A Prospective Study of Bevacizumab and Neoadjuvant Concurrent Chemoradiation in Locally Advanced Esophageal Squamous Cell Carcinoma: Paradoxical Increase in Circulating Vascular Endothelial Growth Factor-A and Effect on Outcome

PURPOSE/OBJECTIVE(S)

In the prior prospective biomarker study, high serum vascular endothelial growth factor-A (VEGF-A) was associated with a poor prognosis. We conducted a prospective phase II trial of adding Bevacizumab, an anti-VEGF-A monoclonal antibody, to neoadjuvant concurrent chemoradiation (neoCCRT) for patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC). This prospective biomarker study aims to evaluate the expressions of angiogenesis-associated circulating biomarkers before and after neoCCRT and compare clinical outcomes for patients receiving platinum/5-fluorouracil (PF) with or without Bevacizumab.

MATERIALS/METHODS

Patients with biopsy-proven resectable non-T4 LA-ESCC were enrolled for the prospective phase II trial investigating PF-neoCCRT plus Bevacizumab (BPF group). A parallel patient cohort enrolled in a prospective biomarker study receiving PF-neoCCRT was included in the present analysis as the control group (PF group). Radiotherapy was delivered with 40 Gy in 20 fractions. All patients had restaging workups after enoCCRT and underwent radical esophagectomy if the disease remained resectable. Serums were collected before and after neoCCRT. The serum concentrations of angiogenesis-associated biomarkers were determined by the multiplex enzyme-linked immunosorbent assay. Survival analyses were performed by the Kaplan-Meier method. The t-test and log-rank test were used to compare differences in biomarker expression and survival between groups.

RESULTS

From 2016 to 2019, 43 patients (BPF/PF group: 21/22) were enrolled in the study. Twenty patients in each group had serum samples available for biomarker analysis. 15 out of 21 patients in the BPF group and 20 out of 22 patients in the PF group underwent radical esophagectomy. Six patients in the BPF group and nine patients in the PF group achieved pathological complete responses. The median overall survival for the BPF and PF group was 20.8 months and not-reached, respectively (hazard ratio = 1.33, long rank p = 0.58). In the BPF group, the serum VEGF-A level was significantly increased from an average value of 446 pg/mL to 723 pg/mL after neoCCRT (p = 0.037), while its level was decreased from 815 ng/mL to 380 pg/mL in the PF group (p = 0.104). In addition, the expression value of circulating Angiopoietin-1 was not changed in the BPF group (before neoCCRT, mean value = 828 pg/mL; after neoCCRT, mean value 762 pg/mL, p = 0.67). In contrast, serum Angiopoietin-1 level was reduced from an average value of 659 pg/mL before neoCCRT to 271 pg/mL after neoCCRT (p = 0.002) in the PF group.

CONCLUSION

The addition of Bevacizumab to PF-neoCCRT did not improve pathological or survival outcomes in patients with resectable LA-ESCC. Adding a single dose of Bevacizumab paradoxically increases circulating VEGF-A while maintaining the Angiopoietin-1 serum level after neoCCRT. Further investigation by using additional VEGF-A inhibition may be required to achieve sustained angiogenesis blocked for tumor control.

Coronary angiographic findings for out-of-hospital cardiac arrest survivors presenting with nonshockable rhythms and no ST elevation post resuscitation

BACKGROUND

Recent guidelines suggest that coronary angiography (CAG) should be considered for out-of-hospital cardiac arrest (OHCA) survivors, including those without ST elevation (STE) and without shockable rhythms. However, there is no prospective data to support CAG for survivors with nonshockable rhythms and no STE post resuscitation.

METHODS

This was a re-analysis of the PEARL study (randomized OHCA survivors without STE to early CAG versus not). Patients were subdivided by initial rhythm as nonshockable (Nsh) vs shockable (Sh). The primary outcome was coronary angiographic evidence of acute culprit lesion, with secondary outcomes being survival to hospital discharge and neurological recovery.

RESULTS

The PEARL study included 99 patients with OHCA from a presumed cardiac etiology, 24 with nonshockable and 75 with shockable rhythms. There was no difference in the frequency of CAG between the two groups [71% (Nsh) and 75% (Sh); p = 0.79], presence of CAD [81% (Nsh) and 68% (sh); p = 0.37, or culprit lesions identified in each group [50% (Nsh) and 45% (Sh); p = 0.78. Nonshockable patients had worse discharge survival [33% (Nsh) vs 57% (Sh); p = 0.04] and those survived, had worse neurological recovery [30% (Nsh) vs 54% (Sh); p = 0.02] compared to shockable patients.

CONCLUSIONS

OHCA survivors presenting with nonshockable rhythms and no STE post resuscitation had similar prevalence of culprit coronary lesions to those with shockable rhythms. CAG may be considered in patients with OHCA without STE regardless of initial presenting rhythm. There was no benefit of emergent CAG both in shockable and non-shockable rhythms.

Pembrolizumab versus chemotherapy for patients with esophageal squamous cell carcinoma enrolled in the randomized KEYNOTE-181 trial in Asia

BACKGROUND

In the randomized phase III KEYNOTE-181 study, pembrolizumab prolonged overall survival (OS) compared with chemotherapy as second-line therapy in patients with advanced esophageal cancer and programmed death-ligand 1 (PD-L1) combined positive score (CPS) ≥10. We report a post hoc subgroup analysis of patients with esophageal squamous cell carcinoma (ESCC) enrolled in KEYNOTE-181 in Asia, including patients from the KEYNOTE-181 China extension study.

