Priya Alagesan, BS: Gastric Cancer Interception

Priya Alagesan, BS, a fourth-year Duke medical student, under the mentorship of Katherine Garman, MD, was named this year’s recipient of the Robert and Barbara Bell Basic Science Cancer Research Award and had the top abstract for the NCI-Designated DCI Cancer Risk, Detection and Interception Research Program (CRDI) that Epplein and Garman co-lead.

Her study — “Examining CXCL8 Expression in Gastric Organoid Models for Gastric Cancer Interception" — is also part of the gastric cancer disparities subproject of the NCl-funded DCI study investigating health disparities in stomach and lung cancer.

Before passing the mic to Garman to introduce her award-winning mentee, Kastan thanked the Bells, who were attending the DCI Scientific Retreat via Zoom, “for their continued support of the Duke Cancer Institute.” They have supported scientific discovery at Duke since 1998.  

“For those of you who don't know Bob, many years ago he was the chair of the Cancer Biology Department. And then he left academia to become head of Oncology Research at GlaxoSmithKline where he had an impact on a lot of cancer drugs that were developed by that company,” said Kastan. “Barbara and Bob have continued to be wonderful supporters of the DCI and we're so grateful.”

Alagesan's interest in research, Garman shared, began in high school and continued when she came to Duke as an undergrad.

• As a high-schooler, she was a summer research fellow at Stony Brook University in New York and earned a spot as an Intel Science Talent Search semifinalist.
• As a Duke undergraduate, she conducted research in the lab of Sudarshan Rajagopal, MD, PhD, on the G protein-coupled receptor CXCR3; earning a distinction in biology for her undergraduate thesis, and graduating summa cum laude and Phi Beta Kappa.
• After graduation, she went on to work as a research technician on projects with human pancreas cancer in the lab of David A Tuveson, MD, PhD, at Cold Spring Harbor Laboratory.
• Alagesan returned to Duke for medical school in 2019.
• Last year — year three of medical school and year one at the Garman Lab — she received a Eugene Stead Student Research Scholarship to fund her stomach cancer research.

"She really brings out the best in pretty much everyone she works with in the lab. She shows up with curiosity and creativity," said Garman before sharing that Alagesan's talents are not limited to science. "She's an outstanding chef and shares her treats with us all the time."

Just a few days after the retreat, the versatile student, who's also a Duke Band member, traveled with the basketball team to play at Madison Square Garden.

Garman also lauded Alagesan's "strong commitment to community service and social justice,” noting how she had served as a Duke Bass Connections graduate-student project manager connecting undergraduate researchers with community partners on the COVID-19 response.

Alagesan is now in her second year in the Garman Lab, which focuses on injury, repair, and cancer development in the gastrointestinal tract.

For her project, she and her team assembled and generated gastric organoids — 3D tissue cultures used to model a simplified version of the stomach — in order to study how cancer develops and grows in the stomach. These organoids were infected with H. pylori. They also developed patient-matched organoids of normal gastric tissue (non-tumor tissue without H. pylori) for comparison.

“We sought to study the molecular mechanisms underlying and implicated in gastric cancer development and identify opportunities to intercept gastric cancer; to basically stop it before it even starts,” said Alagesan.

Her research collaborators included Garman, Paula Scotland, PhD, Julia Butt, PhD, Tim Waterboer (in Germany), Sydnee Crankshaw, MPA, HannahSofia Brown, MD, and Epplein.

They zeroed in on a specific gene — CXCL8 — also known as interleukin 8, which encodes a chemokine expressed and secreted by gastric epithelial cells (the cells of the stomach lining). This gene is known to contribute to H. pylori-induced inflammation and the development of cancer (carcinogenesis). Left untreated, inflammation of the stomach lining (gastritis) can progress to gastric intestinal metaplasia, peptic ulcer, dysplasia (pre-cancerous lesion), then to gastric cancer — a cascade effect. For patients who already have gastric cancer, elevated CXCL8 expression levels are associated with a poor prognosis. 

The patients whom the team successfully recruited to the small study had a spectrum of H. pylori-associated gastric diseases — including cancer. Importantly, half of the patients were Black; a close approximation of the gastric cancer patient population at Duke. 

Black patients make up 19% of the total Duke patient population. However, Alagesan noted, between 62% of all gastric cancer cases seen at Duke occur in Black patients.

