Acute Delta Hepatitis in Italy spanning three decades (1991–2019): Evidence for the effectiveness of the hepatitis B vaccination campaign

Updated incidence data of acute Delta virus hepatitis (HDV) are lacking worldwide. Our aim was to evaluate incidence of and risk factors for acute HDV in Italy after the introduction of the compulsory vaccination against hepatitis B virus (HBV) in 1991. Data were obtained from the National Surveillance System of acute viral hepatitis (SEIEVA). Independent predictors of HDV were assessed by logistic-regression analysis. The incidence of acute HDV per 1-million population declined from 3.2 cases in 1987 to 0.04 in 2019, parallel to that of acute HBV per 100,000 from 10.0 to 0.39 cases during the same period. The median age of cases increased from 27 years in the decade 1991-1999 to 44 years in the decade 2010-2019 (p < .001). Over the same period, the male/female ratio decreased from 3.8 to 2.1, the proportion of coinfections increased from 55% to 75% (p = .003) and that of HBsAg positive acute hepatitis tested for by IgM anti-HDV linearly decreased from 50.1% to 34.1% (p < .001). People born abroad accounted for 24.6% of cases in 2004-2010 and 32.1% in 2011-2019. In the period 2010-2019, risky sexual behaviour (O.R. 4.2; 95%CI: 1.4-12.8) was the sole independent predictor of acute HDV; conversely intravenous drug use was no longer associated (O.R. 1.25; 95%CI: 0.15-10.22) with this. In conclusion, HBV vaccination was an effective measure to control acute HDV. Intravenous drug use is no longer an efficient mode of HDV spread. Testing for IgM-anti HDV is a grey area requiring alert. Acute HDV in foreigners should be monitored in the years to come

Polimorfismi di EZH2 e predizione della risposta alla chemioterapia nell'adenocarcinoma pancreatico

