A platform of patient-derived microtumors identifies treatment response and therapeutic vulnerabilities of ovarian cancer

Ovarian cancer (OvCa) is an insidious disease: due to nonspecific symptoms, these tumors are usually diagnosed at advanced stage with correspondingly devastating consequences for treatment outcome and patient survival. The broad heterogeneity of OvCa manifests itself in the complex composition of the tumor microenvironment. Given the frequent development of therapeutic resistance, there is a strong need for model systems accurately representing OvCa heterogeneity, while enabling parallel drug testing and prediction of appropriate treatment responses in individual patients. Here, we demonstrate the efficient isolation of highly viable OvCa patient-derived microtumors (OvCa PDM). Importantly, our data demonstrate histopathological comparability of OvCa PDM with corresponding patient tumor tissue. Reverse phase protein array (RPPA)-based analyses of >110 total and phospho-proteins enabled the identification of sensitivities to standard, platinum-based as well as experimental, selumetinib-based therapy, and thereby the prediction of treatment-responder. Parallelized drug testing in OvCa PDM allowed functional validation of RPPA data and detection of on- and off-target treatment effects. Strikingly, clinical follow-up of corresponding patients confirmed significantly increased metastasis-free survival of identified carboplatin-responder. Furthermore, flow cytometry-based characterization of autologous TIL populations confirmed the presence of tumor-specific, cytotoxic TILs with stem-like CD39-PD1+ and terminally differentiated CD39+PD1+ phenotypes. Interestingly, our results showed a significant correlation between the presence of CD8+CD39+ Tils and lymph node metastasis in the associated patients. Finally, combining OvCa PDM and autologous TILs for efficacy testing of immune checkpoint inhibitors demonstrated the potential for patient-specific enhancement of cytotoxic TIL activity by this therapeutic approach.

Tapentadol prolonged release in patients with chronic low back pain: real-world data from the German Pain eRegistry

Aim: Comparison of tapentadol prolonged release (PR) with other oral WHO-III PR opioid analgesics (morphine, oxycodone ± naloxone, hydromorphone) in routine medical care of chronic low back pain. Patients & methods: Noninterventional, retrospective 12-week study using anonymized clinical practice data from the German Pain eRegistry. Six effectiveness, tolerability, and safety criteria were aggregated in a primary composite end point (treatment responder). Propensity scoring matched 2331 datasets per treatment cohort. Results: All six single criteria showed significantly better outcomes for tapentadol PR (all parameters p < 0.001). There were significantly more treatment responders under tapentadol PR (65.7 vs 14.2%; p < 0.001). Conclusion: Tapentadol PR showed significantly better effectiveness and tolerability in severe chronic low back pain unsuccessfully treated with WHO-I/II analgesics compared with the other oral WHO-III PR opioids investigated.

Efficacy of a Trial Oral Appliance in OSAS Management: A New Protocol to Recognize Responder/Nonresponder Patients

Oral appliances (OAs) of various types have shown variable success in the treatment of mild-to-moderate obstructive sleep apnoea (OSA). In an OSA sample, this study evaluated the efficacy of a diagnostic trial OA (myTAP™); the efficacy of a definitive custom-fitted mandibular advancement device (MAD) (SomnoDent Flex™); and whether a trial device can be used to distinguish treatment responder from nonresponder patients. Patients underwent overnight home sleep recordings prior to and after fitting of these appliances in order to objectively assess their sleep quality in terms of polysomnographic (PSG) respiratory measures: apnoea-hypopnoea index (AHI), oxygen desaturation index (ODI), and minimum oxygen saturation (LowSpO2). 40 patients with symptomatic OSAS were enrolled, 33 males and 7 females, with a mean age of 55.6 ± 12.73 years and an initial (T0) AHI of 26.51 ± 14.79. Trial devices were used in 16 patients (AHI: 29.9 ± 19.97, ODI: 21.06 ± 16.05, and LowSpO2: 82 ± 10.22 at T0) and definitive MADs in 28 (AHI: 23.90 ± 9.19, ODI: 16.27 ± 11.34, and LowSpO2: 82.87 ± 6.04 at T0). Statistically significant decreases in AHI (9.59 ± 8.94, p < 0.0023 ) and ODI (8.20 ± 9.67, p < 0.0129 ) were observed after treatment with the trial device. Only 8 of the patients in the trial device group went on to use the definitive device. Treatment with the definitive MAD produced statistically significant decreases in AHI (11.46 ± 9.65, p < 0.0001 ) and ODI (9.10 ± 8.47, p < 0.0016 ) and a significant improvement in LowSpO2 (85.09 ± 6.86, p < 0.0004 ). Thus, both types of device proved effective in improving the PSG parameters. This study showed that introducing an easy-to-make and low-cost trial device into the therapeutic pathway of OSAS patients can circumvent the problem of individual responses to treatment by allowing effective classification of patients: in short, it allows a first distinction to be drawn between responders and nonresponders to treatment.