PATIENTS AND METHODS

Three hundred and forty Asian patients with advanced/metastatic ESCC were enrolled in KEYNOTE-181, including the China cohort. Patients were randomly assigned 1 : 1 to receive pembrolizumab 200 mg every 3 weeks for ≤2 years or investigator's choice of paclitaxel, docetaxel, or irinotecan. OS, progression-free survival, response, and safety were analyzed without formal comparisons. OS was evaluated based on PD-L1 CPS expression level.

RESULTS

In Asian patients with ESCC, median OS was 10.0 months with pembrolizumab and 6.5 months with chemotherapy [hazard ratio (HR), 0.63; 95% CI 0.50-0.80; nominal P < 0.0001]. Median progression-free survival was 2.3 months with pembrolizumab and 3.1 months with chemotherapy (HR, 0.79; 95% CI 0.63-0.99; nominal P = 0.020). Objective response rate was 17.1% with pembrolizumab and 7.1% with chemotherapy; median duration of response was 10.5 months and 7.7 months, respectively. In patients with PD-L1 CPS <1 tumors (pembrolizumab versus chemotherapy), the HR was 0.99 (95% CI 0.56-1.72); the HR (95% CI) for death was better for patients with PD-L1 CPS cut-offs >1 [CPS ≥1, 0.57 (0.44-0.75); CPS ≥5, 0.56 (0.41-0.76); CPS ≥10, 0.53 (0.37-0.75)]. Treatment-related adverse events were reported in 71.8% of patients in the pembrolizumab group and 89.8% in the chemotherapy group; grade 3-5 events were reported in 20.0% and 44.6%, respectively.

CONCLUSIONS

Pembrolizumab monotherapy demonstrated promising efficacy in Asian patients with ESCC, with fewer treatment-related adverse events than chemotherapy. PD-L1 CPS ≥1 is an appropriate cut-off and a predictive marker of pembrolizumab efficacy in Asian patients with ESCC.

Hemogram-based decision tree for predicting the metabolic syndrome and cardiovascular diseases in the elderly

BACKGROUND

This study aimed to build a hemogram-based decision tree to evaluate the association between current probability of metabolic syndrome (MetS) and prediction of future hypertension, type 2 diabetes and cardiovascular diseases (CVD) risk.

METHODS

A total of 40 395 elder participants (≥60 years) were enrolled in a standard health examination program in Taiwan from January 1999 to December 2014. A decision tree classification of the presence or absence of MetS at baseline, using age, sex and hemogram (white blood cell, hemoglobin and platelet) as independent variables, was conducted for the randomly assigned training (70%) and validation (30%) groups. Participants without MetS at baseline (n = 25 643) were followed up to observe whether they developed MetS, hypertension, type 2 diabetes or CVD in the future.

RESULTS

Modest accuracy of the decision tree in the training and validation groups with area under the curves of 0.653 and 0.652, respectively, indicated an acceptable generalizability of results. The predicted probability of baseline MetS was obtained from decision tree analysis. Participants without MetS at baseline were categorized into three equally sized groups according to the predicted probability. Participants in the third tertile had significantly higher risks of future MetS (hazard ratio 1.40, 95% confidence interval 1.25-1.58); type 2 diabetes (1.46, 1.17-1.83); hypertension (1.14, 1.01-1.28); and CVD (1.21, 1.01-1.44), compared with those in the first tertile.

CONCLUSIONS

Execution of hemogram-based decision tree analysis can assist in early identification and prompt management of elderly patients at a high risk of future hypertension, type 2 diabetes and CVD.

Changes in symptoms, sleep, oxidative stress, and inflammatory markers among community-dwelling stroke survivors after a tai chi exercise intervention

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Laurence B. Emmons Research Award

Background

Depression is prevalent among one-third to two-thirds of stroke survivors. Despite the availability of pharmacotherapies and/or psychotherapies, depression persists, even 5-10 years post-stroke, reflecting limited treatment responses and/or adherence to this conventional care. Mind-body interventions are commonly used among adults to ameliorate depressive symptoms, thus we investigated the feasibility of Tai Chi, alongside conventional care, to manage post-stroke depression.

Purpose

Describe changes in symptoms of depression, anxiety and stress, sleep, oxidative stress, and inflammatory markers post-intervention among community-dwelling stroke survivors with depressive symptoms.

Methods

In this feasibility study, a single-group pre-post intervention design was used. Due to COVID-19, participants attended a 1-hour Tai Chi exercise class three times per week for 8 weeks, instead of the planned 12-weeks. Symptoms of depression, anxiety and stress were assessed using standardized questionnaires (Center for Epidemiological Studies Depression scale, CESD; Generalized Anxiety Disorder Assessment; Perceived Stress Scale), objective sleep was assessed via a research-grade triaxial accelerometer (ActiGraph GT9X), and blood samples were taken to assess oxidative stress (plasma superoxide dismutase, SOD)  and inflammatory markers (serum tumor necrosis factor-alpha, interleukin-6, interleukin-10). Pre-post intervention changes were assessed using paired t-tests.

