDA. This includes several newly developed methods for preparation of the implant including endotoxin removal, appropriate sterilization of raw materials, formulation of novel pharmaceutical agents, and loading of agents into drug delivery reservoirs. We also discuss protocols and methods developed with FDA to meet regulatory guidelines to ensure continual sterility and endotoxin testing, as well as longer-term stability testing of drugs and biologic agents.•Endotoxin removal and sterilization of raw materials for clinical use.•Formulation and device loading of novel pharmaceutical agents.•Continued testing of pharmaceutical agents and devices to meet regulatory guidelines.

Self-Expanding Anchors for Stabilizing Percutaneously Implanted Microdevices in Biological Tissues.

Percutaneously implanted miniaturized devices such as fiducial markers, miniaturized sensors, and drug delivery devices have an important and expanding role in diagnosing and treating a variety of diseases. However, there is a need to develop and evaluate anchoring methods to ensure that these microdevices remain secure without dislodgement, as even minimal migration within tissues could result in loss of microdevice functionality or clinical complications. Here we describe two anchoring methods made from biocompatible materials: (1) a self-expanding nitinol mesh anchor and (2) self-expanding hydrogel particles contained within pliable netting. We integrate these anchors into existing drug-screening microdevices and experimentally measure forces required to dislodge them from varying tissues. We report similar dislodgement forces of 738 ± 37, 707 ± 40, 688 ± 29, and 520 ± 28 mN for nitinol-anchored microdevices, and 735 ± 98, 702 ± 46, 457 ± 47, and 459 ± 39 mN for hydrogel-anchored microdevices in liver, kidney, fat, and muscle tissues, respectively-significantly higher compared with 13 ± 2, 15 ± 3, 15 ± 2, and 15 ± 3 mN for non-anchored microdevices (p < 0.001 in all tissues). The anchoring methods increased resistance to dislodgement by a factor of 30-50× in all tissues, did not increase the required needle gauge for insertion, and were compatible with percutaneous implantation and removal. These results indicate that anchoring significantly improves microdevice stability and should reduce migration risk in a variety of biological tissues.

A Miniaturized Platform for Multiplexed Drug Response Imaging in Live Tumors.

By observing the activity of anti-cancer agents directly in tumors, there is potential to greatly expand our understanding of drug response and develop more personalized cancer treatments. Implantable microdevices (IMD) have been recently developed to deliver microdoses of chemotherapeutic agents locally into confined regions of live tumors; the tissue can be subsequently removed and analyzed to evaluate drug response. This method has the potential to rapidly screen multiple drugs, but requires surgical tissue removal and only evaluates drug response at a single timepoint when the tissue is excised. Here, we describe a "lab-in-a-tumor" implantable microdevice (LIT-IMD) platform to image cell-death drug response within a live tumor, without requiring surgical resection or tissue processing. The LIT-IMD is inserted into a live tumor and delivers multiple drug microdoses into spatially discrete locations. In parallel, it locally delivers microdose levels of a fluorescent cell-death assay, which diffuses into drug-exposed tissues and accumulates at sites of cell death. An integrated miniaturized fluorescence imaging probe images each region to evaluate drug-induced cell death. We demonstrate ability to evaluate multi-drug response over 8 h using murine tumor models and show correlation with gold-standard conventional fluorescence microscopy and histopathology. This is the first demonstration of a fully integrated platform for evaluating multiple chemotherapy responses in situ. This approach could enable a more complete understanding of drug activity in live tumors, and could expand the utility of drug-response measurements to a wide range of settings where surgery is not feasible.

Aspirin-Exacerbated Respiratory Disease: Association Between Patient-Reported Sinus and Asthma Morbidity.

BACKGROUND: The association between sinonasal and pulmonary symptoms in aspirin-exacerbated respiratory disease is not fully established. OBJECTIVE: To characterize sinonasal and asthma symptomatology, and to determine whether reported sinonasal symptoms predict asthma severity. METHODS: Prospectively collected data from an aspirin-exacerbated respiratory disease registry cohort were included from 2013 to 2018. Sinonasal symptomatology measured by Sino-Nasal Outcomes Test (SNOT) 22-item total scores was used as the predictor variable, with Asthma Control Test (ACT) scores and percent predicted FEV1 (FEV1% predicted) as primary outcomes. All instances of paired data on the same date were used. ACT score was also evaluated with FEV1% predicted as the outcome. Mixed effects regression was completed. RESULTS: From 1065 aspirin-exacerbated respiratory disease registry subjects (mean age, 48.1 ± 12.8 years; 68.0% females, 29.8% males), mean SNOT-22 score was 42.3 ± 24.12 (n = 1307 observations from 869 subjects), mean ACT score was 19.4 ± 5.2 (n = 1511 observations from 931 subjects), and mean FEV1% predicted was 82.8 ± 19.6 (n = 777 observations from 307 subjects). SNOT-22 score significantly predicted ACT scores (P < .0001, 1185 paired observations from 845 subjects) and FEV1% predicted (P = .018, 485 observations from 246 subjects). Any 10-point increase in SNOT-22 score was associated with a 0.87-point decrease in ACT score and a 0.75% decrease in FEV1% predicted. Any 1-point increase in ACT score was associated with a 1.0% increase in FEV1% predicted (P < .0001, 616 observations from 269 subjects). The most severe SNOT-22 symptoms were sense of smell/taste and blockage/congestion of nose. CONCLUSIONS: SNOT-22 scores significantly predict ACT scores and FEV1% predicted, and ACT scores significantly predict FEV1% predicted. This study demonstrates an association between patient-reported rhinosinusitis and asthma symptom severity and subjective and objective measures of asthma severity.

Aspirin-exacerbated respiratory disease: A review.

OBJECTIVES: Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition. DATA SOURCES AND METHODS: Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. RESULTS: AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. CONCLUSION: AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. LEVEL OF EVIDENCE: 5.