Le proteine del gruppo Polycomb (PcG) promuovono la repressione genica attraverso modificazioni di tipo epigenetico della struttura cromatinica. Esse sono organizzate in due complessi multiproteici: il complesso repressivo 1 e 2 di Polycomb (PRC1 e PRC2). PRC2 catalizza la trimetilazione dell’istone H3 sulla lisina 27, innescando il silenziamento del gene. EZH2 è la sua subunità catalitica. EZH2 svolge un ruolo importante nella biologia delle cellule staminali pancreatiche (CST) favorendone i processi di auto-rinnovamento, contribuendo ai fenomeni di progressione tumorale ed è correlato con fattori prognostici negativi dell’adenocarcinoma pancreatico duttale (PDAC): lo stadio, il grading e l’aggressività tumorale. Le linee cellulari pancreatiche resistenti alla gemcitabina si arricchiscono di una quota di CST pancreatiche e il silenziamento genico di EZH2 ripristina la sensibilità di suddette linee pancreatiche al trattamento con gemcitabina. Si è messo in evidenza, inoltre, che il loro trattamento con l’associazione di gemcitabina e DZNeP (inibitore selettivo di EZH2) porta ad un aumento significativo del combination index dei due farmaci. Sulla base di tali evidenze, questo lavoro di tesi ha indagato il ruolo predittivo di quattro polimorfismi a singolo nucleotide (SNPs) di EZH2, selezionati sulla base di analisi tissutali e funzionali, nel PDAC metastatico in pazienti trattati in prima linea con gemcitabina o regimi di combinazione di gemcitabina e Platino. Dei quattro polimorfismi, studiati, due sono risultati interessanti. L’analisi del polimorfismo rs6950683 ha mostrato che nei pazienti con il genotipo C/C (32 su un totale di 88 studiati) vi è stata una risposta obiettiva in 7 (21.9%), nel genotipo C/T (18 pazienti) si è avuta una risposta parziale in 1 (5.6%) e nel genotipo T/T (38 pazienti), solo 4 hanno risposto (10.5%). Suddividendo i pazienti sulla base della presenza dell’allele C, abbiamo dimostrato che il tasso di risposta nel genotipo C/C è stato del 21.9%, mentre nel gruppo “any T” (C/T+T/T) è stato del 8.9% (P=0.08). Questo trend viene confermato nell’analisi per sottogruppo: nei pazienti trattati con sola gemcitabina, quelli con il genotipo C/C (15 pazienti su 63) hanno avuto un tasso di risposta pari al 26.7%, superiore a quello del gruppo “any T” (C/T+T/T)che ha avuto un tasso di risposta pari al 8.3 % (P=0.06). La valutazione comparativa della PFS tra il genotipo C/C vs C/T + T/T ha confermato il trend verso un miglior outcome nel genotipo omozigote C/C (6.5 mesi vs 6.1 mesi, p: 0.76). Questo andamento è stato ribadito dai valori di OS mediana: 11 mesi nei pazienti con il genotipo C/C per il polimorfismo in analisi, verso 7.9 mesi nei pazienti con almeno un allele T. Dai risultati delle nostre analisi è risultato interessante anche lo SNP rs887569 di EZH2. L’analisi sull’intera popolazione di 82 pazienti genotipizzati per questo polimorfismo ha evidenziato un trend verso una migliore risposta nel genotipo A/A. Sui 44 pazienti con tale genotipo, 8 hanno avuto una risposta parziale (18.2%). Invece, il tasso di risposta è stato di 2 pazienti su 29 (6.9%) nel genotipo A/G e solo 1 paziente su 9 nel genotipo G/G (11.1%). Suddividendo i pazienti sulla base della presenza dell’allele A si è visto un trend verso una differenza significativa nel sottogruppo di pazienti trattati con gemcitabina. Infatti: il tasso di risposta nel genotipo A/A è stato del 20%, mentre nel gruppo “any G” (A/G+G/G) è stato del 6.1% (P=0.09) Anche la valutazione comparativa della PFS ha confermato una tendenza al miglior outcome nei pazienti con il genotipo A/A rispetto a quelli con i genotipi A/G e G/G, con una PFS rispettivamente di 7 mesi e 6 mesi (p: 0.48). Questo trend è stato avvalorato dai valori di OS mediana: 8.9 mesi nei pazienti con il genotipo A/A verso 7.9 mesi nei pazienti “any G”. Abbiamo eseguito, inoltre, degli studi in silico in base ai quali abbiamo ipotizzato che i polimorfismi di EZH2 studiati si associano ad alterazioni dei siti di legame di fattori di trascrizione, che potrebbero condizionare una diversa espressione del gene EZH2 In questo studio, quindi, abbiamo dimostrato che il polimorfismo rs6950683 di EZH2 con il genotipo C/ C e il polimorfismo rs887569, genotipo A/A sono associati ad una miglior risposta obiettiva. Questo dato è emerso sia nella valutazione della popolazione globale ed è stato ampiamente confermato nel sottogruppo di pazienti trattati con gemcitabina in monoterapia. Nelle analisi delle funzioni di sopravvivenza si conferma una tendenza a favore dei gruppi più responsivi, sebbene non statisticamente significativa. Tuttavia sarà necessario validare il ruolo prognostico di tali polimorfismi in un’ulteriore coorte di pazienti affetti da PDAC e valutarne il reale valore predittivo nell’ambito di studi prospettici. Sarà necessario, inoltre, caratterizzare funzionalmente i polimorfismi con ulteriori studi in silico e in vivo e valutarne l’associazione con i livelli di espressione della proteina attraverso analisi immunistochimiche di campioni istologici di PDAC. Inoltre, poichè le CST pancreatiche sono coinvolte in prima linea nel fenomeno della ricaduta della malattia dopo resezione chirurgica e nella metastatizzazione, sarà interessante valutare la correlazione tra polimorfismi di EZH2 e l’efficacia del trattamento anche in fase adiuvante. In conclusione, questo studio suggerisce che gli SNPs di EZH2 studiati, potrebbero costituire uno strumento utile in ambito clinico per la selezione dei pazienti da sottoporre ad un trattamento chemioterapico contenente gemcitabina o meno. Inoltre i risultati sinergici osservati tra gli inibitori di EZH2 e la gemcitabina nelle linee cellulari di PDAC suggeriscono un ruolo per EZH2 non solo come fattore prognostico e predittivo ma anche come possibile, futuro target terapeutico per migliorare l'efficacia del trattamento del PDAC

