We have previously reported two single-agent phase I trials, evaluating the dose or schedule, of a DNA vaccine (pTVG-HP) encoding prostatic acid phosphatase (PAP) administered with GM-CSF as the adjuvant. These were in patients with PSA-recurrent, radiographically non-metastatic, prostate cancer (PCa). We report here the long-term safety and overall survival of these patients. Specifically, 22 patients with non-metastatic, castration-sensitive PCa (nmCSPC) were treated with pTVG-HP, 100-1500 mu g, administered over 12 weeks and followed for 15 y. 17 patients with non-metastatic castration-resistant PCa (nmCRPC) were treated with 100 mu g pTVG-HP with different schedules of administration over 1 y and followed for 5 y. No adverse events were detected in long-term follow-up from either trial that were deemed possibly related to vaccination. Patients with nmCSPC had a median overall survival of 12.3 y, with 5/22 (23%) alive at 15 y. 8/22 (36%) died due to prostate cancer with a median survival of 11.0 y, and 9/22 (41%) died of other causes. Patients with nmCRPC had a median overall survival of 4.5 y, with 8/17 (47%) alive at 5 y. The presence of T-cells specific for the PAP target antigen was detectable in 6/10 (60%) individuals with nmCSPC, and 3/5 (60%) individuals with nmCRPC, many years after immunization. The detection of immune responses to the vaccine target years after immunization suggests durable immunity can be elicited in patients using a DNA vaccine encoding a tumor-associated antigen.Trial Registration: NCT00582140 and NCT00849121

The American Association for Anatomy recently charged a task force with updating and expanding upon best practices and recommendations for human body donation programs. The task force comprised American Association for Anatomy members with specific and detailed knowledge about the legal, ethical, and procedural operations of body donation programs in the United States. The task force developed both foundational and aspirational recommendations. These recommendations emphasize the importance of prioritizing the ethical treatment of all body donors across all education and research sectors. Programs must adhere to several principles to operate an ethical body donation program, the foundation of which is informed consent. The policies and procedures of donation programs must clearly and transparently describe their core operational practices including outreach, registration, custody tracking, use, disposition, and memorialization. Such programs should be governed by a diverse oversight committee whose members are not directly responsible for the program's daily operations. These standards require that all body donation programs follow all national, state, and local laws in the program's jurisdiction. The following recommendations for body donation programs were approved by the Board of Directors of the American Association for Anatomy in 2024 and were conceived as a living document intended to be periodically modified and updated as the ethos and legislation of body donations evolve. Given the importance of these recommendations, translations of this document into Chinese and Spanish are available as supplementary materials S2 and S3.

Purpose We have previously reported that a plasmid DNA vaccine encoding prostatic acid phosphatase (pTVG-HP) had greater clinical activity when given in combination with pembrolizumab to patients with metastatic, castration-resistant prostate cancer. The current trial was conducted to evaluate vaccination with PD-1 blockade, using nivolumab, in patients with early, recurrent (M0) prostate cancer.Methods Patients with M0 prostate cancer were treated with pTVG-HP (100 µg administered intradermally) and nivolumab (240 mg intravenous infusion) every 2 weeks for 3 months, and then every 4 weeks for 1 year of total treatment. Patients were then followed for an additional year off treatment. The primary objectives were safety and complete prostate-specific antigen (PSA) response (PSA<0.2 ng/mL).Results 19 patients were enrolled. No patients met the primary endpoint of complete PSA response; however, 4/19 (21%) patients had a PSA decline >50%. Median PSA doubling times were 5.9 months pretreatment, 25.6 months on-treatment (p=0.001), and 9.0 months in the subsequent year off-treatment. The overall median radiographic progression-free survival was not reached. Grade 3 or 4 events included adrenal insufficiency, fatigue, lymphopenia, and increased amylase/lipase. 9/19 (47%) patients developed immune-related adverse effects (irAE). The development of irAE and increased CXCL9 were associated with increased PSA doubling time. Quantitative NaF PET/CT imaging showed the resolution of subclinical lesions along with the development of new lesions at each time point.Conclusions In this population, combining nivolumab with pTVG-HP vaccination was safe, and immunologically active, prolonged the time to disease progression, but did not eradicate disease. Quantitative imaging suggested that additional treatments targeting mechanisms of resistance may be required to eliminate tumors.Trial registration number NCT03600350.

