Showing papers by "Silvia C. Formenti published in 2014"

Consensus guidelines for the detection of immunogenic cell death

Abstract: Apoptotic cells have long been considered as intrinsically tolerogenic or unable to elicit immune responses specific for dead cell-associated antigens. However, multiple stimuli can trigger a functionally peculiar type of apoptotic demise that does not go unnoticed by the adaptive arm of the immune system, which we named "immunogenic cell death" (ICD). ICD is preceded or accompanied by the emission of a series of immunostimulatory damage-associated molecular patterns (DAMPs) in a precise spatiotemporal configuration. Several anticancer agents that have been successfully employed in the clinic for decades, including various chemotherapeutics and radiotherapy, can elicit ICD. Moreover, defects in the components that underlie the capacity of the immune system to perceive cell death as immunogenic negatively influence disease outcome among cancer patients treated with ICD inducers. Thus, ICD has profound clinical and therapeutic implications. Unfortunately, the gold-standard approach to detect ICD relies on vaccination experiments involving immunocompetent murine models and syngeneic cancer cells, an approach that is incompatible with large screening campaigns. Here, we outline strategies conceived to detect surrogate markers of ICD in vitro and to screen large chemical libraries for putative ICD inducers, based on a high-content, high-throughput platform that we recently developed. Such a platform allows for the detection of multiple DAMPs, like cell surface-exposed calreticulin, extracellular ATP and high mobility group box 1 (HMGB1), and/or the processes that underlie their emission, such as endoplasmic reticulum stress, autophagy and necrotic plasma membrane permeabilization. We surmise that this technology will facilitate the development of next-generation anticancer regimens, which kill malignant cells and simultaneously convert them into a cancer-specific therapeutic vaccine.

Radiation fosters dose-dependent and chemotherapy-induced immunogenic cell death.

Abstract: Established tumors are typified by an immunosuppresive microenvironment Countering this naturally occurring phenomenon, emerging evidence suggests that radiation promotes a proimmunogenic milieu within the tumor capable of stimulating host cancer-specific immune responses Three cryptic immunogenic components of cytotoxic-agent induced cell death—namely, calreticulin cell surface exposure, the release of high mobility group box 1 (HMGB1) protein, and the liberation of ATP—have been previously shown to be critical for dendritic cell (DC) activation and effector T-cell priming Thus, these immune-mobilizing components commonly presage tumor rejection in response to treatment We initially set out to address the hypothesis that radiation-induced immunogenic cell death (ICD) is dose-dependent Next, we hypothesized that radiation would enhance chemotherapy-induced ICD when given concomitantly, as suggested by the favorable clinical outcomes observed in response to analogous concurrent chemoradiation regimens Thus, we designed an in vitro assay to examine the 3 hallmark features of ICD at clinically relevant doses of radiation We then tested the immunogenic-death inducing effects of radiation combined with carboplatin or paclitaxel, focusing on these combinations to mimic chemoradiation regimens actually used in clinical trials of early stage triple negative [NCT0128953/NYU-10–01969] and locally advanced [NYU-06209] breast cancer patients, respectively Despite the obvious limitations of an in vitro model, radiotherapy produced both a dose-dependent induction and chemotherapeutic enhancement of ICD These findings provide preliminary evidence that ICD stimulated by either high-dose radiotherapy alone, or concurrent chemoradiation regimens, may contribute to the establishment of a peritumoral proimmunogenic milieu

Combinations of immunotherapy and radiation in cancer therapy.

Abstract: The immune system has the ability to recognize and specifically reject tumors, and tumors only become clinically apparent once they have evaded immune destruction by creating an immunosuppressive tumor microenvironment. Radiotherapy (RT) can cause immunogenic tumor cell death resulting in cross-priming of tumor-specific T-cells, acting as an in situ tumor vaccine; however, RT alone rarely induces effective anti-tumor immunity resulting in systemic tumor rejection. Immunotherapy can complement RT to help overcome tumor-induced immune suppression, as demonstrated in pre-clinical tumor models. Here, we provide the rationale for combinations of different immunotherapies and RT, and review the pre-clinical and emerging clinical evidence for these combinations in the treatment of cancer.

