Gut microbiome modulates response to anti-PD-1 immunotherapy in melanoma patients.

Preclinical mouse models suggest that the gut microbiome modulates tumor response to checkpoint blockade immunotherapy; however, this has not been well-characterized in human cancer patients. Here we examined the oral and gut microbiome of melanoma patients undergoing anti-programmed cell death 1 protein (PD-1) immunotherapy (n = 112). Significant differences were observed in the diversity and composition of the patient gut microbiome of responders versus nonresponders. Analysis of patient fecal microbiome samples (n = 43, 30 responders, 13 nonresponders) showed significantly higher alpha diversity (P < 0.01) and relative abundance of bacteria of the Ruminococcaceae family (P < 0.01) in responding patients. Metagenomic studies revealed functional differences in gut bacteria in responders, including enrichment of anabolic pathways. Immune profiling suggested enhanced systemic and antitumor immunity in responding patients with a favorable gut microbiome as well as in germ-free mice receiving fecal transplants from responding patients. Together, these data have important implications for the treatment of melanoma patients with immune checkpoint inhibitors.

Cancer Evolution during Immunotherapy.

Immune checkpoint blockade has revolutionized cancer treatment. In this issue of Cell, insights from a longitudinal multi-omics analysis of the largest yet-reported cohort of melanoma patients reveal how tumor and immunity co-evolve during anti-PD-1 therapy.

Efficacy and toxicity of treatment with the anti-CTLA-4 antibody ipilimumab in patients with metastatic melanoma after prior anti-PD-1 therapy.

BACKGROUND: Recent phase III clinical trials have established the superiority of the anti-PD-1 antibodies pembrolizumab and nivolumab over the anti-CTLA-4 antibody ipilimumab in the first-line treatment of patients with advanced melanoma. Ipilimumab will be considered for second-line treatment after the failure of anti-PD-1 therapy. METHODS: We retrospectively identified a cohort of 40 patients with metastatic melanoma who received single-agent anti-PD-1 therapy with pembrolizumab or nivolumab and were treated on progression with ipilimumab at a dose of 3 mg kg(-1) for a maximum of four doses. RESULTS: Ten percent of patients achieved an objective response to ipilimumab, and an additional 8% experienced prolonged (>6 months) stable disease. Thirty-five percent of patients developed grade 3-5 immune-related toxicity associated with ipilimumab therapy. The most common high-grade immune-related toxicity was diarrhoea. Three patients (7%) developed grade 3-5 pneumonitis leading to death in one patient. CONCLUSIONS: Ipilimumab therapy can induce responses in patients who fail the anti-PD-1 therapy with response rates comparable to previous reports. There appears to be an increased frequency of high-grade immune-related adverse events including pneumonitis that warrants close surveillance.

Non-HIV-associated Kaposi sarcoma in an immunosuppressed melanoma patient treated with dabrafenib.

WHAT IS KNOWN AND OBJECTIVE: Cutaneous toxicities are commonly seen with BRAF inhibitors, frequently involving painful hyperkeratosis of the feet. We illustrate an unexpected diagnosis of extensive bilateral pedal Kaposi sarcoma masquerading as BRAF inhibitor-related toxicity in a patient treated with dabrafenib for metastatic melanoma. CASE SUMMARY: A HIV-negative, non-diabetic, Italian man with a history of myasthenia gravis and metastatic melanoma presented with enlarging macular/plaque-like rash on his feet preceded by bilateral plantar shooting pains. The rash progressed in the context of acute-on-chronic immunosuppression and was initially thought due to commencement of the BRAF inhibitor (BRAFi) dabrafenib. Histopathological findings from skin biopsies revealed Kaposi sarcoma. The patient was continued on dabrafenib and received superficial radiotherapy to the feet with prompt relief of pain. WHAT IS NEW AND CONCLUSION: This case illustrates the diagnostic pitfalls in patients treated with targeted therapies and highlights the importance of broad differentials for unusual presentations and early biopsy.