Clinical Relevance of Torque Teno Virus (TTV) in HIV/HCV Coinfected and HCV Monoinfected Patients Treated with Direct-Acting Antiviral Therapy

Torque Teno virus (TTV) is a ubiquitous virus that causes chronic infection in humans with unknown clinical consequences. Here, we investigated the influence of TTV infection on HCV direct-acting antiviral (DAA) efficacy in HIV/HCV coinfected and HCV monoinfected patients as controls. Of 92 study patients, 79.3% were TTV DNA positive; untreated patients exhibited a significantly higher proportion of TTV DNA-positivity vs. sustained virological response (SVR) patients (100.0% vs. 65.2%, p < 0.001), while TTV positivity was not significant in DAA failure patients vs. SVR patients despite HIV/HCV coinfection. TTV DNA viral load was higher among HCV monoinfected patients vs. HIV/HCV coinfected, although marginally significant (p = 0.074) and no significant viral load difference was detected between DAA failures and SVR patients, while untreated vs. SVR patients had a significantly higher viral load (19,884, IQR 5977–333,534, vs. 469, IQR 10–4124, p = 0.004). Alpha-genogroup 3 TTV was the most prevalent genetic group, and no specific strain or genogroup was observed in relapser patients. Among HIV/HCV patients with HCV RNA detectable at end of treatment (EOT), TTV DNA was detected in 9/17 treatment responder patients and 3/5 relapser patients, thus, TTV infection does not appear to influence the control HCV viremia after EOT. Levels of IL-6 IL-4, and CD14 were not significantly different between TTV PCR-positive and -negative patients. These results suggest no association between TTV DNA positivity or viral load and HCV DAA failure whether patients were HIV/HCV coinfected or HCV monoinfected.

Levels of Osteopontin (SPP1), Osteonectin (SPARC) and Biglycan (BGN) in Acute Myeloid Leukemia Bone Marrow Biopsies Post-Induction Therapy Define the Status of Osteogenic Niche and Show Inverse Correlation with Therapeutic Response

Background: Acute Myeloid Leukemia (AML) has a five-year survival rate of 25% and its high mortality is linked to poor response to treatment and relapse. Our understanding of the molecular mechanisms controlling relapse and AML progression is limited. Animal models indicate that AML cells significantly modulate their bone marrow microenvironment inducing gradual loss of endosteal and vascular niches, both playing critical roles in support and maintenance of normal hematopoiesis. The goal of this study was to determine microenvironmental factors driving the gradual retraction of endosteal and vascular niches directly in the AML core bone marrow biopsies, and assess the treatment effect on hematopoietic and non-hematopoietic cells. Methods: Transcriptomics and histopathologic evaluations of matched human AML core bone marrow biopsies obtained at diagnosis (n=12) and day 14 post-induction therapy (n=12) with daunorubicin and cytarabine (7+3) were performed. Based on post-treatment frequency of blasts in the AML bone marrow aspirate, patients were classified as responders (&lt;5% blasts) or non-responders (&gt; 5% blasts). Three of 6 responders (3 men, 3 women, average age 59 yrs) had normal karyotype, and three of 6 non-responders (1 man, 5 women, average age 52.6 yrs), had normal karyotype. RNA was isolated from the core bone marrow biopsies and subjected to Clariom D Human Affymetrix arrays. Transcriptomics data were analyzed using Affymetrix Transcriptome Analysis Console with LIMMA R package and Gene Set Enrichment Analysis (GSEA). H&E stained bone marrow biopsy slides were subjected to blinded histopathological assessment. Results: Transcriptomic data analysis of responder vs. non-responder samples at diagnosis indicated significant loss of transcripts associated with heme metabolism (HBB, HBD, GYPE, CA1) suggesting decrease in frequency of erythroid progenitors (Fig.A). Trends of decreased frequency of erythroid progenitors were noted in both bone marrow biopsies and aspirates of diagnostic non-responder samples (Fig.B). Decreased frequency of lymphoid cells was also noted (Fig.B). Interestingly, while post-treatment we noted a relative increase in frequencies of lymphoid cells in both responder and non-responder samples, the increase was more prominent in responders (Fig.B). Trilineage hematopoiesis appeared affected more in diagnostic and post-treatment responder samples. Transcriptome analyses of diagnostic vs. post-treatment responder samples indicated significant increase in transcripts associated with activity within endosteal niche (SPARC, SPP1, DCN, VCAN, BGN) and significant loss of transcripts associated with DNA replication (TOP2, HELLS, E2F8) (Fig.C), the latter was consistent with treatment-related loss of cellularity. Only modest increase in SPARC, SPP1 or BGN levels and no significant decrease in DNA-replication associated transcripts were noted in non-responder post-treatment samples (Fig.1D). These data indicate greater loss of AML cells and greater activity within the endosteal niche in responder in comparison to non-responder samples. Finally, analyses performed on post-treatment responder vs. non-responder samples showed significant decrease in SPARC, SPP1, DCN, VCAN, BGN in non-responder post-treatment samples (Fig.E, F). Endosteal niche in histopathologic evaluation at diagnosis was generally unremarkable in both responder and non-responder samples with only rare osteoblasts present. In contrast, post-treatment, we found an elevated number of osteoblasts in responders in comparison to non-responder samples (Fig.G, H). Conclusions: Transcriptomic and histopathologic analyses of AML bone marrow biopsies procured at diagnosis and post-treatment from responder or non-responders indicate inverse correlation between the activity of endosteal niche and levels of transcripts involved in osteoblast maturation and homeostasis. Significant suppression of mesenchymal/osteoblast component of the niche is observed in non-responder samples. To our knowledge this is a first report showing the correlation between levels of osteopontin (SPP1), osteonectin (SPARC) and biglycan (BGN) and response to chemotherapy directly in the AML core bone marrow biopsies. Our data suggest that osteo-stimulatory factors could be used to achieve better therapeutic outcomes in AML. Disclosures No relevant conflicts of interest to declare.

