Stefano Testa

All Publications

• A Multi-center Retrospective Outcomes Analysis of Patients with Localized Synovial Sarcoma. Cancer research communications Testa, S., Zhou, M. Y., Schulte, B. C., Wang, V. E., Kenny, K., Peng, A., Lohman, M., Desai, A. M., Bockorny, B., Baghian, A., Schmidt, D. R., Bui, N. Q., Pan, M., Ganjoo, K. N., Monga, V. 2026

  Abstract

  To identify clinicopathologic factors associated with outcomes in patients with localized synovial sarcoma (SS). We retrospectively reviewed 248 patients with localized SS treated across three US quaternary medical centers between 2000-2024. Demographics, tumor characteristics, and treatments, including perioperative chemotherapy and radiotherapy, were assessed. Disease-free survival (DFS) and overall survival (OS) were estimated via Kaplan-Meier, and Cox regression was used for univariable and multivariable analysis, including significant univariate factors and confounders such as age and tumor size. Median follow-up was 5.2 years; median age at diagnosis 35 years (IQR 26-46). Median DFS was 110.3 months. Perioperative chemotherapy was given to 150 (60%) patients, while perioperative radiotherapy (RT) was given to 173 (69.8%) patients. Multivariable analysis showed that tumor size correlated with worse DFS (P < 0.001) and OS (P < 0.001), while a location in the chest wall, trunk or extremities correlated with improved DFS (P = 0.006). Percent tumor necrosis was associated with worse OS (P = 0.04), while R0 (P = 0.002) resection margins correlated with improved OS. Perioperative RT or chemotherapy did not correlate with OS or DFS in the whole cohort, though patients with tumor size ≥ 10 cm (n = 47) showed worse OS when receiving perioperative chemotherapy only as opposed to combined perioperative chemotherapy and RT (P = 0.006). Tumor size, location, margin status, and tumor necrosis are independent prognostic factors in localized SS. Combined perioperative chemotherapy and radiotherapy correlated with improved OS in patients with tumors larger than 10 cm.

  View details for DOI 10.1158/2767-9764.CRC-25-0652

  View details for PubMedID 42118560

• Neoadjuvant BO-112 and hypofractionated radiation therapy with or without nivolumab in soft tissue sarcoma: preclinical and phase 1 results. Cancer discovery Deng, J., Pal, A., Testa, S., Xu, J. W., Tran, L. M., Graham, D. S., Hargil, A., Subramanian, A., Campbell, K. M., Limsuwannarot, S., Chumpitaz Lavalle, Á., Chin, S. C., Kremer, S., Tariveranmoshabad, M., Ewongwo, A., Silvia, S. N., Ogana, H., Nemat-Gorgani, N., Dubinett, S. M., Jaycox, J. R., Felix, C., Schaue, D., Nelson, S. D., Levine, B., Motamedi, K., Ghazikhanian, V., Chmielowski, B., Reddy, V., Singh, A. S., Trnkova, Z. J., Good, Z., Quintero, M., Crompton, J. G., Bernthal, N., Eilber, F. C., Moding, E. J., Kalbasi, A. 2026

  Abstract

  Neoadjuvant immune checkpoint blockade (ICB) and radiation therapy (RT) improve disease-free survival in select patients with soft tissue sarcoma (STS). However, most STS are myeloid-rich and lack pre-existing T cells associated with ICB response. In preclinical models, we observed that intratumoral BO-112 (nanoplexed polyinosinic: polycytidylic acid (poly I:C)) engages myeloid cells that persist after RT, ultimately enhancing T cell-dependent tumor control. We evaluated BO-112 and hypofractionated RT, with or without nivolumab, in fourteen patients with high-risk STS in a phase 1 neoadjuvant trial. Consistent with its immunologic potency, the triple combination induced rare immune-related adverse events (myositis-myocarditis-myasthenia gravis spectrum), mitigated by BO-112 and nivolumab dose adjustment. BO-112 and RT reprogrammed tumor-associated myeloid cells toward antigen-presenting states, promoted clonal replacement by less exhausted T cells, and enhanced malignant cell depletion compared to standard RT. These immunologic changes coincided with encouraging disease control in a small, high-risk cohort, supporting further clinical development.

