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Immunotherapy has revolutionized the treatment of advanced melanoma. Because the pathways mediating resistance to immunotherapy are largely unknown, we conducted transcriptome profiling of preimmunotherapy tumor biopsies from patients with melanoma that received PD-1 blockade or adoptive cell therapy with tumor-infiltrating lymphocytes. We identified two melanoma-intrinsic, mutually exclusive gene programs, which were controlled by IFNγ and MYC, and the association with immunotherapy outcome. MYC-overexpressing melanoma cells exhibited lower IFNγ responsiveness, which was linked with JAK2 downregulation. Luciferase activity assays, under the control of JAK2 promoter, demonstrated reduced activity in MYC-overexpressing cells, which was partly reversible upon mutagenesis of a MYC E-box binding site in the JAK2 promoter. Moreover, silencing of MYC or its cofactor MAX with siRNA increased JAK2 expression and IFNγ responsiveness of melanomas, while concomitantly enhancing the effector functions of T cells coincubated with MYC-overexpressing cells. Thus, we propose that MYC plays a pivotal role in immunotherapy resistance through downregulation of JAK2.

Comparison between proteome and transcriptome profiling. Related to Figure 1.

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Immunotherapy has revolutionized the treatment of advanced melanoma. Because the pathways mediating resistance to immunotherapy are largely unknown, we conducted transcriptome profiling of preimmunotherapy tumor biopsies from patients with melanoma that received PD-1 blockade or adoptive cell therapy with tumor-infiltrating lymphocytes. We identified two melanoma-intrinsic, mutually exclusive gene programs, which were controlled by IFNγ and MYC, and the association with immunotherapy outcome. MYC-overexpressing melanoma cells exhibited lower IFNγ responsiveness, which was linked with JAK2 downregulation. Luciferase activity assays, under the control of JAK2 promoter, demonstrated reduced activity in MYC-overexpressing cells, which was partly reversible upon mutagenesis of a MYC E-box binding site in the JAK2 promoter. Moreover, silencing of MYC or its cofactor MAX with siRNA increased JAK2 expression and IFNγ responsiveness of melanomas, while concomitantly enhancing the effector functions of T cells coincubated with MYC-overexpressing cells. Thus, we propose that MYC plays a pivotal role in immunotherapy resistance through downregulation of JAK2.

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Supplementary Table from Adenosine-Deaminase-Acting-on-RNA-1 Facilitates T-cell Migration toward Human Melanoma Cells

The effect of tumor/T-cell interactions on subsequent immune infiltration is undefined. Here, we report that preexposure of melanoma cells to cognate T cells enhanced the chemotaxis of new T cells in vitro. The effect was HLA class I–restricted and IFNγ-dependent, as it was abolished by β2M-knockdown, MHC-blocking antibodies, JAK1 inhibitors, JAK1-silencing and IFNgR1-blocking antibodies. RNA sequencing (RNA-seq) of 73 melanoma metastases showed a significant correlation between the interferon-inducible p150 isoform of adenosine-deaminase-acting-on-RNA-1 (ADAR1) enzyme and immune infiltration. Consistent with this, cocultures of cognate melanoma/T-cell pairs led to IFNγ-dependent induction of ADAR1-p150 in the melanoma cells, as visualized in situ using dynamic cell blocks, in ovo using fertilized chick eggs, and in vitro with Western blots. ADAR1 staining and RNA-seq in patient-derived biopsies following immunotherapy showed a rise in ADAR1-p150 expression concurrently with CD8+ cell infiltration and clinical response. Silencing ADAR1-p150 abolished the IFNγ-driven enhanced T-cell migration, confirming its mechanistic role. Silencing and overexpression of the constitutive isoform of ADAR1, ADAR1-p110, decreased and increased T-cell migration, respectively. Chemokine arrays showed that ADAR1 controls the secretion of multiple chemokines from melanoma cells, probably through microRNA-mediated regulation. Chemokine receptor blockade eliminated the IFNγ-driven T-cell chemotaxis. We propose that the constitutive ADAR1 downregulation observed in melanoma contributes to immune exclusion, whereas antigen-specific T cells induce ADAR1-p150 by releasing IFNγ, which can drive T-cell infiltration.

Supplementary Figure from Adenosine-Deaminase-Acting-on-RNA-1 Facilitates T-cell Migration toward Human Melanoma Cells

