Association Between Physicians' Appropriate Use of Echocardiography and Subsequent Healthcare Use and Outcomes in Patients With Heart Failure

Background

There is little understanding of whether a physician's tendency to order an inappropriate cardiac service is associated with the use of other cardiac services and clinical outcomes in their patients with heart failure (HF).

Methods and Results

We conducted a secondary analysis of 35 Ontario‐based cardiologists who participated in the control arm of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial. Transthoracic echocardiograms, ordered during the trial, were classified as rarely appropriate (rA), appropriate, or maybe appropriate on the basis of the 2011 appropriate use criteria. Cardiologists were grouped into tertiles of rA transthoracic echocardiogram ordering frequency: low ordering (bottom tertile), n=11; moderate ordering, n=12; or high ordering (top tertile), n=12. The main outcomes were measures of cardiac service use, including cardiology‐related physician visits, tests, and medications. Among 1677 patients with heart failure and an outpatient visit to 1 of 35 cardiologists, we found no significant association between rA transthoracic echocardiogram ordering frequency (by tertile) and cardiac testing use, although patients of cardiologists in the high ordering group had fewer physician visits, on average, than patients seen by low ordering cardiologists. In addition, patients of cardiologists in the highest rA ordering tertile had significantly lower odds of receiving potentially effective interventions, such as β blockers (odds ratio, 0.62; 95% CI, 0.43–0.89), than the low ordering group.

Conclusions

Although patients of cardiologists who frequently order rA transthoracic echocardiograms do not appear more (or less) likely to have subsequent cardiac tests, these patients have fewer follow‐up visits and lower odds of receiving evidence‐based medications.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02038101.

The Role of Water in Fast Plant Movements

Plants moved onto land ∼450 million years ago and faced their biggest challenge: living in a dry environment. Over the millennia plants have become masters of regulating water flow and the toolkit they have developed has been co-opted to effect rapid movements. Since plants are rooted, these fast movements are used to disperse reproductive propagules including spores, pollen, and seeds. We compare five plants to demonstrate three ways, used alone or in combination, that water powers rapid movements: the direct capture of the kinetic energy of a falling raindrop propels gemmae from the splash cups of the liverwort, Marchantia; the loss of water powers the explosive dispersal of the spores of Sphagnum moss; the alternate loss and gain of water in the bilayer of the elaters of Equisetum drive the walk, jump, and glide of spores; the gain of water in the inner layer of the arils of Oxalis drive the eversion of the aril that jettisons seeds from the capsule; and the buildup of turgor pressure in the petals and stamens of bunchberry dogwood (Cornus canadensis) explosively propels pollen. Each method is accompanied by morphological features, which facilitate water movement as a power source. The urn shaped splash cups of Marchantia allow dispersal of gemmae by multiple splashes. The air gun design of Sphagnum capsules results in a symmetrical impulse creating a vortex ring of spores. The elaters of Equisetum can unfurl while they are dropping from the plant, so that they capture updrafts and glide to new sites. The arils of Oxalis are designed like miniature toy "poppers." Finally, in bunchberry, the softening of stamen filament tissue where it attaches to the anther allows them to function as miniature hinged catapults or trebuchets.

Low-Value Transthoracic Echocardiography, Healthcare Utilization, and Clinical Outcomes in Patients With Coronary Artery Disease

BACKGROUND

The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes.

METHODS AND RESULTS

A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65-0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66-0.94]); β-blocker prescription (OR, 0.70 [95% CI, 0.55-0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22-0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04-2.28]), although all other outcomes were similar.

CONCLUSIONS

Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02038101.

Use of the Valve Visualization on Echocardiography Grade Tool Improves Sensitivity and Negative Predictive Value of Transthoracic Echocardiogram for Exclusion of Native Valvular Vegetation

BACKGROUND

Transesophageal echocardiography (TEE) remains the preferred test to rule out infective endocarditis (IE) but is resource intensive and carries risk. Multiple studies report low sensitivity of transthoracic echocardiography (TTE) for detection of IE; however, these studies did not account for TTE quality. We test the validity of a simple valve visualization grading tool to stratify TTEs by quality and determine whether a high-quality TTE may be used to exclude valvular vegetation and forgo the need for TEE.