In our role as medical educators and researchers, we support in the strongest manner possible the personal autonomy and self-determination of our students, patients, and colleagues. A fundamental value of the medical profession is for the patient to have personal autonomy in their healthcare decisions, including how they would like to be identified. It is, and will continue to be, an important priority to be taught and encouraged throughout healthcare education,1 and it begins in the anatomy laboratory with the proper and respectful treatment of body donors.2 Learning this value continues with respecting and accepting this same autonomy in fellow students, staff, faculty, and patients. There are some who question whether foregrounding the value of personal autonomy and the right to self-identification in health professions education is an appropriate use of resources and teaching time in an already crowded curriculum. Let us be clear: understanding this value and addressing it in the correct language3 are of paramount importance to the well-being of all involved in healthcare and should be a recurring theme throughout their education and career.4 Personal autonomy is one of the four pillars of bioethics and is a strong antidote to the paternalism and mistakes of recent eras of healthcare delivery. Any individual should be able to make their personal identity known without fear or ridicule, and this is especially important in healthcare fields. Time and resources should be devoted to educating our future healthcare professionals in the proper way to address patients, students, and colleagues. This should occur during all phases of healthcare education and should be practiced and exemplified by those who teach in healthcare. Appropriate identification of individuals, and their right to choose how they wish to be identified, is a fundamental tenet of healthcare professionalism and demands recognition as an integral principle of human rights. Complete healthcare starts with a thorough understanding of the patient, and that includes respect of personal autonomy. Acquiring skills and knowledge around the appropriate application of such principles is necessary as one of many essential components of medical education and training.

In US anatomical gift law, the record on which a person consents to body donation after death is referred to as a document of gift (DG). Due to the lack of legal requirements around minimum information standards, enacted recommendations in the United States, and the unknown variation across extant DGs, a review of publicly-available DGs from US academic body donation programs were performed to benchmark existing statements and recommend specific foundational content for all US DGs. From 117 body donor programs identified, 93 DGs were downloaded (median length three pages, range 1-20). Statements within the DG were qualitatively categorized into 60 codes within eight themes (Communication, Eligibility, Terms of Use, Logistics, Legal References, Financials, Final Disposition, and Signatures), using existing recommendations of academics, ethicists, and professional associations to guide analysis. Of 60 codes, 12 had high disclosure rates (67%-100% of DGs included; e.g., donor personal information), 22 had moderate rates (34%-66%; e.g., discretion to decline a body), and 26 had low disclosure rates (1%-33%; e.g., testing bodies for disease). Some codes with the lowest disclosure frequency were those previously recommended as necessary. Findings highlighted substantial variation in DG statements, with a higher number of baseline disclosure statements than previously recommended. These results present an opportunity to better understand disclosures that have importance for programs and donors alike. Recommendations suggest minimum standards of informed consent practices for body donation programs in the United States. These include clarity around consent processes, consistency of language, and minimum operational standards for informed consent.

PDF file - 729KB, Supplementary Table 1: Adverse events. Supplementary Figure 1: Patient allocation. Supplementary Figure 2: DNA immunization elicits PAP-specific cellular immune responses. Supplementary Figure 3: Immune responses to PSA and tetanus evaluated by intracellular cytokine staining. Supplementary Figure 4: Immune responses to PAP, PSA and tetanus evaluated by cytokine secretion.