The effect of tumor/T-cell interactions on subsequent immune infiltration is undefined. Here, we report that preexposure of melanoma cells to cognate T cells enhanced the chemotaxis of new T cells in vitro. The effect was HLA class I–restricted and IFNγ-dependent, as it was abolished by β2M-knockdown, MHC-blocking antibodies, JAK1 inhibitors, JAK1-silencing and IFNgR1-blocking antibodies. RNA sequencing (RNA-seq) of 73 melanoma metastases showed a significant correlation between the interferon-inducible p150 isoform of adenosine-deaminase-acting-on-RNA-1 (ADAR1) enzyme and immune infiltration. Consistent with this, cocultures of cognate melanoma/T-cell pairs led to IFNγ-dependent induction of ADAR1-p150 in the melanoma cells, as visualized in situ using dynamic cell blocks, in ovo using fertilized chick eggs, and in vitro with Western blots. ADAR1 staining and RNA-seq in patient-derived biopsies following immunotherapy showed a rise in ADAR1-p150 expression concurrently with CD8+ cell infiltration and clinical response. Silencing ADAR1-p150 abolished the IFNγ-driven enhanced T-cell migration, confirming its mechanistic role. Silencing and overexpression of the constitutive isoform of ADAR1, ADAR1-p110, decreased and increased T-cell migration, respectively. Chemokine arrays showed that ADAR1 controls the secretion of multiple chemokines from melanoma cells, probably through microRNA-mediated regulation. Chemokine receptor blockade eliminated the IFNγ-driven T-cell chemotaxis. We propose that the constitutive ADAR1 downregulation observed in melanoma contributes to immune exclusion, whereas antigen-specific T cells induce ADAR1-p150 by releasing IFNγ, which can drive T-cell infiltration.

Several landmark preclinical studies have shown an association between the gut microbiota and the effectiveness of immunotherapy for cancer. These studies have sparked clinical trials aimed at modulating the gut microbiota in order to improve clinical response rates to immunotherapy. Despite this, the mechanisms through which the gut microbiota influences the effectiveness of immunotherapy are still incompletely characterized. Preclinical and preliminary clinical findings from numerous types of gut microbiota modulation studies, including fecal transplantation, probiotics, consortia, and diet, demonstrate that favorable microbiota modulation is associated with increased intratumoral infiltration of CD8+ effector T cells. This CD8+ T-cell infiltration is often associated with enhanced intratumoral activity of T-helper type 1 cells and dendritic cells and a lower density of immunosuppressive cells. Herein, we discuss how gut microbiota may affect the activity of immune cells by at least three interlacing mechanisms: activation of pattern recognition receptors, molecular mimicry, and impact of metabolites. We also discuss the therapeutic potential and limitations of the different gut microbiota modulation techniques and their putative mechanisms of immune activation.

New fecal microbiota for cancer patients The composition of the gut microbiome influences the response of cancer patients to immunotherapies. Baruch et al. and Davar et al. report first-in-human clinical trials to test whether fecal microbiota transplantation (FMT) can affect how metastatic melanoma patients respond to anti–PD-1 immunotherapy (see the Perspective by Woelk and Snyder). Both studies observed evidence of clinical benefit in a subset of treated patients. This included increased abundance of taxa previously shown to be associated with response to anti–PD-1, increased CD8 + T cell activation, and decreased frequency of interleukin-8–expressing myeloid cells, which are involved in immunosuppression. These studies provide proof-of-concept evidence for the ability of FMT to affect immunotherapy response in cancer patients. Science , this issue p. 602 , p. 595 ; see also p. 573

Background The prognostic performance of the recently updated American Joint Committee on Cancer lymph node classification of cutaneous head and neck squamous cell carcinoma (HNSCC) has not been validated. The objective of this study was to assess the prognostic role of extranodal extension (ENE) in cutaneous HNSCC. Methods This was a retrospective analysis of 1258 patients with cutaneous HNSCC who underwent surgery with or without adjuvant therapy between 1995 and 2019 at The University of Texas MD Anderson Cancer Center. The primary outcome was disease-specific survival (DSS). Local, regional, and distant metastases-free survival were secondary outcomes. Recursive partitioning analysis (RPA) and a Cox proportional hazards regression model were used to assess the fitness of staging models. Results No significant differences in 5-year DSS were observed between patients with pathologic lymph node-negative (pN0) disease (67.4%) and those with pN-positive/ENE-negative disease (68.2%; hazard ratio, 1.02; 95% CI, 0.61-1.79) or between patients with pN-positive/ENE-negative disease and those with pN-positive/ENE-positive disease (52.7%; hazard ratio, 0.57; 95% CI, 0.31-1.01). The RPA-derived model achieved better stratification between high-risk patients (category III, ENE-positive with >2 positive lymph nodes) and low-risk patients (category I, pN0; category II, ENE-positive/pN1 and ENE-negative with >2 positive lymph nodes). The performance of the RPA-derived model was better than that of the pathologic TNM classification (Akaike information criterion score, 1167 compared with 1176; Bayesian information criterion score, 1175 compared with 1195). Conclusions The number of metastatic lymph nodes and the presence of ENE are independent prognostic factors for DSS in cutaneous HNSCC, and incorporation of these factors in staging systems improves the performance of the American Joint Committee on Cancer lymph node classification.