METHODS

The Valve Visualization on Echocardiography Grade (VEG) tool scores the TTE from 0 to 10 based on leaflet visualization and valve leaflet clarity. The tool was retrospectively applied to 309 sequential patients who underwent both TTE and TEE at an academic teaching hospital between 2011 and 2015. The TEE report was the gold standard for presence or absence of vegetation. Patients with prosthetic valves and pacemaker wires were excluded. Sensitivity of TTE for detecting vegetation was calculated at each VEG score, and the optimal cutoff was identified.

RESULTS

A total of 309 patients were included in the analysis. Among the 216 negative TTEs, 19 (9%) had a positive TEE. The median VEG score was 4. A VEG score cutoff >6 provided optimal sensitivity and was used as the cutoff. Overall, 75 (25%) patients had a VEG score >6, and 234 (75%) had a score ≤6. Sensitivity and negative predictive value for IE were higher in the VEG >6 versus VEG ≤6 group (sensitivity 96% vs 66%, negative predictive value 97.5% vs 90%; P < .05). The false-negative rate was lower (2.5% vs 10%; P = .04) in VEG > 6 versus VEG ≤ 6 groups, respectively.

CONCLUSIONS

Leaflet visualization and valve leaflet clarity are important components in the TTE evaluation of patients with suspected IE. This study demonstrates that the better the valve leaflets are visualized on TTE (as represented in this population by a score >6), the higher the confidence one can have that the TTE will not be falsely negative for vegetation(s) when vegetation(s) are not noted on these TTEs. If validated in future prospective studies, this may reduce the need to perform an invasive TEE in selected patients undergoing evaluation for native valve IE.

Foliar pathogens of eucalypts

Species of eucalypts are commonly cultivated for solid wood and pulp products. The expansion of commercially managed eucalypt plantations has chiefly been driven by their rapid growth and suitability for propagation across a very wide variety of sites and climatic conditions. Infection of foliar fungal pathogens of eucalypts is resulting in increasingly negative impacts on commercial forest industries globally. To assist in evaluating this threat, the present study provides a global perspective on foliar pathogens of eucalypts. We treat 110 different genera including species associated with foliar disease symptoms of these hosts. The vast majority of these fungi have been grown in axenic culture, and subjected to DNA sequence analysis, resolving their phylogeny. During the course of this study several new genera and species were encountered, and these are described. New genera include: Lembosiniella (L. eucalyptorum on E. dunnii, Australia), Neosonderhenia (N. eucalypti on E. costata, Australia), Neothyriopsis (N. sphaerospora on E. camaldulensis, South Africa), Neotrichosphaeria (N. eucalypticola on E. deglupta, Australia), Nothotrimmatostroma (N. bifarium on E. dalrympleana, Australia), Nowamyces (incl. Nowamycetaceae fam. nov., N. globulus on E. globulus, Australia), and Walkaminomyces (W. medusae on E. alba, Australia). New species include (all from Australia): Disculoides fraxinoides on E. fraxinoides, Elsinoe piperitae on E. piperita, Fusculina regnans on E. regnans, Marthamyces johnstonii on E. dunnii, Neofusicoccum corticosae on E. corticosa, Neotrimmatostroma dalrympleanae on E. dalrympleana, Nowamyces piperitae on E. piperita, Phaeothyriolum dunnii on E. dunnii, Pseudophloeospora eucalyptigena on E. obliqua, Pseudophloeospora jollyi on Eucalyptus sp., Quambalaria tasmaniae on Eucalyptus sp., Q. rugosae on E. rugosa, Sonderhenia radiata on E. radiata, Teratosphaeria pseudonubilosa on E. globulus and Thyrinula dunnii on E. dunnii. A new name is also proposed for Heteroconium eucalypti as Thyrinula uruguayensis on E. dunnii, Uruguay. Although many of these genera and species are commonly associated with disease problems, several appear to be opportunists developing on stressed or dying tissues. For the majority of these fungi, pathogenicity remains to be determined. This represents an important goal for forest pathologists and biologists in the future. Consequently, this study will promote renewed interest in foliar pathogens of eucalypts, leading to investigations that will provide an improved understanding of the biology of these fungi.