Anatomy laboratories can provide rich opportunities for outreach to K-12 and college students interested in pursuing careers in health, medicine, or science. At the University of Missouri, the Department of Pathology and Anatomical Sciences has designed flexible, one-hour interactive sessions that typically cover basic anatomical concepts using whole-body donors. In order to evaluate whether short-duration programs were impactful in increasing enthusiasm for anatomy and the health professions sciences, we used mixed methods to study participant experience covering three topics: (1) enthusiasm for anatomy, (2) interest in pursuing a career in healthcare professions, and (3) perception of the importance of whole-body donation. The same questions were asked pre- and post-session, and the post-session survey had additional questions related to student satisfaction. Quantitative analyses showed an increased interest in anatomy and appreciation for whole-body donation following the session. Students also perceived that they had a better understanding of the body and what it would be like to attend a health professions school. Thematic analysis revealed an appreciation for contextualizing the size, position, and hands-on feel of anatomical structures, and emphasized that students felt that they understood the body better after having seen a donor's anatomy. This work shows that short-duration, flexible outreach sessions involving whole-body donors can provide students with a rare opportunity to confirm their contextual understanding of anatomy, and provide students with an authentic, and humanistic experience.

BACKGROUND:We previously reported a trial using a DNA vaccine encoding prostatic acid phosphatase (MVI-816, pTVG-HP), given over 12 weeks concurrently or sequentially with pembrolizumab, in patients with mCRPC. We report the final analysis of this trial following two additional treatment arms in which patients with mCRPC continued concurrent treatment until progression. MATERIALS AND METHODS:Patients with mCRPC were treated with MVI-816 and pembrolizumab every 3 weeks (arm 3, n=20) or MVI-816 every 2 weeks and pembrolizumab every 4 weeks (arm 4, n=20). The primary objectives were safety, 6-month progression-free survival (PFS), median time to radiographic progression, and objective response rates. Secondary objectives included immunological evaluations. RESULTS:In 25 patients with measurable disease, there were no complete response and one confirmed partial response in a patient who subsequently found to have an MSIhi tumor. 4/40 patients (10%) had a prostate-specific antigen decline >50%. The estimated overall radiographic PFS rate at 6 months was 47.2% (44.4% arm 3, 61.5% arm 4). Accounting for all off-study events, overall median time on treatment was 5.6 months (95% CI: 5.4 to 10.8 months), 5.6 months for arm 3 and 8.1 months for arm 4 (p=0.64). Thirty-two per cent of patients remained on trial beyond 6 months without progression. Median overall survival was 22.9 (95% CI: 16.2 to 25.6) months. One grade 4 event (hyperglycemia) was observed. Immune-related adverse events (irAEs) >grade 1 were observed in 42% of patients overall. Interferon-γ and/or granzyme B immune response to prostatic acid phosphatase was detected in 2/20 patients in arm 3 and 6/20 patients in arm 4. Plasma cytokines associated with immune activation and CD8+ T-cell recruitment were augmented at weeks 6 and 12. The development of irAE was significantly associated with a prolonged time on treatment (HR=0.42, p=0.003). Baseline DNA homologous recombination repair mutations were not associated with longer time to progression. CONCLUSIONS:Findings here demonstrate that combining programmed cell death 1 blockade with MVI-816 is safe, can augment tumor-specific T cells, and can result in a favorable 6-month disease control rate. Correlative studies suggest T-cell activation by vaccination is critical to the mechanism of action of this combination. Future randomized clinical trials are needed to validate these findings. TRIAL REGISTRATION NUMBER:NCT02499835.