Another benefit of dietary fiber The gut microbiome can modulate the immune system and influence the therapeutic response of cancer patients, yet the mechanisms underlying the effects of microbiota are presently unclear. Spencer et al . add to our understanding of how dietary habits affect microbiota and clinical outcomes to immunotherapy. In an observational study, the researchers found that melanoma patients reporting high fiber (prebiotic) consumption had a better response to checkpoint inhibitor immunotherapy compared with those patients reporting a low-fiber diet. The most marked benefit was observed for those patients reporting a combination of high fiber consumption and no use of over-the-counter probiotic supplements. These findings provide early insights as to how diet-related factors may influence the immune response. —PNK

International audience; Treatment with combined immune checkpoint blockade (CICB) targeting CTLA-4 and PD-1 is associated with clinical benefit across tumor types, but also a high rate of immune-related adverse events. Insights into biomarkers and mechanisms of response and toxicity to CICB are needed. To address this, we profiled the blood, tumor and gut microbiome of 77 patients with advanced melanoma treated with CICB, with a high rate of any ≥grade 3 immune-related adverse events (49%) with parallel studies in pre-clinical models. Tumor-associated immune and genomic biomarkers of response to CICB were similar to those identified for ICB monotherapy, and toxicity from CICB was associated with a more diverse peripheral T-cell repertoire. Profiling of gut microbiota demonstrated a significantly higher abundance of Bacteroides intestinalis in patients with toxicity, with upregulation of mucosal IL-1β in patient samples of colitis and in pre-clinical models. Together, these data offer potential new therapeutic angles for targeting toxicity to CICB.

Immunotherapy with checkpoint inhibitors revolutionized melanoma treatment in both the adjuvant and metastatic setting, yet not all metastatic patients respond, and metastatic disease still often recurs among immunotherapy-treated patients with locally advanced disease. TNFSF4 is a co-stimulatory checkpoint protein expressed by several types of immune and non-immune cells, and was shown in the past to enhance the anti-neoplastic activity of T cells. Here, we assessed its expression in melanoma and its association with outcome in locally advanced and metastatic disease. We used publicly available data from The Cancer Genome Atlas (TCGA) and the Cancer Cell Line Encyclopedia (CCLE), and RNA sequencing data from anti-PD1-treated patients at Sheba medical center. TNFSF4 mRNA is expressed in melanoma cell lines and melanoma samples, including those with low lymphocytic infiltrates, and is not associated with the ulceration status of the primary tumor. Low expression of TNFSF4 mRNA is associated with worse prognosis in all melanoma patients and in the cohorts of stage III and stage IIIc-IV patients. Low expression of TNFSF4 mRNAs is also associated with worse prognosis in the subgroup of patients with low lymphocytic infiltrates, suggesting that tumoral TNFSF4 is associated with outcome. TNFSF4 expression was not correlated with the expression of other known checkpoint mRNAs. Last, metastatic patients with TNFSF4 mRNA expression within the lowest quartile have significantly worse outcome on anti-PD1 treatment, and a significantly lower response rate to these agents. Our current work points to TNFSF4 expression in melanoma as a potential determinant of prognosis, and warrants further translational and clinical research.

Background The survival benefit of elective neck dissection (END) for patients with cutaneous squamous cell carcinoma (cSCC) of the head and neck and no evidence of regional metastasis (cN0) has never been reported. The aim of this study was to determine the effect of END on patient survival. Methods The authors included patients with head and neck cSCC who had undergone primary surgery from 1995 to 2017. The primary end point was survival, and the secondary end points were the incidence of occult regional disease and regional disease control. To assess the impact of END on survival, the authors used multivariable Cox proportional hazards models with propensity score and matching techniques for internal validation. Results A total of 1111 patients presented with no evidence of nodal disease; 173 had END, and 938 were observed. Adjuvant radiotherapy to the neck was administered to 101 patients (9%). END resulted in a 5-year overall survival rate of 52%, whereas the rate was 63% in the observation group (P = .003 [log-rank]). The 5-year disease-free survival rate for patients undergoing END was similar to that for the observation group (73% vs 75%; P = .429). A multivariate regression model showed that the performance of END was not associated with improved rates of overall, disease-specific, or disease-free survival; similarly, among patients with advanced disease (T3-4), those who underwent END did not have improved survival rates. Conclusions Among patients with cSCC of the head and neck, observation of the neck nodes resulted in noninferior survival rates in comparison with END at the time of primary surgery. Further studies are required to elucidate the role of END in patients with advanced disease.

While immune checkpoint inhibitor (ICI) therapy has improved melanoma patient outcomes, it has also resulted in the rise of unique immune-related adverse events (irAEs). Here, we review and synthesize irAE management recommendations from several oncological societies into a streamlined format to aid in diagnosis and management. We also include clinical pearls highlighting several recent research studies in this field. Knowledge of immunotherapy toxicity has continually evolved, and several major oncologic societies have recently released new or updated guidelines. Keeping up with the evolving field of immunotherapy and related toxicities is crucial, because ICI use, in combination with other agents, will only continue to increase and likely result in new and different patterns of irAEs. Providing clear and concise references for clinicians will help ensure proper irAE evaluation and management going forward. We present one such reference here, covering management of common and/or serious irAEs.