Results

Community-dwelling stroke survivors (N = 11) on average 69.7 ± 9.3 years old, mainly retired (73%, n = 8), married men (55%, n = 6) with &gt;13 years education (91%, n = 10), reporting depression symptoms (CESD = 17.3 ± 11.4) and 55% taking anti-depressant medications, enrolled. The majority of participants reported having an ischemic stroke (82%, n = 9) with hemiparesis (55%, n = 6), but were able to walk 15 feet without assistance (91%, n = 10). After the Tai Chi intervention, we observed significant reductions in symptoms of depression (-5.3 ± 5.9, p = 0.01), anxiety (-2.2 ± 2.4, p = 0.01) and stress (-4.6 ± 4.8, p = 0.01); along with better sleep efficiency (+1.8 ± 1.8, p = 0.01), less wakefulness after sleep onset (-9.3 ± 11.6, p = 0.04), and less time awake (-9.3 ± 11.6, p = 0.04). In addition, there was a 36% decrease in SOD activity (p = 0.02) indicative of a decreased oxidative environment post-intervention; though no significant changes in any of the inflammatory markers were found (all p-values &gt;0.05).

Conclusion

Symptoms of depression, anxiety and stress were observed in these community-dwelling stroke survivors along with sub-optimal sleep. Among community-dwelling stroke survivors, Tai Chi exercise is a feasible intervention that can be used alongside conventional care to manage post-stroke depression and may also aid in reducing symptoms of anxiety and stress, and improve sleep.  Further research is needed with rigorous study designs and larger samples, before widespread recommendations can be made.

Protocol for a feasibility and early efficacy study of the Comprehensive Lifestyle Improvement Program for Prostate Cancer-2 (CLIPP2)

Background

Although androgen deprivation therapy (ADT) for prostate cancer demonstrates improved overall and disease-free survival, it is associated with adverse effects such as obesity and metabolic syndrome that increase risk of cardiometabolic disease and diabetes type 2. ADT also leads to fatigue, depression and erectile dysfunction, which reduce quality of life (QoL). Lifestyle modification has shown promise in reducing obesity, metabolic syndrome and diabetes type 2 in other disease types. However, there is a paucity of data regarding the utility of lifestyle modification in men receiving ADT for prostate cancer.

Methods

The primary aim of the Comprehensive Lifestyle Improvement Program for Prostate Cancer-2 (CLIPP2) is to test the feasibility of conducting a 24-week lifestyle modification intervention in men on ADT for prostate cancer. Additionally, it will also determine the effect of this intervention on weight loss, cardiometabolic markers (secondary aim and markers of interest: serum glucose, insulin resistance, hemoglobin A1C and lipid panel), and QoL (tertiary aim). The intervention will be delivered weekly via telephone for the first 10 weeks and bi-weekly for the remaining 14 weeks. Questionnaires and serum samples will be collected at baseline, week 12, and week 24. Anthropometric measurements will be collected at baseline, week 6, week 12, week 18 and week 24.

Results

We hypothesize that the CLIPP2 intervention will produce a 7% weight loss that will result in improved markers associated with cardiometabolic disease and type 2 diabetes in the study population.

Conclusion

Results will provide insight into the role of lifestyle modification in addressing ADT adverse effects as well as provide preliminary data to inform the development of future lifestyle interventions in this area.

Trial registration

NCT04228055 Clinicaltrials. gov.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of hepatocellular carcinoma (HCC) was published in 2018, and covered the diagnosis, management, treatment and follow-up of early, intermediate and advanced disease. At the ESMO Asia Meeting in November 2018 it was decided by both the ESMO and the Taiwan Oncology Society (TOS) to convene a special guidelines meeting immediately after the Taiwan Joint Cancer Conference (TJCC) in May 2019 in Taipei. The aim was to adapt the ESMO 2018 guidelines to take into account both the ethnic and the geographic differences in practice associated with the treatment of HCC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with intermediate and advanced/relapsed HCC representing the oncology societies of Taiwan (TOS), China (CSCO), India (ISMPO) Japan (JSMO), Korea (KSMO), Malaysia (MOS) and Singapore (SSO). The voting was based on scientific evidence, and was independent of the current treatment practices, the drug availability and reimbursement situations in the individual participating Asian countries.

Helicobacter pylori infection and the risk of colorectal cancer: a nationwide population-based cohort study

BACKGROUND

The role of Helicobacter pylori (H. pylori) infection in the development of colorectal neoplasia has been a matter of scientific debate with controversial findings.

AIMS

This study examined the association between H. pylori infection and colorectal cancer (CRC) in a nationwide population-based Chinese cohort study.

METHODS

A total of approximately 3936 individuals with newly diagnosed H. pylori infection (the H. pylori-infected cohort) and 15 744 age- and sex-matched patients with diagnoses absence of H. pylori infection (the comparison cohort) from 2000 to 2005 were identified from Taiwan's National Health Insurance Research Database. The Kaplan-Meier method was used for measuring the cumulative incidence of CRC in each cohort. Cox proportional hazards models were used to compute hazard ratios (HRs) and accompanying 95% confidence intervals (CIs) for the estimation of the association between H. pylori infection and CRC.

RESULTS

The cumulative incidence of CRC was higher in H. pylori-infected cohort than that in the comparison cohort (log-rank test, P < 0.001). After adjustment for potential confounders, H. pylori infection was associated with a significantly increased risk of CRC (adjusted HR 1.87; 95% CI 1.37-2.57). In addition, the HR of CRC appeared to increase with increasing frequency of clinical visits for H. pylori infection.

CONCLUSIONS

Our study demonstrated that H. pylori infection was associated with an increased risk of CRC, which warrants confirmation and exploration of the underlying biologic mechanisms by future studies.