Genera of phytopathogenic fungi: GOPHY 3

This paper represents the third contribution in the Genera of Phytopathogenic Fungi (GOPHY) series. The series provides morphological descriptions, information about the pathology, distribution, hosts and disease symptoms for the treated genera, as well as primary and secondary DNA barcodes for the currently accepted species included in these. This third paper in the GOPHY series treats 21 genera of phytopathogenic fungi and their relatives including: Allophoma, Alternaria, Brunneosphaerella, Elsinoe, Exserohilum, Neosetophoma, Neostagonospora, Nothophoma, Parastagonospora, Phaeosphaeriopsis, Pleiocarpon, Pyrenophora, Ramichloridium, Seifertia, Seiridium, Septoriella, Setophoma, Stagonosporopsis, Stemphylium, Tubakia and Zasmidium. This study includes three new genera, 42 new species, 23 new combinations, four new names, and three typifications of older names.

Priorities for future research into asthma diagnostic tools: A PAN-EU consensus exercise from the European asthma research innovation partnership (EARIP)

The diagnosis of asthma is currently based on clinical history, physical examination and lung function, and to date, there are no accurate objective tests either to confirm the diagnosis or to discriminate between different types of asthma. This consensus exercise reviews the state of the art in asthma diagnosis to identify opportunities for future investment based on the likelihood of their successful development, potential for widespread adoption and their perceived impact on asthma patients. Using a two-stage e-Delphi process and a summarizing workshop, a group of European asthma experts including health professionals, researchers, people with asthma and industry representatives ranked the potential impact of research investment in each technique or tool for asthma diagnosis and monitoring. After a systematic review of the literature, 21 statements were extracted and were subject of the two-stage Delphi process. Eleven statements were scored 3 or more and were further discussed and ranked in a face-to-face workshop. The three most important diagnostic/predictive tools ranked were as follows: "New biological markers of asthma (eg genomics, proteomics and metabolomics) as a tool for diagnosis and/or monitoring," "Prediction of future asthma in preschool children with reasonable accuracy" and "Tools to measure volatile organic compounds (VOCs) in exhaled breath."

Association of Ras-Raf-MEK-Erk/JNK pathway mutations with overall survival for lung squamous cell carcinoma patients

e14754

Background: Genomic alterations often lead to aberrant signaling pathways which play an important role in tumorigenesis and development. Here we report the mutational status of genes associated with the Ras-Raf-MEK-Erk/JNK signaling pathway as a biomarker for predicting overall survival (OS) for Lung squamous cell carcinoma (SQCC) patients. Methods: We used the cBioPortal platform to analyze a cohort of 494 SQCC samples from TCGA data. The general Ras-Raf-MEK-Erk/JNK signaling pathway includes 26 genes (KRAS, HRAS, BRAF, RAF1, MAP3K1, MAP3K2, MAP3K3, MAP3K4, MAP3K5, MAP2K1, MAP2K2, MAP2K3, MAP2K4, MAP2K5, MAPK1, MAPK3, MAPK4, MAPK6, MAPK7, MAPK8, MAPK9, MAPK12, MAPK14, DAB2, RASSF1, RAB25). We analyzed the number of samples with/without mutations in the Ras-Raf-MEK-Erk/JNK pathway and found is 214 and 284 that had, or didn’t have, mutations in this pathway, respectively. The overall survival of these two groups was analyzed using the Kaplan-Meier Estimate, and the statistical difference between these groups was calculated using the log-rank test afterwards. Results: The log-rank test p-value is 2.086e-3, which indicates a significant difference in the overall survival between the two groups. It shows that the group with alterations in the Ras-Raf-MEK-Erk/JNK signaling pathway had a longer overall survival than the group without those alterations. The details are as follows: Conclusions: Ras-Raf-MEK-Erk/JNK pathway mutations are significantly associated with longer OS for lung SQCC patients. Mutations in this pathway can be a potential indicator for SQCC patients, but the biological reasons behind this relationship remain to be explored.[Table: see text]

Combinational analysis of IDH1/IDH2 mutations, 1p/19q deletions and MGMT promoter methylation for molecular testing of glioma