Omics analyses often result in dozens to hundreds of potential targets, requiring validation for their biological relevance. Current high-throughput functional investigation methods are frequently labor-intensive, expensive, and display low reproducibility. The Immune Co-Culture Cell Microarray (ICCM) is a formalin-fixed paraffin-embedded cell block microarray based on co-cultures of patient-derived tumor-infiltrating lymphocytes and their autologous melanoma cells. Each ICCM slide represents the same experiment and can be stained using standard immunohistochemistry and immunofluorescence techniques. Functional dynamics assessment of both proteins and microRNAs using ICCM stained slides demonstrated similar findings to flow cytometry assays and to previously published patient-derived biopsy reports.

BRAF inhibitors (BRAFi) and MEK inhibitors (MEKi) are among the cornerstones of metastatic melanoma therapy demonstrating excellent response rates with duration of 7–12 m. Long-term benefit from these agents was reported in patients with normal lactate dehydrogenase (LDH) and less than three disease sites. However, a treatment-dependent marker for long-term efficacy is lacking. Data suggest that immune-related adverse events (irAEs) are associated with clinical benefit in patients treated with immunotherapy and that response to BRAF/MEK therapy may have an underlying immune mechanism. We hypothesised that AEs with an underlying immune mechanism may be associated with a durable response to targeted therapy. We retrospectively identified a cohort of 78 BRAF V600–mutant metastatic melanoma patients treated with BRAFi or BRAFi + MEKi between November 2010 and November 2013. Four treatment-related AEs including vitiligo, uveitis, erythema nodosum and keratitis sicca were defined as irAEs of interest. Retrospective analysis of AEs in relationship to progression-free survival (PFS), disease burden and LDH levels was performed. Median PFS (mPFS) for all patients was 7.5 months with responses ongoing in eight patients as of April 2017. Ten patients were identified with the AEs defined previously. Cox regression analysis revealed a very strong association between those AEs and PFS; mPFS was 42.8 m in patients with at least one AE versus 6.1 m in those without an AE (hazard ratio [HR] 0.22, p = 0.002). This association was independent of LDH levels and disease burden (HR 0.24, p = 0.035). This analysis demonstrates a strong association between immune AEs and durable response to targeted therapy and may provide a treatment-related biomarker to estimate the outcome of therapy.

Intercellular adhesion molecule 1 (ICAM-1) protein is an important adhesion molecule that facilitates metastasis on one hand, and on the other hand supports the immunological synapse necessary for T-cell mediated elimination. The expression pattern of ICAM-1 in melanoma was studied more than two decades ago, mainly in cell lines or in unmatched melanoma specimens. By using real time PCR we could not demonstrate a clear difference in ICAM-1 mRNA levels between primary melanocytes and primary cultures of metastatic melanoma. However, immunohistochemistry staining of progression tissue microarray comprised of samples of different disease stages derived from different patients, demonstrated a dramatic ICAM-1 upregulation particularly upon the transition from primary tumor to lymph node metastasis. There was no significant difference between lymph node and distant metastases. Importantly, these results were confirmed in an independent tissue microarray comprised of patient-paired specimens from progressive stages of the patient's disease. These data indicate that ICAM-1 upregulation is required to initiate the lymphatic spread of melanoma (Stage III) but no further increase is associated with progression to remote organs (Stage IV).

Hemorrhage is a leading cause of preventable death on the battlefield. Timely tourniquet application to massively bleeding extremity wounds is critical for casualty survival albeit with reported adverse effects to extremity integrity. The aim of this study was to describe the immediate- and short-term outcomes of point of injury (POI) tourniquet applications during "Operation Protective Edge" (OPE).A case series study regarding tourniquet application at the POI during OPE was collected. The data gathered included reports by medical providers at the POI, aerial and land evacuation vehicles, and receiving hospitals. Variables collected included, the number of tourniquet applications, caregiver level, tourniquet type, limb characters, tourniquet effectiveness, in-hospital procedures, complications, and short-term limb outcome.During OPE, the Israeli Defense Forces Medical Corps treated 704 casualties. Of these, 90 casualties were treated with 119 tourniquets of which 79 survived. Penetrating trauma was the mechanism of injury in 97.8% (88 of 90) of the casualties. Injuries sustained from improvised explosive devices and shrapnel were related to the use of more than one tourniquet per casualty and per limb (p = 0.034). The success rate of the first tourniquet was reported to be 70% (84 of 119), regardless of caregiver level (p = 0.56), tourniquet type (p = 0.16), or limb characters (p = 0.48). Twenty-seven (25.7%) of 105 of the tourniquets were converted to direct pressure dressings enroute to receiving hospitals two of the conversions failed and thus a new tourniquet was applied. Fasciotomy was performed on eight casualties (a single limb in each). Vascular injury was presumed to be the indication for fasciotomy in three of these cases, in the other five limbs (6%, 5 of 85), no vascular involvement was discovered during surgery, and the fasciotomy is suspected as tourniquet related. 7%) 6 of 85) suffered from neurological sequela that could not be explained by their primary injury. Total complication rate was 11.7% (10 of 85) (one patient had both fasciotomy and neural complication without vascular injury).Tourniquet use on the battlefield is a simple method of eliminating preventable death, we believe that clinical practice guidelines should promote liberal use of tourniquets by trained combatants and medical personnel with abilities to convert to direct pressure hemorrhage control when possible since an unjustified tourniquet application risks low rates minor morbidity, whereas a justifiable tourniquet not applied may be lethal.Epidemiologic study, level III; Therapeutic study, level IV.

