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Archive for the ‘Death by Stem Cells’ Category

Research breakthrough could mean better treatment for patients with most deadly form of brain tumor – EurekAlert

Tuesday, October 26th, 2021

image:Glioblastoma under microscope with dyes. view more

Credit: Credit to Brain Tumour Research Centre of Excellence at Queen Mary University of London.

Scientists studying the most common and aggressive type of brain tumour in adults have discovered a new way of analysing diseased and healthy cells from the same patient.

Crucially, the work which has been funded by the charity Brain Tumour Research could pave the way for truly personalised treatment for patients diagnosed with glioblastoma multiforme (GBM). Only 25% of patients with this type of brain tumour survive for more than one year and just 5% live for more than five years.

A team at the Brain Tumour Research Centre of Excellence at Queen Mary University of London has established an entirely new experimental research pipeline which, in a trial involving ten patients, has revealed new insights into how GBM develops, identifying potential new targets for individualised treatments. It could also help predict a patients response to drugs currently in clinical use for other diseases which would be extremely valuable as the average survival time for this type of brain tumour is just 12 to 18 months.

Their paper, Comparative epigenetic analysis of tumour initiating cells and syngeneic EPSC-derived neural stem cells (SYNGN) in glioblastoma, is published in the high impact journal Nature Communications today (Thursday 21 October). Professor Silvia Marino, who leads the team, said: We have used this powerful technique to identify changes in the function of genes that occur in GBM that do not entail a change in the genetic code (epigenetics). This has revealed new insights for how GBM develops and identified potential new targets for individualised treatments.

By using a combination of laboratory work and sophisticated analytical computer programmes, the team at Queen Mary has identified significant molecular differences which could be exploited to develop new treatments. It is an innovative approach enabling the comparison of normal and malignant cells from the same patient helping to identify genes that play a role in growth of the tumour.

The research is particularly significant as GBM is the most common malignant brain tumour in adults. Its aggressive nature means it spreads extensively into surrounding brain tissue making complete removal by surgery almost impossible. It is extremely resistant to radiotherapy and chemotherapy meaning it is very likely to recur following treatment.

Hugh Adams, spokesman for Brain Tumour Research, said: The complex nature of this particular tumour type means that the standard of care for these patients has not changed in a generation so this research brings much-needed hope for the future. One of the main challenges in developing effective treatments for GBM is that the tumour exhibits significant variation between patients and there can even be significant variation within a single patients tumour. These variations can arise from change to the cells genetic code known as mutations combined with changes to how specific genes are controlled.

There is strong evidence that GBM cells develop from neural stem cells but previous studies have not been able to compare tumour cells and their putative cell of origin from the same person. Prof Marino and her team have now harnessed state-of-the-art stem cell technologies and next-generation DNA sequencing methods to compare diseased and healthy cells from the same patient. Their results have shown how this approach can reveal novel molecular events that appear to go awry when GBM develops, thereby identifying targets for potentially new treatments.

The results of the teams work have shown how this approach can reveal novel molecular targets for potentially new treatments. For example, the results reveal how some GBM tumours can control the movement of regulatory T cells, a type of immune cell and has also revealed epigenetic changes that could be used to predict the response to drugs currently in clinical use.

Brain tumours kill more children and adults under the age of 40 than any other cancer yet historically just 1% of the national spend on cancer research has been allocated to this devastating disease.

Brain Tumour Research funds sustainable research at dedicated centres in the UK. It also campaigns for the Government and the larger cancer charities to invest more in research into brain tumours in order to speed up new treatments for patients and, ultimately, to find a cure. The charity is calling for a national annual spend of 35 million in order to improve survival rates and patient outcomes in line with other cancers such as breast cancer and leukaemia and is also campaigning for greater repurposing of drugs.

http://www.braintumourresearch.org

-ENDS-

For further information, please contact:

Sue Castle-Smith, Head of PR & Communications at Brain Tumour Research on 07887 241639 or Susan@braintumourresearch.org

Notes to Editors

Brain Tumour Research is the only national charity in the UK singularly focused on finding a cure for brain tumours through campaigning for an increase in the national investment into research to 35 million per year, while fundraising to create a sustainable network of brain tumour research centres in the UK.

The 35 million a year funding would bring parity with other cancers such as breast and leukaemia after historically just 1% of the national spend on cancer research has been allocated to brain tumours. This increased commitment would enable the ground-breaking research needed to accelerate the translation from laboratory discoveries into clinical trials and fast-track new therapies for this devastating disease.

Brain Tumour Research is a powerful campaigning organisation and represents the voice of the brain tumour community across the UK. We helped establish and provide the ongoing Secretariat for the All-Party Parliamentary Group for Brain Tumours (APPGBT) which published its report Brain Tumours A cost too much to bear? in 2018. Led by the charity, the report examines the economic and social impacts of a brain tumour diagnosis.

We are also a leading player on the Steering Group for the Tessa Jowell Brain Cancer Mission and we were a key influencer in the Governments 2018 funding announcement, following her death, to commit 40 million over five years. So far, just 9.3 million has been allocated and we continue to work through the APPGBT to hold the Government to account and ensure this money is spent on research into brain tumours.

Key statistics on brain tumours:

Please quote Brain Tumour Research as the source when using this information. Additional facts and statistics are available from our website. We can also provide case studies and research expertise for the media.

Nature Communications

Comparative epigenetic analysis of tumour initiating cells and syngeneic EPSC-derived neural stem cells in glioblastoma

21-Oct-2021

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

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European Commission Selects Humanigen’s Lenzilumab as One of the 10 Most Promising Treatments for COVID-19 – Galveston County Daily News

Tuesday, October 26th, 2021

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European Commission Approves Merck’s KEYTRUDA (pembrolizumab) Plus Chemotherapy as Treatment for Certain Patients With Locally Recurrent Unresectable…

Tuesday, October 26th, 2021

KENILWORTH, N.J.--(BUSINESS WIRE)--Merck (NYSE: MRK), known as MSD outside the United States and Canada, today announced that the European Commission (EC) has approved KEYTRUDA, Mercks anti-PD-1 therapy, in combination with chemotherapy for the first-line treatment of locally recurrent unresectable or metastatic triple-negative breast cancer (TNBC) in adults whose tumors express PD-L1 (Combined Positive Score [CPS] 10) and who have not received prior chemotherapy for metastatic disease. Triple-negative breast cancer is an aggressive type of breast cancer. This represents KEYTRUDAs first approval in Europe in a breast cancer setting.

The approval is based on final analysis from the Phase 3 KEYNOTE-355 trial, in which KEYTRUDA in combination with chemotherapy (nab-paclitaxel, paclitaxel or gemcitabine/carboplatin) significantly improved overall survival (OS), reducing the risk of death by 27% (HR=0.73 [95% CI, 0.55-0.95]; p=0.0093), and progression-free survival (PFS), reducing the risk of disease progression or death by 34% (HR=0.66 [95% CI, 0.50-0.88]; p=0.0018) compared to chemotherapy alone in these patients. In this trial, 38% of enrolled patients had tumors expressing PD-L1 with CPS 10.

This approval is an important milestone for appropriate patients with metastatic TNBC who are in need of new treatment options, said Dr. Javier Corts, head of the International Breast Cancer Center (IBCC), Quironsalud Group. With this approval, patients in Europe with metastatic TNBC whose tumors express PD-L1 (CPS 10) have a new immunotherapy treatment option that can be used in combination with different chemotherapy agents.

At Merck, we are committed to improving outcomes for people with difficult-to-treat cancers, such as TNBC, around the world and are proud of this first European approval for KEYTRUDA in a breast cancer setting, said Dr. Vicki Goodman, vice president, clinical research, Merck Research Laboratories. Now patients with metastatic TNBC who have tumors that express PD-L1 (CPS 10) in Europe have the new option of KEYTRUDA in combination with chemotherapy, a regimen that has shown significant improvement in overall survival. Today marks an important step forward in the treatment of this aggressive disease.

This approval allows marketing of the combination with KEYTRUDA in all 27 European Union member states plus Iceland, Lichtenstein, Norway and Northern Ireland.

Merck is committed to delivering meaningful advances in breast cancer and womens cancers. The company is rapidly advancing a broad portfolio in gynecologic and breast cancers through an extensive clinical development program for KEYTRUDA and several other investigational and approved medicines across these areas.

Data Supporting the European Approval

The approval was based on data from KEYNOTE-355 (NCT02819518), a multicenter, randomized, placebo-controlled, Phase 3 trial that enrolled 847 patients with locally recurrent unresectable or metastatic TNBC who had not been previously treated with chemotherapy in the advanced setting. Patients were randomized 2:1 to receive KEYTRUDA (200 mg every three weeks) plus chemotherapy (investigators choice of paclitaxel, nab-paclitaxel or gemcitabine/carboplatin) or placebo plus chemotherapy. Treatment with KEYTRUDA or placebo, both in combination with chemotherapy, continued until disease progression, unacceptable toxicity or a maximum of 24 months. Patients could continue to be treated with chemotherapy, per standard of care. Patients could continue to be treated with KEYTRUDA beyond RECIST-defined disease progression if the patient was clinically stable and deriving clinical benefit as determined by the investigator. The dual primary efficacy outcome measures were OS and PFS. Secondary efficacy outcome measures included objective response rate and duration of response.

In the final analysis of the study, median OS was 23.0 months (95% CI, 19.0-26.3) with KEYTRUDA plus chemotherapy versus 16.1 months (95% CI, 12.6-18.8) with chemotherapy alone. Median PFS was 9.7 months (95% CI, 7.6-11.3) with KEYTRUDA plus chemotherapy versus 5.6 months (95% CI, 5.3-7.5) with chemotherapy alone.

The safety of KEYTRUDA in combination with chemotherapy has been evaluated in 2,033 patients with non-small cell lung cancer (NSCLC), head and neck squamous cell carcinoma (HNSCC), esophageal carcinoma or TNBC receiving 200 mg, 2 mg/kg bodyweight (bw) or 10 mg/kg bw KEYTRUDA every three weeks in clinical studies. In this patient population, the most frequent adverse reactions were anemia (52%), nausea (52%), fatigue (37%), constipation (34%), neutropenia (33%), diarrhea (32%), decreased appetite (30%) and vomiting (28%). Incidences of Grades 3-5 adverse reactions were 67% for KEYTRUDA plus chemotherapy and 66% for chemotherapy alone in patients with NSCLC; 85% for KEYTRUDA plus chemotherapy and 84% for chemotherapy plus cetuximab in patients with HNSCC; 86% for KEYTRUDA plus chemotherapy and 83% for chemotherapy alone in patients with esophageal carcinoma; and 78% for KEYTRUDA plus chemotherapy and 74% for chemotherapy alone in patients with TNBC.

About Triple-Negative Breast Cancer

Triple-negative breast cancer is a type of breast cancer that tests negative for estrogen hormone receptors, progesterone hormone receptors and overexpression of human epidermal growth factor receptor 2 (HER2). It is an aggressive type of breast cancer that characteristically has a high recurrence rate within the first five years after diagnosis. Approximately 10-15% of patients with breast cancer are diagnosed with TNBC, which tends to be more common in people who are younger than 40 years of age, who are Black or who have a BRCA1 mutation.

About KEYTRUDA (pembrolizumab) Injection, 100 mg

KEYTRUDA is an anti-programmed death receptor-1 (PD-1) therapy that works by increasing the ability of the bodys immune system to help detect and fight tumor cells. KEYTRUDA is a humanized monoclonal antibody that blocks the interaction between PD-1 and its ligands, PD-L1 and PD-L2, thereby activating T lymphocytes which may affect both tumor cells and healthy cells.

Merck has the industrys largest immuno-oncology clinical research program. There are currently more than 1,600 trials studying KEYTRUDA across a wide variety of cancers and treatment settings. The KEYTRUDA clinical program seeks to understand the role of KEYTRUDA across cancers and the factors that may predict a patient's likelihood of benefitting from treatment with KEYTRUDA, including exploring several different biomarkers.

Selected KEYTRUDA (pembrolizumab) Indications in the U.S.

Melanoma

KEYTRUDA is indicated for the treatment of patients with unresectable or metastatic melanoma.

KEYTRUDA is indicated for the adjuvant treatment of patients with melanoma with involvement of lymph node(s) following complete resection.

Non-Small Cell Lung Cancer

KEYTRUDA, in combination with pemetrexed and platinum chemotherapy, is indicated for the first-line treatment of patients with metastatic nonsquamous non-small cell lung cancer (NSCLC), with no EGFR or ALK genomic tumor aberrations.

KEYTRUDA, in combination with carboplatin and either paclitaxel or paclitaxel protein-bound, is indicated for the first-line treatment of patients with metastatic squamous NSCLC.

KEYTRUDA, as a single agent, is indicated for the first-line treatment of patients with NSCLC expressing PD-L1 [tumor proportion score (TPS) 1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is:

KEYTRUDA, as a single agent, is indicated for the treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS 1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving KEYTRUDA.

Head and Neck Squamous Cell Cancer

KEYTRUDA, in combination with platinum and fluorouracil (FU), is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent head and neck squamous cell carcinoma (HNSCC).

KEYTRUDA, as a single agent, is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent HNSCC whose tumors express PD-L1 [combined positive score (CPS) 1] as determined by an FDA-approved test.

KEYTRUDA, as a single agent, is indicated for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy.

Classical Hodgkin Lymphoma

KEYTRUDA is indicated for the treatment of adult patients with relapsed or refractory classical Hodgkin lymphoma (cHL).

KEYTRUDA is indicated for the treatment of pediatric patients with refractory cHL, or cHL that has relapsed after 2 or more lines of therapy.

Primary Mediastinal Large B-Cell Lymphoma

KEYTRUDA is indicated for the treatment of adult and pediatric patients with refractory primary mediastinal large B-cell lymphoma (PMBCL), or who have relapsed after 2 or more prior lines of therapy. KEYTRUDA is not recommended for treatment of patients with PMBCL who require urgent cytoreductive therapy.

Urothelial Carcinoma

KEYTRUDA is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma (mUC):

Non-muscle invasive Bladder Cancer

KEYTRUDA is indicated for the treatment of patients with Bacillus Calmette-Guerin-unresponsive, high-risk, non-muscle invasive bladder cancer (NMIBC) with carcinoma in situ with or without papillary tumors who are ineligible for or have elected not to undergo cystectomy.

Microsatellite Instability-High or Mismatch Repair Deficient Cancer

KEYTRUDA is indicated for the treatment of adult and pediatric patients with unresectable or metastatic microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) solid tumors that have progressed following prior treatment and who have no satisfactory alternative treatment options.

This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials. The safety and effectiveness of KEYTRUDA in pediatric patients with MSI-H central nervous system cancers have not been established.

Microsatellite Instability-High or Mismatch Repair Deficient Colorectal Cancer

KEYTRUDA is indicated for the treatment of patients with unresectable or metastatic MSI-H or dMMR colorectal cancer (CRC).

Gastric Cancer

KEYTRUDA, in combination with trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy, is indicated for the first-line treatment of patients with locally advanced unresectable or metastatic HER2-positive gastric or gastroesophageal junction (GEJ) adenocarcinoma.

This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Esophageal Cancer

KEYTRUDA is indicated for the treatment of patients with locally advanced or metastatic esophageal or GEJ (tumors with epicenter 1 to 5 centimeters above the GEJ) carcinoma that is not amenable to surgical resection or definitive chemoradiation either:

Cervical Cancer

KEYTRUDA, in combination with chemotherapy, with or without bevacizumab, is indicated for the treatment of patients with persistent, recurrent, or metastatic cervical cancer whose tumors express PD-L1 (CPS 1) as determined by an FDA-approved test.

KEYTRUDA, as a single agent, is indicated for the treatment of patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD-L1 (CPS 1) as determined by an FDA-approved test.

Hepatocellular Carcinoma

KEYTRUDA is indicated for the treatment of patients with hepatocellular carcinoma (HCC) who have been previously treated with sorafenib. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Merkel Cell Carcinoma

KEYTRUDA is indicated for the treatment of adult and pediatric patients with recurrent locally advanced or metastatic Merkel cell carcinoma (MCC). This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Renal Cell Carcinoma

KEYTRUDA, in combination with axitinib, is indicated for the first-line treatment of adult patients with advanced renal cell carcinoma.

Tumor Mutational Burden-High Cancer

KEYTRUDA is indicated for the treatment of adult and pediatric patients with unresectable or metastatic tumor mutational burden-high (TMB-H) [10 mutations/megabase] solid tumors, as determined by an FDA-approved test, that have progressed following prior treatment and who have no satisfactory alternative treatment options. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials. The safety and effectiveness of KEYTRUDA in pediatric patients with TMB-H central nervous system cancers have not been established.

Cutaneous Squamous Cell Carcinoma

KEYTRUDA is indicated for the treatment of patients with recurrent or metastatic cutaneous squamous cell carcinoma (cSCC) or locally advanced cSCC that is not curable by surgery or radiation.

Triple-Negative Breast Cancer

KEYTRUDA is indicated for the treatment of patients with high-risk early-stage triple-negative breast cancer (TNBC) in combination with chemotherapy as neoadjuvant treatment, and then continued as a single agent as adjuvant treatment after surgery.

KEYTRUDA, in combination with chemotherapy, is indicated for the treatment of patients with locally recurrent unresectable or metastatic TNBC whose tumors express PD-L1 (CPS 10) as determined by an FDA-approved test.

Selected Important Safety Information for KEYTRUDA

Severe and Fatal Immune-Mediated Adverse Reactions

KEYTRUDA is a monoclonal antibody that belongs to a class of drugs that bind to either the PD-1 or the PD-L1, blocking the PD-1/PD-L1 pathway, thereby removing inhibition of the immune response, potentially breaking peripheral tolerance and inducing immune-mediated adverse reactions. Immune-mediated adverse reactions, which may be severe or fatal, can occur in any organ system or tissue, can affect more than one body system simultaneously, and can occur at any time after starting treatment or after discontinuation of treatment. Important immune-mediated adverse reactions listed here may not include all possible severe and fatal immune-mediated adverse reactions.

Monitor patients closely for symptoms and signs that may be clinical manifestations of underlying immune-mediated adverse reactions. Early identification and management are essential to ensure safe use of antiPD-1/PD-L1 treatments. Evaluate liver enzymes, creatinine, and thyroid function at baseline and periodically during treatment. For patients with TNBC treated with KEYTRUDA in the neoadjuvant setting, monitor blood cortisol at baseline, prior to surgery, and as clinically indicated. In cases of suspected immune-mediated adverse reactions, initiate appropriate workup to exclude alternative etiologies, including infection. Institute medical management promptly, including specialty consultation as appropriate.

Withhold or permanently discontinue KEYTRUDA depending on severity of the immune-mediated adverse reaction. In general, if KEYTRUDA requires interruption or discontinuation, administer systemic corticosteroid therapy (1 to 2 mg/kg/day prednisone or equivalent) until improvement to Grade 1 or less. Upon improvement to Grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month. Consider administration of other systemic immunosuppressants in patients whose adverse reactions are not controlled with corticosteroid therapy.

Immune-Mediated Pneumonitis

KEYTRUDA can cause immune-mediated pneumonitis. The incidence is higher in patients who have received prior thoracic radiation. Immune-mediated pneumonitis occurred in 3.4% (94/2799) of patients receiving KEYTRUDA, including fatal (0.1%), Grade 4 (0.3%), Grade 3 (0.9%), and Grade 2 (1.3%) reactions. Systemic corticosteroids were required in 67% (63/94) of patients. Pneumonitis led to permanent discontinuation of KEYTRUDA in 1.3% (36) and withholding in 0.9% (26) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, 23% had recurrence. Pneumonitis resolved in 59% of the 94 patients.

Pneumonitis occurred in 8% (31/389) of adult patients with cHL receiving KEYTRUDA as a single agent, including Grades 3-4 in 2.3% of patients. Patients received high-dose corticosteroids for a median duration of 10 days (range: 2 days to 53 months). Pneumonitis rates were similar in patients with and without prior thoracic radiation. Pneumonitis led to discontinuation of KEYTRUDA in 5.4% (21) of patients. Of the patients who developed pneumonitis, 42% interrupted KEYTRUDA, 68% discontinued KEYTRUDA, and 77% had resolution.

Immune-Mediated Colitis

KEYTRUDA can cause immune-mediated colitis, which may present with diarrhea. Cytomegalovirus infection/reactivation has been reported in patients with corticosteroid-refractory immune-mediated colitis. In cases of corticosteroid-refractory colitis, consider repeating infectious workup to exclude alternative etiologies. Immune-mediated colitis occurred in 1.7% (48/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (1.1%), and Grade 2 (0.4%) reactions. Systemic corticosteroids were required in 69% (33/48); additional immunosuppressant therapy was required in 4.2% of patients. Colitis led to permanent discontinuation of KEYTRUDA in 0.5% (15) and withholding in 0.5% (13) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, 23% had recurrence. Colitis resolved in 85% of the 48 patients.

Hepatotoxicity and Immune-Mediated Hepatitis

KEYTRUDA as a Single Agent

KEYTRUDA can cause immune-mediated hepatitis. Immune-mediated hepatitis occurred in 0.7% (19/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.4%), and Grade 2 (0.1%) reactions. Systemic corticosteroids were required in 68% (13/19) of patients; additional immunosuppressant therapy was required in 11% of patients. Hepatitis led to permanent discontinuation of KEYTRUDA in 0.2% (6) and withholding in 0.3% (9) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, none had recurrence. Hepatitis resolved in 79% of the 19 patients.

KEYTRUDA with Axitinib

KEYTRUDA in combination with axitinib can cause hepatic toxicity. Monitor liver enzymes before initiation of and periodically throughout treatment. Consider monitoring more frequently as compared to when the drugs are administered as single agents. For elevated liver enzymes, interrupt KEYTRUDA and axitinib, and consider administering corticosteroids as needed. With the combination of KEYTRUDA and axitinib, Grades 3 and 4 increased alanine aminotransferase (20%) and increased aspartate aminotransferase (13%) were seen at a higher frequency compared to KEYTRUDA alone. Fifty-nine percent of the patients with increased ALT received systemic corticosteroids. In patients with ALT 3 times upper limit of normal (ULN) (Grades 2-4, n=116), ALT resolved to Grades 0-1 in 94%. Among the 92 patients who were rechallenged with either KEYTRUDA (n=3) or axitinib (n=34) administered as a single agent or with both (n=55), recurrence of ALT 3 times ULN was observed in 1 patient receiving KEYTRUDA, 16 patients receiving axitinib, and 24 patients receiving both. All patients with a recurrence of ALT 3 ULN subsequently recovered from the event.

Immune-Mediated Endocrinopathies

Adrenal Insufficiency

KEYTRUDA can cause primary or secondary adrenal insufficiency. For Grade 2 or higher, initiate symptomatic treatment, including hormone replacement as clinically indicated. Withhold KEYTRUDA depending on severity. Adrenal insufficiency occurred in 0.8% (22/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.3%), and Grade 2 (0.3%) reactions. Systemic corticosteroids were required in 77% (17/22) of patients; of these, the majority remained on systemic corticosteroids. Adrenal insufficiency led to permanent discontinuation of KEYTRUDA in <0.1% (1) and withholding in 0.3% (8) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement.

Hypophysitis

KEYTRUDA can cause immune-mediated hypophysitis. Hypophysitis can present with acute symptoms associated with mass effect such as headache, photophobia, or visual field defects. Hypophysitis can cause hypopituitarism. Initiate hormone replacement as indicated. Withhold or permanently discontinue KEYTRUDA depending on severity. Hypophysitis occurred in 0.6% (17/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.3%), and Grade 2 (0.2%) reactions. Systemic corticosteroids were required in 94% (16/17) of patients; of these, the majority remained on systemic corticosteroids. Hypophysitis led to permanent discontinuation of KEYTRUDA in 0.1% (4) and withholding in 0.3% (7) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement.

Thyroid Disorders

KEYTRUDA can cause immune-mediated thyroid disorders. Thyroiditis can present with or without endocrinopathy. Hypothyroidism can follow hyperthyroidism. Initiate hormone replacement for hypothyroidism or institute medical management of hyperthyroidism as clinically indicated. Withhold or permanently discontinue KEYTRUDA depending on severity. Thyroiditis occurred in 0.6% (16/2799) of patients receiving KEYTRUDA, including Grade 2 (0.3%). None discontinued, but KEYTRUDA was withheld in <0.1% (1) of patients.

Hyperthyroidism occurred in 3.4% (96/2799) of patients receiving KEYTRUDA, including Grade 3 (0.1%) and Grade 2 (0.8%). It led to permanent discontinuation of KEYTRUDA in <0.1% (2) and withholding in 0.3% (7) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement. Hypothyroidism occurred in 8% (237/2799) of patients receiving KEYTRUDA, including Grade 3 (0.1%) and Grade 2 (6.2%). It led to permanent discontinuation of KEYTRUDA in <0.1% (1) and withholding in 0.5% (14) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement. The majority of patients with hypothyroidism required long-term thyroid hormone replacement. The incidence of new or worsening hypothyroidism was higher in 1185 patients with HNSCC, occurring in 16% of patients receiving KEYTRUDA as a single agent or in combination with platinum and FU, including Grade 3 (0.3%) hypothyroidism. The incidence of new or worsening hypothyroidism was higher in 389 adult patients with cHL (17%) receiving KEYTRUDA as a single agent, including Grade 1 (6.2%) and Grade 2 (10.8%) hypothyroidism.

Type 1 Diabetes Mellitus (DM), Which Can Present With Diabetic Ketoacidosis

Monitor patients for hyperglycemia or other signs and symptoms of diabetes. Initiate treatment with insulin as clinically indicated. Withhold KEYTRUDA depending on severity. Type 1 DM occurred in 0.2% (6/2799) of patients receiving KEYTRUDA. It led to permanent discontinuation in <0.1% (1) and withholding of KEYTRUDA in <0.1% (1) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement.

Immune-Mediated Nephritis With Renal Dysfunction

KEYTRUDA can cause immune-mediated nephritis. Immune-mediated nephritis occurred in 0.3% (9/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.1%), and Grade 2 (0.1%) reactions. Systemic corticosteroids were required in 89% (8/9) of patients. Nephritis led to permanent discontinuation of KEYTRUDA in 0.1% (3) and withholding in 0.1% (3) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, none had recurrence. Nephritis resolved in 56% of the 9 patients.

Immune-Mediated Dermatologic Adverse Reactions

KEYTRUDA can cause immune-mediated rash or dermatitis. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with antiPD-1/PD-L1 treatments. Topical emollients and/or topical corticosteroids may be adequate to treat mild to moderate nonexfoliative rashes. Withhold or permanently discontinue KEYTRUDA depending on severity. Immune-mediated dermatologic adverse reactions occurred in 1.4% (38/2799) of patients receiving KEYTRUDA, including Grade 3 (1%) and Grade 2 (0.1%) reactions. Systemic corticosteroids were required in 40% (15/38) of patients. These reactions led to permanent discontinuation in 0.1% (2) and withholding of KEYTRUDA in 0.6% (16) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, 6% had recurrence. The reactions resolved in 79% of the 38 patients.

