PURPOSE The aim of the current study was to assess the economic impact of using next-generation sequencing (NGS) versus single-gene testing strategies among patients with metastatic non–small-cell lung cancer (mNSCLC) from the perspective of the Centers for Medicare & Medicaid Services (CMS) and US commercial payers. METHODS A decision analytic model considered patients who were newly diagnosed with mNSCLC who received programmed death ligand 1 and genomic alteration tests— EGFR, ALK, ROS1, BRAF, MET, HER2, RET, and NTRK1—using upfront NGS (all alterations tested simultaneously plus KRAS), sequential testing (sequence of single-gene tests), exclusionary testing ( KRAS plus sequential testing), and hotspot panels ( EGFR, ALK, ROS1, and BRAF tested simultaneously plus single-gene tests or NGS for MET, HER2, RET, and NTRK1). Model outcomes for each strategy were time-to-test results, the proportion of patients identified harboring alterations with or without US Food and Drug Administration–approved therapies, and total testing costs. A budget impact analysis assessed the economic effects of increasing the proportion of NGS-tested patients. RESULTS In a hypothetical 1,000,000-member health plan, 2,066 Medicare-insured patients and 156 commercially insured patients were estimated to have mNSCLC and to be eligible for testing. Time-to-test results were 2.0 weeks for NGS and the hotspot panel, faster than exclusionary and sequential testing by 2.7 and 2.8 weeks, respectively. NGS was associated with cost savings for both CMS ($1,393,678; $1,530,869; and $2,140,795 less than exclusionary, sequential testing, and hotspot panels, respectively) and commercial payers ($3,809; $127,402; and $250,842 less than exclusionary, sequential testing, and hotspot panels, respectively). Increasing the proportion of NGS-tested patients translated into substantial cost savings for both CMS and commercial payers. CONCLUSION Use of upfront NGS testing in patients with mNSCLC was associated with substantial cost savings and shorter time-to-test results for both CMS and commercial payers.

Aberrant elevation in the levels of the pro-inflammatory cytokine interleukin-1b (IL-1b) contributes to neuroinflammatory diseases. Blood-brain barrier (BBB) dysfunction is a hallmark phenotype of neuroinflammation. It is known that IL-1b directly induces BBB hyperpermeability but the mechanisms remain unclear. Claudin-5 (Cldn5) is a tight junction protein found at endothelial cell-cell contacts that are crucial for maintaining brain microvascular endothelial cell (BMVEC) integrity. Transcriptional regulation of Cldn5 has been attributed to the transcription factors b-catenin and forkhead box protein O1 (FoxO1), and the signaling molecules regulating their nuclear translocation. Non-muscle myosin light chain kinase (nmMlck, encoded by the Mylk gene) is a key regulator involved in endothelial hyperpermeability, and IL-1b has been shown to mediate nmMlck-dependent barrier dysfunction in epithelia. Considering these factors, we tested the hypothesis that nmMlck modulates IL-1b-mediated downregulation of Cldn5 in BMVECs in a manner that depends on transcriptional repression mediated by b-catenin and FoxO1. We found that treating BMVECs with IL-1b induced barrier dysfunction concomitantly with the nuclear translocation of b-catenin and FoxO1 and the repression of Cldn5. Most importantly, using primary BMVECs isolated from mice null for nmMlck, we identified that Cldn5 repression caused by b-catenin and FoxO1 in IL-1b-mediated barrier dysfunction was dependent on nmMlck.