Abstract P5-13-19: Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona

Background In Arizona, female breast cancer has the highest incidence rate and the second highest death rate compared to all other cancers. This ongoing single arm intervention study investigates non-adherence with recommended annual mammography or follow-up breast imaging. Data collected for this study is both retrospective, using the university Electronic Health Record (EHR) system (January 1, 2014 to September 30, 2017), and prospective, implementing a questionnaire during the intervention phase. Potential study participants were identified using EHR and categorized by BI-RADS (Breast Imaging-Reporting and Data System) 0 to 5. With IRB approval from University of Arizona, we designed a questionnaire to measure barriers to adherence and we navigate participants to schedule and attend follow-up appointments. This study's overall specific aims are to increase first time mammography screening by 25% among women in Southern Arizona; increase adherence or repeat screening rate by 20% among women lost to follow-up; establish the framework for a community- academic partnership in ethnically diverse areas. Women, age 40 and older who are not compliant with recommended annual mammograms or recommended follow-up screenings after a suspicious finding are eligible to participate in this study. Men and children, as well as women for whom breast imaging is not recommended are excluded from participating in this study. Results Patient's age was summarized by mean ± standard deviation for continuous variables and frequency and the associated percentage for categorical variables. BI-RADS scores were classified into Negative, Benign, Possible Malignancy and Proven Malignancy and compared between ethnic and racial groups using Fisher's exact test. Of 8823 non-compliant woman over nearly 4 years of data, 0.2% are BI-RADS 4 and 5, 2.2% are BI-RADS 3, 96% are BI-RADS 1 and 2, and 0.3% are BI-RADS 0. The mean age is 61.59 years, with 25% reporting as Hispanic, 66% reporting as non-Hispanic women (NHW), and 10% preferring to receive care in Spanish. Initial data shows only .24% with proven malignancies. Further, the data reveals that Hispanics have a slightly higher rate of possible malignancy (.36%) than NHW (.18%); however, NHW show a slightly higher rate of proven malignancy (.27% compared to .18%, respectively). Discussion These data provide valuable information for the direction of this study; in particular, understanding the disparity between Hispanic and NHW malignancies and developing culturally competent interventions and education materials to increase compliance with breast cancer screening recommendations. Further, these data indicate our focus should be on screening compliance for BI-RADS 1 and 2. These data also point to a possible high non-compliance issue. Comparing non-compliance data from other regional clinics will continue to shape this study's direction. The target sample size for this study is 300 participants. We accept a 95% confidence level and a 5% margin of error. Out of 420 recruitment letters mailed, the navigators have reached 152 potential participants by phone and have a 26% study recruitment rate (n=40).

Citation Format: Huff AJ, Gomez J, Calhoun E, Hsu C-H, Chalasani P, Fitzpatrick K, Borders M, Lang L, Prado Y. Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-19.

Abstract P5-13-08: Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients

Introduction

Preoperative chemotherapy can demonstrate an individual's response to the chemotherapeutic regimen by comparing the amount of cancer at presentation to the amount remaining after treatment. Multiple previous studies have demonstrated that the amount of residual cancer, or final pathologic stage, is a better indicator of prognosis than the initial stage at presentation.

Tumor infiltrating lymphocytes have been recognized in breast cancer, and when found concentrated in breast cancer specimens, have been associated with a good prognosis. Breast cancer is not only a heterogeneous disease, but also displays varied presentation and behavior in patients of different race/ethnicities.

This study was performed to evaluate factors which predict response to chemotherapy. The effectiveness of different chemotherapeutic regimens, the effect of breast cancer subtype, and tumor infiltrating lymphocytes (TILs) were evaluated in our racial/ethnic minority population.

Methods

All patients at the safety net institution in Phoenix, AZ who underwent preoperative chemotherapy from 2002 to 2017 and had tissue available for evaluation were included in the study. Response to chemotherapy regimen was recorded. Pathologic complete response (pCR) was defined as no invasive cancer in the breast and lymph nodes in the final pathologic specimen. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal subtypes were classified based on Ki67 (&gt;15%) and/or PR (&lt;20%) for Luminal B. Her2 subtype was defined as Her2 IHC 3+ or Her2 FISH amplified. Triple negative breast cancer (TNBC) was defined as ER and PR (&lt;5%) and Her2 negative. TILs concentration was determined from fixed formalin paraffin embedded (FFPE) core needle biopsy specimens.

Results

A total of 259 patients were included in the study. The mean age was 45 years. 80% of the population were racial/ethnic minorities. The vast majority (94%) were underinsured or uninsured, with 75% uninsured. The mean clinical tumor size at presentation was 6cm. 52% presented at clinical stage 2 while 48% presented at clinical stage 3. The overall pCR rate was 32%. pCR rate was impacted by breast cancer subtype with TNBC 52% and Her2 38% showing a better response to chemotherapy, while Luminal B was 16% and Luminal A 2% (p &lt; 0.05). In TNBC, chemotherapy regimens with anthracycline and docetaxel may have improved efficacy with pCR of 56% (p = 0.05). In the subgroup available for TIL evaluation, breast cancer subtype appeared to show similar importance with pathologic complete response rates of TNBC 50%, Her2 44%, Luminal B 12%, and Luminal A 0%. TIL appeared to affect the likelihood of pCR. When TIL were less than 5% the pCR rate was 16% compared to when there were TIL of at least 5% or more the pCR rate was 41% (p &lt; 0.05).

