Phase II study of pembrolizumab in refractory esophageal cancer with correlates of response and survival.

BACKGROUND: Immune checkpoint inhibitors have revolutionized cancer treatment, but the benefits in refractory patients with esophageal cancer have been modest. Predictors of response as well as new targets for novel therapeutic combinations are needed. In this phase 2 clinical trial, we tested single-agent pembrolizumab in patients with advanced esophageal cancer, who received at least one prior line of therapy. METHODS: Pembrolizumab 200 mg every 3 weeks was tested in 49 patients with refractory esophageal cancer: 39 with adenocarcinoma and 10 with esophageal squamous cell carcinoma. Major endpoints were radiological response by Immune-related Response Evaluation Criteria In Solid Tumors and survival. Tumor samples were evaluated for programmed cell death ligand 1 (PD-L1) expression, tumor mutational burden (TMB), and immune contexture by both NanoString mRNA expression analysis and flow cytometry. Peripheral blood mononuclear cells and a panel of circulating chemokines were also analyzed. RESULTS: The overall response rate (ORR) was 8% (4 of 49 patients; 95% CI 2.3% to 19.6%). Median overall survival (OS) was 5.8 months (95% CI 4.0 to 9.5). ORR and OS were not associated with histology. For PD-L1-positive patients, ORR was 13.3% (95% CI 1.7% to 40.5%) and median OS was 7.9 months (95% CI 4.7 to 15.5). A trend toward improved OS was observed in seven patients with a TMB ≥10 mut/Mb (p=0.086). Tumors with a PD-L1 Combined Positive Score ≥1 showed enrichment of LAG3 (p=0.005) and IDO1 (p=0.04) gene expression. Baseline levels of circulating CXCL10, interleukin 2 (IL2) receptor α (IL2RA) and IL6 were associated with survival: CXCL10 favorably, (HR 0.37, p=0.002 (progression-free survival); HR 0.55, p=0.018 (OS)); IL2RA and IL6 unfavorably (HR 1.57, p=0.020 for IL6 (OS); HR 2.36, p=0.025 for IL2RA (OS)). CONCLUSIONS: Pembrolizumab monotherapy was modestly effective in refractory esophageal cancer. Circulating CXCL10 at baseline appeared to be a robust predictor of response. Other T cell exhaustion markers are upregulated in PD-L1-positive patients, suggesting that immunotherapy combinations such as anti-LAG3/programmed cell death protein 1 (PD-1) or anti-IDO1/PD-1 may be of promise in refractory esophageal cancer.

Are cell phones an indicator of personal exposure to organophosphate flame retardants and plasticizers?

BACKGROUND: Exposure to organophosphate ester (OPE) flame retardants and plasticizers is widespread and is of concern due to their toxicity. OBJECTIVES: To investigate relationships between and within OPE concentrations in air, dust, hands, electronic product wipes and urinary metabolites with the goal of identifying product sources and exposure pathways. METHODS: Women in Toronto and Ottawa, Canada, provided a urine sample, two sets of hand wipes, access to their homes for air and dust sampling, and completed a questionnaire. OPE concentrations were obtained for air and floor dust in the bedroom (n = 51) and most used room (n = 26), hand wipes (n = 204), and surface wipes of handheld (n = 74) and non-handheld electronic devices (n = 125). All air, dust and wipe samples were analyzed for 23 OPE compounds; urine samples (n = 44) were analyzed for 8 OPE metabolites. RESULTS: Five-8 OPEs were detected in >80% of samples depending on the sample type. OPE median concentrations in hand wipes taken 3 weeks apart were not significantly different. Palms had higher concentrations than the back of hands; both were significantly correlated. Concentrations of 9 OPEs were significantly higher in surface wipes of handheld than non-handheld electronic devices. Six OPEs in hand wipes were significantly correlated with cell phone wipes, with two to four OPEs significantly correlated with tablet, laptop and television wipes. Multiple regression models using hand wipes, cell phone wipes and dust explained 8-33% of the variation in creatinine-adjusted urinary metabolites; air concentrations did not have explanatory power. OPEs in cell phone wipes explained the greatest variation in urinary metabolites. CONCLUSIONS: Handheld electronic devices, notably cell phones, may either be sources or indicators of OPE exposure through hand-to-mouth and/or dermal uptake.

Species-specific pharmacology of maximakinin, an amphibian homologue of bradykinin: putative prodrug activity at the human B2 receptor and peptidase resistance in rats.