Other Immune-Mediated Adverse Reactions

The following clinically significant immune-mediated adverse reactions occurred at an incidence of <1% (unless otherwise noted) in patients who received KEYTRUDA or were reported with the use of other antiPD-1/PD-L1 treatments. Severe or fatal cases have been reported for some of these adverse reactions. Cardiac/Vascular: Myocarditis, pericarditis, vasculitis; Nervous System: Meningitis, encephalitis, myelitis and demyelination, myasthenic syndrome/myasthenia gravis (including exacerbation), Guillain-Barr syndrome, nerve paresis, autoimmune neuropathy; Ocular: Uveitis, iritis and other ocular inflammatory toxicities can occur. Some cases can be associated with retinal detachment. Various grades of visual impairment, including blindness, can occur. If uveitis occurs in combination with other immune-mediated adverse reactions, consider a Vogt-Koyanagi-Harada-like syndrome, as this may require treatment with systemic steroids to reduce the risk of permanent vision loss; Gastrointestinal: Pancreatitis, to include increases in serum amylase and lipase levels, gastritis, duodenitis; Musculoskeletal and Connective Tissue: Myositis/polymyositis, rhabdomyolysis (and associated sequelae, including renal failure), arthritis (1.5%), polymyalgia rheumatica; Endocrine: Hypoparathyroidism; Hematologic/Immune: Hemolytic anemia, aplastic anemia, hemophagocytic lymphohistiocytosis, systemic inflammatory response syndrome, histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis), sarcoidosis, immune thrombocytopenic purpura, solid organ transplant rejection.

Infusion-Related Reactions

KEYTRUDA can cause severe or life-threatening infusion-related reactions, including hypersensitivity and anaphylaxis, which have been reported in 0.2% of 2799 patients receiving KEYTRUDA. Monitor for signs and symptoms of infusion-related reactions. Interrupt or slow the rate of infusion for Grade 1 or Grade 2 reactions. For Grade 3 or Grade 4 reactions, stop infusion and permanently discontinue KEYTRUDA.

Complications of Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)

Fatal and other serious complications can occur in patients who receive allogeneic HSCT before or after antiPD-1/PD-L1 treatment. Transplant-related complications include hyperacute graft-versus-host disease (GVHD), acute and chronic GVHD, hepatic veno-occlusive disease after reduced intensity conditioning, and steroid-requiring febrile syndrome (without an identified infectious cause). These complications may occur despite intervening therapy between antiPD-1/PD-L1 treatment and allogeneic HSCT. Follow patients closely for evidence of these complications and intervene promptly. Consider the benefit vs risks of using antiPD-1/PD-L1 treatments prior to or after an allogeneic HSCT.

Increased Mortality in Patients With Multiple Myeloma

In trials in patients with multiple myeloma, the addition of KEYTRUDA to a thalidomide analogue plus dexamethasone resulted in increased mortality. Treatment of these patients with an antiPD-1/PD-L1 treatment in this combination is not recommended outside of controlled trials.

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Everything You Need To Know About COVID Booster Shots – Colorado Times Recorder

Tuesday, October 26th, 2021

Millions more people across the U.S. now may get COVID-19 booster vaccine doses after leaders of theU.S. Food and Drug Administration (FDA)and theCenters for Disease Control and Prevention (CDC)authorized mix-and-match vaccines and provided long-awaited guidance to people who received Moderna and Johnson & Johnson (J&J) vaccines.

Research shows that COVID-19 vaccines are remarkably effective in preventing hospitalizations and deaths, but the effectiveness of vaccines wanes over time. Booster doses two months after a J & J vaccine or six months or longer after two initial doses of Pfizer or Moderna vaccines can jumpstart vaccine efficacy, bringing it back up to remarkably protective levels of about 95%.

Who should get booster shots?

Dr. Rochelle Walensky, head of the CDC, on Thursday night endorsed the guidance that medical experts at both the CDC and FDA had recommended. The new rules pave the way for J & J recipients to finally get booster doses. And, Americans are free to make their own choices about mixing and matching they types of vaccines that they receive. If those who got the single-dose J & J vaccine now want to pump up their immunities with an mRNA dose from Moderna or Pfizer, they are free to do so. Similarly, people who received doses of Moderna or Pfizer for their initial two doses may also get a different brand for their booster dose. They can do whats most convenient and easiest for them.

Heres the newest guidance:

For individuals who received a Pfizer-BioNTech or Moderna COVID-19 vaccine, the following groups are eligible for a booster shot at 6 months or more after their initial series:

For the nearly 15 million people who received a J & J COVID-19 vaccine, booster shots are also recommended for those who are 18 and older and who were vaccinated two or more months ago.

Health experts agree that the best way to end the pandemic as soon as possible is for all eligible unvaccinated people to get their first doses of vaccines as soon as possible.(Learn more about getting COVID-19 vaccines and booster doses.)

But, broad availability of COVID-19 booster shots will help drive down infections,

These recommendations are another example of our fundamental commitment to protect as many people as possible from COVID-19. The evidence shows that all three COVID-19 vaccines authorized in the United States are safe as demonstrated by the over 400 million vaccine doses already given. And, they are all highly effective in reducing the risk of severe disease, hospitalization, and death, even in the midst of the widely circulating Delta variant, Walensky said in a statement October 21, hours after a CDC advisory panel unanimously endorsed new booster recommendations.

AddedDr. Michelle Barron, senior medical director of infection prevention at UCHealth:

We know booster shots play an important role in the fight against COVID-19, and were still in the midst of a pandemic.Vaccine efficacy may diminish over time with the potential risk for increased susceptibility to breakthrough infections.

COVID-19 infections and hospitalizations in Colorado remain very high, prompting Barron and others to urge people to get initial vaccines immediately and booster doses as soon as people are eligible. Coloradans should continue to be very cautious and wear masks in crowded indoor spaces.

Now that booster shots have been formally authorized for millions of other Americans, were providing answers to your key questions on COVID-19 booster shots.

A booster shot is an additional dose of a vaccine after a person has received an earlier dose (or two in the case of COVID-19 mRNA vaccines). An extra dose boosts your immune system, sparking better protection against an illness.

Its normal for some vaccines to wane or become slightly less effective over time. Research both by the COVID-19 vaccine makers and independent scientists is showing that the mRNA COVID-19 vaccines are waning several months after recipients get their first doses. Also, the delta variant is extremely contagious and it has caused hundreds of thousands of new infections. Because of new infections and waning effectiveness of some COVID-19 vaccines, FDA and CDC experts are recommending booster doses for many people.

The new guidance focuses on getting boosters for older people as quickly as possible because they are most vulnerable to severe disease from a COVID-19 infection. But, anyone who is 18 and older and lives and works in a high-risk environment also can opt to get a booster dose.

If you received a J & J vaccine, you should get a booster shot two months or longer after your vaccine. If you received Pfizer or Moderna vaccines, you should get a third dose at least six months after you received your first vaccine doses.

Yes. Research shows that half a dose of Moderna works well as a booster dose. So, the Moderna booster doses will now be 50 micrograms compared with 100-microgram initial doses.

No. People who receive Pfizer or J & J will continue receiving the same doses that they previously did.

A third shot is now the standard initial dose for immunocompromised people. These are people who have specific conditions that make it hard for them to build up antibodies to fight infections.

Immunocompromised people should get a third shot about one month after their first two doses of mRNA vaccines like Pfizer and Moderna.

Booster shots, on the other hand, are for everyone else. Healthy vaccinated people should wait two months after a J & J vaccines or six months or longer after their second dose of Moderna or Pfizer to get a booster vaccine dose.

No. To streamline booster doses, people can self-attest that they qualify for a booster dose. Also, no one needs a doctors order to get initial doses of COVID-19 vaccines. They are free and easy to find through hospitals, doctors offices, pharmacies, and at some mass vaccination clinics.Learn more about vaccine locations in Colorado.

Booster doses are free, just like the initial COVID-19 vaccine doses.

Its safe to get flu and COVID-19 vaccines or booster shots at the same time. But, some vaccine clinics only offer COVID-19 vaccines. You may need to schedule a flu shot separately. Please check with your doctor.

Health experts are encouraging people to get both COVID-19 vaccines and flu shots as soon as possible since we may have an early flu season andthe U.S. might face a twindemic of infectious diseases this fall and winter.

Yes. Research likethis new study in the New England Journal of Medicineis showing that both the Pfizer and Moderna vaccines are highly effective and very safe. Its also common for some vaccines to diminish in their effectiveness over time. The Pfizer vaccine seems to be waning (or becoming somewhat less effective) more quickly than the Moderna vaccine.

According to new data from the CDC, vaccine effectiveness in preventing hospitalizations for COVID-19 was highest for people who received Moderna vaccines 93% compared with efficacy rates of 88% for people who had received Pfizer vaccines and 71% for those who had received the Johnson & Johnson vaccine.

About 15 million people in the U.S. received J & J vaccines, far fewer those who have received Moderna and Pfizer vaccines. J & J recipients should get a second vaccine two or more months after they got their J & J vaccine. People who received J & J may stick with that brand or they can opt to get a single dose of a Pfizer or Moderna vaccine.

Yes. CDC health experts say that vaccines are plentiful. So, supply is not a problem. Get your initial vaccines as soon as possible and feel free to get a booster dose if you are eligible.

Both theModernaand thePfizervaccines which account for more than 95% of U.S. vaccinations so far remain highly effective for at least six months after people receive their second dose. The efficacy data is based on studies of how clinical trial participants have fared over time. The efficacy has declined slightly over the summer and fall, both because of the delta variant and the waning effect.

People who are getting boosters can go with their personal presence. If you received Pfizer or Moderna and you want to stick with your original brand, you may do so. But, if you want to bump up your immunities with a different type or brand of vaccine, you are welcome to do so. ANational Institutes of Health study that included a small number of peoplefound that mixing and matching vaccine types helped increase immunities to the virus that causes COVID-19.

So farside effects for boosters are similar to those that people experienced when they got their first two doses.

Individuals may experience a sore arm, headache, muscle aches, a low-grade fever or feel tired. These side effects typically last fewer than three days. Experts from Pfizer told FDA and CDC officials during recent testimony that many people receiving booster doses have experienced fewer side effects after third doses than they did with their second dose.

Young, fully-vaccinated, healthy people probably dont need booster doses because the vaccines are working very well to protect them from severe infections, hospitalizations and death from COVID-19, according to CDC experts.

Because the vaccines are holding up so well for young, healthy people, some infectious disease experts were hesitant to recommend booster doses for all adults.

In addition, in very rare cases, young men who have been vaccinated have experienced heart issues known as myocarditis. Due to this very rare vaccine side effect, some younger men, ages 18 to 30, may decide to skip booster doses.

Yes. Israel has led the way. In Israel, older adults began getting booster doses in the early summer and now, anyone who is 12 or older can get a booster dose. Other countries like the United Kingdom and Germany also are offering booster doses.

Yes, there are antibody tests. But, doctors do not recommend antibody testing outside of clinical trials. The best way to stay healthy is to get your primary COVID-19 vaccines as soon as possible, then to get a booster dose if you qualify or fall into one of the recommended groups.

Yes.Studies like this oneare finding that vaccines are even more protective than natural antibodies. And, people can get COVID-19 after having previously had it. So, its best to get fully vaccinated.

No. Researchers are finding that antibodies from vaccines team up with natural memory cells in our bodies. These are known as B and T cells. CDC researchers estimate that antibodies play a majority role in fighting COVID-19 infections, but B and T cells are also crucial.

Erin Emery is a co-author of this article.

Editors Note: During the pandemic, the Colorado Times Recorder will occasionally post articles, like this one, fromUCHealth Today,which is published by UCHeatlh, the hospital associated with the University of Colorado School of Medicine. Our goal is to provide as many people as possible with accurate information about the virus and related topics.

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Stem cells and their role in lung transplant rejection – Michigan Medicine

Tuesday, October 5th, 2021

A lung transplant can mean the difference between life and death for people with diseases such as pulmonary fibrosis, chronic obstructive pulmonary disease (COPD) and even severe COVID-19. Yet, recipients of donor lungs must take daily medications to stave off damage caused by their own immune system, which attacks the organs it recognizes as foreigna process known as rejection.

A new University of Michigan Health study, published in the Journal of Clinical Investigation, has identified cells that appear to play a pivotal role in creating the scarring, or fibrosis, characteristic of chronic rejection following a lung transplant.

Almost 15 years ago, Vibha Lama, MBBS, M.S., a professor in the Division of Pulmonary Disease and Critical Care Medicine, and her lab described the presence of stem-cell-like cells, called mesenchymal stromal cells, in lung sample fluid from lung transplant recipients.

We found that even ten years post-transplant, these cells belonged to the donor, not the recipient, she explained. At that time, we had no clue where in the lung they were coming from or what role they played.

To figure this out, her lab generated a mouse model to recreate what happens within a lung transplant recipient. With the model, they followed a transcription factor known as FOXF1 as a sort of trail of breadcrumbs back to the cells original location.

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They discovered that these cells formed a reservoir of stem cells within the bronchovascular bundle deep inside the lung. These bundles contain a bronchus (airway), arteries, connective tissue and other structures and is the part of the lung which connects it to the outside environment.

In this study, explained Lama, who is senior author on the paper, they show that these specific stem cells are interacting with neighboring epithelial cells within that airway niche.

Epithelial cells line and protect the airways and produce a protein known as Sonic hedgehog. Via this protein, epithelial cells signal the stem-cell-like mesenchymal cells, which make up the scaffolding of the lungs, to make FOXF1, a repressor that keeps the stem cells in check.

We are just recently understanding that there are many different kinds of mesenchymal cells in the lung, said Lama. What we describe here is not only are there many kinds of mesenchymal cells, FOXF1 is retained only in these specific stem-cell-like cells.

In the case of lung transplant rejection, Lama hypothesized that immune cells from the recipient attack the epithelial cells which disrupts the balance between them and the mesenchymal cells.

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Because of the damage caused by rejection, the epithelial cells get damaged, Sonic hedgehog is reduced and that interrupts the signaling to the mesenchymal cells to keep quiet, she said. Because of that, these cells start dividing and they lay down more collagen, which leads to fibrotic scarring.

The work sets the stage for more research into the interaction of these cells with epithelial and other cells it their vicinity to further characterize what happens during chronic rejection and potentially how to prevent it. Furthermore, discovery of these cells is also important in understanding other airway diseases like asthma and COPD.

Paper cited: Transcription factor FOXF1 identifies compartmentally distinct mesenchymal cells with a role in lung allograft fibrogenesis, J Clin Invest. DOI: 10.1172/JCI147343

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Losing Your Hair? You Might Blame the Great Stem Cell Escape. – The New York Times

Tuesday, October 5th, 2021

Every person, every mouse, every dog, has one unmistakable sign of aging: hair loss. But why does that happen?

Rui Yi, a professor of pathology at Northwestern University, set out to answer the question.

A generally accepted hypothesis about stem cells says they replenish tissues and organs, including hair, but they will eventually be exhausted and then die in place. This process is seen as an integral part of aging.

Instead Dr. Yi and his colleagues made a surprising discovery that, at least in the hair of aging animals, stem cells escape from the structures that house them.

Its a new way of thinking about aging, said Dr. Cheng-Ming Chuong, a skin cell researcher and professor of pathology at the University of Southern California, who was not involved in Dr. Yis study, which was published on Monday in the journal Nature Aging.

The study also identifies two genes involved in the aging of hair, opening up new possibilities for stopping the process by preventing stem cells from escaping.

Charles K.F. Chan, a stem cell researcher at Stanford University, called the paper very important, noting that in science, everything about aging seems so complicated we dont know where to start. By showing a pathway and a mechanism for explaining aging hair, Dr. Yi and colleagues may have provided a toehold.

Stem cells play a crucial role in the growth of hair in mice and in humans. Hair follicles, the tunnel-shaped miniature organs from which hairs grow, go through cyclical periods of growth in which a population of stem cells living in a specialized region called the bulge divide and become rapidly growing hair cells.

Sarah Millar, director of the Black Family Stem Cell Institute at the Icahn School of Medicine at Mount Sinai, who was not involved in Dr. Yis paper, explained that those cells give rise to the hair shaft and its sheath. Then, after a period of time, which is short for human body hair and much longer for hair on a persons head, the follicle becomes inactive and its lower part degenerates. The hair shaft stops growing and is shed, only to be replaced by a new strand of hair as the cycle repeats.

But while the rest of the follicle dies, a collection of stem cells remains in the bulge, ready to start turning into hair cells to grow a new strand of hair.

Dr. Yi, like most scientists, had assumed that with age the stem cells died in a process known as stem cell exhaustion. He expected that the death of a hair follicles stem cells meant that the hair would turn white and, when enough stem cells were lost, the strand of hair would die. But this hypothesis had not been fully tested.

Together with a graduate student, Chi Zhang, Dr. Yi decided that to understand the aging process in hair, he needed to watch individual strands of hair as they grew and aged.

Ordinarily, researchers who study aging take chunks of tissue from animals of different ages and examine the changes. There are two drawbacks to this approach, Dr. Yi said. First, the tissue is already dead. And it is not clear what led to the changes that are observed or what will come after them.

He decided his team would use a different method. They watched the growth of individual hair follicles in the ears of mice using a long wavelength laser that can penetrate deep into tissue. They labeled hair follicles with a green fluorescent protein, anesthetized the animals so they did not move, put their ear under the microscope and went back again and again to watch what was happening to the same hair follicle.

What they saw was a surprise: When the animals started to grow old and gray and lose their hair, their stem cells started to escape their little homes in the bulge. The cells changed their shapes from round to amoeba-like and squeezed out of tiny holes in the follicle. Then they recovered their normal shapes and darted away.

Sometimes, the escaping stem cells leapt long distances, in cellular terms, from the niche where they lived.

If I did not see it for myself I would not have believed it, Dr. Yi said. Its almost crazy in my mind.

The stem cells then vanished, perhaps consumed by the immune system.

Dr. Chan compared an animal's body to a car. If you run it long enough and dont replace parts, things wear out, he said. In the body, stem cells are like a mechanic, providing replacement parts, and in some organs like hair, blood and bone, the replacement is continual.

But with hair, it now looks as if the mechanic the stem cells simply walks off the job one day.

But why? Dr. Yi and his colleagues next step was to ask if genes are controlling the process. They discovered two FOXC1 and NFATC1 that were less active in older hair follicle cells. Their role was to imprison stem cells in the bulge. So the researchers bred mice that lacked those genes to see if they were the master controllers.

By the time the mice were 4 to 5 months old, they started losing hair. By age 16 months, when the animals were middle-aged, they looked ancient: They had lost a lot of hair and the sparse strands remaining were gray.

Now the researchers want to save the hair stem cells in aging mice.

This story of the discovery of a completely unexpected natural process makes Dr. Chuong wonder what remains to be learned about living creatures.

Nature has endless surprises waiting for us, he said. You can see fantastic things.

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Will humans ever be immortal? – Livescience.com

Tuesday, October 5th, 2021

If you are human, you are going to die. This isn't the most comforting thought, but death is the inevitable price we must pay for being alive. Humans are, however, getting better at pushing back our expiration date, as our medicines and technologies advance.

If the human life span continues to stretch, could we one day become immortal? The answer depends on what you think it means to be an immortal human.

"I don't think when people are even asking about immortality they really mean true immortality, unless they believe in something like a soul," Susan Schneider, a philosopher and founding director of the Center for the Future Mind at Florida Atlantic University, told Live Science. "If someone was, say, to upgrade their brain and body to live a really long time, they would still not be able to live beyond the end of the universe."

Scientists expect the universe will end, which puts an immediate dampener on a mystery about the potential for human immortality. Some scientists have speculated about surviving the death of the universe, as science journalist John Horgan reported for Scientific American, but it's unlikely that any humans alive today will experience the universe's demise anyway.

Related: What happens when you die?

Many humans grow old and die. To live indefinitely, we would need to stop the body from aging. A group of animals may have already solved this problem, so it isn't as far-fetched as it sounds.

Hydra are small, jellyfish-like invertebrates with a remarkable approach to aging. They are largely made up of stem cells that constantly divide to make new cells, as their older cells are discarded. The constant influx of new cells allows hydra to rejuvenate themselves and stay forever young, Live Science previously reported.

"They don't seem to age, so, potentially they are immortal," Daniel Martnez, a biology professor at Pomona College in Claremont, California, who discovered the hydra's lack of aging, told Live Science. Hydra show that animals do not have to grow old, but that doesn't mean humans could replicate their rejuvenating habits. At 0.4 inches (10 millimeters) long, hydra are small and don't have organs. "It's impossible for us because our bodies are super complex," Martnez said.

Humans have stem cells that can repair and even regrow parts of the body, such as in the liver, but the human body is not made almost entirely of these cells, like hydra are. That's because humans need cells to do things other than just divide and make new cells. For example, our red blood cells transport oxygen around the body. "We make cells commit to a function, and in doing that, they have to lose the ability to divide," Martnez said. As the cells age, so do we.

We can't simply discard our old cells like hydra do, because we need them. For example, the neurons in the brain transmit information. "We don't want those to be replaced," Martnez said. "Because otherwise, we won't remember anything." Hydra could inspire research that allows humans to live healthier lives, for example, by finding ways for our cells to function better as they age, according to Martnez. However, his gut feeling is that humans will never achieve such biological immortality.

Though Martnez personally doesn't want to live forever, he thinks humans are already capable of a form of immortality. "I always say, 'I think we are immortal,'" he said. "Poets to me are immortal because they're still with us after so many years and they still influence us. And so I think that people survive through their legacy."

The oldest-living human on record is Jeanne Calment from France, who died at the age of 122 in 1997, according to Guinness World Records. In a 2021 study published in the journal Nature Communications, researchers reported that humans may be able to live up to a maximum of between 120 and 150 years, after which, the researchers anticipate a complete loss of resilience the body's ability to recover from things like illness or injury. To live beyond this limit, humans would need to stop cells from aging and prevent disease.

Related: What's the oldest living thing alive today?

Humans may be able to live beyond their biological limits with future technological advancements involving nanotechnology. This is the manipulation of materials on a nanoscale, less than 100 nanometers (one-billionth of a meter or 400-billionths of an inch). Machines this small could travel in the blood and possibly prevent aging by repairing the damage cells experience over time. Nanotech could also cure certain diseases, including some types of cancer, by removing cancerous cells from the body, according to the University of Melbourne in Australia.

Preventing the human body from aging still isn't enough to achieve immortality; just ask the hydra. Even though hydra don't show signs of aging, the creatures still die. They are eaten by predators, such as fish, and perish if their environment changes too much, such as if their ponds freeze in winter, Martnez said.

Humans don't have many predators to contend with, but we are prone to fatal accidents and vulnerable to extreme environmental events, such as those intensified by climate change. We'll need a sturdier vessel than our current bodies to ensure our survival long into the future. Technology may provide the solution for this, too.

As technology advances, futurists anticipate two defining milestones. The first is the singularity, in which we will design artificial intelligence (A.I.) smart enough to redesign itself, and it will get progressively smarter until it is vastly superior to our own intelligence, Live Science previously reported. The second milestone is virtual immortality, where we will be able to scan our brains and transfer ourselves to a non-biological medium, like a computer.

Researchers have already mapped the neural connections of a roundworm (Caenorhabditis elegans). As part of the so-called OpenWorm project, they then simulated the roundworm's brain in software replicating the neural connections, and programmed that software to direct a Lego robot, according to Smithsonian Magazine. The robot then appeared to start behaving like a roundworm. Scientists aren't close to mapping the connections between the 86 billion neurons of the human brain (roundworms have only 302 neurons), but advances in artificial intelligence may help us get there.

Once the human mind is in a computer and can be uploaded to the internet, we won't have to worry about the human body perishing. Moving the human mind out of the body would be a significant step on the road to immortality but, according to Schneider, there's a catch. "I don't think that will achieve immortality for you, and that's because I think you'd be creating a digital double," she said.

Schneider, who is also the author of "Artificial You: AI and the Future of Your Mind" (Princeton University Press, 2019), describes a thought experiment in which the brain either does or doesn't survive the upload process. If the brain does survive, then the digital copy can't be you as you're still alive; conversely, the digital copy also can't be you if your brain doesn't survive the upload process, because it wouldn't be if you did the copy can only be your digital double.

Related: What is consciousness?

According to Schneider, a better route to extreme longevity, while also preserving the person, would be through biological enhancements compatible with the survival of the human brain. Another, more controversial route would be through brain chips.

"There's been a lot of talk about gradually replacing parts of the brain with chips. So, eventually, one becomes like an artificial intelligence," Schneider said. In other words, slowly transitioning into a cyborg and thinking in chips rather than neurons. But if the human brain is intimately connected to you, then replacing it could mean suicide, she added.

The human body appears to have an expiration date, regardless of how it is upgraded or uploaded. Whether humans are still human without their bodies is an open question.

"To me, it's not even really an issue about whether you're technically a human being or not," Schneider said. "The real issue is whether you're the same self of a person. So, what really matters here is, what is it to be a conscious being? And when is it that changes in the brain change which conscious being you are?" In other words, at what point does changing what we can do with our brains change who we are?

Schneider is excited by the potential brain and body enhancements of the future and likes the idea of ridding ourselves of death by old age, despite some of her reservations. "I would love that, absolutely, she said. "And I would love to see science and technology cure ailments, make us smarter. I would love to see people have the option of upgrading their brains with chips. I just want them to understand what's at stake."

Originally published on Live Science.

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Healthcare Researchers Are Putting HUMAN Immune Systems In Pigs To Study Illnesses-Here’s The Tech Behind It – Tech Times

Tuesday, October 5th, 2021

RJ Pierce, Tech Times 05 October 2021, 09:10 am

Healthcare research has gone a long way from the dark days of old, when today's simplest illnesses can be a death sentence. And now, there's reason to look forward to a brighter future because of this news.

(Photo : Getty Images )

According to BigThink, a team from Iowa State University claimed that they've found a way to integrate human immune systems in pigs, as a way to study illnesses much closer.

In other words, they basically "humanized" the pigs to try and find out how to better treat human diseases in the future.

The implications of their research are quite profound, too. As per the researchers, this breakthrough could theoretically advance healthcare research in areas such as virus and vaccines, cancer, and even stem cell treatments.

Before this, scientists often used mice in their biotech and biomedical experiments. However, the problem is that mice-based results don't translate well to humans.

Aside from mice, primates have also been used in related fields of healthcare research due to their direct biological connections with humans. Nevertheless, a lot of ethical issues popped up, thus leading to the retirement of primates, including chimpanzees, from this type of research eight years ago.

This won't be the first time that healthcare research has produced what's basically human-animal hybrids to study illnesses.

Three years ago, a team of scientists from Rockefeller University in New York managed to create a human-chicken embryo, in an attempt to take a closer look at the intricacies of stem cell therapies.

Read also: Scientists Want To Create Part-Human Part-Animal Chimeras To Find Cure For Diseases

It started when the same scientists from Iowa State University discovered a genetic mutation in pigs that caused an illness called SCID (Severe Combined Immunodeficiency).

Some people may know this from the film "The Boy In The Plastic Bubble" from 1976, which tells the story of a child whose immune system never fully developed. As such, he was forced to literally live inside a sterile bubble because even the slightest cold would kill him.

Upon this discovery, the researchers then developed a pig that's far more immunocompromised compared to a person with SCID, then successfully "humanized" it by injecting human immune stem cells into the livers of piglets.

The researchers were able to do this by using ultrasound imaging as a guide.

Ultrasound imaging, also known as sonography, makes use of high-frequency waves to look inside the body.