Two phase I dose-escalation/pharmacokinetics studies of low temperature liposomal doxorubicin (LTLD) and mild local hyperthermia in heavily pretreated patients with local regionally recurrent breast cancer

Abstract: Purpose: Unresectable chest wall recurrences of breast cancer (CWR) in heavily pretreated patients are especially difficult to treat. We hypothesised that thermally enhanced drug delivery using low temperature liposomal doxorubicin (LTLD), given with mild local hyperthermia (MLHT), will be safe and effective in this population.Patients and methods: This paper combines the results of two similarly designed phase I trials. Eligible CWR patients had progressed on the chest wall after prior hormone therapy, chemotherapy, and radiotherapy. Patients were to get six cycles of LTLD every 21–35 days, followed immediately by chest wall MLHT for 1 hour at 40–42 °C. In the first trial 18 subjects received LTLD at 20, 30, or 40 mg/m2; in the second trial, 11 subjects received LTLD at 40 or 50 mg/m2.Results: The median age of all 29 patients enrolled was 57 years. Thirteen patients (45%) had distant metastases on enrolment. Patients had received a median dose of 256 mg/m2 of prior anthracyclines and a median do...

The Optimal Partnership of Radiation and Immunotherapy: from Preclinical Studies to Clinical Translation

Abstract: The main role of the immune system is to restore tissue homeostasis when altered by pathogenic processes, including neoplastic transformation. Immune-mediated tumor rejection has been recognized as an extrinsic tumor suppressor mechanism that tumors need to overcome to progress. By the time a tumor becomes clinically apparent it has successfully escaped immune control by establishing an immunosuppressive microenvironment. Ionizing radiation applied locally to a tumor alters these tumor-host interactions. Accumulating evidence indicates that standard therapeutic doses of radiation have the potential to recover tumor immunogenicity and convert the tumor into an in situ personalized vaccine. Radiotherapy induces an immunogenic tumor cell death promoting cross-presentation of tumor-derived antigens by dendritic cells to T cells. In addition, radiotherapy stimulates chemokine-mediated recruitment of effector T cells to the tumor, and cellular recognition and killing by T cells that is facilitated by upregulation of major histocompatibility antigens, NKG2D ligands, adhesion molecules and death receptors. Despite these effects, radiotherapy alone is only rarely capable of generating enough proinflammatory signals to sufficiently overcome suppression, as it can also activate immunosuppressive factors. However, our group and others have shown that when combined with targeted immunotherapy agents radiotherapy significantly contributes to a therapeutically effective anti-tumor immune response. To illustrate this partnership between radiation and immunotherapy we will discuss as an example our experience in preclinical models and the molecular mechanisms identified. Additionally, the clinical translation of these combinations will be discussed.

Phase 2 trial of everolimus and carboplatin combination in patients with triple negative metastatic breast cancer.

Abstract: Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in breast cancer cell lines. Combination of everolimus also known as RAD001 (oral mammalian target of rapamycin (mTOR) inhibitor) and carboplatin may have activity in metastatic triple-negative breast cancer (TNBC). The primary objective of this study was to determine clinical benefit rate (CBR), that is (complete remission (CR) + partial remission (PR) + stable disease (SD) lasting ≥6 months) and the toxicity of everolimus/carboplatin in women with metastatic TNBC. Prior carboplatin was allowed. Treatment consisted of intravenous carboplatin area under the curve (AUC) 6 (later decreased to AUC 5 and subsequently to AUC 4) every 3 weeks with daily 5 mg everolimus. We enrolled 25 patients in this study. Median age was 58 years. There were one CR, six PRs, seven SDs and eight PDs (progression of disease). CBR was 36% (95% confidence interval (CI) 21.1 to 57.4%). One SD was achieved in a patient progressing on single agent carboplatin. The median progression free survival (PFS) was 3 months (95% CI 1.6 to 4.6 months) and overall survival (OS) was 16.6 months (95% CI 7.3 months to not reached). There were seven patients (28%) with ≥ grade 3 thrombocytopenia; three (12%) with grade 3 neutropenia (no bleeding/febrile neutropenia) and one (4%) with grade 3 anemia. Greater hematological toxicity was seen in the first seven patients treated with carboplatin AUC5/6. After the amendment for starting dose of carboplatin to AUC 4, the regimen was well tolerated with only one out of 18 patients with grade 3 neutropenia and two patients with grade 3 thrombocytopenia. There was only one case of mucositis. Everolimus-carboplatin was efficacious in metastatic TNBC. Dose limiting hematological toxicity was observed when AUC5/6 of carboplatin was combined with everolimus. However, carboplatin AUC 4 was well tolerated in combination with everolimus with continuing responses. ClinicalTrials.gov NCT01127763 .

