PD-L1 blockade in combination with carboplatin as immune induction in metastatic lobular breast cancer: the GELATO trial.

Invasive lobular breast cancer (ILC) is the second most common histological breast cancer subtype, but ILC-specific trials are lacking. Translational research revealed an immune-related ILC subset, and in mouse ILC models, synergy between immune checkpoint blockade and platinum was observed. In the phase II GELATO trial ( NCT03147040 ), patients with metastatic ILC were treated with weekly carboplatin (area under the curve 1.5 mg ml-1 min-1) as immune induction for 12 weeks and atezolizumab (PD-L1 blockade; triweekly) from the third week until progression. Four of 23 evaluable patients had a partial response (17%), and 2 had stable disease, resulting in a clinical benefit rate of 26%. From these six patients, four had triple-negative ILC (TN-ILC). We observed higher CD8+ T cell infiltration, immune checkpoint expression and exhausted T cells after treatment. With this GELATO trial, we show that ILC-specific clinical trials are feasible and demonstrate promising antitumor activity of atezolizumab with carboplatin, particularly for TN-ILC, and provide insights for the design of highly needed ILC-specific trials.

Prostate cancer in multi-ethnic Asian men: Real-world experience in the Malaysia Prostate Cancer (M-CaP) Study.

Prostate cancer is the third most common cancer in Malaysia with the lifetime risk of 1 in 117 men. Here, we initiated a longitudinal Malaysia Prostate Cancer (M-CaP) Study to investigate the clinical and tumour characteristics, treatment patterns as well as disease outcomes of multi-ethnic Asian men at real-world setting. The M-CaP database consisted of 1839 new patients with prostate cancer diagnosed between 2016 and 2018 from nine public urology referral centres across Malaysia. Basic demographic and clinical parameters, tumour characteristics, primary treatment, follow-up and vital status data were retrieved prospectively from the hospital-based patients' case notes or electronic medical records. Primary endpoints were overall survival (OS) and biochemical progression-free survival (bPFS). The median age at diagnosis of M-CaP patients was 70 years (interquartile range, IQR 65-75). Majority of patients were Chinese (831, 45.2%), followed by Malays (704, 38.3%), Indians (124, 6.7%) and other races (181, 9.8%). The median follow-up for all patients was 23.5 months (IQR 15.9-33.6). Although 58.1% presented with late-stage cancer, we observed ethnic and geographic disparities in late-stage prostate cancer diagnosis. Curative radiotherapy and primary androgen deprivation therapy were the most common treatment for stage III and stage IV diseases, respectively. The median OS and bPFS of stage IV patients were 40.1 months and 19.2 months (95% CI 17.6-20.8), respectively. Late stage at presentation remains a challenge in multi-ethnic Asian men. Early detection is imperative to improve treatment outcome and survival of patients with prostate cancer.

Tumor infiltrating lymphocytes (TIL) therapy in metastatic melanoma: boosting of neoantigen-specific T cell reactivity and long-term follow-up.

Treatment of metastatic melanoma with autologous tumor infiltrating lymphocytes (TILs) is currently applied in several centers. Robust and remarkably consistent overall response rates, of around 50% of treated patients, have been observed across hospitals, including a substantial fraction of durable, complete responses. PURPOSE: Execute a phase I/II feasibility study with TIL therapy in metastatic melanoma at the Netherlands Cancer Institute, with the goal to assess feasibility and potential value of a randomized phase III trial. EXPERIMENTAL: Ten patients were treated with TIL therapy. Infusion products and peripheral blood samples were phenotypically characterized and neoantigen reactivity was assessed. Here, we present long-term clinical outcome and translational data on neoantigen reactivity of the T cell products. RESULTS: Five out of 10 patients, who were all anti-PD-1 naïve at time of treatment, showed an objective clinical response, including two patients with a complete response that are both ongoing for more than 7 years. Immune monitoring demonstrated that neoantigen-specific T cells were detectable in TIL infusion products from three out of three patients analyzed. For six out of the nine neoantigen-specific T cell responses detected in these TIL products, T cell response magnitude increased significantly in the peripheral blood compartment after therapy, and neoantigen-specific T cells were detectable for up to 3 years after TIL infusion. CONCLUSION: The clinical results from this study confirm the robustness of TIL therapy in metastatic melanoma and the potential role of neoantigen-specific T cell reactivity. In addition, the data from this study supported the rationale to initiate an ongoing multicenter phase III TIL trial.