Given these statistics as well as national numbers showing that Black Americans are twice as likely to develop gastric cancer and more than twice as likely to die from gastric cancer once they have it than non-Hispanic White Americans, Alagesan and her team were hoping the study might help uncover why Black Americans are at increased risk for gastric cancer.

Overall, the team did not find any difference in CXCL8 expression in gastric organoids by race. They did, however, find higher levels of CXCL8 expression in the men in the study. They also found increased levels of CXCL8 in the gastric-disease organoids vs. organoids from the non-diseased tissue. And they found that CXCL8 expression was two to five times higher in the gastric-cancer organoids, than in non-tumor tissue cultures.

“We found an association between higher CXCL8 expression and more severe diagnoses of gastric metaplasia and gastric cancer,” said Alagesan.

The team concluded that examining the levels of CXCL8 expression in patients with gastric disease may be useful for identifying patients at greatest risk of their disease progressing to cancer.

Alagesan's study was supported by The Stead Committee (a Eugene Stead Student Research Scholarship); the National Cancer Institute-funded DCI study investigating health disparities in stomach and lung cancer (NCI P20 exploratory grant); and the NIH NCI Cancer Center Support Grant (also known as core grant or the P30 grant), which supports DCI’s broad range of clinical, research, and educational programs that aim to reduce the impact of cancer on the lives of people in North Carolina and beyond.

Lyla Stanland, BS: EBV and Gastric Cancer

Lyla Stanland, BS, a PhD student in the Duke Department of Molecular Genetics and Microbiology (MGM), like Alagesan, researches infection-associated gastric cancer.

Like Emma Bonglack, last year’s Bell Award winner, Stanland researches Epstein-Barr virus (EBV)-associated cancers in the Luftig Lab.

Mentored by Micah Luftig, PhD, and Kris Wood, PhD, Stanland had the winning abstract this year for the NCI-Designated DCI Cancer Biology Research Program: “Identification of CBFB loss as a resistance mechanism to PI3Kα inhibition in PIK3CA mutant gastric cancer.”

For this project, part of her thesis work, she collaborated with members of the Luftig Lab, the Wood Lab, and the Tan Lab (Duke National University of Singapore (Duke-NUS)), including: Wood, Luftig, Hazel Ang, PhD (Karolinska Institutet), Yunqiang Chu (PhD student), and Patrick Tan, PhD.

Stanland joined the Luftig Lab as a research technician after graduating with honors from UNC Wilmington with a BS in Biology. She’s also a senior fellow with the Duke Translation & Commercialization Office (formerly known as the OTC).

“She really developed an interest in something that our lab typically doesn't work on, which is gastric cancer,” said Luftig, introducing her at the retreat. “It turns out about 10% of gastric cancers are associated with Epstein-Barr virus infection. Lyla started working on that and really matured as a young scientist, as a technician in the group, and then applied to graduate school and was admitted to the MGM program in 2018. Now, she’s a fifth-year graduate student. Her EBV- associated gastric work broadened into studying the role of PIK3CA, which is mutated in virtually all EBV-positive gastric cancers, and she branched out in a collaboration with Kris Wood (Wood Lab). Lyla has really been exceptional in the lab. She's published two reviews in the space of EBV and gastric cancer and a co-authored paper and has some really nice work that will be published soon, which she’ll tell you about today.”

As Epplein mentioned, there's an antibiotic treatment to eradicate H. pylori. There are vaccines for HPV, HBV, and HCV. But there are no treatments or vaccines for EBV. (LEARN MORE: DCI Virologist Pursues EBV Pathways to Cancer)

A ubiquitous herpes virus that infects more than 90% of the world's population and the first virus shown to cause cancer in humans, EBV infections don’t show symptoms or turn into cancer in most individuals infected with the virus. Similarly, most infections with the other cancer-causing viruses (HPV, HBV, and HCV) and infections with the H. pylori bacteria don't show symptoms or turn into cancer either. Except for when they do.

Of 20 million cancer cases diagnosed each year worldwide, 2.2 million cases are associated with infection:

• About 37% (mainly gastric cancer) are associated with H. pylori.
• Less than 1% of cases are associated with EBV; mainly nasopharyngeal cancer, certain types of blood cancers, and some cases of stomach cancer
• About 32% are caused by the human papillomavirus (HPV);
• An estimated 24% are caused by hepatitis B (HBV) & C (HCV) viruses; mainly liver cancer
• The rest of cases are caused by other infections.