Conclusions

In our racial/ethnic minority population, breast cancer subtype and chemotherapy regimen did affect likelihood of pathologic complete response. Tumor infiltrating lymphocyte concentration as low as 5% may indicate a higher likelihood of pathologic complete response and could be used as an additional factor in the evaluation of patients for preoperative therapy.

Citation Format: Komenaka IK, Cocco D, Huliyar R, Hsu C-H, Martinez ME, Gago M, Nodora J, Mehta D, Caruso DM. Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-08.

Lenalidomide as second-line therapy for advanced hepatocellular carcinoma: exploration of biomarkers for treatment efficacy

BACKGROUND

Lenalidomide has immunomodulatory and anti-angiogenic effects and showed moderate anti-tumour efficacy in patients with. advanced hepatocellular carcinoma (HCC) AIM: To explore potential biomarkers of lenalidomide efficacy as second-line therapy for HCC.

METHODS

Eligible patients were diagnosed with advanced HCC, documented progression on sorafenib, and Child-Pugh class A liver function. Patients received 25 mg/day lenalidomide orally on days 1-21 every 4 weeks. The primary endpoint was 6 month progression-free survival rate. Early α-fetoprotein response was defined as a > 20% decline of α-fetoprotein levels from baseline within the first 4 weeks of treatment. Vascular response, evaluated using dynamic contrast-enhanced magnetic resonance imaging, was defined as a > 40% decline in K^trans after 2 weeks of treatment. The percentage of peripheral blood lymphocyte subsets were also analysed.

RESULTS

Fifty-five patients were enrolled. The response rate was 13%, and the disease-control rate was 53%. The 6 month progression-free survival rate was 9.1%. The median progression-free and overall survival was 1.8 months and 8.9 months respectively. Early α-fetoprotein response was significantly associated with higher disease-control rate (76% vs 22%, P = .001) and longer progression-free survival (P = .020). Vascular response was not associated with any treatment outcomes. Patients with a high pre-treatment B cell percentage were more likely to have disease control (70% vs 36%, P = .010) and exhibited longer progression-free survival (P < .001) and overall survival (P = .042).

CONCLUSIONS

Lenalidomide exhibited moderate activity as second-line therapy for advanced HCC. Its immunomodulatory effects should be further explored (www.clinicaltrials.gov NCT01545804).

Use of iDXA spine scans to evaluate total and visceral abdominal fat

OBJECTIVES

Abdominal fat may be a better predictor than body mass index (BMI) for risk of metabolically-related diseases, such as diabetes, cardiovascular disease, and some cancers. We sought to validate the percent fat reported on dual energy X-ray absorptiometry (DXA) regional spine scans (spine fat fraction, SFF) against abdominal fat obtained from total body scans using the iDXA machine (General Electric, Madison, WI), as previously done on the Prodigy model.

METHODS

Total body scans and regional spine scans were completed on the same day (N = 50). In alignment with the Prodigy-based study, the following regions of interest (ROI) were assessed from total body scans and compared to the SFF from regional spine scans: total abdominal fat at (1) lumbar vertebrae L2-L4 and (2) L2-Iliac Crest (L2-IC); (3) total trunk fat; and (4) visceral fat in the android region. Separate linear regression models were used to predict each total body scan ROI from SFF; models were validated by bootstrapping.

RESULTS

The sample was 84% female, a mean age of 38.5 ± 17.4 years, and mean BMI of 23.0 ± 3.8 kg/m² . The SFF, adjusted for BMI, predicted L2-L4 and L2-IC total abdominal fat (%; Adj. R² : 0.90) and total trunk fat (%; Adj. R² : 0.88) well; visceral fat (%) adjusted R² was 0.83. Linear regression models adjusted for additional participant characteristics resulted in similar adjusted R² values.

CONCLUSIONS

This replication of the strong correlation between SFF and abdominal fat measures on the iDXA in a new population confirms the previous Prodigy model findings and improves generalizability.

CK1δ/GSK3β/FBXW7α axis promotes degradation of the ZNF322A oncoprotein to suppress lung cancer progression

Overexpression of Cys2His2 zinc-finger 322A (ZNF322A) oncogenic transcription factor is associated with lung tumorigenesis. However, the mechanism of ZNF322A overexpression remains poorly understood. Here, we discover that protein stability of ZNF322A is regulated by coordinated phosphorylation and ubiquitination through the CK1δ/GSK3β/FBXW7α axis. CK1δ and GSK3β kinases sequentially phosphorylate ZNF322A at serine-396 and then serine-391. Moreover, the doubly phosphorylated ZNF322A protein creates a destruction motif for the ubiquitin ligase FBXW7α leading to ZNF322A protein destruction. Overexpression of FBXW7α induces ZNF322A protein degradation, thereby blocks ZNF322A transcription activity and suppresses ZNF322A-induced tumor growth and metastasis in vitro and in vivo. Clinically, overexpression of ZNF322A correlates with low FBXW7α or defective CK1δ/GSK3β-mediated phosphorylation in lung cancer patients. Multivariate Cox regression analysis indicates that patients with ZNF322A high/FBXW7 low expression profile can be used as an independent factor to predict the clinical outcome in lung cancer patients. Our results reveal a new mechanism of ZNF322A oncoprotein destruction regulated by the CK1δ/GSK3β/FBXW7α axis. Deregulation of this signaling axis results in ZNF322A overexpression and promotes cancer progression.