Is tumor (R)ejection by the immune system the "5th R" of radiobiology?

Abstract: Traditional factors of DNA damage and tumor cell kill, described by the “4 R’s” of radiobiology (Reassortment, Reoxygenation, Repair, and Repopulation) fall short in explaining the role of immunity in hosts treated with radiotherapy. We propose a “5th R,” (immune-mediated) Rejection, which recognizes the contribution of the immune system to the antineoplastic effects of radiotherapy.

Risk and Risk Reduction of Major Coronary Events Associated With Contemporary Breast Radiotherapy

Abstract: Author Affiliations: Department of Emergency Medicine, University of California, San Francisco (Brownell, Hsia); medical student, School of Medicine, University of California, San Francisco (Wang); Division of Geriatrics, Department of Medicine, University of California, San Francisco (Smith); Geriatrics, Palliative and Extended Care, San Francisco Veterans Affairs Medical Center (Smith, Stephens); Department of Community Health Systems, University of California, San Francisco (Stephens).

Prone Breast Intensity Modulated Radiation Therapy: 5-Year Results

Abstract: Purpose To report the 5-year results of a technique of prone breast radiation therapy delivered by a regimen of accelerated intensity modulated radiation therapy with a concurrent boost to the tumor bed. Methods and Materials Between 2003 and 2006, 404 patients with stage I-II breast cancer were prospectively enrolled into 2 consecutive protocols, institutional trials 03-30 and 05-181, that used the same regimen of 40.5 Gy/15 fractions delivered to the index breast over 3 weeks, with a concomitant daily boost to the tumor bed of 0.5 Gy (total dose 48 Gy). All patients were treated after segmental mastectomy and had negative margins and nodal assessment. Patients were set up prone: only if lung or heart volumes were in the field was a supine setup attempted and chosen if found to better spare these organs. Results Ninety-two percent of patients were treated prone, 8% supine. Seventy-two percent had stage I, 28% stage II invasive breast cancer. In-field lung volume ranged from 0 to 228.27 cm 3 , mean 19.65 cm 3 . In-field heart volume for left breast cancer patients ranged from 0 to 21.24 cm 3 , mean 1.59 cm 3 . There was no heart in the field for right breast cancer patients. At a median follow-up of 5 years, the 5-year cumulative incidence of isolated ipsilateral breast tumor recurrence was 0.82% (95% confidence interval [CI] 0.65%-1.04%). The 5-year cumulative incidence of regional recurrence was 0.53% (95% CI 0.41%-0.69%), and the 5-year overall cumulative death rate was 1.28% (95% CI 0.48%-3.38%). Eighty-two percent (95% CI 77%-85%) of patients judged their final cosmetic result as excellent/good. Conclusions Prone accelerated intensity modulated radiation therapy with a concomitant boost results in excellent local control and optimal sparing of heart and lung, with good cosmesis. Radiation Therapy Oncology Group protocol 1005, a phase 3, multi-institutional, randomized trial is ongoing and is evaluating the equivalence of a similar dose and fractionation approach to standard 6-week radiation therapy with a sequential boost.