Stanland received a pilot award for studying the genomics of EBV-associated gastric cancer from the Duke University School of Medicine Precision Genomics Collaboratory.

*Because this research is pending publication, further details of Stanland's presentation are not explored in this blog post

Allison O. Taylor, MD, MS: Evaluating the Patient Experience of Non-Hispanic Black Patients with AML

Allison O. Taylor, MD, MS — a third-year Duke Internal Medicine resident and incoming Hematology/Oncology fellow conducting cancer patient experience research under the mentorship of DCI Chief Patient Experience & Safety Officer Thomas LeBlanc, MD, MA — was awarded best abstract in the NCI-Designated DCI Cancer Prevention and Control Research Program: “Facilitators and Barriers to Care Encountered During Treatment in Non-Hispanic Black Patients with Newly Diagnosed AML — A Duke University Medical Center Experience.”

Leah Zullig, PhD, MPH, co-leader with Kathryn Pollak, PhD, of that program, introduced Taylor.

“Dr. Taylor received her undergraduate training, her master's degree and her medical training from Georgetown University. So, we’re delighted that she decided to come to Duke as well. Clinically, Dr. Taylor's practice has been broad as she’s an internal medicine resident, but she has also developed a very deep interest in hematologic malignancies, and her research is primarily focused on outcomes in patients that have blood cancer; specifically, she's interested in acute myeloid leukemia (AML),” said Zullig. “She has won several awards, including funding to support her research from a variety of prestigious groups, including from ASH (American Society of Hematology). This includes the 2017 Minority Medical Student Award, the 2020 ASH Abstract Achievement Award, and the 2022 American Society of Hematology Minority Resident Award. We are delighted that she's part of Cancer Prevention and Control and look forward to hearing from her today.”

Taylor began her oral presentation by stating, "Evidence suggests that non-Hispanic Black patients with AML experience worse clinical outcomes compared to their non-Hispanic White counterparts.” 

In an effort to identify potential areas of intervention that might improve clinical outcomes, Taylor and her team — including Laura Fish, MPH, PhD, Kris Herring, PhD, Jordan Infield, MD, Kimberly S. Johnson, MD, and LeBlanc — wanted to hear directly from AML patients at Duke about the facilitators and barriers to care they encountered during treatment.

In inpatient and outpatient settings, Taylor interviewed nine newly diagnosed Black patients (five men and four women) with primary or secondary AML and in treatment with different regimens.

Taylor said patients named faith or belief in a higher power/belief in God; their support system of family and friends; communication with their oncologist and other members of their care team and trust in their knowledge; and prior experiences with treatment at Duke, either personally or knowing someone who had been treated there; as playing a strong role in their ability to cope with treatment.

Taylor said the team also learned through interviews that patients faced challenges related to:

• “issues with childcare, especially with patients having to be hospitalized unexpectedly;
• unexpected infections due to being immune-compromised;
• high pill burden from needing to be on oral chemotherapy and prophylactic medications;
• the financial constraints that come with not being able to work and a subsequent loss of income;
• a caregiver role reversal for some patients who were used to doing everything themselves and now had to be taken care of;
• relocation specifically for transplant patients who didn’t live in Durham or in surrounding areas and had to move here for the period of time right after transplant;
• physical limitations and the intense fatigue that comes with some treatments;
• not being able to do stuff they did before;
• and the psychological impact of the diagnosis — from depression, anxiety, and just (feelings of) uncertainty about the treatments and the diagnosis.”

Taylor said that this subset of patients did not mention race, insurance status, or mistrust as barriers to care. However, she noted in her presentation that “it remains unclear if patients were comfortable sharing any negative experiences about their clinical team with me.”

She thanked all of her co-authors, in particular Leblanc, Fish, and Johnson, as well as Aimee Zaas, MD, director of the Duke Internal Medicine Residency Program, for their support of her research efforts.

Taylor's study was funded by a Duke Internal Medicine Residency Program 2021-22 Faculty Resident Research grant ("Influence of socioeconomic & psychological factors on treatment patterns in Black patients with Acute Myeloid Leukemia”) and her 2022 ASH Minority Resident Award.