(Photo : Getty Images )

The resulting pigs had excellent healthcare research potential, because they were found to have human immune cells in their blood, thymus gland, spleen, and liver.

However, the SCID-afflicted pigs are in constant danger of infections. As such, they have to be housed in so-called bubble biocontainment facilities. These facilities work by maintaining high positive pressure, which keeps dangerous pathogens out. All staff members have to wear sterile protective gear at all times.

They've basically turned into their own versions of the boy in the bubble.

Before this research, pigs have often been used to know more about the human body because of how strikingly similar their anatomy is to humans.

In fact, a few scientists even believe that with how biologically similar pigs are to humans, they might be classified into an animal family occupied by primates, reportedScience.org.au.

But of course, there have been ethical issues involving the use of these human-animal hybrids for healthcare research. Eventually, though, the National Institutes of Health (NIH) relaxed their regulations a bit back in 2016, which made it easier for scientists to transfer human stem cells into animal embryos.

Related: Scientists Grow Sheep Embryos With Human Cells To Revolutionize Organ Transplant

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Written by RJ Pierce

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Faster healing of wounds can decrease pain and suffering and save lives – ABC 12 News

Tuesday, October 5th, 2021

ORLANDO, Fla., Oct. 4, 2021 /PRNewswire/ --Billions of dollars are spent every year because of complications of wound healing. Researchers at the College of Medicine at the University of Central Florida (UCF) in Orlando have discovered a new technology to accelerate wound healing. Their research is published in the Life Cell Biology and Tissue Engineering Journal (https://pubmed.ncbi.nlm.nih.gov/34575027/). The UCF lab's research focus is to develop stem cell therapies for neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, wound healing and ALS.

Researchers at the College of Medicine at UCF in Orlando have discovered a new technology to accelerate wound healing.

Dr. Frederick R Carrick, Professor of Neurology at the College of Medicine at UCF, reported that animals with wounds and injured stem cells that were placed on a special ceramic blanket healed much faster than controls. Gladiator Therapeutics manufactured the therapeutic ceramic blanket that was used in this research. The researchers reported that wounds in animals and in stem cells were both repaired significantly faster when they treated them with the ceramic blankets.

This research was designed and accepted for presentation at the USA Department of Defense's premier scientific meeting, the Military Health System Research Symposium (MHSRS). Dr Carrick stated that the new ceramic blankets do not need a power supply and are ideally suited for use in both combat and civilian wound treatments. Large wounds, such as those suffered in combat are easily infected and may result in increased suffering, disability and death amongst Warfighters. Faster healing of wounds can decrease pain and suffering and save lives.

The UCF College of Medicine research team is conducting ongoing research on the use of the Gladiator ceramic blanket in animal models of Alzheimer's and Parkinson's disease, traumatic brain injury and wound care. They have recently developed a new Alzheimer's therapy combining drugs that affect stem cells that increase the development of brain cells and improve brain function. The UCF lab is also the first to transplant stem cells isolated from the human brain to aged rats where they showed increased development of new brain cells and improvement of cognition.

Dr. Kiminobu Sugaya, Professor of Medicine at the UCF College of Medicine is excited about their findings. Dr. Sugaya stated that the benefits of using the Gladiator ceramic blanket are that it can be used anywhere without a power supply or the side effects that are commonly found when injecting chemicals or drugs.

Further information about this study:

drfrcarrick@post.harvard.edu 321-868-6464

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SOURCE University of Central Florida College of Medicine

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Why Bezos, Musk, Page and other billionaires want to live forever – New York Post

Tuesday, October 5th, 2021

Almost two months after Jeff Bezosblasted off into space debuting his rocket along with a new, plumper face the Amazon honcho announced anew investmentinAltos Labs, a startupdedicated todiscovering how to reverse the aging process.

While non-Botoxed eyebrows were raised around the world, Bezos isnt the only mega-wealthy man who wants to become Dorian Gray.

Eternal life has become the new space quest for the tech overlords.

Its a little bit juvenile,Rami Kaminski, MD,Kaminski, who is the founder and director of The Institute of Integrative Psychiatry(TiiPS). You may go to Mars, but you cannot go out into the solar system. [These wealthy men] are limited. What theyre trying to do is get away from the mortal coil. Every day when you look in the mirror you are reminded you are made of carbon. It is degrading and has to be recycled.

Peter Thiel, the PayPal co-foundertoldBusiness Insiderin 2012.,There are all these people who say that death is natural, its just part of life, and I think that nothing can be further from the truth, noting that death is a problem that can be solved.

Also on the hunt for the Fountain of Youth is Larry Page, one of the co-founders of Google. In 2013,Google founded Calico, a biology company with the stated goal of solv[ing] death. The company, according to itsWeb site, Seek(s) to answer the most challenging biological questions of our time how humans age and can we develop interventions to allow people. To live longer, healthier lives.

Keith Campbell, a psychology and social personality professor at the University of Georgia, told The Post: I call this process rebuilding Frankenstein [The desire]comes from a radical misunderstanding of the human condition, [where] materialism and behaviorism are mashed up with AI. That coupled with egoand fear and lots of money leads to the search.

Silicon Valleyentrepreneur Serge Faguet founder of the video platform TokBox and the Russian booking Web site Ostrovok has spent more than $250,000 on biohacking. Hes also a fan of microdosing with MDMA, telling The Guardian its all helped him become calmer, thinner, extroverted, healthier and happier. Oh, and its increased his sex drive, helping him (pick) up girls.

Meanwhile, lets not leave out TeslasElon Musk, who doesnt care about his body he simply wants his thoughts and brain to live forever via his new company,Neuralink.

The quest for the Fountain of Youth is not a new one. Ponce De Len never found it. In modern times, you have men like Peter Nygard. The disgraced fashion execbuilt a bio science lab in the Bahamasas part of a scheme to gather stem cells from the aborted fetuses of women hed impregnate all to elongate his life. (Hes now in jail in Canada, facing trial for sex trafficking and racketeering, amid several sexual assault allegations.)

Why are so many powerful men eager to, seemingly, live forever?

Death is the great equalizer the only thing that can bring [these men] down is death and you can not do anything about it. Unless you can,Kaminski told the Post. They are literally scared to die and immortality is the ultimate defense.

They want to defeat the only thing they cannot. They have the means and the power. When you have limitless amount of money you start pushing the boundaries. For the super billionaires, its not surprising they are choosing the ultimate limit.

And because these men have done the seemingly impossible in their work lives, and are treated like demigods on social media, their ego has morphed into a Dr. Frankenstein-esque manner, where they think they can now control the one thing man has never been able to control: death.

People with big egos think they matter more than their organizations, Campbell said. They think that, if they were gone, the world would fall apart because they are smarter than others and they were put here for a reason. Because theyve been so successful in putting their will on reality they think, Why cant I beat [death]? I can beat anything.

This feeling of being able to master the universe and manipulate all in their realm leads to a very real God Complex.

When an individual is exposed to excess wealth and power over an extended period of time it can alter their entire worldview; (they believe) they are special and better than others because of their ability to amass and hoard money, Dr.BethanyCook, a licensed psychotherapist told the Post. If one has vast amounts of money and power, along with a God complex, its easy to see why they may invest in discovering the secret to eternal life; they wish to retain their power and wealth for as long as possible.

The psychologists and psychiatrists The Post spoke to also noted that while these men think they are masters of the universe, their actions suggest immaturity and a fear of the inevitable.

Our old elites had some life experiences, like going to war or even doing sales, and were not psychological children like this new crowd, said Campbell. These arent spiritually grounded individuals. They may have a high IQ, but they are linear and very detached from reality.

And while some see the billionaires continued quest for everlasting life as interesting, Campbell finds it worrisome.

Im utterly terrified of people who think they know better than everyone else and who have power and arent afraid to use it, he said. Thats what a tyrant is. People who think they can control the world, who have power without humility makes me nervous.

And once the Fountain of Youth is discovered, how do we stop it? Already scientists are predicting humans can live to 130 years and that its not improbable to think we could live forever and the consequences have already been dire. This week, 23 more species, including the ivory-billed woodpecker, were declared extinct due to human activity. What will happen if we all live forever and keep reproducing?

Kaminski warns, Maybe there will be a breakthrough [for longevity] but then what do we do with humanity? If they had a pill to stop everyone from dying, people would be crawling all over the planet there wouldnt be a place to sit. The problem is the defiance of nature.

That, thus far, has never really worked out for humans.

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U.S. FDA Approves Kite’s Tecartus as the First and Only Car T for Adults With Relapsed or Refractory B-cell Acute Lymphoblastic Leukemia – Business…

Tuesday, October 5th, 2021

SANTA MONICA, Calif.--(BUSINESS WIRE)--Kite, a Gilead Company (Nasdaq: GILD), today announced the U.S. Food and Drug Administration (FDA) has granted approval for Tecartus (brexucabtagene autoleucel) for the treatment of adult patients (18 years and older) with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL). Following FDA Breakthrough Therapy Designation and a priority review, Tecartus is the first and only chimeric antigen receptor (CAR) T-cell therapy approved for adults (18 years and older) with ALL. There is a high unmet need, as half of this patient population will relapse, and median overall survival (OS) is only approximately eight months with current standard-of-care treatments. Patients can access Tecartus through 109 authorized treatment centers across the U.S.

Adults with ALL face a significantly poorer prognosis compared to children, and roughly half of all adults with B-ALL will relapse on currently available therapies, said Bijal Shah, MD, ZUMA-3 investigator and medical oncologist, Moffitt Cancer Center, Tampa, Florida. We now have a new meaningful advancement in treatment for these patients. A single infusion of Tecartus has demonstrated durable responses, suggesting the potential for long-term remission and a new approach to care.

The approval is based on results from ZUMA-3, a global, multicenter, single-arm, open-label study in which 65% of the evaluable patients (n=54) achieved complete remission (CR) or CR with incomplete hematological recovery (CRi) at a median actual follow-up of 12.3 months. The duration of CR was estimated to exceed 12 months for more than half the patients. Among efficacy-evaluable patients, median duration of remission (DOR) was 13.6 months. Among the patients treated with Tecartus at the target dose (n=78), Grade 3 or higher cytokine release syndrome (CRS) and neurologic events occurred in 26% and 35% of patients, respectively, and were generally well-managed.

Today marks Kites fourth FDA approved indication in cell therapy in under four years, demonstrating our commitment to advancing CAR T for patients across many different hematologic malignancies, said Christi Shaw, Chief Executive Officer of Kite. Tecartus has already transformed outcomes for adults living with mantle cell lymphoma, and we look forward to offering the hope for a cure to patients with ALL.

Adults with relapsed or refractory ALL often undergo multiple treatments including chemotherapy, targeted therapy and stem cell transplant. CAR T-cell therapy works differently, by harnessing a patients own immune system to fight cancer. With CAR T, the patients blood is drawn and the T cells are separated. Then the T cells are genetically engineered with a specific receptor that enables them to identify and attack cancer cells, and put back into the patients body.

Roughly half of all ALL cases actually occur in adults, and unlike pediatric ALL, adult ALL has historically had a poor prognosis, said Lee Greenberger, PhD, Chief Scientific Officer of The Leukemia & Lymphoma Society (LLS). Developing new therapies that would be life-changing for people with cancer has been a dream of LLS. We are proud to see the potential of CAR T realized for even more people with this approval for brexucabtagene autoleucel.

Tecartus is also currently under review in the European Union and United Kingdom for the treatment of adult patients with relapsed or refractory B-cell precursor ALL.

The Tecartus U.S. Prescribing Information has a BOXED WARNING for the risks of CRS and neurologic toxicities, and Tecartus is approved with a Risk Evaluation and Mitigation Strategy (REMS) due to these risks; see below for Important Safety Information.

Additional Information About ZUMA-3 Trial

Further efficacy results from the ZUMA-3 trial have been published and presented in scientific forums. Published Phase 1 data showed 32% of responders (n=22) were still in remission at the median follow-up of 22.1 months. In Phase 2 data presented at the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting, investigators reported that among treated patients (n=54), 31% of these patients were in ongoing response at a median follow-up of 16.4 months. 97% of responders had deep molecular remission, with undetectable minimal residual disease (MRD), and median OS among all responders has not yet been reached. A safety analysis, reported in the Lancet, showed among all patients who experienced a neurologic event, 94% of CRS events and 88% of neurologic events were resolved.

ZUMA-3 is an international multicenter, registrational Phase 1/2 study in adult patients (18 years old) with ALL whose disease is refractory to or has relapsed following first standard systemic therapy with remission of 12 months or less, after two or more lines of systemic therapy or at least 100 days after allogeneic stem cell transplantation. Seventy-one patients were enrolled (and leukapheresed) in the study, and the primary endpoint was overall complete remission rate (OCR, equaling complete remission plus complete remission with incomplete hematologic recovery) as determined by an independent review.

About ALL

ALL is an aggressive type of blood cancer that can also involve the lymph nodes, spleen, liver, central nervous system and other organs. Approximately 1,000 adults are treated annually for relapsed or refractory ALL. B-cell precursor ALL is the most common form, accounting for approximately 75% of cases, and treatment is typically associated with inferior outcomes compared with other types of ALL. Survival rates remain very poor in adult patients with relapsed or refractory ALL, with median OS at less than eight months.

About Tecartus

Tecartus is an autologous, anti-CD19 CAR T-cell therapy. Tecartus uses the XLP manufacturing process that includes T cell enrichment, a necessary step in certain B-cell malignancies in which circulating lymphoblasts are a common feature. Tecartus is also being evaluated in pediatric ALL, where its use is investigational, and its safety and efficacy have not been established.

About Kite

Kite, a Gilead Company, is a global biopharmaceutical company based in Santa Monica, California, with commercial manufacturing operations in North America and Europe. Kites singular focus is cell therapy to treat and potentially cure cancer. As the cell therapy leader, Kite has more approved CAR T indications to help more patients than any other company. For more information on Kite, please visit http://www.kitepharma.com.

About Gilead Sciences

Gilead Sciences, Inc. is a biopharmaceutical company that has pursued and achieved breakthroughs in medicine for more than three decades, with the goal of creating a healthier world for all people. The company is committed to advancing innovative medicines to prevent and treat life-threatening diseases, including HIV, viral hepatitis and cancer. Gilead operates in more than 35 countries worldwide, with headquarters in Foster City, California.

Tecartus Indication

Tecartus is a CD19-directed genetically modified autologous T cell immunotherapy indicated for the treatment of:

This indication is approved under accelerated approval based on overall response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.

U.S. IMPORTANT SAFETY INFORMATION

BOXED WARNING: CYTOKINE RELEASE SYNDROME and NEUROLOGIC TOXICITIES

Cytokine Release Syndrome (CRS), including life-threatening reactions, occurred following treatment with Tecartus. In ZUMA-2, CRS occurred in 91% (75/82) of patients receiving Tecartus, including Grade 3 CRS in 18% of patients. Among the patients who died after receiving Tecartus, one had a fatal CRS event. The median time to onset of CRS was three days (range: 1 to 13 days) and the median duration of CRS was ten days (range: 1 to 50 days). Among patients with CRS, the key manifestations (>10%) were similar in MCL and ALL and included fever (93%), hypotension (62%), tachycardia (59%), chills (32%), hypoxia (31%), headache (21%), fatigue (20%), and nausea (13%). Serious events associated with CRS included hypotension, fever, hypoxia, tachycardia, and dyspnea.

Ensure that a minimum of two doses of tocilizumab are available for each patient prior to infusion of Tecartus. Following infusion, monitor patients for signs and symptoms of CRS daily for at least seven days at the certified healthcare facility, and for four weeks thereafter. Counsel patients to seek immediate medical attention should signs or symptoms of CRS occur at any time. At the first sign of CRS, institute treatment with supportive care, tocilizumab, or tocilizumab and corticosteroids as indicated.

Neurologic Events, including those that were fatal or life-threatening, occurred following treatment with Tecartus. Neurologic events occurred in 81% (66/82) of patients with MCL, including Grade 3 in 37% of patients. The median time to onset for neurologic events was six days (range: 1 to 32 days) with a median duration of 21 days (range: 2 to 454 days) in patients with MCL. Neurologic events occurred in 87% (68/78) of patients with ALL, including Grade 3 in 35% of patients. The median time to onset for neurologic events was seven days (range: 1 to 51 days) with a median duration of 15 days (range: 1 to 397 days) in patients with ALL. For patients with MCL, 54 (66%) patients experienced CRS before the onset of neurological events. Five (6%) patients did not experience CRS with neurologic events and eight patients (10%) developed neurological events after the resolution of CRS. Neurologic events resolved for 119 out of 134 (89%) patients treated with Tecartus. Nine patients (three patients with MCL and six patients with ALL) had ongoing neurologic events at the time of death. For patients with ALL, neurologic events occurred before, during, and after CRS in 4 (5%), 57 (73%), and 8 (10%) of patients; respectively. Three patients (4%) had neurologic events without CRS. The onset of neurologic events can be concurrent with CRS, following resolution of CRS or in the absence of CRS.

The most common neurologic events (>10%) were similar in MCL and ALL and included encephalopathy (57%), headache (37%), tremor (34%), confusional state (26%), aphasia (23%), delirium (17%), dizziness (15%), anxiety (14%), and agitation (12%). Serious events including encephalopathy, aphasia, confusional state, and seizures occurred after treatment with Tecartus.

Monitor patients daily for at least seven days for patients with MCL and at least 14 days for patients with ALL at the certified healthcare facility and for four weeks following infusion for signs and symptoms of neurologic toxicities and treat promptly.

REMS Program: Because of the risk of CRS and neurologic toxicities, Tecartus is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the Yescarta and Tecartus REMS Program which requires that:

Hypersensitivity Reactions: Serious hypersensitivity reactions, including anaphylaxis, may occur due to dimethyl sulfoxide (DMSO) or residual gentamicin in Tecartus.

Severe Infections: Severe or life-threatening infections occurred in patients after Tecartus infusion. Infections (all grades) occurred in 56% (46/82) of patients with MCL and 44% (34/78) of patients with ALL. Grade 3 or higher infections, including bacterial, viral, and fungal infections, occurred in 30% of patients with ALL and MCL. Tecartus should not be administered to patients with clinically significant active systemic infections. Monitor patients for signs and symptoms of infection before and after Tecartus infusion and treat appropriately. Administer prophylactic antimicrobials according to local guidelines.

Febrile neutropenia was observed in 6% of patients with MCL and 35% of patients with ALL after Tecartus infusion and may be concurrent with CRS. The febrile neutropenia in 27 (35%) of patients with ALL includes events of febrile neutropenia (11 (14%)) plus the concurrent events of fever and neutropenia (16 (21%)). In the event of febrile neutropenia, evaluate for infection and manage with broad spectrum antibiotics, fluids, and other supportive care as medically indicated.

In immunosuppressed patients, life-threatening and fatal opportunistic infections have been reported. The possibility of rare infectious etiologies (e.g., fungal and viral infections such as HHV-6 and progressive multifocal leukoencephalopathy) should be considered in patients with neurologic events and appropriate diagnostic evaluations should be performed.

Hepatitis B virus (HBV) reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, can occur in patients treated with drugs directed against B cells. Perform screening for HBV, HCV, and HIV in accordance with clinical guidelines before collection of cells for manufacturing.

Prolonged Cytopenias: Patients may exhibit cytopenias for several weeks following lymphodepleting chemotherapy and Tecartus infusion. In patients with MCL, Grade 3 or higher cytopenias not resolved by Day 30 following Tecartus infusion occurred in 55% (45/82) of patients and included thrombocytopenia (38%), neutropenia (37%), and anemia (17%). In patients with ALL who were responders to Tecartus treatment, Grade 3 or higher cytopenias not resolved by Day 30 following Tecartus infusion occurred in 20% (7/35) of the patients and included neutropenia (12%) and thrombocytopenia (12%); Grade 3 or higher cytopenias not resolved by Day 60 following Tecartus infusion occurred in 11% (4/35) of the patients and included neutropenia (9%) and thrombocytopenia (6%). Monitor blood counts after Tecartus infusion.

Hypogammaglobulinemia: B cell aplasia and hypogammaglobulinemia can occur in patients receiving treatment with Tecartus. Hypogammaglobulinemia was reported in 16% (13/82) of patients with MCL and 9% (7/78) of patients with ALL. Monitor immunoglobulin levels after treatment with Tecartus and manage using infection precautions, antibiotic prophylaxis, and immunoglobulin replacement.

The safety of immunization with live viral vaccines during or following Tecartus treatment has not been studied. Vaccination with live virus vaccines is not recommended for at least six weeks prior to the start of lymphodepleting chemotherapy, during Tecartus treatment, and until immune recovery following treatment with Tecartus.

Secondary Malignancies may develop. Monitor life-long for secondary malignancies. In the event that one occurs, contact Kite at 1-844-454-KITE (5483) to obtain instructions on patient samples to collect for testing.

Effects on Ability to Drive and Use Machines: Due to the potential for neurologic events, including altered mental status or seizures, patients are at risk for altered or decreased consciousness or coordination in the 8 weeks following Tecartus infusion. Advise patients to refrain from driving and engaging in hazardous activities, such as operating heavy or potentially dangerous machinery, during this period.

Adverse Reactions: The most common non-laboratory adverse reactions ( 20%) were fever, cytokine release syndrome, hypotension, encephalopathy, tachycardia, nausea, chills, headache, fatigue, febrile neutropenia, diarrhea, musculoskeletal pain, hypoxia, rash, edema, tremor, infection with pathogen unspecified, constipation, decreased appetite, and vomiting. The most common serious adverse reactions ( 2%) were cytokine release syndrome, febrile neutropenia, hypotension, encephalopathy, fever, infection with pathogen unspecified, hypoxia, tachycardia, bacterial infections, respiratory failure, seizure, diarrhea, dyspnea, fungal infections, viral infections, coagulopathy, delirium, fatigue, hemophagocytic lymphohistiocytosis, musculoskeletal pain, edema, and paraparesis.

Please see full Prescribing Information, including BOXED WARNING and Medication Guide.

Forward-Looking Statements

This press release includes forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995 that are subject to risks, uncertainties and other factors, including the risk that physicians and patients may not see the potential benefits of Tecartus for the treatment of adult patients with relapsed or refractory B-cell ALL; the possibility of unfavorable results from ongoing and additional clinical trials involving Tecartus; and the possibility that Tecartus may not receive regulatory approvals in the European Union and United Kingdom for the treatment of adult patients with relapsed or refractory B-cell ALL in the anticipated timelines or at all, and the risk that any such approvals, if granted, may have sigfniciant limitationon its use. These and other risks, uncertainties and other factors are described in detail in Gileads Quarterly Report on Form 10-Q for the quarter ended June 30, 2021, as filed with the U.S. Securities and Exchange Commission. These risks, uncertainties and other factors could cause actual results to differ materially from those referred to in the forward-looking statements. All statements other than statements of historical fact are statements that could be deemed forward-looking statements. Investors are cautioned that any such forward-looking statements are not guarantees of future performance and involve risks and uncertainties and are cautioned not to place undue reliance on these forward-looking statements. All forward-looking statements are based on information currently available to Kite and Gilead, and Kite and Gilead assume no obligation and disclaim any intent to update any such forward-looking statements.

U.S. Prescribing Information for Tecartus including BOXED WARNING, is available at http://www.kitepharma.com and http://www.gilead.com.

Kite, the Kite logo, Yescarta, Tecartus, XLP and GILEAD are trademarks of Gilead Sciences, Inc. or its related companies.

For more information on Kite, please visit the companys website at http://www.kitepharma.com or call Gilead Public Affairs at 1-800-GILEAD-5 or 1-650-574-3000. Follow Kite on social media on Twitter (@KitePharma) and LinkedIn.

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Skeletons’ broken clavicles tell a centuries-old tale of humans and horses – Massive Science

Tuesday, October 5th, 2021

For the first time, a type of CRISPR/Cas9 genome editing, called prime editing, has been performed in mini-organs to correct the mutation causing cystic fibrosis.

Cystic fibrosis is thought to affect more than 70,000 people worldwide.It is a genetic disease caused by a mutation in a single gene, called the CFTR gene, which result in a dysfunctional CFTR protein. This dysfunctional protein aspect is what causes the main symptom of cystic fibrosis; a sticky mucus buildup in the respiratory tract and lungs.

Published in Life Science Alliance, researchers from the Hubrecht Institute, in collaboration with UMC Utrecht and Oncode Institute, demonstrated that they were able to correct a mutation in CFTR that causes cystic fibrosis by performing genome editing in a mini-organ called an organoid. The organoids, mini intestines, had been grown from stem cells originally collected from patients with cystic fibrosis.

Prime editing is different than traditional CRISPR genome editing. Instead of acting as a pair of scissors, prime editing uses a modified Cas9 protein to make a direct change to the DNA sequence. In doing so, the researchers are able to change the underlying DNA sequence without cutting the DNA. This also reduces the risk of Cas9 cutting randomly elsewhere in the genome.

To test if the prime editing was successful, the researchers, led by Hans Clever, added a treatment called forskolin to the organoids. In healthy organoids, addition of forskolin causes the mini-intestines to swell up due to movement of fluids into the center. The researchers found that this happened in some of the prime edited organoids as well, suggesting that the mutation had been corrected. Organoids that carried a CFTR gene with a mutation however, did not respond to forskolin treatment.

Prime editing efficiency is variable between organoids and cell types, an important consideration in the developments towards gene therapy for cystic fibrosis and other diseases. Moreover, significant research effort should be invested into ensuring that prime editing techniques do not cause any unintended off-target effects. Despite this, these proof-of-principle research findings provide a step forward for the understanding and future developments of gene therapy for cystic fibrosis treatment.

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Environmental Factor – August 2021: Extramural Papers of the Month – Environmental Factor Newsletter

Wednesday, August 4th, 2021

ExtramuralBy Megan Avakian

An NIEHS-funded study in mice showed how chlorine exposure leads to Acute Chest Syndrome (ACS), a leading cause of death in patients with sickle cell disease (SCD). The results point to a potential lifesaving therapy for SCD patients exposed to chlorine. Chlorine is found in some household cleaning products and is commonly encountered in industrial accidents and chemical warfare.

SCD is a group of blood disorders in which the hemoglobin protein is defective, causing red blood cells (RBCs) to rupture. The researchers used genetically engineered mice that resembled SCD in humans (sickle mice) and compared them to healthy control mice with human hemoglobin. They exposed both groups to chlorine gas or normal air and assessed survival, lung injury, and hemolysis, or the rupture of RBCs which releases hemoglobin into the blood. They repeated this process but injected mice with hemopexin, which binds to hemoglobin.

Within six hours of chlorine exposure, 64 percent of sickle mice died while none of the controls died. Compared to controls, surviving sickle mice had hemolysis and lung injury. Hemolysis resulted in increased blood levels of heme, a component of hemoglobin known to cause lung injury. Hemopexin treatment following exposure significantly improved survival and reduced blood heme levels and lung injury. RBCs from chlorine-exposed sickle mice had high carbonylation, which increases cell rupture. Carbonylation was absent after hemopexin treatment.

According to the authors, results indicate that chlorine exposure induces ACS-like outcomes in sickle mice and that hemopexin treatment after exposure reduces death and lung injury.