e13152

Background: Mutations in IDH1 and IDH2, co-deletion of 1p and 19q, and the hyper methylation of the MGMT promoter are the most reported genetic alterations in glioma tumors. Therefore, we designed a study to analyze the prevalence of these biomarkers in glioma, and the correlation of these biomarkers with diagnosis and prognosis. Methods: From September 2018 to January 2019, eighteen patients with primary glioma were prospectively enrolled. For each patient, freshly frozen tissue or FFPE samples were collected. DNA was extracted from these samples and sequenced to at least 5,000× coverage. IDH1/IDH2 mutations and 1p/19q deletions were detected from the sequencing data, whereas MGMT promoter methylation was evaluated by real-time fluorescence qPCR. Results: Of the eighteen patients, 44.4%(8/18) and 33.3%(6/18) harbored IDH1 /IDH2 mutations and 1p/19q deletions, respectively, and 72.2%(13/18) contained MGMT promoter hyper methylation. Within these patients, we found a correlation between IDH1/IDH2 mutation and 1p/19q deletion. Namely, among the 8 patients with a IDH1/IDH2 mutation, 75%(6/8) also contained a 1p/19q deletion, whereas none of the 10 patients with wide-type IDH1/IDH2 displayed the 1p/19q deletion. There was also a correlation between mutations at the loci and MGMT promoter hyper-methylation, specifically, 87.5%(7/8) of the patients with IDH1/IDH2 mutations also exhibited hyper-methylation in MGMT, whereas only hyper-methylation was observed in only 40% (4/10) of IDH1/IDH2 negative patients. Conclusions: From our preliminary result, IDH1/IDH2 mutations may be associated with 1p/19q deletion. To further verify this result, a larger, longitudinal study is ongoing at our institution.

DNA Input, sequencing depth, and maximum somatic allele frequency may affect the concordance between blood TMB and tumor TMB

e13163

Background: Tumor mutation burden (TMB) is recognized as a promising biomarker for PD-1/PD-L1 blockade therapy. However, a tissue biopsy is often not available, and hence a liquid biopsy using blood can be used to evaluate TMB (which is known as blood TMB). Unfortunately, the concordance of blood TMB (bTMB) and tissue TMB (tTMB) is not stable, and may be affected by the sample preparation methodology and sequencing depth. Therefore, e designed a study to explore the factors, which may significantly impact the concordance between bTMB and tTMB. Methods: From September 2018 to January 2019, 98 patients with pan-cancer were prospectively enrolled. For each patient, a tissue sample and paired plasma sample were collected. These samples were sequenced using a custom 605 cancer specificgene panel. Results: The data indicated that bTMB and tTMB were correlated, but the DNA input, sequencing depth and maximum somatic allele frequency (MSAF) might affect their concordance. The Spearman’s rank correlation (SRC) between bTMB and tTMB of 38 patients with > = 25ng cfDNA vs. 60 patients with < 25ng cfDNA was 0.77 vs. 0.15, respectively. Additionally, we explored the impact of sequencing depth and determined that the SRC (between bTMB and tTMB) of 25 patients with a sequencing depth > = 2,500x vs. 73 patients with a sequencing depth < 2,500x was 0.74 vs. 0.28, respectively. Finally, we showed that the allele frequency was critically important as well. We determined that the SRC (between bTMB and tTMB) of 50 patients with cfDNA MSAF > = 1% vs. 48 patients with cfDNA < 1% was 0.71 vs. -0.03. Conclusions: To improve concordance between bTMB and tTMB for better predicting efficacy of immunotherapy, we recommend that cfDNA input should be more than 25ng, and average effective sequencing depth should be higher than 2,500x, and the correlation hold for an allele frequency treating than 1%.

Prevalence, distribution and risk factors of farmer reported swine influenza infection in Guangdong Province, China

A cross-sectional study was undertaken to better understand the husbandry, management and biosecurity practices of pig farms in Guangdong Province (GD), China to identify risk factors for farmer reported swine influenza (SI) on their farms. Questionnaires were administered to 153 owners/managers of piggeries (average of 7 from each of the 21 prefectures in GD). Univariable and multivariable logistic regression analyses were used to identify risk factors for farmer reported SI in piggeries during the six months preceding the questionnaire administration. The ability of wild birds to enter piggeries (OR 2.50, 95% CI: 1.01-6.16), the presence of poultry on a pig-farm (OR 3.24, 95% CI: 1.52-6.94) and no biosecurity measures applied to workers before entry to the piggery (OR 2.65, 95% CI: 1.04-6.78) were found to increase the likelihood of SI being reported by farmers in a multivariable logistic regression model. The findings of this study highlight the importance of understanding the local pig industry and the practices adopted when developing control measures to reduce the risk of SI to pig farms.

Association Between Transthoracic Echocardiography Appropriateness and Echocardiographic Findings

BACKGROUND

The association between appropriate use criteria and echocardiographic findings in patients with chronic cardiovascular diseases is unknown.