Margaret (Peggy) Goodell, PhD, Baylor College of Medicine: Keynote

Margaret (Peggy) Goodell, PhD, — professor and chair of Molecular and Cellular Biology at Baylor College of Medicine and director of the Stem Cells and Regenerative Medicine Center there — delivered this year’s *O. Michael Colvin Memorial Lecture. Established in 2015, the lecture has been a featured highlight at every DCI Scientific Retreat since.

Before calling Goodell to the stage, Kastan spent a few minutes talking about Michael Colvin, MD, in whose honor the lecture is named, and his legacy. Colvin was director of the Duke University Comprehensive Cancer Center from 1995 to 2002 and the William W. Shingleton Professor of Cancer Research. He retired in 2008 and passed away in 2013.

“There's a handful of us in the audience that have known him,” said Kastan, “He is internationally known for many things and has many honors along the way, but he was probably the world's expert on cyclophosphamide, which is one of the most commonly used chemotherapeutic agents. He really developed the process by which we give high-dose cyclophosphamide as a purging agent before stem cell transplant with both hematological malignancies as well as solid tumors. And when he came to Duke, on top of everything else that he did, he was a really strong advocate and leader for our cancer patient support services. But what's really special about him was who he was as a person. He was incredibly thoughtful. He was a wonderful mentor. And I can speak to that personally because he certainly mentored me during my time at Hopkins. And he was a wonderful family man, father, and husband to Macy (Colvin), who frequently attends. Macy, if you're there on Zoom, "Hello to you. It's always great for us to think about Mike and thank you for your continued support of the Duke Cancer Institute.”

Kastan introduced Goodell, who earned her PhD from the University of Cambridge, as having done "one of the most impactful things in stem cell biology" while a postdoctoral fellow at the Whitehead Institute working with Richard Mulligan, PhD.

She discovered a novel method to isolate hematopoietic stem cells, a type of adult stem cell, which are responsible for the production of mature blood cells in the bone marrow.

“She's had a stellar career, first by developing the novel ‘side population method’ for isolating stem cells in various tissues, including cancer tissues. And she's made seminal insights into mechanisms that control stem cell quiescence,” said Kastan. “She identified DNA methyltransferase 3 A (DNMT3A) as a key epigenetic regulator of hematopoietic stem cell function, and a contributor to stem cell renewal and differentiation in aging and inflammation in cancer. She's developed numerous tools that we all use to study epigenetic regulation and stem cells including whole genome methylation profiling.”

In her keynote — "Stem Cell Expansion and Cancer Risk in Clonal Hematopoiesis" — Goodell explained how the discovery of clonal hematopoiesis (CH) in older people has impacted the way aging is viewed.

She described how CH is the result of competition among long-lived stem cells in the bone marrow that evolves over a long period of time; likening this competition of stem cells to a marathon race.

She noted the enormous complexity in the normal pool of hematopoietic stem cells (HSCs) as people age; explaining how by age 70, there's about 1 million coding mutations spread across the whole stem cell pool.

"These mutations make each hematopoietic stem cell a unique 'runner' with slightly different features that may help or hurt its chances to win over time," wrote Goodell, with Grant Challen, PhD, in the Oct. 2020 issue of the American Society of Hematology journal Blood. "Over a long race, many minor factors can come into play, including psychology, weather, and terrain. Chance always plays some role, and finally, the likelihood of winning also depends also on the number of competing runners. When we extrapolate these concepts to CH, we ask how can a stem cell 'win' ? "The combination of the total numbers of mutations accumulated, our long lifespan, and the initial HSC pool size accounts for the inevitability of CH."

Goodell enlightened the audience on her lab’s current work on the mechanisms that regulate hematopoietic stem cells (HSCs), including how mis-regulation of HSCs leads to the development of leukemia; either chance and time or external factors drive mutant clones to expand to various degrees in different individuals, as well as progress to leukemia, which happens in an even smaller fraction of people. (READ MORE about Goodell's current work)

*Before his loss in 2013, O. Michael Colvin, MD, served as Director Emeritus of the Duke University Comprehensive Cancer Center and Professor Emeritus of Medicine at Duke University School of Medicine. As co-leader of the Duke Cancer Center’s Experimental Research Program, his many achievements included pioneering work on drugs that damage the genetic material causing cancer cells to replicate. Begun in 2015, the O. Michael Colvin Memorial Lecture has been a featured highlight at every DCI Scientific Retreat since.