The therapeutic potential of adoptive cell therapy (ACT) in cancer patients was first acknowledged 3 decades ago, but it was an esoteric approach at the time. In recent years, technological advancements have transformed ACT into a viable therapeutic option that can be curative in some patients. In fact, current ACT response rates are 80% to 90% for hematological malignancies and 30% for metastatic melanoma refractory to multiple lines of therapy. Although these results are encouraging, there is still much to be done to fulfill ACT's potential, specifically with regard to improving clinical efficacy, expanding clinical indications, reducing toxicity, and increasing production and cost-effectiveness. This review addresses the current major obstacles to ACT and presents potential solutions. Cancer 2017;123:2154-62. © 2017 American Cancer Society.

Introduction Although a lifesaving skill, currently, there is no consensus for the required amount of practice in tourniquet use. We compared the effect of 2 amounts of practice on performance of tourniquet use by nonmedical personnel. Methods Israeli military recruits without previous medical training underwent their standard tactical first aid course, and their initial performance in use of the Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC) was assessed. The educational intervention was to allocate the participants into a monthly tourniquet practice program: either a single-application practice (SAP) group or a triple-application practice (TAP) group. Each group practiced according to its program. After 3 months, the participants' tourniquet use performance was reassessed. Assessments were conducted using the HapMed Leg Tourniquet Trainer (CHI Systems, Fort Washington, PA), a mannequin which measures time and pressure. Results A total of 151 participants dropped out, leaving 87 in the TAP group and 69 in the SAP group. On initial assessment, the TAP group and the SAP group performed similarly. Both groups improved their performance from the initial to the final assessment. The TAP group improved more than the SAP group in mean application time (faster by 18 vs 8 seconds, respectively; P = .023) and in reducing the proportion of participants who were unable to apply any pressure to the mannequin (less by 18% vs 8%, respectively; P = .009). Conclusion Three applications per monthly practice session were superior to one. This is the first prospective validation of a tourniquet practice program based on objective measurements.

Tourniquet application is a lifesaving skill taught worldwide in first aid bleeding control courses. We observed performance among non-medical users of tourniquets in their confidence, competence, and reasons for failure.179 Israeli military recruits without prior medical training underwent their standard first aid course where they learned Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC, USA) use. After course completion, they self-reported confidence in tourniquet use. User performance was assessed 7-14 days later using a HapMed™ mannequin that assessed time, pressure, and blood loss. Competent performance required in aggregate: 1) use with pressure of 200 mmHg or more, 2) hemorrhage volume of less than 638 mL, and 3) correct placement of the tourniquet. For failed performance, a reason for failure was reported independently by both the user and an expert observer.45 of 179 user performances (25%) were competent. Users who reported high confidence had only a slightly higher chance of achieving competence in tourniquet application (r = 0.17, p = 0.022). The most common reason for failure was excess slack in the CAT's strap (experts 55%, users 39%), and too few turns of the windlass (23% and 31%, respectively) was the second most common reason. Expert and user evaluations had poor agreement (κ = 0.44, 95% CI 0.32-0.56).The most common reason for failed use of tourniquets among non-medical users was excess slack in the tourniquet strap. Users self-evaluated their performance inaccurately and demonstrated a confidence-competence mismatch. These pitfalls in performance may help tourniquet instructors improve training of caregivers.

Study objective In 2012, the Israel Defense Forces Medical Corps (IDF-MC) set a goal of reducing mortality and eliminating preventable death on the battlefield. A force buildup plan entitled “My Brother's Keeper” was launched addressing: trauma medicine, training, change of Clinical Practice Guidelines (CPGs), injury prevention, data collection, global collaboration and more. The aim of this article is to examine how military medical care has evolved due “My Brother's Keeper” between Second Lebanon War (SLW, 2006) to Operation Protective Edge (OPE, 2014). Methods Records of all casualties during OPE and SLW were extracted and analyzed from the I.D.F Trauma Registry. Noncombat injuries and civilian injuries from missile attacks were excluded from this analysis. Results The plans main impacts were; incorporation of a physician or paramedic as an integral part of each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted freeze dried plasma (25 casualties) and transexamic acid (98 casualties). During OPE, 704 soldiers sustained injuries compared with 833 casualties during SLW. Fatalities were 65 and 119, respectively, cumulating to Case Fatality Rate of 9.2% and 14.3%, respectively. Conclusions Significant changes in the way the IDF-MC provides combat casualty care have been made in recent years. It is the transformation from concept to doctrine and integration into a structured and Goal-Oriented Casualty Care System, especially POI care that led to the unprecedented survival rates in IDF as shown in this conflict.