Maximakinin (MK), an amphibian peptide possessing the C-terminal sequence of bradykinin (BK), is a BK B2 receptor (B2R) agonist eliciting prolonged signaling. We reinvestigated this 19-mer for species-specific pharmacologic profile, in vivo confirmation of resistance to inactivation by angiotensin converting enzyme (ACE), value as a module for the design of fusion proteins that bind to the B2R in mammalian species and potential activity as a histamine releaser. Competition of the binding of [3H]BK to recombinant human myc-B2Rs in cells that express these receptors revealed that MK possessed a tenuous fraction (<0.1%) of the affinity of BK, despite being only ∼20-fold less potent than BK in a contractility assay based on the human isolated umbilical vein. These findings are reconciled by the generation of C-terminal fragments, like Lys-Gly-Pro-BK and Gly-Pro-BK, when the latent MK is incubated with human venous tissue (LC-MS), supporting activation via hydrolysis upstream of the BK sequence. At the rat recombinant myc-B2R, MK had a lesser affinity than that of BK, but with a narrower margin (6.2-fold, radioligand binding competition). Accordingly, MK (10 nM) stimulated calcium transients in cells that expressed the rat receptors, but not the human B2R. Recombinant MRGPRX2, a receptor that mediates cationic peptide-induced mast cell secretion, minimally responded by increased [Ca+2]i to MK at 10 µM. Enhanced green fluorescent protein fused to MK (EGFP-MK) labeled cells that expressed rat, but not human B2Rs. Intravenous MK induced dose-dependent hypotensive, vasodilator and tachycardic responses in anesthetized rats and the effects were antagonized by pretreatment with icatibant but not modified by pyrilamine or enalaprilat. Strong species-specific responses to the toxin-derived peptide MK and its prodrug status in the isolated human vein were evidenced. Accordingly, MK in the EGFP-MK fusion protein is a pharmacophore module that confers affinity for the rat B2R, but not for the human form of the B2R. MK is unlikely to be an efficient mast cell activator, but its resistance to inactivation by ACE was confirmed in vivo.

Infrared-emitting, peptidase-resistant fluorescent ligands of the bradykinin B2 receptor: application to cytofluorometry and imaging.

BACKGROUND: We have previously reported the design, pharmacological properties and imaging application of bradykinin (BK) B2 receptor (B2R) ligands conjugated with fluorophores such as fluorescein derivatives at their N-terminus. To take advantage of the high penetration of infrared light into living tissues and their low autofluorescence in this region of the spectrum, additional probes conjugated with cyanine dye 7 (Cy7) were synthesized and characterized. RESULTS: The antagonist B-9430 (D-Arg-[Hyp3,Igl5,D-Igl7,Oic8]-BK) and the agonist B-9972 (D-Arg-[Hyp3,Igl5,Oic7,Igl8]-BK) were N-terminally extended with the infrared fluorophore Cy7, producing the peptides B-10665 and B-10666, respectively. Pharmacological studies indicated that the agonist B-10666 lost much affinity for the B2R vs. the parent peptide, whereas the antagonist B-10665 better retained its potency vs. B-9430 (competition of [3H]BK binding to human B2R, contractility of the human isolated umbilical vein for which potency losses were more important in each case). Both probes stained HEK 293 cells that expressed the B2R-green fluorescent protein (GFP) construction in a specific manner (confocal microscopy) and with very extensive co-localization of the green and infrared fluorescence in either case. The agonist B-10666 at 100 nM promoted the endocytosis of B2R-GFP in live cells, but not the antagonist version at 10-25 nM. The Cy7-labeled peptides did not label cells expressing the ß2-adrenoceptor-GFP construction. B-10665 at low nanomolar concentrations was an effective probe for the recombinant B2Rs in cytofluorometry and macroscopic imaging of cell wells (IVIS imaging system operated for infrared fluorescence detection). CONCLUSIONS: Despite a propensity for non-specific binding when used at high concentrations and limited sensitivity, Cy7-conjugated peptidase-resistant B2R ligands support original imaging and cytofluorometric applications.

The isolated human umbilical vein as a bioassay for kinin-generating proteases: An in vitro model for therapeutic angioedema agents.