Xiang Li, MS: Deep Learning & the Immune Micro-Environment

Xiang Li, MS, a PhD student working in the Lafata Lab, Duke Electrical and Computer Engineering Department, Pratt School of Engineering, was awarded best abstract for the NCI-Designated DCI Radiation Oncology and Imaging Research Program: “Computational mapping of lymphocytic topology on digital pathology images with single-cell resolution immuno-histochemistry validation.”

Li is mentored by Assistant Professor of Radiology, Radiation Oncology, and Electrical and Computer Engineering Kyle Lafata, PhD. Their research focuses on the theory and application of multi-scale computational biomarkers.

For this project, a pathology/immunochemistry computational mapping study using deep learning to characterize the features of the immune micro-environment landscape — she collaborated with Lafata; Gina Sotolongo, MD; Casey Heirman, BS; Ashlyn Rickard, PhD; Rico Castillo, BS; Jeffery Hodgin, MD, PhD; Jeffrey Everitt, MD; Yvonne Mowery, MD, PhD;  Andrew Janowczyk, PhD; and Laura Barisoni, MD.

"New approaches to computationally interrogate the immune microenvironment on digitized tissue samples will help bridge a knowledge gap between abstract imaging features and basic biology,” said Lafata in an interview earlier this year about Li being selected to present her work during the John R. Cameron Early-Career Investigator Symposium at the American Association of Physicists in Medicine (AAPM) Annual Meeting and Exhibition in July 2022. “Xiang’s work has diverse biomedical applications, from modeling the immune response of cancer treatments, to detecting antibody-mediated rejection of transplanted organs."

Li began her oral presentation by describing the importance of the immune microenvironment, the “major role that immunology plays in oncology,” and the connections between immune dysregulation and the development and progression of cancer.

She explained how with the advent of whole slide imaging, biopsies on glass slides can now be scanned to produce digital pathology images allowing scientists to get a fuller picture of the different topological characteristics of inflammation and better capture the appearance, development, and behavior of the tumor in the immune microenvironment.

This digitization has opened up a new field of study called pathomics, the study of biological information computationally derived from digitized tissue samples.

Li described how the team has validated their work with: (1) cancerous human nephrectomy tissue (kidney tumor tissue that’s been surgically removed), for clinical relevance (2) genetically engineered mice with head & neck tumors, for biological relevance.

Li acknowledged the Department of Defense, the Lafata Laboratory, Duke Radiation Oncology, and the Duke Electrical and Computer Engineering Department for supporting her research.

The abstract was presented at the American Association of Physicists in Medicine annual conference AAPM 2022 and can also be found here: "Computational Mapping of Lymphocytic Topology On Digital Pathology Images with Single-Cell Resolution Immunohistochemistry Validation." Li, X., G. Sotolongo, Y. Mowery, J. Hodgin, A. Janowczyk, L. Barisoni, and K. Lafata. Medical Physics: The International Journal of Medical Physics Research and Practice, vol. 49, no. 6, pp. E310-E310. 111 RIVER ST, HOBOKEN 07030-5774, NJ USA: WILEY, 2022.

Li began her PhD work in Electrical and Computer Engineering in 2021. She has been a research associate at Duke since August 2020 — analyzing biomarkers from medical imaging (radiology and pathology) for disease predictions. She earned her MS in Electrical and Computer Engineering from Duke in 2020 and in between academic years was a machine learning summer intern at Duke. Li earned her bachelor’s degree in Telecommunications Engineering from Northwest University in Shaanxi province, Northwestern China.

Nicholas Levering, BS: Targeting Fusion-Driven Rhabdomyosarcoma in Children

Nicholas Levering, BS, a research technician in the lab of Michael Deel, MD, Duke Department of Pediatrics, Division of Hematology-Oncology, had the top abstract in the NCI-Designated DCI Precision Cancer Medicine and Investigational Therapeutics Research Program: “Targeting transcriptional co-activators YAP1/TAZ in fusion-positive rhabdomyosarcoma demonstrates a novel strategy in ablating transcriptional programming of a fusion-driven sarcoma.”

"Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children with about 350 new cases diagnosed in the U.S. every year. And currently, children diagnosed with RMS today will be treated with the same cytotoxic chemotherapy regimen developed in the '70s which is a combination of vincristine, actinomycin, and cyclophosphamide," said Levering, beginning his oral presentation.