  View details for DOI 10.1158/2159-8290.CD-25-1132

  View details for PubMedID 41784328

• IL-9 as a naturally orthogonal cytokine with optimal JAK/STAT signaling for engineered T cell therapy. Immunity Jiang, H., Limsuwannarot, S., Kulhanek, K. R., Pal, A., Labiad, O., Rysavy, L. W., Wong, A., Su, L., Cavender, S., Soro, J., Testa, S., Ogana, H., Waghray, D., Tao, P., Jude, K. M., Seet, C. S., Crooks, G. M., Moding, E. J., Garcia, K. C., Kalbasi, A. 2025

  Abstract

  Cytokines and their receptors enable precise tuning of T cell function. Leveraging this biology holds tremendous promise for optimizing antitumor immunity. Arming T cells with a synthetically orthogonal interleukin (IL)-9 receptor (o9R), for instance, permits facile engraftment and potent anti-tumor functions. Exploiting the paucity of wild-type IL-9R expression and the safety of high doses of IL-9, here, we showed that, compared with o9R, T cells engineered with wild-type IL-9R exhibited superior tissue infiltration, stemness, and anti-tumor activity. These qualities were consistent with a stronger Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signal, which included canonically IL-12-driven STAT4 in addition to STAT1/3/5. IL-9R T cells were exquisitely sensitive to perturbations of proximal signaling, including structure-guided attenuation, amplification, and rebalancing of JAK/STAT signals. Biased IL-9R mutants showed that STAT1 acts as a rheostat between stem-like and effector states. In summary, we identify IL-9/IL-9R as a naturally orthogonal cytokine-receptor pair with an optimal JAK/STAT signaling profile for engineered T cell therapy.

  View details for DOI 10.1016/j.immuni.2025.10.024

  View details for PubMedID 41274289

  View details for PubMedCentralID PMC12643178

• SCAN-ACT: adoptive T cell therapy target discovery through single-cell transcriptomics. Genome medicine Testa, S., Pal, A., Subramanian, A., Varma, S., Tang, J. P., Graham, D., Arfan, S., Pan, M., Bui, N. Q., Ganjoo, K. N., Dry, S., Huang, P., van de Rijn, M., Jiang, W., Kalbasi, A., Moding, E. J. 2025; 17 (1): 89

  Abstract

  The FDA approval of T cell receptor-engineered T cells (TCR-T) for synovial sarcoma demonstrates the potential for adoptive T cell therapies (ACTs) in solid tumors. However, the paucity of tumor-associated targets without expression in normal tissues remains a major bottleneck, especially in rare cancer subtypes.We developed a comprehensive computational pipeline called SCAN-ACT that leverages single-cell RNA sequencing and multi-omics data from tumor and normal tissues to nominate and prioritize putative targets for both chimeric antigen receptor (CAR)- and TCR-T cells. For surface membrane targets, SCAN-ACT proposes monospecific targets and potential target pairs for bispecific Boolean logic-gated CAR T cells. For peptide-MHC targets, SCAN-ACT proposes intracellular peptides bound to a diverse set of human leukocyte antigens. Selected targets were validated experimentally by protein expression and for peptide-MHC binding.We applied the SCAN-ACT pipeline to soft tissue sarcoma (STS), analyzing 986,749 single cells to identify and prioritize 395 monospecific CAR-T targets, 14,192 bispecific CAR-T targets, and 5020 peptide-MHC targets for TCR-T cells. Proposed targets and target pairs reflected the mesenchymal, neuronal, and hematopoietic ontogeny of STS. We further validated SCAN-ACT in glioblastoma revealing its versatility.This work provides a robust data repository along with a web-based and user-friendly set of analysis tools to accelerate ACT development for solid tumors ( https://scanact.stanford.edu/ ).

  View details for DOI 10.1186/s13073-025-01514-9

  View details for PubMedID 40814001

  View details for PubMedCentralID PMC12351953

• Medical digital twins: enabling precision medicine and medical artificial intelligence. The Lancet. Digital health Sadée, C., Testa, S., Barba, T., Hartmann, K., Schuessler, M., Thieme, A., Church, G. M., Okoye, I., Hernandez-Boussard, T., Hood, L., Shmulevich, I., Kuhl, E., Gevaert, O. 2025: 100864

  Abstract

  The notion of medical digital twins is gaining popularity both within the scientific community and among the general public; however, much of the recent enthusiasm has occurred in the absence of a consensus on their fundamental make-up. Digital twins originate in the field of engineering, in which a constantly updating virtual copy enables analysis, simulation, and prediction of a real-world object or process. In this Health Policy paper, we evaluate this concept in the context of medicine and outline five key components of the medical digital twin: the patient, data connection, patient-in-silico, interface, and twin synchronisation. We consider how various enabling technologies in multimodal data, artificial intelligence, and mechanistic modelling will pave the way for clinical adoption and provide examples pertaining to oncology and diabetes. We highlight the role of data fusion and the potential of merging artificial intelligence and mechanistic modelling to address the limitations of either the AI or the mechanistic modelling approach used independently. In particular, we highlight how the digital twin concept can support the performance of large language models applied in medicine and its potential to address health-care challenges. We believe that this Health Policy paper will help to guide scientists, clinicians, and policy makers in creating medical digital twins in the future and translating this promising new paradigm from theory into clinical practice.

