Acidic Conditions in the NHE2 -/-

Background: The mechanisms bacteria use to proliferate and alter the normal bacterial composition remain unknown. The ability to link changes in the intestinal micro-environment, such as ion composition and pH, to bacterial proliferation is clinically advantageous for diseases that involve an altered gut microbiota, such as Inflammatory Bowel Disease, obesity and diabetes. In human and mouse intestine, the apical Na+/H+ exchangers NHE2 and NHE3 affect luminal Na+, water, and pH. Loss of NHE2 results in acidic luminal pH. Since acid resistance systems in gram-positive bacteria are well documented, we hypothesize that gram-positive bacteria would increase in representation in the acidic NHE2-/- intestine. Methods: Intestinal ion composition was measured by fame photometry and chloridometry and pH measured electrochemically. DNA extracted from intestinal flushes or from mucosal scrapings was analyzed by qRT-PCR to examine luminal and mucosa-associated bacterial populations. Epithelial mucus oligosaccharide patterns were examined by histology with FIT-C labeled lectins. Results: Although total luminal and mucosa-associated bacteria were unchanged in NHE2-/- intestine, gram-positive bacterial phyla were increased in the mucosa-associated bacterial population in a region-specific manner. The genera Clostridium and Lactobacillus were increased in the cecum and colon which corresponded to changes in NHE2-/- mucus oligosaccharide composition of mannose, N-acetyglucosamine, N-acetygalactosamine and galactose. Conclusions: Together these data indicate that changes in ion transport induce region-specific bacterial changes, which alter host mucus oligosaccharide patterns. These host-bacterial interactions provide a possible mechanism of niche-development and shed insight on how certain groups proliferate in changing environments and maintain their proliferation by altering the host

Results of a randomized phase IIb trial of nelipepimut-S + trastuzumab vs trastuzumab to prevent recurrences in high-risk HER2 low-expressing breast cancer patients.

PURPOSE: Preclinical data provide evidence for synergism between HER2-targeted peptide vaccines and trastuzumab. The efficacy of this combination was evaluated in HER2 low-expressing breast cancer patients in the adjuvant setting. EXPERIMENTAL DESIGN: A phase IIb, multicenter, randomized, single-blinded, controlled trial enrolled disease-free patients after standard therapy completion (NCT01570036). Eligible patients were HLA-A2, A3, A24, and/or A26+, and had HER2 immunohistochemistry 1+/2+, FISH nonamplified breast cancer, that was node positive and/or hormone receptor negative (triple negative breast cancer [TNBC]). Patients received trastuzumab for one year and were randomized to placebo (granulocyte-macrophage colony-stimulating factor [GM-CSF], control) or nelipepimut-S (NPS) with GM-CSF. Primary outcome was 24-month disease-free survival (DFS). Secondary outcomes were 36-month DFS, safety, and immunologic response. RESULTS: Overall, 275 patients were randomized; 136 received NPS with GM-CSF and 139 received placebo with GM-CSF. There were no clinicopathologic differences between groups. Concurrent trastuzumab and NPS with GM-CSF was safe with no additional overall or cardiac toxicity compared to control. At median follow up of 25.7 (interquartile range, IQR: 18.4-32.7) months, estimated DFS did not significantly differ between NPS and control (HR 0.62, 95% CI: 0.31-1.25, p=0.18). In a planned exploratory analysis of TNBC patients, DFS was improved for NPS vs control (HR 0.26, 95% CI: 0.08-0.81, p=0.01). CONCLUSION: The combination of NPS with trastuzumab is safe. In HER2 low-expressing breast cancer, no significant difference in DFS was seen in the intention-to-treat analysis; however, significant clinical benefit was seen in TNBC patients. These findings warrant further investigation in a phase III randomized trial

Subgroup analysis of nelipepimut-S plus GM-CSF combined with trastuzumab versus trastuzumab alone to prevent recurrences in patients with high-risk, HER2 low-expressing breast cancer.

HER2-targeted therapy has not benefited patients with low levels of HER2 expression; however, combination therapy may be effective. Primary analysis of a phase IIb trial investigating the HER2-derived vaccine nelipepimut-S (NPS) did not benefit the intention-to-treat population, but subset analysis showed a benefit in triple-negative breast cancer (TNBC) patients. The subset analysis of this multicenter, randomized, single-blind, phase IIb trial identified significant improvement in 36-month disease-free survival (DFS) between NPS (n = 55) and placebo (n = 44) in TNBC (HR 0.25, p = 0.01) and those who express HLA-A24 (HR 0.41, p = 0.05). The TNBC cohort demonstrated improved 36-month DFS in those with HER2 1+ expression (HR 0.17, p = 0.01), HLA-A24 positivity (HR 0.08, p \u3c 0.01), or in those who received neoadjuvant chemotherapy (HR 0.21, p \u3c 0.01). NPS vaccination with trastuzumab was associated with improved 36-month DFS among patients with TNBC. The observed benefit to this high-risk subgroup warrants confirmation in a phase III trial