The International Cancer Expert Corps: A unique approach for sustainable cancer care in low and lower-middle income countries

Abstract: The growing burden of non-communicable diseases including cancer in low- and lowermiddle income countries (LMICs) and in geographic-access limited settings within resource-rich countries requires effective and sustainable solutions. The International Cancer Expert Corps (ICEC) is pioneering a novel global mentorship‐partnership model to address workforce capability and capacity within cancer disparities regions built on the requirement for local investment in personnel and infrastructure. Radiation oncology will be a key component given its efficacy for cure even for the advanced stages of disease often encountered and for palliation. The goal for an ICEC Center within these health disparities settings is to develop and retain a high-quality sustainable workforce who can provide the best possible cancer care, conduct research, and become a regional center of excellence. The ICEC Center can also serve as a focal point for economic, social, and healthcare system improvement. ICEC is establishing teams of Experts with expertise to mentor in the broad range of subjects required to establish and sustain cancer care programs. The Hubs are cancer centers or other groups and professional societies in resource-rich settings that will comprise the global infrastructure coordinated by ICEC Central. A transformational tenet of ICEC is that altruistic, human-service activity should be an integral part of a healthcare career. To achieve a critical mass of mentors ICEC is working with three groups: academia, private practice, and senior mentors/retirees. While in-kind support will be important, ICEC seeks support for the career time dedicated to this activity through grants, government support, industry, and philanthropy. Providing care for people with cancer in LMICs has been a recalcitrant problem. The alarming increase in the global burden of cancer in LMICs underscores the urgency and makes this an opportune time fornovel and sustainable solutions to transform cancer care globally.

Current status and recommendations for the future of research, teaching, and testing in the biological sciences of radiation oncology: Report of the american society for radiation oncology cancer biology/radiation biology task force, executive summary

Abstract: In early 2011, a dialogue was initiated within the Board of Directors (BOD) of the American Society for Radiation Oncology (ASTRO) regarding the future of the basic sciences of the specialty, primarily focused on the current state and potential future direction of basic research within radiation oncology. After consideration of the complexity of the issues involved and the precise nature of the undertaking, in August 2011, the BOD empanelled a Cancer Biology/Radiation Biology Task Force (TF). The TF was charged with developing an accurate snapshot of the current state of basic (preclinical) research in radiation oncology from the perspective of relevance to the modern clinical practice of radiation oncology as well as the education of our trainees and attending physicians in the biological sciences. The TF was further charged with making suggestions as to critical areas of biological basic research investigation that might be most likely to maintain and build further the scientific foundation and vitality of radiation oncology as an independent and vibrant medical specialty. It was not within the scope of service of the TF to consider the quality of ongoing research efforts within the broader radiation oncology space, to presume to consider their future potential, or to discourage in any way the investigators committed to areas of interest other than those targeted. The TF charge specifically precluded consideration of research issues related to technology, physics, or clinical investigations. This document represents an Executive Summary of the Task Force report.

Chemoradiation Therapy versus Chemotherapy Alone for Gastric Cancer after R0 Surgical Resection: A Meta-Analysis of Randomized Trials

Abstract: Objective: Current national guidelines include category 1 recommendations for perioperative chemotherapy or adjuvant chemoradiation with surgical resection for patients with stage IB-IIIB gastric cancer. We conducted a meta-analysis of randomized trials in which chemotherapy was prospectively tested against chemoradiation with surgical resection. Methods: We electronically searched PubMed and EMBASE for randomized, controlled clinical trials involving patients with gastric adenocarcinoma, status post-R0 resection. The interventions compared were adjuvant chemotherapy versus chemoradiation, with any chemotherapy regimen. The primary outcomes of interest were disease-free survival and overall survival. The Mantel-Haenszel random-effects model was used to calculate effect sizes. Results: Six trials that included 1,171 patients were evaluated; 599 were randomized to adjuvant chemoradiation and 572 to chemotherapy alone. Chemoradiation was associated with a significant increase in disease-free survival (odds ratio 1.48, 95% confidence interval 1.08-2.03) when compared to chemotherapy alone. However, there was no significant difference in overall survival (odds ratio 1.27, 95% confidence interval 0.95-1.71). Five trials found no statistically significant differences in toxicities between the two groups. Conclusion: In patients with gastric cancer status post-R0 resection, adjuvant chemoradiation was associated with higher disease-free survival when compared to chemotherapy alone. It remains appropriate to design trials testing new systemic agents with radiotherapy.

Taxanes as radiosensitizers.