METHODS

As a substudy of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial, 9,230 transthoracic echocardiographic (TTE) examinations from six Ontario academic hospitals were linked to a registry of echocardiographic findings. The TTE studies were rated appropriate), rarely appropriate, or may be appropriate according to the 2011 appropriate use criteria. TTE findings of appropriately ordered examinations were compared with those of rarely appropriate examinations for specific disease subsets, including heart failure and valvular heart disease.

RESULTS

There were 7,574, 1,087, and 569 TTE examinations ordered for appropriate, rarely appropriate, and may be appropriate indications, and of the 7,574 appropriate studies, 6,399 were ordered for specific indications and 1,175 for general indications. TTE examinations ordered for general indications had lower rates of left ventricular dysfunction (19.6% vs 9.1%, P < .001) and moderate to severe aortic stenosis (15.5% vs 2.6%, P < .001). Of the 2,395 TTE examinations ordered for patients with heart failure, appropriately ordered studies were more likely to result in left ventricular segmental abnormality (37.0% vs 24.9%, P = .012) but similar rates of right ventricular dilatation (15.4% vs 14.7%, P = .79), right ventricular dysfunction (14.8% vs 11.3%, P = .22), and moderate to severe mitral regurgitation (12.1% vs 9.2%, P = .35). Of the 2,859 studies ordered to assess valvular heart disease, appropriately ordered studies were significantly more likely to find moderate to severe valvular pathology, including aortic stenosis (30.4% vs 24.6%, P = .008), aortic regurgitation (8.9% vs 1.6%, P < .001), mitral stenosis (6.7% vs 3.1%, P = .002), and mitral regurgitation (16.1% vs 6.1%, P < .001), but similar rates of tricuspid regurgitation (11.2% vs 13.0%, P = .60).

CONCLUSIONS

Overall, appropriately ordered TTE examinations for heart failure and valvular heart disease were significantly more likely to have abnormal findings than rarely appropriate examinations. TTE studies ordered for general indications had fewer, although still a significant proportion, of abnormalities compared with studies ordered for specific indications.

TM3-1 Idiopathic intracranial hypertension: consensus guidelines on investigation and management

Objectives

The aim was to capture interdisciplinary expertise from a large group of clinicians, reflecting practice from across the UK and further, to inform subsequent development of a national consensus guidance for optimal management of Idiopathic Intracranial Hypertension.

Design

Consensus guideline critically reviewed by the Association of British Neurologists, British Association for the Study of Headache, the Society of British Neurological Surgeons and the Royal College of Ophthalmologists.

Subjects

An initial UK survey of attitudes and practice in IIH was sent to a wide group of physicians and surgeons.

Methods

Between September 2015 and October 2017 a specialist interest group including neurology, neurosurgery, neuro-radiology, ophthalmology, nursing, primary care doctors, and patient representatives met. A comprehensive systematic literature review was performed to assemble the foundations of the statements.

Results

Over twenty questions were constructed: One based on the diagnostic principles for optimal investigation of papilloedema and twenty-one for the management of IIH. 3 main principles were identified:

to treat the underlying disease;

to protect the vision and

to minimise the headache morbidity.

Statements presented provide insight to uncertainties in IIH where research opportunities exist.

Conclusions

In collaboration with many different specialists, professions and patient representatives we have developed guidance statements for the investigation and management of adult IIH.

Abstract P3-10-10: DYRK2 is a novel therapeutic target in ER negative breast cancer

Background

Dual specificity tyrosine-phosphorylation-regulated kinase 2 (DYRK2) belongs to a family of CMGC kinases that function as modulators of different downstream pathways that allow cells to cope with hypoxia, DNA damage and various stress signals. Additionally, DYRK2 has been implicated in various human cancers with both pro- and anti-tumour roles, which are probably cancer type- and cell type-dependent. Furthermore, studies show that DYRK2 is involved in epithelial-mesenchymal transition, hence suggesting a role in tumour metastasis. The current study investigates the prognostic role of DYRK2 in breast cancer and investigates its potential as a novel therapeutic target.

Methods

Immunohistochemistry was employed to investigate if nuclear expression of DYRK2 was associated with clinical outcome measures in a cohort of 715 patients. Expression was determined using the weighted histoscore method. Antibody specificity was confirmed in paraffin embedded cell pellets +/- DYRK2 silencing. Cell counts in parental and CRISPR-mediated DYRK2 knocked-out MDA-MB-468 and MDA-MB-231 cells (ER, PR, HER2, AR negative) were measured using Alamar Blue; NSGTMmice (n=8) were injected subcutaneously with MDA-MDB-231 with or without DYRK2 depletion to assess tumour growth in vivo.