  View details for DOI 10.1016/j.landig.2025.02.004

  View details for PubMedID 40518342

• A multi-center retrospective outcomes analysis of patients with localized synovial sarcoma. Testa, S., Zhou, M., Schulte, B., Wang, V., Kenny, K., Peng, A., Desai, A. M., Bockorny, B., Baghian, A., Schmidt, D. R., Okimoto, R., Bui, N., Pan, M., Ganjoo, K. N., Monga, V. LIPPINCOTT WILLIAMS & WILKINS. 2025: e23555

  View details for DOI 10.1200/JCO.2025.43.16_suppl.e23555

  View details for Web of Science ID 001690324100029

• IL-9 as a naturally orthogonal cytokine with optimal JAK/STAT signaling for engineered T cell therapy. bioRxiv : the preprint server for biology Jiang, H., Limsuwannarot, S., Kulhanek, K. R., Pal, A., Rysavy, L. W., Su, L., Labiad, O., Testa, S., Ogana, H., Waghray, D., Tao, P., Jude, K. M., Seet, C. S., Crooks, G. M., Moding, E. J., Garcia, K. C., Kalbasi, A. 2025

  Abstract

  Arming T cells with a synthetically orthogonal IL-9 receptor (o9R) permits facile engraftment and potent anti-tumor functions. We considered whether the paucity of natural IL-9R expression could be exploited for T cell immunotherapy given that, in mice, high doses of IL-9 were well-tolerated without discernible immune modulation. Compared to o9R, T cells engineered with IL-9R exhibit superior tissue infiltration, stemness, and anti-tumor activity. These qualities are consistent with a stronger JAK/STAT signal, which in addition to STAT1/3/5, unexpectedly includes STAT4 (canonically associated with IL-12 but not common γ-chain cytokines). IL-9R T cells are exquisitely sensitive to perturbations of proximal signaling, including structure-guided attenuation, amplification, and rebalancing of JAK/STAT signals. Biased IL-9R mutants uncover STAT1 as a rheostat between proliferative stem-like and terminally differentiated effector states. In summary, we identify native IL-9/IL-9R as a natural cytokine-receptor pair with near-orthogonal qualities and an optimal JAK/STAT signaling profile for engineered T cell therapy.

  View details for DOI 10.1101/2025.01.15.633105

  View details for PubMedID 39868284

  View details for PubMedCentralID PMC11760723

• Surgery and stereotactic radiosurgery for spinal leiomyosarcoma: a single-institution retrospective series and systematic review. Journal of neurosurgery. Spine Zamarud, A., Marianayagam, N. J., Sekar, V., Testa, S., Park, D. J., Yener, U., McCleary, T. L., Yoo, K. H., Emrich, S., Tayag, A., Ustrzynski, L., Pollom, E., Soltys, S., Wang, L., Charville, G., Ganjoo, K., Chang, S. D., Meola, A. 2023: 1-13

  Abstract

  Leiomyosarcoma (LMS) is a rare, aggressive soft-tissue sarcoma that seldom spreads to the bone. The spine can be either the site of LMS osseous metastases or the primary tumor site. The optimal treatment option for spinal LMS is still unclear. The authors present a cohort of patients with spinal LMS treated with either upfront surgery or upfront CyberKnife stereotactic radiosurgery (SRS).The authors retrospectively studied the clinical and radiological outcomes of 17 patients with spinal LMS treated at their institution between 2004 and 2020. Either surgery or SRS was used as the upfront treatment. The clinical and radiological outcomes were assessed. A systematic review of the literature was also conducted.Of the 17 patients (20 spinal lesions), 12 (70.6%) were female. The median patient age was 61 years (range 41-80 years). Ten patients had upfront surgery for their spinal lesions, and 7 had upfront CyberKnife radiosurgery. The median follow-up was 11 months (range 0.3-130 months). The median overall survival (OS) for the entire cohort was 13 months (range 0.3-97 months). In subgroup analysis, the median OS was lower for the surgical group (13 months, range 0.3-50 months), while the median OS for the SRS group was 15 months (range 5-97 months) (p = 0.5). Forty percent (n = 4) of those treated with surgery presented with local recurrence at a median of 6.7 months (range 0.3-36 months), while only 14% (n = 1) of those treated with CyberKnife radiosurgery had local recurrence after 5 months. Local tumor control (LTC) rates at the 6-, 12-, and 18-month follow-ups were 72%, 58%, and 43%, respectively, for the SRS group and 40%, 30%, and 20%, respectively, for the surgery group (p < 0.05). The literature review included 35 papers with 70 patients harboring spinal LMS; only 2 patients were treated with SRS. The literature review confirms the clinical and radiological outcomes of the surgical group, while data on SRS are anecdotal.The authors present the largest series in the literature of spinal LMS and the first on SRS for spinal LMS. This study shows that LTC is statistically significantly better in patients receiving upfront SRS instead of surgery. The OS does not appear different between the two groups.