Abstract P3-13-18: Technical skill of surgical residents may affect margin status of breast conserving operations

Background: Quality of patient care and surgical outcomes have come under increased scrutiny. Numerous other studies have examined outcomes at teaching hospitals compared to non-teaching hospitals. The most important factor to determine early success of breast conservation is the attainment of pathologically negative margins. Few studies, however, have examined the effect of teaching residents on margin status. The current study was performed to evaluate the effect teaching residents on margin status after lumpectomy.

Methods: Retrospective review of all patients from July 2006-June 2015 was evaluated. A resident was usually considered the primary surgeon. If the resident was unavailable or unprepared to operate, the attending surgeon was the primary surgeon. As part of the routine evaluation of surgical residents, technical ability was classified as satisfactory or unsatisfactory for level of training. All evaluations of the technical ability of the residents were completed prior to the collection of the current data. The effect of surgical residents' participation and their technical ability to perform lumpectomy was evaluated to determine if there was an effect on margin status. Logistic regression analysis was performed to adjust for clinical variables known to affect margin status.

Results: Of 292 patients, 15% of patients had positive margins. The attending surgeon has positive margin rate of 10.7% vs 16% for Residents (p = 0.32).When technical skill evaluation was included, Residents with unsatisfactory technical skills had positive margin rate of 27% compared to 10.2% for residents with satisfactory skills (p = 0.002). In multivariate logistic regression analysis, operating surgeon remained significantly associated with positive margins. Operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.39, 95% CI 0.22-0.86; p = 0.03). Patients who underwent preoperative chemotherapy were also less like to have positive margins (OR 0.40, 95% CI 0.18-0.91); p = 0.04). In patients with at least 2 years of followup (mean follow up of 48 months) breast cancer specific survival was 94% and 2% had local recurrences as a first event.

Conclusions: Technically ability of residents may affect margin status after lumpectomy. With the increased use of surgical outcomes to measure quality of care in medicine, the importance of teaching surgical residents needs to be considered in future quality of care evaluation.

Citation Format: Komenaka IK, Djenic B, Hsu C-H, Nodora J, Winton L, Bouton M, Martinez ME. Technical skill of surgical residents may affect margin status of breast conserving operations [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-18.

Abstract P5-13-02: Weight gain after breast cancer diagnosis and patients' opinion on weight loss strategies

Background: The rate of obesity is increasing in many countries worldwide. Most populations are not aware of steady weight gain with age. In addition, obesity is increasingly being recognized as a risk factor for breast cancer. Some studies have also demonstrated that weight gain after diagnosis is associated with increased risk for recurrence. The current study was performed to evaluate weight gain in a population of patients seen at a safety net institution. Additionally, patients also gave their opinion on weight loss strategies.

Methods: A retrospective review of all breast cancer patients seen at the county, safety net institution from July 2001 to June 2014 who had at least 2 years of follow up were evaluated for change in weight. For the question on weight loss strategies, all patients from May 2014 to May 2015 were included. Sociodemographic, clinical, and treatment variables were evaluated.

Results: From July 2001 to June 2014, 225 breast cancer patients had follow up prior to January 2013. Of these patients 59% gained weight after their diagnosis of breast cancer. Overall these patients gained an average of 2 kg after their diagnosis.

Starting in January 2013, patients were given a simple message, “avoiding gaining weight” after their diagnosis. For 115 patients with follow up after January 2013, only 35% gained weight and on average, this group of patient lost 4 kg from diagnosis. Patients who initially gained weight were provided with basic weight loss strategies.

From May 2014 to May 2015, 1198 consecutive patients were seen. The average age was 45 years. 12% were non-Hispanic White. Only 30% of patients stated that their primary care provider discussed weight maintenance or weight loss as part of their routine health care. 40% of patients did feel that a permanent change was necessary to facilitate weight loss. However, fewer than half (44%) the patients felt that exercise was necessary. Dietary beliefs were varied, with the most commonly held belief was that vegetarian/vegan diet was necessary (28%). Patients rarely cited commonly recommended weight loss strategies: lower caloric intake (9%), eat frequently (0.3%), adequate fiber (0.1%), adequate protein (0.6%), enough sleep (0.1%), don't eat late (0.1%), no fast food (2%), avoid soda (1%), drink more water (1%). 6% of patients felt a low/no carbohydrate diet was important. By contrast, older strategies or popular ideas: low fat (8%), no flour/wheat/gluten (4%) were also felt to be important. 7.3% stated they did not know any strategy. 5% patients recommended stopping eating altogether to lose weight.

Conclusions: Similar to population wide data, breast cancer patients treated at a safety net institution tend to gain weight with follow up. Also similar to most populations, the population was not aware of recommended weight loss strategies and most do not feel that exercise is an important component of weight maintenance. As with the rest of the US population significant effort will be necessary to help patients avoid weight gain after diagnosis. Making patients aware of their weight may help patients avoid gaining weight.

Citation Format: Komenaka IK, VanderVelde J, Hsu C-H, Nodora J, Winton L, Bouton M, Martinez ME. Weight gain after breast cancer diagnosis and patients' opinion on weight loss strategies [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-02.

An unusual case of focal segmental glomerulosclerosis presenting with retropharyngeal edema

INTRODUCTION

Acute neck swelling with pharyngeal signs often triggers emergency consultation. Treatment and diagnosis are usually multidisciplinary. Failing to find a possible etiology may lead to misdiagnosis.