Citation:Alishlash AS, Sapkota M, Ahmad I, Maclin K, Ahmed NA, Molyvdas A, Doran S, Albert CJ, Aggarwal S, Ford DA, Ambalavanan N, Jilling T, Matalon S. 2021. Chlorine inhalation induces acute chest syndrome in humanized sickle cell mouse model and ameliorated by postexposure hemopexin. Redox Biol 44:102009.

Women exposed to higher temperatures had a lower ovarian reserve, found NIEHS-funded researchers. Ovarian reserve refers to the number and quality of a womans eggs. A diminished ovarian reserve reduces a womans ability to get pregnant.

The study included 631 women aged 18-45 years enrolled in a reproductive health study in Massachusetts. Using each womans home address, the researchers estimated daily ambient temperature exposures for three months, one month, and two weeks before the ovarian reserve examination. They used ultrasonography to measure antral follicle count (AFC), a measure of ovarian reserve.

Exposure to higher temperatures was associated with a lower AFC. Specifically, a 1-degree Celsius increase in average maximum temperature three months before ovarian reserve testing was associated with a 1.6 percent lower AFC. This relationship remained negative but weakened for one month and two weeks before AFC testing. The negative association between temperature and AFC was stronger in November through June compared to the summer months. According to the researchers, this suggests that women may be more susceptible to heat during certain times of the year, potentially because they adapt to heat in the summer.

Study findings raise concerns that the steady increase in global temperature due to climate change may result in accelerated reproductive aging in women, say the researchers.

Citation:Gaskins AJ, Minguez-Alarcon L, VoPham T, Hart JE, Chavarro JE, Schwartz J, Souter I, Laden F. 2021. Impact of ambient temperature on ovarian reserve. Fertil Steril; doi: 10.1016/j.fertnstert.2021.05.091. [Online 8 June 2021]

NIEHS grantees developed a gene expression atlas that captures the cellular makeup of the mammary gland across life stages, providing clues to how breast cancer originates. The female breast is made up of different cell types and undergoes reorganization during development, pregnancy, and menopause, increasing breast cancer risk.

To build the atlas, the researchers used single cell RNA sequencing data, which assesses gene and protein expression of an individual cell. They integrated data from 50,000 mouse mammary cells covering eight life stages and 24,000 adult human mammary cells.

The data formed three clusters. Using known genetic markers, they identified the clusters as three breast epithelial cell types. Connecting the clusters were embryonic mammary stem cells, which can give rise to each epithelial cell type. Advanced computational methods suggested the breast epithelium originated from embryonic mammary stem cells that differentiated into epithelial cells through postnatal progenitor cells.

The researchers compared genetic profiles for each epithelial cell type with known cancer-related genes to infer breast cancer cells of origin. This can help pinpoint tumor origin since cancer often starts from a single transformed cell. They also examined how reorganization during different life stages altered breast cellular makeup and breast cancer subtype risk. For example, during pregnancy the breast had increased basal epithelial cells, potentially increasing risk of the basal breast cancer subtype. According to the authors, the atlas provides insights into cellular makeup and development of breast cancer subtypes.

Citation:Saeki K, Chang G, Kanaya N, Wu X, Wang J, Bernal L, Ha D, Neuhausen SL, Chen S. 2021. Mammary cell gene expression atlas links epithelial cell remodeling events to breast carcinogenesis. Commun Biol 4(1):660.

The placenta may play a critical role in conveying the effects of particulate matter air pollution (PM2.5) exposure during pregnancy to the developing fetus, according to a new NIEHS-funded study. The researchers found that maternal PM2.5 exposure during certain periods of pregnancy leads to reduced fetal growth, especially in females.

The study included 840 women and their children enrolled in a birth cohort study in Rhode Island between 2009-2013. Using spatiotemporal models and the womens home addresses, the researchers estimated maternal weekly PM2.5 exposure from 12 weeks preconception until birth. They overlaid a previously developed placental gene network with PM2.5 exposure data to identify genes associated with air pollution exposure. They used gestational age and birth weight collected at birth to assess fetal growth.

The researchers identified a sensitive window spanning 12 weeks prior to and 13 weeks into pregnancy during which higher maternal PM2.5 exposure was associated with significantly lower infant birthweight and shorter gestational age across all timepoints. Female infants were particularly vulnerable to PM2.5-induced deficits in fetal growth. Disruption of placental genes important in amino acid transport and cellular respiration were correlated with maternal PM2.5 exposure and infant birthweight, suggesting that the placenta conveyed air pollution-related impacts to the developing fetus.

According to the authors, results suggest that maternal PM2.5 exposure may alter placental programming of fetal growth, with potential implications for downstream health effects.

Citation:Deyssenroth MA, Rosa MJ, Eliot MN, Kelsey KT, Kloog I, Schwartz JD, Wellenius GA, Peng S, Hao K, Marsit CJ, Chen J. 2021. Placental gene networks at the interface between maternal PM2.5 exposure early in gestation and reduced infant birthweight. Environ Res 199:111342.

(Megan Avakian is a research and communication specialist for MDB Inc., a contractor for the NIEHS Division of Extramural Research and Training.)

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Environmental Factor - August 2021: Extramural Papers of the Month - Environmental Factor Newsletter

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Role of traumatic brain injury in the development of glioma | JIR – Dove Medical Press

Wednesday, August 4th, 2021

Introduction

Traumatic brain injury is a leading global cause of mortality and morbidity and the main cause of death in young people living in industrialized countries.1,2 Traumatic brain injury is mainly caused by an external mechanical force causing brain trauma. Traumatic brain injury and the ensuing neuroinflammation, in addition to causing motor and cognitive deficits, may persist long after the initial injury.3 Furthermore, long-term neuroinflammation has been related to increased risk of neurodegenerative disorders and various other deficits.4 Traumatic brain injury as a risk factor for brain tumors has been a controversial topic in medicine for over a century.58 However, as statistical reports on brain tumors often exclude post-traumatic glioma, relevant information on the incidence of gliomas caused by traumatic brain injuries is rare. Although previous clinical studies and case reports are often vague and difficult to evaluate since most of them were published so many years ago,512 some are quite striking, such as the cohort study by Munch et al5 in which the reduced long-term risk of malignant astrocytic tumors after structural brain injury was evaluated. However, this study was conducted using a small population. Furthermore, it is to be noted that traumatic brain injury is only one type of structural brain injury in this study. Additionally, it is challenging to confirm the incidence of post-traumatic glioma owing to the frequently considerable time gap between traumatic brain injury and glioma. Thus, there is an urgent need to systematically evaluate the role and outcome of head trauma in the incidence and progression of glioma. In this review, our primary focus is to document the interrelationship between traumatic brain injury and glioma based on a comprehensive review of the existing literature, which is discussed in detail. First, we present an overview of previous cohort studies and various case reports regarding the relationship between traumatic brain injury and glioma. Next, we discuss the roles of microglial cells, macrophages, astrocytes, and stem cells in post-traumatic glioma formation and development. Moreover, we also briefly discuss the various carcinogenic factors during traumatic brain injury that could explain the interplay between these two parameters. We have also summarized the common inflammatory and oxidative stress-related signaling pathways related to traumatic brain injury and glioma. Lastly, we have elaborated on the strategy that could be considered in a clinical setting, and have concluded this review with directions for future research.

All previously published cohort studies and case-control studies are not directly comparable owing to differences in exposures and outcomes (Table 1). A population-based study by Inskip et al8 reveals an increased overall incidence of intracranial tumors of head trauma patients, whereas no significant association was found in the case of malignant astrocytic tumors. In a cohort study by Nygren et al7 no significant association between traumatic brain injuries and brain tumors was identified; moreover, specific risks for malignant astrocytic tumors were not reported. However more recently, a cohort study by Chen et al6 indicated an increased risk for not otherwise specified malignant brain tumors within 3 years after a traumatic brain injury. Besides, interestingly, a research group demonstrated a decreased risk 5 or more years after structural brain injury; however, they did not find convincing evidence for an association between structural brain injury and malignant astrocytic tumors within the first 5 years of follow-up.5 The authors speculated that the inflammatory response after traumatic injury could cause elevated immunological alertness for astrocytes undergoing neoplastic transformation, as well as a clearance of premalignant astrocytes or neural stem cells, which may otherwise have developed into glioma. Although their study demonstrated that structural brain injury may generally reduce the long-term risk of malignant astrocytic tumors, their data also supported that structural brain injury specifically caused by trauma (different from other types of exposures such as cerebral ischemic infarction and intracerebral hemorrhage) could increase the long-term risk of malignant astrocytic tumors. Thus, the relationship between traumatic brain injury and glioma is still not conclusive and warrants further studies.

Table 1 Overview of Published Epidemiological Studies Exploring the Causal Relationship Between Traumatic Brain Injury and Glioma

It is often a challenge to compare the results of previously published epidemiological studies,58 as it involves individuals of different ages who live in different environments. Importantly, most studies have also not been standardized regarding the type or the severity of brain damage. The low incidence of brain tumors also hinders the design of relevant research. There is currently an urgent need for more comprehensive and larger-scale epidemiological investigations, including cohort studies and case-control studies, to evaluate post-traumatic glioma. To date, very few case-control studies have specifically reported the risk for malignant astrocytoma/glioma after traumatic brain injury, and conclusively, the currently available findings are equivocal with null9,10 or positive associations.11,12 For the first time, Hochberg et al12 have done a case-control study of 160 persons with glioblastoma, and the results suggested that severe head trauma in adults is a significant risk factor for glioblastoma. After that, Zampieri et al12 did another case-control study to find potential risk factors for cerebral glioma in adults, however, their study yielded no meaningful association between head trauma and glioma. Besides, the case-control study done by Preston-Martin et al10 investigated the role of head trauma from injury in adult brain tumor risk. Although not significant association between head trauma and glioma has been found, their findings suggest that an association between head trauma and brain tumor risk cannot be ruled out and should therefore be further studied, and future studies of head trauma and brain tumor risk should consider potential initiators of carcinogenesis, such as nitrite from cured meats, as modifiers of the trauma effect on risk of brain tumor. Furthermore, Hu et al11 also exerted case-control study of risk factors for glioma in adults, interestingly positive associations between brain trauma and glioma has been found. Unfortunately, all case-control studies were conducted before the year 1998, and no newly published research worthy of reference could be found suitable for discussion in this review. The advantages of cohort studies have been highlighted in various studies; therefore, most researchers give more weightage to cohort studies than case-control studies when systematically evaluating evidence.13,14 Thus, additional more cohort investigations with correct and standardized study designs are much needed to gain a better understanding of post-traumatic glioma.

The results of the published epidemiological studies could not be compared uncritically, as the types of brain injuries differed, and patients belonged to different ethnic groups and different ages. Difficulties in conducting epidemiological studies can be attributed to the low incidence of brain tumors. More efforts should be directed toward investigating the causal relationship between traumatic brain injury and glioma, which is supported by several published case reports.1527 Although these reports from epidemiological observations have not conclusively confirmed the relationship between traumatic brain injury and glioma,58 some reports discuss the follow-up details of patients in great detail and are indicative of the possibility of such a relationship.1527 Anselmi et al15 reported two cases of brain glioma that developed in the scar of an old brain trauma, these two cases fulfill the established criteria for a traumatic origin of brain tumors and add further support to the relationship between cranial trauma and the onset of glioma. Di Trapani et al16 reported that several years after sustaining a commotive left parietal trauma, one patient developed a mixed glioma in the left temporo-parietal-occipital region in continuity with the scar resulting from the trauma. Magnavita et al17 reported the case of a patient who suffered a severe head injury to the right temporoparietal lobe, and the patient developed a glioblastoma multiforme at the precise site of the meningocerebral scar 4 years later. Moorthy et al18 reported a case of a 56-year-old man who had history of head injury 5 years prior with CT evidence of bilateral basifrontal contusions. Imaging showed a large left frontal intra-axial mass lesion and the histopathology was reported as glioblastoma multiforme. The authors formulated additional radiologic criteria for tumors that may present following trauma. Mrowka et al19 reported that a glioblastoma multiforme developed 30 years after a penetrating craniocerebral injury in the left parietal region caused by fragments of an artillery projectile. Sabel et al20 reported that a patient developed a left-sided frontal glioblastoma multiforme at the precise site of the meningocerebral scar and posttraumatic defect 37 years later. Witzmann et al21 reported a case of a 28-year-old male who suffered a frontal penetrating gunshot injury with subsequent bifrontal brain abscess and subdural empyema, and five years later developed a large bifrontal glioblastoma multiforme at the precise site of the meningo-cerebral scar and posttraumatic defect. Zhou et al22 also reported one case of glioblastoma multiforme that developed in the scar of an old brain trauma 10 years ago. Han et al23 presented the first case of pregnancy-related post-traumatic malignant glioma in a 29-year-old female, and suggested that pregnancy may promote the manifestation of the clinical symptoms. Tyagi et al24 used radiographic evidence from two patients to assess the possibility of a link between TBI and glioblastoma multiforme. Salvati et al25 presented 4 cases of post-traumatic glioma with radiological evidence of absence of tumor at the time of the injury. Henry et al26 reported a case of post-traumatic malignant glioma with radiological evidence of only a contusion prior to the development of the glioma. Simiska et al27 reported one case of post-traumatic glioma 2 years after head injury. Overall, some data from these studies might support the conclusion that the association is almost weak, while others not; but a causal relationship between traumatic brain injury and glioma is highly possible. This is because traumatic brain injury initiates inflammation, oxidative stress, repair, oncogene activation, and other pathophysiological changes, which are bound to lead to malignancy in at least some patients.28,29

Besides, to better identify reported cases addressing the relationship between traumatic brain injury and the incidence and development of glioma, an important aspect is to be able to recognize and differentiate between a tumor, traumatic brain injury-induced glioma, and post-traumatic glioma. We believe that only specific cases that fulfill certain conditions or criteria, could add to revealing the etiological association between head trauma and glioma. Thus, more efforts should be directed in establishing if there is a relationship between traumatic brain injury and gliomas, as well as diagnosing post-traumatic glioma. Since traumatic incidents are much more frequent than a possibly related tumor, James Ewing30 defined five criteria that could aid in the identification of post-traumatic glioma that could contribute to establishing the relationship between brain injury and the subsequent glioma. Subsequently, Zulch and Manuelidis31 revised Ewings criteria while adding their viewpoints. And Moorthy and Rajshekhar32 further added imaging-related screening criteria to this list. We believe that specific cases that fulfill these criteria, as well as possibly other cases with accurate retrospective data of traumatic brain injury and high risk of developing glioma, could add to the clarification of the etiological association between traumatic brain injury and glioma.

Neuroinflammation accompanying the activation of microglial cells and other effector cells has been suggested as an important mechanism of TBI.33 Active microglial cells can transform to the M1 phenotype, to secrete proinflammatory or cytotoxic mediators that mediate post-TBI cell death and neuronal dysfunction, or to the M2 phenotype, to participate in phagocytosis and secrete anti-inflammatory cytokines and neurotrophic factors that are important for neural protection and repair.34 Indeed, they can become polarized ranging from the classic M1 phenotype to an alternative M2 phenotype after TBI.35 The M1 response is presumed to be pro-inflammatory,36 whereas the M2 phenotype owns anti-inflammatory effects.37 Multiple molecular pathways, such as STAT, nuclear factor-B (NF-B), and interferon regulatory factor (IRF), are involved in the regulation of M1/M2 phenotypic transitions.3840 Preclinical evidence indicated that mixed phenotypes are present in the pathological processes of TBI, which offer opportunities for therapeutic interventions.41

Several mechanisms have been shown to be associated with the formation of post-traumatic glioma, specifically, inflammatory processes and oxidative stress, both of which are mainly involved in the removal of damaged components from the brain and are known to play irreplaceable roles in this process.24 In the brain, these mechanisms are mainly mediated by the microglia or other cells of the immune system.24,42 Microglia in the brain play a role in phagocytosis and antigen presentation, leading to the release of chemokines or cytokines.43 Interestingly, recent in vivo studies have shown that microglia could have different effects on the development of brain glioma, and also result in immunosuppressive conditions that promote glioma development.44,45 Although the growth-promoting effect of glioma by microglia after traumatic brain injury is controversial, its significant role in promoting an environment that can facilitate glioma development has been identified.43 Microglia can produce metalloproteinases in the tissues adjacent to glioma, which can facilitate tumor invasion.44 Besides, PGE2 can also contribute to the creation of an environment that facilitates glioma development.46 PGE2 is released by the microglia accompanying the developing glioma and can suppress T lymphocytes. The net effect is a decreased expression of major histocompatibility complex (MHC) class II molecules on antigen-presenting cells.46 Brain-repair processes mainly involve the microglia in normal conditions; however, during traumatic brain injury, various other cells from the immune system can also enter the brain parenchyma along with blood. These effects cannot be ignored.

Oxidative stress caused by ROS in the acute phase of TBI and cerebral infarction is thought to be detrimental, and macrophages have been recognized as the main cells that produce ROS.47 During traumatic brain injury, macrophages migrate to the site of the damaged blood-brain barrier and secrete interleukin 6 (IL-6). In normal conditions, the expression of IL-6 is very low, whereas, during traumatic brain injury, its production increases considerably.48 Brain injury elevates IL-6 production in both serum and CSF to high concentration. Notably, multiple TBI patients samples have also showed that the combination of elevated IL-6 concentrations is correlated with better outcomes in patients with TBI, suggesting IL-6 as a new therapeutic strategy as well as for prediction of disease outcome of patients with TBI.49 Importantly, high levels of IL-6 in the brain generally result in an adverse impact on microcirculation and lead to the destruction of the blood-brain barrier in an obviously wider area compared to the initial area of trauma.27 Thus, in traumatic brain injuries, it is crucial that the blood-brain barrier is not initially compromised, as IL-6 can subsequently promote the entry of macrophages to the site of injury and aggravate brain edema.24,42 Besides, Xu et al reported that IL-6 also impacts cell-cycle regulation42 and activates signal transducer and activator of transcription-3 (STAT3), which is important for cell proliferation, differentiation, and apoptosis. Previous studies show that STAT3 inhibition suppresses the growth of glioma cells and promotes apoptosis.43 These findings have also been confirmed in other in vivo studies.50,51 Besides, STAT3 activation can inhibit T lymphocytes and MHC II molecules on microglial and other antigen-presenting cells.43 Thus, STAT3 has an immunosuppressive effect and is likely a carcinogenic factor for glioma. Importantly, the increased concentrations of IL-6 and its receptors in the cerebrospinal fluid of patients who underwent traumatic brain injury are indicative of the involvement of IL-6 in glioma progression.42,43

The neuronal stem cells in the brain are mainly generated from the subgranular zone of the hippocampal dentate gyrus and the subependymal zones of the lateral ventricles.24 Traumatic brain injury leads to the migration of neuronal stem cells to the damaged sites to promote regeneration, thereby differentiating into astrocytes, neurons, and oligodendrocytes. Additionally, neuronal stem cells could release cytokines and neurotrophic factors such as glial cell-derived neurotrophic factor (GDNF) and brain-derived neurotrophic factor (BDNF).24 Thus neuronal stem cells may be an effective treatment for neurological recovery after TBI.52 Interestingly, neuronal stem cells show a high expression of oncogenic genes and high sensitivity to chemical mutagenic factors.24 This is important because stem cells are involved in the production of ROS and various pro-inflammatory factors.24 Neuronal stem cells can be highly sensitive to mutagenic agents and could, thus, be easily mutated as a result of the action of certain agents. These characteristics may promote the formation of rapidly proliferating tumor cells and increase the progression of glioma in the brain.24,53 Migration of stem cells has already been identified in cases of traumatic brain injury, ischemia, and demyelination. However, there is a much higher risk of increased neoplastic transformation only during traumatic brain injury.24 Therefore, it is reasonable to accept the causal relationship between traumatic brain injury that induces brain stem cell activity and subsequent development of glioma.24 Stem cells have been generally recognized as potentially oncogenic in glioma54 and several studies have demonstrated their important role in the formation of gliomas.5557 The role of stem cells should be emphasized in the analysis of relevant mechanisms leading to glioma development induced by traumatic brain injury.

Multiple studies have suggested that astrocytes play a key role in the pathogenesis of TBI.58,59 Increased reactive astrocytes and astrocyte-derived factors are generally observed in both experimental animal models and TBI patients.60 Astrocytes have beneficial and detrimental effects on TBI, including acceleration and suppression of neuroinflammation, promotion and restriction of neurogenesis and synaptogenesis, and disruption and repair of the BBB through various bioactive factors.61 Additionally, astrocytic aquaporin-4 is also involved in the formation of cytotoxic edema. Thus, astrocytes are attractive targets for novel therapeutic drugs for TBI.

Based on case reports studying glioblastomas, neoplastic transformation of damaged astrocytes has been proposed as a possible mechanism occurring at the site of traumatic brain injuries.1527 Besides, it is generally accepted that astrocytes are essential components of the blood-brain barrier, and damage to the blood-brain barrier often occurs after the action of pro-inflammatory prostaglandins and leukotrienes, which triggers the effect of the relaxing of tight junctions.54 The pro-inflammatory factors lead to a relaxation of the capillary epithelium and the glial cells are exposed to potentially mutagenic agents.62 Traumatic brain injury accompanied by damage to the blood-brain barrier always causes a recovery reaction, which explains the recurrence of glioma in some cases.

To conclude, the summary of various carcinogenic factors that play a role during traumatic brain injury is presented in Figure 1. Traumatic brain injury can lead to the influx of macrophages to the site of brain injury, where they are activated and produce IL-6. Traumatic brain injury also induces enhanced IL-6 secretion by astrocytes and microglial cells. Increased IL-6 levels caused by traumatic brain injury can thus activate STAT3, thereby increasing cell proliferation at the site of injury and resulting in the inhibition of apoptosis. STAT3 can suppress T lymphocytes and decrease the activity of MHC class II molecules on cells of the immune system. Furthermore, the increased levels of IL-6 also impact the blood-brain barrier. Additionally, microglial cells secrete metalloproteinases in the tissues adjacent to the tumor, facilitating its migration and, consequently, facilitating its development. PGE2, which is synthesized by microglial cells during the development of the glioma, suppresses the T lymphocytes and decreases the expression of MHC II molecules. Besides, the generation of reactive oxygen species (ROS) might lead to certain mutations in stem cells that migrate to the injury site. At the site of injury, the risk of mutations and cell proliferation increases, and along with the inhibition of apoptosis, these factors may jointly contribute to carcinogenesis.

Figure 1 Schematic representation of various carcinogenic factors during traumatic brain injury. Traumatic brain injury could lead to the migration of macrophages to the site of injury, followed by increased IL-6 production. Traumatic brain injury also induces enhanced IL-6 secretion by astrocytes and microglial cells. The increased IL-6 could thus activate STAT3, which increases cell proliferation at the site of injury, as well as inhibition of apoptosis. STAT3 suppresses T lymphocytes and inhibits major histocompatibility complex (MHC) class II molecules on cells of the immune system. The increased IL-6 also damages the blood-brain barrier (BBB). In addition, microglia secretes metalloproteinases in the tissues adjacent to the tumor, facilitating its migration and development. PGE2 is also synthesized by microglia and suppress T lymphocytes, and also decrease the expression of MHC II molecules on antigen-presenting cells. Besides, reactive oxygen species (ROS) might lead to certain mutations in stem cells that migrate to the site of injury. At the site of injury, the risk of these mutations, and cell proliferation increase, as well as the apoptosis inhibition, may jointly contribute to carcinogenesis.

Inflammation at the site of traumatic brain injury and glioma has been well documented in the literature.63,64 Besides, ROS, the major contributor of oxidative stress, are metabolic byproducts originating from different sources in hypoxic65 conditions and exhibit condition-dependent functions.66,67 The activation of inflammation and oxidative stress are reported in both traumatic brain injury and glioma, and both conditions appear to share a common network of signaling for downstream functions (Figure 2). Interestingly, the activation of inflammation can also contribute to oncogenesis via the generation of ROS and the activation of oxidative stress,68 and conversely, oxidative stress also promotes inflammation.69 Specifically, in this situation, astrocytes, microglia, stem cells, and even neurons can be stimulated to increase ROS and RNS (NO, ONOO),7072 which participate in regulating inflammation and oxidative stress in traumatic brain injury and glioma.

Figure 2 Common inflammatory and oxidative stress-related signaling pathways for traumatic brain injury and glioma. Activation of inflammation and oxidative stress are reported in both traumatic brain injury and glioma, and both conditions share a common network of signaling for downstream functions. Specifically, in the cases of oxidative stress or inflammation in the brain, more ROS could thus be generated. Several cancer-specific external stimuli like the TNF-, could lead to a decrease in the mitochondrial membrane potential that activates ROS generation. Besides, the NADPH oxidase (NOXs) family proteins are one of the main producers of ROS in various cancers, as well as in traumatic brain injuries. And specific signals like TGF-, MAPK, AKT, ERK and various others, could lead to conformational changes in the NOX complex and increase ROS generation. Another important pathway that acts on glioma and traumatic brain injury in a similar manner is hypoxia-inducing factor 1 (HIF-1), which could be upregulated due to the inhibition of degradation via PHD inactivation. HIF-1 could increase the expression of glucose transporter 3 (GLUT3), erythropoietin (EPO), VEGF, as well as BNIP3. Besides, nuclear factor-B (NF-B) can increase the production of ROS, which can also be regulated by the Ras-Raf-MEK pathway via regulating GATA-6. Transcriptional enhancement of HSF1 by Ras could activate the SESN1 and SESN3 genes to promote the production of ROS. TGF also increases the production of ROS through activating GSK3 and mTOR signaling pathways in mitochondria, as well as inhibiting antioxidant enzymes, like the SOD and glutathione peroxidase (GPx).

After traumatic brain injury, there is sequential migration of the resident microglia and myeloid inflammatory cells to the site of injury.73 These inflammatory cells contribute to oncogenesis via promoting ROS generation, which has mutagenic properties, or via the secretion of cytokines and growth factors, in addition to maintaining an inflammatory response.68 During oxidative stress or inflammation in the brain, there is an increase in ROS could generation in the mitochondria.7476 Several cancer-specific external stimuli, including TNF-, lead to a decrease in the mitochondrial membrane potential and interfere with the components of the electron transport chain (ETC), thereby promoting ROS generation.77,78 Besides, the NADPH oxidase (NOXs) protein family is one of the main producers of ROS in various cancers and traumatic brain injuries.79 Moreover, specific markers, such as TGF-, MAPK, AKT, and ERK, among others,80,81 can lead to conformational changes in the NOX complex and increase ROS generation.82 Another indispensable pathway that has an impact on glioma and traumatic brain injury is hypoxia-inducing factor 1 (HIF-1), which can be upregulated owing to the inhibition of degradation via the inactivation of PHD.83,84 HIF-1 increases the expression of glucose transporter 3 (GLUT3), erythropoietin (EPO), VEGF, and BNIP3.8588 Several other signaling pathways are involved in the activation of inflammation and oxidative stress. Nuclear factor-B (NF-B) can increase ROS generation via a positive feedback loop of TNF regulation.89 Additionally, ROS can be regulated by the Ras-Raf-MEK pathway through the transcriptional regulation of GATA-6.90,91 It has been reported that transcriptional enhancement of HSF1 by Ras upregulates SESN1 and SESN3 genes to promote ROS production.92 Besides, TGF also increases the production of ROS by activating the GSK3 and mTOR signaling pathways in the mitochondria and inhibiting antioxidant enzymes, including SOD and glutathione peroxidase (GPx) (Figure 2).93,94

Following a traumatic brain injury, there is an increase in free radicals and the expression of several pro-inflammatory genes by various transcription factors such as NF-B.95,96 This knowledge could be used in anticancer drug discovery. ROS levels increased by oxidation therapy can trigger cell death via necrosis or apoptosis.97 Flavonoids, such as quercetin,98,99 catechins,100 and proanthocyanins,101,102 protect glial cells from inflammation and oxidative stress. These compounds exert protective effects in the brains of patients with cancer and help prevent traumatic brain injury. An anticancer agent, gallic acid, is not only toxic to glioma cells but also exerts beneficial effects in the recovery from traumatic brain injuries.103105 Cardamonin (a chalcone) is effective as an anti-inflammatory and anti-carcinogenic agent in glioma.106,107 Hyperbaric oxygen (HBO) therapy is a recently developed method108 that has been extensively used as an adjuvant in the treatment of various diseases predominantly related to hypoxic conditions. As traumatic brain injury and glioma are related to hypoxia, HBO therapy may be expected to be efficacious in the management of these diseases.109111 However, there could be significant differences in outcomes among patients, depending on the size of the lesion, tumor type, and malignancy.112114 Besides, several drugs, including glycyrrhizin,115 salidroside,116118 and astragaloside,119,120 may be used in both glioma and traumatic brain injury treatment due to the counteracting effect of common signaling pathways (Figure 3).