Clinical Outcomes in Fibrolamellar Hepatocellular Carcinoma Treated with Immune Checkpoint Inhibitors

Background: Fibrolamellar hepatocellular carcinoma (FLC) is a rare form of liver cancer primarily affecting children and young adults. Although considered a subset of hepatocellular carcinoma (HCC), FLC has unique molecular and pathologic characteristics, suggesting that it may require different treatment. Immune checkpoint inhibitors (ICIs) are used in the treatment of HCC, but efficacy and safety in FLC has not been characterized. Methods: We performed a multicenter retrospective analysis of patients with FLC to determine responses to ICI therapy. Response rates were assessed based on RECIST 1.1 criteria, and Kaplan–Meier statistics were used for progression-free survival (PFS) and overall survival (OS). Results: FLC tumors were characterized by low tumor mutational burden (TMB) and absent PD-L1 expression. We identified 19 patients who received ICIs, including 15 who received ICI therapy alone [programmed death receptor 1 (PD-1) inhibitor, +/− cytotoxic T lymphocyte antigen-4 (CTLA-4) inhibitor]. Objective tumor responses were observed in 3/19 patients (15.8%), including 2/15 patients (13.3%) who received ICIs alone, all partial responses. Median PFS and OS were 5.5 and 26.0 months, respectively. Grade 3–4 immune related adverse events were observed in 4/19 (21.1%) patients. Conclusions: ICI therapy has modest clinical activity in FLC, and novel therapeutic combinations are needed

Clinical value of chip-based digital-PCR platform for the detection of circulating DNA in metastatic colorectal cancer

International audienc

An analysis of genetic heterogeneity in untreated cancers

Genetic intratumoural heterogeneity is a natural consequence of imperfect DNA replication. Any two randomly selected cells, whether normal or cancerous, are therefore genetically different. Here, we review the different forms of genetic heterogeneity in cancer and re-analyse the extent of genetic heterogeneity within seven types of untreated epithelial cancers, with particular regard to its clinical relevance. We find that the homogeneity of predicted functional mutations in driver genes is the rule rather than the exception. In primary tumours with multiple samples, 97% of driver-gene mutations in 38 patients were homogeneous. Moreover, among metastases from the same primary tumour, 100% of the driver mutations in 17 patients were homogeneous. With a single biopsy of a primary tumour in 14 patients, the likelihood of missing a functional driver-gene mutation that was present in all metastases was 2.6%. Furthermore, all functional driver-gene mutations detected in these 14 primary tumours were present among all their metastases. Finally, we found that individual metastatic lesions responded concordantly to targeted therapies in 91% of 44 patients. These analyses indicate that the cells within the primary tumours that gave rise to metastases are genetically homogeneous with respect to functional driver-gene mutations, and we suggest that future efforts to develop combination therapies have the potential to be curative

A phase 2 trial of gemcitabine and docetaxel in patients with metastatic colorectal adenocarcinoma with methylated checkpoint with forkhead and ring finger domain promoter and/or microsatellite instability phenotype