Risk Associated with Malaria Infection in Tihama Qahtan, Aseer Region, Kingdom of Saudi Arabia: 2006-2007.

INTRODUCTION: Since 2004, the Kingdom of Saudi Arabia has pursued a policy of malaria elimination. The distribution of malaria at this time was constrained to regions located in the South Western part of the country. The present study aimed to understand the risk of malaria infection and factors associated with these events between March 2006 and August 2007 in one part of Aseer region. METHODS: The study was carried out in Tihama Qahtan area in the far southeastern part of Aseer, historically the most malaria endemic area of this region. The area covers 54 villages served by three primary health care centres (Wadi Alhayah, Alfarsha and Albuqaa). Malaria cases were detected using passive case detection (PCD) at the three health centres for 18 months from March 2006, each positive case was investigated using patient and household level enquiries. In addition, four cross-sectional surveys in 12 villages were undertaken using rapid diagnostic tests within the catchments of each health centre coinciding with malaria transmission seasons. RESULTS: Among 1840 individuals examined in the PCD survey, 49 (2.7%) were positive for malaria, most were Plasmodium falciparum cases and one was a P. vivax case. The majority of these infections were likely to have been acquired outside of the area and represent imported cases, including those from the neighboring region of Jazan. Among the 18 locally acquired cases, the majority were adult males who slept outdoors. 3623 individuals were screened during the cross-sectional surveys, 16 (0.44%) were positive and infections only detected during peak, potential transmission periods. CONCLUSION: There was evidence of local malaria transmission in the Tihama Qahtan area in 2006-2007, however prevalence and incidence of new infections was very low, making the future ambitions of elimination biologically feasible. The constant source of imported infections must be considered in the area's elimination ambitions, alongside strong behavioural community messages about sleeping outdoors unprotected and travel to malaria endemic areas outside the region.

Publisher Correction: Immune induction strategies in metastatic triple-negative breast cancer to enhance the sensitivity to PD-1 blockade: the TONIC trial.

In the version of this article originally published, there was an error in Fig. 3j. A label on the heatmap read "TGF-α signaling via NF-κB". It should have read "TNF-α signaling via NF-κB". The error has been corrected in the HTML and PDF versions of this article.

Immune induction strategies in metastatic triple-negative breast cancer to enhance the sensitivity to PD-1 blockade: the TONIC trial.

The efficacy of programmed cell death protein 1 (PD-1) blockade in metastatic triple-negative breast cancer (TNBC) is low1-5, highlighting a need for strategies that render the tumor microenvironment more sensitive to PD-1 blockade. Preclinical research has suggested immunomodulatory properties for chemotherapy and irradiation6-13. In the first stage of this adaptive, non-comparative phase 2 trial, 67 patients with metastatic TNBC were randomized to nivolumab (1) without induction or with 2-week low-dose induction, or with (2) irradiation (3 × 8 Gy), (3) cyclophosphamide, (4) cisplatin or (5) doxorubicin, all followed by nivolumab. In the overall cohort, the objective response rate (ORR; iRECIST14) was 20%. The majority of responses were observed in the cisplatin (ORR 23%) and doxorubicin (ORR 35%) cohorts. After doxorubicin and cisplatin induction, we detected an upregulation of immune-related genes involved in PD-1-PD-L1 (programmed death ligand 1) and T cell cytotoxicity pathways. This was further supported by enrichment among upregulated genes related to inflammation, JAK-STAT and TNF-α signaling after doxorubicin. Together, the clinical and translational data of this study indicate that short-term doxorubicin and cisplatin may induce a more favorable tumor microenvironment and increase the likelihood of response to PD-1 blockade in TNBC. These data warrant confirmation in TNBC and exploration of induction treatments prior to PD-1 blockade in other cancer types.