  View details for DOI 10.3171/2023.10.SPINE23666

  View details for PubMedID 38157539

• Use of Voice-Based Conversational Artificial Intelligence for Basal Insulin Prescription Management Among Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA network open Nayak, A., Vakili, S., Nayak, K., Nikolov, M., Chiu, M., Sosseinheimer, P., Talamantes, S., Testa, S., Palanisamy, S., Giri, V., Schulman, K. 2023; 6 (12): e2340232

  Abstract

  Optimizing insulin therapy for patients with type 2 diabetes can be challenging given the need for frequent dose adjustments. Most patients receive suboptimal doses and do not achieve glycemic control.To examine whether a voice-based conversational artificial intelligence (AI) application can help patients with type 2 diabetes titrate basal insulin at home to achieve rapid glycemic control.In this randomized clinical trial conducted at 4 primary care clinics at an academic medical center from March 1, 2021, to December 31, 2022, 32 adults with type 2 diabetes requiring initiation or adjustment of once-daily basal insulin were followed up for 8 weeks. Statistical analysis was performed from January to February 2023.Participants were randomized in a 1:1 ratio to receive basal insulin management with a voice-based conversational AI application or standard of care.Primary outcomes were time to optimal insulin dose (number of days needed to achieve glycemic control), insulin adherence, and change in composite survey scores measuring diabetes-related emotional distress and attitudes toward health technology and medication adherence. Secondary outcomes were glycemic control and glycemic improvement. Analysis was performed on an intent-to-treat basis.The study population included 32 patients (mean [SD] age, 55.1 [12.7] years; 19 women [59.4%]). Participants in the voice-based conversational AI group more quickly achieved optimal insulin dosing compared with the standard of care group (median, 15 days [IQR, 6-27 days] vs >56 days [IQR, >29.5 to >56 days]; a significant difference in time-to-event curves; P = .006) and had better insulin adherence (mean [SD], 82.9% [20.6%] vs 50.2% [43.0%]; difference, 32.7% [95% CI, 8.0%-57.4%]; P = .01). Participants in the voice-based conversational AI group were also more likely than those in the standard of care group to achieve glycemic control (13 of 16 [81.3%; 95% CI, 53.7%-95.0%] vs 4 of 16 [25.0%; 95% CI, 8.3%-52.6%]; difference, 56.3% [95% CI, 21.4%-91.1%]; P = .005) and glycemic improvement, as measured by change in mean (SD) fasting blood glucose level (-45.9 [45.9] mg/dL [95% CI, -70.4 to -21.5 mg/dL] vs 23.0 [54.7] mg/dL [95% CI, -8.6 to 54.6 mg/dL]; difference, -68.9 mg/dL [95% CI, -107.1 to -30.7 mg/dL]; P = .001). There was a significant difference between the voice-based conversational AI group and the standard of care group in change in composite survey scores measuring diabetes-related emotional distress (-1.9 points vs 1.7 points; difference, -3.6 points [95% CI, -6.8 to -0.4 points]; P = .03).In this randomized clinical trial of a voice-based conversational AI application that provided autonomous basal insulin management for adults with type 2 diabetes, participants in the AI group had significantly improved time to optimal insulin dose, insulin adherence, glycemic control, and diabetes-related emotional distress compared with those in the standard of care group. These findings suggest that voice-based digital health solutions can be useful for medication titration.ClinicalTrials.gov Identifier: NCT05081011.

  View details for DOI 10.1001/jamanetworkopen.2023.40232

  View details for PubMedID 38039007

• Response to trastuzumab deruxtecan in a patient with HER2-low metastatic breast cancer previously treated with sacituzumab govitecan CURRENT PROBLEMS IN CANCER: CASE REPORTS Testa, S., Dickerson, J. C., Telli, M. 2023; 11

  View details for DOI 10.1016/j.cpccr.2023.100258

  View details for Web of Science ID 001067888400001

• Milky Way: Management of Primary Intestinal Lymphangiectasia. Digestive diseases and sciences Norman, J. S., Testa, S., Wang, C. X., Savage, T. 2023

  View details for DOI 10.1007/s10620-023-08077-y

  View details for PubMedID 37634185

  View details for PubMedCentralID 7789053

• Milky Way: Management of Primary Intestinal Lymphangiectasia Digestive Diseases and Sciences Norman, J. S., Testa, S., Wang, C., Savage, T. 2023