Abstract We previously reported CHFR methylation in a subset of colorectal cancer (CRC; ∼30%) with high concordance with microsatellite instability (MSI). We also showed that CHFR methylation predicted for sensitivity to docetaxel, whereas the MSI‐high phenotypes were sensitive to gemcitabine. We hypothesized that this subset of patients with CRC would be selectively sensitive to gemcitabine and docetaxel. We enrolled a Phase 2 trial of gemcitabine and docetaxel in patients with MSI‐high and/or CHFR methylated CRC. The primary objective was Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 response rate. Enrolled patients were treated with gemcitabine 800 mg/m2 on days 1 and 8 and docetaxel 70 mg/m2 on day 8 of each 21‐day cycle. A total of 6 patients with CHFR‐methylated, MSI‐high CRC were enrolled from September 2012 to August 2016. The study was closed in September of 2017 due to poor accrual prior to reaching the first interim assessment of response rate, which would have occurred at 10 patients. No RECIST criteria tumor responses were observed, with 3 patients (50%) having stable disease as best response, 1 lasting more than 9 months. Median progression‐free survival (PFS) was 1.79 months (95% confidence interval [CI] = 1.28, not available [NA]) and median overall survival (OS) was 15.67 months (95% CI = 4.24, NA). Common grade 3 toxicities were lymphopenia (67%), leukopenia (33%), and anemia (33%). Although negative, this study establishes a proof‐of‐concept for the implementation of epigenetic biomarkers (CHFR methylation/MSI) as inclusion criteria in a prospective clinical trial to optimize combinatorial strategies in the era of personalized medicine. Study Highlights WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC? CHFR silencing via DNA methylation has been suggested to be predictive of taxane sensitivity in diverse tumors. The frequent association of CHFR methylation with microsatellite instability (MSI) suggested a possible combination therapy with gemcitabine, because the MSI phenotype may result in sensitivity to nucleoside analogues. WHAT QUESTION DID THIS STUDY ADDRESS? We hypothesized that metastatic colorectal cancer (mCRC), which have CHFR methylation and MSI phenotype were sensitive to gemcitabine and docetaxel, and have designed this Phase 2 trial in biomarker‐selected mCRC to test this prediction. WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE? The study enrolled a molecularly defined subgroup of patients with colorectal cancer (CRC) and showed that the combination is safe in this population. Nevertheless, due to poor enrollment and early termination, no conclusions on the primary and secondary end points could be made. HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE? This study supports the feasibility of implementing DNA methylation markers in a prospective clinical trial and further efforts toward their application as predictive biomarkers for therapeutic agents in defined subsets of patients are warranted

Clinical, Genomic, and Transcriptomic Data Profiling of Biliary Tract Cancer Reveals Subtype-Specific Immune Signatures.

PurposeBiliary tract cancers (BTCs) are aggressive cancers that carry a poor prognosis. An enhanced understanding of the immune landscape of anatomically and molecularly defined subsets of BTC may improve patient selection for immunotherapy and inform immune-based combination treatment strategies.MethodsWe analyzed deidentified clinical, genomic, and transcriptomic data from the Tempus database to determine the mutational frequency and mutational clustering across the three major BTC subtypes (intrahepatic cholangiocarcinoma [IHC], extrahepatic cholangiocarcinoma, and gallbladder cancer). We subsequently determined the relationship between specific molecular alterations and anatomical subsets and features of the BTC immune microenvironment.ResultsWe analyzed 454 samples of BTC, of which the most commonly detected alterations were TP53 (42.5%), CDKN2A (23.4%), ARID1A (19.6%), BAP1 (15.5%), KRAS (15%), CDKN2B (14.2%), PBRM1 (11.7%), IDH1 (11.7%), TERT (8.4%), KMT2C (10.4%) and LRP1B (8.4%), and FGFR2 fusions (8.7%). Potentially actionable molecular alterations were identified in 30.5% of BTCs including 39.1% of IHC. Integrative cluster analysis revealed four distinct molecular clusters, with cluster 4 predominately associated with FGFR2 rearrangements and BAP1 mutations in IHC. Immune-related biomarkers indicative of an inflamed tumor-immune microenvironment were elevated in gallbladder cancers and in cluster 1, which was enriched for TP53, KRAS, and ATM mutations. Multiple common driver genes, including TP53, FGFR2, IDH1, TERT, BRAF, and BAP1, were individually associated with unique BTC immune microenvironments.ConclusionBTC subtypes exhibit diverse DNA alterations, RNA inflammatory signatures, and immune biomarkers. The association between specific BTC anatomical subsets, molecular alterations, and immunophenotypes highlights new opportunities for therapeutic development

Table S1 from Salvage Ipilimumab plus Nivolumab after Anti-PD-1/PD-L1 Therapy in Advanced Hepatocellular Carcinoma

Table S1. PFS and OS based on Clinical Characteristics</p

TABLE 1 from Salvage Ipilimumab plus Nivolumab after Anti-PD-1/PD-L1 Therapy in Advanced Hepatocellular Carcinoma

Patient demographicsa</p