The gut microbiota impacts response to immunotherapy in cancer patients. We sought to evaluate the role of physiologic colonic fluorine-18-fluorodeoxyglucose (F-FDG) uptake, a test that was recently shown to reflect colonic bacterial load, as a possible predictor for response to immunotherapy. We carried out a retrospective study in metastatic melanoma patients who received the immune checkpoint inhibitor ipilimumab as first-line therapy. All patients underwent an F-FDG PET scan before treatment initiation. The primary outcome was defined as response to treatment according to the RECIST criteria. Regions of interest were drawn on each transaxial slice around the outer boundaries of the colon. Uptake was measured using maximum and mean standardized uptake value (SUV). A nonparametric test was used to compare SUV between response groups. The study included 14 melanoma patients, of whom two (14.3%) achieved a complete response (CR) following treatment, eight (57.1%) achieved a partial response (PR), and four (28.6%) developed progressive disease (PD). The mean SUVmax was 1.33±0.04, 2.2±0.46, and 3.33±2.67 for individuals with CR, PR, and PD, respectively. The difference between individuals with CR and those without CR (PR or PD) in total colonic SUVmax was statistically significant (P=0.03). Thus, physiologic colonic F-FDG uptake may predict CR to immunotherapy in metastatic melanoma patients.

In the neoadjuvant treatment of locally advanced rectal adenocarcinoma, long- and short-course radiotherapy are considered to be of equivalent efficacy based upon several randomized trials. The present study assessed the effect of radiotherapy dose on overall survival. Using the National Cancer Database (2006-2013) 458 individuals with clinical stage II/III rectal adenocarcinoma treated were identified, with either short- (25 Gy) or long- (45 or 50.4 Gy) course neoadjuvant radiotherapy followed by surgery, without neoadjuvant or adjuvant chemotherapy. Multivariate COX regression was employed to evaluate differences in overall survival according to radiotherapy regimen. An association with improved overall survival in individuals treated with long- compared with short-course radiotherapy was demonstrated (HR=0.50, 0.34-0.73). The 30- and 90-day post-surgery mortality rates were higher in the short-course group when compared with the long-course group (12.2 vs. 2.4%; and 18.5 vs. 5.4%, respectively). Following the exclusion of patients that succumbed within 90-days post-surgery, overall survival advantage in the long-course group compared with the short-course group was maintained [hazard ratio (HR)=0.62, 0.39-0.99], with a median overall survival of 25.3 months (IQR 16.9-41.6) for the short-course group compared with 43.5 months (IQR 25.6-67.9) for the long-course group. To the best of our knowledge, the present results suggest for the first time that long-course radiotherapy is associated with an improved overall survival compared with short-course radiotherapy in locally advanced rectal adenocarcinoma in the absence of chemotherapy usage. This possible advantage is clinically relevant mainly in patients who cannot tolerate systemic chemotherapy.

Introduction Immune checkpoint inhibitors (ICIs) have changed the oncologic landscape in the past few years. Alongside impressive antitumor responses, new novel immune-related adverse events (irAEs) have emerged; pneumonitis is an irAE that can potentially be fatal and necessitates a proper management. No consensus exists regarding steroid treatment duration or drug rechallenge options. Our study describes the clinical and radiological course of melanoma patients diagnosed with immune-related pneumonitis that has recurred because of rechallenge attempt or despite complete treatment discontinuation (unprovoked). Materials and Methods The study population was composed of patients with metastatic melanoma who were treated with anti-programmed cell death 1 (PD-1) as monotherapy or in combination with anti-cytotoxic T lymphocyte antigen-4 and who were diagnosed with immune-related pneumonitis. For recurrent cases after clinical and radiological resolution, we explored the differences from cases with no recurrence. Results Nineteen out of 386 (4.8%) patients treated with ICI were diagnosed with pneumonitis. Median age was 66 years, and 53% were male. Compared with single-agent nivolumab, patients treated with ipilimumab-nivolumab combination presented with an earlier onset (27.5 vs. 10.3 weeks, respectively, p = .015) and had higher grades of severity. After complete resolution, rechallenge was attempted in seven patients; three of them had recurrent pneumonitis. Three other patients experienced recurrent pneumonitis despite complete discontinuation of the drug (unprovoked by rechallenge). The latter were characterized with an earlier onset of the first pneumonitis compared with those who did not experience recurrence (median, 12.4 vs. 26.4 weeks) and a shorter course of steroid treatment at first episode (median, 5.1 vs. 10 weeks). Recurrent cases were generally more severe than the first episode. Conclusion Unprovoked recurrent pneumonitis is a new, poorly reported entity that requires further investigation. Our observations suggest that cases of pneumonitis that present early in the course of immunotherapy treatment may recur despite treatment discontinuation, thus necessitating closer monitoring and a longer course of steroid treatment.