The forward motion of terrestrial vertebrates can be divided into stride lengths (distance traveled by the body from touchdown to the next touchdown of a limb) which is the sum of the lengths of stance and swing phases for each limb. Those lengths are influenced by the anatomy of the limbs; longer limbs, for example, produce longer steps and strides. During typical quadrupedal walking, at least one forelimb and hindlimb are in contact with the ground at any given time. This means the fore‐ and hindlimbs (regardless of limb proportions) should have the same stride length, though the length of the phases (stance, swing) may differ, as long as they sum to equal stride lengths. In addition to the anatomical limb length (ALL), joint excursion patterns, which often differs between the forelimb and hindlimb can influence stance and step. Animals can behaviorally adjust their limb postures to change their effective limb lengths (ELL, the minimum distance between the shoulder/hip and wrist/ankle) in order to achieve the necessary stride length. Thus, we hypothesize that forelimb and hindlimb stride lengths should be equal, but this may be achieved in different ways and therefore all other parameters may vary possibly in relation to limb proportions.To study this, we examined 69 quadrupedal walking bouts of four New World monkeys with differing ALL. Preliminary analyses indicate a close correlation of forelimb and hindlimb stride length (0.93, p<0.01), regardless of differences in ALL proportions. Factors that contribute to an equal stride length are more variable. Forelimb and hindlimb stance phase length were highly correlated (0.700, p<0.01), and forelimb and hindlimb swing phase length were highly correlated (0.834, p<0.01). Although significant, a low correlation of the length of swing and stance phase was found for both the forelimb (0.412, p<0.01) and the hindlimb (0.430, p<0.01). When modeling step length in stance by angular excursion and ELL, the model accounts for an average of 85% of the distance traveled. Taken as a whole, these data, especially the intralimb and interlimb patterns, suggest that the step and swing lengths are not easily predicted by limb anatomy or effective limb lengths alone. Thus, other factors must also contribute to step length and thus equal stride lengths, such as bending of the back and contributions made by hand and foot posture. Overall, these data indicate that although stride lengths do need to be equal between the forelimb and hindlimb, contributing parameters vary between strides and may vary by species anatomy and ecology.Support or Funding InformationNSF BCS‐9222526

Metastatic castration-resistant prostate cancer (mCRPC) is a challenging disease to treat, with poor outcomes for patients. One antitumor vaccine, sipuleucel-T, has been approved as a treatment for mCRPC. DNA vaccines are another form of immunotherapy under investigation. DNA immunizations elicit antigen-specific T cells that cause tumor cell lysis, which should translate to meaningful clinical responses. They are easily amenable to design alterations, scalable for large-scale manufacturing, and thermo-stable for easy transport and distribution. Hence, they offer advantages over other vaccine formulations. However, clinical trials with DNA vaccines as a monotherapy have shown only modest clinical effects against tumors. Standard therapies for CRPC including androgen-targeted therapies, radiation therapy and chemotherapy all have immunomodulatory effects, which combined with immunotherapies such as DNA vaccines, could potentially improve treatment. In addition, many investigational drugs are being developed which can augment antitumor immunity, and together with DNA vaccines can further enhance antitumor responses in preclinical models. We reviewed the literature available prior to July 2020 exploring the use of DNA vaccines in the treatment of prostate cancer. We also examined various approved and experimental therapies that could be combined with DNA vaccines to potentially improve their antitumor efficacy as treatments for mCRPC.

An animal's fitness is influenced by the ability to move safely through its environment. Recent models have shown that aspects of body geometry, for example, limb length and center of mass (COM) position, appear to set limits for pitch control in cursorial quadrupeds. Models of pitch control predict that the body shape of these and certain other primates, with short forelimbs and posteriorly positioned COM, should allow them to decelerate rapidly while minimizing the risk of pitching forward. We chose to test these models in two non-cursorial lemurs: Lemur catta, the highly terrestrial ring-tailed lemur, and Eulemur fulvus, the highly arboreal brown lemur. We modeled the effects of changes in limb length and COM position on maximum decelerative potential for both species, as well as collecting data on maximal decelerations across whole strides. In both species, maximum measured decelerations fell below the range of pitch-limited deceleration values predicted by the geometric model, with the ring-tailed lemur approaching its pitch limit more closely. Both lemurs showed decelerative potential equivalent to or higher than horses, the only comparative model currently available. These data reinforce the hypothesis that a relatively simple model of body geometry can predict aspects of maximum performance in animals. In this case, it appears that the body geometry of primates is skewed toward avoiding forward pitch in maximal decelerations.