Abstract: In parallel with the discovery of the taxanes, our understanding of the molecular underpinnings that comprise the classic biologic principles of fractionated radiotherapy has rapidly evolved over the past half century. Early studies have implicated DNA as the primary target for radiation-induced lethality. More recently, however, the molecular biology involved in radiosensitization of tumor cells has been unveiled. Specifically, factors associated with DNA damage and cell killing, collectively known as the 'four Rs' of radiobiology, including (r)eassortment of tumor cells into the radiosensitive phases of the cell cycle (G2/M), (r)eoxygenation of hypoxic areas within a tumor, (r)epair of sublethal DNA damage, and (r)epopulation of surviving tumor cells, have been elucidated, and upon manipulation of each factor or a combination of factors a significant impact on radiation-associated tumor control probabilities was found. Not only does spatial cooperation have a theoretical benefit in patients with undetectable micrometastatic disease at presentation, but the manipulation of either of the 'four Rs' using taxanes provokes further local radiation-associated tumor cell killing with an associated improvement in clinical responses. Numerous studies have shown that taxanes radiosensitize tumor cells directly and/or indirectly by perturbing the tumor microenvironment in a time-dependent and dose-dependent manner. Herein, the impact of taxanes on radiobiological tenets as a mode of radiosensitizing tumor cells and their clinical implications are reviewed.

Burnout in United States Academic Chairs of Radiation Oncology Programs

Abstract: Purpose The aims of this study were to determine the self-reported prevalence of burnout in chairs of academic radiation oncology departments, to identify factors contributing to burnout, and to compare the prevalence of burnout with that seen in other academic chair groups. Methods and Materials An anonymous online survey was administered to the membership of the Society of Chairs of Academic Radiation Oncology Programs (SCAROP). Burnout was measured with the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Results Questionnaires were returned from 66 of 87 chairs (76% response rate). Seventy-nine percent of respondents reported satisfaction with their current positions. Common major stressors were budget deficits and human resource issues. One-quarter of chairs reported that it was at least moderately likely that they would step down in the next 1 to 2 years; these individuals demonstrated significantly higher emotional exhaustion. Twenty-five percent of respondents met the MBI-HSS criteria for low burnout, 75% for moderate burnout, and none for high burnout. Group MBI-HSS subscale scores demonstrated a pattern of moderate emotional exhaustion, low depersonalization, and moderate personal accomplishment, comparing favorably with other specialties. Conclusions This is the first study of burnout in radiation oncology chairs with a high response rate and using a validated psychometric tool. Radiation oncology chairs share similar major stressors to other chair groups, but they demonstrate relatively high job satisfaction and lower burnout. Emotional exhaustion may contribute to the anticipated turnover in coming years. Further efforts addressing individual and institutional factors associated with burnout may improve the relationship with work of chairs and other department members.

Abstract 633: Inhibition of TGFβ as a strategy to convert the irradiated tumor into in situ individualized vaccine

Abstract: Proceedings: AACR Annual Meeting 2014; April 5-9, 2014; San Diego, CA Accumulating data support the concept that ionizing radiation therapy (RT) has the potential to convert the tumor into an in situ, individualized vaccine; however this potential is rarely realized by RT alone. Transforming growth factor β (TGFβ) is an immunosuppressive cytokine that is activated by RT and inhibits the antigen-presenting function of dendritic cells and the differentiation of effector CD8+ T cells. Here we tested the hypothesis that TGFβ hinders the ability of RT to promote anti-tumor immunity. Development of tumor-specific immunity was examined in two pre-clinical models of metastatic breast cancer and analyzed in patients with metastatic breast cancer treated with local radiotherapy and the TGFβ-neutralizing antibody Fresolimumab. Mice bearing established 4T1 and TSA mouse mammary carcinomas treated with pan-isoform specific TGFβ neutralizing antibody, 1D11, showed significantly improved control of the irradiated tumor and non-irradiated metastases, but no effect in the absence of RT. Notably, whole tumor transcriptional analysis demonstrated the selective upregulation of genes associated with immune-mediated rejection only in tumors of mice treated with RT+TGFβ blockade. Mice treated with RT+TGFβ blockade exhibited cross-priming of CD8+ T cells producing IFNγ in response to three tumor-specific antigens in tumor-draining lymph nodes, which was not evident for single modality treatment. Likewise, HLA-A2.1+ metastatic breast cancer patients (n=8) enrolled in [NCT01401062][1] trial of local RT and fresolimumab were examined for CD8+ T cells specific for the tumor antigen survivin by tetramer staining. Three patients developed increased frequencies of survivin-specific CD8+ T cells in the blood during treatment, while two patients negative at baseline became positive. Analysis of the immune infiltrate in mouse tumors showed a significant increase in CD4+ and CD8+ T cells only in mice treated with the combination of RT+TGFβ blockade. Depletion of CD4+ or CD8+ T cells abrogated the therapeutic benefit of RT+TGFβ blockade. These data identify TGFβ as a master inhibitor of the ability of RT to generate an in situ tumor vaccine, which supports testing inhibition of TGFβ during radiotherapy to promote therapeutically effective anti-tumor immunity. Supported by DOD BCRP Multi-Team Award BC100481. Citation Format: Claire I. Vanpouille-Box, Julie M. Diamond, Jiri Zavadil, James Babb, Dorthe Schaue, Mary Helen Barcellos-Hoff, William H. McBride, Silvia C. Formenti, Sandra Demaria. Inhibition of TGFβ as a strategy to convert the irradiated tumor into in situ individualized vaccine. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 633. doi:10.1158/1538-7445.AM2014-633 [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01401062&atom=%2Fcanres%2F74%2F19_Supplement%2F633.atom