He then explained why it remains challenging to treat RMS, particularly in adolescents and older children, before describing some of the research being conducted in the Deel Lab that could lead to better treatments.

"RMS is best classified on the basis of what we call fusion status, meaning the presence or absence of a chromosomal translocation, which generates the fusion oncoprotein PAX3-FOXO1. Fusion negative is the more common subtype and occurs more frequently in younger children and typically exhibits RAS pathway mutation. Fusion-positive RMS is a little less common and occurs in more adolescents and older children, and is characterized by that PAX3-FOXO1 that I was talking about. So, fusion-positive RMS has a much worse prognosis than fusion-negative, with a five-year overall survival of less than 30%. This fusion protein (PAX3-FOXO1) has been identified as a key oncogenic driver in fusion-positive RMS, but it has been challenging to directly inhibit this protein. So, it's critical to find other ways to target the PAX3-FOXO1 protein, to treat it, and we've taken a variety of approaches to do so."

Levering's acknowledgements included his research collaborators — Corinne Linardic, MD, PhD; Everardo Macias, PhD; Beat Schaefer, PhD (Zurich); Javed Khan, MD (NCI); and Beth Stewart, MD (St. Jude Children's Research Hospital) — as well as members of the Deel Lab, the directors of the Duke Core Facilities (Proteomics, Functional Genomics, Sequencing, Bioinformatics, and Small Molecule Synthesis, and several labs and groups for "intellectual rapport" (Linardic Lab, Blobe Lab, Watts Lab, Kirsch Lab, Duke Sarcoma team, National Institutes of Health National Center for Biotechnology Information (NIH NCBI) COG Soft Tissue Sarcoma Biology Committee, NIH NCBI COG Rhabdomyosarcoma Therapeutic Task Force Committee, and the National Pediatric Cancer Foundation Rhabdomyosarcoma Subcommittee)

His research received funding support from the National Institutes of Health (NIH) National Institute of Child Health and Human Development (NICHD), the V Foundation for Cancer Research, Hyundai Hope on Wheels, the National Pediatric Cancer Foundation, and St. Baldrick's Foundation.

Levering earned a Bachelor of Science in Genetics from North Carolina State University in 2021. While an undergraduate, he worked at NC State as a researcher and joined Duke as a researcher in September 2021.

*Because this research is pending publication, further details of Levering's presentation are not explored in this blog post

Michael Sun, BS: Targeting Glioblastoma

Michael Sun, BS, a fifth-year Duke Department of Pathology PhD candidate working in the Yiping He Lab, had the top abstract in the NCI-Designated DCI Neuro-Oncology Research Program: “Repurposing clemastine to target glioblastoma cell stemness.”

Glioblastoma is the most common cancerous brain tumor and is almost always lethal. Glioblastoma stem cells, also known as brain tumor-initiating cells (BTICs), drive tumor growth and resistance to treatments.

This “stemness” — the ability of cells to self-renew and differentiate into multiple lineages — poses “formidable challenges to advancing effective treatments,” explained Sun in his abstract.

"We postulated that inducing BTIC differentiation can serve as a solution to diminishing their stem-like features," he said.

Using patient-derived glioblastoma models and a mouse neural stem cell-derived glioma model, Sun and his Duke co-author on the study Rui Yang, PhD, found that clemastine — an over-the-counter, commercially available antihistamine drug that's used to relieve hay fever and allergy symptoms (including sneezing, runny nose, and red, itchy, tearing eyes) — reduced the stemness and proliferation of those brain tumor-initiating cells (glioblastoma stem cells) with PDGFRA (platelet-derived growth factor receptor alpha gene) amplification. About 15% of glioblastomas are PDGFRA+.

The study essentially “identified pathways essential for the perpetuation of stemness  in glioblastoma,” Sun explained, “and implicates a non-oncology drug (clemastine) with a well-established safety profile that can be repurposed to mitigate the stem-like properties of glioblastoma.”