Results

In a cohort of 715 patients, median follow-up was 160 months with 155 breast cancer deaths and 135 deaths due to other causes. The majority of patients were over 50 years of age (71%), had ductal carcinoma (88%), tumours &lt;20mm in size (56%) and node negative disease (57%). 489 patients had ER positive disease, 226 had ER negative disease and of these 148 had TN (triple-negative) disease. DYRK2 expression was observed in the cell cytoplasm and nucleus and ranged from 3 to 200 weighted histoscore units (WHS) and ROC analysis was used to determine cut-offs, tumours with a cytoplasmic and nuclear WHS &lt;145 were classified as low expression and tumours with a cytoplasmic and nuclear WHS &gt;145 were classified as high expression. In the full cohort (p=0.087) and ER negative (p=0.066) cohort DYRK2 was not associated with cancer specific survival. However in TN disease high DYRK2 expression was associated with cancer specific survival (p=0.012, mean survival 145 months versus 107 months). This was potentiated in patients with ER, PR, HER2, AR negative disease (p=0.005, mean survival 166 months versus 100 months) and independent in multivariate analysis with age, histological tumour type, tumour size tumour grad, nodal status, ki67 index, chemotherapy, radiotherapy and recurrence (p=0.13, HR 3.920). Following this observation, patients with ER, AR negative disease were investigated and again high DYRK2 expression was associated with cancer specific survival (p=0.0003, mean survival 163 months versus 86 months) and was independent when combined in multivariate analysis (p=0.001, HR 4.154).

To investigate if DYRK2 was a potential target in TN breast cancer, the effect of silencing DYRK2 was investigated. CRISPR-mediated DYRK2 depletion impeded cell proliferation in TN cell-lines and markedly reduced tumour burden in mouse MDA-MDB-231 xenografts (p&lt;0.0001).

Conclusions

Our studies indicate that DYRK2 is indeed a potential therapeutic target for patients with TN breast cancer or ER, AR negative breast cancer.

Citation Format: Edwards J, Baillie G, Quinn J, Monreno R, Banerjee S, Tomkinson N, MacKay S, De La Vega L. DYRK2 is a novel therapeutic target in ER negative breast cancer [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 P3-10-10.

Abstract P2-08-23: A combined score of tumour budding and tumour necrosis has prognostic value for cancer specific survival in both ER positive and ER negative primary operable breast cancer

Background: As new systemic therapies emerge for the treatment of breast cancer, new prognostic markers are required to help stratify patients into higher and lower risk groups to aid treatment decision making. Features of the tumour microenvironment, such as tumour necrosis, tumour-stroma percentage (TSP), and tumour budding have been shown to have prognostic value in some cancers. However, their role in breast cancer is unclear.

Methods: Patients who underwent surgery for primary operable breast cancer in 2 centres between 1995-2007 and who had paraffin-embedded tissue blocks available were identified. Clinicopathological details and survival data were obtained from patient records. Haematoxylin & Eosin-stained slides were visually assessed within a set visual field for TSP (&lt;50% or &gt;50% tumour stroma), tumour necrosis (&lt;25% or &gt;25% necrosis) and tumour budding (&lt;20 buds or &gt;20 buds). A combined score of tumour necrosis and tumour budding was then created. A score of 0 was assigned to tumours where both components were low, 1 to those where only one component was high, and 2 to those where both were high. Multivariate cox regression analysis was carried out for cancer specific survival (CSS).