Feasibility and efficacy of local radiotherapy with concurrent novel agents in patients with multiple myeloma.

Abstract: Introduction This study evaluated the safety and efficacy of radiotherapy (RT) with concurrent novel agents (NAs), cytotoxic therapy (CTx), or both in the management of osteolytic bone lesions in multiple myeloma (MM). Patients and methods A total of 39 patients with MM received RT to 64 different bone sites during the 2007-2012 period, with a dose of 8 to 37.5 Gy (mean, 26.8 Gy) delivered in 1 to 15 fractions (median, 10 fractions). Of these patients, 21 also received concurrent NAs or CTx. Pain response, M protein and κ light chain response, and adverse events were evaluated. Results RT was completed in 35 of 39 patients (89.7%) in this study. Pain relief was observed in 30 of 31 patients (96.7%). Hematologic toxicity (grade 3 or 4 by the Radiation Therapy Oncology Group system) was seen in 43.2% of treated patients, and NA therapy was stopped in 2 patients owing to grade 4 toxicity. RT adverse effects resolved at 4 to 6 weeks posttreatment. Changes in pre- and posttreatment levels of M protein trended toward significance in patients treated with RT + systemic therapy (ST) versus. RT alone (ΔM ProteinRT+ST = 5.6 g/L; ΔM ProteinRT = 0 g/L; P = .089). Conclusion Treating MM with RT concurrently with CTx including NAs was safe and well tolerated in the majority of patients (14 of 16 [87.5%] for those taking NAs and 19 of 21 [90.5%] for all patients). Excellent clinical pain response (> 95%) was also seen in patients regardless if they were treated with RT + ST or RT alone.

Hypofractionated radiation therapy for early stage breast cancer: outcomes, toxicities, and cost analysis.

Abstract: A French prospective randomized trial comparing whole breast radiotherapy with 45 Gy in 25 fractions versus 23 Gy in four fractions demonstrated equivalent 5-year local control and survival. On the basis of this data, we offer the hypofractionated regimen to women who refuse to undergo standard radiotherapy. We report our outcomes and a cost analysis. Between 2000 and 2012, 84 patients participated in this IRB-approved study and underwent whole breast radiation to 23 Gy in four fractions. Local control and survival were analyzed using the Kaplan-Meier method. Acute toxicities and overall long-term cosmetic results were assessed. Costs were estimated from 2012 Medicare reimbursement data and compared to costs from standard courses of 25 and 16 fractions. All 84 patients are included in this report. Median age was 83 (range 42-98). Most patients had stage I (80%), hormone receptor positive (90%) breast cancer. Fifty-eight patients (69%) were treated prone and 26 (31%) supine. At a median follow-up of 3 years, one local recurrence has occurred, of ductal carcinoma in situ histology. Among the 13 patients deceased, two died of metastatic breast cancer. Five-year actuarial local control is 99%, breast cancer-specific survival is 98%, and overall survival is 79%. Toxicities were limited to grade 1 dermatitis in 32 patients (38%) and grade 2 fatigue in three (4%). Sixty-three patients (75%) reported good or excellent cosmetic outcome at their last follow-up. Collected Medicare reimbursement was $4,798 for the hypofractionated course. Compared to the projected reimbursement of standard regimens, $10,372 for 25 fractions and $8,382 for 16 fractions, it resulted in a difference of $5,574 and $3,584, respectively. At a follow-up of 3 years, this hypofractionated regimen appears to be a promising approach, primarily for elderly women who are unable to undergo longer treatment courses but have indications for whole breast radiotherapy.