Glutaminyl cyclase is an enzymatic modifier of the CD47- SIRPα axis and a target for cancer immunotherapy.

Cancer cells can evade immune surveillance through the expression of inhibitory ligands that bind their cognate receptors on immune effector cells. Expression of programmed death ligand 1 in tumor microenvironments is a major immune checkpoint for tumor-specific T cell responses as it binds to programmed cell death protein-1 on activated and dysfunctional T cells1. The activity of myeloid cells such as macrophages and neutrophils is likewise regulated by a balance between stimulatory and inhibitory signals. In particular, cell surface expression of the CD47 protein creates a 'don't eat me' signal on tumor cells by binding to SIRPα expressed on myeloid cells2-5. Using a haploid genetic screen, we here identify glutaminyl-peptide cyclotransferase-like protein (QPCTL) as a major component of the CD47-SIRPα checkpoint. Biochemical analysis demonstrates that QPCTL is critical for pyroglutamate formation on CD47 at the SIRPα binding site shortly after biosynthesis. Genetic and pharmacological interference with QPCTL activity enhances antibody-dependent cellular phagocytosis and cellular cytotoxicity of tumor cells. Furthermore, interference with QPCTL expression leads to a major increase in neutrophil-mediated killing of tumor cells in vivo. These data identify QPCTL as a novel target to interfere with the CD47 pathway and thereby augment antibody therapy of cancer.

Small-scale GMP production of plasmid DNA using a simplified and fully disposable production method.

In the past years, the demand for small batches of clinical grade plasmid DNA has been growing. For that purpose, we designed and qualified a scaled-down Good Manufacturing Practices (GMP) production method, able to produce small batches (1-4 mg) of plasmid. The developed method does not require any complex production equipment and utilizes only disposable production materials, which makes it easy to implement and simplifies line-clearance. We have successfully used this method to produce several small batches of two different plasmids. The produced plasmids, both formulated in an Electroporation Buffer, are mixed and filled into small, single-use, aliquots. Quality control confirmed the robustness of the developed method and a stability study showed that the final formulation is stable for at least two years. The final patient formulation will be subsequently used in a phase I/II clinical trial in which retina cells of patients with Age Related Macular Degeneration, are transfected. The presented production method can be generically used for other plasmid constructs and final formulation designs.

Extraction and characterization of lignin from oil palm biomass via ionic liquid dissolution and non-toxic aluminium potassium sulfate dodecahydrate precipitation processes.

The objective of this study is to extract and characterize lignin from oil palm biomass (OPB) by dissolution in 1-butyl-3-methylimidazolium chloride ([bmim][Cl]), followed by the lignin extraction through the CO2 gas purging prior to addition of aluminum potassium sulfate dodecahydrate (AlK(SO4)2 · 12H2O). The lignin yield, Y(L) (%wt.) was found to be dependent of the types of OPB observed for all precipitation methods used. The lignin recovery, RL (%wt.) obtained from CO2-AlK(SO4)2 · 12H2O precipitation was, however dependent on the types of OPB, which contradicted to that of the acidified H2SO4 and HCl solutions of pH 0.7 and 2 precipitations. Only about 54% of lignin was recovered from the OPB. The FTIR results indicate that the monodispersed lignin was successfully extracted from the OPT, OPF and OPEFB having a molecular weight (MW) of 1331, 1263 and 1473 g/mol, and degradation temperature of 215, 207.5 and 272 °C, respectively.

Effect of high pressure processing on the conversion of dihydroxyacetone to methylglyoxal in New Zealand manuka (Leptospermum scoparium) honey and models thereof.

