The long and winding road to biomarkers for immunotherapy: a retrospective analysis of samples from patients with triple-negative breast cancer treated with pembrolizumab.

BACKGROUND: Immune checkpoint blockade (ICB) in combination with chemotherapy improves outcome of patients with triple-negative breast cancer (TNBC) in metastatic and early settings. The identification of predictive biomarkers able to guide treatment decisions is challenging and currently limited to programmed death-ligand 1 (PD-L1) expression and high tumor mutational burden (TMB) in the advanced setting, with several limitations. MATERIALS AND METHODS: We carried out a retrospective analysis of clinical-pathological and molecular characteristics of tumor samples from 11 patients with advanced TNBC treated with single-agent pembrolizumab participating in two early-phase clinical trials: KEYNOTE-012 and KEYNOTE-086. Clinical, imaging, pathological [i.e. tumor-infiltrating lymphocytes (TILs), PD-L1 status], RNA sequencing, and whole-exome sequencing data were analyzed. We compared our results with publicly available transcriptomic data from TNBC cohorts from TCGA and METABRIC. RESULTS: Response to pembrolizumab was heterogeneous: two patients experienced exceptional long-lasting responses, six rapid progressions, and three relatively slower disease progression. Neither PD-L1 nor stromal TILs were significantly associated with response to treatment. Increased TMB values were observed in tumor samples from exceptional responders compared to the rest of the cohort (P = 3.4 × 10-4). Tumors from exceptional responders were enriched in adaptive and innate immune cell signatures. Expression of regulatory T-cell markers (FOXP3, CCR4, CCR8, TIGIT) was mainly observed in tumors from responders except for glycoprotein-A repetitions predominant (GARP), which was overexpressed in tumors from rapid progressors. GARP RNA expression in primary breast tumors from the public dataset was significantly associated with a worse prognosis. CONCLUSIONS: The wide spectrum of clinical responses to ICB supports that TNBC is a heterogeneous disease. Tumors with high TMB respond better to ICB. However, the optimal cut-off of 10 mutations (mut)/megabase (Mb) may not reflect the complexity of all tumor subtypes, despite its approval as a tumor-agnostic biomarker. Further studies are required to better elucidate the relevance of the tumor microenvironment and its components as potential predictive biomarkers in the context of ICB.

How I treat endocrine-dependent metastatic breast cancer.

Estrogen receptor-positive (ER+)/HER2-negative (HER2-), the so-called luminal-type breast cancer, is the most frequent subset, accounting for around 70% of all breast cancer cases. Endocrine therapy (ET) combined with cyclin-dependent kinases (CDK) 4/6 inhibitors is the standard first option in the management of advanced luminal breast cancer independently of disease extension. Classically, patients undergo multiple lines of ET ± targeted treatments until endocrine resistance occurs and palliative chemotherapy is proposed. Understanding endocrine resistance mechanisms and development of novel ET options is one of the main challenges in current clinical research. Another area of utmost interest is the improvement of post-endocrine therapeutic approaches. Among others, the development of antibody-drug conjugates (ADCs) is very promising, and some of these drugs will probably soon become a part of the therapeutic arsenal against this incurable disease. This review paper provides an overview of currently available treatment options in ER+/HER2- metastatic breast cancer and extensively discusses new approaches in late clinical development.

Continuous versus intermittent extended adjuvant letrozole for breast cancer: final results of randomized phase III SOLE (Study of Letrozole Extension) and SOLE Estrogen Substudy.