New three‐dimensional digital imaging technologies permit much richer reconstructions of soft‐tissue anatomy. We used algorithmic fiber‐tracking software, or 3D muscle tractography to model the muscle architecture of distal forearm and hand muscles via diffusible iodine contrast‐enhanced computed tomography (DiceCT) of a deidentified donor. Excellent soft‐tissue staining and high CT resolution (<50 μm) allowed for the visualization of many tissues difficult to simultaneously resolve using other imaging modalities, including muscle fascicles, integumentary collagen fibers, as well as bony trabeculae. Muscle fascicles were tracked and modeled as curved cylinders from which fascicle‐specific information, such as length and orientation, was gathered. By modeling numerous fascicles within a whole muscle, we collected muscle‐wide distributions, rather than single‐value estimates, of quantitative muscle architecture variables. These comprehensive data afforded by DiceCT and algorithmic fascicle modeling promise to aid in biomechanical modeling. Further, the volume and fascicle models produced by these methods are an excellent teaching resource in medical education.Support or Funding InformationNSF IOS 1457319, NSF EAR 1631684, Missouri Research Council, Life Sciences Research Fellowship, University of Missouri Department of Pathology and Anatomical SciencesThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

5037 Background: Phase I/II studies of pTVG-HP showed safety and increases in prostatic acid phosphatase (PAP)-specific T cells. Based on these, we conducted a multi-center, randomized phase II trial using pTVG-HP with GM-CSF adjuvant vs GM-CSF alone in patients with PSA-recurrent, non-metastatic, non-castrate, prostate cancer (stage M0). Methods: 99 patients with M0 prostate cancer (negative CT and bone scan) with PSA doubling time (DT) of < 12m were randomly assigned to pTVG-HP + GM-CSF vs GM-CSF. Treatments were every 2 wk x 6, and then quarterly for up to 24m. Primary endpoint was 2-year MFS. Secondary endpoints included median MFS, changes in PSA DT, and immune response to PAP antigen. Additional analysis included quantitative changes in bone lesion activity by NaF PET/CT. Results: Few grade 3/4 events were observed and were not statistically different between arms. 2-year MFS between control and pTVG-HP was 42.3% and 41.8% (p = 0.97). Median MFS was not different (18.3m control versus 18.9m pTVG-HP, HR = 1.6, p = 0.13). Changes in PSA DT, and immunity to the PAP target, were not different between study arms. A pre-planned subset analysis showed median MFS was significantly longer in patients with rapid PSA DT ( < 3m) treated with pTVG-HP (6.1m versus 12.0m, n = 21, HR = 4.4, p = 0.03). In patients with baseline metastases detected on NaF PET/CT, total activity (SUVtotal) increased 17% with GM-CSF alone, but decreased 29% with pTVG-HP from baseline to month 6 (n = 27, p = 0.07). Conclusions: This trial did not demonstrate an overall increase in 2-year MFS following treatment with pTVG-HP, but suggested a modest effect in patients with rapidly progressive disease. NaF PET/CT imaging suggests that pTVG-HP has a detectable effect on decreasing metastatic activity in bone. A separate trial suggests that pTVG-HP is an immune activating agent that improves activity of PD-1 blockade. A trial using pTVG-HP in combination with nivolumab in patients with M0 prostate cancer is currently underway. Clinical trial information: NCT01341652.

We previously found that PD-L1 expression is increased on tumor cells following vaccination treatments that lead to increased tumor-specific T cells that secrete IFNγ. Indoleamine 2,3-dioxygenase (IDO) is another IFNγ inducible gene that has potent immunosuppressive effects. There have been reports of IDO expression in prostate cancer; however, it is unknown whether IDO expression might similarly increase in prostate tumors following T-cell-based immunotherapy. Blood samples from normal male blood donors (n = 12) and patients with different stages of prostate cancer (n = 89), including patients with metastatic, castration-resistant prostate cancer treated with a DNA vaccine and/or pembrolizumab, were evaluated for IDO activity by kynurenine and tryptophan levels. Metastatic tissue biopsies obtained pre- and post-treatments were evaluated for IDO expression. IDO suppression of vaccine-induced T-cell function was assessed by ELISPOT. Overall, IDO activity was increased in patients with more advanced prostate cancer. This activity, and IDO expression as detected immunohistochemically, increased following treatment with either a DNA vaccine encoding the prostatic acid phosphatase (PAP) tumor antigen or PD-1 blockade with pembrolizumab. Increased IDO activity after treatment was associated with the absence of clinical effect, as assessed by lack of PSA decline following treatment. Increased antigen-specific T-cell response, as measured by IFNγ release, to the vaccine target antigen was detected following in vitro stimulation of peripheral blood cells with 1-methyltryptophan. These findings suggest that IDO expression is a mechanism of immune evasion used by prostate cancer and that future clinical trials using T-cell-based immune strategies might best include IDO inhibition.