Unique changes in the TCR repertoire of tumor-infiltrating lymphocytes underlie the synergy of radiotherapy with CTLA-4 blockade

Abstract: Meeting abstracts Checkpoint blockade is increasingly becoming a valuable immunotherapeutic tool in the management of advanced malignancies. Monoclonal antibodies (mAb) that target CTLA-4 have significantly extended survival of patients with metastatic melanoma, however the number of responders

Clinical Trial Evidence of the Antitumor Activity of Topical Imiquimod for Breast Cancer Skin Metastases

Abstract: TO THE EDITOR: Henriques et al recently published a case report demonstrating successful treatment of refractory breast cancer skin metastases with topical imiquimod added to systemic therapy. Application of imiquimod, a Toll-like receptor 7 agonist, resulted in partial regression of the skin metastases. The authors state in their introduction that a literature review only revealed a “single case report describing the use of topical imiquimod . . . to successfully treat breast cancer skin metastasis.” In 2012, we published a phase II trial of topical imiquimod in the treatment of breast cancer skin metastasis which included extensive correlative studies in tumor biopsies and blood. Imiquimod was applied five times per week as in the regimen approved for the treatment of superficial basal cell carcinoma and used in the previous case report of breast cancer. Similar to the report by Henriques et al, patients in the trial had the option to continue receiving a systemic regimen concurrently (if no previous response in skin was seen). The results of our prospective study showed that imiquimod treatment in women with heavily pretreated and refractory breast cancer skin metastases achieved a response rate of 20% (partial response in two of 10 patients). Changes in the tumor microenvironment of the responders were strongly suggestive of an immune-mediated response. We observed an induction of a Th1-polarized immune response as well as a reduction of a preexisting immunosuppressive milieu. Our results from a prospective trial demonstrate that imiquimod can be effective in patients with breast cancer that is metastatic to skin. However, the majority of tumors did not regress, which has important implications for future research. Combinatorial approaches should be tested to increase local response and to induce a more powerful antitumor immune response that is capable of controlling systemic metastases, as visceral disease ultimately causes the patient’s death. Preliminary evidence of systemic disease control has been observed in two patients from the imiquimod trial who experienced long-lasting complete remissions after immuno-endocrine therapy, accompanied by treatment-induced priming and boosting of tumor antigen–specific T cells, detectable ex vivo (manuscript submitted for publication). To inform clinical studies, our group and others have studied and identified synergistic combinations in murine models of mammary carcinoma. In the TSA murine model of breast cancer with cutaneous involvement, the combination of topical imiquimod and local radiotherapy induced complete regression of the treated lesions and improved systemic tumor control, leading to enhanced survival. Improved antitumor efficacy and prolonged survival was also observed in neu transgenic mice, in which topical imiquimod was combined with antibodies against interleukin-10. Clinical trials are ongoing to study these and other combinations (NCT01421017 and NCT00821964).

Radiotherapy induces responsiveness of a resistant mammary carcinoma to PD-1 blockade

Abstract: ligands, PDL-1/2, were upregulated by RT on TSA cells and tumor-infiltrating myeloid cells, suggesting PD-1’s interaction with its ligands may limit RT-activated antitumor T-cell activity. Consistent with this hypothesis, RMP1-14 alone had no effect on tumor growth; RT delayed growth (p < 0.01), but only 1/6 mice showed tumor regression, whereas all mice receiving RT+RMP114 completely rejected tumors by day 25. In spleen, RMP1-14 had no effect on AH1-specific CD8 + T-cells

Fractionated but not single dose radiation releases key signals of in situ tumor vaccination