AIMS: The isolated human umbilical vein is a robust contractile bioassay for ligands of the bradykinin (BK) B2 receptor (B2R), also extendable to B1 receptor (B1R) pharmacology. We hypothesized that, as a freshly isolated vessel, it also contains traces of plasma proteins that may confer responses to exogenous proteases via the formation of kinins. MAIN METHODS: Rings of human umbilical veins were mounted in organ baths containing Krebs buffer maintained at 37°C and purified proteases were introduced in the bathing fluid along with additional drugs/proteins that permit mechanistic analysis of effects. KEY FINDINGS: The previously described contractile response to human recombinant tissue kallikrein (KLK-1, 1-10nM) is not influenced by metabolic inhibitors, suggesting its dependence on a preexisting reservoir of low molecular weight-kininogen (LK). Active plasma kallikrein (apK, ≤5nM) was inactive in fresh tissues, unless high molecular weight-kininogen (HK, 39-197nM) replenishment was applied. The effects of KLK-1 and HK+apK are abolished by pretreating tissues with icatibant, but not with tranexamic acid. C1-esterase inhibitor inhibited only HK+apK. Purified plasmin and neutrophil proteinase-3 produced small contractions in the presence of HK only, and tissue plasminogen activator, none. B1R stimulation was pharmacologically evidenced in response to KLK-1 if LK was supplied. SIGNIFICANCE: The pharmacology of KLK-1 and HK+apK in the human isolated umbilical vein is essentially based on the activity of locally generated kinins and this assay models the inhibitory action of some therapeutic agents active in angioedema states. Proteases that indirectly generate kinins have little activity in the system.

Pharmacological effects of recombinant human tissue kallikrein on bradykinin B2 receptors.

Tissue kallikrein (KLK-1), a serine protease, initiates the release of bradykinin (BK)-related peptides from low-molecular weight kininogen. KLK-1 and the BK B2 receptor (B2R) mediate beneficial effects on the progression of type 2 diabetes and renal disease, but the precise role of KLK-1 independent of its kinin-forming activity remains unclear. We used DM199, a recombinant form of human KLK-1, along with the isolated human umbilical vein, a robust bioassay of the B2R, to address the previous claims that KLK-1 directly binds to and activates the human B2R, with possible receptor cleavage. DM199 (1-10 nmol/L) contracted the isolated vein via the B2R, but in a tachyphylactic, kinin-dependent manner, without desensitization of the tissue to exogenously added BK. In binding experiments with recombinant N-terminally tagged myc-B2Rs expressed in HEK 293a cells, DM199 displaced [(3)H]BK binding from the rabbit myc-B2R, but not from the human or rat myc-B2Rs. No evidence of myc-B2R degradation by immunoblot analysis was apparent following treatment of these 3 myc-B2R constructs with DM199 (30 min, ≤10 nmol/L). In HEK 293 cells stably expressing rabbit B2R-GFP, DM199 (11-108 pmol/L) elicited signaling-dependent endocytosis and reexpression, while a higher concentration (1.1 nmol/L) induced a partially irreversible endocytosis of the construct (microscopy), paralleled by the appearance of free GFP in cells (immunoblotting, indicative of incomplete receptor down-regulation). The pharmacology of DM199 at relevant concentrations (<10 nmol/L) is essentially based on the activity of locally generated kinins. Binding to and mild down-regulation of the B2R is possibly a species-dependent idiosyncratic response to DM199.

In Vivo Effects of Bradykinin B2 Receptor Agonists with Varying Susceptibility to Peptidases.

We reported evidence of bradykinin (BK) regeneration from C-terminal extended BK sequences that behave as peptidase-activated B2 receptor (B2R) agonists. Further to these in vitro studies, we carried out in vivo experiments to verify hemodynamic effects of BK analogs exhibiting variable susceptibility toward vascular and blood plasma peptidases. Rats were anesthetized and instrumented to record blood pressure and heart rate responses to bolus intravenous (i.v.) injection of increasing doses of BK, B-9972 (D-Arg-[Hyp(3),Igl(5),Oic(7),Igl(8)]-BK), BK-Arg, BK-His-Leu or BK-Ala-Pro, in the absence or presence of specific inhibitors. In some experiments, pulsed Doppler flow probes measured hindquarter Doppler shift in response to i.v. injections of kinins. BK caused rapid, transient and dose-related hypotensive effects. These effects were potentiated ∼15-fold by the angiotensin converting enzyme (ACE) inhibitor, enalaprilat, but extensively inhibited by icatibant (a B2R antagonist) and not influenced by the Arg-carboxypeptidase (CP) inhibitor (Plummer's inhibitor). The hypotensive responses elicited by the peptidase-resistant B2R agonist, B-9972, were not affected by enalaprilat, but were inhibited by icatibant. The hypotensive responses to BK-Arg were abolished by pre-treatment with either the Arg-CP inhibitor or icatibant, pharmacologically evidencing BK regeneration. The hypotensive effects of BK-His-Leu and BK-Ala-Pro, previously reported as ACE-activated substrates, were abolished by icatibant, but not by enalaprilat. In vivo regeneration of BK from these two C-terminally extended analogs with no affinity for the B2R must follow alternative cleavage rules involving unidentified carboxypeptidase(s) when ACE is blocked. The transient hypotensive responses to BK and three tested analogs coincided with concomitant vasodilation (increased Doppler shift signal). Together, these results provide in vivo evidence that interesting hypotensive and vasodilator effects can be extracted from prodrug peptides that behave as peptidase-activated B2R agonists.