Safety and Tolerability of Manual Push Administration of Subcutaneous IgPro20 at High Infusion Rates in Patients with Primary Immunodeficiency: Findings from the Manual Push Administration Cohort of the HILO Study

Purpose To evaluate the safety and tolerability of IgPro20 manual push (also known as rapid push) infusions at flow rates of 0.5–2.0 mL/min. Methods Patients with primary immunodeficiency (PID) with previous experience administering IgPro20 (Hizentra®, CSL Behring, King of Prussia, PA, USA) were enrolled in the Hizentra® Label Optimization (HILO) study (NCT03033745) and assigned to Pump-assisted Volume Cohort, Pump-assisted Flow Rate Cohort, or Manual Push Flow Rate Cohort; this report describes the latter. Patients administered IgPro20 via manual push at 0.5, 1.0, and 2.0 mL/min/site for 4 weeks each. Responder rates (percentage of patients who completed a predefined minimum number of infusions), safety outcomes, and serum immunoglobulin G (IgG) trough levels were evaluated. Results Sixteen patients were treated; 2 patients (12.5%) discontinued at the 1.0-mL/min level (unrelated to treatment). Responder rates were 100%, 100%, and 87.5% at 0.5-, 1.0-, and 2.0-mL/min flow rates, respectively. Mean weekly infusion duration decreased from 103–108 to 23–28 min at the 0.5- and 2.0-mL/min flow rates, respectively. Rates of treatment-related treatment-emergent adverse events (TEAEs) per infusion were 0.023, 0.082, and 0.025 for the 0.5-, 1.0-, and 2.0-mL/min flow rates, respectively. Most TEAEs were mild local reactions and tolerability (infusions without severe local reactions/total infusions) was 100% across flow rate levels. Serum IgG levels (mean [SD]) were similar at study start (9.36 [2.53] g/L) and end (9.58 [2.12] g/L). Conclusions Subcutaneous IgPro20 manual push infusions at flow rates up to 2.0 mL/min were well tolerated and reduced infusion time in treatment-experienced patients with PID. Trial Registration NCT03033745

AB0390 ASSOCIATION BETWEEN INITIAL SERUM “TUMOR NECROSIS FACTOR-LIKE WEAK INDUCER OF APOPTOSIS” (TWEAK) LEVEL AND TREATMENT RESPONSE IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) NEPHROPATHY