Results: A breast cancer cohort of 1301 patients was utilised, from which 1186 H&E slides were scored for necrosis, TSP and tumour budding. Median follow up was 158 months (26-183) and there were 234 breast cancer deaths. In the full cohort, necrosis (p&lt;0.0001), high TSP (p=0.010) and high budding (p&lt;0.0001) were associated with CSS and all 3 were independently prognostic on multivariate analysis (necrosis HR 1.54, 95%CI 1.15-2.07, p=0.004; high TSP HR 1.49, 95%CI 1.12-1.98; p=0.006; high budding HR 1.38, 95%CI 1.02-1.87, p=0.035). In ER positive disease (n=826), necrosis was associated with worse CSS (p&lt;0.0001) and was independently prognostic (HR 1.46, 95%CI 1.03-2.08, p=0.033). In ER negative disease (n=359), necrosis, high TSP and high budding were associated with worse CSS (p=0.001, p=0.002, p&lt;0.0001 respectively) and were independently prognostic (necrosis HR 2.44, 95%CI 1.34-4.43, p=0.003; high TSP HR 1.64, 95%CI 1.06-2.53, p=0.026; high budding HR 2.47, 95%CI 1.56-3.89, p&lt;0.0001) . To assess if combining these markers added additional prognostic power a combined budding/necrosis score was established. This was associated with worse CSS in ER positive disease (p&lt;0.0001) and a score of 2 was independently associated with worse CSS compared to a score of 0 (HR 1.96, 95%CI 1.19-3.23, p=0.008). This was potentiated in node-negative patients (HR 5.14, 95%CI 2.18-12.08, p&lt;0.0001). In ER negative disease, an increasing score was associated with worse CSS (p&lt;0.0001) and was independently prognostic (combined score 1 vs. 0: HR 2.37, 95%CI 1.13-5.00, p=0.023; score 2 vs. 0: HR 5.93, 95%CI 2.62-13.40, p&lt;0.0001).

Conclusions: A combined score of tumour necrosis and budding shows promise as a readily-available prognostic tool to aid treatment decision making in primary operable breast cancer, both by stratifying risk in ER negative disease, and by identifying a high-risk group in ER positive, node negative disease.

Citation Format: Morrow ES, Gujam F, Mohammed Z, McMillan DC, Horgan PG, Roseweir AK, Edwards J. A combined score of tumour budding and tumour necrosis has prognostic value for cancer specific survival in both ER positive and ER negative primary operable breast cancer [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 P2-08-23.

Abstract P3-10-13: Dual targeting of androgen receptor and IKK alpha is a potential therapeutic strategy for triple negative breast cancer

Background

There are limited treatments for triple negative breast cancer (TNBC) patients and an unmet need for targeted approaches in these patients. In the last 4-5 years, the prevalence of high androgen receptor (AR) expression in TNBCs has been noted in up to 50% of tumors suggesting it has clinical relevance. The non-canonical NF-kB pathway is also upregulated in this patient group and it has been reported that that there is crosstalk between these pathways. Therefore the aim of this study was to examine the expression of IKKα and AR in breast cancer tissue samples, to assess if combining these markers increased prognostic power.

Methods

Immunohistochemistry was performed on tissue microarray of 410 patients to assess proteins level of IKK alpha and AR. Protein expression levels were assessed using the weighted histoscore (WHS) method. The median was employed as the cut off for IKK alpha and 1% as cut off for AR. Expression was analyzed for associations with cancer-specific survival (CSS) and recurrence-free survival (RFS).

Results

In a cohort of 370 breast cancers nether AR nor IKK alpha alone or combined were associated with CSS or RFS. Stratifying patients by ER status did not impact CSS or RFS. However, in TNBC patients (n=82) high expression of AR was associated with shorter CSS (HR 2.55 95 CI 1.61-5.59, p=0.013). To assess if combining AR and IKK alpha increased prognostic power, AR and IKK alpha were combined into a single score: 0= low expression of both or high expression of one and 1= high expression of both. In the full cohort or when stratified by ER status the score was not associated with CSS or RFS, however in TNBC the combined score potentiated the effect observed with AR alone, (HR 1.68 95 CI 1.20-2.33, p=0.001). Patient CSS was stratified from 11.5 years to 4.6 years and was independently associated with CSS when compared with common clinicopathological factors (HR 1.56 95CI 1.11-2.21, p=0.011). In addition, the combined score was associated with decrease radiotherapy use (p=0.032), increased recurrence rate (p=0.014), decreased cytotoxic T cells (p=0.007), B cells (p=0.043) and macrophages (p=0.037).

Conclusions

A combined AR and IKK alpha score is an independent prognostic classification for patients with TNBC. Patients with high expression of both AR and IKK alpha a significantly reduced survival and were immune cell cold. This study suggests that this patient group will not benefit from immunotherapy but dual targeting with anti-androgens and IKK alpha selective inhibitors could offer a novel therapeutic strategy for this patient group.

Citation Format: Roseweir AK, Khongthong P, Dickson K, Bennett L, Edwards J. Dual targeting of androgen receptor and IKK alpha is a potential therapeutic strategy for triple negative breast cancer [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 P3-10-13.