CASE PRESENTATION

A young man presented to the emergency room with a 4-day history of cough, neck swelling and sore throat. Laboratory testing showed a leukocyte count of 9200 without left shift. Mild elevated CRP with 1.7 was noted and computed tomography (CT) showed fluid accumulation in the retropharyngeal space and neck edema down to thyroid region. Antibiotic was prescribed and admitted to infection ward under the impression of deep neck infection. During hospitalization, needle aspiration was performed where water fluid was collected without pus. Investigations showed massive proteinuria, hypoalbuminemia and hypercholesterolemia. The early focal segmental glomerulosclerosis was found by renal biopsy. After prednisolone 60mg daily and albumin supplement, the neck swelling, swallowing pain and general edema had completely resolved.

DISCUSSION

The purpose of this case is to raise awareness of nephrotic syndrome as an unusual but possibly cause of retropharyngeal edema. We highlight the diagnostic features that will allow the physicians to make the correct diagnosis, avoid unnecessary incision and drainage, and commence effective treatment early in the disease course.

Dual energy X-ray absorptiometry spine scans to determine abdominal fat in postmenopausal women

Body composition may be a better predictor of chronic disease risk than body mass index (BMI) in older populations.

OBJECTIVES

We sought to validate spine fat fraction (%) from dual energy X-ray absorptiometry (DXA) spine scans as a proxy for total abdominal fat.

METHODS

Total body DXA scan abdominal fat regions of interest (ROI) that have been previously validated by magnetic resonance imaging were assessed among healthy, postmenopausal women who also had antero-posterior spine scans (n = 103). ROIs were (1) lumbar vertebrae L2-L4 and (2) L2-Iliac Crest (L2-IC), manually selected by two independent raters, and (3) trunk, auto-selected by DXA software. Intra-class correlation coefficients evaluated intra and inter-rater reliability on a random subset (N = 25). Linear regression models, validated by bootstrapping, assessed the relationship between spine fat fraction (%) and total abdominal fat (%) ROIs.

RESULTS

Mean age, BMI, and total body fat were 66.1 ± 4.8 y, 25.8 ± 3.8 kg/m² and 40.0 ± 6.6%, respectively. There were no significant differences within or between raters. Linear regression models adjusted for several participant and scan characteristics were equivalent to using only BMI and spine fat fraction. The model predicted L2-L4 (Adj. R² : 0.83) and L2-IC (Adj. R² : 0.84) abdominal fat (%) well; the adjusted R² for trunk fat (%) was 0.78. Model validation demonstrated minimal over-fitting (Adj. R² : 0.82, 0.83, and 0.77 for L2-L4, L2-IC, and trunk fat, respectively).

CONCLUSIONS

The strong correlation between spine fat fraction and DXA abdominal fat measures make it suitable for further development in postmenopausal chronic disease risk prediction models. Am. J. Hum. Biol. 28:918-926, 2016. © 2016Wiley Periodicals, Inc.

Perceptions and Practices of Mass Bat Exposure Events in the Setting of Rabies Among U.S. Public Health Agencies

Current guidelines in the setting of exposures to potentially rabid bats established by the Advisory Committee on Immunization Practices (ACIP) address post-exposure prophylaxis (PEP) administration in situations where a person may not be aware that a bite or direct contact has occurred and the bat is not available for diagnostic testing. These include instances when a bat is discovered in a room where a person awakens from sleep, is a child without an adult witness, has a mental disability or is intoxicated. The current ACIP guidelines, however, do not address PEP in the setting of multiple persons exposed to a bat or a bat colony, otherwise known as mass bat exposure (MBE) events. Due to a dearth of recommendations for response to these events, the reported reactions by public health agencies have varied widely. To address this perceived limitation, a survey of 45 state public health agencies was conducted to characterize prior experiences with MBE and practices to mitigate the public health risks. In general, most states (69% of the respondents) felt current ACIP guidelines were unclear in MBE scenarios. Thirty-three of the 45 states reported prior experience with MBE, receiving an average of 16.9 MBE calls per year and an investment of 106.7 person-hours annually on MBE investigations. PEP criteria, investigation methods and the experts recruited in MBE investigations varied between states. These dissimilarities could reflect differences in experience, scenario and resources. The lack of consistency in state responses to potential mass exposures to a highly fatal disease along with the large contingent of states dissatisfied with current ACIP guidance warrants the development of national guidelines in MBE settings.

Ghrelin level negatively predicts quality of life in obese women

A cross-sectional cohort study was conducted to investigate whether ghrelin level in obese women predicts the quality of life (QOL). A total of 307 subjects fulfilled the criteria: (1) age between 20 and 65 years old, (2) body mass index ≥27 kg/m² (3) waist circumference ≥80 cm were enrolled in the study. All subjects were assigned to one of the plasma ghrelin level categories according to the quartiles. The median of age and BMI of the 307 obese women were 45 ± 18 years and 29.9 ± 4.1 kg/m², respectively. The main outcome evaluated is the associations of plasma ghrelin level and QOL, which were evaluated using multiple linear regression analysis. Results of linear trend test show significant statistical difference in plasma lipoproteins (triglyceride, cholesterol, HDL-cholestero and LDL-cholesterol = and levels of obesity-related hormone peptides, including leptin, adiponectin, insulin among quartiles of ghrelin. Multiple liner regression analysis of serum obesity-related hormone peptide level and QOL using stepwise method shows ghrelin concentration was the only predictor of QOL, including PCS-12 level (β = -0.18, p = 0.001), MCS-12 level (β = -0.14, p = 0.009), WHOQOL-BREF scores: physical (β = -0.13, p = 0.03), psychological (β = -0.16, p = 0.007), social (β = -0.21, p =  < 0.001), and environmental (β = -0.22, p =  <0.001), after adjusting other factors for obese female subjects. This study demonstrated that ghrelin concentration is strongly associated with QOL level among obese women. Hence, ghrelin concentration might be a valuable marker to be monitored in obese women.