Figure 3 Selected common therapeutic approaches applied for both glioma and traumatic brain injury. An anticancer agent, gallic acid, could be of great toxic effects on glioma cells, and together exerts beneficial effects on recovery of traumatic brain injuries. Cardamonin (a chalcone) indicates effective anti-inflammatory and anti-carcinogenic activity in glioma. Hyperbaric oxygen (HBO) therapy is a recently developed method that has been extensively used as an adjunctive treatment for various diseases predominantly related to hypoxic conditions, and could be effective for treatment of both glioma and traumatic brain injury. Besides, several other kinds of drugs, like the glycyrrhizin, salidroside and astragaloside, could be used in both glioma and traumatic brain injury treatment due to the counteracting effect of common signaling pathways. Several flavonoids such as quercetin, catechins, and proanthocyanins also protect the glial cells from inflammation and oxidative stress, and could be potentially effective for treatment of these two diseases.

Currently, comprehensive research establishing the relationship between the mechanisms of traumatic brain injury and tumorigenesis is necessary. However, there could be some obstacles. First, the considerable time interval between brain injury and the onset of glioma poses a challenge to perform in vivo studies. Secondly, designing in vitro studies using primary cultures can also be difficult owing to a large number of different types of cells that constitute the brain tissue. The use of immortalized glial cell lines is also excluded owing to their physiological dissimilarity with normal brain cells. Therefore, more efforts should be directed toward establishing suitable in vivo and in vitro models to explore the causal relationship between traumatic brain injury and glioma.

The possible association between traumatic brain injury and glioma should be further examined by designing additional experimental and clinical research. Much more additional factors may be involved in the formation of the post-traumatic glioma. These factors might have been unintentionally omitted during the selection of study groups in various previous studies, leading to the result of the lack of connection between injury and glioma, which is why further explorations on the etiology of post-traumatic glioma are urgently needed. Besides, it may be more difficult to effectively treat patients who suffer from both glioma and traumatic brain injury compared to those with traumatic brain injury without glioma. The survival rate of patients with glioma is bound to increase with the development of anticancer drugs, including those suggested in this review. Treating traumatic brain injury in patients with glioma can be still challenging and requires specific treatment modalities. Thus, the development of effective strategies in the management of traumatic brain injury in patients with glioma is essential.

The authors warrant that the article and all figures included in this work are the authors original work and has not been published before.

The authors declare no competing financial interests and no conflicts of interest for this work.

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36. Loane DJ, Kumar A. Microglia in the TBI brain: the good, the bad, and the dysregulated. Exp Neurol. 2016;275(3):316327. doi:10.1016/j.expneurol.2015.08.018

37. Cherry JD, Olschowka JA, OBanion MK. Neuroinflammation and M2 microglia: the good, the bad, and the inflamed. J Neuroinflammation. 2014;11:98. doi:10.1186/1742-2094-11-98

38. Kobayashi K, Imagama S, Ohgomori T, et al. Minocycline selectively inhibits M1 polarization of microglia. Cell Death Dis. 2013;4:e525. doi:10.1038/cddis.2013.54

39. Qin H, Yeh WI, De Sarno P, et al. Signal transducer and activator of transcription-3/suppressor of cytokine signaling-3 (STAT3/SOCS3) axis in myeloid cells regulates neuroinflammation. Proc Natl Acad Sci U S A. 2012;109:50045009. doi:10.1073/pnas.1117218109

40. Tanaka T, Murakami K, Bando Y, Yoshida S. Interferon regulatory factor 7 participates in the M1-like microglial polarization switch. Glia. 2015;63:595610. doi:10.1002/glia.22770

41. Xu H, Wang Z, Li J, et al. The polarization states of microglia in TBI: a new paradigm for pharmacological intervention. Neural Plast. 2017;2017:5405104. doi:10.1155/2017/5405104

42. Xu B, Yu DM, Liu FS. Effect of siRNA induced inhibition of IL 6 expression in rat cerebral gliocytes on cerebral edema following traumatic brain injury. Mol Med Rep. 2014;10:18631868. doi:10.3892/mmr.2014.2462

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45. Zhai H, Heppner FL, Tsirka SE. Microglia/macrophages promote glioma progression. Glia. 2011;59:472485. doi:10.1002/glia.21117

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47. Ma MW, Wang J, Dhandapani KM, Wang R, Brann DW. NADPH oxidases in traumatic brain injury-Promising therapeutic targets? Redox Biol. 2018;16:285293. doi:10.1016/j.redox.2018.03.005

48. Li Z, Xiao J, Xu X, et al. M-CSF, IL-6, and TGF-beta promote generation of a new subset of tissue repair macrophage for traumatic brain injury recovery. Sci Adv. 2021;7(11):eabb6260. doi:10.1126/sciadv.abb6260

49. Li Z, Xiao J, Xu X, et al. M-CSF, IL-6, and TGF-beta promote generation of a new subset of tissue repair macrophage for traumatic brain injury recovery. Sci Adv. 2021;7(11):eabb6260.

50. Chen F, Xu Y, Luo Y, et al. Down-regulation of Stat3 decreases invasion activity and induces apoptosis of human glioma cells. J Mol Neurosci. 2010;40:353359. doi:10.1007/s12031-009-9323-3

51. Iwamaru A, Szymanski S, Iwado E, et al. A novel inhibitor of the STAT3 pathway induces apoptosis in malignant glioma cells both in vitro and in vivo. Oncogene. 2007;26:24352444. doi:10.1038/sj.onc.1210031

52. Haus DL, Lpez-Velzquez L, Gold EM, et al. Transplantation of human neural stem cells restores cognition in an immunodeficient rodent model of traumatic brain injury. Exp Neurol. 2016;281:116. doi:10.1016/j.expneurol.2016.04.008

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58. Burda JE, Bernstein AM, Sofroniew MV. Astrocyte roles in traumatic brain injury. Exp Neurol. 2016;275(Pt 3):305315. doi:10.1016/j.expneurol.2015.03.020

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Accumulation of Regulatory T Cells in Triple Negative Breast Cancer Ca | CMAR – Dove Medical Press

Wednesday, August 4th, 2021

Introduction

Significant attention has been given to regulatory T cells (Tregs) expressing the transcription factor fork head box protein P3 (Foxp3).1 Tregs have a fundamental role in sustaining immunological tolerance and controlling autoimmunity.2 They act by controlling the activation and differentiation of CD4+ Th cells and CD8+ cytotoxic T cells in response to environmental, autogenous, or tumor associated antigens. Studies have confirmed that Tregs have opposing actions in cancer immunity leading to immune evasion of cancer cells and implying a functional impact on tumor progression and metastasis.35

Interestingly, the clinical relevance of tumor-infiltrating Tregs has been found ambiguous. For instance, a high Tregs density in hepatocellular carcinoma is predictive of poor prognosis, in line with the hypothesis that Tregs enhance tumor progression through tumor-specific T cell suppression. On the other hand, improved clinical outcome in other tumors as colorectal carcinoma is associated with a high Tregs density. These contrasting results indicate that the role of Tregs in tumor development may vary substantially according to the affected site.6

Similarly, Tregs were suggested to be correlated with good outcome of breast cancer in one study,7 while other studies revealed that Tregs were associated with poor outcome of breast cancer.8,9

Triple negative breast cancer (TNBC) is a type of breast tumors that do not express estrogen receptors (ER), progesterone receptors (PR), and human epidermal growth factor receptor 2 (HER2) on the surface.10 Patients with this TNBC have enhanced risk of metastasis and relapse, and cannot utilize targeted therapy.11

Increased tumor-infiltrating-lymphocytes (TILs) in TNBC support the high immunogenic nature of this subtype of breast cancer.1214

It is not evident whether the Tregs found intra-tumoral are comparable to those in normal tissues or in the peripheral blood. The tumor microenvironment might imprint distinctive transcriptional and functional characteristics upon Tregs.15,16 Recently, peripheral blood Tregs represented the main source of intra-tumoral Tregs in human breast cancers and that their response to cytokine signaling indicates intra-tumoral immunosuppressive possibility and predicts clinical outcome.17

So far, the prognostic value of Tregs in breast cancer is still controversial, and further studies are needed to fully understand its significance.1822 The present study was conducted to evaluate the number of Tregs in TNBC, in normal breast parenchyma and in the peripheral blood of these patients and controls, in addition to their correlations with the clinico-pathologic features and the outcomes of TNBC.

Thirty adult treatment-nave women undergoing surgical treatment of non-metastatic TNBC in the South Egypt Cancer Institute and Clinical Oncology Department, Assiut University Hospital were enrolled. The clinical and histopathological characteristics of the patients are shown in Table 1. In addition, 20 age matched healthy females participated as a control group.

Table 1 Clinical and Histopathological Characteristics of the TNBC Patients Group

The Committee of Medical Ethics of faculty of medicine, Assiut University reviewed and accepted the research proposal (IRB no. 17300416) and the study was done in compliance with the ethical guidelines of the Declaration of Helsinki 1975. Informed consent was obtained from all research participants before sharing in the study.

After confirmation of breast cancer by needle biopsy, patients were offered preoperative assessment by multisclice cut scans of chest and abdomen, bone scan, and tumor markers including CA15-3, and CEA in order to exclude metastatic cases, and then patients underwent either modified radical mastectomy (MRM), or breast conservative surgery (BCS).

After surgery, pathologic assessment of tumor type, size, grade, lymph node (LN) status was done, followed by immunophenotyping to ensure negativity of estrogen and progesterone receptors, and HER2neu. All patients received adjuvant chemotherapy according to standardized guidelines, patients with BCS, > T2 lesions, positive LN, positive surgical margins, and perineural invasion were treated with 3 DCRT with doses ranging from 40 to 66 Gy over 1533 fractions.

TNBC women in our study were followed up monthly by clinical examinations for the first 2 years, then every 36 months for additional 3 years, then yearly later on, MSCT chest and abdomen and tumor marker were done every 3 months in the first 2 years, then every 6 months in the next 3 years, and then yearly later on, bone scan was done when indicated (bone pain, rising ALP, rising serum calcium, etc.), these follows ups continued until disease recurrence or death of patients to determine their disease free survival (DFS).

Peripheral blood samples were collected from all participants in tubes containing heparin. Fresh tumor tissues were also obtained from all patients undergoing surgery for primary breast cancer immediately after surgery. In addition, 30 apparently normal breast tissue samples were obtained from the same patients from areas adjacent to the safety margins (20 tissue samples were areas devoid of any abnormalities; whether inflammatory or benign lesions and subsequently included for comparison, while the other remaining 10 sample tissues were found to have abnormalities subsequently, were excluded). The tumor tissues were mechanically fragmented to prepare single-cell suspension. The cell suspensions were filtered through cell strainers (100 M). The contaminating red blood cells were removed by incubation with lysing solution for 5 minutes at 4C, and the resultant suspension was washed twice with phosphate buffered saline (PBS).

Fluoroisothiocyanate (FITC)-conjugated-Foxp3 (clone PCH101, eBioscience, Invitrogen, Thermofisher, US), phycoerythrin (PE) conjugated-CD25 (clone 2A3, Becton Dickinson (BD) Bioscience, CA, USA) and peridinium-chlorophyll-protein (Per-CP)-conjugated-CD4 (clone SK3, BD Bioscience, CA, USA) were used to detect Tregs. For assessment of Tregs, 1106 cells of the breast tissue sample in 100 L of PBS in one tube and 50 L of blood sample in another tube were incubated with 5 L of CD4, CD25 for 15 minutes at 4C in the dark. Following incubation, red blood cells lysis, washing with PBS then addition of fixation solution to fix the cells and incubation for 10 minutes were done. After that, the cells were washed with PBS, and permeabilization solution (IntraSureTM kit, BD CA, USA) and 5 L of Foxp3 were added and incubated for 20 minutes. The cells were then resuspended in PBS and analyzed by FACSCalibur flow cytometry with Cell Quest software (Becton Dickinson Biosciences, USA). An isotype-matched IgG negative control was used for each sample. Forward and side scatter histogram was used to define the lymphocytes population. Then CD4+cells were gated. Total CD4+CD25+low, CD4+CD25+High and CD4+CD25+HighFoxp3+ T cells were evaluated as percentages of CD4+ cells in both blood and tumor tissue as shown in Figures 1 and 2, respectively.

Figure 1 Gating strategy to identify regulatory T cells in peripheral blood. (A) The lymphocyte population was identified based on the forward and side scatter characteristics and was selected by R1. (B, C) CD4+ cells among the gated lymphocytes were selected by (R2) for further analysis on the basis of the level of CD25 expression. (R3), (R4) and (R5) were drawn to identify CD4+cells with no, low and high CD25 expression, respectively. (D) Dot plot representing FoxP3 expression among the CD4+CD25+high cells to detect Tregs (CD4+CD25+high FoxP3+).

Figure 2 Gating strategy to identify regulatory T cells in tumor tissue. (A) The lymphocyte population was selected by R1. (B, C) CD4+ cells among the gated lymphocytes were selected by (R2) then (R3), (R4) and (R5) were drawn to identify CD4+cells with no, low and high CD25 expression, respectively. (D) Dot plot representing FoxP3 expression among the CD4+CD25+high cells to detect Tregs (CD4+CD25+high FoxP3+). (E, F) Representative dot plots of isotype control.

Numerical data was expressed as mean, median and standard deviation or standard error mean. Qualitative data were presented as number and percentage. The independent sample t-test and One-way ANOVA were used to assess the statistical differences between groups. Paired-t-test was applied to compare the percentages of cells between tumor tissue and peripheral blood. Pearson correlation was used to evaluate the strength of linear association between variables. The disease-free survival (DFS) was calculated using KaplanMeier curve and the receiver operating characteristic (ROC) curve was employed to estimate the accuracy of tumor-infiltrating Tregs in prediction of DFS (3 years). All analysis was performed by SPSS 20.0 software (SPSS, Inc., Chicago, IL, USA).

The patients ages ranged from 28 to 77 years with a mean of 50.410.4. The tumor size in most of the patients was T2 (63.3%). Most of the patients were either N0 (46.7%) or N1 (46.7%). Pathologic examination of breast cancer tissue showed that the majority was infiltrating ductal carcinoma (IDC) (98.3%) of G2 (83.3%). Modified radical mastectomy (MRM) was done in 73.3% of patients, whereas breast conservative surgery (BCS) in 26.7%. Local recurrence was observed in 16.7% of them. The median DFSSE was 322.1 months (95% CI= 2836.1) (Table 1).

As shown in Table 2, while the level of total CD4+ T cells in the peripheral blood was significantly lower in patients than healthy controls, their level in the malignant breast cancer tissue was higher than that in the normal tissue. The mean percentages of CD4+CD25+highT cells and Tregs were higher in TNBC than healthy controls and in malignant tissue than normal tissue. Moreover, the frequencies of tumor-infiltrating CD4+T cells and Tregs were exceeding those in the peripheral blood of cancer patients (p <0.0001).

Table 2 Tregs Levels in Peripheral Blood and Breast Cancer Tissue of Patients with TNBC in Comparison with the Control Group

CD4+CD25+subsets and Tregs have shown no significant associations with most of the tested clinicopathologic characteristics in both breast tissue and peripheral blood. Only tumor-infiltrating Tregs have shown increasing levels with the increase in the tumor size (p<0.0001) and were significantly higher in patients with local recurrences than those without recurrence (p =0.001), (Tables 3 and 4, Figure 3).

Table 3 Relations Between Tumor-Infiltrating Tregs and the Clinicopathologic Characteristics of Patients with TNBC

Table 4 Relations Between Peripheral Blood Tregs and the Clinicopathologic Characteristics of Patients with TNBC

Figure 3 Tumor-infiltrating Tregs showing increasing levels with the increase in the tumor size (A) and in patients with local recurrences (B).

Among all tested tumor-infiltrating CD4+CD25+subsets, only Tregs showed significant inverse relation with DFS (r=0.6, p<0.0001) and direct relation with the level of the peripheral Tregs (r= 0.4, p= 0.046). The predictive accuracy of the levels of tumor-infiltrating Tregs in assessing the DFS period (3 years) was estimated using the ROC curve. Tumor-infiltrating Tregs showed good predictive accuracy [Area under the curve (AUC) =0.90.06, 95% confidence interval (CI): 0.791.00, p=0.001) at the cutoff point 6.91% with a sensitivity of 86% and a specificity of 87%. The mean DFS for TNCB patients with tumor-infiltrating Tregs <6.91% was 47.84 months (95% CI=40.1555.43), while for those with Tregs >6.91% was 27.13 months (95% CI=21.832.4), log rank=17.36, (p<0.001) (Figure 4). Of the 30 TNBC patients, 19 had tumor-infiltrating Tregs level <6.91%, only one of them displayed local recurrence (5%), and 11 had Tregs level >6.91%, six of them showed local recurrences (55%) (p= 0.004).

Figure 4 Tumor-infiltrating Tregs (A) correlation with DFS, (B) correlation with peripheral Tregs, (C) accuracy of prediction of DFS period (3 years) using ROC curve and (D) differences in DFS according to the cutoff value of Tregs.

TNBC is an aggressive type of breast cancer characterized by poor prognosis and lack of targeted therapy.23 TNBC has higher immunogenicity and tends to have higher Tregs infiltration than other subtypes.22,24,25

Inconsistent findings on the influence and prognostic value of Tregs in TNBC has been reported in previous reports.1822

In this study, the mean percentages of Tregs were higher in the peripheral blood of TNBC patients than healthy controls and in tumor tissue than normal breast parenchyma. Consistent with our findings, Wang and Huang reported significantly increased serum levels of CD4+CD25+Foxp3+ Tregs in patients with breast cancer compared with healthy individuals.26 In addition, Plitas et al.16 found increased Tregs in breast cancer tissue as compared to normal breast parenchyma and peripheral blood. Furthermore, breast tumor cells utilize immune regulatory cells such as Treg and different immunosuppressive pathways involving CD39, PD-1 and CTLA-4 molecules in creating disturbed immune environment for them to survive.27

The increased tumor-infiltrating Tregs could be explained by expression of homing of receptors on Tregs that directs the migration of distinct populations to certain tissues28 and regional extension of pre-existing tissue resident Tregs.16 In addition, powerful stimulation of T cell receptors is needed for Treg cell activation, proliferation and inhibitory function.29 Additionally, chemokine signaling, and cell migration were found to be the main single group of genes enriched in tumor-infiltrating Tregs.16

The tumor-infiltrating Tregs showed significant direct relation with the level of Tregs in the peripheral blood. Similarly, Cai et al.30 reported that the level of CD25+Foxp3+ Tregs in circulating CD4+T cells was positively correlated with the level ofCD25+Foxp3+Tregs in CD4+tumor-infiltrating lymphocytes in TNBC.

In contrast to tissue infiltrating Tregs, peripheral blood CD 4+CD 25+Foxp3+ Tregs had no association with any of the clinico-pathological features of TNBC. These findings support the notion that tumor resident Tregs have distinct features that differ from Tregs in peripheral blood.16 On the other hand, the proportions of circulating Tregs were found to be associated with an increased occurrence of breast cancer.26

The association between the Tregs and the clinico-pathological features of TNBC suggested that increasing tumor-infiltrating Tregs was associated with increased tumor size and local recurrence as well as decreased disease-free survival.

Increased frequency of tumor-infiltrating Tregs was observed in the more aggressive BC subset; TNBC and was associated with higher-grade lesions among all studied breast cancer subsets.16 Liu et al.31 observed increased CD4+CD25+Foxp3+ Tregs infiltration in breast cancer tissues and that was associated with high histologic grade, negative estrogen and progesterone receptors status, and overexpression of human epidermal growth factor receptor type 2, along with diminished overall as well as progression-free survivals. On the other hand, Yeong et al.21 reported that high number of tumor-infiltrating CD4+CD25+Foxp3+ Tregs in TNBC patients was linked to a higher tumor grade, lymph node status and better prognosis. Increasing the numbers of tumor-infiltrating Tregs may augment local immunosuppressive abilities, suppressing the anti-tumor immunity, thus enhancing tumor growth and invasion,32 in addition; early breast cancer has an inflammatory milieu characterized by mDC, Treg, and cancer stem cells (CSC) infiltration. The frequencies of Treg, CSC and CD8/Treg ratio were associated with disease progression including lymph node metastasis.33

Moreover, a previous review34 proposed that Tregs have cytotoxic capability that may directly kill effector T cell, which may explain the association between Foxp3+ Tregs infiltration and poor recurrence free survival of breast cancer patients.35

The study findings support the notion that Tregs can directly contribute to tumor progression rather than they accumulate in the tumor tissue as a consequences of other immunologic mechanisms controlling tumor progression.

The current study had a number of limitations, the small number of patients was a crucial limitation that was responsible for absence of several statistical relations, and heterogeneity of patients as the study recruited early and locally advanced diseases.

The findings of the current study support the possibility that TNBC microenvironment conveys specific characteristics on Tregs distinguishing them from those in normal breast tissue or Tregs in peripheral blood, improving the capabilities of tumor-infiltrating Tregs to enhance tumor growth, local recurrence and reduce the DFS. They also suggest the therapeutic value of targeting the function of tumor-infiltrating Tregs in TNBC.

All analyzed data are included within the article.

There is no funding to report.

All authors reported no conflicts of interest for this work.

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4. Joshi NS, Akama-Garren EH, Lu Y, et al. Regulatory T cells in tumor-associated tertiary lymphoid structures suppress anti-tumor T cell responses. Immunity. 2015;43:579590.

5. Pastille E, Bardini K, Fleissner D, et al. Transient ablation of regulatory T cells improves antitumor immunity in colitis-associated colon cancer. Cancer Res. 2014;74:42584269.

6. Ladoire S, Martin F, Ghiringhelli F. Prognostic role of FOXP3+ regulatory T cells infiltrating human carcinomas: the paradox of colorectal cancer. Cancer Immunol Immunother. 2011;60:909918.

7. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557560.

8. Demir L, Yigit S, Ellidokuz H, et al. Predictive and prognostic factors in locally advanced breast cancer: effect of intratumoral FOXP3+ tregs. Clin Exp Metastasis. 2013;30(8):10471062.

9. Takenaka M, Seki N, Toh U, et al. FOXP3 expression in tumor cells and tumor-infiltrating lymphocytes is associated with breast cancer prognosis. Mol Clin Oncol. 2013;1(4):625632.

10. Bauer KR, Brown M, Cress RD, Parise CA, Caggiano V. Descriptive analysis of estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, and HER2-negative invasive breast cancer, the so-called triple-negative phenotype. Cancer. 2007;109(9):17211728. doi:10.1002/cncr.22618

11. Newman LA, Reis-Filho JS, Morrow M, Carey LA, King TA. The 2014 Society of Surgical Oncology Susan G. Komen for the cure symposium: triple-negative breast cancer. Ann Surg Oncol. 2015;22(3):874882.

12. Disis ML, Stanton SE. Triple-negative breast cancer: immune modulation as the new treatment paradigm. Am Soc Clin Oncol Educ Book. 2015;35:2530.

13. Kwa MJ, Adams S. Checkpoint inhibitors in triple-negative breast cancer (TNBC): where to go from here. Cancer. 2018;124:20862103.

14. Denkert C, Liedtke C, Tutt A, Minckwitz GV. Molecular alterations in triple-negative breast cancer-the road to new treatment strategies. Lancet. 2017;389:24302442.

15. Kim S, Lee A, Lim W, et al. Zonal difference and prognostic significance of foxp3 regulatory T cell infiltration in breast cancer. J Breast Cancer. 2014;17:817.

16. Plitas G, Konopacki C, Wu K, et al. Regulatory T cells exhibit distinct features in human breast cancer. Immunity. 2016;45(5):11221134. doi:10.1016/j.immuni.2016.10.032

17. Wang L, Simons DL, Lu X, et al. Connecting blood and intratumoral Treg cell activity in predicting future relapse in breast cancer. Nat Immunol. 2019;20:12201230.

18. Mahmoud SM, Paish EC, Powe DG, et al. An evaluation of the clinical significance of FOXP3+ infiltrating cells in human breast cancer. Breast Cancer Res Treat. 2011;127:99108.

19. Lee S, Cho EY, Park YH, Ahn JS, Y-h IM. Prognostic impact of FOXP3 expression in triple negative breast cancer. Acta Oncol. 2013;52:7381.

20. West NR, Kost SE, Martin SD, et al. Tumour-infiltrating FOXP3(+) lymphocytes are associated with cytotoxic immune responses and good clinical outcome in estrogen receptor-negative breast cancer. Br J Cancer. 2013;108:155162.

21. Yeong J, Thike AA, Lim JCT, et al. Higher densities of Foxp3+ regulatory T cells are associated with better prognosis in triple-negative breast cancer. Breast Cancer Res Treat. 2017;163:2135.

22. Zhang L, Wang XI, Ding J, et al. The predictive and prognostic value of Foxp3+/CD25+ regulatory T cells and PD-L1 expression in triple negative breast cancer. Ann Diagn Pathol. 2019;40:143151.

23. Foulkes WD, Smith IE, Reis-Filho JS. Triple-negative breast cancer. N Engl J Med. 2010;363:19381948.

24. Denkert C, Von Minckwitz G, Darb-Esfahani S, et al. Tumor-infiltrating lymphocytes and prognosis in different subtypes of breast cancer: a pooled analysis of 3771 patients treated with neoadjuvant therapy. Lancet Oncol. 2018;19:4050.

25. Kim ST, Jeong H, Woo OH, et al. Tumor-infiltrating lymphocytes, tumor characteristics, and recurrence in patients with early breast cancer. Am J Clin Oncol. 2013;36:224231.

26. Wang R, Huang K. CCL11 increases the proportion of CD4+CD25+Foxp3+ Tregs and the production of IL-2 and TGF- by CD4+ T cells via the STAT5 signaling pathway. Mol Med Rep. 2020;21.6:25222532.

27. Syed Khaja AS, Toor SM, El Salhat H, et al. Preferential accumulation of regulatory T cells with highly immunosuppressive characteristics in breast tumor microenvironment. Oncotarget. 2017;8:3315933171.