BACKGROUND: Late recurrences in postmenopausal women with hormone receptor-positive breast cancers remain an important challenge. Avoidance or delayed development of resistance represents the main objective in extended endocrine therapy (ET). In animal models, resistance was reversed with restoration of circulating estrogen levels during interruption of letrozole treatment. This phase III, randomized, open-label Study of Letrozole Extension (SOLE) studied the effect of extended intermittent letrozole treatment in comparison with continuous letrozole. In parallel, the SOLE estrogen substudy (SOLE-EST) analyzed the levels of estrogen during the interruption of treatment. PATIENTS AND METHODS: SOLE enrolled 4884 postmenopausal women with hormone receptor-positive, lymph node-positive, operable breast cancer between December 2007 and October 2012 and among them, 104 patients were enrolled in SOLE-EST. They must have undergone local treatment and have completed 4-6 years of adjuvant ET. Patients were randomized between continuous letrozole (2.5 mg/day orally for 5 years) and intermittent letrozole treatment (2.5 mg/day for 9 months followed by a 3-month interruption in years 1-4 and then 2.5 mg/day during all of year 5). RESULTS: Intention-to-treat population included 4851 women in SOLE (n = 2425 in the intermittent and n = 2426 in the continuous letrozole groups) and 103 women in SOLE-EST (n = 78 in the intermittent and n = 25 in the continuous letrozole groups). After a median follow-up of 84 months, 7-year disease-free survival (DFS) was 81.4% in the intermittent group and 81.5% in the continuous group (hazard ratio: 1.03, 95% confidence interval: 0.91-1.17). Reported adverse events were similar in both groups. Circulating estrogen recovery was demonstrated within 6 weeks after the stop of letrozole treatment. CONCLUSIONS: Extended adjuvant ET by intermittent administration of letrozole did not improve DFS compared with continuous use, despite the recovery of circulating estrogen levels. The similar DFS coupled with previously reported quality-of-life advantages suggest intermittent extended treatment is a valid option for patients who require or prefer a treatment interruption.

Adjuvant therapeutic approaches of HER2-positive breast cancer with a focus on neratinib maleate.

Introduction: Breast cancer (BC) is the most common cancer in women. Human epidermal growth factor receptor 2-positive (HER2-positive) BC represents up to 15% of all BC cases and is associated with a poor prognosis. Despite the substantial improvement obtained with the addition to the treatment of trastuzumab in this subtype of BC, disease recurrence can still occur. Areas covered: Anti-HER2 targeting drugs such as trastuzumab, pertuzumab, and T-DM1 have shown significant results in (neo)adjuvant setting. In this article, we will focus on available data for neratinib to reduce BC recurrence based mainly on the results of the ExteNET trial. This trial aimed to investigate whether neratinib can further reduce the risk of recurrence of patients diagnosed with HER2-positive BC. This trial demonstrated a significant reduction in the risk of invasive disease-free survival, particularly in hormone receptor-positive population. In addition, this review provides an expert opinion and analysis of the current situation in the adjuvant HER2-positive BC setting and in particular the escalation strategy of HER2 targeting. Expert opinion: The treatment landscape of HER2 positive BC in this setting will evolve in the coming years with a need for clinical and molecular perspective tools to guide therapy.

Radiosensitization by a novel Bcl-2 and Bcl-XL inhibitor S44563 in small-cell lung cancer.

Radiotherapy has a critical role in the treatment of small-cell lung cancer (SCLC). The effectiveness of radiation in SCLC remains limited as resistance results from defects in apoptosis. In the current study, we investigated whether using the Bcl-2/Bcl-XL inhibitor S44563 can enhance radiosensitivity of SCLC cells in vitro and in vivo. In vitro studies confirmed that S44563 caused SCLC cells to acquire hallmarks of apoptosis. S44563 markedly enhanced the sensitivity of SCLC cells to radiation, as determined by a clonogenic assay. The combination of S44563 and cisplatin-based chemo-radiation showed a significant tumor growth delay and increased overall survival in mouse xenograft models. This positive interaction was greater when S44563 was given after the completion of the radiation, which might be explained by the radiation-induced overexpression of anti-apoptotic proteins secondary to activation of the NF-κB pathway. These data underline the possibility of combining IR and Bcl-2/Bcl-XL inhibition in the treatment of SCLC as they underscore the importance of administering conventional and targeted therapies in an optimal sequence.

[Experience with clindamycin in stomatologic diseases]. / Clindamycin alkalmazásával végzett klinikai vizsgálataink tapasztalatai sztomatológiai kórképekben.

In 114 patients suffering from dental inflammatory diseases (periostitis, gingivitis, sinusitis, periodontitis etc.) and in 41 cases of dental surgical procedures (implantation, dentoalveolar surgery etc.) 3 x 300 mg/day clindamycin was applied during 7 days in the framework of GCP phases IV. In 150 cases (97%) the product proved to be effective and only in 2 cases a mild side effect was observed. On the base of the results clindamycin can be advised for the treatment of stomatological diseases.

[Cholinergic innervation of the oviduct in rabbits]. / Cholinergická inervácia vajíckovodu králika.