  View details for DOI 10.1007/s10620-023-08077-y

  View details for PubMedCentralID 7789053

• Systemic Treatments and Molecular Biomarkers for Perivascular Epithelioid Cell Tumors: A Single-institution Retrospective Analysis. Cancer research communications Testa, S., Bui, N. Q., Ganjoo, K. N. 2023; 3 (7): 1212-1223

  Abstract

  Perivascular epithelioid cell tumors (PEComa) are a large family of mesenchymal neoplasms, with variable clinical course. Evidence regarding treatment of advanced PEComas is scarce, with only one FDA-approved treatment available. The goals of this study were to provide data regarding systemic treatments for advanced PEComas and to identify biomarkers of prognostic relevance. This is a single-institution retrospective study of patients with advanced PEComas requiring systemic treatment, including malignant PEComa, angiomyolipoma (including the epithelioid variant), and lymphangioleiomyomatosis. Outcomes measured were overall survival (OS), first-line and combined progression-free survival (PFS), and tumor response. Kaplan-Meier, univariable, and multivariable Cox proportional hazards analysis were performed. A total of 29 patients were included, most with malignant PEComa (n = 17). Median OS was 204.9 months, while median PFS was 92.4 months from first-line, and 15.8 months for all lines combined. TFE3 overexpression correlated with higher risk of death (HR: 11.8, P = 0.04), and shorter median OS (P = 0.001). Chemotherapy and mTOR inhibitors showed similar OS (P = 0.84), and first-line PFS (P = 0.67). Combined PFS was similar between individual mTOR inhibitors, chemotherapy, immune checkpoint inhibitors and other treatments (P = 0.19). Different mTOR inhibitors demonstrated similar efficacy, making cost and availability important considerations when choosing a specific agent. mTOR inhibitors showed similar outcomes as chemotherapy, suggesting that these should be preferred whenever possible for patients with PEComas given the morbidity associated with chemotherapy. TFE3 overexpression highlighted a subgroup of PEComas with worse prognosis and more aggressive behavior.Significance: This study examines systemic treatments for advanced PEComas, a rare group of sarcomas, and identifies molecular biomarkers of prognosis. Our results show that mTOR inhibitors have similar efficacy as chemotherapy, and that TFE3 overexpression, on IHC or FISH, correlates with a more aggressive disease course.

  View details for DOI 10.1158/2767-9764.CRC-23-0139

  View details for PubMedID 37448552

• Prevalence, mutational spectrum and clinical implications of clonal hematopoiesis of indeterminate potential in plasma cell dyscrasias. Seminars in oncology Testa, S., Kumar, J., Goodell, A. J., Zehnder, J. L., Alexander, K. M., Sidana, S., Arai, S., Witteles, R. M., Liedtke, M. 2022

  Abstract

  Clonal hematopoiesis of indeterminate potential (CHIP) is common both in healthy individuals and patients with hematological cancers. Recent studies have showed worse prognosis for patients with multiple myeloma (MM) and non-Hodgkin lymphoma undergoing stem cell transplant, that have concomitant presence of CHIP. Data regarding the clinical and biological role of CHIP in plasma cell dyscrasias (PCDs) is rapidly increasing. However, the prevalence and prognostic implication of CHIP in patients with MM outside of the transplant setting, and in those with other more indolent PCDs remains elusive. Here we explored the prevalence and clinical implications of CHIP detected through next-generation sequencing in 209 patients with PCDs including MM, light chain (AL) amyloidosis (ALA), monoclonal gammopathy of undetermined significance (MGUS), and smoldering multiple myeloma (SMM). To avoid attributing the mutations to the plasma cell clone, CHIP was defined as the presence of DNMT3A, TET2, or ASXL1 mutations in the peripheral blood or bone marrow (DTA-CH). The prevalence of DTA-CH was 19% in patients with PCDs, with no difference between each PCD. TET2 (23%) and DNMT3A (22%), were the most frequently mutated genes. DTA-CH correlated with older age in MM (P = .001) and MGUS/SMM (P = 0.0007), as well as with coronary artery disease or congestive heart failure in MM (P = .03). DTA-CH did not predict worse OS or PFS in either MM or ALA, nor it predict higher risk of progression to MM in patients with MGUS/SMM. Our results overall further elucidate the prevalence and mutational spectrum of CHIP in PCDs, providing more information regarding the clinical relevance of CHIP in this patient population.