28. Huehn J, Siegmund K, Lehmann JC, et al. Developmental stage, phenotype, and migration distinguish naive- and effector/memory-like CD4+ regulatory T cells. J Exp Med. 2004;199:303313.

29. Levine AG, Arvey A, Jin W, Rudensky AY. Continuous requirement for the TCR in regulatory T cell function. Nat Immunol. 2014;15:10701078.

30. Cai B, Ma P, Ding P, Sun D-W, Bu Q, Zhang J. Composition and plasticity of triple-negative breast carcinoma-infiltrating regulatory T cells. APMIS. 2020;128:260269.

31. Liu F, Lang R, Zhao J, et al. CD 8+ cytotoxic T cell and FOXP3+ regulatoryT cell infiltration in relation to breast cancer survival and molecular subtypes. Breast Cancer Res Treat. 2011;130:645655.

32. Xue D, Xia T, Wang J, Chong M, Wang S, Zhang C. Role of regulatory T cells and CD8+ T lymphocytes in the dissemination of circulating tumor cells in primary invasive breast cancer. Oncol Lett. 2018;16(3):30453053. doi:10.3892/ol.2018.8993

33. Solis-Castillo LA, Garcia-Romo GS, Diaz-Rodriguez A, et al. Tumor-infiltrating regulatory T cells, CD8/Treg ratio, and cancer stem cells are correlated with lymph node metastasis in patients with early breast cancer. Breast Cancer. 2020;27(5):837849.

34. Lu L, Barbi J, Pan F. The regulation of immune tolerance by FOXP3. Nat Rev Immunol. 2017;17(11):703717. doi:10.1038/nri.2017.75

35. Zhou Y, Shao N, Aierken N, et al. Prognostic value of tumor-infiltrating Foxp3+ regulatory T cells in patients with breast cancer: a meta-analysis. J Cancer. 2017;8(19):40984105. doi:10.7150/jca.21030

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Targeted Therapeutics Market: Increase in Incidence of Cancer to Drive Global Market – BioSpace

Wednesday, August 4th, 2021

Targeted Therapeutics Market: Introduction

According to the report, the global targeted therapeutics market was valued over US$ 67.8 Bn in 2020 and is projected to expand at a moderate CAGR during the forecast period. Targeted therapies are drugs or other substances that block the growth of unwanted cells and pathogens by interfering with specific molecules ("molecular targets") involved in the growth, progression, and spread of disease. Targeted therapies are sometimes called molecularly targeted drugs, molecularly targeted therapies, precision medicines, etc. The emerging field of target therapeutics offers varied potential treatments. Targeted therapies offer the possibility of finding a cure for diseases with significant unmet needs, including orphan diseases and diseases having a high burden globally. Targeted therapy is widely used in the treatment of different forms of cancer such as renal, breast, lung, colorectal, and leukemia, and other diseases such as multiple sclerosis and wet age-related macular degeneration. The global targeted therapeutics market is driven by rise in prevalence of cancer across the globe, increase in global geriatric population, and surge in product approvals.

North America dominated the global targeted therapeutics market in 2020, followed by Europe, and the trend is anticipated to continue during the forecast period. North Americas dominance can be ascribed to high prevalence and increase in incidence rates of cancer, well-established healthcare industry, and rise in adoption of targeted therapeutics monoclonal antibodies in the region.

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Increase in Incidence of Cancer to Drive Global Market

The increase in incidence of cancers such as breast, lung, and leukemia has fueled the demand for targeted therapeutics. Cancer is a leading cause of death across the globe. It is more prevalent in developed and emerging markets. According to the International Agency for Research on Cancer, one in five persons develops cancer during his or her lifetime, and one in eight men, and one in 11 women succumbs to the disease. Tobacco smoking, pollution, changing lifestyle, and transmission of carcinogens and carcinogenic infections such as HPV, H. Pylori, and HCV have increased the incidence rate of cancer across the globe.

According to the International Agency for Research on Cancer (IARC), an estimated 19.3 million new cancer cases were recorded in 2020 and nearly 10 million individuals died from cancer-related causes. The global burden is expected to increase to 27.5 million new cancer cases and 16.3 million cancer deaths by 2040, primarily due to increase and aging of the population. Targeted therapy has proven to offer promising therapeutic outcomes across a broad range of cancers and is increasingly used in healthcare facilities. Hence, high prevalence and increase in incidence rate of cancer across the globe is a major factor projected to boost the growth of the global targeted therapeutics market during the forecast period.

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Targeted Therapeutics Market: Prominent Regions

In terms of region, the global targeted therapeutics market has been segmented into North America, Europe, Asia Pacific, Latin America, and Middle East & Africa. North America dominated the global targeted therapeutics market in 2020, followed by Europe. The U.S. dominated the targeted therapeutics market in North America in 2020, due to the presence of key players, adoption of targeted therapeutics monoclonal antibodies, and adequate reimbursement policies. This, in turn, is expected to boost the market in the region. The targeted therapeutics market in Asia Pacific is likely to expand at a high CAGR from 2021 to 2031. The growth of the market in the region can be attributed to the adoption of new targeted therapeutic drugs, increase in awareness about various oncological disorders, rise in healthcare expenditure, and high penetration of research activities across the region.

Strategic Acquisition and Collaborations by Key Players to Fuel Global Market

The global targeted therapeutics market is consolidated in terms of number of players. The market is dominated by key players with strong geographic presence. Key players operating in the global targeted therapeutics market include Amgen, Inc., F. Hoffmann-La Roche Ltd., AstraZeneca, Bristol-Myers Squibb Company, Bayer AG, Merck & Co., Inc., Novartis AG, and Pfizer, Inc. In March 2021, Amgen and Five Prime Therapeutics, a clinical-stage biotechnology company focused on developing immuno-oncology and targeted cancer therapies, announced an agreement under which Amgen will acquire Five Prime Therapeutics for US$ 38.00 per share in cash, representing an equity value of approximately US$ 1.9 Bn. This acquisition adds Five Prime's innovative pipeline to Amgen's leading oncology portfolio.

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In October 2020, Bristol-Myers Squibb and MyoKardia, Inc. announced a definitive merger agreement, under which Bristol-Myers Squibb will acquire MyoKardia for US$ 13.1 Bn, or US$ 225.00 per share in cash. The transaction was unanimously approved by the Boards of Directors of Bristol-Myers Squibb and MyoKardia and is anticipated to close during the fourth quarter of 2020. MyoKardia is a clinical-stage biopharmaceutical company discovering and developing targeted therapies for the treatment of serious cardiovascular diseases.

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Novel CAR-T Cell Therapy Produces Early and Deep Responses in Certain Patients with Multiple Myeloma – Curetoday.com

Monday, June 7th, 2021

Treatment with a single infusion of the novel CAR-T cell therapy ciltacabtagene autoleucel (cilta-cel) induced early and deep responses in a group of patients with relapsed/refractory multiple myeloma, according to results of a phase 2 study.

The findings, which were presented during the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting, demonstrated that a single-infusion of the CAR-T cell therapy resulted in an overall response rate (which includes a partial response or better) of 95% with a stringent complete response rate of 75%, and a very good partial response rate or better of 85%.

Cilta-cel, formerly JNJ-68284528, is a second-generation CAR-T cell therapy with two BCMA-targeting, single-domain antibodies designed to confer avidity. Previous data that were published from the phase 1b/2 CARTITUDE-1 trial demonstrated that single infusion of cilta-cel was associated with deep and durable response among heavily pretreated patients with relapsed/refractory disease.

Measuring minimal residual disease negativity, or the small number of cancer cells in the body after cancer treatment, was the main goal of the study. Other goals included assessing overall response rate, duration of response, as well as time and duration of minimal residual disease negativity and incidence and severity of side effects.

The study comprised 20 patients (median age, 60 years; 65% men) who were either refractory to treatment with the chemotherapy lenalidomide or relapsed after one to three prior lines of treatment. One of the patients was treated in an outpatient setting.

Twelve of the patients had received fewer than three lines of prior therapy, and the remaining individuals received three prior lines of therapy.

All the patients had been previously treated with a proteasome inhibitor, an immunomodulatory drug and the steroid dexamethasone. Almost all (95%) of the patients were exposed to alkylating agents, and 65% received treatment with Darzalex (daratumumab).

As of the data cutoff of January 2021, four evaluable patients achieved minimal residual disease negativity.

Blood-related side effects that occurred in 20% or more of the patients included neutropenia (95%), thrombocytopenia (80%), anemia (65%), lymphopenia (60%) and leukopenia (55%). Moreover, cytokine release syndrome (which involves the cytokines overstimulating the immune system so that it attacks healthy organs) occurred in 85% of patients, of which 10% were considered serious or severe.

The safety profile was manageable, including in the one patient that was treated in the outpatient setting, said study author Dr. Mounzer E. Agha, director of the Mario Lemieux Center for Blood Cancers and clinical director of Hematopoietic Stem Cell Transplantation at the UPMC Hillman Cancer Center in Pittsburgh, during a recorded presentation of the data. There were no cases of movement and neurocognitive adverse effects.

Agha noted that one death occurred 100 days after the infusion of cilta-cel due to COVID-19 infection and was assessed as treatment-related by the investigators.

Early and deep responses were observed with a single infusion of cilta-cel in lenalidomide refractory patients with multiple myeloma, who received one-to three prior lines of therapy, he concluded.

The CAR-T cell therapy is being evaluated in other cohorts of the CARTITUDE-2 in earlier line settings, as well as in the phase 3 CARTITUDE-4 study in patients with one to three prior lines of therapy.

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Autophagy suppresses the formation of hepatocyte-derived cancer-initiating ductular progenitor cells in the liver – Science Advances

Monday, June 7th, 2021

Abstract

Hepatocellular carcinoma (HCC) is driven by repeated rounds of inflammation, leading to fibrosis, cirrhosis, and, ultimately, cancer. A critical step in HCC formation is the transition from fibrosis to cirrhosis, which is associated with a change in the liver parenchyma called ductular reaction. Here, we report a genetically engineered mouse model of HCC driven by loss of macroautophagy and hemizygosity of phosphatase and tensin homolog, which develops HCC involving ductular reaction. We show through lineage tracing that, following loss of autophagy, mature hepatocytes dedifferentiate into biliary-like liver progenitor cells (ductular reaction), giving rise to HCC. Furthermore, this change is associated with deregulation of yes-associated protein and transcriptional coactivator with PDZ-binding motif transcription factors, and the combined, but not individual, deletion of these factors completely reverses the dedifferentiation capacity and tumorigenesis. These findings therefore increase our understanding of the cell of origin of HCC development and highlight new potential points for therapeutic intervention.

Liver cancer is predicted to be the third leading cause of cancer-related deaths by 2030 (1). Hepatocellular carcinoma (HCC) is the major form of liver cancer and develops in patients with chronic liver conditions, including viral hepatitis, as well as alcoholic and nonalcoholic fatty liver disease (2). Generally, chronic liver injuries lead to inflammation, stromal activation, regeneration, fibrosis, and cirrhosis before progression to HCC (3).

Autophagy (strictly macroautophagy but hereafter referred to simply as autophagy) is a catabolic membrane-trafficking process that serves to deliver cellular constituents including misfolded proteins and damaged organelles to lysosomes for degradation (4). There is now clear evidence that autophagy is important in various diseases including neurodegenerative diseases, chronic liver diseases, and cancer (57). The role of autophagy in cancer, however, is complex and not fully understood, with seemingly opposing roles described in different tumors and at different stages of tumor evolution (812). In the early stages of malignant transformation, autophagy removes damaged mitochondria responsible for the production of reactive oxygen species (ROS) (13) and prevents genomic instability (14), highlighting its role in preventing tumor initiation. Conversely, in established tumors, autophagy not only can adopt a protumorigenic role, for example, by promoting survival under hypoxic conditions (15) and supporting invasion and metastasis (16), but also can have a tumor-suppressive role by preventing the proliferative outgrowth of disseminated tumor cells from dormant states at metastatic sites (1719).

In the liver, autophagy has primarily been described as tumor suppressive (11). Liver-specific deletion of the central autophagy-related protein 5 (ATG5) or ATG7 in mice leads to the formation of liver steatosis, inflammation, ROS production, oval cell formation, fibrosis, hepatomegaly, and the development of HCCs (11, 20). In many cases, loss of autophagy causes accumulation of the autophagy adapter protein p62 (Sqstm1), and this can influence antioxidant responses by affecting the axis between Kelch-like ECH-associated protein 1 (KEAP1) and nuclear factor (erythroid-derived 2)-like 2 (NRF2) (21). In autophagy-deficient livers, studies have shown that p62 accumulation activates the NRF2 signaling pathway to induce metabolic reprogramming, hepatomegaly, and tumorigenesis (22, 23).

The liver is a plastic organ in which cell fate can change upon injuries to regenerate liver function loss. Hepatocytes and cholangiocytes, epithelial cells that form the liver parenchyma and the bile duct, respectively, can transdifferentiate into one another to reestablish bile duct or liver parenchyma functions (24, 25), with hepatocytes being the primary source of liver regeneration upon injury. Following chronic injury, ductular cells develop in the liver parenchyma when hepatocyte or cholangiocyte function is severely impaired, a process called ductular reaction (26). The ductular reaction is a repair mechanism for generating new hepatocytes or cholangiocytes, depending on which liver cells are injured (27). However, the origin of the ductular reaction and its role in liver tumorigenesis are controversial with reports indicating that ductular cells can arise from cholangiocyte expansion (28, 29) or through hepatocyte dedifferentiation (30, 31) and reports concluding that the ductular reaction is involved in forming HCC (32, 33), while other studies report the opposite (34, 35). Autophagy-deficient livers undergo a ductular reaction (36), and we considered this as an excellent system in which to explore its origin and the role, this phenomenon plays in tumorigenesis.

In this study, we report that autophagy prevents hepatocyte dedifferentiation into ductular liver progenitor cells (LPCs). This ductular LPC population affects HCC formation in autophagy-deficient livers. Mechanistically, we show that autophagy deletion activates both yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ) in hepatocytes, which are connected to the ductular reaction leading, ultimately, to tumorigenesis. We show that YAP/TAZ coexpression is required to trigger the ductular reaction and tumorigenesis in autophagy-deficient livers.

Autophagy loss in the murine liver results in hepatomegaly, inflammation, and fibrosis leading to the formation of liver HCCs at 12 months of age (20). Phosphatase and tensin homolog (PTEN) expression is lost in approximately half of human liver cancers, and hepatic Pten-deficient mice develop HCC at 74 weeks (37). To accelerate the autophagy phenotype in the liver, we used the liver-specific promoter Albumin-Cre to selectively delete either Atg7flox/flox or Atg5flox/flox in the liver in combination with either heterozygous Pten+/flox (Alb-Cre+; Atg7fl/fl; Pten+/fl or Alb-Cre+; Atg5fl/fl; Pten+/fl) or homozygous Ptenflox/flox (Alb-Cre+; Atg7fl/fl; Ptenfl/fl or Alb-Cre+; Atg5fl/fl; Ptenfl/fl). The reduced gene dosage of Pten in an autophagy-deficient background significantly decreased mouse life span similarly in males and females (Fig. 1A and fig. S1A). At end point, while Alb-Cre+; Atg7fl/fl; Pten+/fl and Alb-Cre+; Atg5fl/fl; Pten+/fl mice developed liver HCCs (Fig. 1B and fig. S1B), Alb-Cre+; Atg7fl/fl; Ptenfl/fl and Alb-Cre+; Atg5fl/fl; Ptenfl/fl mice were culled because of extensive hepatomegaly and did not form tumors. To evaluate whether the decreased survival of Alb-Cre+; Atg7fl/fl; Pten+/fl and Alb-Cre+; Atg5fl/fl; Pten+/fl mice was a result of an early tumor onset, we compared the tumorigenesis of Pten+/+ and Pten+/fl mice with an autophagy-deficient background at 140 days. This revealed that heterozygous deletion of Pten significantly accelerated tumorigenesis in autophagy-deficient livers (Fig. 1, B and C, and fig. S1, B and C). Although conditional double knockout mice did not develop HCC at end point (4 to 5 weeks), they presented with excessive liver overgrowth. When we compared the liver size in 4- to 5-week-old mice, we observed that PTEN loss significantly increased the hepatomegaly of autophagy-deficient livers (Fig. 1D and fig. S1D).

(A) Kaplan-Meier analysis comparing overall survival of mice between males and females (left), males only (middle), or females only (right) (n = 6 males and n = 7 females per group). Data were analyzed by log-rank Mantel Cox test (***P < 0.001 and ****P < 0.0001). (B) Macroscopic pictures from a representative Alb-Cre+; Atg7fl/fl (Alb-Cre+; 7fl/fl) (top) and Alb-Cre+; Atg7fl/fl; Pten+/fl (Alb-Cre+; 7fl/fl; P+/fl) (bottom) liver in 140-day-old mice. (C) Quantification of tumor numbers in Alb-Cre+; 7fl/fl and Alb-Cre+; 7fl/fl; P+/fl at 140 days. Data are means SD of six mice per group and were analyzed by Mann-Whitney test (**P < 0.01). (D) Liver-to-body weight ratio in 4- to 5-week-old mice. Data are means SD of five mice per group and were analyzed by one-way analysis of variance (ANOVA) with Tukey correction for multiple comparison tests (***P < 0.001 and ****P < 0.0001). Please note that data are the same controls for WT and Alb-Cre+; Pfl/fl mice as shown in fig. S1D. (E) Hematoxylin and eosin (H&E) staining and immunohistochemical (IHC) analysis of neutrophil recruitment (Ly6G), hepatic stellate cell activation (-SMA), and collagen deposition (Sirius Red) on paraffin-embedded sections of livers from 4- to 5-week-old mice. Red arrowhead represents ductular structures. Scale bars, 50 m. Left: Representative staining. Right: Quantifications. Data are means SD of four or five mice per group and were analyzed by one-way ANOVA with Tukey correction for multiple comparison tests (*P < 0.05, **P < 0.01, and ****P < 0.0001). All data points are the mean from five pictures per mouse. FoV, field of vision. Please note that data are the same controls for WT and Alb-Cre+; Pfl/fl mice as shown in fig. S1 (E to G).

Next, we assessed whether PTEN loss promotes early development of a tumor-permissive microenvironment in 4- to 5-week-old autophagy-deficient livers by looking for markers of inflammation (38) and fibrosis. This showed that both hemizygous and homozygous Pten deletion significantly increased the recruitment of Ly6G+ neutrophils (Fig. 1E and fig. S1E) and activated smooth muscle actin+ (-SMA+) expressing hepatic stellate cells (Fig. 1E and fig. S1F) in the parenchyma of autophagy-deficient livers, concomitant with a significantly enhanced collagen deposition (Fig. 1E and fig. S1G). PTEN deficiency in 4- to 5-week-old autophagy-competent livers (Alb-Cre+; Pfl/fl) did not result in hepatomegaly, inflammation, hepatic stellate cell activation, or fibrosis (Fig. 1, D and E, and fig. S1, D to G). Together, our data suggest that PTEN loss accelerates the early formation of a tumor-prone microenvironment (inflammation, hepatic stellate cell activation, and fibrosis) and tumorigenesis in autophagy-deficient livers.

Following histological examination, we observed an accumulation of atypical ductular structures in the parenchyma of conditional double knockout livers (Fig. 1E), called ductular reaction. Under normal conditions, the liver has ductular structures, called the bile duct, that are formed out of cholangiocytes (Fig. 1E). The ductular reaction is a regeneration program that occurs in the liver following chronic liver injury that impairs the hepatocyte capacity to regenerate the liver (27). To evaluate whether hepatocytes are injured upon loss of autophagy, we first assessed the expression of enzymes for liver damage in the serum of 4- to 5-week-old livers. All autophagy-deficient livers had a significant increase in alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and -glutamyl transferase (GGT) levels in comparison to wild-type (WT) (Alb-Cre+; Atg7+/+ or Atg5+/+; Pten+/+) mice (Fig. 2A and fig. S2, A to D). In addition, we determined whether hepatocytes were dying in our model by looking for cells positive for cleaved caspase 3 (CC3), a marker of apoptosis. We noted a significant augmentation of CC3+ hepatocytes in 4- to 5-week-old autophagy-deficient livers when compared to WT livers (Fig. 2, B and C, and fig. S2E), indicating that autophagy prevents hepatocyte cell death. Next, we observed a significant accumulation of the ductular markers sex-determining region Y-box 9 (SOX9), cytokeratin-19 (CK19), and panCK in Alb-Cre+; Atg7fl/fl; Ptenfl/fl or Alb-Cre+; Atg5fl/fl; Ptenfl/fl livers in comparison to Alb-Cre+; Atg7fl/fl; or Alb-Cre+; Atg5fl/fl single knockout counterparts (Fig. 2, B and D to F, and fig. S2, F to H), confirming that the ductular reaction is occurring in our accelerated model.

(A) Serum analysis of the liver damage markers ALP, ALT, AST, and GGT levels in 4- to 5-week-old mice. Data are means SD of three to five mice per group and were analyzed by one-way ANOVA with Dunnett correction for multiple comparison tests (*P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001). Please note that data are the same controls for WT and Alb-Cre+; Pfl/fl mice as shown in fig. S2 (A to D). (B) IHC analysis of cell death (CC3) and the duct markers SOX9, CK19, and panCK on paraffin-embedded sections of livers from 4- to 5-week-old mice. Scale bars, 50 m. (C to F) Quantification of CC3 (C), SOX9 (D), CK19 (E), and panCK (F) from (B). Data are means SD of five mice per group and were analyzed by one-way ANOVA with Tukey correction for multiple comparison tests (**P < 0.01, ***P < 0.001, and ****P < 0.0001). All data points are the mean from five pictures per mouse. Please note data are the same controls for WT and Alb-Cre+; Pfl/fl mice as shown in fig. S2 (E to H).

As the ductular reaction is a regenerative process for the de novo generation of hepatocytes upon chronic liver injury (2831), we hypothesized that ductular cells in our model are LPCs forming to repair injured hepatocytes. To test this, we first looked at the expression of liver stem cell markers in Atg- and Pten-deficient livers and found increased levels of epithelial cell adhesion molecule (EpCAM), CD133, and CD44 within ductular cells (Fig. 3A and fig. S3, A to C) of autophagy-deficient livers. The expression of the stem cell makers was autophagy dependent but PTEN independent (Fig. 3A and fig. S3, A to C), although Pten deletion appears to exacerbate the phenotype caused by Atg5 or Atg7 deletion. In addition, we assessed the expression of a-fetoprotein (AFP), a fetal marker reexpressed during HCC and liver stem cell regeneration (39). We observed a significant increase in Afp mRNA levels (Fig. 3B and fig. S3D) and AFP protein level in the serum (Fig. 3C and fig. S3E) of autophagy-deficient mice when compared to WT counterparts.

(A) IHC analysis of the liver stem cell markers EpCAM, CD133, and CD44 on paraffin-embedded sections of livers from 4- to 5-week old mice. Left: Representative staining. Scale bars, 50 m. Right: Quantifications. Data are means SD of five mice per group and were analyzed by one-way ANOVA with Tukey correction for multiple comparison tests (*P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001). All data points are the mean were from five pictures per mouse. Please note that data are the same controls for WT and Alb-Cre+; Pfl/fl mice as shown in fig. S3 (A to C). (B) Quantitative reverse transcription polymerase chain reaction (RT-PCR) analysis of Afp mRNA isolated from 4- to 5-week-old livers. 18S was used as the internal amplification control. Data are means SD of three mice per group and were analyzed by one-way ANOVA with Tukey correction for multiple comparison tests (**P < 0.01 and ****P < 0.0001). All data points are the mean from technical triplicates. CT, cycle threshold. (C) Enzyme-linked immunosorbent assay (ELISA) analysis of AFP from the serum of 4- to 5-week-old mice. Data are means SD of three mice per group and were analyzed by one-way ANOVA with Dunnett correction for multiple comparison tests (****P < 0.0001). All data points are the mean from technical triplicates. (D) Schematic representation of the lineage tracing experiment for ductular origin. Eight-week-old Atg7flox/flox; Ptenflox/flox; Rosa26mTmG/mTmG mice were infected with hepatocyte-specific Cre-expressing adenovirus (AAV8-TBG-Cre) and aged for 40 days. Rosa26mTmG, Rosa26LoxP-Tomato-Stop-LoxP-GFP. (E) Representative IHC analysis of GFP, tdTomato and SOX9 staining on paraffin-embedded serial sections of liver from Atg7flox/flox; Ptenflox/flox; Rosa26mTmG/mTmG mice 40 days after infection with AAV8-Cre or the vehicle control (AAV8-null). Scale bars, 20 m.

We were interested to know how the ductular-reactive cells were forming within the liver parenchyma. It has been established that ductular-reactive cells can originate from dedifferentiated hepatocytes in the parenchyma (30, 31) or from the activation and the proliferation of hepatic progenitor cells from the canal of Hering to regenerate the liver parenchyma when the regenerative function of hepatocytes is impaired (29). To determine the cell of origin for the ductular-reactive cells in our model, we crossed Alb-Cre; Atg7fl/fl; Ptenfl/fl or Alb-Cre; Atg5fl/fl; Ptenfl/fl mice with the double reporter Rosa26LoxP-Tomato-LoxP-GFP (Rosa26mTmG) and caused Cre-mediated recombination only in hepatocytes using the AAV8-TBG-Cre adeno-associated virus (AAV) (Fig. 3D and fig. S3F), where the Cre recombinase is expressed under the hepatocyte-specific thyroxine binding globulin (TBG) promoter (29). Following recombination, green fluorescent protein (GFP) will only be expressed in hepatocytes at the membrane, while non-recombined cells and unaffected tissues will remain Tomato+. Using this approach, we found that SOX9+ ductular-reactive cells expressed GFP at the membrane 40 days following AAV8-Cre infection in autophagy-deficient livers (Fig. 3E), confirming the hepatocyte origin of the ducts (fig. S3G). Together, our data establish that autophagy prevents dedifferentiation of hepatocytes into ductular LPCs.

ATG7-deficient livers develop HCCs at around 1 year of age (20). Since the ductular reaction is an early event following autophagy inhibition to regenerate the liver and ductular reactive cells express stem cell markers (Fig. 3A and fig. S3, A to C) found in cancer stem cells from HCC (40), we hypothesized that ductular LPCs form HCCs in autophagy-deficient livers. To test this, we first assessed whether autophagy-deficient HCCs retain the expression of the duct marker SOX9, and we noted the presence of two distinct hepatocyte populations (SOX9+ and SOX9) in the normal region surrounding liver HCCs, with SOX9+ hepatocytes found adjacent to ductular structures (Fig. 4A). We found that hepatocytes forming HCCs preserved the ductular marker SOX9 (Fig. 4A). To further evaluate the role of the ductular reaction in tumorigenesis, we infected Alb-Cre+; Atg7fl/fl; Pten+/fl and WT mice with the AAV8-TBG-GFP adenovirus at 6 weeks of age to label hepatocytes with GFP (Fig. 4B). At this age, the ductular reaction is occurring in autophagy-deficient livers, which allows us to distinguish and discriminate between resident hepatocytes (GFP+) and ductular reactive cells (GFP) following AAV8-TBG-GFP infection to trace their role in tumorigenesis. First, we confirmed that at 7 days after AAV8-TBG-GFP infection, SOX9+ LPCs were GFP, while hepatocytes (SOX9) expressed GFP in autophagy-deficient livers (Fig. 4C), confirming that ductular LPCs are not expressing GFP following AAV8-TBG-GFP infection. We then assessed the expression of GFP in autophagy-deficient HCCs 100 days after AAV8-TBG-GFP infection. This revealed that tumors forming in Alb-Cre+; Atg7fl/fl; Pten+/fl livers expressed no GFP in comparison to the surrounding normal hepatocytes, which retained GFP expression (Fig. 4D), highlighting that the ductular cells initiate tumorigenesis in autophagy-deficient livers. We also found that high expression of SOX9 correlates with a decreased survival in human HCCs (Fig. 4E). Together, our data establish that ductular LPCs, formed early upon autophagy deficiency, ultimately lead to the generation of HCCs in autophagy-deficient livers.