Sun’s other collaborators on the project included Heng Liu, PhD; Wenzhe Wang, PhD; Xiao Song, MD, PhD (Robert Lurie Comprehensive Cancer Center); Bo Hu, PhD (Robert Lurie Comprehensive Cancer Center); Nathan Reynolds, PhD; Kristen Roso, BS; Lee H. Chen, MD, PhD; Paula K. Greer, BS; Stephen T. Keir, DrPH, MPH, MMCi; Roger E. McLendon, MD; Shi-Yuan Cheng, PhD (Robert Lurie Comprehensive Cancer Center); Darrell D. Bigner, MD, PhD; David M. Ashley, PhD; Christopher J. Pirozzi, PhD; and Yiping He, PhD.

The study was supported by The Preston Tisch Brain Tumor Center at Duke Cancer Institute, the Duke Department of Pathology, Duke Cancer Institute (as part of the NCI P30 Cancer Center Support Grant), the American Brain Tumor Association and the National Institute of Neurological Disorders and Stroke (NINDS) at the National Institutes of Health (NIH) .

A preprint was posted on Dec. 13, 2022: Repurposing clemastine to target glioblastoma cell stemness | bioRxiv

Sun earned a BS in Pharmacy from National Taiwan University in Taipei, Taiwan, in 2017, during which time he had a six-month clinical internship at National Taiwan University Hospital and a two-month research internship at the University of Maryland School of Pharmacy. He joined Duke in August 2018.

In an interview posted on his Duke Pathology profile page, Sun said he chose Duke and the Pathology program "because it offers excellent faculty with diverse research interests, flexible course design, and boundless resources that altogether create a great environment for my PhD study."

Bin-Jin Hwang, PhD: A Breast Cancer Vaccine

Bin-Jin Hwang, PhD, a postdoctoral associate in the Duke Department of Surgery, Division of Surgical Sciences, working in the Hartman Lab, had the top abstract for the NCI-Designated DCI Immuno-Oncology Research Program: “Sensitizing breast cancers to immune checkpoint inhibitors through CD27 agonism and vaccination against the tumor-associated antigen.”

Hwang has been a postdoctoral fellow at Duke since May 2018. He joined Duke directly after completing his PhD at UNC-Chapel Hill, Department of Microbiology and Immunology. He earned his MS in Biochemistry from George Washington University in 2010 after having received his BS in Life Science from National Dong Hwa University in Taiwan.

For this project, Hwang, whose research focus is tumor biology, inflammation, and immunology, collaborated with his mentor Zachary Hartman, PhD; along with Erika Crosby, PhD; Timothy Trotter, PhD; and H. Kim Lyerly, MD.

As Hwang explained, breast cancer is comprised of multiple diseases of different molecular subtypes, distinct oncogenic drivers, and unique treatment strategies.

Immune checkpoint inhibitors, which have worked well in lung cancer and melanoma, have shown only modest improvement in overall survival when used to treat breast cancer. Hwang argued this is “likely caused by not enough potent cellular immunity.”

Cellular immunity, which happens inside infected cells — in this case, cancer cells — is an immune response mediated by T-cells that begins with T-cell recognition of the antigen (the cancer marker) on those cells and ends eventually with the death of those cancer cells.

The Hartman Lab focuses on using vaccines to induce cellular immunity against HER2+ breast cancer, a type of breast cancer that comprises about 25% of all breast cancer cases. HER2 stands for human epidermal growth factor receptor 2, a gene that makes a protein found on the surface of all breast cells. In normal cells, HER2 helps keep cell growth under control. HER2+ breast cancer means that HER2 has been detected as amplified in breast cancer cells and is driving those cells to grow quickly.

In an experimental pilot study at Duke led by Michael Morse, MD, more than 20 years ago, a group of seven HER2+ patients with advanced or metastatic breast cancer were administered a dendritic cell vaccine. (Dendritic cells are a special type of immune cell, found in tissues, which boosts immune system response by stimulating the development of killer T cells and showing these immune cells how to recognize foreign cells, such as cancer cells.) Each dendritic cell vaccine administered to the seven patients was also loaded with a recombinant HER2 protein (a manufactured form derived from HER2 protein fragments in the intracellular domain) and/or a restricted peptide fragment of the extracellular domain of the HER2 protein — to induce the body's T-cells to recognize, ramp up, and destroy the breast cancer cells.

Each vaccine also contained the individual patients’ peripheral blood mononuclear cells (PBMCs), which consist mainly of immune cells (a.k.a. lymphocytes), including T cells, B cells, and natural killer cells, plus monocytes and a small number of dendritic cells. So, the vaccines were, in part, personalized. 