EFFECT OF SELENIUM SUPPLEMENTATION ON PROTEOMIC SERUM BIOMARKERS IN ELDERLY MEN

OBJECTIVES

To determine the effect of selenium supplementation on the human proteomic profile.

DESIGN

Serum samples were collected in this pilot study from a randomized placebo controlled Phase 2 clinical trial (Watchful Waiting (WW)).

SETTING

Subjects were followed every three months for up to five years at the University of Arizona Prostate Cancer Prevention Program.

PARTICIPANTS

One hundred and forty men (age < 85 years) had biopsy-proven prostate cancer, a Gleason sum score less than eight, no metastatic cancer, and no prior treatment for prostate cancer.

INTERVENTION

As part of the WW trial, men were randomized to placebo, selenium 200 μg/day or selenium 800 μg/day. For the purpose of the current study, 40 subjects enrolled in the WW study (20 from the placebo group and 20 from Se 800 μg/day group) were selected.

MEASUREMENTS

Baseline serum samples were collected at each follow-up visit and stored at -80 degrees Celsius. A multiplexed proteomic panel investigated changes in 120 proteins markers simultaneously.

RESULTS

Thirteen proteins (Apolipoprotein J, IL-10, IL-1 alpha, MMP-3, IL-12p70, IL-2 receptor alpha, cathepsin B, eotaxin, EGFR, FGF-basic, myeloperoxidase, RANTES, TGF-beta) were determined to be either statistically (p-value < 0.05) or marginally significantly (0.05 < p-value <0.1) changed in the selenium supplemented group as compared to placebo.

CONCLUSION

Although independent validation of these results is needed, this study is the first of its kind to utilize high throughput fluorescence based protein multiplex panel in analyzing changes in the proteomic profile due to selenium supplementation. Results from this study provide insight into the ability of selenium to modulate numerous protein markers and thus impact various biological processes in humans.

Does supplementation with green tea extract improve acne in post-adolescent women? A randomized, double-blind, and placebo-controlled clinical trial

BACKGROUND

Green tea is believed to have beneficial effects in the prevention and treatment of acne.

OBJECTIVE

To examine the effects of a decaffeinated green tea extract (GTE), providing a daily dose of 856 mg of epigallocatechin gallate (EGCG) upon women with post-adolescent acne.

METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted from May 2012 through October 2013. A final group of 80 subjects were randomly assigned to receive either 1500 mg of decaffeinated GTE or placebo (cellulose) daily for 4 weeks. Inflammatory lesion counts were used as the major outcome measurement. At baseline and after 4 weeks of treatment, anthropometric measurements, fasting glucose levels and a lipid profile were measured from both groups.

RESULTS

Sixty-four of 80 women, from 25 to 45 years of age with moderate-to-severe acne completed the study. Statistically significant differences were noted in inflammatory lesion counts distributed on the nose, periorally and on the chin between the two groups. However, there were no significant differences between groups for total lesion counts. Within-group comparison revealed that the GTE group had significant reductions in inflammatory lesions distributed on the forehead and cheek, and significant reductions in total lesion counts. GTE resulted in significant reductions in total cholesterol levels within the GTE group.

CONCLUSIONS

GTE resulted in significant reductions in lesions located on the nose, perioral area and chin. More research is required to determine whether a decaffeinated GTE standardized for EGCG content will provide clinical benefits in women with post-adolescent acne.

Abstract P6-12-06: Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population

Background: Although the Hispanic population is among the fastest growing in the United States, however, less is known about them then other populations. Breast cancer in different racial/ethnic populations display different behaviors. The current study was performed to examine response to preoperative chemotherapy regimen and by breast cancer subtype in a Hispanic safety net population.

Methods: A retrospective review of Hispanic breast cancer patients who underwent preoperative chemotherapy from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Response to chemotherapy regimen was recorded. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal B subtype was classified based on Ki67 (&gt;15%) and PR (&lt;20%).

Results: The average age of the 133 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). The average size of the cancers at presentation was 5cm. Overall 86% of patients had a clinical response to preoperative chemotherapy and 35% had pathologic complete response (pCR). AC and TC regimens had the lowest rate of pCR at 16%. AC/T (every 3 week and weekly) had similar rates of pCR 23% and 29%, while dose dense regimens showed pCR 40%. Herceptin containing regimens had pCR 57%. 7 patients received TAC and 71% had pCR.

By subtype, Luminal A and B patients had low rates of pCR 9% and 14% respectively. Luminal B patients did benefit from preoperative chemotherapy as 86% of patients who were not candidates for breast conservation at presentation were able to undergo lumpectomy after preoperative chemotherapy. Her2 subtype patients who got Herceptin had pCR 57%. Triple negative patients had pCR 54%.

Conclusions: In this underinsured, Hispanic population who presented at advanced stages, differences in response to preoperative chemotherapy were seen based on breast cancer subtype. Differences were also seen based on chemotherapy regimen. TAC maybe a particularly effective regimen in triple negative Hispanic women.

Citation Format: Mehta D, Winton L, Walters J, Hsu C-H, Nodora J, Martinez ME, Bouton M, Komenaka IK. Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-06.