Abstract: Meeting abstracts The balance between pro-inflammatory and immunosuppressive signals in the tumor microenvironment dictates the responsiveness of the immune system. Local radiotherapy (RT) has the potential to switch this balance in favor of anti-tumor immunity by promoting cross-priming of anti-

Influence of water activity and anti-fungal compounds on development and competitiveness of Fusarium verticillioides

Abstract: This investigated the roles of water activity (a w ) and fungicides on the competitiveness of two Fusarium verticillioides strains against other spoilage fungi commonly present in maize ( F. proliferatum, Aspergillus niger, A. flavus, A. ochraceus and Penicillium verrucosum ). Fungal strains were inoculated on artificial media containing maize flour. The effects were determined of three a w levels (0.99, 0.98 and 0.95) and three fungicides (tebuconazole, procloraz and prothioconazole) on fungal interactions, the Index of Dominance (I D ) of isolates and fumonisin B 1 +B 2 (FBs) production. The two strains of F. verticillioides showed similar behaviour in conditions where water was freely available (0.99 a w ); at 0.98 and 0.95 a w both F. verticilliodes strains had the lowest total I D scores (8–6 and 10–12, respectively). They showed the same ability to compete against other fungi having the highest I D scores against P. verrucosum and A. ochraceus and the lowest against A. niger and A. flavus. The lowest water activity gave (0.95 a w ) was the most conducive for fumonisin production with significant differences to 0.98 and 0.99 a w . In a co-inoculation experiment, only FBs production from P. verrucosum was greater in the presence of the F. verticilliodes strains other fungi. The use of fungicides reduced Indices of Dominancy (I D ) for both F. verticilliodes strains. A significant reduction in F. verticilloides growth was observed when combining water stress and fungicide treatments. This information provides increased understanding of the colonisation patterns of F. verticillioides in relation to other mycobiota and to both environmental and chemical stresses, and has implications in relation to future climate change scenarios.

Abstract 5020: Cooperative effects of programmed cell death-1 blockade and radiation in a model of a poorly immunogenic breast carcinoma

Abstract: We have previously shown that radiation therapy (RT) converts poorly immunogenic tumors resistant to antibodies (mAbs) against the checkpoint receptor CTLA-4 into susceptible ones. Importantly, RT induced the upregulation of PDL-1 and PDL-2 on the tumor cells and infiltrating myeloid cells in the TSA mouse breast cancer, suggesting that PD-1 ligands may limit rejection of the irradiated tumor by T cells. PD-1 is a checkpoint receptor upregulated on T cells shortly after activation and expressed at high levels on exhausted T cells. To test the hypothesis PD-1 blockade can promote the ability of RT to induce effective anti-tumor immunity we employed BALB/c mice inoculated s.c. with the syngeneic poorly immunogenic TSA breast cancer cells. When tumors became palpable mice were randomly assigned to one of 4 treatment groups (N=6-7): (1) control, (2) RT, (3) anti-PD-1 mAb and (4) RT+anti-PD-1 mAb. RT was delivered exclusively to the primary tumor in 8 Gy fractions on days 13, 14 and 15 post tumor inoculation. PD-1 blocking mAb RMP1-14 was given on day 15 and every 4 days thereafter, and mice were followed for tumor growth. In a separate experiment, mice were euthanized on day 20 to characterize tumor-infiltrating lymphocytes (TILs) and development of CD8+ T cells specific for the tumor epitope AH1 by pentamer analysis. TSA tumors were resistant to PD-1 blockade. RT significantly delayed tumor growth (p Overall, data suggest that the IgG2a anti-PD-1 mAb RMP1-14 selectively depletes CD8+PD-1hi TILs, possibly by ADCC, while enhancing the RT-elicited priming and activation of tumor-specific CD8+ T cells. We propose that this represents a novel mechanism of anti-tumor activity of anti-PD-1 mAb and supports testing its combination with radiotherapy. Supported by the Breast Cancer Alliance (Exceptional Project Award). Citation Format: Karsten Pilones, Joseph Aryankalayil, Silvia Formenti, Sandra Demaria. Cooperative effects of programmed cell death-1 blockade and radiation in a model of a poorly immunogenic breast carcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5020. doi:10.1158/1538-7445.AM2014-5020