  View details for DOI 10.1053/j.seminoncol.2022.11.001

  View details for PubMedID 36503855

• Management of Patients with Newly Diagnosed Desmoid Tumors in a First-Line Setting. Cancers Testa, S., Bui, N. Q., Charville, G. W., Avedian, R. S., Steffner, R., Ghanouni, P., Mohler, D. G., Ganjoo, K. N. 2022; 14 (16)

  Abstract

  The initial management of desmoid tumors (DTs) is shifting from surgery towards active surveillance, with systemic and locally ablative treatments reserved for enlarging and/or symptomatic disease. However, it remains unclear which patients would benefit most from an initial conservative rather than interventional approach. To answer this question, we retrospectively analyzed adult and pediatric patients with DTs treated at a tertiary academic cancer center between 1992 and 2022. Outcomes measured were progression-free survival (PFS) and time to next treatment (TTNT) after first-line therapy. A total of 262 treatment-naïve patients were eligible for analysis with a median age of 36.5 years (range, 0-87 years). The 5-year PFS and the median TTNT (months) after first-line treatment were, respectively: 50.6% and 69.1 mo for surgery; 64.9% and 149.5 mo for surgery plus adjuvant radiotherapy; 57.1% and 44.7 mo for surgery plus adjuvant systemic therapy; 24.9% and 4.4 mo for chemotherapy; 26.7% and 5.3 mo for hormonal therapy; 41.3% and 29.6 mo for tyrosine kinase inhibitors (TKIs); 44.4% and 8.9 mo for cryoablation and high intensity focused ultrasound; and 43.1% and 32.7 mo for active surveillance. Age ≤ 40 years (p < 0.001), DTs involving the extremities (p < 0.001), a maximum tumor diameter > 60 mm (p = 0.04), and hormonal therapy (p = 0.03) predicted a higher risk of progression. Overall, our results suggest that active surveillance should be considered initially for patients with smaller asymptomatic DTs, while upfront TKIs, local ablation, and surgery achieve similar outcomes in those with more aggressive disease.

  View details for DOI 10.3390/cancers14163907

  View details for PubMedID 36010900

• Fingolimod-Conjugated Charge-Altering Releasable Transporters Efficiently and Specifically Deliver mRNA to Lymphocytes In Vivo and In Vitro. Biomacromolecules Testa, S., Haabeth, O. A., Blake, T. R., Del Castillo, T. J., Czerwinski, D. K., Rajapaksa, R., Wender, P. A., Waymouth, R. M., Levy, R. 2022

  Abstract

  Charge-altering releasable transporters (CARTs) are a class of oligonucleotide delivery vehicles shown to be effective for delivery of messenger RNA (mRNA) both in vitro and in vivo. Here, we exploited the chemical versatility of the CART synthesis to generate CARTs containing the small-molecule drug fingolimod (FTY720) as a strategy to increase mRNA delivery and expression in lymphocytes through a specific ligand-receptor interaction. Fingolimod is an FDA-approved small-molecule drug that, upon in vivo phosphorylation, binds to the sphingosine-1-phosphate receptor 1 (S1P1), which is highly expressed on lymphocytes. Compared to its non-fingolimod-conjugated analogue, the fingolimod-conjugated CART achieved superior transfection of activated human and murine T and B lymphocytes in vitro. The higher transfection of the fingolimod-conjugated CARTs was lost when cells were exposed to a free fingolimod before transfection. In vivo, the fingolimod-conjugated CART showed increased mRNA delivery to marginal zone B cells and NK cells in the spleen, relative to CARTs lacking fingolimod. Moreover, fingolimod-CART-mediated mRNA delivery induces peripheral blood T-cell depletion similar to free fingolimod. Thus, we show that functionalization of CARTs with a pharmacologically validated small molecule can increase transfection of a cellular population of interest while conferring some of the targeting properties of the conjugated small molecule to the CARTs.

  View details for DOI 10.1021/acs.biomac.2c00469

  View details for PubMedID 35748182

• Training Internal Medicine Residents in Difficult Diagnosis: A Novel Diagnostic Second Opinion Clinic Experience. Journal of medical education and curricular development Testa, S., Joshi, M., Lotfi, J., Lin, B., Artandi, M., Chiang, K. F., Chang, K., Singh, B., Geng, L. N. 2022; 9: 23821205221091036

  Abstract

  Background: In primary care clinics, time constraints and lack of exposure to highly complex cases may limit the breadth and depth of learning for internal medicine residents. To address these issues, we piloted a novel experience for residents to evaluate patients with puzzling symptoms referred by another clinician.Objective: To increase internal medicine residents' exposure to patients with perplexing presentations and foster a team-based approach to solving diagnostically challenging cases.Methods: During the academic year 2020-2021, residents participating in their 2-week primary care "block" rotation were given protected time to evaluate 1-2 patients from the Stanford Consultative Medicine clinic, an internist-led diagnostic second opinion service, and present their patients at the case conference. We assessed the educational value of the program with resident surveys including 5-point Lickert scale and open-ended questions.Results: 21 residents participated in the pilot with a survey response rate of 66.6% (14/21). Both the educational value and overall quality of the experience were rated as 4.8 out of 5 (SD 0.4, range 4-5; 1:"very poor"; 5:"excellent"). Residents learned about new diagnostic tools as well as how to approach complex presentations and diagnostic dilemmas. Residents valued the increased time devoted to patient care, the team-based approach to tackling difficult cases, and the intellectual challenge of these cases. Barriers to implementation include patient case volume, time, and faculty engagement.Conclusions: Evaluation of diagnostically challenging cases in a structured format is a highly valuable experience that offers a framework to enhance outpatient training in internal medicine.