Melanoma cells use different migratory strategies to exit the primary tumor mass and invade surrounding and subsequently distant tissues. We reported previously that ADAR1 expression is downregulated in metastatic melanoma, thereby facilitating proliferation. Here we show that ADAR1 silencing enhances melanoma cell invasiveness and ITGB3 expression. The enhanced invasion is reversed when ITGB3 is blocked with antibodies. Re-expression of wild-type or catalytically inactive ADAR1 establishes this mechanism as independent of RNA editing. We demonstrate that ADAR1 controls ITGB3 expression both at the post-transcriptional and transcriptional levels, via miR-22 and PAX6 transcription factor, respectively. These are proven here as direct regulators of ITGB3 expression. miR-22 expression is controlled by ADAR1 via FOXD1 transcription factor. Clinical relevance is demonstrated in patient-paired progression tissue microarray using immunohistochemistry. The novel ADAR1-dependent and RNA-editing-independent regulation of invasion, mediated by ITGB3, strongly points to a central involvement of ADAR1 in cancer progression and metastasis., In metastatic melanoma, ADAR1 is downregulated, facilitating proliferation. Here, the authors show an ADAR1-dependent and RNA-editing-independent regulation of melanoma invasion mediated by ITGB3 expression, which can be reversed when ITGB3 is blocked.

Immune-checkpoint inhibitor (ICI)–related diarrhea is attributed to inflammatory colitis, with no other drug-related differential diagnosis. Here, we investigated the occurrence of pancreatic atrophy (PA) in ICI-treated cancer patients and its correlation to exocrine pancreatic insufficiency (EPI). Metastatic melanoma, non–small cell lung carcinoma, and head and neck squamous cell carcinoma patients (n = 403) treated with anti–PD-1 (n = 356) or anti–CTLA-4 (n = 47) were divided into a case group (radiologic evidence of PA); control group matched by age, gender, and previous lines of treatment; and colitis group (ICI-induced colitis). Quantitative pancreatic volumetry was used for calculation of the decrease in pancreatic volume over time (atrophy rate). Thirty-one patients (7.7%) developed PA compared with 41 matched controls (P = 0.006). Four patients developed EPI, all from the anti–PD-1–treated group, which resolved with oral enzyme supplementation. The atrophy rate did not correlate with EPI (P = 0.87). EPI-related diarrhea presented at a median of 9 months, whereas the diarrhea of anti–PD-1–induced colitis patients (n = 22) was presented at a median of 2 months (P = 0.029). ICI-induced PA is irreversible and can result in EPI. EPI should be suspected in cases of late-onset steroid-resistant diarrhea with features of steatorrhea and treated with oral enzyme supplements.

During the past 6 years the Israel Defense Forces Medical Corps (IDF-MC) deployed three humanitarian delegation field hospitals (HDFHs) in disaster zones around the globe: Haiti (2010), the Philippines (2013), and Nepal (2015).To compare the activity of these HDFHs and the characteristics of the patients they served.This retrospective study was based on the HDFHs' operation logs and patients medical records. The study population included both the staff who participated and the patients who were treated in any of the three HDFHs.The Philippine HDFH was a "hybrid" type, i.e., it was integrated with a local hospital. Both the Haitian and the Nepali HDFHs were the "stand-alone" type, i.e., were completely autonomic in resources and in function. The Nepali HDFH had a larger staff, departed from Israel 4 hours earlier and was active 7 hours earlier as compared to the Haitian one. In total, 5465 patients, 55% of them female, were treated in the three HDFHs. In Haiti, Nepal and the Philippines, disaster-related injuries accounted for 66%, 26% and 2% of the cases, respectively. Disaster-related injuries presented mainly in the first days of the HDFHs' activity.The next HDFH should be planned to care for a significant proportion of routine medical illnesses. The IDF-MC continuous learning process will enable future HDFHs to save more lives as we "extend a helping hand" to foreign populations in crisis.

Summary Immunotherapy has revolutionized cancer treatment, yet most patients do not respond. Here, we investigated mechanisms of response by profiling the proteome of clinical samples from advanced stage melanoma patients undergoing either tumor infiltrating lymphocyte (TIL)-based or anti- programmed death 1 (PD1) immunotherapy. Using high-resolution mass spectrometry, we quantified over 10,300 proteins in total and ∼4,500 proteins across most samples in each dataset. Statistical analyses revealed higher oxidative phosphorylation and lipid metabolism in responders than in non-responders in both treatments. To elucidate the effects of the metabolic state on the immune response, we examined melanoma cells upon metabolic perturbations or CRISPR-Cas9 knockouts. These experiments indicated lipid metabolism as a regulatory mechanism that increases melanoma immunogenicity by elevating antigen presentation, thereby increasing sensitivity to T cell mediated killing both in vitro and in vivo. Altogether, our proteomic analyses revealed association between the melanoma metabolic state and the response to immunotherapy, which can be the basis for future improvement of therapeutic response.