Recently, the Hartman Lab was able to reconnect with all seven patients. They were still alive. They got consent from five of them to draw their blood and analyze it. Working with Crosby’s lab, they found a significantly increased presence of CD27+ memory T cells. CD27 is required for the activation and maintenance of long-term T-cell immunity. For example, when developed following an infection, CD27+ memory T cells can protect against subsequent infections with the same pathogen. Recent reports involving the SARS-CoV2 (Covid-19) mRNA vaccine, in fact, suggest that CD27+ memory T cells play a critical role in long-lasting cellular immunity against SARS-CoV2 infection.

The CD27+ memory T-cells that they found — primed to recognize and fight cancer — had most likely played a role in those patients’ continued survival. That’s what the Morse team had aimed for. Getting there again isn’t so simple.

“The idea and dogma behind that approach (the Morse-led study) was that activated dendritic cells would express CD70, thereby stimulating CD27 on T cells to elicit long-term T cell memory responses. And it worked,” said Hartman. “But one thing that was learned by Drs. Morse and Lyerly in pursuing clinical dendritic cell vaccines was that it was very complex and not easily scalable, which is why only a handful of patients were ever treated this way.”

Searching for another, less complex, way to increase cellular immunity against HER2+ breast cancer, Hwang suggested targeting the CD27 gene with a monoclonal antibody directly in combination with a promising new HER2 vaccine recently developed in the Hartman Lab. The new vaccine, known as a viral vaccine, uses a neutralized virus vector to carry genetic information that targets HER2 proteins.

In collaboration with Crosby, Hartman, and Lyerly, Hwang has already tested his hypothesis in pre-clinical studies with transgenic mice. The study looks promising.

Hwang reported that they found “a robust increase in HER2-specific T cells, especially CD27+ memory T cells” when a CD27 antibody was used with the HER2 vaccine, compared to the vaccination alone. Nearly 24% of the mouse models who received both treatments were still alive 150 days later. They found that T cell responses were even further enhanced by adding an immunotherapy drug to the mix — an anti-PD1 immune checkpoint inhibitor antibody, which is designed to prevent T cell exhaustion. This triple combo led to total tumor regression in 90% of the HER2+ tumor-bearing mice.

The team is hoping to publish a paper on this study later this year.

"I'd like to acknowledge everyone in my lab, especially Dr. Hartman and Dr. Kim Lyerly," Hwang said, concluding his oral presentation. "I also want to acknowledge Dr. Michael Morse for his pioneering work 20 years ago on a dendritic cell vaccine against HER2+ breast cancer, and also Dr. Erika Crosby — she was our postdoc and has now moved on to become an independent PI now — for her earlier work on the follow-up study with the recipients of the (dendritic cell) cancer vaccine."

Hwang also acknowledged the funding sources for the study, including two grants from the Department of Defense (BC191055; BC201085P2) — one to Hartman and one to Lyerly (overall PI) with Hartman as site lead; support from a National Cancer Institute-funded R01 award (1R01CA238217-01A1) to Hartman; and the provision of reagents (CD27 antibodies and CD27 transgenic mice) from CellDex Therapeutics.

Future directions, Hwang said, include getting a better understanding of why and how the CD27 gene is so important to cellular immunity and potentially proceeding to a clinical trial for breast cancer patients using a CD27 antibody, the HER2 vaccine, and an anti-PD1 immune checkpoint inhibitor drug.

"Dr. Hwang's study supports the use of CD27 antibodies to enhance the effects of our new HER2 vaccine —hopefully giving T cells the boost they need in eliciting long-term T cell memory responses — and potentially to even greater effect if used in combination with an anti-PD1 antibody,” said Hartman, Hwang’s mentor on the study. “Dr. Hwang is offering us a glimpse of the future; a future that could further improve on what we’re exploring clinically now."

Lyerly is currently leading a phase 2 trial of the HER2 vaccine plus the anti-PD-1 immune checkpoint inhibitor drug pembrolizumab in patients with advanced HER2+ breast cancer who are already being treated with the antibodies trastuzumab and pertuzumab. The clinical trial follows a lab study and a successful phase 1 trial showing that an anti-PD-1 immune checkpoint inhibitor antibody (pembrolizumab) could enhance the HER2 vaccine-induced T-cell response.