The effect of high pressure processing (HPP) on the conversion of dihydroxyacetone (DHA) to methylglyoxal (MGO) was examined in New Zealand manuka honey and models thereof. The objective was to confirm that previously reported increases of MGO with HPP treatment originated from conversion of DHA. RP-HPLC was used to quantify DHA, MGO and hydroxymethylfurfural (HMF) after derivatisation with O-(2,3,4,5,6-pentafluorobenzyl)hydroxylamine hydrochloride (PFBHA) or (in the case of MGO) separately with o-phenylenediamine (OPD). Fresh and stored manuka honey, clover honey with DHA added and artificial 26 honey with DHA added were subjected to nine different pressures and holding times and compared to untreated samples. There was no consistent trend of decrease in DHA or increase in MGO for any of the samples with any treatment. Samples showed random change generally within 5-10% of an untreated sample for MGO, DHA and HMF. HPP does not accelerate the conversion of DHA to MGO in honey.

Construction of single-chain variable fragment antibodies against MCF-7 breast cancer cells.

A phage display library of single chain variable fragment (scFv) against MCF-7 breast cancer cells was constructed from C3A8 hybridoma cells. RNA from the C3A8 was isolated, cDNA was constructed, and variable heavy and light immunoglobulin chain gene region were amplified using PCR. The variable heavy and light chain gene regions were combined with flexible linker, linked to a pCANTAB 5E phagemid vector and electrophoresed into supE strain of Escherichia coli TG1 cells. Forty-eight clones demonstrated positive binding activity to MCF-7 breast cancer cell membrane fragments and the strongest of 48 clones was selected for analysis. The anti-MCF-7 library evaluated by SfiI and NotI digests demonstrated that anti-MCF-7 scFv antibodies possess individual patterns that should be able to recognize distinct human breast cancer cells. The C3A8 scFv, with an apparent molecular weight of 32 kDa, showed high homology (99%) with single chain antibody against rice stripe virus protein P20. In summary, the anti MCF-7 scFv antibody can be used for pretargeting breast cancer for clinical diagnosis of patients; it also has potential for therapeutic applications.

Fever prevalence and management among three rural communities in the North West Zone, Somalia.

Between March and August 2008 we undertook 2 cross-sectional surveys among 1375 residents of 3 randomly selected villages in the district of Gebiley in the North-West Zone, Somalia. We investigated for the presence of malaria infection and the period prevalence of self-reported fever 14 days prior to both surveys. All blood samples examined were negative for both species of Plasmodium. The period prevalence of 14-day fevers was 4.8% in March and 0.6% in August; the majority of fevers (84.4%) were associated with other symptoms including cough, running nose and sore throat; 48/64 cases had resolved by the day of interview (mean duration 5.4 days). Only 18 (37.5%) fever cases were managed at a formal health care facility: 7 within 24 hours and 10 within 24-72 hours of onset. None of the fevers were investigated for malaria; they were treated with antibiotics, antipyretics and vitamins.

Fever prevalence and management among three rural communities in the North West Zone, Somalia

Between March and August 2008 we undertook 2 cross-sectional surveys among 1375 residents of 3 randomly selected villages in the district of Gebiley in the North-West Zone, Somalia. We investigated for the presence of malaria infection and the period prevalence of self-reported fever 14 days prior to both surveys. All blood samples examined were negative for both species of Plasmodium. The period prevalence of 14-day fevers was 4.8% in March and 0.6% in August; the majority of fevers [84.4%] were associated with other symptoms including cough, running nose and sore throat; 48/64 cases had resolved by the day of interview [mean duration 5.4 days]. Only 18 [37.5%] fever cases were managed at a formal health care facility: 7 within 24 hours and 10 within 24-72 hours of onset. None of the fevers were investigated for malaria; they were treated with antibiotics, antipyretics and vitamins

The accuracy of human population maps for public health application.