Background: The majority of metastatic melanoma patients treated with Programed cell Death (PD)-1 blockade fail to achieve durable response. The gut microbiota profoundly affects host immunity, and fecal microbiota transplantations (FMT), which transfers the entire gut microbiota from one host to another, has been shown to enhance anti-PD-1 effectiveness in murine models. We report initial safety and efficacy results from the first three patients treated on a Phase I study of FMT and re-induction anti-PD-1 therapy in anti-PD-1 refractory metastatic melanoma. Methods: FMT donors were two metastatic melanoma patients who achieved a durable complete response. FMT Recipients were metastatic melanoma patients who failed at least one anti-PD-1 line of treatment. FMT was conducted by both colonoscopy and oral ingestion of stool capsules, followed by anti-PD-1 re-treatment (Nivolumab, BMS). Each recipient underwent pre- and post-treatment stool sampling, tissue biopsy of both gut and tumor, and total body imaging. Results: Recipients #1 and #3 received fecal implants from Donor #1, while Recipient #2 receive implants from Donor #2. No FMT-related or immunotherapy-related adverse events were observed. To assess engraftment of the new microbiota, recipients were paired with their respective donors and stool 16S rDNA gene sequence analysis performed. Ideal engraftment from a single donor would result in identical microbiota composition between that donor and recipients. In the case of two donors, ideal engraftment would result in two distinctive recipient-donor compositions. Sequencing results demonstrated post-FMT compositional dissimilarity (Unweighted UniFrac, p=0.04, FDR q=0.22) between the two recipient-donor groups. Immunohistochemical stains of biopsies demonstrated an increased post-FMT infiltration of antigen presenting cells (CD68+) in the gut (paired T test, p=0.008) and in the tumor (p=0.076). Post-treatment intra-tumoral CD8+ T-cells infiltration was also increased (p=0.096), especially in recipients #1, #3. Recipient #1 and Recipient #3 demonstrated clinical and radiological benefit from treatment. Conclusion: FMT in metastatic melanoma patients seemed to be safe and may alter recipient gut microbiota to resemble that of a responder donor. This alteration may result in intra-tumoral T-cell activity, which was translated to a clinical and radiological benefit in two recipients. Citation Format: Erez N. Baruch, Ilan Youngster, Rona Ortenberg, Guy Ben-Betzalel, Lior H. Katz, Adi Lahat, Iris Barshack, Daniela Dick-Necula, Ronac Mamtani, Naamah Bloch, Bella Ungar, Daniel Rotin, Camila Avivi, Liat Anafi, Yael Steinberg-Silman, Nethanel Asher, Ronnie Shapira-Frommer, Tal Brosh-Nissimov, Yael Eshet, Stephen Raskin, Hagit Harati, Jenny Melnichenko, Jacob Schachter, Omry Koren, Gal Markel, Ben Boursi. Fecal microbiota transplantation (FMT) and re-induction of anti-PD-1 therapy in refractory metastatic melanoma patients - preliminary results from a phase I clinical trial (NCT03353402) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT042.

During resuscitation in the field, intraosseous (IO) access may be achieved using a variety of available devices, often attempted by inexperienced users.We sought to examine the success rate and ease-of-use ratings of an IO device, the NIO® (New Intraosseous Persys Medical, Houston, TX, USA) in comparison to the Arrow® EZ-IO® (Teleflex Medical Research Triangle Park, NC, USA) by novice users.We performed a randomized crossover trial. The study model was a porcine hind leg which was cut distally in order to expose the marrow. The Study population was composed of pre-graduate medical students without prior experience in IO use, all designated future field physicians. The students underwent instruction and practiced the use of both devices. After practice completion, each student attempted a single IO insertion with both devices sequentially in randomized fashion. Success was defined as a flow of fluid through the bone marrow after a single IO attempt. Investigators which determined the success rate were blinded to the used device.50 users (33 males, 17 females) participated in the trial, mean age of 21.7 years (±1). NIO users were successful in 92% (46/50) attempts while EZ-IO user success rate was 88% (44/50). NIO success rates were comparable to those of EZ-IO (p = NS). Results were similar when examining only the initial device used. Median score of ease of use was 4 (5 point Likert scale) in both devices (p = NS). 54% (27/50) of the participants preferred using the EZ-IO over the NIO (p = NS).Novice users were equally successful in establishing IO access with the NIO® in comparison to the EZ-IO® in a porcine model.

Background Intravenous (IV) access has an essential role in the care provided for trauma patients, allowing for transfusion of blood products, fluids, and drugs. Decisions should be made regarding the necessity of IV access while considering cost-benefit of the procedure in terms of delayed evacuation times. Methods A retrospective review of all trauma patients in whom at least one attempt at IV access was performed were reviewed. Data were abstracted from the Israeli Defense Force Trauma Registry. Results Of 7,476 patients, 1,082 patients who had at least one documented attempt at IV access between January 1997 and April 2013 were included in this study. Overall cumulative success rate at IV access was 82%. Success rates for IV access were 86%, 68%, 63%, 50%, 20% for the first, second, third, fourth, and fifth attempts, respectively. The first and second attempts accounted for 96% of the successful procedures. Mortality in patients for whom IV access was successful was 13%; mortality in patients for whom IV access was not successful was 35%. Conclusion The success rate of IV access declined with each subsequent attempt. There was minimal improvement of overall success rate seen after the second attempt. Our findings suggest that the inability to obtain peripheral venous access is associated with severe injuries. These finding support a policy of limiting the number of venous access attempts to two attempts, followed by a reevaluation of need for parenteral access. Improved training of combat medics and paramedics might marginally increase the success rates of IV access. Point-of-injury data, used for ongoing learning and research, form the ground for improving combat casualty care and thus help saving lives. Level of evidence Therapeutic study, level IV.