(A) IHC analysis of the duct marker SOX9 on Alb-Cre+; Atg7fl/fl; Pten+/fl livers from 140-day-old mice. The red dashed line separates tumor (T) from normal tissue (NT) in the liver. Red and green rectangles outline SOX9+ and SOX9 region in normal tissue, respectively. Scale bar, 100 m. (B) Schematic representation of lineage tracing for tumor origin. Six-week-old Alb-Cre+; Atg7fl/fl; Pten+/fl and WT mice were infected with hepatocyte-specific GFP-expressing adenovirus (AAV8-TBG-GFP) and aged for either 7 or 100 days. (C) Immunofluorescence (IF) analysis of GFP and SOX9 on Alb-Cre+; Atg7fl/fl; Pten+/fl and WT livers 7 days following AAV8-TBG-GFP infection. 4,6-diamidino-2-phenylindole (DAPI) stains nuclei. Scale bars, 75 m. (D) IHC analysis of GFP on Alb-Cre+; Atg7fl/fl; Pten+/fl or WT livers 100 days following AAV8-TBG-GFP infection. The red dashed line separates tumor from normal tissue in the liver. Scale bars, 100 m. (E) Kaplan-Meier analysis comparing overall survival between high and low SOX9 mRNA expression in human liver cancer data (The Cancer Genome Atlas Liver Hepatocellular Carcinoma). Each group represents 20th lower and 20th higher percentile (n = 72 per group).

Blocking the formation of the ductular reaction would be beneficial in preventing human HCC (41). YAP and TAZ are transcriptional coactivators essential in controlling organ size (42), hepatocyte dedifferentiation (31), stemness (43), and liver tumorigenesis (44, 45). The Hippo pathway regulates the activation of YAP and TAZ, and phosphorylation of both coactivators primes them for degradation. As our autophagy-deficient liver model develops severe hepatomegaly (Fig. 1D and fig. S1D), dedifferentiates hepatocytes into ductular LPCs (Figs. 2 and 3 and figs. S2 and S3), and induces tumorigenesis, we next investigated whether YAP and TAZ are active in early-stage autophagy-deficient livers exhibiting ductular reaction. First, we compared the protein levels of the inactive forms of YAP and TAZ (phosphorylated YAP and phosphorylated TAZ), with the levels of total YAP and total TAZ (active forms) in 4- to 5-week-old livers (Fig. 5A). We noticed that the ratio of phosphorylated YAP and phosphorylated TAZ was reduced in autophagy-deficient livers in comparison to WT counterparts (Fig. 5A), highlighting that unphosphorylated YAP and unphosphorylated TAZ accumulate in autophagy-deficient livers undergoing ductular reaction.

(A) Immunoblotting analysis of phosphorylated YAP (p-YAP), total YAP, phosphorylated TAZ (p-TAZ), total TAZ, CTGF, ATG7, and PTEN from 4- to 5-week-old total liver lysates. Extracellular signalregulated kinase 2 (ERK2) was used as the loading control. (B) Quantitative RT-PCR analysis of the YAP/TAZ targets Ctgf, Cyr61, and Areg mRNA isolated from 4- to 5-week-old livers. 18S was used as the internal amplification control. Data are means SD of three mice per group and were analyzed by one-way ANOVA with Dunnett correction for multiple comparison tests (*P < 0.05, **P < 0.01, and ***P < 0.001). All data points are the mean from technical triplicates. (C) IHC analysis of YAP and TAZ on paraffin-embedded sections of livers from 4- to 5-week-old mice. Scale bars, 50 m.

To evaluate whether YAP and TAZ are functionally active in autophagy-deficient livers, we tested for the expression of YAP/TAZ transcriptional targets in 4- to 5-week-old livers. We found that mRNA levels of connective tissue growth factor (Ctgf), amphiregulin (Areg), and cysteine-rich angiogenic inducer 61 (Cyr61), three YAP/TAZ target genes (46, 47), were all significantly up-regulated in autophagy-deficient livers (Fig. 5B and fig. S4A). At the protein level, CTGF was increased in total liver lysates of all autophagy-deficient conditions (Fig. 5A). Next, we assessed the localization of YAP and TAZ in 4- to 5-week-old autophagy-deficient livers and observed that both YAP and TAZ strongly accumulated in the ductular cells, whereas YAP and TAZ were found in the bile duct and the canal of Hering of WT counterparts (Fig. 5C and fig. S4B). Collectively, our data therefore indicate that autophagy loss in hepatocytes triggers a YAP/TAZ signature within the ductular LPC population.

YAP is turned over not only by the proteasome (48, 49), but also by autophagy as shown in recent reports (20, 50). As TAZ is a YAP homolog, we next wondered whether TAZ accumulation and activation in our autophagy-deficient livers were due to blockage of autophagy-mediated degradation of TAZ. To test more directly whether TAZ is degraded by autophagy, we first deleted ATG7 or ATG5 expression in the liver cancer cell lines HLE and Huh7 using the CRISPR-Cas9mediated gene disruption system. Next, we treated each cell line with Earles balanced salt solution (EBSS), to induce starvation-mediated autophagy, in combination with or without 200 nM bafilomycin A1 (Baf) for 2 hours to prevent lysosomal degradation of autophagosomes. We checked for the efficient disruption of ATG7 or ATG5 expression following lenti-CRISPR infection in HLE (fig. S5A) and Huh7 (fig. S5B), and we analyzed the conversion of microtubule-associated protein 1A/1B-light chain 3 (LC3)I (diffuse form in the cytosol) into LC3-II (lipidated form attached to autophagosomes), to confirm loss of autophagy. Examination of TAZ revealed that its levels did not change upon starvation-induced autophagy (EBSS), blockage of lysosomal autophagy degradation [Dulbeccos modified Eagles medium (DMEM) + Baf and EBSS + Baf], or disruption of ATG7/ATG5 (ATG7CRISPR/ATG5CRISPR) in HLE and Huh7 cells (fig. S5, A and B). Unexpectedly, we also observed that not only YAP levels accumulated under EBSS only and EBSS and Baf conditions but also this occurred in ATG7CRISPR/ATG5CRISPR cells, indicating that this was an autophagy-independent effect. Together, our data indicate that TAZ and YAP are not directly turned over by autophagy in liver cells and that the accumulation of YAP and TAZ in autophagy-deficient livers is not the result of the inhibition of the autophagy degradation pathway but instead is due to the expansion of ductular cells in vivo, which are known to express YAP and TAZ (Fig. 5 and fig. S4) (51).

Deletion of YAP partially rescued hepatomegaly, fibrosis, and tumorigenesis induced by autophagy blockage in the liver (20). As a YAP homolog, TAZ can compensate YAP activity if the latter is lost (52). Since we observed in our model that YAP and TAZ are activated within the ductular LPC population, we hypothesized that deleting both YAP and TAZ might prevent the early ductular reaction and subsequent HCC formation in autophagy-deficient livers. First, we evaluated whether TAZ has a role in the phenotype of autophagy-deficient livers. To test this, we crossed Wwtr1flox/flox (encoding TAZ) mice (53) with our liver-specific autophagy-deficient model, and we observed that loss of TAZ significantly reduced liver size of 4- to 5-week-old autophagy-deficient livers (Fig. 6A and fig. S6A). Next, we found that TAZ loss also significantly reduced the accumulation of activated -SMA+ hepatic stellate cells and collagen deposition in 4- to 5-week-old autophagy-deficient livers (Fig. 6B and fig. S6B), indicating that TAZ contributes to hepatic stellate cell activation and fibrosis in our model. In addition, TAZ loss significantly decreased SOX9+, panCK+, and EpCAM+ cells in 4- to 5-week-old autophagy-deficient livers (Fig. 6B and fig. S6B), highlighting that TAZ loss hinders the formation of ductular LPCs upon autophagy deficiency in the liver. We next compared tumor formation between Alb-Cre+; Atg7fl/fl; Pten+/fl or Alb-Cre+; Atg5fl/fl; Pten+/fl and Alb-Cre+; Atg7fl/fl; Pten+/fl; Tazfl/fl or Alb-Cre+; Atg5fl/fl; Pten+/fl; Tazfl/fl in 140-day-old livers and noted that TAZ deletion caused a highly significant decrease in tumorigenesis in autophagy-deficient livers (Fig. 6, C and D, and fig. S6, C and D) that was accompanied by a significant increase in the survival of autophagy-deficient mice (Fig. 6E and fig. S6E). Last, we evaluated whether TAZ has a role in the proliferation of ductular LPCs. We found that TAZ loss did not impair the number of Ki-67+ proliferative LPCs in 4- to 5-week-old autophagy-deficient livers (fig. S7).

(A) Liver-to-body weight ratio in 4- to 5-week-old mice. Data are means SD of three mice per group and were analyzed by unpaired two tailed t test (**P < 0.01). (B) IHC analysis of hepatic stellate cell activation (-SMA), collagen deposition (Sirius Red), duct markers (SOX9 and panCK), and liver stem cell marker EpCAM on paraffin-embedded sections of livers from 4- to 5-week-old mice. Scale bars, 50 m. Left: Representative staining. Right: Quantifications. Data are mean SD of three mice per group and were analyzed by unpaired two-tailed t test (*P < 0.05, **P < 0.01, and ***P < 0.001). All data points are the mean from five pictures per mouse. (C) Macroscopic pictures of Alb-Cre+; Atg7fl/fl; Pten+/fl (top) and Alb-Cre+; Atg7fl/fl; Pten+/fl; Tazfl/fl (Alb-Cre+; 7fl/fl; P+/fl; T/) (bottom) liver in 140-day-old mice. (D) Quantification of tumor numbers in Alb-Cre+; Atg7fl/fl; Pten+/fl and Alb-Cre+; Atg7fl/fl; Pten+/fl; Tazfl/fl at 140 days. Data are means SD of five mice per group and were analyzed by unpaired two-tailed t test (***P < 0.001). (E) Kaplan-Meier analysis comparing overall survival between Alb-Cre+; Atg7fl/fl; Pten+/fl and Alb-Cre+; Atg7fl/fl; Pten+/fl; Tazfl/fl mice (n = 5 males and n = 5 females per group). Data were analyzed by log-rank Mantel-Cox test (****P < 0.0001).

To evaluate whether there was any redundancy between YAP and TAZ in our model, we crossed Yap1flox/flox mice (53) to our liver-specific (Alb-Cre) autophagy- and TAZ-deficient model to evaluate the effect of YAP/TAZ double knockout on the ductular reaction and tumorigenesis of autophagy-deficient livers. Unexpectedly, we observed that 40% (9 of 22 mice) of YAP-deficient mice developed jaundice within 6 to 8 weeks regardless of Atg7, Atg5, Pten, or Wwtr1 genotype. This is likely because YAP is highly expressed in the bile duct of WT mice (Fig. 5C and fig. S4B), and the Albumin promoter driving Cre recombinase expression is expressed in hepatoblasts, the embryonic progenitor cells generating hepatocytes and cholangiocytes (54). YAP deletion in our Albumin-Cre model can therefore impair cholangiocyte function in the bile duct leading to acute jaundice. To overcome this phenotype for long term studies, we used AAV8-TBG-Cre adenovirus to induce Cre recombination more specifically in the hepatocytes of our Atg7flox/flox; Ptenflox/flox; Yap flox/flox; Tazflox/flox model (Fig. 7A). First, we assessed the effect of YAP/TAZ deletion on the hepatomegaly and ductular reaction of autophagy-deficient livers 3 weeks following AAV8-TBG-Cre recombination and confirmed the recombination of Atg7, Pten, Yap, and Wwtr1 alleles in AAV8-TBG-Creinfected livers (fig. S8). We found that although YAP or TAZ deletion significantly reduced hepatomegaly of autophagy-deficient livers (Fig. 7B), YAP/TAZ double knockout mice significantly restored liver size to that observed in nonrecombined counterparts infected with the AAV8-TBG-null adenovirus (Fig. 7B). In addition, we noted that while the individual deletion of Yap or Taz significantly impaired the formation of SOX9+ cells in autophagy-deficient livers (Fig. 7, C and D), only YAP/TAZ codeletion completely blocked the formation of SOX9+ cells in autophagy-deficient livers (Fig. 7, C and D). In this AAV8-TBG-Cre model, Atg7/; Pten/ mice had to be culled because of hepatomegaly and did not develop tumors at humane end point. To evaluate the role of YAP/TAZ loss in the tumorigenesis of autophagy-deficient livers, we infected Atg7flox/flox; Pten+/flox; Yapflox/flox; Tazflox/flox with AAV8-TBG-Cre adenovirus and assessed tumor formation 140 days following AAV8 infection (Fig. 7E). We observed that while Yap or Taz deletion significantly impaired tumorigenesis in autophagy-deficient livers (Fig. 7, F and G), only YAP/TAZ codeletion completely prevented tumor formation (Fig. 7, F and G). Our data therefore show that deleting YAP and TAZ suppresses the ductular reaction and tumorigenesis of autophagy-deficient livers. However, in this context, we observed functional redundancy between YAP and TAZ, and only the combined deletion of both these genes could revert the effects on tissue overgrowth and tumor development.

(A) Schematic representation. Eight-week old Atg7fl/fl; Ptenfl/fl Yapfl/fl (Yfl/fl) and/or Tazfl/fl (Tfl/fl) mice were infected with AAV8-TBG-Cre and aged for 3 weeks before hepatomegaly and ductular reaction analysis. (B) Liver-to-body weight ratio in mice 3 weeks after AAV8 infection. Data are means SD of five mice per group and were analyzed by one-way ANOVA with Tukey correction for multiple comparison tests (*P < 0.05, ***P < 0.001, and ****P < 0.0001). (C) IHC analysis of the duct marker SOX9 on paraffin-embedded sections of livers from mice 3 weeks after AAV8 infection. Scale bars, 50 m. (D) Quantification of SOX9 from (C). Data are means SD of five mice per group and were analyzed by one-way ANOVA with Tukey correction for multiple comparison tests (****P < 0.0001). All data points are the mean from five pictures per mouse. (E) Schematic representation. Eight-week-old Atg7fl/fl; Pten+/fl; Yapfl/fl and/or Tazfl/fl mice were infected with AAV8-TBG-Cre and aged for 140 days before tumor analysis. (F) Macroscopic pictures from 140 days after AAV8-Cre livers. (G) Quantification of tumor numbers in 140 days after AAV8-Cre livers. Data are means SD of five mice per group and were analyzed by one-way ANOVA with Tukey correction for multiple comparison tests (*P < 0.05, **P < 0.01, and ****P < 0.0001). All data points are the mean from five pictures per mouse. Xfl/fl, AAV8-null infected; X/, AAV8-Cre infected.

We report a new model for extensive ductular reaction upon deletion of ATG5 or ATG7 and PTEN in the murine liver. Although Pten-deficient livers develop steatosis and HCC (37), we observed that hepatic Pten deletion alone did not initiate liver damage, inflammation, hepatic stellate cell activation, fibrosis, or a ductular reaction in young livers, but these effects were observed on hepatic deletion of ATG5 or ATG7. ATG5 and ATG7 are two proteins that are essential for the stage of autophagy that involves LC3 conjugation. ATG5 and ATG7 are also important for two other processes that involve the LC3 conjugation machinery: LC3-associated phagocytosis (LAP) (55) and LC3-associated endocytosis (LANDO) (56). We consider, however, that the core observations in our study relating to tumor development and liver injury are connected to autophagy, as previous studies have shown that they can be reversed by concomitant deletion of the autophagy adapter protein p62 (11, 22, 57), and autophagy adapter proteins are not thought to be involved in LAP or LANDO (58). We cannot fully discount that some of the effects we observe on deletion of ATG5 or ATG7 may be related to LAP or LANDO rather than autophagy or a combination thereof. Future studies to clarify this point using deletion of other factors such as FIP200 or ATG13 that are involved in autophagy, but not LAP and LANDO (5962), would certainly be merited to investigate this possibility.

Autophagy is impaired in Pten-deficient mice due to mTORC1 activation; however, autophagy is not blocked in Pten-deficient livers (63). LC3 is still conjugated to phosphatidylethanolamine leading to autophagosome and autolysosome formation when Pten expression is lost (63). This dictates an important role for autophagy in hepatocytes to prevent the microenvironmental remodeling and ductular reaction in healthy livers, with Pten cooperating with the autophagy-specific phenotype. Pten loss induces cellular senescence to protect from tumorigenesis in different models (64, 65). However, we noticed the presence of apoptotic hepatocytes following autophagy abrogation and Pten deletion. The extent of injury in hepatocytes determines their fate toward senescence or cancer (66). Acute injury in hepatocytes results in senescence (67), while chronic injury does not activate senescence in hepatocytes, ultimately leading to HCC (66). Autophagy degrades damaged mitochondria, a process named mitophagy, to maintain cellular homeostasis. In hepatocytes, loss of autophagy leads to ROS accumulation, damaged mitochondria, and dysfunction (11, 22, 68, 69). We suggest that the persistence of chronic damage and defects in damaged mitochondria clearance by mitophagy drive apoptosis and tumorigenesis in our autophagy- and Pten-deficient livers.

In our autophagy- and Pten-deficient model, we observed that following liver injury, hepatocytes dedifferentiate into ductular LPCs. This ductular reactive phenotype is not unique to the loss of autophagy as it has previously been observed in animal models subjected to diet modification, e.g., a diet enriched in 3,5-diethoxycarboncyl-1,4-dihydrocollidine (70) or choline-deficient, ethionine-supplemented diet (71). This indicates that the ductular reaction is likely to be a secondary effect of autophagy inhibition due to liver damage caused by autophagy loss. The origin of the ductular reaction in rodents is still controversial, with reports indicating the role of biliary cells (28, 29) or hepatocytes (30, 31) in forming LPCs with the capacity for generating new hepatocytes upon liver injury. Here, we show in a genetically modified mouse model that ductular reactive cells arise from mature hepatocytes upon injury induced by autophagy deficiency. The cellular plasticity of human hepatocytes can also generate ductular cells in a transplantation mouse model (30), strengthening the hepatocyte origin of the ductular reaction in human liver diseases.

The plastic differentiation program of the ductular reaction for liver regeneration is defined by the origin of the injuries. Following bile duct injury, resident LPCs/biliary cells (26) and hepatocyte-derived LPCs (72) regenerate biliary cells. When hepatocyte function is impaired, resident LPCs/biliary cells (28, 29, 73) or hepatocyte-derived LPCs (30, 31, 74) generate new hepatocytes. The decision to recruit biliary cells or hepatocytes during the ductular reaction remains elusive, and future studies will be required to shed further light on this mechanism.

Autophagy loss has been previously shown to give rise to HCC in mice (20). Our results suggest that the hepatocyte-derived ductular reaction gives rise to HCC in autophagy-deficient livers. While some studies conclude that the ductular reaction is not involved in liver carcinogenesis (34, 35, 74), other studies do report a role for the ductular reaction in initiating HCCs (32, 33). Although all these studies recombine LPCs for lineage tracing, they differ with respect to the timing between the induction of LPC labeling and the start of the injury. Recombination of LPCs for lineage tracing before inducing liver injury (34, 35, 74) does not label hepatocyte-derived LPCs, excluding them from the lineage tracing of HCCs. In contrast, recombination of LPCs for lineage tracing following liver injury results in LPC-derived HCCs (32, 33). In our autophagy- and Pten-deficient model, we report that hepatocyte-derived LPCs generate SOX9+ hepatocytes that give rise to HCC. The ability of LPCs to induce tumorigenesis has been controversial since it is generally accepted that HCC originates from hepatocytes. Here, we reconcile these findings by showing that HCC does originate from hepatocytes, but these hepatocytes, early upon liver injury, dedifferentiate into LPCs to attempt to regenerate liver function, before transforming into HCC.

In human liver diseases, the accumulation of LPCs is observed in nonalcoholic steatohepatitisinduced cirrhosis preceding HCC (75), and the presence of peritumoral ductular reaction is a poor prognostic factor for human HCC after resection (76), indicating the importance of targeting the ductular reaction in human liver diseases. The gene signature of autophagy-deficient mice is similar to the human transcriptomes of nonalcoholic fatty livers (20), and rat livers from rats fed a high-fat diet reduce their autophagy function (77). Restoring autophagy could therefore be a beneficial treatment in injured livers harboring a ductular reaction.

Mechanistically, we report that YAP and TAZ cooperate to drive hepatocyte dedifferentiation and tumorigenesis in autophagy-deficient livers. Unlike a previous study on YAP (20), we uncovered that TAZ also plays a role in promoting hepatomegaly, ductular reaction, stromal activation, fibrosis, and tumorigenesis in autophagy-deficient livers. TAZ deletion alone, similar to YAP deletion alone (20), only impaired carcinogenesis in autophagy-deficient livers. However, TAZ loss did not impair the proliferative outgrowth of the ductular LPC population. Here, we speculate that TAZ is involved in the differentiation switch in our model as its homolog YAP can directly drive hepatocyte dedifferentiation (31), and, more recently, YAP/TAZ have been described as regulators of stemness and cell plasticity in glioblastoma (78). We found that YAP and TAZ are not directly turned over by autophagy and that their accumulation in the absence of autophagy in vivo is associated with the increased presence of ductular cells, which are known to express YAP and TAZ (79). YAP and TAZ are mechanosensors and mechanotransducers (80), and their activation is linked to the stiffness of the extracellular matrix (81). As we noted a significant increase in extracellular matrix remodeling and fibrosis (Fig. 1E and fig. S1, F and G) correlating with a significant increase in YAP+/TAZ+ ductular LPCs in our models, we suggest that YAP and TAZ are also activated in response to the microenvironment changes following autophagy and PTEN deletion in the liver. Building on these findings, we observed that only the combined deletion of YAP and TAZ prevented the emergence of hepatocyte-derived LPCs that initiate tumorigenesis in autophagy-deficient livers. Our study uncovered a role for autophagy in suppressing the emergence of hepatocyte-derived ductular LPCs that can give rise to HCCs via concomitant activation of YAP and TAZ.

Male and female animals were housed in a pathogen-free environment and kept under standard conditions with a 12-hour day/night cycle and access to food and water ad libitum. All in vivo experiments were carried out under guidelines approved by the Glasgow University Animal Welfare and Ethical Review Body and in accordance with U.K. Home Office guidelines under license P54E3DD25. As described previously (82), Alb-Cre+ mice [RRID (research resource identifier): MGI:2176228] were crossed to Atg7fl/fl (68) (RRID: MGI:3590136) or Atg5fl/fl (83) (RRID: MGI:3612279) and Ptenfl/fl (84) (RRID: MGI:2182005) to generate the different combinations on a mixed background. Subsequently, Atg7fl/fl; Ptenfl/fl and Atg5fl/fl; Ptenfl/fl mice were crossed to Yap1fl/fl; Wwtr1fl/fl (the Jackson laboratory, stock 030532, RRID: IMSR_JAX:030532) (53) animals to generate all the different combinations. Experimental cohort (males and females) sizes were based on previous similar studies that have given statistically significant results while also respecting the limited use of animals in line with the 3R system: replacement, reduction, and refinement. All treatment studies were randomized but did not involve blinding. Genotyping was performed by Transnetyx. To lineage trace the ductular cell origin, we crossed our model with the Rosa26-mtdTomato-mEGFP mouse (the Jackson laboratory, stock 007576, RRID: IMSR_JAX:007576) (85).

In AAV8 studies, AAV8 recombination was performed as previously described (67). Briefly, viral particles [2 1011 genomic copies per mouse] of AAV8.TBG.PI.Cre.rBG (Addgene, catalog no. 107787-AAV8), AAV8.TBG.PI.eGFP.WPRE.bGH (Addgene, catalog no. 105535-AAV8), or AAV8.TBG.PI.Null.bGH (Addgene, catalog no. 105536-AAV8) were injected in 6-week-old (AAV8-GFP and AAV8-null) or 8-week-old (AAV8-Cre and AVV8-null) mice via tail vein in 100 L of phosphate-buffered saline (PBS).

Mice were euthanized by CO2 inhalation followed by cervical dislocation, and blood was harvested by cardiac puncture in accordance with U.K. Home Office guidelines. Tissues were weighed and stored immediately at 80C or in paraffin blocks after fixation in 10% formalin (in PBS) for 24 hours, followed by dehydration in 70% ethanol before embedding. Blood samples (EDTA-plasma and serum) were stored at 80C following 10-min centrifugation at 900g at 4C. Serum was sent to the Veterinary Diagnostic Services (University of Glasgow) for ALT, AST, ALP, and GGT analyses.

Plasma AFP levels were assessed using the enzyme-linked immunosorbent assay (ELISA) kit (catalog no. ab210969) according to the manufacturers instruction. Each sample was analyzed in triplicate.

For immunohistochemical (IHC) or immunofluorescence (IF) studies, paraffin-embedded sections were deparaffinized, rehydrated, and heated to 95 to 97C either in Lab Vision Citrate Buffer for heat-induced epitope retrieval (pH 6.0) (Thermo Fisher Scientific, catalog no. 12638286), EnVision FLEX Target Retrieval Solution, High pH (Agilent, catalog no. K8004), BOND Epitope Retrieval Solution 2 (ER2) (Leica, catalog no. AR9640), or Antigen Unmasking Solution, Citric Acid Based (Vector Laboratories, catalog no. H-3300) for antigen retrieval, depending on the primary antibody used. Primary antibodies used for IHC analyses: Ly6G (Bio X Cell, catalog no. BE0075-1, RRID: AB_1107721, rat, ER2; 1:60,000), -SMA (Sigma-Aldrich, catalog no. A2547, RRID: AB_476701, mouse, citric acid; 1:25,000), CC3 (Asp175, Cell Signaling Technology, catalog no. 9661, RRID: AB_2341188, rabbit, ER2; 1:500), SOX9 (Millipore, catalog no. AB5535, RRID: AB_2239761, rabbit, high pH; 1:500), CK19 (Novus, catalog no. NB100-687, RRID: AB_2265512, rabbit, high pH; 1:100), panCK (Lab Vision, catalog no. MS-343-P, RRID: AB_61531, mouse, Citric acid; 1:100), EpCAM (Abcam, catalog no. ab71916, RRID: AB_1603782, rabbit, high pH; 1:1500), CD133 (Abcam, catalog no. ab19898, RRID: AB_470302, rabbit, citrate pH 6; 1:200), CD44 (BD Biosciences, catalog no. 550538, RRID: AB_393732, rat, ER2; 1:300), GFP (Cell Signaling Technology, catalog no. 2555, RRID: AB_10692764, rabbit, ER2; 1:600), red fluorescent protein (Rockland, catalog no. 600-401-379, RRID: AB_2209751, rabbit, high pH; 1:1000), YAP (Cell Signaling Technology, catalog no. 4912, RRID: AB_2218911, rabbit, high pH; 1:50), WW domain containing transcription regulator 1 (WWTR1)/TAZ (Sigma-Aldrich, catalog no. HPA007415, RRID: AB_1080602, rabbit, high pH; 1:100), and Ki-67 (Cell Signaling Technology, catalog no. 12202, RRID: AB_2620142, rabbit, ER2; 1:1000). Primary antibodies were incubated with sections for 40 min at room temperature or overnight at 4C. For IHC analysis, primary antibodies were detected using mouse or rabbit EnVision+ System kits (Agilent, catalog no. K4001 and K4006) or ImmPRESS horseradish peroxidase (HRP) goat anti-rat immunoglobulin G (IgG) polymer detection kit (Vector Laboratories, catalog no. MP-7404) and 3,3-diaminobenzidine substrate (Agilent, catalog no. K4011). Slides were then counterstained with hematoxylin solution. Images were obtained on a Zeiss AX10 (light microscopy) at a 20 or 40 magnification.