Indoor air quality in Montréal area day-care centres, Canada.

Indoor air quality (IAQ) has been understudied in day-care centres (DCCs), even though it can affect the respiratory health of children. This study was undertaken to assess IAQ in a randomly selected sample of 21 DCCs having space for at least 40 children in Montréal, Canada, and to determine associations between building characteristics and IAQ. Questionnaires on building characteristics and operation of the DCC were administered to managers. Temperature, relative humidity, and concentrations of carbon dioxide (CO(2)), formaldehyde and volatile organic compounds were measured in January and February 2008 in rooms attended by children aged between 18 and 60 months. Most DCCs (81%) had a mechanical ventilation system. Over 85% of the DCCs had a mean CO(2) concentration higher than 1000 ppm, the value generally targeted for comfort in buildings. Mean CO(2) concentrations were significantly lower in DCCs having a floor space meeting the provincial standards. The mean (standard deviation-SD) formaldehyde concentration was 22.9 (8.2) µg/m(3), with all participating DCCs being within Health Canada's Residential IAQ Guideline of 50 µg/m(3). The presence of a mechanical ventilation system and a large surface of play area per child were significantly associated with lower CO(2) levels, explaining 44% of the variance in indoor CO(2) concentrations. The presence of a mechanical ventilation system was also associated with significantly lower formaldehyde and acetaldehyde levels. Moreover, 68% of the variance in indoor acetaldehyde concentrations was explained by CO(2) levels, indicating that CO(2) was a better proxy of ventilation than the presence of a ventilation system, as this latter variable did not imply that the ventilation system was running or functioning adequately. These results demonstrate the need for on-going efforts to ensure sufficient floor space and adequate ventilation in DCCs to maintain good IAQ.

Innu food consumption patterns: traditional food and body mass index.

PURPOSE: Food consumption patterns of an Innu community were described and the benefits of traditional food (TF) were investigated in relation to body mass index (BMI). METHODS: A cross-sectional study was conducted using food frequency and 24-hour recall questionnaires to evaluate consumption patterns (n=118) and to assess energy and nutrient intakes from TF and store-bought food (SBF) (n=161). Body mass index was calculated with a sub-sample of 45 participants. RESULTS: Mean yearly TF meal consumption was significantly related to age (p=0.05). Participants reporting high TF and low SBF consumption presented with a normal body weight (BMI=24.1) at the lower quartile and a slightly overweight status (BMI=25.8) at the median. Mean values for protein and carbohydrate intake were higher than the Dietary Reference Intakes, whereas dietary fibre intake was below these guidelines for both genders. Store-bought food provided higher levels of energy and nutrients, except for protein. CONCLUSIONS: Although Innu consume high amounts of TF and SBF, a lack of some essential nutrients was observed. Because TF intake was related to a tendency toward a lower BMI, a combined, targeted diet could be proposed. Health services could reinforce the importance of TF consumption and promote traditional dietary practices that offer advantages at many levels.

Gender differences in the effects of organochlorines, mercury, and lead on thyroid hormone levels in lakeside communities of Quebec (Canada).

Environmental chemicals can disrupt endocrine balance and in particular thyroid hormone (TH) homeostasis. However, studies differ with respect to thyroid profile changes and gender differences are rarely examined. This study investigated the THs, triodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH), in relation to serum organochlorines (OCs), bioindicators of mercury (Hg) and blood lead (Pb) in 211 freshwater fish consumers (124 men and 87 women) from two communities in Canada. Thyroid hormones were within the normal range and the bioindicators of exposure were low compared to other reports on fish consumers. Stratified analysis showed that for women, serum T3 concentrations were negatively related to serum concentrations of PCB 138, PCB 153, the non-coplanar congeners, Arochlor 1260, and SigmaPCB, as well as p,p'-DDE. No relations were observed between T4 and any of the chemicals measured, but TSH was negatively related to blood Pb. For men, serum T4 was inversely related to PCB 138, non-ortho-substituted (dioxin-like) PCBs and SigmaPCB. A significant positive relationship was observed between serum TSH and different PCB congeners (PCB 138, PCB 180, non-coplanar congeners, mono-ortho coplanar congeners, dioxin-like PCBs), as well as SigmaPCB. Serum TSH increased with hair and blood Hg concentrations and was highest among those in the highest 50th percentile for both Hg and dioxin-like PCB congeners compared to the others. No associations were observed for T3 in men. These findings suggest that even at low concentrations, these environmental contaminants can interfere with thyroid status and effects may differ by gender.