9047 Background: Upregulation of CD73 in multiple cancers increases adenosine production, leading to local immunosuppression. Oleclumab, a human IgG1λ mAb, inhibits CD73 function and may increase antitumor immunity. Initial data from a Phase I, first-in-human, dose-escalation and expansion study showed that oleclumab ± durvalumab had manageable safety and encouraging clinical activity in pts with advanced CRC or PDAC. We report updated safety and activity in these cohorts and the first results in an expansion cohort of pts with advanced EGFRm NSCLC. Methods: Previously treated pts with histologically or cytologically confirmed microsatellite stable CRC, PDAC, or EGFRm NSCLC received oleclumab 5–40 mg/kg (escalation) and 40 mg/kg (expansion) IV Q2W, alone (escalation only) or with durvalumab 10 mg/kg IV Q2W. The primary objective was safety; secondary efficacy objectives included objective response (OR) per RECIST v1.1 and duration of response (DoR). Results: 66 pts were enrolled in the escalation phase (35 CRC, 31 PDAC) and 126 in the expansion phase (42 CRC, 42 PDAC, 42 EGFRm NSCLC). At data cutoff (DCO; June 9, 2020), the median number of oleclumab doses was 4 in pts on monotherapy (range 1–26) and 4 in pts on combination therapy across both phases (range 1–76). In the escalation phase, there were no DLTs in pts on monotherapy or combination therapy; treatment-related adverse events (TRAEs) occurred in 54.8% of pts on monotherapy (Grade 3–4 in 7.1%) and 54.2% of pts on combination therapy (Grade 3–4 in 20.8%); fatigue was the most common TRAE with both regimens. No TRAEs resulted in death. In previous interim analyses before this DCO, no ORs were reported in the escalation phase. In the expansion phase, 5 pts were treated for ≥12 mos; 6 pts were ongoing at DCO. TRAEs occurred in 54.0% (Grade 3–5 in 15.1%); the most common TRAEs were fatigue (15.1%), diarrhea (9.5%), and rash (7.1%). One pt had a TRAE resulting in death (systemic inflammatory response syndrome). ORs were seen in 1 CRC pt (DoR 35.9+ mos [+ = ongoing response]), 2 PDAC pts (DoR 22.1+ and 28.6+ mos), and 4 EGFRm NSCLC pts (DoR range 5.6 to 15.7+ mos, median not reached; only 1 of the 4 pts had ≥25% programmed cell death ligand-1 [PD-L1]+ tumor cells). Nine CRC pts, 8 PDAC pts, and 9 EGFRm NSCLC pts had SD. Of 6 pts with matched biopsies who received combination therapy, 5 had increases in CD8+ T cells, PD-L1, and granzyme B. Baseline tumor CD73 expression and association with clinical response will be presented. Conclusions: Oleclumab ± durvalumab had a tolerable safety profile and combination therapy showed promising antitumor activity in EGFRm NSCLC. ORs and SD were durable, even in tumor types that are generally immunotherapy-resistant. Clinical trial information: NCT02503774.

The Thy1.2 YFP-16 mouse expresses yellow fluorescent protein (YFP) in specific subsets of peripheral and central neurons. The original characterization of this model suggested that YFP was expressed in all sensory neurons, and this model has been subsequently used to study sensory nerve structure and function. Here, we have characterized the expression of YFP in the sensory ganglia (DRG, trigeminal and vagal) of the Thy1.2 YFP-16 mouse, using biochemical, functional and anatomical analyses. Despite previous reports, we found that YFP was only expressed in approximately half of DRG and trigeminal neurons and less than 10% of vagal neurons. YFP-expression was only found in medium and large-diameter neurons that expressed neurofilament but not TRPV1. YFP-expressing neurons failed to respond to selective agonists for TRPV1, P2X2/3 and TRPM8 channels in Ca2+ imaging assays. Confocal analysis of glabrous skin, hairy skin of the back and ear and skeletal muscle indicated that YFP was expressed in some peripheral terminals with structures consistent with their presumed non-nociceptive nature. In summary, the Thy1.2 YFP-16 mouse expresses robust YFP expression in only a subset of sensory neurons. But this mouse model is not suitable for the study of nociceptive nerves or the function of such nerves in pain and neuropathies.

The recombination-activating genes (RAG) 1 and 2 are indispensable for diversifying the primary B cell receptor repertoire and pruning self-reactive clones via receptor editing in the bone marrow; however, the impact of RAG1/RAG2 on peripheral tolerance is unknown. Partial RAG deficiency (pRD) manifesting with late-onset immune dysregulation represents an ‘experiment of nature’ to explore this conundrum. By studying B cell development and subset-specific repertoires in pRD, we demonstrate that reduced RAG activity impinges on peripheral tolerance through the generation of a restricted primary B cell repertoire, persistent antigenic stimulation and an inflammatory milieu with elevated B cell-activating factor. This unique environment gradually provokes profound B cell dysregulation with widespread activation, remarkable extrafollicular maturation and persistence, expansion and somatic diversification of self-reactive clones. Through the model of pRD, we reveal a RAG-dependent ‘domino effect’ that impacts stringency of tolerance and B cell fate in the periphery.