OBJECTIVES: Human population totals are used for generating burden of disease estimates at global, continental and national scales to help guide priority setting in international health financing. These exercises should be aware of the accuracy of the demographic information used. METHODS: The analysis presented in this paper tests the accuracy of five large-area, public-domain human population distribution data maps against high spatial resolution population census data enumerated in Kenya in 1999. We illustrate the epidemiological significance, by assessing the impact of using these different human population surfaces in determining populations at risk of various levels of climate suitability for malaria transmission. We also describe how areal weighting, pycnophylactic interpolation and accessibility potential interpolation techniques can be used to generate novel human population distribution surfaces from local census information and evaluate to what accuracy this can be achieved. RESULTS: We demonstrate which human population distribution surface performed best and which population interpolation techniques generated the most accurate bespoke distributions. Despite various levels of modelling complexity, the accuracy achieved by the different surfaces was primarily determined by the spatial resolution of the input population data. The simplest technique of areal weighting performed best. CONCLUSIONS: Differences in estimates of populations at risk of malaria in Kenya of over 1 million persons can be generated by the choice of surface, highlighting the importance of these considerations in deriving per capita health metrics in public health. Despite focussing on Kenya the results of these analyses have general application and are discussed in this wider context.

Assessing the accuracy of satellite derived global and national urban maps in Kenya.

Ninety percent of projected global urbanization will be concentrated in low income countries (United-Nations, 2004). This will have considerable environmental, economic and public health implications for those populations. Objective and efficient methods of delineating urban extent are a cross-sectoral need complicated by a diversity of urban definition rubrics world-wide. Large-area maps of urban extents are becoming increasingly available in the public domain, as are a wide-range of medium spatial resolution satellite imagery. Here we describe the extension of a methodology based on Landsat ETM and Radarsat imagery to the production of a human settlement map of Kenya. This map was then compared with five satellite imagery-derived, global maps of urban extent at Kenya national-level, against an expert opinion coverage for accuracy assessment. The results showed the map produced using medium spatial resolution satellite imagery was of comparable accuracy to the expert opinion coverage. The five global urban maps exhibited a range of inaccuracies, emphasising that care should be taken with use of these maps at national and sub-national scale.

Creating spatially defined databases for equitable health service planning in low-income countries: the example of Kenya.

Equity is an important criterion in evaluating health system performance. Developing a framework for equitable and effective resource allocation for health depends upon knowledge of service providers and their location in relation to the population they should serve. The last available map of health service providers in Kenya was developed in 1959. We have built a health service provider database from a variety of traditional government and opportunistic non-government sources and positioned spatially these facilities using global positioning systems, hand-drawn maps, topographical maps and other sources. Of 6674 identified service providers, 3355 (50%) were private sector, employer-provided or specialist facilities and only 39% were registered in the Kenyan Ministry of Health database during 2001. Of 3319 public service facilities supported by the Ministry of Health, missions, not-for-profit organizations and local authorities, 84% were registered on a Ministry of Health database and we were able to acquire co-ordinates for 92% of these. The ratio of public health services to population changed from 1:26,000 in 1959 to 1:9300 in 1999-2002. There were 82% of the population within 5 km of a public health facility and resident in 20% of the country. Our efforts to recreate a comprehensive, spatially defined list of health service providers has identified a number of weaknesses in existing national health management information systems, which with an increased commitment and minimal costs can be redressed. This will enable geographic information systems to exploit more fully facility-based morbidity data, population distribution and health access models to target resources and monitor the ability of health sector reforms to achieve equity in service provision.

Predictors of the quality of health worker treatment practices for uncomplicated malaria at government health facilities in Kenya.

BACKGROUND: When replacing failing drugs for malaria with more effective drugs, an important step towards reducing the malaria burden is that health workers (HW) prescribe drugs according to evidence-based guidelines. Past studies have shown that HW commonly do not follow guidelines, yet few studies have explored with appropriate methods why such practices occur. METHODS: We analysed data from a survey of government health facilities in four Kenyan districts in which HW consultations were observed, caretakers and HW were interviewed, and health facility assessments were performed. The analysis was limited to children 2-59 months old with uncomplicated malaria. Treatment was defined as recommended (antimalarial recommended by national guidelines), a minor error (effective, but non-recommended antimalarial), or inappropriate (no effective antimalarial). RESULTS: We evaluated 1006 consultations performed by 135 HW at 81 facilities: 567 children received recommended treatment, 314 had minor errors, and 125 received inappropriate treatment (weighted percentages: 56.9%, 30.4%, and 12.7%). Multivariate logistic regression analysis revealed that programmatic interventions such as in-service malaria training, provision of guidelines and wall charts, and more frequent supervision were significantly associated with better treatment quality. However, neither in-service training nor possession of the guideline document showed an effect by itself. More qualified HW made more errors: both major and minor errors (but generally more minor errors) when second-line drugs were in stock, and more major errors when second-line drugs were not in stock. Child factors such as age and a main complaint of fever were also associated with treatment quality. CONCLUSIONS: Our results support the use of several programmatic strategies that can redress HW deficiencies in malaria treatment. Targeted cost-effectiveness trials would help refine these strategies and provide more precise guidance on affordable and effective ways to strengthen and maintain HW practices.