Response to MAPK pathway inhibitors in BRAF V600M-mutated metastatic melanoma.

WHAT IS KNOWN AND OBJECTIVE: The management of metastatic melanoma has changed significantly in the past decade with the development of immunotherapies and targeted molecular therapies. Trials of targeted therapies have focused mainly on patients with the most common BRAF V600 mutations, namely V600E/K substitutions, with very little information available on the benefit of targeted therapies on less commonly occurring mutations such as V600R/D and M. CASE SUMMARY: We present a 54-year-old man with metastatic melanoma harbouring a rare BRAF V600M mutation, who experienced clinical and radiological response to combined therapy with the BRAF inhibitor dabrafenib and MEK inhibitor trametinib. WHAT IS NEW AND CONCLUSION: As our understanding of these therapies evolves and an increasing number of patients have mutational testing performed, there is a clear imperative--as highlighted by this case--to test for rarer mutations and facilitate their inclusion both in everyday practice and in future clinical trials.

Identification of mutations conferring insecticide-insensitive AChE in the cotton-melon aphid, Aphis gossypii Glover.

We have identified two mutations in the ace1 gene of Aphis gossypii that are associated with insensitivity of acetylcholinesterase (AChE) to carbamate and organophosphate insecticides. The first of these, S431F (equivalent to F331 in Torpedo californica), is associated with insensitivity to the carbamate insecticide pirimicarb in a range of A. gossypii clones. The S431F mutation is also found in the peach-potato aphid, Myzus persicae (Sulzer), and a rapid RFLP diagnostic allows the identification of individuals of both aphid species with a resistant genotype. This diagnostic further revealed the presence of S431 in several other pirimicarb-susceptible aphid species. The serine at this position in the wild-type enzyme has only been reported for aphids and provides a molecular explanation of why pirimicarb has a specific aphicidal action. A less specific insensitivity to a wide range of carbamates and organophosphates is associated with a second mutation, A302S (A201 in T. californica).

Phosphorus uptake into algal biofilms in a lowland chalk river.

This paper examines the growth and uptake of phosphorus into algal biofilms in the River Kennet, a lowland chalk (Cretaceous-age) stream in southern England. Algal biofilms were grown on artificial plastic substrates (templates) placed (i) on the riverbed and (ii) within the mid-water column. Experiments were set up to examine differences in growth rates of newly colonising biofilms compared with biofilms left to accumulate for periods of up to 6 months. Rates of algal biofilm production were measured by the chlorophyll a concentration that had accumulated per cm2 over the number of days that the biofilm template had been immersed in the river water. An algal biofilm bloom occurred in early spring, prior to peak suspended chlorophyll a concentrations within the water column. Biofilm samples collected in February and March had the highest chlorophyll a and total phosphorus concentrations. The biofilm bloom corresponded with increased solar radiation and declining river flow conditions. Periodic increases in soluble reactive phosphorus concentrations in the overlying river water did not correspond with any significant increase in biofilm production. These results suggest that light, rather than phosphorus is a key factor for biofilm growth in the River Kennet. Higher rates of chlorophyll a development in mid-water column biofilms may be linked to greater light exposure; however, maximum total-P concentrations were similar for both bed and water column biofilms. Newly colonising biofilms exhibited higher chlorophyll a and total-P concentrations than biofilms left to accumulate over longer terms, suggesting that fresh substrate availability promotes high rates of biofilm growth. Both 'condensed and organic' P (stored in biomass) and 'inorganic' (mineral) P fractions within the biofilms were present in varying proportions, although the early spring biofilm bloom resulted in maximum proportions and absolute concentrations of 'condensed and organic' P. Calcite was the only crystalline mineral detected within the biofilms. Ratios of Ca:inorganic P are largely consistent with the presence of CaCO3-P co-precipitates, although one very low value suggested that there may also be additional sources of inorganic P, possibly P adsorbed to clays or organics within the biofilm. However, poor linkages between CaCO3 and inorganic P concentrations suggest that, although the inorganic P fraction within the biofilm may be derived largely from CaCO3-P co-precipitation, the subsequent processes controlling overall CaCO3 and inorganic P concentrations in the biofilm are complex.