Background:SLE is a chronic inflammatory immunologic abnormalities disease which produce a number of antinuclear antibodies. The SLE renal involvement is clinically apparent in approximately 50% patients (Norby et al., 2017). It is very important to introduce the prompt treatment to prevent the permanent end stage renal disease.Objectives:This study aimed to identify the serum biomarkers that correlate with pretreatment disease activity in patients with SLE nephropathy and predict the treatment outcome so that we may identify the unresponsive cases and switch to the other biologic agents like anti-TWEAK monoclonal antibody in the future.Methods:This was a hospital-based prospective analytical study conducted from January 2018 to November 2019 in Rheumatology Department, Yangon Specialty Hospital. 88 SLE nephropathy patients with 24-hour urinary protein above 0.5g/day planned to have 6 months course of IV cyclophosphamide were enrolled. The paired serum sample of each patient was analyzed by ELISA twice to get the mean serum TWEAK value. Pretreatment SLE disease activity was assessed by the SLEDAI 2k. After the completion of 6 months of aggressive treatment, the treatment response was assessed by measuring the 24 hour urinary protein.Results:Among the 88 patients, 63 patients (71.6%) had completed total 6-months course and 25 patients (28.4%) had not completed:11 patients (12.5%) expired and 2 patients (2.27%) had been changed to other DMARD and 12 patients (13.63%) did not attend the follow up clinic. The mean serum TWEAK level was 856 ± 77 pg/ml in 88 patients. According to the range of serum TWEAK level, most of the patients had serum TWEAK level of 601-900 pg/ml (53.4% of the study population). There was positive correlation between pre-treatment SLEDAI 2k score and pretreatment serum TWEAK level (r=0.464 and P <0.001). When the SLEDAI 2k score was grouped into mild, moderate, high and very high disease activity, the serum TWEAK level also had positive association with the different levels of disease activity (p<0.001). Among 63 treatment completed patients, 55 patients (87.3%) were the treatment responders but 8 patients (12.7%) were treatment non-responders. There was significant difference in the pretreatment SLEDAI 2k in terms of disease activity between treatment responder and treatment non-responder (p<0.001). There was significant difference in the pretreatment SLEDAI 2k in terms of reduction in 24-hours urinary protein between treatment responder and treatment non-responder (p<0.001). There was no significant difference in the level of pretreatment serum TWEAK level between treatment responders and treatment non responders (p=1.000). There was also no significant difference in the pretreatment serum TWEAK level between treatment responders and treatment non-responders in terms of reduction in 24 hours urinary protein (p=0.804).Conclusion:Although the pretreatment serum TWEAK level had a positive correlation with pretreatment disease activity of SLEDAI 2k, it did not reflect the outcome of the responsiveness to the intensive therapy.References:[1]Norby, et al (2017) Outcome in biopsy-proven lupus nephritis: evaluation of biopsies from the Norwegian kidney biopsy registry.Lupus; 26:88Acknowledgments:Prof.Chit Soe, Prof.Hlaing Mya WinDisclosure of Interests:None declared

Cost-Effectiveness of Virtual Reality Cognitive Behavioral Therapy for Psychosis: Health-Economic Evaluation Within a Randomized Controlled Trial

Background Evidence was found for the effectiveness of virtual reality-based cognitive behavioral therapy (VR-CBT) for treating paranoia in psychosis, but health-economic evaluations are lacking. Objective This study aimed to determine the short-term cost-effectiveness of VR-CBT. Methods The health-economic evaluation was embedded in a randomized controlled trial evaluating VR-CBT in 116 patients with a psychotic disorder suffering from paranoid ideation. The control group (n=58) received treatment as usual (TAU) for psychotic disorders in accordance with the clinical guidelines. The experimental group (n=58) received TAU complemented with add-on VR-CBT to reduce paranoid ideation and social avoidance. Data were collected at baseline and at 3 and 6 months postbaseline. Treatment response was defined as a pre-post improvement of symptoms of at least 20% in social participation measures. Change in quality-adjusted life years (QALYs) was estimated by using Sanderson et al’s conversion factor to map a change in the standardized mean difference of Green’s Paranoid Thoughts Scale score on a corresponding change in utility. The incremental cost-effectiveness ratios were calculated using 5000 bootstraps of seemingly unrelated regression equations of costs and effects. The cost-effectiveness acceptability curves were graphed for the costs per treatment responder gained and per QALY gained. Results The average mean incremental costs for a treatment responder on social participation ranged between €8079 and €19,525, with 90.74%-99.74% showing improvement. The average incremental cost per QALY was €48,868 over the 6 months of follow-up, with 99.98% showing improved QALYs. Sensitivity analyses show costs to be lower when relevant baseline differences were included in the analysis. Average costs per treatment responder now ranged between €6800 and €16,597, while the average cost per QALY gained was €42,030. Conclusions This study demonstrates that offering VR-CBT to patients with paranoid delusions is an economically viable approach toward improving patients’ health in a cost-effective manner. Long-term effects need further research. Trial Registration International Standard Randomised Controlled Trial Number (ISRCTN) 12929657; http://www.isrctn.com/ISRCTN12929657