For IF analysis, SOX9/GFP immunofluorescent primary antibodies were applied sequentially. First, slides were incubated with a chicken polyclonal GFP antibody (Abcam, catalog no. ab13970, RRID: AB_300798, citrate; 1:200) overnight at 4C and was detected using a biotinylated goat anti-chicken (Vector Laboratories, catalog no. BA-9010, RRID: AB_2336114; 1:200) coupled to Avidin-HRP (Vector Laboratories, PK-7100) and a PerkinElmer TSA Plus Cyanine 3 signaling amplification kit (NEL744B001KT; 1:50). This was followed by a second antigen retrieval to denature any antibodies in the tissue. Slides were then incubated with a rabbit monoclonal SOX9 antibody (Abcam, catalog no. ab185230, RRID: AB_2715497, citrate; 1:500) overnight at 4C and detected using a donkey anti-rabbit Alexa Fluor 488 secondary antibody (Molecular Probes, catalog no. A-21206, RRID: AB_2535792; 1:200). Slides were then counterstained with 4,6-diamidino-2-phenylindole (DAPI). Images were obtained on a Zeiss 710 confocal microscope at a 20 magnification. For collagen staining, sections were rehydrated and then immersed in Picro Sirius Red solution [0.1% Direct Red 80 (Sigma-Aldrich, 41496LH) and 0.1% Fast Green FCF (Raymond Lamb, S142-2) diluted in aqueous picric acid solution] for 2 hours.

HLE and Huh7 were grown in DMEM (Gibco, 21969-035) supplemented by 10% fetal bovine serum (FBS; Gibco, 10270-106), 2 mM glutamine (Gibco, 25030-032), streptomycin (100 g/ml), and penicillin (100 U/ml; Gibco, 15140-122) (complete DMEM) at 37C and 5% CO2. For starvation-induced autophagy experiments, cells were washed twice in PBS and starved in EBSS (Sigma-Aldrich, E2888) containing or not 200 nM Baf (LC Labs, B-1080) for 2 hours. HLE and Huh7 cell lines were provided by T. Bird.

Lentiviruses were produced using human embryonic kidney (HEK) 293T cells using calcium/phosphate transfection protocol. Cells were transfected overnight with lentiviral, packaging, and envelope plasmids (pPAX2 and pVSVG). The following day, media were replaced by complete DMEM containing 20% FBS for 24 hours. Then, virus-enriched media were collected, filtered (0.45 m), supplemented with polyprene (4 g/ml; Sigma-Aldrich, H9268), and transferred to recipient cells. In the meantime, HEK293T cells were kept in DMEM containing 20% FBS for an additional 24 hours to perform a second round of infection of recipient cells as described before. Last, infected cells were selected with puromycin (2 g/ml; Sigma-Aldrich, P9620) for 10 days. The following single-guide RNA sequences were used in this study: human ATG7, 5-GAA GCT GAA CGA GTA TCG GC-3 (86); human ATG5, 5-AAG AGT AAG TTA TTT GAC GT-3 (86); nontargeting control, 5-GTA GCG AAC GTG TCC GGC GT-3 (87).

Livers were dissociated using a Precellys Evolution (Bertin Technologies) and lysed in 1% Triton X-100, 0.1% SDS, 50 mM Hepes (pH 7.5), 150 mM NaCl, 100 mM NaF, and 10 mM EDTA, supplemented with Halt protease and phosphatase inhibitor cocktail (Thermo Fisher Scientific, catalog no. 87786). After 15-min centrifugation at 12,000g at 4C, the supernatant was removed, and the concentration of solubilized proteins was determined with the Pierce bicinchoninic acid assay (Thermo Fisher Scientific, catalog no. 23225). Protein lysates were separated by SDSpolyacrylamide gel electrophoresis with Criterion TGX Stain-Free precast gels (Bio-Rad) or the NuPAGE 4 to 12% bis-tris gel (Invitrogen) and blotted onto polyvinylidene difluoride membranes (Merck). Criterion TGX Stain-Free precast gels (Bio-Rad) were activated using the ChemiDoc (Bio-Rad) to detect total protein levels. Total protein level was measured before and after transfer. Western blot analysis was performed according to the manufacturers instructions for Criterion TGX Stain-Free precast gels or for the NuPAGE 4 to 12% bis-tris gel (Invitrogen). The following antibodies were used at a dilution of 1:1000 unless otherwise stated: p-YAP (Cell Signaling Technology, catalog no. 13008, RRID: AB_2650553), YAP (Cell Signaling Technology, catalog no. 4912, RRID: AB_2218911; 1:750), p-TAZ (Cell Signaling Technology, catalog no. 59971, RRID: AB_2799578), YAP/TAZ (Cell Signaling Technology, catalog no. 8418, RRID: AB_10950494), CTGF (Abcam, catalog no. ab125943, RRID: AB_2858254), ATG7 (Cell Signaling Technology, catalog no. 8558, RRID: AB_10831194), PTEN (Cell Signaling Technology, catalog no. 9559, RRID: AB_390810), extracellular signalregulated kinase 2 (ERK2; Santa Cruz Biotechnology, catalog no. sc-154, RRID: AB_2141292), LC3B (Cell Signaling Technology, catalog no. 2775, RRID: AB_915950), ATG5 (Cell Signaling Technology, catalog no. 12994, RRID: AB_2630393), glyceraldehyde-3-phosphate dehydrogenase (Abcam, catalog no. ab9485, RRID: AB_307275), anti-rabbit IgG HRP-linked (Cell Signaling Technology, catalog no. 7074, RRID: AB_2099233; 1:4000), and anti-mouse IgG HRP-linked (Cell Signaling Technology, catalog no. 7076, RRID: AB_330924; 1:4000).

RNAs were extracted from livers using the RNeasy Mini Kit (QIAGEN, catalog no. 74101) and quantified using a NanoDrop200c (Thermo Fisher Scientific). Complementary DNAs (cDNAs) were produced using the High-Capacity RNA-to-cDNA Kit (Thermo Fisher Scientific, catalog no. 4388950) according to the manufacturers instruction. Quantitative polymerase chain reactions (qPCRs) were performed using the DyNAmo HS SYBR Green qPCR Kit (Thermo Fisher Scientific, catalog no. F-410) on a Step-One Plus (Applied Biosystems) as follows: 20 s at 95C, followed by 40 cycles of 3 s at 95C, and 30 s at 60C. mRNA quantification was calculated using Ct method. The following mouse primers were used: mouse Ctgf (QIAGEN, QT00174020), mouse Ctgf (QIAGEN, QT00096131), mouse Cyr61 (QIAGEN, QT00245217), mouse Areg (QIAGEN, QT00112217), 18S forward (5-GTAACCCGTTGAACCCCATT-3), and 18S reverse (5-CCATCCAATCGGTAGTAGCG-3).

For IHC studies, five representative pictures were taken per mouse and were analyzed using Fiji software. For all in vivo studies, data are shown as means SD. Sample normality was assessed by Shapiro-Wilk test. Statistical significances were determined by two-tailed unpaired Students t test for two-group comparison, two-way analysis of variance (ANOVA) with Tukey or Dunnett for multiple group comparison, and log-rank (Mantel-Cox) test for survival comparison using GraphPad Prism software. Results were considered statistically different when *P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001 with ns indicating no significance.

J. OPrey, J. Sakamaki, A. D. Baudot, M. New, T. Van Acker, S. A. Tooze, J. S. Long, K. M. Ryan, in Methods in Enzymology, vol. 588 of Molecular Characterization of Autophagic Responses, Part B, L. Galluzzi, J. M. Bravo-San Pedro, G. Kroemer, Eds. (Academic Press, 2017), pp. 79108.

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Autophagy suppresses the formation of hepatocyte-derived cancer-initiating ductular progenitor cells in the liver - Science Advances

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Cancer research: New advances and innovations – Medical News Today

Monday, June 7th, 2021

In the second part of our whats exciting the experts series, Medical News Today spoke with another group of cancer experts. We asked them what recent advances have given them the most hope. Here, we provide a sneak peek at the fascinating forefront of cancer research in 2021.

Cancer is not a single disease but a collection of diseases. It is complex and does not readily give up its secrets. Despite the challenges cancer poses, scientists and clinicians continue to hone the way in which they diagnose and treat it.

Modern medicine means that diagnosis rates for many cancers are up, as are survival rates. However, with an estimated 19.3 million new cases of cancer worldwide in 2020, there is still much work to be done.

MNT recently contacted a number of medical experts and researchers and asked them to speak about the aspects of cancer research that they find most exciting. Their answers are fascinating and demonstrate the incredible variety of approaches that scientists are using to understand and combat cancer.

We will start todays journey into cutting edge oncology with a surprising guest: magnetically responsive bacteria.

Due to the difficulty of targeting systemically delivered therapeutics for cancer, interest has grown in exploiting biological agents to enhance tumor accumulation, explained Prof. Simone Schrle-Finke, Ph.D., from ETH Zurich in Switzerland.

In other words, getting cancer drugs to the right place is not as straightforward as one might hope. Prof. Schrle-Finke is among the researchers who are now enlisting the help of specialized bacteria.

She told MNT how scientists have known for a century that certain bacteria can colonize tumors and trigger regression. She explained that today, thanks to modern genetic engineering techniques, attenuated bacteria are available that can have a therapeutic effect exactly where this is necessary.

These therapeutic effects include secretion of toxins, competition for nutrients, and modulation of immune responses.

However, despite the promise of bacterial cancer therapy, there are still challenges to meet. Delivering the doses to the right place and getting them into the tumor remain foremost among challenges hampering clinical translation only about 1% of a systemically injected dose reaches the tumor, explained Prof. Schrle-Finke.

To address these challenges, her team at ETH Zurich is using magnetically responsive bacteria.

These so-called magnetotactic bacteria naturally orient themselves like compass needles to Earths magnetic field.

Although this ability evolved for navigation, scientists are keen to find out whether magnetic steering or pulling could allow them to repurpose it for cancer delivery.

In a recent study, Prof. Schrle-Finke and her colleagues used rotating magnetic fields to override the bacterias natural propulsion. As the authors of the study explain, they used swarms of magnetotactic bacteria to create a directable living ferrofluid.

These magnetotactic bacteria have a high demand for iron, so once they reach the tumor, as Prof. Schrle-Finke told MNT, they can metabolically influence cancer cells through starvation from this vital nutrient. We have shown in in vitro models that an increasing number of bacteria induce an upregulation of iron-scavenging receptors and death in cancer cells.

By uniting engineering principles and synthetic biology, we aim to provide a new framework for bacterial cancer therapy that addresses a major remaining hurdle by improving the efficiency of bacterial delivery using safe and scalable magnetic stimuli to these promising living therapeutic platforms.

Prof. Simone Schrle-Finke, Ph.D.

Personalized medicine is transforming the landscape of medicine and how healthcare providers can offer and plan personalized care for each of their patients, believes Dr. Santosh Kesari, Ph.D., director of neuro-oncology at Providence Saint Johns Health Center in Santa Monica, CA.

Dr. Kesari is also chair of the Department of Translational Neurosciences at Saint Johns Cancer Institute and regional medical director for the Research Clinical Institute of Providence Southern California.

Describing personalized medicine, Dr. Kesari said, It is an approach for disease prevention and treatment that takes into account biological, genetic, behavioral, environmental, and social risk factors that are unique to every individual.

He continued, Personalized medicine is rooted in early detection and prevention; integrating data from genomics and other advanced technologies; digital health monitoring; and incorporating the latest medical innovations for optimizing outcomes.

This is becoming very apparent in oncology, where genetic testing for tumor mutations and predispositions is increasingly being utilized and showing more value in using targeted drugs more wisely and improving outcomes.

Dr. Santosh Kesari, Ph.D.

Some personalized cancer approaches are already in use, such as EGFR, HER2, and NTRK inhibitors and the super personalized CAR-T cells.

According to Dr. Kesari, the future of personalization is bright, and progress has only accelerated in the past 5 years.

Continuing with the personalization theme, Dr. Robert Dallmann from Warwick Medical School at Warwick University in the United Kingdom talked with us about chronotherapy:

Propelled by the 2017 Nobel Prize in Medicine or Physiology [going] to three circadian biologists for uncovering the molecular mechanism of circadian biological clocks, cancer chronotherapy is gaining critical momentum to enter mainstream oncology especially in the context of personalized medicine.

Dr. Dallmann explained that many key physiological processes in the cells of our body are modulated in a daily fashion by the circadian clock. These cellular clocks are disrupted in some tumors but not in others.

Interestingly, a functional clock in the tumor predicts the survival time of patients, which has been shown for brain as well as breast tumors.

Therefore, he explained, if scientists could determine the clock status in solid tumors, it would allow doctors to more easily determine whether a patient is at high or low risk. It might also help guide therapy.

There is great potential in optimizing treatment plans with existing drugs by taking into account the interaction with the circadian system of the patient, continued Dr. Dallmann.

More recently, the circadian clock mechanism itself has been proposed as a novel treatment target in glioblastoma. The authors of the glioblastoma study concluded that pharmacologic targeting of circadian networks specifically disrupted cancer stem cell growth and self-renewal.

However, whether this might be generalized to many solid tumors or even other chronic diseases remains to be elucidated, said Dr. Dallmann.

In summary, he told MNT, circadian clocks have long been recognized to modulate chronic disease on many levels. The increased mechanistic understanding has the potential to improve diagnosis and existing treatments of cancer, as well as develop a new class of clock-targeting treatments.

Dr. Chung-Han Lee is a medical oncologist at Memorial Sloan Kettering Cancer Center in New York. He is also a member of the Kidney Cancer Associations Medical Steering Committee. He talked us through recent advances in the treatment of kidney cancer.

The development and subsequent regulatory approval of combination immunotherapy for patients with metastatic kidney cancer have led to transformative change in the lives of many patients and are the hallmark of how greater scientific understanding has impacted cancer care, Dr. Lee told MNT.

Prior to 2005, treatment for metastatic kidney cancer was very limited, with most patients passing away in less than 1 year despite undergoing treatment. According to Dr. Lee, the development of antiangiogenic drugs that inhibit the growth of new blood vessels was among the first breakthroughs to improve the outcomes for patients.

However, even with antiangiogenic drugs, most patients ultimately developed resistance to treatment, and 18 months was considered a long-term response. Next came immunotherapies.

Prior to the development of antiangiogenic medications, it was known that kidney cancer could be treated by activating the immune system to better recognize the disease. However, the tools to activate the immune system were often very nonspecific. Therefore, responses to these early immunotherapies were rare, and the side effects related to treatment were not only burdensome but also could be life threatening.

With recent advances in immunotherapy, we have demonstrated that more targeted immunotherapies that activate specific immune checkpoints are not only possible but can have substantially increased activity against disease.

Two emerging treatment approaches have now become the new standard of care for kidney cancer: dual immunotherapies (such as ipilimumab/nivolumab) or combinations of antiangiogenic targeted therapies with immunotherapies (such as axitinib/pembrolizumab).

In patients treated with ipilimumab and nivolumab, over 50% remain alive at 4 years, and with some [combined antiangiogenic and immunotherapy approaches], nearly 50% of patients remain on their initial therapy at 2 years.

Despite these advances, Dr. Lee is far from complacent, telling us that there remains considerable work to be done. [] Unfortunately, in 2021, for most patients, kidney cancer remains fatal. Even for those who have outstanding responses to treatment, most still require ongoing systemic therapy.

With the rapid improvements in treatments, the development of correlative biomarkers, and the improved biologic understanding of the disease, we have only started to entertain the possibility of curative, time-limited therapy.

Building on the sacrifices of patients and caregivers and the hard work of clinicians, research staff, and scientists, a cure may, one day, be a reality for our patients, he concluded.

Our study from late 2020 has shown that the antidepressant sertraline helps to inhibit the growth of cancer cells in mice, Prof. Kim De Keersmaecker from KU LEUVEN in Belgium told MNT.

Other studies had already indicated that the commonly used antidepressant has anticancer activity, but there was no explanation for the cause of this. Weve been able to demonstrate that sertraline inhibits the production of serine and glycine, causing decreased growth of cancer cells.

Cancer cells and healthy cells are often reliant on the amino acids serine and glycine, which they extract from their environment. However, certain cancer cells produce serine and glycine within the cell. They can become addicted to this production.

This internal production of serine and glycine requires certain enzymes, and these enzymes have become targets for cancer researchers. Preventing them from functioning can starve the cancer cells.

Previous studies have identified inhibitors of serine/glycine synthesis enzymes, but none have reached the clinical trial stage. As the authors of a KU LEUVEN study note, because sertraline is a clinically used drug that can safely be used in humans, it might make a good candidate.

Prof. De Keersmaecker explained that when used with other therapeutics, the drug strongly inhibited the growth of cancer cells in the mice.

The authors of the study concluded: Collectively, this work provides a novel and cost efficient treatment option for the rapidly growing list of serine/glycine synthesis-addicted cancers.

Christy Maksoudian from the NanoHealth & Optical Imaging Group team at KE LEUVEN is excited about the promise of nanotechnology for the treatment of cancer. She told MNT that because of the unique properties that emerge at such a small scale, nanoparticles can be designed in a multitude of ways to exhibit specific behaviors in organisms.

Currently, she explained, many available nanoformulations in the clinic are composed of organic materials because of their biocompatibility and safety. In this context, organic refers to compounds that include carbon.

However, she explains that inorganic nanomaterials, which do not contain carbon, also hold promise for cancer treatment because they possess further functionalities.

For instance, some magnetic nanoparticles, such as those of superparamagnetic iron oxide, can be magnetically guided toward the tumor, while gold nanoparticles generate heat upon exposure to near-infrared light and can, therefore, be used for photothermal therapy (via tumor tissue ablation).

In short, it is possible to introduce gold nanoparticles to the bloodstream of people with cancer. From there, these nanoparticles accumulate in tumors because tumors have particularly leaky blood vessels. Once that region is exposed to near-infrared light, the gold nanoparticles heat up and, consequently, kill cancer cells.

Because of the potential of such broad range of nanomaterial designs, there are always novel cancer therapies being developed.

Christy Maksoudian

I am excited to take part in this movement with my work on copper oxide nanoparticles. Maksoudian and her colleagues use copper oxide nanoparticles doped with 6% iron.

Maksoudian told MNT that these nanoparticles exploit intrinsic metabolic differences between cancer cells and healthy cells to induce high levels of toxicity in cancer cells while only causing reversible damage in healthy tissue.

The fact that such cancer-selective properties can arise due to minor modifications of the nanoparticles at the nanoscale is truly extraordinary and reaffirms the significant role that nanomedicine can play in expanding the treatment landscape for oncology.

Cancer is complex, so approaches to its treatment must match that complexity. As the summaries above demonstrate, scientists are not short on ingenuity, and the battle against cancer continues at pace.

Read the first part of our series on cancer researchers and their exciting work here.

Link:
Cancer research: New advances and innovations - Medical News Today

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Fulvestrant Alone Found to be Superior to Venetoclax/Fulvestrant Combo in ER+/HER2- Breast Cancer – Targeted Oncology

Monday, June 7th, 2021

Compared to fulvestrant (Faslodex) alone, venetoclax (Venclexta) and fulvestrant did not improve overall outcomes in patients with locally advanced or metastatic estrogen receptor (ER)positive, HER2-negative breast cancer who had previously received a CDK4/6 inhibitor, according to findings from the phase 2 VERONICA trial (NCT03584009) that were presented during the 2021 ASCO Annual Meeting.

At a median follow-up of 9.9 months, the clinical benefit rate (CBR) was 11.8% (95% CI, 4.44%-23.87%) with venetoclax/fulvestrant vs 13.7% (95% CI, 5.7%-26.26%) with fulvestrant alone, translating to a risk difference of -1.96% (95% CI, -16.86%-12.94%).

The primary analysis of VERONICA revealed a largely endocrine-refractory population of patients. Venetoclax added to fulvestrant did not improve CBR or progression-free survival [PFS], [nor did] overall survival [OS] favor [the combination], lead study author Geoffrey J. Lindeman, MD, joint head of the Stem Cells and Cancer Division at The Walter and Eliza Hall Institute of Medical Research, said in a virtual presentation of the data.

Despite the use of the combination of a CDK4/6 inhibitor and chemotherapy, which has become the standard frontline therapy for patients with metastatic ER-positive, HER2-negative breast cancer, disease progression is inevitable.

BCL-2 is a pro-survival protein that is overexpressed in the majority of primary and relapsed ER-positive breast cancers. The BCL-2 inhibitor venetoclax has shown promising activity in patients with endocrine-nave, ER-positive, BCL-2positive metastatic breast cancer.

To that end, investigators evaluated the activity of adding the BCL-2 inhibitor to fulvestrant in patients with progressive ER-positive, HER2-negative disease.

Eligibility criteria stipulated that females, 18 years of age or older, had to have locally advanced or metastatic ER-positive, HER2-negative breast cancer, received 2 or fewer lines of therapy in the locally advanced or metastatic setting without chemotherapy, received a CDK4/6 inhibitor at least 8 weeks before enrollment, and have measurable disease.

Patients were randomized 1:1 to 800 mg of oral, daily venetoclax (n = 51) plus 500 mg of intramuscular fulvestrant on day 1 and 15 of cycle 1 and day 1 of each 28-day cycle thereafter or fulvestrant alone (n = 52). Treatment was continued until disease progression, unacceptable toxicity, withdrawal of consent, death, or predefined study end.

CBR, defined as the total complete response (CR), partial response (PR), and stable disease rate after at least 24 weeks, served as the primary end point of the study. Secondary end points included PFS, OS, objective response rate (ORR)defined as the total CR and PR rateand duration of response (DOR).

Additional end points included safety and tolerability, biomarker analysis, pharmacokinetics, and patient-reported outcomes.

The primary analysis took place on August 5, 2020, and the updated analysis took place in April 2021.

Regarding baseline demographics, the median age was 58 years in the venetoclax arm vs 59.5 years in the fulvestrant-alone arm. Approximately half of all patients had an ECOG performance status of 0 in both arms, at 54.9% and 59.6%, respectively. Moreover, in both arms, the majority of patients were White (78.4% vs 88.5%, respectively), had ductal histology (78.4% vs 65.4%, respectively), at least 1 visceral metastatic lesion (92.2% vs 82.7%, respectively), and 1 prior line of endocrine therapy in the metastatic setting (80.4% vs 82.7%, respectively).

All patients had received prior endocrine therapy in the venetoclax and fulvestrant-alone arms, whereas approximately half had received adjuvant chemotherapy (58.8% vs 51.9%, respectively), and less than a quarter had received prior neoadjuvant chemotherapy (23.5% vs 13.5%, respectively).

The median duration of exposure to prior treatment with a CDK4/6 inhibitor in the metastatic setting was 15 months in the venetoclax arm vs 16.5 months in the fulvestrant-alone arm, with palbociclib (Ibrance; 56.9% vs 75%, respectively) and ribociclib (Kisqali; 43.1% vs 25%, respectively).

Regarding BCL-2 status, more patients had high expression in the venetoclax and fulvestrant-alone arms (64.7% vs 65.4%, respectively) than low expression (35.3% vs 34.6%, respectively).

Biomarker status in the venetoclax and fulvestrant-alone arms, respectively, indicated the presence of mutations in the PIK3CA (39.6% vs 30.4%), ESR1 (43.8% vs 41.3%), TP53 (47.9% vs 34.8%), and RB1(18.8% vs 8.7%) genes.

Additional results demonstrated that the ORR was 3.9% in the venetoclax arm vs 5.9% in the fulvestrant-alone arm and consisted all of PRs.

The median PFS was 2.69 months (95% CI, 1.94-3.71) in the venetoclax arm vs 1.94 months (95% CI, 1.84-3.55) in the fulvestrant-alone arm (HR, 0.94; 95% CI, 0.61-1.45; P = .7853). The 6-month PFS rates were 12.3% vs 18.8%, respectively.

The OS data were not mature at the time of the primary analysis but did not favor the venetoclax arm. The median OS was 16.76 months (95% CI, 10.12-not evaluable [NE]) in the venetoclax arm vs NE (95% CI, 16-NE) in the fulvestrant-alone arm (HR, 2.56; 95% CI, 1.11-5.89; P = .0218). The updated analysis showed comparable results, with a numerically lower hazard ratio of 1.85 (95% CI, 1.01-3.39).

Notably, similar CBR and PFS was observed between arms irrespective of BCL-2 expression.

However, increased CBR and PFS was reported in the PIK3CA wild-type subgroup in an exploratory analysis. Here, the CBR was 20.7% in the venetoclax arm (n = 29) vs 9.7% in the fulvestrant-alone arm (n = 31). The median PFS was 3.71 months (95% CI, 1.94-4.53) vs 1.87 (95% CI, 1.74-3.55), respectively (HR, 0.66; 95% CI, 0.38-1.17; P = .1549).

A higher number of deaths was reported in the venetoclax arm vs the fulvestrant-alone arm primarily because of progressive disease at least 28 days after the last dose of study treatment. A similar trend was reported in the updated analysis.

The safety profile of the combination was consistent with the known safety profile of each agent alone, and no new signals were identified.

The occurrence of at least 1 adverse effect (AE) was reported in 94% of patients in the venetoclax arm vs 76.5% of patients in the fulvestrant-alone arm. Grade 3 or 4 AEs were reported in 26% vs 11.8% of patients, respectively. Serious AEs occurred in 8% vs 2% of patients, respectively. One case of urosepsis leading to death occurred in the venetoclax arm but was unrelated to the study drug.

Treatment-related AEs leading to drug withdrawal occurred in 8% of patients in the venetoclax arm vs 0% of patients in the fulvestrant-alone arm. AEs leading to dose modification or interruption occurred in 44% vs 2% of patients, respectively.

The most common grade 3 or 4 AEs in the venetoclax arm included fatigue (6%), neutropenia (12%), lymphopenia (4%), and dyspnea (4%) vs a 2% incidence of grade 3 or 4 fatigue in the fulvestrant-alone arm.

It remains unclear whether a BCL-2 inhibitor would be effective in an endocrine therapyresponsive, CDK4/6 inhibitornave setting, concluded Lindeman.

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Fulvestrant Alone Found to be Superior to Venetoclax/Fulvestrant Combo in ER+/HER2- Breast Cancer - Targeted Oncology

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