The psychological status at school age of children conceived by in-vitro fertilization.

This study assessed the behavioural and psychological profiles of children conceived by in-vitro fertilization (IVF) who are now at school age. A total of 743 IVF children born at one institution and now of school age, over 4 years old, were surveyed with Achenbach questionnaires. Follow-up telephone interviews were conducted with non-responders. The results from the study group were compared to the questionnaire control group using one-tailed t-test with statistical significance set less than 0.05. There was an 84% overall response rate. Sixty-seven per cent returned questionnaires. An additional 17% completed a telephone interview. The study group had no statistically significant increase in the rate of behavioural or psychological problems compared with the control group. There were no statistically significant differences within the study group related to sex or to multiple gestation IVF births. This large group of school-age IVF children has normal psychological development with no identified adverse effect of their status as IVF children. Determining the role, if any, of IVF in the very small number of children with behavioural and psychological problems will require additional study.

The absorption of oral micronized progesterone: the effect of food, dose proportionality, and comparison with intramuscular progesterone.

OBJECTIVES: To examine the effects of food ingestion and administered dose on the absorption of oral micronized P (Utrogestan; Besins-Iscovesco, Paris, France) and to compare the bioavailability of intramuscular versus oral routes of administration. DESIGN: Prospective, randomized, open label crossover protocol with 7 days between dosages. SETTING: Academic institution. PARTICIPANTS: Fifteen normal postmenopausal women. INTERVENTIONS: All subjects participated in three separate protocols: [1] micronized P (200 mg) or placebo under fasting or nonfasting conditions once daily for 5 days; [2] micronized P (100, 200, or 300 mg) once daily under fasting conditions for 5 days; and [3] micronized P (200 mg) or intramuscular P (50 mg in oil) administered once daily for 2 days. MAIN OUTCOME MEASURES: Serum P concentrations were measured in all groups. RESULTS: Concomitant food ingestion increased the area under the serum P concentration versus time curve (AUC0 to 24) and the maximum serum P concentration (Cmax) without affecting time to maximum serum concentration (Tmax) (P < 0.05). Micronized P absorption and elimination were first-order processes and exhibited dose-independent pharmacokinetics between 100 and 300 mg. After intramuscular P, Cmax was higher and Tmax occurred later compared with the oral P preparation. Oral P had lower relative bioavailability (8.6%) than intramuscular P. CONCLUSIONS: Absorption of micronized P was enhanced twofold in the presence of food. Both absorption and elimination were dose-independent, dose proportionality being confirmed. Bioavailability of the oral P was approximately 10% compared with intramuscular P.

Papillary peritoneal carcinomatosis after prophylactic oophorectomy.

Prophylactic oophorectomy has been recommended in patients with a strongly positive family history for ovarian carcinoma. A patient with a strongly positive family history underwent a prophylactic oophorectomy and, 5 years later, developed a primary peritoneal papillary serous adenocarcinoma. A prophylactic oophorectomy does not afford complete protection in some patients with familial ovarian cancer syndrome. Any tissue derived from the coelomic epithelium may potentially undergo multifocal malignant transformation.

An analysis of the obstetric outcome of 125 consecutive pregnancies conceived in vitro and resulting in 100 deliveries.

One hundred twenty-five consecutive pregnancies conceived in vitro resulted in 100 deliveries of 115 babies. There were 23 clinical abortions (18.4%) and two tubal pregnancies. During the same interval 30 preclinical pregnancies occurred, but these pregnancies did not progress. There were 26 multiple pregnancies (37.1%) before the twelfth week; these reduced spontaneously to 14 (22.2%) multiple births at delivery. Eight infants were delivered prematurely, and three of these died. Three babies had some congenital abnormality. Vaginal bleeding occurred during pregnancy in 59% of patients. Cesarean section was the method of delivery in 56% of patients. Other complications of pregnancy were similar to those of comparable populations.