M16. PROFILING GLUTAMATE AND D-SERINE PATHWAYS IN TREATMENT RESISTANT EARLY PSYCHOSIS PATIENTS

Background Pharmacological, neurochemical and electrophysiological studies provide compelling evidence that N-methyl-D-aspartate-receptor (NMDAR) hypofunction is a pathologic feature of schizophrenia (SZ). GWAS studies highlighted risk genes such as Serine Racemase (SRR), which synthesizes D-Serine (D-Ser), the co-agonist of glycine site at NMDARs, and Serine Hydroxymethyltransferase (SHMT1) which synthesizes L-Serine (L-Ser), the substrate of SRR. Around 30% of patients do not respond to dopamine modulation and are considered to suffer from treatment resistant SZ (TRS). While the exact cause of TRS remains unclear, multiple lines of evidence suggest the involvement of a dysregulation of the Glutamate (Glu) neurotransmission. To test the hypothesis whether Glu system dysregulation mediated by NMDAR hypofunction is an underlying mechanism of TRS, we investigate the Glu and D-Ser pathways in TRS and treatment responder (RESP) early psychosis patients (EPP). Methods From a total of 621 EPP aged 18 to 35, included in the TIPP (early Intervention Program in Lausanne, Baumann & al., 2013), 225 EPP were classified as TRS (n=33) or RESP (n=192) according to the strict Treatment Response and Resistance in Psychosis (TRRIP) criteria (Howes & al., 2017), with compliance ascertained by antipsychotic plasma levels. A matched healthy control (HC) group (N=114) was also recruited (DIGS criteria). No patient was taking clozapine at baseline. Clinical data was collected over a 3-year period. At baseline, following systems were assessed: 1) D-Ser pathway: plasmatic D-Ser, L-Ser and Glycine by HPLC (Hashimoto & al., 2016), protein levels of SRR and SHMT1 by ELISA; 2) Glu pathway: Glu and glutamine in plasma (HPLC) and prefrontal cortex (magnetic resonance spectroscopy, Xin & al., 2016). Results D-Ser pathway: in TRS, SRR levels were decreased by 56% as compared to RESP. Interestingly, we observed a positive correlation between plasma levels of D-Ser (SRR metabolite) and L-Ser (SRR substrate) in the TRS (r= 0.58; p =0.0015) but not in the RESP group, suggesting that SRR dysregulation might be a limiting factor in TRS patients. Moreover, in TRS patients, SHMT1 levels were decreased by 15% as compared to RESP, with a positive correlation between the substrate and metabolite of SHMT1, glycine and L-Ser (r =0.48; p =0.011). Dysregulation of SHMT1 might thus be a limiting factor in the TRS group. As compared to HC, L-Ser and D-Ser were significantly increased in patients (p &lt;0.001 for L-Ser, p =0.0001 for D-Ser). However, no difference was observed in D-Ser, L-Ser and glycine in TRS as compared to RESP, although L-Ser tended to be higher in male TRS patients (p =0.06). Glu pathway: comparing TRS with RESP patients, plasma Glu levels were increased in the TRS group (p &lt;0.0001), whereas they were higher in both patient groups compared to HC (p &lt;0.0001). Interestingly, plasma and brain Glu levels showed a negative correlation in EPP, mostly driven by RESP (r = -0.42; p =0.035), a correlation which was absent in HC. Global Assessment of Functioning (GAF): at baseline, TRS and RESP displayed the same range of GAF. After a 3-year follow-up, TRS patients had poorer functioning as compared to RESP group (p &lt;0.0001). Discussion Taken together, our results suggest that the TRS group, in which the levels of SRR and SHMT1 were lower and Glu plasma levels were higher, display a different regulation of the synthesis, degradation and/or accumulation of D-Ser and Glu as compared to the RESP group. However, replication in larger groups is needed. Moreover, our findings highlighted a dysregulation of D-Ser and Glu pathways in TRS patients in their early phase of psychosis. On the clinical side, our results confirm the significantly poorer functioning outcome in TRS patients.