Distribution of cholinergic nerves in the oviduct wall in rabbits was investigated by a neurohistochemical method after El Badawi and Schenk (1967). Higher density of cholinergic nerve fibres was confirmed to occur mainly in the isthmic part, but in contrast with literary data it was also found in the ampullar part of oviducts. In the basal parts of oviduct mucosa there were only few cholinergic nerve fibres unlike their density in woman's oviduct. A major part of cholinergic nerves are concentrated in a thick muscular tissue; this is probable to be related with its influence on oviduct motility. In the course of pregnancy, progesterone reduces the number of cholinergic nerves in rabbit oviducts, the number is largely reduced in all layers. These results are considered as preliminary with respect to the number of test rabbits; they indicate that the rabbit oviduct is not any ideal model to study the development of cholinergic innervation in dependence on oestrous cycle phase and pregnancy duration and that they should not be applied to changes in the functional neuromorphology of tuba uterina in woman.

[Changes in cholinergic innervation in the human oviduct during pregnancy]. / Zmeny cholinergickej inervácie l'udského vajíckovodu pocas tehotnosti.

Using a neurohistochemical method for visualization of ACHE positive nerves according to El Badawi and Schenk (5), the authors investigated the distribution of the cholinergic innervation in the oviducts of pregnant women. The cholinergic nerve fibres were present in the oviducts during all trimesters of pregnancy. ACHE positivity of nerve structures in the musculature did not display substantial changes. On the other hand, the authors observed in the mucosa of the oviduct marked changes. In the first trimester they found few cholinergic fibres, in the second and third trimester the number of cholinergic nerve fibres increases. The findings provide evidence that the cholinergic innervation of the mucosa of the oviduct is oestrogen dependent. It will be necessary to elucidate the problem of increasing ACHE positivity of nerve structures during pregnancy by further observations.

Mass mortality and its environmental and evolutionary consequences.

The latest Mesozoic and earliest Tertiary sediments at Deep Sea Drilling Project site 524 provide an amplified record of environmental and biostratographic changes at the end of Cretaceous. Closely spaced samples, representing time intervals as short as 10(2) or 10(3) years, were analyzed for their bulk carbonate and trace-metal compositions, and for oxygen and carbon isotopic compositions. The data indicate that at the end of Cretaceous, when a high proportion of the ocean's planktic organisms were eliminated, an associated reduction in productivity led to a partial transfer of dissolved carbon dioxide from the oceans to the atmosphere. This resulted in a large increase of the atmospheric carbon dioxide during the next 50,000 years, which is believed to have caused a temperature rise revealed by the oxygen-isotope data. The lowermost Tertiary sediments at site 524 include fossils with Cretaceous affinities, which may include both reworked individuals and some forms that survived for a while after the catastrophe. Our data indicate that many of the Cretaceous pelagic organisms became extinct over a period of a few tens of thousands of years, and do not contradict the scenario of cometary impact as a cause of mass mortality in the oceans, as suggested by an iridium anomaly at the Cretaceous-Tertiary boundary.

[Adrenergic and cholinergic innervation of the kidneys in several mammals]. / Adrenergicheskaia i kholinergicheskaia innervatsiia pochek nekotorykh mlekopitaiushchikh.

In dogs and some other mammals, the major neuronal sources for plexus renalis, distribution, architectonics and topographic interrelations of intrarenal neuronal plexus were studied. Adrenergic nerve fibres were revealed by the luminiscent histochemical technique; cholinergic--by the cytochemical method for acetylcholinesterase identification. Peculiar patterns of the intrarenal adrenergic and cholinergic neuronal plexus around the preglomerular arterial bed (main periarterial and adventitial plexus), innervation of efferent arterrioles and vasa recta are described. The system of fine varicous fibres forming neuronal plexus in the marginal zones of the connective tissue and at the cortico-medullar border, that of cortical tubes, venous, pelvic and fibrous capsule innervation of the organ are considered. Some species differences are discovered. The data obtained are compared with those from literature and discussed in terms of functional neuromorphology.

Relationship of blood vessels to small intensely fluorescent cells in the autonomic ganglion.

In our experiments we observed the relationship of the blood vessels to the small, intensely fluorescent cells (SIF cells) in the lower mesenteric ganglion of the cat. We injected the solution of Evan's blue into the ganglia and processed them with the fluorescent histochemical method by Falck and Hillarp. We observed that the SIF cells are placed in the ganglia closely to the blood vessels or closely round them. When observing lager groups of SIF cells placed at the edge of the ganglia a dense network of the blood vessels was observed among these cells.