Reconstructive pelvic operations for in vitro fertilization.

Lysis of adhesions, bilateral salpingectomy, and ovarian suspension were carried out in 54 normal ovulatory patients with long-standing infertility that was associated with severe pelvic adhesions after multiple laparotomies for reimplantation of the fallopian tubes, salpingostomy, lysis of adhesions, or severe endometriosis. Ovulation was induced in 39 patients after laparotomy for in vitro fertilization, with the use of human menopausal gonadotropin, pure follicle-stimulating hormone, and human chorionic gonadotropin. Oocyte retrieval by laparoscopy was accomplished in 37 patients, and embryo transfer was carried out in 36. Pregnancy after in vitro fertilization and embryo transfer occurred in 14 patients. Although severe adhesions recurred in four patients, a significant improvement was obtained after the procedure in the others.

Three years of in vitro fertilization at Norfolk.

During the 3 years from 1981 to 1983, 319 consecutive patients in 560 cycles were treated in a program of in vitro fertilization at Norfolk. All patients were stimulated by human menopausal gonadotropin supplemented by human chorionic gonadotropin. There were transfers in 429 cycles, resulting in 105 pregnancies. Over the 3-year span, the pregnancy rate by cycle was 19%; by transfer, 25%; and by patient, 33%.

In vitro fertilization in Norfolk, Virginia, 1980-1983.

Three years of progress of the Vital Initiation of Pregnancy (VIP) Program in Norfolk is reported. No conception resulted from 41 oocyte aspirations during spontaneous menstrual cycles in 1980. An average of 3.7 oocytes per cycle, or a 73.5% recovery rate, resulted in 362 human menopausal gonadotropin/human chorionic gonadotropin-induced cycles from January 1981 to March 1983. Forty percent of the oocytes recovered from these cycles were preovulatory, 35% atretic, and 25% immature. Immature oocytes were often matured in vitro, fertilized, and found to produce pregnancies. A total of 62 pregnancies occurred, which represents a 17 or 23% pregnancy rate, based on laparoscopies or embryo transfers, respectively. There were 11 preclinical and 7 clinical miscarriages. Twenty-nine normal babies have been delivered, including a set of twins. The remainder appears to be normally progressing pregnancies. Polyspermia was observed in 8.8% of the fertilizable oocytes.

What is a pregnancy? A question for programs of in vitro fertilization.

Pregnancy outcome in studies of normal reproduction and in programs of in vitro fertilization (IVF) is usually classified as "chemical beta-human chorionic gonadotropin (beta-hCG) abortion," "trimester abortion," and "term delivery." The distinction between a chemical beta-hCG abortion and a first-trimester abortion is not clearly stated in the literature, although such terms are commonly used. It is proposed that in programs of IVF pregnancy outcome be classified as "menstrual abortion," "preclinical abortion," "clinical abortion," or "viable pregnancy." Pregnancy outcome of 190 consecutive cycles induced by human menopausal gonadotropin/human chorionic gonadotropin in the program of IVF at Norfolk is compared with contemporary studies of pregnancy outcome in normal reproduction. The in vitro data indicate that the Norfolk program has recorded no menstrual abortions, a 33% preclinical and clinical abortion rate, and a viable pregnancy rate that approaches but does not equal the term delivery rate of normal reproduction. However, these results have been achieved by the transfer of multiple concepti, whereas normal reproduction depends on the fertilization of a single oocyte.

The importance of the follicular phase to success and failure in in vitro fertilization.

One hundred seventy-five cycles in patients with irreparable tubal disease were stimulated by human menopausal gonadotropin/human chorionic gonadotropin for the purpose of in vitro fertilization. As judged by the height of the peripheral estradiol response, the patients were classified as high, intermediate, or low responders. In addition, the estradiol pattern of the response was found to be separable into six categories. The pregnancy rate was found to be related to the height and to the pattern of peripheral response. The overall pregnancy rate in this consecutive series was 19% but varied according to the height and pattern of response from 40% to 0%.