  View details for DOI 10.1177/23821205221091036

  View details for PubMedID 35372696

• Efficacy and Safety of Trans-Arterial Yttrium-90 Radioembolization in Patients with Unresectable Liver-Dominant Metastatic or Primary Hepatic Soft Tissue Sarcomas. Cancers Testa, S., Bui, N. Q., Wang, D. S., Louie, J. D., Sze, D. Y., Ganjoo, K. N. 2022; 14 (2)

  Abstract

  Patients with liver-dominant metastatic or primary hepatic soft tissue sarcomas (STS) have poor prognosis. Surgery can prolong survival, but most patients are not surgical candidates, and treatment response is limited with systemic chemotherapy. Liver-directed therapies have been increasingly employed in this setting, and Yttrium-90 trans-arterial radioembolization (TARE) is an understudied yet promising treatment option. This is a retrospective analysis of 35 patients with metastatic or primary hepatic STS who underwent TARE at a single institution between 2006 and 2020. The primary outcomes that were measured were overall survival (OS), liver progression-free survival (LPFS), and radiologic tumor response. Clinical and biochemical toxicities were assessed 3 months after the procedure. Median OS was 20 months (95% CI: 13.9-26.1 months), while median LPFS was 9 months (95% CI: 6.2-11.8 months). The objective response rate was 56.7%, and the disease control rate was 80.0% by mRECIST at 3 months. The following correlated with better OS post-TARE: liver disease control (DC) at 6 months (median OS: 40 vs. 17 months, p = 0.007); LPFS ≥ 9 months (median OS: 50 vs. 8 months, p < 0.0001); ECOG status 0-1 vs. 2 (median OS: 22 vs. 6 months, p = 0.042); CTP class A vs. B (median OS: 22 vs. 6 months, p = 0.018); and TACE post-progression (median OS: 99 vs. 16 months, p = 0.003). The absence of metastases at diagnosis was correlated with higher median LPFS (7 vs. 1 months, p = 0.036). Two grade 4 (5.7%) and ten grade 3 (28.6%) laboratory toxicities were identified at 3 months. There was one case of radioembolization-induced liver disease and two cases of radiation-induced peptic ulcer disease. We concluded that TARE could be an effective and safe treatment option for patients with metastatic or primary hepatic STS with good tumor response rates, low incidence of severe toxicity, and longer survival in patients with liver disease control post-TARE.

  View details for DOI 10.3390/cancers14020324

  View details for PubMedID 35053486

• Uterine Leiomyosarcoma with FN1-Anaplastic Lymphoma Kinase Fusion Responsive to Alectinib and Lorlatinib. Case reports in oncology Testa, S., Million, L., Longacre, T., Bui, N. 2021; 14 (2): 812-819

  Abstract

  Uterine leiomyosarcoma (LMS) is a rare malignant neoplasm of the female genital tract poorly responsive to conventional chemotherapy and radiotherapy, with an overall poor prognosis. Pazopanib is at the moment the only FDA-approved targeted molecular therapy for uterine LMS, given the exceedingly rare occurrence of actionable genetic mutations in this type of cancer. Here, we describe the first reported case of metastatic uterine LMS with an FN1-anaplastic lymphoma kinase (ALK) fusion mutation occurring in a 63-year-old woman with a history of uterine leiomyomas. The patient progressed on several lines of therapy, including conventional chemotherapy, pazopanib, and the first-generation ALK inhibitor crizotinib. Interestingly, the patient showed a remarkable 16-month response to second generation ALK inhibitors alectinib and lorlatinib. This case demonstrates that ALK inhibitors can be an effective therapeutic strategy for patients with ALK fusion-positive uterine LMS that has progressed on conventional chemotherapy.