PURPOSEWe previously reported the safety and immunologic effects of a DNA vaccine (pTVG-HP [MVI-816]) encoding prostatic acid phosphatase (PAP) in patients with recurrent, nonmetastatic prostate cancer. The current trial evaluated the effects of this vaccine on metastatic progression.PATIENTS AND METHODSNinety-nine patients with castration-sensitive prostate cancer and prostate-specific antigen (PSA) doubling time (DT) of less than 12 months were randomly assigned to treatment with either pTVG-HP co-administered intradermally with 200 μg granulocyte-macrophage colony-stimulating factor (GM-CSF) adjuvant or 200 μg GM-CSF alone six times at 14-day intervals and then quarterly for 2 years. The primary end point was 2-year metastasis-free survival (MFS). Secondary and exploratory end points were median MFS, changes in PSA DT, immunologic effects, and changes in quantitative 18F-sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT) imaging.RESULTSTwo-year MFS was not different between study arms (41.8% vaccine v 42.3%; P = .97). Changes in PSA DT and median MFS were not different between study arms (18.9 v 18.3 months; hazard ratio [HR], 1.6; P = .13). Preplanned subset analysis identified longer MFS in vaccine-treated patients with rapid (< 3 months) pretreatment PSA DT (12.0 v 6.1 months; n = 21; HR, 4.4; P = .03). PAP-specific T cells were detected in both cohorts, including multifunctional PAP-specific T-helper 1-biased T cells. Changes in total activity (total standardized uptake value) on 18F-NaF PET/CT from months 3 to 6 increased 50% in patients treated with GM-CSF alone and decreased 23% in patients treated with pTVG-HP (n = 31; P = .07).CONCLUSIONpTVG-HP treatment did not demonstrate an overall increase in 2-year MFS in patients with castration-sensitive prostate cancer, with the possible exception of a subgroup with rapidly progressive disease. Prespecified 18F-NaF PET/CT imaging conducted in a subset of patients suggests that vaccination had detectable effects on micrometastatic bone disease. Additional trials using pTVG-HP in combination with PD-1 blockade are under way.

Background. Sipuleucel T, an autologous cell-based vaccine targeting prostatic acid phosphatase (PAP), has demonstrated efficacy for the treatment of advanced prostate cancer. DNA vaccines encoding PAP and live attenuated Listeria vaccines have entered clinical trials for patients with prostate cancer, and have advantages in terms of eliciting predominantly Th1-biased immunity. In this study, we investigated whether the immunogenicity and anti-tumor efficacy of a DNA and Listeria vaccine, each encoding PAP, could be enhanced by using them in a heterologous prime/boost approach. Methods. Transgenic mice expressing HLA-A2.01 and HLA-DRB1*0101 were immunized alone or with a heterologous prime/boost strategy. Splenocytes were evaluated for MHC class I and II-restricted, PAP-specific immune responses by IFNγ ELISPOTs. Anti-tumor activity to a syngeneic, PAP-expressing tumor line was evaluated. Results. PAP-specific cellular immunity and anti-tumor activity were elicited in mice after immunization with DNA- or listeria-based vaccines. Greater CD4+ and CD8+ responses, and anti-tumor responses, were elicited when mice were immunized first with DNA and boosted with Listeria, but not when administered in the opposite order. This was found to be dependent on CD4+ T cells elicited with DNA priming, and was not due to inflammatory signals by Listeria itself or due to B cells serving as antigen-presenting cells for DNA during priming. Conclusions. Heterologous prime/boost vaccination using DNA priming with Listeria boosting may provide better anti-tumor immunity, similar to many reports evaluating DNA priming with vaccines targeting foreign microbial antigens. These findings have implications for the design of future clinical trials.