Use of intermittent presumptive treatment and insecticide treated bed nets by pregnant women in four Kenyan districts.

The roll back malaria (RBM) movement promotes the use of insecticide-treated bednets (ITNs) and intermittent presumptive treatment (IPT) of malaria infection as preventive measures against the adverse effects of malaria among pregnant women in Africa. To determine the use of these preventive measures we undertook a community-based survey of recently pregnant women randomly selected from communities in four districts of Kenya in December 2001. Of the 1814 women surveyed, only 5% had slept under an ITN. More than half of the 13% of women using a bednet (treated or untreated) had bought their nets from shops or markets. Women from rural areas used bednets less than urban women (11% vs. 27%; P < 0.001), and 41% of the bednets used by rural women had been obtained free of charge from a research project in Bondo or a nationwide UNICEF donation through antenatal clinics (ANCs). Despite 96% of ANC providers being aware of IPT with sulphadoxine-pyrimethamine (SP), only 5% of women interviewed had received two or more doses of SP as a presumptive treatment. The coverage of pregnant women with at least one dose of IPT with SP was 14%, though a similar percentage also had received at least a single dose as a curative treatment. The coverage of nationally recommended strategies to prevent malaria during pregnancy during 2001 was low across the diverse malaria ecology of Kenya. Rapid expansion of access to these services is required to meet international and national targets by the year 2005. The scaling up of malaria prevention programmes through ANC services should be possible with 74% of women visiting ANCs at least twice in all four districts. Issues of commodity supply and service costs to clients will be the greatest impediments to reaching RBM targets.

Defining equity in physical access to clinical services using geographical information systems as part of malaria planning and monitoring in Kenya.

Distance is a crucial feature of health service use and yet its application and utility to health care planning have not been well explored, particularly in the light of large-scale international and national efforts such as Roll Back Malaria. We have developed a high-resolution map of population-to-service access in four districts of Kenya. Theoretical physical access, based upon national targets, developed as part of the Kenyan health sector reform agenda, was compared with actual health service usage data among 1668 paediatric patients attending 81 sampled government health facilities. Actual and theoretical use were highly correlated. Patients in the larger districts of Kwale and Makueni, where access to government health facilities was relatively poor, travelled greater mean distances than those in Greater Kisii and Bondo. More than 60% of the patients in the four districts attended health facilities within a 5-km range. Interpolated physical access surfaces across districts highlighted areas of poor access and large differences between urban and rural settings. Users from rural communities travelled greater distances to health facilities than those in urban communities. The implications of planning and monitoring equitable delivery of clinical services at national and international levels are discussed.

Improved bioavailability of vitamin E with a self emulsifying formulation.

A single dose study was conducted to evaluate the bioavailability of a novel self-emulsifying vitamin E preparation, in comparison with that of a commercial product, Natopherol, available as soft gelatin capsules under fasted condition. The self-emulsifying preparation achieved a faster rate and higher extent of absorption. A statistically significant difference was observed between the values of the two preparations in the parameters AUC, Cmax and Tmax. Moreover, the 90% confidence interval of the logarithmic transformed AUC values of the self-emulsifying preparation over those of the soft gelatin capsule product was found to be between 2.1 and 4.1, suggesting an increase in bioavailability of between 210 and 410%. As for Cmax, the 90% confidence interval was between 2.1 and 3.0. However, no statistically significant difference was observed between the t(1/2) values estimated from the plasma concentration versus time data of the two preparations. The values are also comparable to those reported in the literature.