  View details for DOI 10.1159/000516758

  View details for PubMedID 34248545

• Serial FNA allows direct sampling of malignant and infiltrating immune cells in patients with B-cell lymphoma receiving immunotherapy. Cancer cytopathology Mooney, K. L., Czerwinski, D. K., Shree, T., Frank, M. J., Haebe, S., Martin, B. A., Testa, S., Levy, R., Long, S. R. 2021

  Abstract

  Fine-needle aspiration (FNA) is used to diagnose malignancies, recurrences, and metastases. The procedure is quick and well tolerated and can be facilitated by ultrasound guidance.This article describes the authors' experience in using serial FNA to harvest cellular material during 4 clinical trials of immunotherapy by in situ vaccination in patients with low-grade lymphoma.Two hundred ninety-six FNA samples were collected from 44 patients over a span of approximately 6 weeks for each patient. Samples were sufficient in quantity and quality to be analyzed by flow cytometry and/or single-cell messenger RNA sequencing. FNA samples yielded an average of 12 × 106 cells with a mean cellular viability of 86%. Material collected from the tumor lymph nodes differed significantly in the proportions and phenotypes of cellular populations in comparison with matched peripheral blood samples. A comparison of flow cytometry results obtained by FNA directly from the patient and by FNA performed ex vivo and a dissociation of the same lymph node after surgical excision confirmed that FNA sampling of the patient accurately represented the tumor and the microenvironment. An analysis of the FNA samples from immunotherapy-treated target lymph nodes versus nodes from nontreated tumor sites provided insight into the impact of specific immunotherapy regimens.This is the largest study describing the use of serial FNA sampling to harvest cellular material during immunotherapy clinical trials. The success of this technique opens the door for FNA sampling to expand significantly future investigations of the dynamic effects of investigational agents, be they immunotherapies or targeted therapies.

  View details for DOI 10.1002/cncy.22531

  View details for PubMedID 34780125

• A Retrospective Comparative Analysis of Outcomes and Prognostic Factors in Adult and Pediatric Patients with Osteosarcoma. Current oncology (Toronto, Ont.) Testa, S., Hu, B. D., Saadeh, N. L., Pribnow, A., Spunt, S. L., Charville, G. W., Bui, N. Q., Ganjoo, K. N. 2021; 28 (6): 5304-5317

  Abstract

  Osteosarcoma is the most common primary bone malignancy in both children and adults. Despite introduction of intensive multimodal treatment with chemotherapy and surgery, outcomes are still poor, especially for patients with metastatic disease and adults. Hence, there is an ongoing need for better prognostic markers and outcome data to inform management decisions in both the adult and pediatric setting. Here, we retrospectively analyzed 112 patients with bone osteosarcoma treated at two large adult and pediatric tertiary academic centers between 1989 and 2019. Patients were divided into an adult (≥18 years) and pediatric (<18 years) cohort for comparison. Our aim was to evaluate predictors of outcomes in pediatric and adult patients, with a specific focus on the role of methotrexate when added to a combination of doxorubicin-cisplatin; the prognostic value of tumor necrosis after neoadjuvant chemotherapy; and outlining any differences in outcomes between adults and pediatric patients that could inform clinical management. Adult patients treated with methotrexate-doxorubicin-cisplatin and those treated with doxorubicin-cisplatin had similar 5-year PFS (26%, 95%CI: 45.5%-10% vs. 50%, 95%CI: 69.6%-26.2%, p = 0.1) and 5-year OS (63%, 95%CI: 82%-34%, vs. 78%, 95%CI: 90.6%-52.6%, p = 0.5). In the adult cohort, there was no difference between patients with ≥90% necrosis and <90% necrosis in either 5-year PFS (42%, 95%CI: 71.1%-11.3% vs. 38%, 95%CI: 57.7%-18.2%, p = 0.4) or 5-year OS (85%, 95%CI: 97.8%-33.4% vs. 56%, 95%CI: 76.8%-27.6%, p = 0.4). In the pediatric cohort, compared to patients with <90% necrosis, those with ≥90% necrosis had significantly better 5-year PFS (30%, 95%CI: 49.3%-14.1% vs. 55%, 95%CI: 73.9%-38.5%, p = 0.003) and 5-year OS (64%, 95%CI: 80.8%-41.1% vs. 78%, 95%CI: 92%-60.9%, p = 0.04). Adult and pediatric patients had similar 5-year OS (69%, 95%CI: 83.2%-49.8% vs. 73%, 95%CI: 83.2%-59.3%, p = 0.8) and 5-year PFS (37%, 95%CI: 52.4%-22.9% vs. 43%, 95%CI: 56.2%-30.4% p = 0.3) even though the proportion of patients with ≥90% necrosis after neoadjuvant chemotherapy was higher for children compared to adults (60.3% vs. 30%, OR: 3.54, 95%CI: 1.38-8.46, p = 0.006). In conclusion, in adult patients, the addition of methotrexate to doxorubicin and cisplatin did not correlate with a significant survival benefit, questioning the therapeutic value of methotrexate overall. Our study confirms the prognostic utility of percent tumor necrosis after neoadjuvant chemotherapy in pediatric patients but not in adult patients. Lastly, this is one of the few reported studies where patients with osteosarcoma younger and older than 18 years had similar PFS and OS.

  View details for DOI 10.3390/curroncol28060443

  View details for PubMedID 34940082