2b. Laryngoscope, 127:2539-2544, 2017.

Background: There is inconclusive evidence that single station N2 disease has better prognosis compared to multi-level N2 or N3 involvement in NSCLC. We aimed to evaluate the prognostic impact of the extent and location of nodal involvement in NSCLC treated with radical chemoradiation (CRT). Method: We retrospectively evaluated patients treated with radical CRT between 2007-2015 in a single tertiary institution. Nodal staging was based on imaging (CT/PET) and/or endoscopic/surgical evaluation. Nodal involvement was categorised as N0, N1, single station N2 (N2 single), multi-level N2 (N2 multi), ipsilateral N3 SCF (N3 scf) and contralateral mediastinal/SCF N3 (N3 contra). Single station N2 was further divided into one or >1 nodal deposits. Overall survival (OS) and disease-free survival (DFS) were defined from the date of radiation commencement to the date of death and relapse, respectively. Cox regression and Kaplan-Meier methods were used for survival analysis. Result: A total of 207 patients were included, with 165 (80%) treated with concurrent and 42 (20%) with sequential CRT. Most tumours were adenocarcinomas (55%: EGFR+ 26%, EGFR-49%, unknown 25%) followed by SCC (36%) and other subtypes (9%). Clinical nodal staging was as follows: N0¼8%, N1¼7%, N2 single ¼19%, N2 multi ¼37%, N3 scf ¼12% and N3 contra ¼16%. Conventional AJCC nodal staging was not prognostic of OS (p¼0.4) or PFS (p¼0.4). However, patients with N2 single (median OS¼40 months) and N3 scf (median OS¼55 months) had improved OS compared to N2 multi (median OS¼23 months) and N3 contra (median¼20 months) (p¼0.005) (Figure 1). In the N2 single subset, those with single nodal deposit had longer median OS (44 months) compared to >1 nodal deposits (27 months) but this was not statistically significant, likely due to the small number of patients (p¼0.4). There was no significant difference in DFS between nodal groups, although N2 single and N3 scf showed a trend towards longer PFS compared to N2 multi and N3 contra (p¼0.09). In multivariate analysis, N2 multi (HR 1.71, 95% CI 1.08-2.71, p¼0.02), T4 (HR 2.02, 95% CI 1.12-3.65, p¼0.02) and older age (HR 1.03, 95% CI 1.01-1.05, p¼0.003) were associated with inferior OS but not the use of sequential CRT (HR 1.31, 95% CI 0.86-1.99, p¼0.2). Conclusion: In this study, N2 single and N3 scf stage III NSCLC showed improved overall survival compared to N2 multi and N3 contra disease after CRT. These findings suggest that nodal distribution, rather than conventional AJCC nodal staging, may have a greater prognostic impact in NSCLC treated with CRT.

Objective: To determine whether surgical case volume is a predictive factor of surgical outcomes when managing geriatric patients with head andneck cancer. Methods: A cross-sectional study design was used. Data were obtainedfrom the Vizient Database, which included a total of 93 academicinstitutions. Men and women aged between 65 and 100 years undergoing head and neck cancer surgery during 2009 and 2012,excluding cases of thyroid cancer and skin cancer of the head and neck(n = 4544) were included in the study. Hospital case volume was definedas low (≤21 cases/year), moderate (22-49 cases/year), or high (≥50 cases/year). The frequency of comorbidities and complications wasmeasured by hospital case volume using a χ2 test. Significancewas determined with an α level of .05. Results: The largest number of head and neck cancer cases involving comorbidities (90.54%) and the highest rate of overall complications(27.50%) occurred in moderate case volume institutions compared to athe complication rate of 22.89% in low volume hospitals and 21.50% in highvolume hospitals ( P < .0001). The most common comorbidities across all3 hospital case volumes included hypertension, metastatic cancer,and chronic pulmonary disease and the most common complicationsincluded hemorrhage/hematoma and postoperative pulmonarycompromise. Conclusion: With more geriatric patients requiring surgery for head andneck cancer, it would be beneficial to manage the more complex cases at high volume centers and to develop multidisciplinary teams to optimizecase management and minimize complications.